MD - Health Care Compliance Association

OIG 2006 Work Plan ...continued from page 7
■ Documented medical necessity and actual
receipt of durable medical equipment
■ Medicare drug reimbursement generally,
including focus on acquisition and reimbursement
under the average sales price,
oral antiemetic medications, and duplicate
payments for Part B drugs
■ Prior approval for services provided, physician
supervision, and licensure of personnel
performing tests in Independent
Diagnostic Testing Facilities (IDTFs)
■ Documented medical necessity for appropriate
services provided in Comprehensive
Outpatient Rehabilitation Facilities
(CORFs)
■ Part B payments for inpatient radiology
services
■ Pricing of laboratory services provided to
Medicare patients vs. patients covered by
other payors
■ Controls for identifying inappropriate
payments for or utilization of covered preventive
care services
■ Physicians’ roles in over prescribing
OxyContin and other prescription drugs
Finally, in addition to these focus areas, in
light of the recent advisory opinions, fraud
alerts, corporate integrity agreements, and
ongoing investigations, physicians should take
the opportunity in 2006 to catalogue their
current relationships with other providers and
suppliers in the health care industry and consult
qualified counsel to determine whether
those relationships are compliant with federal
and state laws, particularly the federal Anti-
Kickback Statute and Stark II. ■
1. The OIG Fiscal Year 2006 Work Plan is available at
http://www.oig.hhs.gov/publications/docs/workplan/2006/
WorkPlanFY2006.pdf
2. The OIG first issued a CPG for hospitals in 1998 (“1998
CPG”). See OIG Compliance Program Guidance for
Hospitals, 63 Fed. Reg. 8987 (February 23, 1998). The 1998
CPG was primarily intended to encourage hospitals to design
and implement corporate compliance plans and programs. As a
supplement to this early guidance, the OIG issued the
“Supplemental Compliance Program Guidance for Hospitals”
on January 31, 2005 (“Supplemental CPG”). See OIG
Supplemental Compliance program Guidance for Hospitals, 70
Fed. Reg. 4858 (January 31, 2005). The Supplemental CPG is
focused on measuring and improving the effectiveness of existing
compliance efforts, identifies specific fraud and abuse risk
areas that hospitals should actively monitor, and describes the
OIG’s expectations regarding compliance program design and
guidelines for monitoring existing compliance programs.
3. See HHS and DOJ, Health Care Fraud and Abuse Control
Program (HCFAC) Annual Report For FY 2004 available at
http://www.oig.hhs.gov/publications/docs/hcfac/hcfacreport2004.htm.
During 2004, the federal government won or
negotiated approximately $605 million in judgments and settlements,
and it attained additional administrative impositions in
health care fraud cases and proceedings. The Medicare Trust
Fund received transfers of more than $1.51 billion during this
period as a result of these efforts, as well as those of preceding
years, and an additional $99 million in federal Medicaid money
was similarly transferred to the Centers for Medicare and
Medicaid Services (CMS) as a result of these efforts. The
HCFAC account has returned over $7.3 billion to the Medicare
Trust Fund since the inception of the program in 1997.
4. Specifically, in the 2006 Work Plan, the OIG noted that during
a recent audit it found that hospitals admitted patients for
dialysis treatment, which lasted from 24 to 48 hours in which
medical reviewers indicated that the stays were for the purpose
of observation rather than treatment. The CMS Intermediary
Manual requires the physician’s order to clearly state that the
level of care the patient requires; e.g., “admission to inpatient
status” or “admission to observation status.” Accordingly, the
OIG intends in 2006 to examine whether payments made for
“inpatient admissions” related to dialysis services were appropriate
given the physicians’ orders in the case.
Helpful Hints
Eight steps to take in using the OIG
Work Plan in your compliance program
■ Review the table of contents. It lists
the specific topics of concern of the
OIG by the type of organization
■ Highlight those areas that are potential
applicable concerns and high priorities
for your organization
■ Review, in detail, the OIG’s concerns
with the specific risk area
■ Analyze your organization’s
compliance program based on
those stated concerns
■ Determine whether your organization’s
compliance program is meeting its
established objectives and addressing
these particular risk areas for your
organization
■ Discuss this analysis with key individuals
of the organization’s compliance
team to focus your compliance program
on the specific areas of interest
of the OIG for the coming year
■ Educate the organization’s staff about
these identified risk areas
■ Ensure that an effective monitoring
system is established and put in place
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January 2006
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