OIG Gets Proactive in 2010 Work Plan

HealthLeaders Media Staff, October 5, 2009

Hospital readmissions, adverse events, and issues related to the American Recovery and Reinvestment Act of 2009 are some of the highlights of the 2010 OIG Work Plan.

"These are relatively new issues so this is pretty proactive on the OIG's part," says Steve Miller, JD, chief compliance and privacy officer at Capital Health in Trenton, NJ.

In previous years, many of the OIG's planned reviews were on topics that have been around for a while, such as bad debt, Medicare secondary payer, and wage indices.

"They're getting a jump on these newer issues right away," Miller says. This is a good move, he adds, because newer issues tend to present a higher opportunity for errors.

In the 2010 Work Plan, the OIG grouped ongoing and planned reviews into two major parts:

  • CMS: Reviews related to Medicare, Medicaid, information systems controls, the Children's Health Insurance Program, and related investigation and legal counsel to OIG.
  • Public Health and Human Services Programs and Department-wide Issues: Reviews related to agencies, such as the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, the Administration on Aging, and the Administration for Children and Families. This part also describes department-wide issues, such as financial accounting and information systems management.

Hospital readmissions
In 2004, CMS implemented an edit to reject subsequent claims for beneficiaries whom the hospital readmitted on the same day. According to the Medicare Claims Processing Manual, if a same-day readmission occurs for symptoms related to or for evaluation or management of the prior stay's medical condition, the hospital is entitled to only one DRG group payment and should combine the original and subsequent stays in a single claim. The OIG plans to test the effectiveness of this edit and determine the extent of oversight of readmission cases.

"It's interesting because this is an issue that is getting more attention from CMS this year," Miller says. In fact, in April, CMS announced a pilot program "Care Transitions" to focus on eliminating unnecessary hospital readmissions.

This is not only a quality of care concern, but also a hospital efficiency problem, says Marta G. Hernandez, BPS, HSA, CHC, RHIT, senior auditor in Miami.

"Most facilities that are efficient have been found to have a higher standard of patient care," she says. "This then results in better patient outcomes and less readmissions for the same conditions."

Adverse events
In the 2009 Work Plan, the OIG included a review of payments for and incidences of never events, focusing on CMS' administrative processes regarding detection of never events and payment. This year, it included five different reviews, using the term "adverse" events instead, to include hospital-acquired conditions (HAC). These reviews include:

  • Hospitals: National incidence among Medicare beneficiaries—The OIG will employ a panel of physicians with expertise in patient safety to estimate the national incidence of adverse events, identify the type of event, and assess if the event was preventable.
  • Hospitals: Methods to identify events—This review will examine methods of identifying adverse events, including:
    • Medical records reviews by both nurses and physicians
    • Administrative data analysis using the Agency for Healthcare Research and Quality's patient safety indicators and present on admission (POA) indicators
    • Hospital incident reports
    • Interviews with Medicare beneficiaries or their representatives
  • Hospitals: Early implementation of Medicare's policy for HACs—The OIG will review CMS' administrative process, including how it identifies HACs and denies reimbursement for related care.
  • Hospitals: Responses by Medicare oversight entities—In this review, the OIG will look at how state survey and certification agencies, state licensure boards, and Medicare accreditors responded to adverse events in hospitals.
  • Public disclosure of adverse event information—This is another review of CMS policy and procedure, as well as selected patient safety organizations. The OIG will look at how these organizations handled the disclosure of information and patient privacy.

These detailed reviews show that the OIG is serious about analyzing how many adverse events are occurring across the nation and how all involved parties are handling the events from beginning to end, Miller says.

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