Kusserow on Compliance: OIG’s planned work for home health agencies

Home Health Agencies (HHAs) remain one of the top enforcement priorities for the DOJ and HHS Office of Inspector General (OIG). Considerable OIG investigative resources are devoted to HHA fraud. However, the OIG auditors and evaluators are also focusing on HHA waste and abuse. For example, in May 2019, the OIG released several audit reports related to HHAs, including those for EHS Home Health, Excella Home Care, Great Lakes Home Health, and Metropolitan Jewish Home Care. The OIG found a number of deficiencies, including beneficiaries who were not homebound that were able to ambulate without assistance and perform home exercises, or had only a partial episode (wound healed). In addition, in many cases, documentation was not provided or did not support services. To continue its efforts in this area, the OIG has added several planned audits and evaluations related to HHAs, including the following:

  1. OIG will review supporting documentation to determine whether home health claims with 5 to 10 skilled visits in a payment episode, in which the beneficiary was discharged home, met the conditions for coverage and were adequately supported as required by federal guidance.

 

  1. Recent OIG reports disclosed high error rates at individual HHAs, consisting primarily of beneficiaries who were not homebound or who did not require skilled services. So, the OIG will continue its efforts regarding whether home health claims were paid in accordance with federal requirements.

 

  1. Using data from the CMS’s Comprehensive Error Rate Testing (CERT), the OIG plans to identify the common characteristics of “at risk” HHA providers that could be used to target pre- and post-payment review of claims.

 

  1. The OIG will review Medicare Part A payments to HHAs to determine whether claims billed to Medicare Part B for items and services were allowable and in accord with federal regulations. Generally, certain items, supplies, and services furnished to patients are covered under Part A and should not be separately billable to Part B. the OIG has previously found noncompliance with these Medicare billing requirements.

 

  1. The OIG will compare HHA survey documents to Medicare claims data to look for evidence of patients omitted from HHA-supplied patient information from select recertification surveys using Medicare claims data.

 

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: OIG 2017 Work Plan projects relating to hospitals

The OIG released the 2017 Work Plan that summarizes new and ongoing reviews and activities they plans to pursue.  They removed items that were completed, postponed, or canceled, as well as those “Revised” items.  The major focus of the OIG is on the programs of CMS, which include Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  These programs account for more than 80 percent of HHS’s budget with total Federal program spending of $986 billion for FY 2016.  Medicare alone accounted for approximately $595 billion, which includes inpatient hospital, skilled nursing, home health, hospice, and physician services payments, as well as incentive payments for adopting health information technology, such as electronic health records (EHRs). CMS uses Medicare Administrative Contractors to administer Medicare Part A and Medicare Part B and to process claims for both parts for more than 37 million people and approximately $371 billion in payments. In addition, Medicare expended over $85 billion in Part D benefit payments in CY 2015, serving over 41 million beneficiaries. The following projects are those related to hospital.

  1. Hyperbaric oxygen (HBO) therapy. Determine whether Medicare payments related to HBO outpatient claims were reimbursed in accordance with Federal requirements.
  2. Incorrect Medical Assistance Days Claimed by Hospitals. Determine whether Medicare administrative contractors properly settled Medicare cost reports for Medicare disproportionate share hospital payments in accordance with Federal requirements.
  3. Inpatient Psychiatric Facilities. Determine whether such facilities complied with Medicare documentation, coverage, and coding requirements for stays that resulted in outlier payments.
  4. Inpatient rehabilitation (rehab) hospitals. Assess a sample of rehabilitation hospital admissions to determine whether the patients participated in and benefited from intensive therapy; and identify reasons patients were not able to participate and benefit from therapy.
  5. Intensity-modulated radiation therapy (IMRT). Determine whether the payments were made in accordance with Federal requirements.
  6. Outpatient Outlier Payments for Short-Stay Claims. Determine the extent of potential Medicare savings if hospital outpatient stays were ineligible for an outlier payment.
  7. Comparison of Provider-Based and Freestanding Clinics. Determine the difference in payments made to the clinics for similar procedures; and assess the potential impact on Medicare and beneficiaries of hospitals’ claiming provider-based status for such facilities.
  8. Reconciliations of Outlier Payments. Determine whether CMS performed necessary reconciliations in a timely manner to enable Medicare contractors to perform final settlement of the hospitals’ associated cost reports, as well as whether the Medicare contractors referred all hospitals that meet the criteria for outlier reconciliations to CMS.
  9. Hospitals’ Use of Outpatient and Inpatient Stays Under Medicare’s Two-Midnight Rule. Determine how hospitals’ use of outpatient and inpatient stays changed under Medicare’s two-midnight rule by comparing claims for hospital stays in the year prior to and the year following the effective date of that rule; and the extent to which the use of outpatient and inpatient stays varied among hospitals.
  10. Medicare Costs Associated with Defective Medical Devices. Identify the costs to Medicare resulting from additional use of medical services associated with defective or recalled medical devices.
  11. Payment Credits for Replaced Medical Devices That Were Implanted. Determine whether Medicare payments for replaced medical devices were made in accordance with Medicare requirements.
  12. Medicare Payments for Overlapping Part A Inpatient Claims and Part B Outpatient Claims. Determine whether outpatient claims billed to Medicare Part B for services provided during inpatient stays were made in accordance with Federal requirements.
  13. Selected Inpatient and Outpatient Billing Requirements. Determine hospitals’ compliance with selected billing requirements and recommend recovery of overpayments. Focus will be on those hospitals with claims that may be at risk for overpayments.
  14. Duplicate Graduate Medical Education Payments. Assess the effectiveness of preventing duplicate payments for DGME costs; and any appropriate payments.
  15. Indirect Medical Education Payments. Determine whether the IME payments were calculated properly.
  16. Outpatient Dental Claims. Roll up the results of our audits of Medicare hospital outpatient payments for dental services to provide CMS with cumulative results and make recommendations for any appropriate changes to the program.
  17. Nationwide Review of Cardiac Catheterizations and Endomyocardial Biopsies. Review Medicare payments to hospitals nationwide for outpatient RHCs and endomyocardial biopsies performed during the same patient encounter.
  18. Payments for Patients Diagnosed with Kwashiorkor. Roll up the results of our audits of Medicare hospital payments for kwashiorkor to provide CMS with cumulative results and make recommendations for any appropriate changes to the program.
  19. Review of Hospital Wage Data Used to Calculate Medicare Payments. Review hospital controls over the reporting of wage data used to calculate wage indexes for Medicare payments.
  20. CMS Validation of Hospital-Submitted Quality Reporting Data. Determine the extent to which CMS-validated hospital inpatient quality reporting data are accurate and complete.
  21. Long-Term-Care Hospitals Adverse Events in Postacute Care for Medicare Beneficiaries. Identify factors contributing to these events and determine the extent to which the events were preventable.
  22. Hospital Preparedness and Response to Emerging Infectious Diseases. Describe hospitals’ efforts to prepare for the possibility of public health emergencies resulting from emerging infectious disease threats; review use of HHS resources; and identify lessons and challenges faced by hospitals as they prepare to respond to emerging infectious disease threats.

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 © 2016 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG testifies regarding Detroit investigation results

The HHS OIG provided testimony before the House Ways and Means Subcommittee on Oversight, describing their work in Detroit to protect Medicare and Medicaid beneficiaries and to fight health care fraud from the field agent’s perspective. The OIG typically conducts investigations in partnership with other Federal and State agencies, as well as the private sector. Often investigations are part of the Detroit-based Medicare Fraud Strike Force, which combines the resources of Federal, State and local law enforcement entities to prevent and combat health care fraud across the country.

The OIG receives complaints or investigative leads from a variety of sources, including the OIG hotline, law enforcement partners, beneficiaries, providers, and informants. Traditional means of identifying fraud include conducting interviews of cooperating witnesses and surveillance. The schemes investigated range from billing for services not actually performed to organized criminal enterprises. The perpetrators of these frauds can range from highly respected physicians to individuals with no prior experience in the health care industry. The OIG highlighted some major areas of where they have been focusing, including:

  • Home and community-based services. Home and community-based services, including personal care services (PCS), which are particularly vulnerable to fraud, with investigations resulting in more than 350 criminal and civil actions and $975 million in investigative receivables for fiscal years 2011 – 2015.
  • Unnecessary prescriptions. Physicians write medically unnecessary controlled substance prescriptions in exchange for cash or submission by a patient to medically unnecessary services.
  • Prescription drug fraud. Enforcement action against and prevention of prescription drug fraud is a major priority to address a rapidly growing national health care problem, and an opioid epidemic with 678 pending complaints and cases involving Medicare Part D, which represents a 152-percent increase in the last 5 years.

The OIG employs data analytics and real-time field intelligence to detect and investigate program fraud and to target our resources for maximum impact. They also reported being a leader in the use of data analytics, employing a dedicated data analytics unit. The OIG also has direct access to Medicare claims data and use innovative methods to analyze billions of data points to identify trends that may indicate fraud, geographical hot spots, emerging schemes, and individual providers of concern. Testimony summarized the OIG national investigative results during the period of 2013 through 2015, as follows:

  • $11 billion in receivables, or money ordered or agreed in settlements
  • 2,856 criminal actions
  • 1,447 civil actions, and
  • 11,343 program exclusions.

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 © 2016 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Personal care services (PCS) attendants need stricter screening

 

The HHS OIG issued an “Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Services” (PCS), a nonmedical assistance to the elderly, people with disabilities, and individuals with chronic or temporary conditions so that they can remain in their homes and communities. It is typically provided by an attendant who works for personal care agencies enrolled in the Medicaid program. PCS is an optional Medicaid benefit that States may choose to provide under State plan options and/or through Medicaid waiver and demonstration authorities approved by CMS and it is their responsibility to develop qualifications or requirements for attendants to ensure quality of care. The OIG has issued a number of reports concerning high levels of improper payments, questionable care quality, and high amounts of fraud summarized in a Portfolio of 2012. The current report provides additional data concerning the problem and included results of a survey of State Medicaid Fraud Control Units (MFCUs) about fraud trends in the PCS program. Since that report, the OIG has opened more than 200 investigations involving fraud and patient harm and neglect in the PCS program across the country.

The OIG cited a number of examples of different schemes and the negative consequences, including billing for PCS either not necessary or not actually provided; recruiting Medicaid beneficiaries to participate in fraud schemes; and noting instances where patients were harmed, as result of abuse or neglect, resulting in some cases in hospitalizations and even death. The OIG reported discussing potential administrative actions with the CMS, including:

  • Issuing informational bulletins to states on how to improve internal controls for PCS.
  • Establishing minimum Federal qualifications and screening standards for PCS workers, including background checks.
  • Requiring States to enroll or register all PCS attendants and assign them unique numbers.
  • Require that PCS claims identify the dates of service and the PCS attendant who provided the service.
  • Considering whether additional controls are needed to ensure that PCS are allowed under program rules and are provided.