current oig enforcement initiatives: a road map for high risk

10th Annual HCCA Compliance Institute Session
Las Vegas, NV – April 25, 2006
CURRENT OIG
ENFORCEMENT INITIATIVES:
A ROAD MAP FOR HIGH RISK
COMPLIANCE AREAS
MARK HARDIMAN
HOOPER, LUNDY & BOOKMAN, INC.
1875 CENTURY PARK EAST, SUITE 1600
LOS ANGELES, CA 90067-2799
TEL: (310) 551-8197; FAX: (310) 551-8188
E-MAIL: [email protected]
PURPOSE OF OIG WORK PLAN
Not a “fraud” roadmap,
but a “plan” for where
OIG will invest its
resources in coming
year
p However, OIG Work
Plan is a valuable tool
for compliance
professionals with
respect to identifying
high risk “fraud and
abuse” areas
p
OIG WORK PLAN AUDITS/EVALUATIONS
OIG work plan audits/evaluations can
involve:
„ written record requests
„ on-site reviews by OIG auditors
„ witness interviews
p OIG will usually give provider a chance to
comment on preliminary findings
p OIG may assess overpayments
p Provider can have attorney present during
questioning (judgment call)
p
OIG WORK PLAN PROVIDER CATEGORIES
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Medicare hospitals, home health
agencies (HHAs), skilled nursing
facilities (SNFs), hospices, physicians &
professionals, durable medical equipment
(DME) suppliers, and other Medicare
providers (lab, IDTF, CORF, ambulance)
Medicaid hospitals, long term &
community care providers, mental health
care providers, and other Medicaid
providers
HOSPITAL HIGH RISK ITEMS
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Inpatient Admissions for Dialysis Services
DRG Coding
Inpatient Rehab Facility (IRF) Services
Inpatient Psychiatric Services
Long Term Care Hospitals
Organ Acquisition Costs
Hospital Rebates
Coronary Artery Stents
Outpatient Services
Hospital Lab & Radiology Services
Medicaid “72-hour” Payment Window
INPATIENT DIALYSIS ADMISSIONS
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Observation services are outpatient
services, lasting up to 48 hours, paid on
hourly basis, while inpatient services are
paid under a Diagnosis-Related Group
(DRG) at a much higher rate
OIG will examine hospital admissions
for dialysis treatment – lasting from 24
to 48 hours – to determine whether
underlying physician orders were for
“admission to observation status”
ABERRANT DRG CODES
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Under prospective payment system
(PPS), proper DRG payments for
inpatient acute care depend on
accurate coding of diagnoses and
procedures
OIG will examine DRGs with history
of aberrant coding to identify hospitals
with aberrant coding patterns
Note: Hospitals may be selected
based on First look Analysis Tool for
Hospital Outlier Monitoring (FATHOM)
IRF SERVICES
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Inpatient rehabilitation facilities
(IRF) services are reimbursed
under PPS
OIG will examine whether IRF
claims were made in accordance
with applicable Medicare laws &
regulations
Focus on IRF admissions,
interrupted stays, and reduced
payments for late patient
admission and discharge
assessments
INPATIENT PSYCHIATRIC SERVICES
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Inpatient psychiatric services are now
generally reimbursed under PPS, rather
than on reasonable cost basis
OIG will examine whether hospitals
submitted improper PPS claims for
inpatient psychiatric services which lacked
medical necessity or otherwise were
nonallowable
LONG-TERM HOSPITAL CARE
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After PPS reimbursement for long-term
hospitals implemented, “explosive”
growth in long-term care provider group
occurred
OIG will examine whether claims by
long-term care hospitals were
submitted in accordance with
Medicare laws & regulations
Focus on early discharges to home,
interrupted stays, outlier payments, and
whether patients were receiving acutelevel services or could be cared for in
SNFs
HOSPITAL ORGAN ACQUISITION COSTS
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Hospitals are retrospectively
reimbursed on reasonable cost
basis for costs of acquiring organs
for transplant
OIG will examine whether hospitals have
improperly claimed organ acquisition costs in
cost reports by shifting costs from posttransplant to pre-transplant activities and from
other hospital cost centers to organ
acquisition cost center, and reasonableness of
payments to organ procurement organizations
HOSPITAL REBATES
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Hospitals required to report
rebates and discounts as
purchase credits on separate
line item on cost reports
OIG will examine whether
hospitals are properly reporting
purchase credits by comparing
hospital cost reports with
rebate payment records of
several large medical supply
vendors
HOSPITAL CORONARY ARTERY STENTS
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Arterial stent implantation is a
covered service
OIG will examine inpatient &
outpatient claims for coronary
arterial stents to determine
whether service was medically
necessary, properly
documented, and in the case
of stents implanted during
multiple surgeries, whether
stents could have been
implanted simultaneously
HOSPITAL OUTPATIENT SERVICES
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As of 2000, hospital outpatient
services are reimbursed under the
Hospital Outpatient PPS
OIG will examine whether
outpatient services were paid in
accordance with Medicare
regulations, with a focus on outlier
payments, unbundling, billing for
multiple or repeat procedures and
global surgeries, and “inpatient
only” services performed in an
outpatient setting
HOSPITAL LAB AND RADIOLOGY SERVICES
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In 2001, Medicare paid $73
million for lab services furnished
in hospital setting, although it
only pays for the PC
OIG will examine whether
claims for such lab services
were allowable
Note: In a similar study, OIG
will also examine whether
radiology tests furnished to
inpatients were separately billed
to Medicare Part B
MEDICAID HOSPITAL “72-HOUR”
PAYMENT WINDOW
Medicare regulations prohibit separate
hospital billing of laboratory and other
services within 3 days of hospital
admission because such services are
already included in hospital’s DRG
discharge rate
p OIG will examine whether Medicaid
overpayments occurred in states with
a similar regulatory prohibition against
separate hospital reimbursement for
inpatient-stay-related lab and other
services
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NURSING HOME HIGH RISK ITEMS
Hospital & SNF
consecutive inpatient
stays
p SNF day of discharge
payments
p SNF rehabilitation
and infusion therapy
services
p SNF imaging and lab
services
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HOSPITAL/SNF CONSECUTIVE
INPATIENT STAYS
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A Medicare SNF stay must be
preceded by an inpatient hospital
stay in order to be covered
OIG will examine claims for
patients who had three or more
consecutive inpatient stays,
including at least one SNF
facility, to determine whether
such stays were medically
necessary and reasonable
SNF DAY OF DISCHARGE PAYMENTS
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A SNF patient’s day of discharge is not a
day of billable Medicare services
OIG will examine whether SNFs are
improperly claiming payment for services
on the date of a patient’s discharge
SNF REHAB & INFUSION
THERAPY SERVICES
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Medicare covers rehabilitation and
infusion therapy service services for
a variety of medical and postsurgical
conditions ordered by a physician
and performed by the SNF’s nursing
staff
OIG will examine whether claimed
SNF rehabilitation and infusion
therapy services were medically
necessary, adequately documented,
and actually provided as ordered
SNF IMAGING & LAB SERVICES
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Medicare covers medically
necessary imaging and
laboratory services
provided to SNF residents
OIG will examine whether
claimed SNF imaging and
laboratory services ($200
million per year) were
medically necessary and
reasonable by reviewing a
sample of SNF claims and
SNF utilization patterns
PHYSICIAN HIGH RISK ITEMS
Excluded ordering physicians
p Physician hospice care plan
oversight
p Physician pathology, wound care,
& mental health services
p Physician cardiography and
echocardiography services
p “Long distance” physician claims
p Physical & occupational therapist
services
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EXCLUDED ORDERING PHYSICIANS
Medicare claims for services
ordered by excluded physicians
are nonallowable
p OIG will examine the amount of
claimed Medicare services
ordered by excluded physicians
p Note: Potential Civil Monetary
Penalty (CMP) exposure for
facilities or individuals that bill for
services of excluded physician
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PHYSICIAN HOSPICE CARE
PLAN OVERSIGHT
Medicare covers physician oversight of
hospice care plans if the care
involves complex or multidisciplinary
modalities requiring regular physician
supervision and revision of the plan
p OIG will examine whether claimed
physician oversight – increasing
from $15 million in 2000 to $41 million in
2001 – was furnished in accordance with
Medicare regulations
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PHYSICIAN PATHOLOGY, WOUND
CARE, & MENTAL HEALTH SERVICES
Medicare covers pathology,
wound care, and mental health
services performed in physician
offices
p OIG will examine (a) the medical necessity of
such pathology services and the relationship
between ordering physicians and outside
pathology companies, and (b) whether such
wound care and mental health care services
were medically necessary and properly billed
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PHYSICIAN CARDIOGRAPHY SERVICES
Medicare covers
cardiography and
echocardiography services
p OIG will examine whether
physicians properly billed
for cardiography and
echocardiography by using
billing modifier 26 when
only the professional
interpretation was
performed
p
“LONG DISTANCE” PHYSICIAN
SERVICES
Medicare covers physician
specialist services and physician
services during patient travel
p OIG will examine whether claimed “long
distance” physician services for face-toface encounters where a “significant
distance” separated the practice setting
and the patient’s location were actually
provided and accurately reported
p
PHYSICAL & OCCUPATIONAL
THERAPIST SERVICES
pMedicare
covers therapy services
provided by physical and
occupational therapists if prescribed
by physicians and medically needed
to improve or restore functions,
prevent further disabilities, and
relieve symptoms
p OIG will examine whether claimed therapy
services (especially in Comprehensive
Outpatient Rehabilitation Facilities (CORFs))
were reasonable and necessary, adequately
documented, and certified by physicians
OTHER WORK PLAN HIGH RISK ITEMS
High cost or high volume
DME items
p Home Health Agency
(HHA) DME claims
p Independent Diagnostic
Testing Facility (IDTF)
services
p Ambulance services
p
HIGH COST OR HIGH VOLUME DME
Medicare covers therapeutic
footwear for diabetes patients,
power wheel chairs, wound care
equipment and supplies, and
glucose testing supplies
p OIG will examine whether these
claimed high cost or high volume
DME items were medically
necessary, adequately
documented, and delivered to the
patients
p
HOME HEALTH AGENCY DME CLAIMS
Medicare covers certain
DME items and supplies
for patients receiving
home health care
p OIG will examine whether
these DME items and
supplies were reasonable
and necessary for the
patients’ medical
conditions
p
IDTF SERVICES
Medicare covers IDTF diagnostic
testing services if the services are
medically necessary and satisfy
physician supervision and
technician qualification
requirements
p OIG will examine whether IDTF
services had “prior approval” and
were performed with the designated
level of physician supervision and by
properly licensed technicians
p
AMBULANCE SERVICES
Medicare covers outpatient
ambulance services when the
use of other means of
transportation are
contraindicated by the patient’s
condition
p OIG will examine whether
claimed outpatient ambulance
services were (a) medically
necessary and reasonable, and
(b) improperly provided to
inpatients in 2001 and 2002
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INTEGRATION OF OIG WORKPLAN
INTO COMPLIANCE PLANS
Compliance committee agenda
p Amend compliance plan
p Add risk areas
p Conduct audits
p Educate management, staff and
physicians (distribute plan with
explanation and conduct
Inservices & seminars)
p Documentation
p