A new OIG report has found that more than $33 million Medicare funds might have been overpaid to physicians as a result of poorly coded doctor claims between January 2010 and September 2012. The OIG discovered this after an audit of claims for services physicians performed in ambulatory care centers and other outpatient settings. The coding errors, however, led Medicare contractors to believe they were performed in physicians’ offices or clinics and have been attributed to “internal control weaknesses at the physician billing level and to insufficient post-payment reviews at the Medicare contractor level to identify potential place-of-service billing errors.” So far, most of physicians cited have expressed their intent to refund potential overpayments for incorrectly coded services.
According to new guidance from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG), healthcare providers must focus on four major principles in order to create effective compliance programs.
The increase in fraud crackdowns means compliance is more important than ever. OIG collaborated with industry leaders to develop the four following guidelines:
Define your audit, compliance and legal departments’ jobs and relationships with one another. Make sure each department understands its role in the compliance process.
Assess your organization’s protocols for gathering information and reporting issues. Make sure each compliance-related sector reports on its compliance and risk-management efforts and measures its implementation of compliance programs.
Identify and audit potential risk areas. Make sure to establish clear processes for risk identification.
Encourage compliance throughout the enterprise. The OIG recommends regular performance assessments to help facilitate this process.
For beneficiaries living in assisted living facilities, the OIG will review the level of services provided, including the length of stay, level of care received and common terminal illnesses. This information is necessary for CMS to reform the hospice payment system, collect data relevant to revising hospice payments, and develop quality measures. Furthermore, hospice care may be provided to individuals and their families in various settings. These settings include the beneficiary’s place of resident, such as an assisted living facility. Typically, assisted living facility residents have the longest lengths of stay in hospice care, thus requiring more monitoring and examination.
The OIG will also assess the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care. The OIG will review hospice medical records to address concerns that this level of hospice care is being misused. Beneficiaries may revoke their election of hospice care and return to standard Medicare coverage at any time.
According to a new report from the Department of Health and Human Services Office of Inspector General, one in four nursing home residents on Medicare was hospitalized in 2011, costing Medicare $14.3 billion. The OIG has recommended a new quality measure for tracking hospital admissions. Quality measures (QMs) are normally used in the government’s Five-Star Rating System and are correlated to hospitalization rates; low staffing levels, especially, are related to higher hospitalization rates. CMS was urged to create a QM for hospitalization rates and is now developing a 30 day readmissions measure for skilled nursing facilities to submit to the National Quality Forum by the end of the year.
Congress should direct the HHS Secretary to begin a two-year rebasing of home health rates in 2013 and eliminate the market basket update for 2012.
The HHS Secretary should revise the home health case-mix system to rely on patient characteristics to set payment for therapy and non-therapy services and should no longer use the number of therapy visits as a payment factor.
Congress should direct the HHS Secretary to establish a per episode copay for home health episodes that are not preceded by hospitalization or post-acute care use.
Compliance programs are an important and effective way to maintain internal controls and procedures that promote adherence to statutes and regulations applicable to federal healthcare programs. The Office of Inspector General (OIG) believes every effective compliance program should address all of the elements listed below:
Establish compliance standards through the development of a code of conduct and written policies and procedures;
Assign a compliance officer who reports to the CEO
Conduct comprehensive training and education on practice ethics, policies and procedures
Conduct internal monitoring and auditing focused on high-risk billing and coding issues through periodic audits
Develop accessible lines of communication to keep practice employees updated regarding compliance activities
Ensure employees are aware compliance is treated seriously and violations will be dealt with consistently and uniformly