By Nina Youngstrom - October 3, 2012

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It’s that time of year again, when the HHS Office of Inspector General (OIG) unveils its annual Work Plan, and the 2013 version has some intriguing new targets. The Work Plan, announced Oct. 2, is the OIG’s roadmap of audits and investigations for the coming fiscal year. One new target may foreshadow the expansion of Medicare’s three-day DRG window payment policy. According to the Work Plan, OIG will “analyze claims data to determine how much CMS could save if it bundled outpatient services delivered up to 14 days prior to an inpatient hospital admission into the diagnosis related group (DRG) payment.”

Also in FY 2013, OIG expects to complete its examination of recovery audit contractors (RACs). OIG is nailing down the extent to which RACs identified improper payments and vulnerabilities, and referred potential fraud cases, in 2010 and 2011. “We will also review the activities that CMS performed to resolve RAC-identified vulnerabilities, address potential fraud referrals, and evaluate RAC performance,” the Work Plan states. In another new risk area, OIG will examine payments to hospitals for canceled surgeries, an emerging hot spot. OIG says that “our preliminary analysis of Medicare claims data for inpatient stays demonstrated significant occurrences of an initial PPS payment to hospitals for a canceled surgical procedure followed by a second, higher PPS payment to the same hospitals for the rescheduled surgical procedure. For these claims, the canceled surgical procedure was the principal reason for the initial hospital admission. For these short-stay claims, few, if any, inpatient services (i.e., laboratory or diagnostic tests) were provided by the hospitals because the surgical procedure was canceled. Medicare makes two payments to hospitals that generate two bills unless the patient is readmitted to the hospital on the same day, in which case a single payment is made.” OIG also is targeting payments for mechanical ventilation to determine whether the DRG assignments and Medicare payments were accurate. As always, OIG is focusing on some aspect of provider-based entities, which seem to stick in its craw. This year, it will be “the impact of non-hospital-owned physician practices billing Medicare as provider-based physician practices.” There are a lot more targets on the OIG Work Plan – hospital and physician, Medicaid and managed care and post-acute care risk areas – as well as reviews of legal and investigative activities. For example, OIG plans to review entities that settled fraud cases but refused to enter into corporate integrity agreements.

What targets in the OIG Work Plan will your organization add to its own internal risk assessment?

Were you surprised by anything in the Work Plan for 2013?