2014 OIG Work Plan Contains New Priorities Specific to Hospitals

February 27, 2014 By

The Department of Health and Human Services, Office of the Inspector General (OIG) recently released its Fiscal Year (FY) 2014 Work Plan.  The Plan contains new priorities specific to Hospitals in areas related to Policies and Practices, Billing and Payments, and Quality of Care and Safety.  For a complete copy of the OIG 2014 Work Plan, please click here.

The OIG Work Plan provides a description of what the OIG will be focusing on in the coming year, giving providers insight into identifying corporate compliance risk areas and providing focus for ongoing efforts relating to compliance program activities, audits, and policy development.  Some of the hospital-specific priority areas identified as ‘New’ include the following:

A.      Policies and Practices

  1.  2 Midnight Rule: As of FY 2014, physicians should admit inpatients where they expect the patient’s care to last at least 2 nights in the hospital.  This modification is due to the OIG’s previous findings of over payments for inpatient stays, inappropriate billings and inconsistent billing practices.  OIG plans to review the impact of this new admission criteria and how billing varies among hospitals.
  2. Defective Medical Devices: OIG will review the increased costs to Medicare resulting from additional services necessitated by the use of defective medical devices.
  3. Comparison of Provider-Based and Free-Standing Clinics:  OIG will compare the payments made in provider-based settings and free-standing clinics with respect to similar procedures to determine the potential impact to the Medicare program for hospitals claiming provider-based status, and presumably, whether providers claiming provider-based status meet the criteria in 42 CFR § 413.65(d).

B.      Billing and Payments

  1.  Outpatient Evaluation and Management Services:  OIG will review payments made for outpatient E/M services to determine if they were appropriately billed as “new” or “established.”  Patients are generally considered “new” unless they were seen as a registered inpatient or outpatient within the past 3 years.
  2. Cardiac Catheterization and Heart Biopsies:  Billings for right heart catheterizations will be reviewed to determine if they were appropriately billed separate and apart from billings for heart biopsies.
  3. Payments for Patients Diagnosed with Kwashiorkor:  Due to the high level of reimbursement, billings for Kwashiorkor will be reviewed to determine whether diagnoses are supported by the medical record.
  4. Bone Marrow or Stem Cell Transplants: OIG will review procedure and diagnosis codes to determine the appropriateness of bone marrow and stem cell transplantation.

C.      Quality of Care and Safety

  1. Pharmaceutical Compounding:  In light of a recent meningitis outbreak resulting from contaminated injections of compounded drugs, OIG will review the oversight and accreditation assessment of pharmaceutical compounding in Medicare-participating acute care hospitals.
  2. Review of Hospital Privileging:  OIG will review how hospitals consider medical staff candidates prior to granting initial privileges, verification of credentials, and review of the National Practitioner Databank.

For additional information regarding the 2014 OIG Workplan or hospital/corporate compliance please contact Adam Snyder.

 

 

Filed Under: Compliance, Hospitals, OIG Tagged With: , , ,

Hospital Medical Staff Lacks Capacity To Sue – Medical Staff Bylaws Are Not a Contract

July 29, 2013 By

The Minnesota Court of Appeals recently issued a decision that, in Minnesota, hospital medical staffs do not have capacity to sue as unincorporated associations.  In addition, the Court concluded that, at least in this case, medical staff bylaws do not constitute a contract between members of the medical staff and the hospital.

With respect to the issue of whether the medical staff bylaws create a contract between members of the medical staff and the hospital, the court focused on two points: (1) repeated reference in the medical staff bylaws to the right of the hospital board to approve, amend, and/or repeal the medical staff bylaws, and; (2) Minnesota rules that require hospitals to have medical staff bylaws approved by the governing body.  On this second point, the decision relies on a series of decisions from other jurisdiction holding medical staff bylaws not to create a contract for lack of consideration due to the existence of state laws requiring such bylaws.

The court relied on prior Minnesota court decisions for its conclusion that the medical staff could not sue as an unincorporated association.

These two issues are regularly litigated in courts around the country and there is hardly unanimity in the decisions.  This decision contains a very useful collection of cases going both ways on the issues and the legal theories relied on for the differing conclusions.  For questions concerning this case or related hospital medical staff issues please contact Greg Montgomery.

Filed Under: Hospitals, Medical Staff Tagged With: , ,

New Requirements for Provider-Based Clinics

December 18, 2012 By

A reminder to all licensed hospitals operating “provider-based clinics,” “off campus,”: the Washington State legislature during its 2012 session enacted HB 2582 requiring provider-based clinics to comply with certain new and additional requirements.  This bill goes into effect January 1, 2013.  This bill was intended to ensure that patients were informed about the cost of receiving services in a provider-based setting.  Among other things, the bill contains new signage requirements, patient notification requirements (including on the provider’s website) and reporting requirements.  Note, not all Medicare provider-based departments meet the definition of a “provider-based clinic” under this law.  A copy of the bill can be located here.

Please contact Don Black or Lee Kuo if you have additional questions.

Filed Under: Hospitals, Washington Tagged With: