OIG to Investigate Hospital Payments in 2013

Payment to critical access hospitals for swing beds

Investigators will examine whether current policy, which allows critical access hospitals to bill Medicare at 101% of reasonable cost for patient care provided in swing beds (beds that can be used for either acute or skilled nursing care), should be adjusted to "a more cost-effective payment methodology" when patients are provided traditional skilled nursing care. 

Currently, there is no established length-of-stay limit for swing bed utilization in critical access hospitals.

Long-term care hospital interrupted-stay payment

Prior investigations by the OIG "has identified vulnerabilities in CMS's ability to detect readmissions and appropriately pay for interrupted stays" in long-term care facilities, which require a Medicare payment adjustment.

"An interrupted stay occurs when a patient is discharged from an LTCH for treatment and services that are not available at the LTCH and is readmitted after a specific number of days."

Recovery Audit Contractors

Because previous OIG and Government Accountability Office reports found problems with Recovery Audit Contractors' (RACs') ability to identify and report potential fraud, "and with CMS's handling of vulnerabilities identified by RACs," a new program will look at RACs performance and results under the Medicaid program.

State Medicaid programs were required to establish such programs by the end of 201.

"The RACs were initially established to conduct postpayment reviews to identify Medicare overpayments and underpayments," the work plan said.  "The Affordable Care Act expanded the use of RACs to Medicaid."