OIG Report: Poorly Coded Doctor Claims Cost Medicare $33 Million

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.

Click here to see the OIG report.

Click here to read more.

Tiptastic Tuesday: 4 Essential Steps For Healthcare Compliance

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:

  1. Define your audit, compliance and legal departments’ jobs and relationships with one another. Make sure each department understands its role in the compliance process.
  2. 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.
  3. Identify and audit potential risk areas. Make sure to establish clear processes for risk identification.
  4. Encourage compliance throughout the enterprise. The OIG recommends regular performance assessments to help facilitate this process.

Click here to see the guidance.

Click here to read more.

2015 OIG Work Plan Highlights: Hospice Services

Yesterday, we highlighted the home health services section of the 2015 OIG Work Plan. Today, we’ll take a closer look at the hospice services section of the Work Plan:

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.

Click here to see the plan.

New Quality Measure Needed to Track Hospital Admissions

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.

Click here to read more

Final Rule Allows Data Mining Matching Funds

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a final rule allowing State Medicaid Fraud Control Units (MFCU) to receive federal matching funds to identify fraud through data mining, statistical models which identify abnormal utilization and billing practices. The regulations go into effect on June 17, 2013.

Click here to read more.

OIG Finds Medicare Billing Discrepancies For Hospice Inpatients

A report by the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) there were unusual Medicare billing patterns for hospice inpatient stays. The report also found that 27% of Medicare hospices did not provide General Inpatient Care (GIP) in 2011 and often did not provide the appropriate level of hospice care.

Click here to read more.

NY Received $27.5M In Improper Medicaid Payments

Federal regulators at the Department for Health and Human Services (HHS) Office of Inspector General (OIG) say the state of New York took nearly $27.5 million in improper Medicaid payments. A report issued earlier today found 84 out of 100 Medicaid claims submitted did not comply with federal and state regulations.

Click here to read more.

MedPAC Home Health Recommendations

Late last week, MedPAC released its annual report to Congress on payment policy. Below is a summary summary of recommendations for home health.  Stay tuned to the HMS Healthcare Management Solutions blog for the hospice recommendations later today.

Home Health Recommendations:

  • The Health & Human Services (HHS) Secretary, with the Office of the Inspector General (OIG), should conduct medical review activities in counties that have abnormal home health utilization. New authorities should be implemented to suspend payment and enrollment of new providers if they indicate significant fraud.
  • 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.

OIG: SNFs Fail To Meet Requirements For Care, Discharge Planning

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released Skilled Nursing Facilities Often Fail to Meet Care Planning & Discharge Planning Requirements the latest in a series of studies examining Skilled Nursing Facility (SNF) payments and quality of care. The report found for 37% of stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans.

Click here to read more.

7 Elements Of A Corporate Compliance Program

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
  • Respond to violations appropriately

Contact HMS Healthcare Management Solutions for assistance developing your corporate compliance program.