Volume Ten Number One January 2008 Published Monthly visit www.compliance-institute.org HIPAA’s Privacy Regulations: Appropriate safeguard, Meet HCCA’s 5,000 th Member Libby Easton-May unmanageable Director of Compliance, Operations & Marketing, obstacle, or WellPoint Senior Business Division page 14 convenient scapegoat? Also: page 4 When worlds collide: Health care Feature Focus: Review of the OIG compliance and Work Plan FY 2008 union work force page 32 page 44
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org care Hospitals” and “Medicaid Hospitals” sections, so a comprehensive to continue or initiate with respect to the programs and operations of the Department of Health and Human Services.” The 2008 Work Plan serves as an important compliance tool for hospitals, physicians, and Several provisions of the 2008 Work Plan are of primary importance to hospitals for both Medicare and Medicaid issues. Tiere are 25 work plan topics specifjcally related to hospitals (20 relate to Medicare and 5 relate to Medicaid). Tie 2008 Work Plan as it relates to hospitals includes many of the same action items from the 2007 Work Plan, but it also incorporates 13 new areas identifjed as “new start” (10 relate to Medicare and 3 relate to Medicaid) and 12 areas identifjed as “work in progress” (10 relate to Medicare and 2 relate to Medicaid). Some view of the 2008 Work Plan topics specifjcally related to hospitals. mary areas in which it intends to focus its attention for the upcoming OIG will review: for assets such as equipment and facilities). OIG will determine whether capital payments to hospitals are appropriate and will examine the methodology used to update capital rates and analyze the appropriateness of the payment level. are payments made for new medical services and technologies that qualify as “new” under Medicare regulations and are demonstrated to be otherwise inadequately paid under the Diagnosis-Related Group (DRG) system. OIG will determine whether hospitals have submitted bursed for costs associated with the new devices and technologies. patients to specifjed co-located providers and directly readmits more than 5% of the total number of its Medicare inpatients fiscal year. The 2008 Work Plan is intended to reflect what OIG “plans other health care providers and should be closely reviewed. discharged from that setting, special payment provisions apply. Jones Day and may be reached at 202/879-5449. Department of Health and Human Services (OIG) released n October 1, 2007, the Office of Inspector General of the Work Plan FY 2008 704/927-4480. Healthcare West and may be reached at 916/851-2180. tor General Fiscal Year 2008 Work Plan. We thank the authors for their Arent Fox LLP and may be reached at 202/857-6341. its Work Plan for the 2008 fiscal year. On an annual basis, feature focus Review of the OIG Editor’s note: Tie following articles review items related to hospital, home health/hospice, long-term care, health plans and Medicare Part D outlined in the U.S. Department of Health and Human Services Offjce of Inspec- contributions to our Feature Focus. If you have questions you may contact the following authors by telephone: Asha B. Scielzo is a Senior Associate in the Washington, DC offjce of hospital-related topics can be found in sections outside of the “Medi - Deborah A. Randall is a Partner in the Washington, DC offjces of review of the entire Work Plan is advisable. Tie following is an over - “New Start” Items Identified in the 2008 Work plan Mary Ann LeVesque is System Compliance Director for Catholic Medicare Dorothy DeAngelis is a Managing Director in Huron Consulting n Hospital inpatient capital spending (i.e., a hospital’s expenditures Group’s Health Plans and Pharmaceuticals practice and may be reached at Implications for hospitals n Hospital inpatient costs for new services and technologies. Tiese By Asha B. Scielzo, Esq. O OIG conducts a comprehensive planning process to identify the pri - claims in accordance with the criteria and were appropriately reim - n Special payment provisions for patients who are transferred to onsite providers and readmitted to long-term care hospitals (LTCH). Pursuant to Medicare regulations, if an LTCH discharges January 2008 34
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org procedures regarding the Joint Commission hospital accreditation funding being used to pay for services provided to individuals who are state Medicaid programs to determine the magnitude of federal DSH OIG will review: Conditions of Participation for Hospitals. hospitals by the Joint Commission to be deemed to meet the Medicare process. Medicare laws and regulations allow institutions accredited as OIG will evaluate the extent and adequacy of CMS’s policies and review whether states appropriately determined provider eligibility the providers’ charges or the allowed amount. procedures for identifying and resolving credit balance situations have other insurance coverage, which will include an evaluation of preventing inappropriate Medicare payments for benefjciaries who payer). OIG will assess the efgectiveness of current procedures in potential overuse of diagnostic imaging services. 21 to 64 years old and residing in institutions for mental disorders. for Medicaid reimbursement. 2005 testimony before Congress, reported concerns regarding the payments for provider-operated nursing and allied health education Medicare requirements for reporting wage data and determine the IPPS. OIG will determine whether hospitals have complied with of the hospital wage data used to calculate wage indices for the OIG will evaluate hospital and Medicare controls over the accuracy costs were appropriate. programs and determine whether payments to providers for these refmected in the revised Medicare reimbursement. ments. OIG will examine the threshold that hospitals must meet to OIG will determine whether the adjustments were appropriately ate medical education costs when settling Medicare cost reports. 2002 base-year cost reports. are correct and supported, based on allowable costs from the FY hospitals, OIG will determine whether payments made to MDHs OIG will review: mend changes to the program. increasing cost of imaging services for Medicare benefjciaries and that occur when payments from Medicare and other insurers exceed Medicare Payment Advisory Commission (MedPAC), in its March provisions were appropriately applied. components of the calculation methodology, determine whether were made in accordance with Medicare criteria and review various ments in this area. OIG will determine whether these payments to determine the appropriateness of payments. OIG notes that the needs. According to OIG, Medicare DSH payments have been disproportionate numbers of low-income patients with special may be reduced. OIG will determine whether the special payment amounts of uncompensated care costs that hospitals incur. threshold outlined in the regulations, payments to the LTCH tients admitted from the co-located hospital exceeds the applicable Medicare inpatient population admitted to an LTCH or LTCH Medicare regulations, special payment provisions apply to the appropriately applied. OIG will determine whether the special payment provisions were the hospitals’ classifjcations are appropriate, and examine the total Continued on page 37 for diagnostic x-rays performed in hospital emergency departments made for facilities that operate emergency departments. review a sample of Medicare Part B paid claims and medical records services for the period in which the recoveries were made. write-ofgs were properly used to reduce the cost of benefjciary cilities, and skilled nursing facilities). OIG will determine whether the debts were reimbursable and whether recoveries of prior year Oversight of the Joint Commission Hospital Accreditation Process. n Special payment provisions for patients who are discharged from LTCH to co-located or satellite providers. Pursuant to satellite facility from a co-located hospital. If the number of pa - Medicaid n States’ use of funds for mental institutions. OIG will review several n Medicare Disproportionate Share Hospital (DSH). DSH serve n Provider eligibility for Medicaid reimbursement. OIG will steadily increasing, and previous OIG work has identifjed overpay - n DSH payment threshold. OIG will review the Medicaid inpatient utilization rate used to determine eligibility for Medicaid DSH pay - qualify for Medicaid DSH payments and, if appropriate, recom - n Inpatient psychiatric facility emergency department adjust- ments. OIG will determine whether appropriate adjustments were “Work in Progress” continued from 2007 n Provider bad debts (claimed by acute care inpatient hospitals, Medicare LTCHs, inpatient rehabilitation facilities, inpatient psychiatric fa - n Appropriateness of costs for the Medicare-Dependent Hospital (MDH) Program. For a selected number of Medicare-dependent n Diagnostic x-rays in hospital emergency departments. OIG will n Adjustments for graduate medical education. Audit adjustments are made by Fiscal Intermediaries for direct and indirect gradu - n Nursing and allied health education payments. OIG will review n Beneficiaries who have other insurance (Medicare secondary n Inpatient Prospective Payment System (IPPS) wage indices. January 2008 35
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