Kusserow on Compliance: Congressional hearing on Medicare fraud

The HHS Deputy Inspector General for Audit Services provided Congressional testimony related to Medicare fraud and began by noting that Medicare spending $700 billion annually on behalf of 59 million beneficiaries has grown to the point where it is more than 15 percent of all federal spending. With increasing number of beneficiaries and rising health care costs, it is estimated that Part A Trust Fund will be depleted by 2026; and spending for Medicare Part B will grow by more than 8 percent over the next 5 years, outpacing the U.S. economy. Medicare and Medicaid improper payments reported by HHS was $90 billion a year with two thirds involving Medicare fee-for-service payments due to errors associated with insufficient or no documentation. Although improper payments may occur in all types of health care, home health, skilled nursing facility (SNF), and inpatient rehabilitation facility (IRF) are areas of particular concern, representing 33 percent of the overall estimated improper payment rate for Medicare fee-for-service.

Responding to this high level of improper payments, the OIG is using advanced data analytics help the agency more effectively assess risk and pinpoint oversight efforts. The OIG uses data analytics to analyze millions of claims and billions of data points. At the macro level, the OIG analyzes data patterns to assess fraud and other types of risk across Medicare services, provider types, and geographic locations to prioritize our work and more effectively deploy our resources. At the micro level, the OIG uses data analytics, including near- real-time data, to identify potential fraud suspects for more in-depth analysis and to efficiently target investigations. OIG enforcement efforts involve a three-pronged approach that focuses on prevention, detection, and enforcement. The CMS’s Fraud Prevention System (FPS) was cited as serving an important tool with data analytics and predictive analytics for fraud-detection.  Once suspected fraud is identified, the OIG investigate the facts and pursue enforcement to hold perpetrators accountable and recover misspent taxpayer dollars.

 

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 © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Inappropriate denial of services and payments in the Medicare Advantage program

In an update to its Workplan, the HHS office of Inspector General (OIG) added a new project in June. The OIG Office of Evaluation and Inspection will be reviewing and evaluating the question of inappropriate denial of service and payment in the Medicare Advantage program. Medicare Advantage Plans must cover all of the services that original Medicare covers. Capitated payment models are used for these plans. It is based on payment per person rather than payment per service provided. A central concern about the capitated payment model used in Medicare Advantage is that there may be an incentive to inappropriately deny access to, or reimbursement for, health care services in an attempt to increase profits for managed care plans. There have been questions raised as to whether some of the plans may be inappropriately denying service claims as a means to increase their profits.  The OIG plans to conduct medical record reviews to determine the extent to which beneficiaries and providers were denied preauthorization or payment for medically necessary services covered by Medicare. To the extent possible, we will determine the reasons for any inappropriate denials and the types of services involved.

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 © 2018 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG report on vulnerabilities in the Medicare hospice program

15 specific actions recommended to reduce Hospice vulnerability

4 million Hospice beneficiaries with an annual cost of $17 billion

CMS plans to increase hospices reimbursement by $340 million

 

The HHS Office of Inspector General (OIG) reported on numerous evaluations, audits, and investigations of the hospice program that have resulted in questioned costs, as well as criminal and civil prosecutions. The result of this work has identified vulnerabilities in the program. By way of background, the objective of hospice is to provide great comfort and care to beneficiaries, their families, and caregivers at the end of a beneficiary’s life. This program has grown steadily over the past decade, with Medicare now paying about $17 billion annually on behalf of 1.5 million beneficiaries—grown from a half million in 2000. According to CMS, hospice expenditures are anticipated to continue rising 8 percent annually as more beneficiaries utilize the care. In their review of this program, the OIG found:

  1. Hospice providers do not always provide needed services to beneficiaries; sometimes provide poor quality care; and were not able to effectively manage symptoms or medications, leaving beneficiaries in unnecessary pain for many days.
  2. Beneficiaries and their families and caregivers do not receive crucial information to make informed decisions about their care.
  3. Hospices’ inappropriate billing costs Medicare hundreds of millions of dollars that included billing for an expensive level of care when the beneficiary does not need it.
  4. A number of fraud schemes in hospice care negatively affect beneficiaries and the program with some involving enrolling beneficiaries who are not eligible for hospice care, while other schemes involve billing for services never provided.
  5. The current payment system creates incentives for hospices to minimize their services and seek beneficiaries who have uncomplicated needs with a hospice being paid for every day a beneficiary is in its care, regardless of the quantity or quality of services provided on that day.

The OIG recommended that CMS implement 15 specific actions that relate to seven areas for improvement. The OIG called upon CMS to:

  1. Strengthen the survey process-its primary tool to promote compliance-to better ensure that hospices provide beneficiaries with needed services and quality care.
  2. Seek statutory authority to establish additional remedies for hospices with poor performance.
  3. Develop and disseminate additional information on hospices, including complaint investigations, to help beneficiaries and their families and caregivers make informed choices about hospice care.
  4. Educate beneficiaries and their families and caregivers about the hospice benefit, working with its partners to make available consumer-friendly information.
  5. Promote physician involvement and accountability to ensure that beneficiaries get appropriate care.
  6. Strengthen oversight of hospices, including analyzing claims data to identify hospices that engage in practices that raise concerns.
  7. Take steps to tie payment to beneficiary care needs and quality of care to ensure that services rendered adequately serve beneficiaries’ needs, seeking statutory authority if necessary.

Meanwhile CMS announced in proposed rulemaking plans to increase payments for hospices by 1.8 percent, or $340 million, up from $180 million increase last year. CMS also included under the new Proposed rule:

  • New standards to help determine what measures hospices will no longer have to report under its meaningful measures initiative.
  • Changes to the Hospice Compare policies site to correct massive amounts of incorrect addresses, phone numbers and profit status for providers.
  • Beginning January 1, 2019, Hospices will have 4½ months after the end of each quarter to review and correct data that will be reported publicly on the website.
  • Physician assistants will be recognized as attending physicians for Medicare hospice.
  • Aggregate cap limiting overall annual hospice payment will increase by 1.8 percent to $29,205.44.

 

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 © 2017 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: U.S. Sentencing Commission Federal Register Notice seeking public comment

This is time sensitive for those interested in making comments

The U.S. Sentencing Commission published a request for comment in the Federal Register seeking public comment and feedback on its list of tentative priorities for the amendment cycle ending on May 1, 2019. This is part of the annual amendment cycle, during which the Commission reviews and revises its guidelines. This year, the Commission is focusing on whether the time has come to prioritize amending Chapter Eight to cover drug-related offenses. Broadly defined, those offenses might include drug trafficking offenses, misbranding and adulteration of drugs, the sale of unapproved drugs, and dispensing certain drugs without a prescription. The Commission will not make final decisions on this subject until it has heard from the public. As such, those that have thoughts on this topic should consider weighing in with this opportunity of giving them feedback. If adopted, this priority could lead to guideline changes with a potential impact on the pharmaceutical, health care, and certain retail industries.  This may in turn impact the seven standard elements of an effective compliance program, and, in turn, the work of compliance officers.

Therefore, those that have thoughts about the proposed changes have the opportunity to have their ideas brought before the Commission. This includes whether this should be a priority for them now and, if so, how broad or narrow they should be on this issue. One area to consider is whether there are ideas and suggestions as to how the Commission should study this issue area over the next couple of years. At any rate, the Commission has opened the door for public feedback, ideas, and suggestions; however this is time sensitive in that the Commission will make its final decision on priorities at a public meeting in August, after considering all the public comments. If this is something of interest, more information is available at the Commission’s website.

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 © 2017 Strategic Management Services, LLC. Published with permission.