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The Work Plan

The Office of the Inspector General (OIG) posted its work plan online in the fall of last year.   It describes the areas that are of interest to the OIG and where they expect to find problems with Medicare providers.  For those of you who are unfamiliar with the OIG, this is how the OIG describes its mission:

Office of Inspector General’s (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.

In short, the OIG is the Medicare police for our purposes.  Medicare and Medicaid, as well as other programs lie in the domain of the department of Health and Human Services.  When providers do not respond to gentle persuasion from a MAC or ZPIC to clean up their acts, they may be referred to the OIG.  Alternatively, when a provider blatantly commits fraud, they may become the subject of an OIG investigation.  The OIG does not call upon providers to congratulate them on a job well done; nor do they investigate half-baked conspiracy theories by a lone disgruntled employee who calls to report fraud.  The Office of the Inspector General has enormous resources available to identify potential fraud and they have credible information prior to initiating an investigation.

Understanding what the OIG has on its agenda for this year is a good place to start in your efforts to stay off their radar.  Here’s the part of the plan that addresses home health care and hospice providers


The OIG work plan restates that when a beneficiary elects hospice care, the hospice agency assumes the responsibility for medical care related to the beneficiary’s terminal illness and related conditions.  The OIG will review medical records and billing documentation to determine if billing was compliant.

Although this seems bland, consider that the hospice regulations for the past two years have clarified the definition of terminal illness, with good reason.  In recent years, some hospice providers have chosen a single diagnosis to represent the terminal diagnosis and have not covered medications or treatment for related conditions.  In some instances, the hospice providers did not cover pain medication if the pain was caused by a condition other than the terminal illness.  (Example:  pain meds for arthritis for a patient with terminal heart failure.)

The hospice Conditions of Participation (CoPs) at §418.56(c) require that the hospice must provide all reasonable and necessary services for the palliation and management of the terminal illness, related conditions, and interventions to manage pain and symptoms.

The regulations further state:

…we believe that the unique physical condition of each terminally ill individual makes it necessary for these decisions to be made on a case by case basis. It is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients.” Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis, all conditions are considered to be related to the terminal prognosis and the responsibility of the hospice to address and treat.

The conditions of participation have been in effect since 1983 and the guidance regarding terminal illness has been restated in the federal regs for the last two years.  It would be no surprise if hospice clinical and billing records were reviewed to ensure that virtually all care was covered and those rare instances where care was not covered were explained in the clinical record.  But, we could be wrong.  Those hospice providers who insist that we are  will find out soon enough.

The OIG will also evaluate whether a hospice provider scheduled as visit by a registered nurse at least once every two weeks to oversee the Interdisciplinary Teams  adherence to the plan of care and determine if changes are needed.

This came up in ZPIC investigations last year when many claims were partially denied when the meeting notes for the IDT team meeting that occurred just prior to the claim dates under review, were omitted from the documentation.   If the IDT meeting was held on the 20th of the month and a claim beginning on the first of the following month is chosen for review, the IDT meeting documentation from the 20th of the prior month was to be included in the clinical records submitted for review.  When this did not happen, the days until the next IDT meeting were denied and the reason given was that the updated plan of care was not included.

2017 is not the year to relax your standards on documentation.

Home Health

The OIG work plan notes that in 2014, up to 51 percent of claims, as determined by Comprehensive Error Rate testing were not compliant with billing regulations.  Really?  Half of all claims?

The OIG work plan further goes on to say:

‘Improper payments identified in those OIG reports consisted primarily of beneficiaries who were not homebound or who did not require skilled services.’

But there’s more.  The OIG believes that fraudulent home healthcare agencies might intentionally omit some patients from the lists provided to state surveyors conducting recertification surveys to avoid scrutiny.  Because the state surveyors do not have access to claims data, they have no way of knowing if a patient has been ‘archived’ prior to running a patient report.  It will be interesting to see what happens to agencies who are deliberately withholding information from a surveyor.


When the OIG tells providers where they will be looking for fraud and abuse we question the decision to ignore it.   Yet, many providers are convinced that they are too small to warrant the attention of the OIG or other Medicare contractors.  Others reason that since they have operated in the dark for so many years and been paid, they will continue to be paid even when they demonstrate careless disregard for the regulations.  Of course, our favorite is the rationale that everyone else does it.  It simply is not true – thousands of profitable providers are making good money by doing the right thing and they get to keep it.  They may not drive high end luxury automobiles or live in an exclusive gated community if they have a small to mid-sized provider but they don’t have to worry about who will feed their cat while they are in a federal penitentiary.

There are any number of ways to improve documentation and compliance to payment regulations but there are even more rationales that providers use to justify shortcuts.   Absolutely nothing happens until senior leadership places compliance and education high on the priority list and understanding that compliance includes documentation.   The best care in the world will be denied under review if the documentation does not demonstrate patient eligibility and then it is often too late.

The OIG Work Plan for 2017 is easy to read and well organized.  Download it and share with your staff.  When the senior leadership in your agency buys into compliance on the front end, call us.  We can help.  We can also help defend your ADRs but our success depends on the quality of the documentation requested by your payor sources.  Just saying.

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