Articles Tagged with Compliance

Editor’s Note: This is part of a week long series exploring the impact of the OIG 2013 Work Plan on different types of providers and organizations.

On October 3, 2012 the Department of Health and Human Services Office of Inspector General (OIG) released its Work Plan for fiscal year 2013. Among the new issues the Work Plan outlines are issues that will affect Durable Medical Equipment (DME) suppliers. The Work Plan states that the OIG will examine:

Quality Standards–Accreditation of Medical Equipment Suppliers:
The OIG will review accreditation organizations’ procedures for the accreditation of medical equipment suppliers. Medicare has a series of quality standards to which medical equipment suppliers must comply. Accreditation organization procedures must ensure that all medical equipment suppliers they accredit meet the Medicare quality standards. The OIG review will also examine CMS validation surveys which are intended to monitor accreditation organization procedures.

Lower Limb Prostheses–Supplier Compliance with Payment Requirements:
The OIG will examine Medicare payments to medical equipment suppliers for lower limb prosthetics to ensure that Medicare requirements were met. Providers must furnish, upon request, information to determine amounts due. This can include documentation showing that the order was reasonable and necessary. In past reviews, the OIG has found claims submitted by suppliers with deficiencies in documentation, including claims for beneficiaries with no orders from a referring physician.

DME suppliers should also be aware of other issues that appear in the Work Plan. These include:

• Power Mobility Devices–Supplier Compliance With Payment Requirements • Vacuum Erection Systems–Reasonableness of Medicare’s Fee Schedule Amounts Compared to Amounts Paid by Other Payers • Continuous Positive Airway Pressure Supplies–Reasonableness of Medicare’s Replacement of Supplies Compared to That of Other Federal Programs • Diabetes Testing Supplies–Improper Supplier Billing for Test Strips in Competitive Bidding Areas • Diabetes Testing Supplies–Supplier Compliance With Requirements for Non-Mail-Order Claims • Medical Equipment and Supplies–Potential Savings From the Competitive Bidding Program • Medical Equipment and Supplies–Opportunities To Reduce Medicaid Payment Rates for Selected Items

DME suppliers should be prepared that the identification and review of these issues may lead to additional focus by CMS and its contractors. Compliance plans can be effective measures to help DME suppliers to proactively prepare for increased scrutiny from CMS contractors.
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Editor’s Note: This is part of a week long series exploring the impact of the OIG 2013 Work Plan on different types of providers and organizations.

Recently, the Department of Health and Human Services Office of Inspector General (OIG) released the OIG’s annual Work Plan. The Work Plan includes the reviews and activities that the OIG plans to conduct during fiscal year 2013. The OIG’s 2013 Work Plan will likely affect long term care providers because some of the issues, as described below, target long term care providers.

HHAs–Home Health Face-to-Face Requirement:
The OIG will examine the frequency with which home health agencies are complying with face-to-face requirements. Physicians, or permissible allied health practitioners, are required to have face-to-face encounters with beneficiaries receiving home health care within statutorily mandated time frames. Past OIG reviews have indicated that compliance with face-to-face requirements has been low.

Long -TermCare Hospitals–Payments for Interrupted Stays:
The OIG will determine if inappropriate payments were made by Medicare for interrupted stays in long-term care hospitals, and attempt to identify patterns of readmission directly following interrupted stays. When a patient is discharged from a long-term care hospital to receive services that are not available at the long-term care hospital, and then readmitted, Medicare payment amounts can be affected. Past OIG reviews have identified weaknesses in the ability to detect these inappropriate payments.

Home Health Services–Duplicate Payments by Medicare and Medicaid:
The OIG will determine the frequency with which both Medicare and Medicaid have paid for the same Medicare-covered home health services.

Long term care providers should also be aware of other issues that appear in the 2013 Work Plan. These include:

• Nursing Homes–State Agency Verification of Deficiency Corrections • Nursing Homes–Use of Atypical Antipsychotic Drugs • Nursing Homes–Oversight of the Minimum Data Set Submitted by Long-Term-Care Facilities • HHAs–Employment of Home Health Aides With Criminal Convictions

Long term care providers should anticipate that OIG review of these issues may to lead to additional focus by CMS and its contractors. Long-term care providers should review current compliance programs or implement a compliance program if they do not already have one to prepare for CMS’ increased attention.
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On September 4, 2012 the Department of Health and Human Services Office of Inspector General (OIG) issued a report in which it found that during calendar years 2009 and 2010 Medicare made overpayments to Inpatient Rehabilitation Facilities (IRFs) totaling an estimated $8.4 million.

The Centers for Medicare and Medicaid Services (CMS) establish a prospective payment rate for specific case-mix groups to which each beneficiary is assigned based on their expected clinical resource needs. IRF patient data is transmitted through Patient Assessment Instruments (PAIs) which contain the data on each beneficiary that is necessary to assign each to a case-mix group. IRF claims are processed and paid through Medicare Administrative Contractors (MACs). The IRF must submit the PAI data to the MAC within 27 days from the beneficiary’s discharge date. If PAI data is submitted after the 27 day window, a 25% late assessment penalty is applied to the case-mix group.

In the report, the OIG published the results of an audit conducted over calendar years 2009 and 2010 which examined whether IRFs received the reduced case-mix group payments for claims with PAIs that were submitted after the 27 day window. During the audit timeframe, 2,414 claims were transmitted after the 27 day window which totaled $41.6 million. The audit examined a 108 claim sample, of which 88 did not receive the 25% case-mix reduction. From this sample the OIG estimated that $8.4 million in overpayments were made to IRFs.

The OIG made recommendations to CMS which included the following:

1. Adjust the 88 sampled claims for overpayments of $696,371 to the extent allowed under the law.
2. Work with the OIG to resolve the remaining 2,306 nonsampled claims with potential overpayments estimated at $7.7 million and recover overpayments.
3. Continue to provide specific education to IRFs on the importance of reporting the correct PAI transmission dates on their claims.
4. Support the MACs’ and RACs’ efforts to conduct periodic postpayment reviews of IRF claims.

In response to the report, CMS concurred with the findings of the OIG and outlined implementation possibilities for the recommendations.
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The Centers for Medicare and Medicaid Services (CMS) recently released Comparative Billing Reports (CBRs) to Skilled Nursing Facility (SNF) providers. The CBRs are released to a maximum of 5,000 providers. CBRs can be an effective way to identify potential audit weaknesses and take corrective action before an audit.

SNFs that receive CBRs will see their rehabilitation plus extensive services category RUG code billings broken down by therapy level grouping and compared to regional and national averages. The CBRs are a response to increases in ultra high therapy RUG billings nationwide. Providers with higher than average ultra high therapy RUG billings are encouraged to examine their procedures and compliance plans to determine that therapy level RUG codes are billed appropriately.

The CBRs are produced by SafeGuard Services under contract with CMS and will provide comparative data to help show how these individual providers compare to other providers within the same field. These comparative studies are designed to help providers review their coding and billing practices and utilization patterns, and take proactive compliance measures. Providers should view CBRs as a tool to aid them evaluating their practices to ensure that they are properly complying with Medicare billing rules. Furthermore, providers should carefully analyze the data in CBRs to evaluate whether the CBR adequately reflects the provider’s billing practices. It is also important to understand that CBRs do not contain patient or case-specific data, but rather only summary billing information as a method of ensuring privacy.

In addition to skilled nursing facilities, provider types that have been identified to receive, or have already received, CBRs include: podiatry services, home oxygen services, evaluation and pain management services, cardiology services, advanced diagnostic imaging, electrodiagnostic studies, sleep study, hospice, ambulance services, chiropractic services, physical therapy, and durable medical equipment.
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