Officer In General 2016 Work Plan
The Officer In General 2016 Work Plan recently was announced; it includes ongoing work performed in the 2015 Work Plan and the announcement of some new areas of focus.
The Work Plan is divided by provider type and includes:
? Hospitals,
? Nursing homes,
? Hospices,
? Home health services,
? Medical equipment and supplies,
? Prescription drugs,
? Provider services as well as
? Medicare Part C and D programs and Medicaid programs.
New areas of focus include:
Hospital
? Medical device credits for replaced medical devices.
Reviewing if improper payments to hospitals for inpatient and outpatient claims were made.
? Medicare payments during MS-DRG payment window.
Reviewing if services provided during inpatient stays were paid when they should not be separately reported.
? CMS validation of hospital-submitted quality reporting data.
CMS uses quality data for hospital value-based purchasing programs and hospital acquired condition reduction programs to validate the quality reporting program.
Nursing Homes
? Skilled nursing facility prospective payment system requirements.
Reviewing documentation requirements for claims paid by Medicare.
Medical Equipment and Supplies
? Orthotic braces-reasonableness of Medicare payments compared to amounts paid by others
Comparing Medicare payments to those paid by non-Medicare payers for orthotic braces to identify wasteful spending.
? Osteogenesis stimulators-lump-sum purchase versus rental
Determining cost effectiveness of renting versus purchasing bone-growth stimulators.
? Orthotic braces-supplier compliance with payment requirements.
? Increasing billing for ventilators.
Reviewing if suppliers are inappropriately billing for ventilators on patients with non-life threatening conditions which would not meet medical necessity.
Providers and Suppliers
? Ambulatory surgical centers-quality oversight
Previous reviews found poor oversight and time spans greater than five years between certification surveys for some ASCs. CMS requires ASCs become Medicare-certified by a state survey and certification agency to show conditions have been met.
? Physicians-referring/ordering Medicare services and supplies
? Anesthesia Services-non-covered services
Determining if the beneficiary had services that were reasonable and necessary.
? Physician home visits-reasonableness of services
Verifying documentation for medical necessity of a home visit instead of an office/outpatient visit.
? Prolonged services-reasonableness of services
Prolonged services are considered to be rare and unusual; review of necessity of and appropriate use with a companion E/M service.
? Histocompatibility laboratories-supplier compliance with payment requirements
Review services for accuracy and reasonable costs and necessary services.
Other Part A and B Program Management Issues
? Accountable Care Organizations (ACO): Strategies and Promising Practices
Reviewing of ACOs including performance on quality measures and cost savings.
? Medicare payments for unlawfully present beneficiaries in the United States-mandated review
Reviewing procedures to prevent and recoup Medicare payments to unlawfully present beneficiaries in the United States.
? Medicare payments for incarcerated beneficiaries-mandated review
Determining if payments were made for items and services on incarcerated beneficiaries since Medicare does not have a legal obligation to pay these services.
? CMS management of ICD-10 implementation
Reviewing CMS and MACs to determine how the transition has affected claims processing, including resubmissions, appeals and medical review.