"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:
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."
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:
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.