Kusserow on Compliance: New CMS proposed outpatient rules

The 2020 annual rule cycle has been active for CMS with several proposed rules in the outpatient prospective payment system (OPPS) area. Hospitals and health system executives should monitor these annual rules carefully for provisions that will affect their organizations’ operations. Among the significant regulatory rule proposals for hospital and health system executives are the following:

  1. Mandated disclosure of negotiated charges between health plans and hospitals for all items and services for about 300 “shoppable” services
  2. Proposed penalties which would be over $100,000 a year for noncompliant hospitals
  3. The addition of several ASC procedures
  4. The removal of total hip arthroplasty from the inpatient-only list for 2020, allowing the procedure to be performed on an outpatient basis
  5. Reduction of supervision level for hospital outpatient department from direct to general for hospital outpatient departments
  6. A requirement for prior authorization of certain outpatient department services.
  7. Continued payment reduction for 340B purchased drugs
  8. Increased per-day cost threshold for separate payment for certain outpatient drugs
  9. The establishment a prior authorization process for five categories of services that often may be cosmetic: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation
  10. Various updates to Hospital Outpatient Quality Reporting Program requirements

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

Kusserow on Compliance: Health care waste estimated at $760 – 935 billion

25 percent of health care costs are due to fraud, abuse, and wast

More waste than the Department of Defense budget

The estimated cost of waste in the U.S. health care system ranged from $760 billion to $935 billion, accounting for about one quarter of the of total health care spending of 3.82 trillion, according to a study published in Journal of the American Medical Association by researchers from the Institute of Medicine. The study was based on 6 previously identified domains of health care waste. These waste estimates are larger than the entire U.S. Department of Defense budget of $693 billion.  The researchers further projected potential savings from interventions that reduce waste of 25 percent, equaling about $191 billion to $282 billion. The six factors included in their focus of waste were: (1) failure of care delivery; (2) failure of care coordination; (3) overtreatment or low-value care; (4) pricing failure; (5) fraud and abuse; and (6) administrative complexity. The study noted that the United States spends more on health care than any other country, with costs approaching 18 percent of the gross domestic product (GDP)—more than $10 000 per individual.

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

Kusserow on Compliance: OIG Work Plan update on Hospital Sector

The HHS Office of Inspector General (OIG) Work Plan sets forth various audits and evaluations that are underway or planned during the fiscal year and beyond. Since June 2017, the OIG modifies the plan monthly to add new items and remove completed ones. When developing its plans, the OIG assesses relative risks in HHS programs and operations to identify those areas most in need of attention. The OIG recently reported updates to its planned work in the hospital sector that include:

  1. Determining whether: (1) skilled nursing facility (SNF) level of care was certified by a physician or a physician extender; (2) a condition treated at the SNF was one which the beneficiary received inpatient hospital services or a condition that arose while receiving care in a SNF; (3) daily skilled care was required; (4) services delivered were reasonable and necessary for the treatment of a beneficiary’s illness or injury; (5) improper Medicare payments were made on claims reviewed; and (6) hospital admissions were potentially avoidable.

 

  1. Reports on a data brief that describes nursing staffing levels reported by facilities to the Payroll‐Based Journal; examination of CMS’s efforts to ensure data accuracy and improve resident quality of care.

 

  1. Determining whether CMS corrected the common working file (CWF) edits and ensured they are working Prior review found that CMS CWF edits related to transfers to home health care, SNFs, and non‐IPPS hospitals were not working properly.

 

  1. Review of overstated Medicare charges on outpatient claims that contain both an outlier payment and a reported medical device credit to determine whether Medicare payments for replaced medical devices and their respective outlier payments were made in accordance with Medicare requirements.

 

  1. Determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals and will use results to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.

 

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.

Kusserow on Compliance: New OIG Work Plan items

The HHS Office of Inspector General (OIG) recently issued updates to its Active Work Plan (Work Plan). The Work Plan outlines ongoing and planned audits and evaluations for the fiscal year and beyond. Recent additions related to Medicare/Medicaid include the following:

  1. Medicare Part D Rebates Related to Drugs Dispensed by 340B Pharmacies. Drug manufacturers often do not pay for Medicare Part D prescription rebates filled at 340B-covered entities and contract pharmacies because the manufacturer already provides a discount on the drug. The OIG will conduct a study to determine the potential rebate savings if Part B program sponsors and manufacturers could agree on eligible prescriptions filled at 340B pharmacies that receive rebates.

 

  1. Characteristics of Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose. An OIG data brief found that about 71,000 Medicare Part D beneficiaries were at serious risk of opioid misuse or overdose in 2017. The OIG will study: (1) the characteristics of these beneficiaries, including their demographics and diagnoses; (2) the opioid utilization of these beneficiaries; and (3) the extent to which these beneficiaries have had adverse health effects related to opioids and any overdose incidents.

 

  1. Ensuring Dual-Eligible Beneficiaries’ Access to Drugs Under Part D: Mandatory Review.

Part D plans that meet certain limitations have the discretion to include different Part D drugs and drug utilization tools in their formularies. Under the Affordable Care Act, the OIG conducts an annual study to review the extent to which Part D sponsors’ formularies include drugs commonly used by Medicaid and Medicare Part D beneficiaries.

 

  1. Nursing Facility Staffing: Reported Levels and CMS Oversight. CMS uses the Payroll Based Journal auditable daily staffing data to analyze staffing patterns and populate the staffing component of the Nursing Home Compare website. It aids the public determine the results of health and safety inspections, quality of care at nursing facilities, and staffing. The OIG will issue two reports to: (1) describe nursing staffing levels that facilities report to the Payroll-Based Journal; and (2) examine CMS efforts to ensure data accuracy and improve resident quality of care.

 

  1. Medicare Part B Payments for Podiatry and Ancillary Services. Medicare Part B covers podiatry services for medically necessary treatment of foot injuries, diseases, or other medical conditions affecting the foot, ankle, or lower leg. It does not cover routine foot-care services unless they are: (1) necessary and integral part of otherwise covered services; (2) for the treatment of warts on the foot; (3) in the presence of a systemic condition or conditions; or (4) for the treatment of infected toenails. The OIG will review Part B payments to determine whether podiatry and ancillary services were medically necessary and supported in accordance with Medicare requirements.

 

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 Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

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