INSPECTION OF

INAPPROPRIATE DISCHARGES 
AND 
TRANSFERS 
RICHARD P. KUSSEROW

INSPECTOR GENERAL

Inspection Prepared By:  with Assistance By:

Lead Region:  Headquarters: 
William Moran  David Hsia, M. 
Natalie Coen  Barton McCann, M. 
Barry Steeley 
Kitty Ahern 
Donald Kuhl 
Margaret Shell  Regions: 
John Traczyk

Joe penkrot  Lucille Cop - II

Terry Quirk  Renee Schlesinger - II

Bill Young - III

Kathy Admire - IX

Paul Got tlober - IX

Inspections 
Office of Analysis &  March, 1986 
Region V 
300 So. Wacker Drive 
26th Floor 
Chicago, IL 60606 
OAlt  P-OS-86-000S0  MAJOR FINDINGS

Based on the findings of this 
inspection, it 
apparent that occurrences of premature discharges and 
inappropriate transfers do exist and must continue to 
be addressed aggressively by the Health Care Financing
Administration (HCFA) and the Peer Review Organiza
tions 
(PROs). 
724 cases 
During 10/1/83 - 5/31/85, HCFA reported 4, 
transfers.
of premature discharges and inappropr iate 
Yet, only 2, 688 (57%) of the reported cases could 
found. 
athcteua lly be- This is due to the phasing out of
Medical  inconsistent 
Review Entities (MREs) , 
inaccurate reporting 
instructions given by HCFA, and 
by the PROs. Another 1, 018 cases were reviewed, of
which  5/31/85 and 
282 were reported after  736 had
never been reported (See chart on page 9.  Also, 
during the time frames mentioned above, 14 (30%) of 
the PROs were ntrota nrespfoertrisn.g  premature ditshchea rges or 
Therefore,  overall 
inappropr iate 
extent of the problem is still not fully known. 
Of the 3, 706 cases reviewed, 3, 336 (90%) were
referred by the 
PROs; 370 (10%) were referred prior 
implementation- fifty-seven
t(o4 %P)R Oo f the 3, 706 casOense  whuenrder endo atn din appropriate 
transfers. 
Of the remaining 3, 
discharges or  549 
cases, 2, 907 (82%) were premature discharges, 491 
151 
(14%) were inappropriate transfers, and  ( 4%)
could not be categorized by type. 
Quality issues ranging from very minor to gross and
flagrant were identif ied by the PROs in 2,146 (60%) of 
these 
the 3, 549 cases. PRO disposition of  cases 
ranged from intensified review of identified hospi
all.
tals and physicians to no action being taken at 
In 927  the cases with 
(43%) of  identified quality 
issues the only apparent action taken by the PRO was 
referral to HCFA. 
Of the cases reviewed, medical records involving 133 
patients were referred to OIG physician consultants
for review. 
Nineteen were classified by OIG con
sultants as exhibiting gross and flagrant instances 
action, 
of substandard care. PROs took no corrective 
cases.
oItnhe rth teha n referralo fto  thHCeFA , on 12 of these 19 
opinion  OIG medical consultants,
inappropriate actions were taken on 
of  106" of the 133
cases. Thirty-eight  these cases have 
been 
returned directly to the PROs for various recommended
 actions. The remaining  cases  are currently being 
reviewed by HCFA. 
PROs did have the authority to take action on the 
this study. It 
quali ty issues identif ied in  appears 
that many PROs have not effectively used the authori
instances
toifes p ooro trh qe uparolciteyss cesa raeva ailsasbolce iatote add dwreisths  
premature
discharges and inappropriate transfers.

visits 
During OIG site  conducted in September and

December, 1985, problems were noted with the PRO' 
data  the 
accumulation of  pertaining to  quality of 
care rendered by physicians and hospitals. This data 
is necessary for the identification of abusive pat
action. 
terns and subsequent corrective 
HCFA has reviewed the recommendations contained
this 
report and concurs. It has already beignu n to
correct a 
number of problems identified  the
inspection. 
Details regarding HCFA' s actions can be 
report. 
found in the appendix attached to ththise   Also,
increased sanction activity by  PROs against
physicians/providers demonstrating abusive patterns 
noted. 
of practice has been recently  T ABLE OF CONTENTS

PAGE 
PURPOSE AND METHODOLOGY

II.	
OVERVIEW 
III. CASE RECONCILIATION

IV.	 CATEGORIZING CASES AND DOCUMENTING 
DISPOSITIONS 
MECHANISMS TO ADDRESS CASES OF PREMATURE

DISCHARGE AND INAPPROPRIATE TRANSFER

VI.	 RECOMMNDATIONS 
VII. APPENDIX
 Purpose and Methodology

At the  the 
request of  Inspector General, a national 
porfog ram inspection was conducted of identified instances

premature discharges and inappropriate transfers
occurring under Medicare  Prospective Payment System 
( PPS ) . 
The objectives of this inspection were to: 
1 )	 Determine the number of premature discharges and 
inappropriate transfers referred to the Health Care

Financing Adminisftirsactiaoln  (HCFA  by medical review 
enti ties (MREs ),  intermediar ies (FIs ), and 
Peer Review Organizations (PROs) from 10/1/83 through

5/31/85 ; 
2 )	 Categor i ze the cases and document their disposition; 
3 )	 Review the appropriateness of corrective action on 
cases where the PRO, MRE or FI, through its review

process, identif ied potentially 
gross and flagrant or 
substantive instances of substandard care; and

4 )	 Examine the procedures and instructions pertaining
to the identif 
ication and disposition of these cases. 
This 
inspection was not meant to determine the overall
effect of  of care 
PPS on quality  rendered to Medicare 
benef ic iar ies nor was it des igned to determine the fre
quency of inappropr iate discharges and transfers occurr ing
thin the 
wi  PPS system. It focused only on instances of 
inappropriate discharges and transfers as they were iden
tif ied
time. by the PROs through review mechanisms extant at the
The broader issue of quality of care will be more 
fully addressed in other reports, particularly those to be 
issued by the Inspector General, HCFA, and the Assistant 
Secretary for Planning and Evaluation (ASPE). 
According to HCFA, 4, 724 cases of premature discharges and 
inappropriate transfers were referred to the HCFA regional
offices  5/31/85 by 
between 10/1/83 and  various medical 
review entities, including 33 of the 47 PROs located in 
non-waiver PPS states. The actual referrals were kept in 
the HCFA regional offices, excluding the New York region
wGheernee raalll  (sOtIaGte)s t eaarme esx weempntt  ftroom  tPhPeS n. Oinffe i cree moafi nIinnsgp eHcCtForA 
regions to gather identifying information on the referral 
cases. 
During September and December, 1985, onsite visits 
were also conducted at 19 of the 33 PROs to record what
actions were taken by them on cases with 
issues.  identif ied 
The 
quali ty of care  remaining 14 PROs who had  Page No. 
referred to HCFA minimal numbers of cases were contacted
by the HCFA Project Off 
cases.  icers to ascertain the disposition 
of those  In all instances, the data gathered was 
what was documented in the PRO' s case file. If corrective
action was taken on  not 
cases but  documented in the 
material available to the reviewer, it was not recorded. 
on 
Discussions focusing  premature discharges 
and 
inappropriate transfers and HCFA instructions regarding 
these cases were conducted with HCFA' s Central Off ice, the
nine regional off 
ices, all 47 PROs, and 15 state hospital
associations. 
National associations such as the Amer ican
Medical Association (AM), American Hospital Association
(AHA), American Peer Review Association (AMPRA), and 
Retired Persons 
Amer ican Association of  (AARP) were also
contacted.  . ....... ;.;

. . . 
Page No. 
II. 
Overview 
In March, 1983, Congress passed legislation requiring a new 
system for reimbursing Medicare inpatient hospital stays.
Implementation of the Prospective Payment System began on 
October 1, 1983, and by October 1, 1984, all non-exempt
hospitals 
servicing Medicare inpatients were being paid 
diagnostic related groups i 
based on 46  DRGs) . DRGs cate
gorize patient stays based on principal and 
secondary 
diagnoses and surgical procedures.

the 
Consistent with  new era of competition and sound 
financial practices pervading the private sector of health 
care, Congress built into Medicare s Prospective Payment
System 
economic incentives to curb escalating costs and 
inpatient stays. 
prevent overutilization of  PPS encoura
facilities. It 
outpatient 
ges the use of  rewards hospi
tals that provide efficient care by allowing them to keep
the dollar differences  actual 
between their  operating
costs and Medicare s DRG payment.

While the intent of Congress was to reduce health care 
costs, it was also concerned that the quality of health 
system. To 
care not suffer under this new  ensure the 
integr i ty of PPS and to maintain the high quality of care 
cost 
afforded patients under the  reimbursement system, 
Congress established and provided funding for Peer Review
Organizations. 
The 54 PROs under contract with HCFA are 
the District
located in each state, territory, and 
Columbia. (Forty-seven PROs operate in non-waiver PPS
states. 
They are responsible for determining: 
1 )	 whether the services provided or proposed are reaso
nable and medically necessary for the diagnosis and 
treatment of illness or injury 
whether services could  be effectively fur
2 )	
nished on an outpatient basis 
the 
3 )  medical necessityh,o rsepasiotnaal bleness, and  the 
appropriateness of  admissions  and
discharges; 
of 
inpatient hospital care for
4 )  appropr iateness
which additional  payment is sought under outlier
provisions;  ...;

Page No. 
whether a hospital has misrepresented admission or
5 )	
discharge  has taken an action that
results inin formation or admission 
unnecessary  unnecessary
multiple admissions ... or other inappropriate medi
cal 
or other practices 
6 )	 the validity of diagnostic and procedural information
supplied by the provider; 
the 
7 )	 completeness, adequacy, and quality of hospital 
care prov ided; and 
8 )	 whether the quality of services meets professionally 
recognized standards of health care. 
(Peer Review Organization Manual, 1M 2001.

To assist the PROs in carrying out tthoei r responsibilities,

Congress gave them authority  deny payment for
inappropriate  take corrective 
services, to  actions as 
sanction physicians and 
necessary and to  hospitals pro
viding poor quality care, or attempting to circumvent the
new system. 
Between October, 1983, and October, 1984, MREs and Fls 
were responsible for handling quality of care issues as 
implemented. 
PPS was being  By October, 1984, all non
exempt hospitals were being reimbursed by Medicare under 
PPS, and almost all of the 54 PROs were operational. 
As the 
PROs tbhecaamte  operational, they began encountering
si tuations  involved premature discharges 
and 
transfers. 
inappropr iate  Either of these situations could 
indicate a hospital and/or a physician attempting to cir
cumvent or " 
game " the system. 
Premature Discharges/Inappropriate Transfers

A premature discharge is the releacsea rofe .a  Ipfa tient who 

still in need of acute hospital  the patient
hospital, the 
returns to the  hospital receives a second 
DRG payment. If thes ptaitlile nt does not return to the hospi

hospital  benefits financially by 
tal, the  of its  having
expended less  resources than would have been 
expended had the patient stayed until acute level care was

no longer required.  Pag  No. 
patient,
An inappropriate transfer is the transfer of a 
for no discernable reason, from an acute 
hospital to 
from an 
another acute hospital or  acute hospital to an 
exempt n n-PPS unit (e.g. rehabilitation, psychiatric, and 
alcohol/drug treatment units). The Medicare program suf
inappropriately trans
fers financially when patients are 
ferred back and forth because each facility involved
receives  through 
reimbursements either  DRGs, per diem 
payment, or on a cost basis. 
and 
MREs, Fls  subsequently PROs were required to review 
palalt ireenadtm tirsasinonssf etor sa.  hIonssptrituacl twioi tnhsi nr esgeavredn indagy st,h ean did aelnl
tif ication 
and processing of these cases were contained in 
HCFA' s Transmittal 107 itshseue d in November, T19h8e3s,e a inndi tairael  
now incorporated into  PRO manual. 
instructions dealt only with cases that were determined to
be medically unnecessary stays or medically unnecessary
transfers. If 
the care rendered during the readmission or
following the transfer was determined to be unneces
made. If 
tsearryn,  doenfia l of the second stay could obe r  a pat
unnecessary admissions  transfers 
was
identif ied, 
development of a sanction recommendation was 
to be initiated if violations of Section 1156 of the 
evidence. 
Social Security Act were in 
instructions 
Falling outside of the scope of the initial 
issued by HCFA were instances of premature discharges and 
cinaalplpyro priate transferst hwhee re the resultitnrga nstsafye rw as medi
necessary, or  reason for  was not 
necessary. 
apparent, although the care was 
These cases were to be referred into the HCFA regional 
offices for analysis, pending a Departmental legal deci
sion 
Sectioreng arding (h2o)w  otfo  tihmepl eSmoecnita lt hSee cauutrhitoyr iAticets,  under
1886 ( f)  which 
aiunt horizes PROs to deny stays and initiate sanction action
instances where PPS is being manipulated or circum
vented. It 
was assumed by HCFA that the PROs would handle 
any quality issues associated with these cases in accor
procedures. These provide 
dance with PRO authorities and 
contacts, intensif ied review and ul tima
for educational 
tely sanction of providers if violations of Section 1156 
are identified. 
In July, 1985, HCFA issued Transmittal 5, which instructed
the PROs to deny payment in certain circumstances for  Page No. 
premature discharges and for 
readmissions resulting from 
inappropr iate transfers, and to initiate sanction develop

criteria. 
ment based on prescribed  Page No. 
III. 
Case Reconciliation 
premature discharge and inappropriate
the 
tOfr thae nsfer r724eferrals reported by  HCFA regional 
5/31/85, 2, 688 (57%) of 
offices from 10/1/83 through 
the cases could be located.

Of the referral cases, 2,165 were reported by HCFA to

be MRE/FI referrals and 2,559 were PRO referrals. 
Seventeen percent (370) of the MRE/FI referrals and 
91% (2, 318) of the PRO referrals were located during 
this study. 
In 
addition, 282 cases referred after 5/31/85 were
reviewed and 736 cases that were never referred 
were identified and categorized.

706 cases were reviewed, 3, 549 of 
In all a total of 3, 
which were categorized as premature discharges and
inappropriate transfers. 
Ttho aput tf rtohmes e numbers in perspecPtiPvSe, t hirto ushgohu lMd abye , n1o9t8e5d, 
implementation off or a  of reasons, 
MREs/FlS and PROs reviewed,  var iety 
approximately 2. 1 million cases. The 4, 724 referrals made 
to 
HCFA were contained in a universfeo ro f approximately 
700 cases which were targeted  review because 
345, 
there were two admissions wi thin a seven day period or the 
transferred. 
patient was  Identified premature discharges 
and inappropriate transfer cases referred to HCFA by the 
PROs account for approximately 1. 4% of this specif ic uni
verse. 
However, because of inconsistencies, inaccuracies and non-

reporting, any broad conclusions regarding premature 
these 
discharges and inapppropr iate transfers, based on 
inaccurate. 
figures, would be unfair and  Also, the 1. 4% 
discharge, while premature, did
enxoctl urdeess uclats eins  wahe re the  readmission occurred 
readmission; the 
after seven days; or the readmission was at another hospi
tal. 
It was anticipated that  the referrtaols  made prior to PRO 
implementation might be diff icul t  locate, and indeed 
only 370 (17%) of the  165 MRE/FI referrals could be 
found. It appears that  most of the case information was 
by the 
destroyed or warehoused  MREs/Fls when the PROs 
became operational.  Page No. 
find.
In a few regions PRO referrals were also hard to 
In  case  actual 
some instances,  summaries supporting the 
numbers reportfeod ro n the monntgh ly HCFA-5l6s, the designated
HCFA form  report  premature discharges and 
tiinfayppirnopgr  iinaftoer mtraantsiofenr so,n c tohueld  rneofte rbrea llso cawtaesd  noro tt hceo mipdleent
e 
enough to associate it with a HCFA-5l6. This made cate
impossible. , 
gorization Of those cases  On-site visits to
the 
PROs became more diff icul t because the PROs were 
identifying
required to locate the referral cases without 
information and  issues. 
then document action on quality 
this 
Because of  confusion, 282 cases referred into HCFA 
after 5/31/85 were categorized, as well as 736 cases that

wInere  a' flolu and t oont-aslit e at PROs that had never been referred.
of 3, 706 cases were reviewed in this 
inspection.

ty 
the diff icul  referral

Explanations for  in finding the 
issuing 
cases varied. HCFA, in  instructions regarding 
these referrals, did not stipulate a format or the type of 
information that should be contained in the referrals. 
The regional offices did not give uniform instructions to 
indicated 
PROs regarding these referrals. Some regions 
others issued 
they wanted only the number counts, while 
explici t instructions on what to send in, including cases 
sen
involving quality issues or anything that was of a 
sitive nature. 
Due to the inconsistency of the instructions the PROs were 
This
ciosn fused regarding their reporting retshpeon sibilities. 
evidenced by the disparity in  number of cases 
reported by eaaclhl P.R O and in the 30% of PROs who referred 
no  relationship 
cases at  There is also no direct 
cases referred, Medicare hospital 
between the number of 
utilization within the state, or review activity by the
PROs. In 
addition, of the cases that were located and
identif ied, 157 (4%) were inappropriate PRO referrals 
not  transfers. 
that did  involve premature discharges or 
The chart on page nine indicates total referrals reported 
located. 
on the HCFA-5l6s, and case summaries actually 
The lack of referrals and inconsistent referral rates can 
bPe attRributeOd to sysstem.s p roblems experienced by Fls and 
PoRrO s in identifying these casesd;u punlicclaetaer ,c omuisnutnsd; erstood,
disregarded instructions;  amended 
HCFA-s16 reports; and conf identiali ty concerns by the Page No. 
Of the 3, 706 cases reviewed, 3, 336 
(90%) were referred in 
by PROs, 208 (6%) by MREs, and 162 (4%) by Fls. 
Eliminating the inappropriate referrals reduces the case
549. It 
count to 3, 
is these 3, 549 cases which are 
report. 
discussed in the body of this 
CASE RECONCILIATION

CASES REPORTED BY HCFA

10/1/83 -
CASES  PERCENT
5/31/85 
FOUND  FOUND 
MREs/Fls  2165  370  17% 
PROs  2559  2318  91% 
TOTAL  4724  2688  57% 
CASES REPORTED AFTER 
5/31/85 
282 
CASES NOT REPORTED  736 
TOTAL CASES FOUND  3706 
LESS ERRONEOUS REFERRALS  157 
TOTAL  3549  Page No. 10

IV.  Categorizing Cases and Documenti.ng Dispositions 
Of the 3,  reviewed, 2, 907 
549 cases  (82%) were iden
tif ied 
as being premature discharges, 491 (14%) were
inappropriate transfers and 151 
of  (4%) could not be
categorized by  insufficient infor
type because 
mation.

Of these cases, 2, 146 (60%)  were  identif ied

quality issues by the PROs. 
iIdn e9n2t7i f(i4e3d%,)  tohfe t hoen clays easp pwhaerreen tq uaacltiitoyn i tsasukeesn w ere

was 
offices. 
referral to the HCFA regional 
Of the cases with 
apparent quality issues,  133
patients 
sultan't sr etcoor ds were referred to OIG physician con
review the appropriateness of 
PRO
action. 
PRO action was found to be inappropriate in 106 of 
the 133 cases reviewed by the OIG. 
Quality issues were coded when a PRO physician advisor had

identif ied them in case documentation. 
It should be noted 
that the magnitude of the quality issues identified by the

PROs varied from very minor to potentially very serious. 
However, the review teams did not attempt to categorize
issues. 
the severity of the 
CATEGRIZE CASES  QUALITY ISSUES  Page No. 11

Premature Discharges

this 
The 
premature discharges discussed in  review were
identif ied as 
such by the PROs in their reviews of a sub
sequent readmission to the same hospital. The PROs 
referred these cases to the regional offices because the
patients: 
issue); 
were not appropriately treated - (quality 
were appropr iately treated but released too early in 
issue); 
the course of treatment - (quality 
were discharged in a medically-unstable  condi tion
(quality issue); or 
further treat
were discharged to be readmitted for 
ment when all treatment could have been rendered in 
admission. 
the first  (Generally these cases did not
invol ve quality concerns. 
If a patient is released prematurely it is almost always 
s direction. 
at the physician  However, there may be exte
nuating  035 
circumstances. In 2, (70%) of the 2, 907 
wpreamsa tsuorlee ldyis charges reviewed, tiht ea pdpiesacrehda trhgee p.h Iynsic ian
responsible for  the 
remaining 30% of the cases the discharge was not directly
attributable to the physician. 
For example: 
In 669 (23%) of the premature discharges, the patient 
diagnostic 
was admitted for a  workup, released, and 
for surgery. 
readmi tted  These situations included 
cardiac catheter izations with readmissions for bypass
surgery and biopsies with 
readmissions for major
surgery. 
The first situation is standard in many 
hospi tals : the bypass surgery is not scheduled until
the results of the catheter i zation are known. 
The 
sseectotnlde i sh ifsr/ehqeuern talfyf aduire st ob ethfoe rpea mtieanjto' r  wish to
surgery.
Technically, these patients  in 
are still  need of 
acute care and fall into the category of premature
discharges. 
2 )  wIna s8 9d i(s3c%h)a rogfe dt haet  phreimsa tourre h deirs cohwanr greesq,u tehset  poart iethnet 
family 
s request.  Page No. 12

In 27 (1%) of the cases, the  patient  left  the 
3 ) 
hospi tal against medical advice.

In 87  the 
(3%) of  cases,  miscellaneous  reasons 
4 ) 
accounted for the discharge.

In a very few (12) instances, as annotated in the record 
reviewed, the physician discharged the patient because the
physician had presumably been informed by the hospital
administration that the resources expended on the patient 
were going ' to exceed the DRG payment, causing financial 
loss to the hospital. 
The PROs also identified cases in which the patient was 
tdios charged as no longer needing acute care but was unable
manage at home, necessitating a readmission. A
possible  these 
explanation for  situations is poor
discharge planning. The patient should have been placed 
services 
in a skilled nursing facility or referred for home health
the 
However, based on  sometimes limited 
information available, it was diff icul t to determine 

readmission was due to poor discharge planning or a prema

ture discharge.

Inappropriate Transfers

Generally, a transfer is necessitated. by the inability of 
a hospital to provide a necessary service or a procedure, 
or because a patient is in need of a specialized therapy,
i. e.,  care. 
of a rterhaanbsifleitra tiisv eb aors epds yocnhi aatnr iocr der by Tthhee i naittteinadtiinogn
physician who determines the level and type of care the

patient needs.

Of the 491 transfer cases  majority
reviewed, the 
patients, 388 
(79%), were transferred from one acute care 
l7 
hospi tal to another;  (4%) to a rehabilitation unit; 11 
(2%) to a psychiatric unit; and in 39 (8%) of the cases 
the destination was not known. 
In 36 ( 7%) of the cases reviewed, patients 
were 
facili
transferred" inappropriately to skilled nursing 
ties or swing ' beds. By HCFA def ini tion,  patient is
transferred. 
admi tted to these facilities, not  However, 
for purposes of this review, these cases were considered 
transfer cases.  Page No. 13

In 289  the transfer cases 
(59%) of  reviewed, the PRO 
transfer existed. 
determined no valid reason for  The 
remaining transfer cases represented situations where an

attri.. 
inappropriate transfer did occur but could not be 
follows: 
buted to the physician or hospital. They are as 
fIon r1 43 (29%) of the transfer thcaes efsa rmeviileyw.e d, requests
transfer were made by  In some of 
these cases, the patient had been admitted to a com
expertise to 
muni ty hospital that did not have the 
and perform necessary procedures. 
complete tests 
appropriately transferred
Ttohe rae fore, the patient was 
larger tertiary hospital which, in some rural 
great 
areas, could be located a  distance from the 
patient'  home, family and friends. Once necessary 
procedures were 
tests and  performed, the family or
patient  the 
requested transfer back to  community 
convalescence, which could have taken 
hospital for 
place in the tertiary hospital. 
In 51 (10%) of the cases, miscellaneous or unclear 
2 )	
reasons accounted for the transfer. 
In 6 
3 )	 (1%) of the cases, the patient refused treatment 
at the receiving hospital and was sent back to the 
transferr ing hospital. 
4 )  tIhn attw oa  cases, documetnrtaantsiofen rriend t fhreo mre caonrd  indicated
patient was  acute care 
setting to a specialty unit because if he/she stayed 
in the acute hospital longer he/she would exceed the 
average length of stay , hospital resources expended
might exceed DRG payment, and the hospital might
suffer a financial loss.  Page No. 14

PRO Disposition of Cases With Quality Issues

generally categorized into
PRO follow-up activities were 
intensif ied 
educational contacts,  review, and referral to 
HCFA only. In 927 (43%) of the 2,146 cases with identified 
issues, no action other 
quali ty  than referral to 
HCFA 
was taken. The remaining actions taken by the PROs when 
quality issues were identified are categorized as follows: 
1 )  Educational Contacts 
In 743 (35%) of the cases, the PROs made educational

contacts. The educational contacts ranged 
from 
sending the attending physician and hospital utili za
tion review (UR) committee a copy of the referral to 
HCFA; to a telephone call to the attending physician 
physician 
mbye nttheed  PleROt ter to ther pehvyiseiwceri;a nt ow iat hc aar ecfouplyl yt doo cthue  
hospital UR committee detailing the PRO' s analysis of
the case. Many more of the former two practices were 
review. 
noted in this  In very few instances was the 
phone call well documoern tteidm, gei.v ing any details of the
conversation, date  In some cases contact 
the 
was made with  hospital UR committee instead of 
the physician, or in addition to the physician. 
2 )  Further Review Determined No Problem Evident 
In 208 (10%) of the cases it was determined that 
based on either additional information or review by a 
second PRO physician, there was no quality issue
involved. 
3 )  Intensified Review 
In 64 (3%) of the cases reviewed the PROs instituted

intensified review of the hospital or physician.

4 )  Sanction Development 
In no instance was a sanction development initiated by

the PROs.
 Page No. 15

In 204 (9%) of the cases, actions such as referral to the

PRO quality assurance committee; PRO development underway;

mPRiO sucnaeblle ltao nloecoatue sre ccorad;t eetgc.o, rwyer.e recorded in a 
PRO DISPOSITION OF OASES

WIT  QUALITY ISSUES 
43% 
31% 
10%  tOz 
(DI 
WT 
NO 
NO  1i1t, Mile 
ACTION 
CO FU 
rAKE  ACTI  Page No. 16

Issues 
Quali ty 
Sciextryn spe.r cent of all cases reviewed involved quality con
The quality issues ranged from very minor to 
care. 
gross instances of substandard  Of the 2, 146 cases
identif ied as having quali ty 
ture discharges,  concern  , 2, 050 were prema
42 were inappropriate transfers, and 54
were diagnostic workups with a readmission for surgery. 
It should be noted that not all of the 2, 907 cases identif ied 
aiss spureemast.u re discharges were classified as being quality
Generally the diagnostic workupas sw ith read
surgery, while classified 
missions for  premature 
ini tion, 
cdiasrchea.r ges by HCFA def  did not involve substandard 
practice.
Prior to PPS this was acceptable hospital 
Iinn  atdradintsifoenr,  cqauasleitsy.  of care was generally not a concern
trans
However, some patients were 
for 
ferred in unstable condition or  inappropriate care,
and some of the patients sent home to await surgery
deteriorated in the interim. 
Substantive issues accounted for the vast majority of the
cases reviewed. The 
types of situations which were
identif ied most 
often included: 
of 
condi utrioinnsa nroyt  radeetqeunatteiloyn t,r eiantfeed,c tsiuocnh ,a s indications

etc. , being 
acknowledged but not addressed prior to discharge; 
2 )  nsecoontd abrye icnongdi tions uncovered by laboratory analyses
acknowledged or addressed until
readmission; 
3 )  failure to perform rotuatli ne laboratory tests,
signs, 
failure to document vi  leading to missed
diagnoses. 
All of these cases had been identif 
ied as quality concerns 
by the PRO physician reviewers. When the OIG reviewers 
saw cases in which the situations above appeared to have 
placed the patient in great jeopardy, copies of the medical 
record were requested for further review by OIG physician 
consul tants. 
The OIG physicians reviewed medical 
records for 133
patients and, 
if attached, PRO worksheets and opinions by 
After analysis, 
nurse reviewers or PRO physician advisors.  . ..
Page No. 17

the cases were then grouped into the following categories:
gross  of care; 
instances of poor quality  substantial
instances; possible instances; no instance of: violation;
the case reviewed. 
and no opinion of  PRO physicians 
comments on these cases were also categorized. The result

is displayed on the following chart:

01G MEDICAL  REVI 
OF 133 CASES 
SEVERITY O 
QUALITY /SS(/ 
00/& 
NO  PfIU 
MJt;AUf 
t'QY tlUI  Al 
Y!IJIIt?N& AND 
ORN/fN  FtAS 
CWlE.1E  ..-
- .., 
Page No. 18

In 73 (55%) of the 133 cases, PROs referred the cases to 
taken. 
HCFA and no further action was  madeI.n  36 (27%) of the 
cases an educational contact was  In the remaining 
cases a number of actions, such as referral to the PRO 
quality assurance committees, were made. In no instance 
initiated. 
was a sanction development 
that 
OIG physicians recommend  sanction development be 
taken in 19 (14%) of the cases; additional review of more 
recent cases be done on specific hospitals and physicians
identif ied in 31 
(23%) of the cases; educational contacts 
30 
be made in  (22%) of the cases; no additional action in 
2in7  (1231% )( 1o0f% )t hoef  catshees ;c aansde rse.r eIvni etwh oef  rtehme acinaisneg b 1y 3t h(1e0 %PR)O, 
various other actions are recommended.

OIG MEDICAL REVIEW OF 133 CASES 
AC71  1;A"EN IY  Rl/ 
/9 
f/D 
3/ 
It) 
MI
MlR1  ""'$C,  "Ull  II'''  I .w
oM"  1'1'1l1'
M611  NHD  Page No. 19

In summary, medical records for 133 patients were reviewed 
opinion that 
by OIG physician consultants. It was their 
19 of these cases represented instances of gross and 
flagrant violations. Fifty-five represented substantial 
violations of acceptable medical practice, 21 represented 
possible violation, 37 cases had no quality issues on re-
review, and in one case OIG physicians did not have suf
f icient  render an opinion. Thirty-eight
information to 
cases with identified quality issues where inappropriate 
afcotiro nssa nwcertieo tna kdeenv beyl otphem PeRnOts.  hTahvee  breeemn arientiunrgn ecda steo st haerem 

currently being reviewed by HCFA.  Page No. 20

Mechanisms to Address  Cases  Premature  Discharge 
or Inappropriate Transfer 
physicians and 
The profiling of  providers necessary 
for the identification of abusive patterns is for the 
most part being done manually by the PROs. 
, to 
HCFA instructions pertaining  inappropriate
discharges and transfers were well received by some

PROs, but many expressed a need for further clarifi

cation.

Snaontc btieoinn rge cmoamdmee nbdayt iotnhse   rPegRaOrdsi ning  tahcecoserd acanscees w ai re

available PRO authorities.

Based on the findings of this inspection it appears that 
many PROs have not effectively used the authority or the
process available to them to address instances of prema
iate transfer. 
ture discharge and inappropr  This is due in 
part to their inability to identify patterns of abuse, the
lack of clar i ty and 
adequacy of HCFA instructions per
taining to these cases, and an apparent reluctance to
actions and carry out 
implement corrective  educational 
identified. 
responsibilities when instances have been 
The prevention of premature discharges and inappropriate 
transfers is part of the PROs ' ultimate goal of protecting 
the integrity of the system while safeguarding the quality 
of care provided through this system. 
The process enabling the 
PROs to address  premature 
discharges and inappropriate transfers involves: 
identif ication,
tracking and profiling of providers
and physicians; 
2 )  review and assessment  the  appropr iateness  and 
care; 
quali ty of 
of 
use  corrective measures and 
communicative 
approaches designed to educate and instruct providers
and physicians, as well as 
denial of payment and
sanction actions.  Page No. 21

Identification and Profiling

HCFA requires that all PROs have prof iling capabilities. 
Yet, very little profiling was being done of the providers 
and physicians identif ied in the prematurteh idiss charges and 
inappropr iate transfers reviewed in  inspection. 
Pdroofinlineg  thmat awans ouccaurrlinlg ywas. f or 
 the most part being
A total of 1, 158 hospitals could be identif ied in this 
study, 392 of which had three or more cases identif ied as
being premature  inappropriate transfers. 
discharges or 
One hundred eighty-five had five or more cases identified, 
85 had eight or more instances and 53 hospitals had 10 or 
identified during the time 
more instances  frames of this 
of 
trhevaienw.  1Th0os ei nhsostapintcale sp rovideprsr eimdeanttuifreie dd iassc hhaavrigneg sm ore
and 
s atten
inappropriate transfers will be brought to the PRO' 
for  determine if 
tion by HCFA  additional development to 
exist. 
patterns of substandard care 
In order for the current system to work, it is essential

that individual instances of premature discharges and 
identified and dialogue ini
inappropriate transfers be 
tiated with the physicians and hospitals involved to pre

vent further occurrences.

Under current policy the denial of the second stay should 
serve to deter the physician and/or hospital from manipu
lIia ttaintge  otrh cei ridcuemnvetinft iicnagt itohne  osyfs tem, but it wiplol onro tq ufaacliity-
patterns of 
care unless profiling of physicians and hospitals also 
occurs. 
Diuse  to the heavy volume of cases reviewed by the PROs it
issues be auto
essential that prof iling of quality 
mated.  tracking 
Not only would this provide for accurate 
and analysis, it would also facilitate HCFA monitoring 
processes and PRO reporting responsibilities. 
HCFA Instructions

The issuance of Transmittal 5 addressed in part situations

where premature discharges and inappropriate transfers 
wteor e occurring. HCFA provided guidance to itnh e PROs on how
handle certain situations that were  violation of 
Act. 
Generally, 
Section l886(f)(2) of the Social Security  Page No. 22

the PROs were g5la. d to receive the instructions contained 
in Transmittal  However, when asked if the instructions 
were adequate and could feasibly be incorporated into the
existing processes" they  their 
were less unanimous in 
responses. 
Half of the PROs felt that the instructions were 
not realistic and need further clarification. The focus 
' concerns revolved 
tohf ema ny of the PROs  stay rather thaanr ound the denial of
second, hospital  the first (which
treos ubl tee d in the premature rdeigscahradrigneg) .t hAels oh,o tshpeiyt aalp peared
somewhat unclear  appeal 
rights should payment be denied and the effect of waiver
of liability 
in these situations, although these issues 
are addressed in Transmittal 
Some PROs felt the criteria stipulated by HCFA which would
indicate a pattern of circumventing PPS and necessitate
initiation of a 
consistent 
sanction development was not 
the current sanction procedures. 
wtih teh  trigger of a sanctioonr  developmePnRtO s baalsseod  foenlt  ththreaet 
premature 
inappropriate transfers  discharges in a 
hospitals. 
quarter would unfairly penalize larger  Related 
cthoneceirrn ss teaxfpfr eisnsged a bnyd t he PROs are the potential effect on
budgets that would result from
increased sanction activity. 
Not covered in these instructions are situations where a 
different hospitaL 
patient is readmitted to a  In addi
tion, the instructions do not address premature discharges 
that do not result in another hospital stay, nor do they
apply if the patient or family requests the discharge. 
Also
not addressed are situations where proper discharge 
planning would have prevented the necessity for the second

admission.  Page No. 23

Areas that were not clear to the PROs were: 
Effective date of the instruction. 
iter ia triggering initiation 
Whether the cr 
of a sanc
tion applies to an individual physician or the hospi
taL

Whether to:

Recommend sanction based on 
professionally 
quality which does not meetu nder 
' standards  Section 
recogni zed 
l156(a) (2) of the Social Security Act; or 
circumvention  the  system,  Section 
l886(f) (2); or

Refer for termination of the provider agreement

under l866(B)(2). 
Wahnetdh eirn atphep rroepquriiareteme tnrta tnos freefresr  ipnretoma ture discharges

HCFA via the 
effect. 
HCFA-5l6 is still in 
Use of Educational, Preventive, and Corrective Measures 
wPrieorre  tno oits suance of Transmitdteanl y5  in July, 1985, the PROs
authorized to  payment for premature
discharges and inappropr iate transfers, opfe ntdhinigs  a legal
determination regarding the propr iety  action.
Al though PROs now have instructions regarding this
financial 
authority, it is too early to determine if the 
the identif 
loss to hospi tals resulting from  ication of 
future. 
such practices will serve as a deterrent in the 
However, PROs have always had the responsibility to docu
ment patterns of substandard care and initiate corrective
actions. 
Wi th the issuance of Transmittal 5 the PROs have received
instructions and been 
given criteria that if met should
tr igger a 
sanction development based on circumvention of 
PPS. 
A number of PROs expressed the opinion that if they were

adequately performing their educational and preventive  Page No. 24

role, puni ti ve actions would not have to be taken
frequently.  current process 
Indeed the  encourages an 
early warning to a physician or hospital to prevent the 
necessi ty for drastic action later on. 
However, as mentioned earlier, the PROs are not consistent 
mian dheo ww iotfht etnh oer  htoo swphiatat l epxhteynstic eiadnuc caotimomnauln ictyon wtahcetns  paoroer  
identified. 
quality care has been 
Documentation of educational contacts, whether phone calls 
or letters, could be found in fewer than half of the cases
identif ied by the  having 
PROs as  ihdications of poor
quality. 
In some instances, the OIG physician reviewer 
available 
determined that, on  evidence, the care was 
gross and flagrant violation, yet only a referral to the 
HCFA Regional Office had been made. 
In instances where a copy of the letter sent to the physi
not 
cian was available, it frequently did  document the 
nature of the violation or the PRO' s specific concerns.
It is 
the 
essential to  PRO monitoring process to
document that educational contacts of a specific nature 
have been made with physicians and hospitals when quality 
issues have been identified. It is also essential to the 
arise. 
development of a sanction case should the necessity 
There was no uniformity or  the 
consistency in  cases 
reviewed regarding: when an educational contact was made;

the content of the notif 
ication; with whom the contact was 
made; or documentation of the contact. 
The following is a diagram of the process to identify,
track, and prevent the occurrence of premature discharges 
and inappropriate transfers. Aster isks are used to iden
tify weaknesses irne pthoisr tp. rocess that have been discussed 
throughout this  Correction of these weaknesses 
and aggressive use of this process by the PROs should pre
vent occurrences of premature discharges and inappropriate
transfers in the future.  Page  No. 
000
 Page No. 26

VI.  Recommendations 
HCFA should:

its 
reporting requirements regarding 
. Continue 
inappropriate trans
pfreemrsat.u re discharges and 
Instructions  referrals 
regarding PRO 
and a. uniform format for 
should be clarified 
referrals developed. 
Uniform PRO referral of 
these cases will help to identify the magnitude

of this problem and assess the effectiveness of

the policies contained in Transmittal 

of 
Issue clarification  Transmittal  imme-
ic PRO concerns.

diately, in response to specif 
ing
Eoxfpa nd the PROMPTS rreefveierwr atlo  cianscleusd,e  fmroonmito ird en
sample of 
tif ication through PRO corrective actions, to 
handling these cases is 
ensure the process for 
implemented. 
being correctly 
Reassess, through PROMPTS, PRO operational proce

dures and systems for identifying, profiling and

ttarabcklein gt oin spthayncseisc iaofn sp oaonr dq uhaolistpyi tcaalr ep raotvtirdiebrus
. 
PROs should have the aoutfom ated capability

identifying patterns  substandard care. 
Deficiencies or system problems should be noted

taken. 
and corrective actions 
the 
the 
Provide direction to  PROs regarding 
educa
issuance, content, and documentation of 
tional contacts made prior to sanction develop
ment. 
Initiate  extent 
studies to determine the 
resulting 
which poor discharge planning is 
readmissions. 
hospi tal 
The OIG concurs with HCFA that PRO scopes of work
should be revised to place more emphasis on PRO 
care. 
responsibili ty in monitoring quality of 
Tohfe  Department sh1ou6l2d3 c, ontinue to encouratghee p aSsesnaagtee 
Senate Bill  incorporated in 
Reconciliation package, which would authorize PROs to  Page No. 27

identif ied 
deny payment for  instances of substandard 
care, of a substantive nature, rendered to Medicare
beneficiaries.  &. 
Health Care 
HUMAN SERVICES	 Financing Administration 
DEPARTMENT Of HEALTH 
Memorandum
Jr"..JO  '5/5  198 
Date 
Henry R. Desmarais, M. 
Acting Administrator

From	
Health Care Financing Administration

Subject OIG Draft Report-Inappropriate Discharges and Transfers (OAI-86-o050) 
The Inspector General

Office of the Secretary

We have reviewed the report on inappropriate discharges and transfers under the 
Medicare Prospective Payment System. As recognized in the report, HCF A has 
number of actions to correct the problems referred to in the study 
already taken a 
and is continuing to move aggressively in identifying and resolving quality of care 
problems. 
HCF A fully expects and requires Peer Review Organizations (PROs) to investigate 
quickly and thoroughly all cases where the quality of health care provided to 
Medicare beneficiaries does not meet professionally recognized standards of care. 
HCF A firmly believes this to be a basic purpose of peer review, and we intend to 
make certain that PRO performance in this area is in accord with our expectations 
through intensive monitoring by the regional offices (ROs). 
The OIG study is of assistance to HCF A by identifying areas where further 
PROs and ROs in resolving quality of care issues can be attained 
improvement by 
and we appreciate the time and resources the OIG expended in preparing this report. 
Some general comments and observations about the report may be helpful in any 
future studies: 
The study covered the period from October 1, 1983 through May 31, 1985. The 
sanction regulations became effective May 17 , 1985 and Transmittal 85-5 was 
effective in July 85.

As noted in the report, 30% of the cases classified as premature discharges were 
were reimbursement-related problems.

not directly attributable to physicians but 
DRG 
Review of the records provided to HCF A revealed only one case where the 
payment was a factor in the premature discharge. HCF A needs to know the 
identity of the others, if any, referred to on page 12 so we can discuss them with 
the PRO, physicians and hospitals and take corrective action. 
classified as inappropriate transfers 
Forty-two percent (42%) of the cases 
page 13 are not inappropriate by OIG definition, i.e., they do not question the 
(page 5). 
quality of care provided 
us GOVERNME TPR!NTI  I:C'ICE ' ge2- atl':' 311:2  Page 2 - The Inspector General 
o It is difficult to follow the arithmetic calculations used in the report. 'For 
example, we have been unable to determine exactly how many serious quality 
problems the OIG medical consultants believe were missed by PROs. 
Percentages are applied to various baseline numbers, percentages are taken 
percentages, and numbers are not consistently used. HCF A recommends that 
future reports be uniform in the use of numbers and percentages. 
recommendations made 
We are taking the following actions in regard to the specifc 
in the report: 
OIG Recom menda tion 
inappropriate 
Continue reporting requirements regarding premature discharges and 
PRO referrals should be clarifed and a uniform 
transfers. Instructions regarding 
format for referrals developed. Uniform PRO referral of these cases wil help to 
identify the magnitude of this problem and assess the effectiveness of the policies 
contained in Transmittal 5. 
H CF ACorn ments 
PRO wil be required to refer to the RO only those cases that cannot 
We agree. The 
Transmittals 85-5 and 85-6 require PROs to 
btea rkeseol vaedc utnideor nex iostinng  pinrsterumctiaontsu. r
 e discharges and transfers in most instances. Only cases for 
RO. Concurrently, we wil 
which there is no existing policy should be sent to the 
require that the PRO  report to the RO, on a monthly basis, the nRumOb weri lo af lcsaos bees  
identified as premature discharges or inappropriate transfers. The 
PRO on the referred cases. In addition, 
responsible for responding promptly to the 
ROs wil verify the accuracy of the report on premature discharges and transfers 
and wil insure that PROs take appropriate action on these cases. 
OIG Recommendation 
Issue clarification of Transmittal 5 immediately, in response to specifc PRO 
concerns. 
HCF A Comments 
We agree. Clarifications wil be released shortly and wil resolve the concerns 
identified by ROs and PROs. In addition, HCF A, in conjunction with the Office of 
General Counsel, is in the process of rewriting 85-5 both to expand its application 
and to clarify its content. 
OIG Recommendation 
Expand the PROMPTS review to include monitoring of a sample of referral cases, 
from identification through PRO corrective actions, to ensure the process for 
handling these cases is being correctly implemented. 
H CF ACorn ments 
ROs are currently required to review a sample of cases as part of PROMPTS. This 
activity wil be modified to verify that cases are appropriately handled. 
OIG Recommendation 
Reassess, through PROMPTS, PRO operational procedures and systems for 
identifying, profilng and tracking instances of poor quality care attributable to 
PROs should have the automated capabilty of 
physicians and hospital providers. 
Deficiencies or system problems should be 
identifying patterns of substandard care. 
noted and corrective actions taken.  ~~~
Page 3 - The Inspector General 
HCF A Comments 
We agree. "Profilng" to identify and focus on problems is a prerequisite to 
effective peer review. We wil be providing additional technical assistance in this 
area and aggressively enforcing requirements that , PROs effectively profie 
information optained through review to identify inappropriate patterns of care. 
OIG Recommendation 
Develop guidelines and model letters regarding issuance, content  and 
documentation of educational contacts made prior to sanction development. 
HCF A Comments 
We do not believe it is appropriate for us to put forth model letters in this area, and 
we have been informed by the OIG that they did not mean to require this. OIG 
methods to be used in educational contacts is a local 
agreed that the process and 
will, however, monitor this activity by reviewing documentation 
responsibilty. We 
to assure that the actions taken are effective in correcting the problem. 
OIG Recommendation 
Initiate studies to determine the extent to which poor discharge planning is resulting 
in hospital readmissions. . 
HCFA Comments 
We are currently funding studies by six PROs to identify the extent of the 
premature discharge problem and to identify the most effective  review 
methodologies for dealing with it. 
OIG Recommendation 
The OIG concurs with HCF A that PRO scopes of work should be revised to place 
more emphasis on PRO responsibilty in monitoring quality of care. 
HCF A Comments 
The scope has been revised to focus on quality of care issues through the use of 
generic screens and more focused review. 
OIG Recommendation 
The Department should continue to encourage passage of Senate Bil 1623 
incorporated in the Senate Reconcilation package, which would authorize PROs to 
deny payment for identified instances of substandard care, of a substantive nature, 
rendered to Medicare beneficiaries. 
HCFA Comments 
We concur. 
We would like to  comments in regard to the other findings in this 
offer the following 
report. 
Qua  ty issues ranging from very. minor to gross and flgrant were identified by the 
PROs in 60 percent of the 3,549 cases. PRO disposition ranged from intensifed 
review of identified hospitals and physicians to no action being taken at all. In 43 
percent of the cases with identified quality issues the only apparent action taken by 
the PRO was referral to HCF A.  Page 4 - The Inspector General 
taken. 
Response
We agree with this finding. The ROs are currently aggressively monitoring PRO 
activity in quality of care cases to assure that appropriate corrective action is
Finding 
Medical records involving 133 patients were referred to OIG physician consultants 
for review. Nineteen were classified by OIG consultants as exhibiting gross and 
flagrant instances of substandard care. PROs took no corrective action, other than 
referral to H CF A, on 12 of these 19 cases. In the opinion of the OIG medical 
consultants, inappropriate actions were taken on 106 of the 133 cases. These cases 
have been or wil be returned to the PROs for various recommended actions. 
Response 
While we cannot ascertain from the report how many cases the PRO did not handle 
appropriately, we have completed medical record review on the 77 cases made 
available to us by the OIG. These cases did reflect apparent inadequate PRO 
to the 
intervention. These cases are being transferred  ROs for control and return to 
the PRO. The ROs wiU be responsible for assuring that the PRO develops them and 
takes necessary corrective action. 
Finding
PROs did have the authority to take action on the quality issues identified in this 
study. It appears that many PROs have not effectively used the authorities or the 
instances of poor quality care associated with 
processes available to address 
premature discharges and inappropriate transfers. 
Response 
We agree that PROs had the authority to take action on any quality issues identified 
by them or brought to their attention through the OIG, the fiscal intermediary, 
onsite visits and in other communications 
HCF A or any other source. ROs, during 
with PROs, are monitoring actions taken by PROs in resolving cases of unacceptable 
quality of care in any category, i.e., surgery, drug, premature discharge, 
unnecessary admissions, inappropriate transfers, etc. PROs found out of compliance 
with these requirements wil be subject to contractual enforcement actions. 
Finding 
During OIG site visits conducted in September and December 1985, problems were 
noted with the PROs' accumulation of data pertaining to the quality of care

identification of 
rendered by physicians and hospitals. This data is necessary (or the 
abusive patterns and subsequent corrective action. 
Response 
an instruction that wil futher define the PROs' responsibilty for 
H CF A is preparing 
and in 
maintaining profies to be used in analyzing quality of care problems 
identifying abberant providers or physicians. Corrective action wil be taken against 
any PROs unable or unwiling to monitor quality of care through profie analysis. 
HCF A has emphasized to the ROs that aggressive monitoring and timely and 
complete profiing is required of all PROs.  Page 5 - The Inspector General 
Finding 
noted that since the initiation of this 
It should be  inspection increased activity by 
PROs in this area has occurred. 
HCF A and the  HCF A has issued Transmittal 6 
and has initiated focussed reviews in this area. 
(relating to sanction procedures) 
PROs are increasing sanction activities against physicians/providers demonstrating 
abusive patterns of practice. 
Response
Current reports show greatly  in the 
increased activity  identification and 
development of cases by the PROs that may be violations of obligations, and in the
issuance of first notices where a violation has been determined. In those PROs 
where activity remains minimal, we are directing the ROs to review the PRO' 
application of Transmittals 85-5 and 85-6 and to take immediate corrective acton if 
those instructions are not being followed.