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Office of Inspector General 2014 Work Plan

February 12, 2014


The Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan for Fiscal Year 2014 provides brief descriptions of activities that OIG plans to initiate or continue with respect to HHS programs and operations in fiscal year 2014. The Work Plan describes the primary objectives and provides for each review its internal identification code, the year in which we expect one or more reports to be issued as a result of the review, and indicates whether the work was in progress at the start of the fiscal year or will be a new start during the year. When reports are issued, they are posted to OIG's website.


The Joint Commission Requires Hospitals to Improve Their Alarm Systems

February 5, 2014


The Joint Commission announced in December 2013 the release of the “R3 Report”1 for the new National Patient Safety Goal (NPSG) in an effort to require accredited hospitals and critical access hospitals to improve the safety of their clinical alarm systems.  The goal addresses clinical alarms that can compromise patient safety if they are not properly managed.


Data Breaches Continue to Take Center Stage

January 29, 2014


In light of the frequency with which data breaches come across the front page of prominent news sites, we felt it opportune to remind our readers of the importance of compliance with State and Federal privacy laws.  Namely, the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its impending regulations.  It is all too easy for medical practices and health systems to suffer data breaches, and the financial consequences can be severe.  When a breach of patient data is found and reported, healthcare providers and legal business associates can be liable for penalties of up to $1.5 million for violations of a single HIPAA provision each year.


Uncompensated Care Skyrockets to $45.9 Billion

January 22, 2014


An annual survey of hospitals completed by the American Hospital Association (AHA) indicates uncompensated care provided by U.S. hospitals rose from $4.8 billion (11.7%) in 2012 to a massive $45.9 billion.  AHA is the nation’s most comprehensive source of hospital financial data, and compiles aggregate information annually on the level of uncompensated care.


Survey Results Indicate the Healthcare Industry is Falling Behind with ICD-10 Compliance Readiness

January 15, 2014


The Workgroup for Electronic Data Interchange (WEDI) is a leading authority on the use of Health IT to improve the exchange of healthcare information.  On December 13, 2013 the group announced results from the October 2013 WEDI ICD-10 Readiness Survey to the Centers for Medicare & Medicaid Services (CMS).  The report discloses the Healthcare Industry is not making the grade when it comes to the amount of progress needed for a smooth transition to ICD-10 in October 2014.


CMS Proposed Regulations to Address Emergency Preparedness for Medicare, Medicaid Providers

January 8, 2014


On December 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule that would add emergency preparedness requirements to the conditions of participation and conditions of coverage for a wide range of providers and suppliers. Affected organizations include hospitals (including critical access hospitals), long term care facilities, ambulatory surgical centers, hospices and home health agencies, outpatient rehabilitation providers, programs of all-inclusive care for the elderly, organ procurement organizations, religious non-medical health care institutions, community mental health centers, rural health clinics and end-stage renal disease facilities.


CMS Makes Outpatient Facility Policy and Payment Changes

December 18, 2013


In the Centers for Medicare & Medicaid Services (CMS) final calendar year (CY) 2014 hospital outpatient and Ambulatory Surgical Center (ASC) payment rule [CMS-1601-FC], CMS notified hospitals and ASC that they will replace the current five levels of hospital clinic visit codes for both new and established patients with a single code describing all outpatient clinic visits. “A single code and payment for clinic visits is more administratively simple for hospitals and better reflects hospital resources involved in supporting an outpatient visit,” said a release from CMS.1 The current five levels of outpatient visit codes are designed to distinguish differences in physician work.


How the Physician Value-Based Payment Modifier Program will Affect the 2014 Medicare Physician Fee Schedule

December 11, 2013


The Physician Feedback/Value-Based Modifier Program is provided by The Centers for Medicare and Medicaid Services (CMS) to provide comparative performance information to physicians. CMS is geared towards improving the quality and efficiency of medical care by providing meaningful and actionable information to physicians so they can improve the care they furnish. Physicians can find value rather than volume moving towards physician reimbursement.1


The Office of Inspector General Strategic Plan for Fiscal Years 2014-2018

December 4, 2013


The Office of Inspector General (OIG), United States Department of Health and Human Services (HHS) Strategic Plan focuses on the four goals in the white box shown here. With a return of more than $7 for every $1 invested, no one can doubt the impact the OIG has on saving health care funds and reducing fraud, waste and abuse. The Strategic Plan highlights key strategies and indicators for attaining and measuring results for the next few years.


Medicare Advantage Funding, Open Enrollment, and United Healthcare Plans to Drop Doctors

November 27, 2013


Medicare Open Enrollment for 2014 ends December 7th, 2013 and many beneficiaries that were hoping to stay with their current Medicare Advantage Plan, are scrambling to learn if their doctor is still going to be part of their plan. The reason is some Medicare Advantage plans, with United Healthcare being the largest and most significant one, are in the process of dropping a significant number of doctors from their Medicare Advantage plan networks beginning next year.


Three Things to Remember Regarding Meaningful Use in 2014

November 20, 2013


As we approach the New Year, there are three major factors to keep in mind as you continue (or begin) the EHR Incentive Program popularly referred to as Meaningful Use. These updates can adversely affect your success with the attestation process and, ultimately, your CMS incentive. In addition to all the other supportive material available, keep these three tips on the top of your list to ensure your compliance with the EHR Incentive program.


Hospital and Physician Usage of Devices from Physician-Owned Device Companies

October 30, 2013


In fiscal year (FY) 2012, Medicare paid hospitals a total of $3.9 billion for spinal surgeries, with the average reimbursement being $21,613 for these surgeries. A complicated spinal surgery with extensive instrumentation averages $34,676 per surgery, compared to less complicated cases at $10,289.


Medical Necessity and the Affordable Care Act

October 23, 2013


The Affordable Care Act (ACA) promises to expand care to millions of Americans, but will it happen? One factor, the medical necessity of care, will continue to serve as the key means for determining which health care services get paid or denied.


Two Similar OIG Audit Reports Result in a Lopsided Overpayment Calculation

October 16,2013


Based on information contained in the second hospital audit report, the hospital disagreed with OIG "treating them differently" and extrapolating the results, noting past hospital compliance reports only recommended hospitals repay audited claims.


CMS Moves Forward on Major Provider Revalidation Effort

October 9, 2013


Section 6401(a) of the Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. This revalidation effort applies to those providers and suppliers that were enrolled prior to March 25, 2011. Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011 are generally not impacted.


New CMS Rules Governing Inpatient Admissions and Documentation Requirements for Hospital Medicare Part A Payment Will Have an Impact on Admitting Physicians

October 2, 2013


The Centers for Medicare & Medicaid Services (CMS) announced this week it will delay Recovery Audit Contractor (RAC) audits of the “two-midnight” rule for 90 days. The 2014 Inpatient Prospective Payment System (IPPS) Final Rule, released in August 2013, finalized the “two-midnight” rule, under which hospital inpatient admissions that span at least two midnights presumptively qualify as appropriate under Medicare Part A, and hospital inpatient admissions that span less than two midnights (i.e., less than one Medicare utilization day) are presumptively inappropriate for payment under Part A. When auditing medical necessity, the RACs would presume that the occurrence of two-midnights after formal inpatient hospital admission indicates an appropriate in patient status for a medically necessary claim. If the occurrence of two-midnights after formal in-patient hospital admission does not occur, government recovery auditors do not apply the same presumption, and claims for such admissions receive a higher level of scrutiny.


Health Care Reform and Perhaps Your Medicare Payments May be Held Hostage by Politics

September 25, 2013


The next fiscal year begins October 1st regardless of whether it is funded or not by Congress. According to Congressional watchers, the Senate is set to hold a test vote this week on the continuing resolution legislation passed by the House to cover federal spending through December 15th and to derail funds for the Affordable Care Act (ACA).


Key Facts About the Physician Payments Sunshine Act

September 18, 2013


The collection of payment data to physicians and teaching hospitals from pharmaceutical and medical device companies, as well as reporting of certain ownership interests, under the new Physician Payments Sunshine Act (PPSA) started August 1, 2013. The law covers meals, honoraria, travel expenses, and grants from manufacturers, as well as ownership or investment interests in group purchasing organizations (GPOs), by physicians or members of their immediate family. Information will be posted on a public website that will identify physicians who have received payments or hold ownership. While data collection is underway, public reporting does not start until 2014, under the National Physician Payment Transparency Program (NPPTP) of the Centers for Medicare and Medicaid Services (CMS).


Medicare Recovery Audit Contractors Performance: Office of Inspector General Findings

September 11, 2013


Recovery Audit Contractors (RACs) are designed to protect Medicare by identifying improper payments and referring potential fraud to the Centers for Medicare & Medicaid Services (CMS). In a September 3, 2013 report, the Office of Inspector General (OIG) found that prior OIG work has identified problems with CMS's actions to address RAC referrals of potential fraud were still outstanding. Further, OIG identified vulnerabilities in CMS's oversight of its contractors.


HHS Announces First Guidance Implementing Supreme Court’s Decision on the Defense of Marriage Act (DOMA)

September 4, 2013


On August 29, the Department of Health and Human Services (HHS) issued a memo clarifying that all beneficiaries in private Medicare plans have access to equal coverage when it comes to care in a nursing home where their spouse lives. This is the first guidance issued by HHS in response to the recent Supreme Court ruling, which held Section 3 of the Defense of Marriage Act (DOMA) unconstitutional. HHS, which oversees Medicare, has decided it will adopt the “place of celebration” standard when granting Medicare benefits to same-sex couples. If the marriage took place in a state that recognizes same-sex marriage, then the couple is entitled to benefits, no matter where they live.


HIPAA –The Countdown is On to September 23

August 28, 2013


We have issued numerous alerts about compliance with the new Health Insurance Portability and Accountability Act of 1996 (HIPAA) omnibus regulations that were released on January 25 of this year (Omnibus Rule). Although much has been released about them, many are still behind in ensuring compliance with the new provisions of the rule. In a little over four weeks from now, covered entities must ensure they are complying with these new provisions or they could be leaving themselves exposed to potential liabilities of up to $1,500,000. This is a friendly reminder that there is much to do between now and September 23.


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