On March 17, 2015, The Office of Inspector General at the U.S. Department of Health and Human Services announced its top 25 priorities for saving money and improving quality in Medicare and Medicaid, in a document, entitled the Compendium of Unimplemented Recommendations (Compendium). Consistent with its recent announcements regarding budget neutrality, there are a number of proposals that would reduce hospital reimbursement. For example,
"Medicare could have generated savings of as much as $15 billion for CYs 2012 through 2017 if CMS reduced outpatient department payment rates for ASC-approved procedures to ASC payment levels for procedures performed on beneficiaries with low-risk and no-risk clinical needs. In addition, beneficiaries could potentially save as much as $2 billion to $4 billion more during the 6 years through CY 2017 if CMS reduced outpatient department payment rates for ASC-approved procedures to ASC payment levels.” (See page 4 of the Compendium).
Also, OIG seeks to reduce inappropriate payments to skilled nursing facilities. OIG recommends changes to the current method for determining how much therapy is actually needed to avoid overpayments.
"OIG is conducting ongoing work examining the extent to which changes in SNFs’ billing affected Medicare payments in FYs 2012 and 2013 and the extent to which beneficiary characteristics changed during this time period and is comparing Medicare payments and SNFs’ costs for therapy for selected years from FY 2002 to FY 2012. We continue to monitor CMS’s progress in implementing our recommendations” (See page 8 of the Compendium).
OIG is seeking to scrutinize physicians and other clinicians receiving high cumulative payments. OIG believes that by identifying these high billing clinicians it is likely to identify possible improper payments thus resulting in monies returned to Medicare. It has recommended to CMS that CMS should “establish a cumulative payment threshold, taking into consideration costs and potential program integrity benefits above which a clinician’s claims would be selected for review.” OIG argues that existing procedures may not judiciously identify clinicians responsible for high cumulative payments.
“Of the 303 clinicians who each furnished more than $3 million of Part B services during 2009, MACs and ZPICs identified 104 (34 percent) for improper payment reviews. As of December 31, 2011, the MACs and ZPICs had completed reviews of 80 of the 104 clinicians and identified $34 million in overpayments. In addition, three of the clinicians had their medical licenses suspended and two were indicted.” (See page 34 of the Compendium).
Medicare administrative contractor (MAC)
Zone program integrity contractor (ZPIC)
The Compendium focuses on the top 25 unimplemented recommendations of OIG’s that it believes would result in cost savings and/or quality improvements and should, therefore, be prioritized for implementation. The Table of Contents is grouped by practice area, not necessarily by importance of the implementation suggestion. If you scroll down to the Table of Contents the short version of the recommendation for each practice area appears in gold.
In order for OIG’s recommendations to be implemented, a legislative, regulatory, or administrative action must occur. “OIG relies on policymakers, such as HHS and its operating divisions and staff divisions, the Administration, Congress, and States, to take the necessary steps to achieve optimal outcomes. Although many OIG recommendations are directly implemented by organizations within HHS, some are acted on by States that collaborate with HHS to administer, operate, and/or oversee designated federally funded programs, such as Medicaid.” (See page 3 of the Compendium).
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