Payment window attention goes beyond IPPS
Among hot-button issues on the OIG focus list is the three-day rule, which this past year has seen legislative changes and additional guidance from CMS. Medicare does not make separate payments for outpatient diagnostic services and admission-related nondiagnostic services rendered up to three days before the date of an inpatient admission. In June, Congress passed and President Obama signed legislation to change these rules and redefine services that are related to the admission. Many hospitals had struggled to apply the previous rules correctly.
Although last year's Work Plan also saw a focus on the three-day rule, this year the OIG expanded its scope to include the one-day payment window applicable to non-IPPS facilities, notes Mackaman. Payments to these non-IPPS hospitals for inpatient claims should include diagnostic services and other services related to admission provided the day immediately preceding the date of the patient’s admission.
"IPPS facilities should be vigilant about reviewing the current three-day rule, and the non-IPPS hospitals should review the addition of the one-day rule," Mackaman says.
Provider-based status remains in focus
Provider-based status is another repeat item on the OIG list. In response to the continued attention, hospitals should review the provider-based requirements located at 42 CFR § 413.65(d).
"Hospitals should make sure they are meeting the regulations for billing for hospital outpatient services correctly under the designation of either on-campus or off-campus provider-based departments," Mackaman says. "This would include the rules for billing for services under incident to and direct supervision," she adds.
OIG renews attention to observation, other topics
Those perusing this year’s Work Plan will find plenty of continuity with the FY 2010 edition. Observation services provided as part of an outpatient visit, for example, appear in both documents. But that doesn’t mean compliance officers can let down their guard.
"This area is extremely difficult to manage," Miller says. "It should probably be higher on the list for auditing."
The continued attention to observation may come, in part, due to the increased use of these services as hospitals find themselves pushed by CMS and audited by the recovery audit contractors to ensure medical necessity for inpatient stays.