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.
"They're really looking at that process from a lot of angles," Miller says.
Also, this is another quality of care issue, Hernandez says. The results of adverse events can be devastating for both the patient and the providers. Therefore, she says, the OIG must determine whether CMS is doing its job of enforcement so that facilities understand the repercussions of having an adverse event.
"If CMS pays for the [adverse event], there is no incentive for the facilities to improve," she says.
Hospital admissions with conditions coded as POA
According to the Work Plan, acute care hospitals are required to report on their Medicare claims which diagnoses were POA. The OIG plans to determine how many diagnoses were coded as POA and which diagnoses were coded most frequently as POA.
American Recovery and Reinvestment Act of 2009
This section of the Work Plan includes reviews of the many areas affected by this new act, passed by Congress on February 13, 2009. Top concerns include:
- Breach notification and medical identity theft in Medicare: This review will look at CMS' compliance with new breach notification requirements for personally identifiable information (PII). Section 13402 of the Recovery Act requires entities covered by HIPAA to notify individuals of PII breaches, which can lead to medical identity theft. The OIG also plans to examine CMS' internal procedures and processes related to the breach notification requirements.
- Medicare incentive payments for electronic health records (EHR): Sections 4101 and 4102 of the Recovery Act authorize incentive payments over a five-year period to physicians and hospitals that demonstrate meaningful use of certified EHR technology. The OIG will review Medicare incentive payment data from calendar year 2011 to identify erroneous payments. If the OIG identifies errors, it will assess CMS' actions to correct these mistakes.
With the federal government issuing great sums of money for EHR implementation, this project is open to scrutiny, Hernandez says.
This is also another example of how the OIG is being proactive with newer issues, scheduling the EHR incentive payments review ahead of time, Miller says.
Create your audit plan for 2010
As you're reading through the Work Plan, think about which reviews apply to your facility or practice. Include these reviews in your own audit plan to gauge your facility's compliance.
For example, "if you've had any adverse events involving a Medicare patient in the last year, you might expect the OIG requesting the record for that event," Miller says. In this example, review that case?determine how preventable the event was and how your staff members handled it. This will help you know what to expect and show government auditors that you and your staff members responded appropriately.