2013 OIG Work Plan. Scott McBride Baker & Hostetler LLP 1000 Louisiana, Suite 2000 Houston, Texas

Transcription

1 2013 OIG Work Plan Scott McBride Baker & Hostetler LLP 1000 Louisiana, Suite 2000 Houston, Texas

2 Webinar Essentials * Session is currently being recorded, and will be available on our website at * If you wish to ask questions: Questions may also be typed in the GoToWebinar Question panel. * CPE credit is available for this webinar for attendees who attend the live webinar. Please request credit by sending an to the UT Systemwide Compliance Office at systemwidecomp@utsystem.edu. * Please provide your feedback in the post-session survey.

3 OIG Work Plan U.S. Department of Health & Human Services Office of Inspector General Protect the integrity of HHS programs and operations Protect the well-being of beneficiaries Detect and prevent fraud, waste and abuse Identify opportunities to improve program economy, efficiency, and effectiveness Hold accountable those who do not meet program and legal requirements

4 OIG Work Plan OIG Work Plan New and ongoing reviews that the OIG plans to pursue during Fiscal Year 2013 Past success (FY 2011) $4.6 billion in investigative receivables $627 million in audit receivables $19.8 billion in estimated savings from OIG recommendations 2,662 exclusions of individuals and entities 723 criminal actions 382 civil actions, includes False Claims Act and unjust enrichment lawsuits, civil monetary penalty settlements, and administrative recoveries related to self-disclosure matters

5 Hospitals Inpatient Billing OIG will review how hospital billing for inpatient stays changed from FY2008 to FY2012 Medicare severity diagnosis related group (MS-DRG) OIG will review how inpatient billing varies among hospitals

6 Hospitals Diagnosis Related Group Window Outpatient services furnished 3 days prior to an inpatient stay are bundled into the inpatient admission if furnished by the hospital or by an entity owned or operated by the hospital OIG will evaluate how much money could be saved by expanding the DRG payment window from 3 days to 14 days

7 Hospitals Provider-Based Status OIG will determine the impact of physicians billing as provider-based practices OIG will also determine whether provider-based practices meet billing requirements MedPAC has suggested that payments should be similar

8 Hospitals Transfer and Discharge Issues Review of compliance with Medicare transfer policies and payment impacts for improperly coded discharges Review of discharges to swing beds in another hospital Review of discharges from acute care hospitals to hospice care

9 Hospitals Canceled Surgical Procedures Significant occurrence of canceled surgeries and initial PPS payment Followed by second higher payment for rescheduled surgery OIG says few, if any, inpatient services were furnished on initial inpatient stay Current Medicare policy does not preclude payment

10 Hospitals Present on Admission Indicators Must report which diagnoses were present on admission Payment impact for hospital-acquired conditions Tracking facilities who transfer patients with certain conditions that are coded POA

11 Hospitals Outlier Payments Review of trends Identify hospitals with high or increasing rates of outlier payments Medical Device Replacements How are the costs of replacement reported to Medicare Rebates, credits

12 Hospitals Inpatient Rehabilitation Facilities Appropriateness of admission Level of therapy being furnished Graduate Medical Education Review of resident counts; IRIS Effectiveness of preventing duplicate GME costs

13 Hospitals Same-Day Readmissions Review of CMS edit Outpatient Dental Claims Generally not covered Outpatient Observation Services Appropriateness of service Impact on patient due to cost sharing

14 Hospitals Acquisitions of ASC Hospital acquisition of ambulatory surgical center and then converted to provider-based facility Long Term Care Hospitals Review of payments and vulnerabilities for interrupted stays

15 Hospitals Billing Practices Review of payments and compliance with billing requirements Recovery of overpayments Identify providers that routinely submit improper claims Data mining and computer matching techniques for focused reviews Ranking of hospitals regarding their compliance risk

16 Hospitals Tufts Medical Center Review of 326 (250 inpatient / 76 outpatient) selected claims; 117 inpatient claims still being reviewed Non-compliance on 131 claims, resulting in net overpayments totaling $695,142 Overpayments occurred primarily because the Hospital did not have adequate controls to prevent incorrect billing of Medicare claims and did not fully understand the Medicare billing requirements within the selected risk areas.

17 Hospitals Tufts Medical Center Overpayment risk areas: Inpatient short stays Inpatient psychiatric facility emergency department adjustments Inpatient and outpatient manufacturer credits for replaced medical devices Inpatient transfers Inpatient claims billed with high severity level DRG codes Inpatient and outpatient claims paid in excess of charges Inpatient same-day discharges and readmissions Outpatient claims billed with modifiers Outpatient dental services

18 Hospitals University of Iowa Hospital Review of 398 (321 outpatient / 77 inpatient) selected claims Non-compliance on 274 claims, resulting in overpayments totaling $826,104 for CYs 2008 through 2011 Overpayments occurred primarily because the Hospital did not have adequate controls to prevent incorrect billing of Medicare claims.

19 Hospitals University of Iowa Hospital Overpayment risk areas: Outpatient claims billed for Lupron injections Outpatient and inpatient manufacturer credits for replaced medical devices Outpatient claims with payments greater than $25,000 Outpatient and inpatient claims paid in excess of charges Inpatient claims billed with high severity level DRG codes Inpatient post-acute transfers to skilled nursing facilities (SNF) Inpatient psychiatric facility transfers Inpatient same day discharge and readmission

20 Hospitals Brigham and Women s Hospital Review of 359 (293 inpatient / 66 outpatient) selected claims Non-compliance on 219 claims, resulting in net overpayments totaling $1,518,895 for CYs 2008 through 2010 These overpayments occurred primarily because the Hospital did not have adequate controls to prevent incorrect billing of Medicare claims or did not fully understand the Medicare billing requirements.

21 Hospitals Brigham and Women s Hospital Overpayment risk areas: Inpatient short stays Inpatient claims billed with high severity level DRG codes Inpatient same-day discharges and readmissions Inpatient hospital-acquired conditions and present-on-admission indicator reporting Inpatient claims for blood clotting factor drugs Outpatient claims billed with modifier -59 Outpatient evaluation and management services billed with surgical services Outpatient claims billed during inpatient stays Outpatient and inpatient manufacturer credits for medical devices Outpatient and inpatient claims paid in excess of charges

22 Physicians Compliance with Assignment Rules Billing beneficiaries in excess of Medicare allowed amount Beneficiary awareness of rights regarding billing violations and Medicare coverage guidelines

23 Physicians Physician-owned Distributors (PODs) of Spinal Implants High use of spinal implants Growing into other areas Concern of conflicts of interest and patient safety

24 Physicians Place of Service Errors Physician must identify the place where services are furnished Payment is impacted by POS

25 Physicians Evaluation and Management Services Coding trends; questionable billing in 2010 Use of modifiers during global surgery period Review of electronic health records for use of duplicate documentation (use of macros)

26 Physicians Incident to Services Requirements for incident to billing Qualifications of individual furnishing the service CMS monitoring concerns

27 Other Services / Providers Sleep Testing Anesthesia Services Ophthalmological Services Ambulance Transports Partial Hospitalization Services Electrodiagnostic Testing Chiropractors Pediatric Dental Services

28 Program Integrity High Cumulative Payments High cumulative payments may indicated incorrect billing or fraud and abuse Data mining to identify issues / providers Improper Use of Commercial Mailbox Indication of potential fraud Medical Claims Review at Selected Providers Error-prone providers; CERT results Review and extrapolate for payment recovery

29 Prescription Drugs Off-Label Use Review of support for off-label use Conflicts of Interest Review of conflicts of interest involving drug compendia Immunosuppressive Drug Claims Review of documentation support for modifier KX

30 Prescription Drugs Payment for Herceptin Application of Medicare drug wastage policy Outpatient Payments for Certain Drugs (e.g., chemotherapy) Review of proper billing and coding of units Prior audits identified certain drugs as being vulnerable to incorrect billing

31 Prescription Drugs Physician Administered Drugs Review of whether changes in the payment methodologies would save money Prostate Cancer Drugs Review of financial impact of rescinding the least costly alternative (LCA) policy Court ruled that LCA policy was not authorized under Medicare law

32 Contractors Prepayment Reviews Recovery Audit Contractors Security of Portable Devices

33 Research Construction Grants Review of spent funds for institutions which received construction grants to build, renovate, or repair biomedical and behavioral research facilities Grant Use Review of allowability of costs funded by CDC grant for reducing chronic disease and promoting healthy lifestyles

34 Research Equipment Claims by Grantees Review of equipment purchases to determine if they meet federal requirements Human Subject Protection Practices for Biospecimens Review of human subject protections and informed consent related to biospecimens

35 Research Compliance with OMB Requirements Extra compensation payments to faculty Cost principles Salaries from Multiple Universities Cost Sharing Claims by Universities

36 Research Protection of Human Research Subjects Office of Human Research Protections will be reviewed for its oversight of institutional compliance with Federal requirements Program Vulnerabilities to Grant Fraud

37 Public Health Select Agent Shipments to and from Foreign Countries Access to select agents is restricted to approved individuals Import and export controls will be reviewed Violations of Select Agent Requirements Coordination of efforts with CDC, FBI, and USDA to investigate violations of Federal requirements related to registration, storage, and transfer of select agents and toxins

38 Legal Activities Exclusions Civil Monetary Penalties False Claims Act and Corporate Integrity Agreements Review of entities who do not enter into Corporate Integrity Agreements Provider Compliance Training Provider Self-Disclosure Protocol

39 Compliance Programs Use the Work Plan to help focus on issues and conduct reviews Use the reviews to help demonstrate commitment to compliance Use the compliance activities to help mitigate and avoid liability and sanctions

40 Cincinnati Chicago Cleveland Columbus Costa Mesa Denver Houston Los Angeles New York Orlando Washington, DC International Affiliates São Paulo, Brazil Juárez, Mexico