OIG to increase scrutiny of hospital billing

The Office of Inspector General will be closely examining hospitals' billing practices, according to its 2013 work plan, released yesterday.

The agency, charged with monitoring healthcare fraud, among other program integrity activities, will use new analysis to see whether hospitals are compliant with Medicare rules. The OIG work plan outlines what areas hospitals can expect to be under Health & Human Services' microscope in the coming year.

Among new targets that OIG plans to review in Medicare Part A and B are the following:

Inpatient billing for Medicare beneficiaries
OIG will look at Medicare billing variations of inpatient stays from fiscal year 2008 to 2012. Medicare paid hospital $100 billion for inpatient stays in 2010. Under IPPS, there are 747 Medicare severity diagnosis-related groups (MS-DRG), which each gets a different amount--a sore spot for many providers who call the codes increasingly complex.

Hospitals' DRG window
OIG said CMS could save big by expanding the DRG window from 3 days to 14. OIG will analyze claims data to see if CMS could save money by bundling outpatient services delivered up to 14 days before an inpatient admission into the DRG. Medicare currently bundles all outpatient services delivered 3 days before an admission, in which the program does not pay separately for each preadmission, known as the DRG window, which has been susceptible to improper payments in the past, OIG noted.

Discharges vs. transfers
OIG will also look at how hospitals are coding discharges that should be been classified as transfers, as well as how effective Medicare auditor contractors are identifying compliance with this transfer policy. Medicare pays the full DRG amount for discharges, compared to a graduated per-diem rate for transfers.  

Swing-bed services in other hospitals
Medicare pays a smaller amount for shorter stays of beneficiaries who are transferred, as a deterrent for hospitals to discharge patients too early. Medicare, however, pays the full amount if the patient is discharged to another hospital's swing bed--a bed that can be used interchangeably between two services. Based on OIG's findings, the agency will recommend CMS to change its payment policy.

Canceled surgeries
OIG will also examine inpatient claims for canceled surgeries, particularly payments to hospitals that receive higher reimbursements for the rescheduled surgeries.

Interrupted stays at long-term care hospitals
OIG had previously identified vulnerabilities and said that it will identify patterns in how LTC hospitals--acute care hospitals with average length of stays longer than 25 days--are readmitting patients following interrupted stays. Medicare adjusts payments based on those interrupted stays.

For more information:
- check out the OIG summary and report (.pdf)

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