The OIG will review a number of payment systems including, but not limited to, capital payments, the provider-based status payments, the inpatient prospective payment system, excessive Medicare payments, Medicare disproportionate share payments, duplicate graduate medical education payments, payments for diagnostic radiology services in emergency departments, and compliance with the Medicare conditions of participation (CoP) for intensity modulated and image-guided radiation therapy (IMRT) services. With respect to each of these areas, the OIG will review the following:
• Capital Payments – Whether the capital payments–those reimbursements for equipment and facilities–to hospitals are appropriate. Currently, the methodology for determining the capital prospective rate is found at 42 CFR 412.308.
• Provider-Based Status for Inpatient and Outpatient Facilities – Typically, those hospitals that receive a “provider-based status” may receive higher reimbursement when they include the costs of a provider-based entity on their cost reports. The OIG will examine the appropriateness of this designation and the impact it has on the Medicare system.
• Hospital Payments for Nonphysician Outpatient Services Under the Inpatient Prospective Payment System (IPPS) – Because of the significant number of improper claims submissions, the OIG will review the appropriateness of payments for nonphysician outpatient services provided to beneficiaries shortly before or during Medicare Part A-covered stays at acute care hospitals. Typically, the IPPS payments cover all of the operating costs for inpatient stays and there should be no additional claims submitted under Part B for nonphysician services.
• Medicare Excessive Payments – Historically, the OIG has identified excessive payments when looking at claims with unusually high payments. The OIG will continue to monitor unusually high payments as well as reviewing the effectiveness of the claims processing edits used to identify excessive payments.
• Medicare Disproportionate Share Payments – The number of disproportionate share payments have been increasing. The OIG will review whether these payments have been appropriate alongside the total amounts of uncompensated care costs that hospitals incur.
• Duplicate Graduate Medical Education payments – CMS’s Intern and Resident Information System (IRIS) provides that a resident may not be counted as more than one full-time employee. The OIG will review whether or not duplicate graduate medical education payments have been claimed and which claim is appropriate.
• Payments for Diagnostic Radiology Services in Hospital Emergency Departments – The OIG will determine the appropriateness of Part B claims and medical records for interpretations and reports of diagnostic radiology services performed in hospital emergency departments.
• Hospitals’ Compliance with Medicare CoP for IMRT Services – The OIG will review hospitals’ compliance with the quality and safety requirements of the IMRT services as outlined in 42 CFR 482.26.
For more information, please contact the Health Law Partners, P.C. at (248) 996-8510 or (212) 734-0128 or visit the HLP website.