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OIG Fraud Recoveries Dropped $1.2B This Year

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Compliance, Healthcare, OIG, Payment Rates

The Office of the Inspector General Fraud Recoveries Dropped $1.2 Billion This Year

That might not be a bad thing.

 
The federal government brought in 30% less in fraud recovering in 2018 than it did the previous year, thanks to far few large settlements. But the could be a net benefit, according to the Centers for Medicare & Medicaid Services (CMS). The office of Inspector General (OIG) recovered $2.9 billion from fraud investigations during fiscal year 2018, according to the semiannual report to Congress released last week. That's  $1.2 billion decline from last year, when the agency pulled in $4.13 billion (Sweeney, 2018) The year prior, the agency hauled in a historic $5.6 billion. But lower recoveries are not indicative of lighter enforcement, according to OIG spokesperson Don White. Fraud recoveries fluctuate from year to year, based primarily on the volume of large settlements. In 2017, for example, the OIG inked a $155 million settlement with EHR vendor eClinicalWorks and Mylan paid $465 million in an EpiPen settlement. The prior year, Tenet Healthcare forked over more than $500 million (Sweeney, 2018). On another note…a little alarming because CMS does budget in a % of recovery dollars to justify their fraud investigation program. Resources Sweeney, E. (2018). OIG fraud recoveries dropped $1.2B this year. That might not be a bad thing. FierceHealthcare.com. Retrieved from: https://www.fiercehealthcare.com/payer/oig-fraud-recoveries-dropped-almost-1-2-b-year-might-not-be-a-bad-thing
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Hospice and Medicare Part D: Get the Facts

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Hospice, OIG

Hospice and Medicare Part D: Get the Facts

Hospice and Medicare Part D: Get the Facts. New CMS Guidance.

 
Medicare Part D is a Federal program designed to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.  In 2014 Medicare paid over 77 billion dollars in Part D benefits serving more than 37 million beneficiaries.  Part D administration depends on extensive coordination and information sharing between the Federal and State agencies, healthcare providers, drug plan sponsors, contractors and third-party payers. Hospice programs are required to provide individuals receiving Hospice care with drugs and biologicals related to the palliation and management of the terminal illness defined in the Hospice plan of care.  Medicare pays the Hospice agency for each day in which the patient is receiving hospice care, regardless of the amount of care received on a given day.    Hospice is a Medicare Part A benefit and drugs provided by the hospice are covered under the Medicare payment to the hospice program and not covered under Part D. Prescription drugs may be covered under the Part D benefit for the patient receiving Hospice care if the drug is unrelated to the terminal prognosis of the individual.   In 2012 the Office of the Inspector General (OIG) identified situations in which Medicare was paying twice for prescription drugs for hospice beneficiaries, and those beneficiaries may be paying unnecessary copayments for prescription drugs.  The report indicated that most hospice beneficiaries generally experience common symptoms during the end of life regardless of the terminal diagnosis.  These symptoms include pain, nausea, constipation and anxiety.  The OIG worked with the National Hospice and Palliative Care Organization (NHPCO) to identify 4 common categories of prescription drugs that are typically used to treat these symptoms:  antinauseants, laxatives, analgesics, and antianxiety drugs.  These categories of drugs should be covered under the Hospice benefit; however, some instances occur in which 1 or more of these drug categories may be unrelated to the terminal diagnosis of the beneficiary.  In these situations the Part D benefit is responsible for coverage of the drug and the patient assumes any copayment required. It is beneficial for the provider to understand the steps involved from the Medicare Part D plan sponsor in the coverage or rejection of the claim.
  1. 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.
Code Description
A3 This product may be covered under Hospice-Medicare A
75 Prior Authorization Required
569 Provide Notice:  Medicare Prescription Drug Coverage and Your Rights
2. Plan sponsors are required to provide a point of sale message that states: “Hospice Provider- Request Prior Authorization for Part D Drug Unrelated to Terminal Illness or Related Conditions” This message should also include the 24 hour pharmacy help desk number to call with questions. 3. The beneficiary, beneficiary’s representative, or prescriber may contact the plan sponsor to request a coverage determination.
  • 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.
In some instances the plan sponsor may contact the Hospice provider and receive information that the drug is related to the terminal illness or related condition but it has been determined to be a beneficiary liability.  Once the plan sponsor has received the statement that a drug is unrelated to the terminal illness or related conditions the adjudication process can take no more than 24 hours for expedited requests or 72 hours for standard requests.  (Section 30.2 Chapter 18 Medicare Drug Benefit Manual) Beneficiary liability indicates that the patient is assuming responsibility for the cost of the drug.  Beneficiary liability can occur when the Hospice interdisciplinary group has determined, after discussion with the patient and family, that the existing medication/s may no longer be effective in the intended treatment and/or may be causing negative symptoms in the individual.  The medications would not be covered under the Medicare Hospice benefit as they would not meet the requirements of reasonable and necessary for palliation of pain and/or symptom management.  The patient may choose to have these medications filled through their pharmacy, if this occurs then the medications then become a beneficiary liability for payment and the cost of the medication would not be covered under Medicare Part D.  A patient may also request a drug for his/her terminal illness that is not included in the Hospice formulary and the beneficiary refuses to try a formulary equivalent first; or the drug has been determined by the Hospice provider to be unreasonable or unnecessary for the patient’s palliation of pain and/or symptom management.  The drug then becomes a beneficiary liability and no payment for the drug will be made under the Part D benefit. Hospice providers are encouraged to use the PA form prospectively to prevent the drug claim from rejecting at the point of sale for those drugs that fall into the 4 common categories that are unrelated to the terminal prognosis and the patient is prepared to obtain the drug.  Section II of the PA form is not required, however, as Part D plan sponsors complete retrospective reviews of medications covered under the Part D benefit that fall into the 4 common categories while the patient receives care under the Hospice benefit, the provider would find that incorporating the completion of section II in their practice would mitigate any questions in the future. The information covered in this article represents a fraction of the complexities associated with regulations that govern payment under Medicare benefits.  Select Data is dedicated to assisting your agency in answering these questions to enable you to meet the needs of your patients.  As an expert in the language of CMS, Select Data has over 25 years of preparation to service you.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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The OIG Work Plan and Your Agency

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OIG

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

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The OIG and their Focus on Six Measures of Questionable Billing

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Audits, OIG

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.

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