OIG to Focus on Same-Day Hospital Readmissions, Physician Practice Billing in 2013

The HHS Office of Inspector General has released its work plan for fiscal year 2013, a portion of which details the activities it will conduct in its review of Medicare payments and hospital services in the upcoming year.

Here are some of the work plan's main focuses:

• The agency will analyze claims to determine how much CMS could save if it bundled outpatient services delivered up to 14 days before an inpatient admission into the diagnosis related group payment. Currently, Medicare bundles outpatient services delivered up to three days before an inpatient admission.

• The agency will review Medicare claims to identify trends in same-day hospital readmissions. It will also test the effectiveness of a CMS system control that rejects claims for beneficiaries who were readmitted to the hospital on the same day.

• The OIG will determine the effects of non-hospital-owned physician practices that bill Medicare as provider-based physician practices. Provider-based status allows a subordinate facility to bill as part of the main provider. This can result in additional Medicare payments for services delivered at provider-based facilities, and MedPAC has previously expressed concerns about the financial incentives involved in provider-based status.

• The agency will review Medicare payments to hospitals for discharges that should have been coded as transfers, and it will determine whether these claims were appropriately processed and paid. Under federal regulations, hospitals receive full DRG amounts for discharges, whereas they are paid a graduated per diem rate for transfers that does not exceed the full DRG payment.

• The OIG will determine how much inpatient claims for canceled surgical procedures cost Medicare. The agency has conducted a preliminary analysis, which found significant occurrences of initial prospective payment system reimbursement to hospitals for canceled surgical procedures followed by a second, higher PPS payment to the same hospital for the rescheduled procedure. For these claims, the canceled procedure was the principal reason for the admission in the first place.

More Articles on Hospital Billing and Medicare:

Federal Government: Hospitals Using EHRs for Fraud Will Be Prosecuted
Center for Public Integrity: Billing Abuse, Upcoding on the Rise
IOM: Medicare Geographic Adjustments Could Improve Payment Accuracy

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