The Office of the Inspector General Fraud Recoveries Dropped $1.2 Billion This Year
Hospice and Medicare Part D: Get the Facts
Hospice and Medicare Part D: Get the Facts. New CMS Guidance.
- Once the plan sponsor receives a pharmacy claim, for the beneficiary who has elected Hospice and the drug falls into the 4 common categories, the claim may be rejected using the National Council for Prescription Drug Programs (NCPDP)-approved reject coding.
|A3||This product may be covered under Hospice-Medicare A|
|75||Prior Authorization Required|
|569||Provide Notice: Medicare Prescription Drug Coverage and Your Rights|
- The sponsor can contact the prescriber to complete the Prior Authorization (PA) form.
- The prescriber can provide a verbal explanation to the sponsor as to why the drug is unrelated to the terminal illness or related conditions or complete the PA form and submit it to the sponsor by fax or mail.
- If the prescriber is unaffiliated with the Hospice provider and is unable or unwilling to coordinate with the Hospice provider to provide the statement, the plan sponsor can contact the Hospice Provider for the statement that the drugs are unrelated to the terminal illness or related conditions or complete the PA form.
The Office of the Inspector General releases an annual Work Plan. This year’s plan holds much for all levels of health care. Be certain you review the plan when updating your Corporate Compliance Plan. The Work Plan essentially reflects projects originating and approved within the Office of Audit Services (OAS) responsible for billing/ financial audit and projects approved within the Office of Evaluations and Inspections (OEI). Keep in mind that not all carry-over projects are listed in new annual Work Plans. Acute Care There are 23 projects listed, 12 are new projects. These projects include an analysis of executive salaries, reviewing billing variances among hospitals and implementation of the Two Midnight Rule. Comparison of provider-based and free-standing clinics will occur as well as a nationwide review of cardiac catheterization and heart biopsies. Physicians Physicians are targeted with reviews in ambulatory surgical centers and end- stage renal centers. CMS will be reviewing qualifications of mental health care providers. Nursing Homes The OIG will continue strong review of nursing homes with high rates of re-hospitalization and also questionable billing trends. They will also be auditing for national background checks of long-term care employees. DME Equipment The OIG will be comparing amounts paid by payors in regards to fee schedule methodologies targeting commode chairs, folding walkers, and TENs devices. They will also be evaluating F2F physician –patient exams for power mobility devices. Home Health Services The OIG will continue its focus on home health agencies and their conducting of criminal background checks on employees. Since a prior OIG results report found that 1 in 4 home health agencies had questionable billing practices, the OIG will continue to hone in on billing. “Documentation to support claims” is a key area of scrutiny. Hospice Hospices have been heavily reviewed and will have continued review as to use of general inpatient care and the appropriateness of these claims. Scrutinizing levels of care, length of stay, and terminal illnesses of hospice patients in ALFs is required under the Affordable Care Act which mandates reform of the hospice payment methodology. Summary Every area of health care is under review and the government has added resources to improve success of the Work Plan. Home health agencies should review clinical documentation. Most agencies believe they have clinicians who are inconsistent in documentation quality. Some agencies are unaware of specific documentation for required for coding. Now is the time to consider third party coding services to assist in that endeavor or at least consider periodic audits. Select Data provides both
On August 2, 2012, The Office of the Inspector General addressed Congress identifying how and why they studied home health and what they found. Those findings were frightening: - Approximately one of every four home health agencies had questionable billing - Eighty (80) % of home health agencies with questionable billing were located in four states ~Texas ~Florida ~California ~Michigan Overall, 97% of home health agencies with questionable billing were located in NON Certificate of Need states. Florida, once a Certificate of Need state, but no longer, had the largest representation of agencies with questionable billing practices. Over 52% of the 1,251 Florida agencies will now be scrutinized due to questionable billing practices. The percentage of Florida agencies with questionable practices in billing were six times the national average. Texas reigned in at five times the national average. Excerpts of OIG testimony before Congress on August 2, 2012 The OIG stated that payment of the claim is no assurance that the claim is considered correct. It has met initial CMS standards of payment but can be reviewed with payment recoupment for up to 36 months. The OIG intends to increase reviews and create even more sophisticated algorithms bent on targeting inappropriate billing practices. The OIG further Stated: "We first identified all home health claims with dates of service ending in 2010. In total, we identified approximately 6.96 million Medicare claims for both full and partial home health episodes billed by November, 2003 to identify Home Health Agencies that had questionable billing, we first identified those HHAs that submitted at least 20 claims in 2010. These included 92 percent (10,341) of the 11,203 HHAs and accounted for 6.88 million claims. We next identified HHAs that had questionable billing. We developed six measures of questionable billing based on the results of past OIG analyses and fraud investigations related to home health services, as well as on input from CMS staff and contractors. We considered a HHA’s billing to be unusually high, or questionable, on each of the six measures if it was greater than the 75th percentile plus 1.5 times the interquartile range." The six measures of questionable billing developed included: ¥ High average outlier payment amount per beneficiary. Medicare makes outlier payments to HHAs that provide services to beneficiaries who require high cost care. This measure was based on the total outlier payments each HHA was paid in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. ¥ Each HHA total outlier payments was calculated relative to total Medicare payments in 2010. An agency was targeted if it showed a higher than average number of visits per beneficiary. We based this measure on the total number of visits each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. ¥ High percentage of beneficiaries for whom other HHAs billed Medicare. When multiple HHAs bill for services provided to the same beneficiary in a given period, there is potential for fraud (i.e., beneficiary sharing). We based this measure on the percentage of each HHA’s beneficiaries for whom at least one other HHA billed Medicare in 2010. ¥ High average number of late episodes per beneficiary. In a sequence of episodes, late (i.e., third and subsequent) episodes have higher payment rates than early episodes. We based this measure on the total number of late episodes each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. ¥ High average number of therapy visits per beneficiary. Beneficiaries who required a greater number of therapy services have episodes with higher payment rates. We based this measure on the total number of therapy visits each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. ¥ High average Medicare payment amount per beneficiary. We based this measure on the total payment for home health services that each HHA received in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. The OIG will be implementing process edits and sophisticated algorithms designed to weed out those agencies that practice poor billing implementation. MACs are to identify questionable claims and either flag the practices and/or deny payment. CMS has instructed MACs and Z-PICs to monitor the billing applying the above six measures. Additionally, the OIG has instructed CMS to consider lowering the outlier cap as 78% of HHA with total outlier payments greater than 5% of total Medicare payments also exceeded the threshold "for our measure of questionable billing specific to outlier payments, indicating potential fraud" stated the OIG. The OIG sent a separate memorandum to CMS stating that "appropriate action regarding claims that are associated with inappropriate payments is expected." Agencies in all states, but especially in Florida, California, Texas, and Michigan had better review their billing practices because the OIG has spoken and CMS and the auditors are coming. The OIG officially had five recommendations and actions expected: 1. CMS is to implement claims processing edits to prevent inappropriate payments 2. CMS is to increase the monitoring of billing in home health services 3. CMS should enforce and consider lowering the 10 percent cap on the total outlier payments 4. CMS should consider imposing a moratorium on new HHA enrollments in Florida and Texas 5. CMS should take appropriate action regarding inappropriate payments and HHA with questionable billing CMS response, "we concur with the recommendations." Those agencies located in the four identified states will be under scrutiny. Agencies, get ready. Begin your own audits proactively so you can demonstrate your active compliance program. Update your Corporate Compliance Plan, because you may need to demonstrate your quality orientation and commitment to billing compliance.