Kusserow on Compliance: OIG reports top unimplemented recommendations

The HHS Office of Inspector General (OIG) Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs is an annual OIG publication. These recommendations, if implemented, are ones that would most positively impact HHS programs in terms of cost savings, program effectiveness and efficiency, and public health and safety. All were derived from audits and evaluations issued through December 31, 2019, which predated the COVID-19 public health emergency. Fourteen of the 25 were related to Medicare and Medicaid. The recommendations called for CMS to:

  1. Take actions to ensure that incidents of potential abuse or neglect of Medicare beneficiaries are identified and reported.
  2. Reevaluate the inpatient rehabilitation facility payment system, which could include seeking legislative authority to make any changes necessary to more closely align inpatient rehabilitation facility payment rates and costs.
  3. Seek legislative authority to comprehensively reform the hospital wage index system.
  4. Seek legislative authority to implement least costly alternative policies for Part B drugs under appropriate circumstances.
  5. Provide consumers with additional information about hospices’ performance via Hospice Compare.
  6. Continue to work with the Accredited Standards Committee X12 to ensure that medical device-specific information is included on claim forms and require hospitals to use certain condition codes for reporting device replacement procedures.
  7. Analyze the potential impacts of counting time spent as an outpatient toward the three-night requirement for skilled nursing facility (SNF) services so that beneficiaries receiving similar hospital care have similar access to these services.
  8. Provide targeted oversight of Medicare Advantage organizations (MAOs) that had risk adjusted payments resulting from unlinked chart reviews for beneficiaries who had no service records in the 2016 encounter data.
  9. Require MAOs to submit ordering and referring provider identifiers for applicable records in the encounter data.
  10. Develop and execute a strategy to ensure that Part D does not pay for drugs that should be covered by the Part A hospice benefit.
  11. Ensure that States’ reporting of national Medicaid data is complete, accurate, and timely.
  12. Collaborate with partners to develop strategies for improving rates of follow-up care for children treated for attention deficit hyperactivity disorder (ADHD).
  13. Develop policies and procedures to improve the timeliness of recovering Medicaid overpayments and recover uncollected amounts identified by OIG’s audits.
  14. Identify States that have limited availability of behavioral health services and develop strategies and share information to ensure that Medicaid managed care enrollees have timely access to these services.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Medicare overpaid hospitals $267M for post-acute care transfers to home health

An HHS Office of Inspector General (OIG) audit identified 89,213 inpatient claims totaling $948 million at risk of overpayment because of hospital transfer policies to home health agencies for post-acute care. The OIG selected a stratified sample of 150 claims which was reviewed by an independent medical review contractor to assess the relatedness of the home health services to the hospital admission. The review found that Medicare improperly paid most inpatient claims subject to the transfer policy when beneficiaries resumed home health services within 3 days of discharge. Hospitals failed to code the inpatient claim as a discharge to home health services when the hospitals applied condition codes 42 (home health not related to inpatient stay) or 43 (home health not within 3 days of discharge). Of the 150 inpatient claims in the sample, Medicare properly paid for just three claims. As a result, CMS improperly paid for 147 claims, for a total of $722,288 in overpayments. Medicare should have paid these inpatient claims using a graduated per diem rate rather than the full payment. The OIG estimated that Medicare improperly paid $267 million during a 2-year period for hospital services that should have been paid a graduated per diem payment.

Prior OIG audits identified Medicare overpayments to hospitals that did not comply with Medicare’s post-acute-care transfer policy and in response CMS instituted new corrective actions into the system. The OIG later found the policies were still not properly designed. The result is that hospitals may be using condition codes to bypass CMS’s system edits to receive higher reimbursements for inpatients transferred to home health services. Compliance officers should consider this—the transfer of patients from hospital in-patient care to post-acute care at home health agencies—as a risk area warranting an internal review.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG response plan—four goals for the COVID-19 Crisis

The HHS Office of Inspector General (OIG) has identified four goals to respond to the COVID-19 Pandemic: protecting people, protecting funds, protecting infrastructure, and promoting effectiveness. The OIG set out its framework in the OIG Strategic Plan: Oversight of COVID-19 Response and Recovery.

PROTECT PEOPLE. The OIG plans for this goal include to: (1) issue guidance on its administrative fraud enforcement authorities related to delivering needed patient care; (2) conduct rapid-cycle reviews of conditions affecting HHS beneficiaries or health care providers; (3) inform/support response efforts; (4) help ensure continuity of HHS operations during the public health emergency; (5) identify and investigate fraud and scams that endanger HHS beneficiaries and the public; (6) alert the public to fraud schemes related to COVID-19; and (7) assess the impacts of HHS programs on the health and safety in the acquisition, management, and distribution of COVID-19 tests and vaccine and treatment research and development.

PROTECT FUNDS. HHS was appropriated $251 billion for COVID-19 response and recovery—to prevent, prepare for, and respond to coronavirus, along with funds from other appropriations. The OIG plans for this  goal include: (1) reviewing of oversight, management, and internal controls for awarding, disbursement, and use of funds; (2) assessing whether recipients met requirements; (3) mitigating major risks that cut across program and agency boundaries; (4) ensuring that intended purposes of funds granted are being used properly; (5) identifying and investigating suspected fraud and exercising OIG’s administrative enforcement authorities; (6) identifying program integrity vulnerabilities and recommend safeguards; and (7) providing alerts to potential fraud risks or schemes to steal funds.

PROTECT INFRASTRUCTURE. Objectives for this goal include: (1) protecting the security and integrity of IT systems and health technology; (2) identifying IT vulnerabilities and incidents, mitigating threats, and restoring IT services; and (3) focusing on identifying and investigating cybersecurity vulnerabilities related to COVID-19 response.

PROMOTE EFFECTIVENESS. The OIG’s plans for this goal include: (1) focusing on COVID-19 efforts to identify successful practices and lessons learned from the emergency preparedness and response; (2) reviewing pandemic preparedness planning to identify how preparedness funding was spent; and (3) assessing COVID-19 impact on HHS programs and beneficiaries, including expanded telehealth in Medicare.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2020 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Medicare overpaying for graduate medical education (GME)

A study published in the Journal of the American Medical Association (JAMA) Internal Medicine raises questions about overpayments by Medicare for graduate medical education (GME) to train residents. By way of background, the Medicare Program makes payments to teaching hospitals for training physician residents. These payments are known as GME payments. Hospitals may also incur real and significant costs beyond training residents in the patient care setting. For those such costs, the Medicare Program makes direct GME (DGME) payments to hospitals for added direct costs incurred by teaching hospitals, such as stipends and/or fringe benefits paid to residents or to faculty who supervise the residents. The JAMA reported study suggests that if Medicare capped funds for GME at $150,000 per resident, it would free up over $1 billion a year and use the savings to address the shortage of doctors in certain specialties in underserved areas. The training of residents is funded by GME payments made to hospitals and health systems, largely through Medicare and Medicaid. Researchers examined cost reports to calculate GME payments to hospitals from 2000 to 2015 at among 1,624 teaching hospitals. The study found GME payment rates to hospitals in 2015 varied significantly, with 25 percent of hospitals receiving less than $105,761 while 25 percent received more than $182,233 per resident. Nearly half of teaching hospitals received more than the $150,000 per resident rate.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.