CURRENT OIG ENFORCEMENT INITIATIVES: A ROAD MAP FOR HIGH RISK COMPLIANCE AREAS

Transcription

1 10 th 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 CENTURY PARK EAST, SUITE 1600 LOS ANGELES, CA TEL: (310) ; FAX: (310) MHARDIMAN@HEALTH-LAW.COM LAW.COM

2 PURPOSE OF OIG WORK PLAN Not a fraud roadmap, but a plan for where OIG will invest its resources in coming year However, OIG Work Plan is a valuable tool for compliance professionals with respect to identifying high risk fraud and abuse areas

3 OIG WORK PLAN AUDITS/EVALUATIONS OIG work plan audits/evaluations can involve: written record requests on-site reviews by OIG auditors witness interviews OIG will usually give provider a chance to comment on preliminary findings OIG may assess overpayments Provider can have attorney present during questioning (judgment call)

4 OIG WORK PLAN PROVIDER CATEGORIES Medicare hospitals, home health agencies (HHAs( HHAs), skilled nursing facilities (SNFs( 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

5 HOSPITAL HIGH RISK ITEMS 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

6 INPATIENT DIALYSIS ADMISSIONS 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

7 ABERRANT DRG CODES 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)

8 IRF SERVICES 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

9 INPATIENT PSYCHIATRIC SERVICES 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

10 LONG-TERM HOSPITAL CARE 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 acute- level services or could be cared for in SNFs

11 HOSPITAL ORGAN ACQUISITION COSTS 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 post- transplant to pre-transplant activities and from other hospital cost centers to organ acquisition cost center, and reasonableness of payments to organ procurement organizations

12 HOSPITAL REBATES 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

13 HOSPITAL CORONARY ARTERY STENTS 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

14 HOSPITAL OUTPATIENT SERVICES 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

15 HOSPITAL LAB AND RADIOLOGY SERVICES 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

16 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 s DRG discharge rate OIG will examine whether Medicaid overpayments occurred in states with a similar regulatory prohibition against separate hospital reimbursement for inpatient-stay stay-related lab and other services

17 NURSING HOME HIGH RISK ITEMS Hospital & SNF consecutive inpatient stays SNF day of discharge payments SNF rehabilitation and infusion therapy services SNF imaging and lab services

18 HOSPITAL/SNF CONSECUTIVE INPATIENT STAYS 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

19 SNF DAY OF DISCHARGE PAYMENTS A SNF patient s 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 s discharge

20 SNF REHAB & INFUSION THERAPY SERVICES 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

21 SNF IMAGING & LAB SERVICES 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

22 PHYSICIAN HIGH RISK ITEMS Excluded ordering physicians Physician hospice care plan oversight Physician pathology, wound care, & mental health services Physician cardiography and echocardiography services Long distance physician claims Physical & occupational therapist services

23 EXCLUDED ORDERING PHYSICIANS Medicare claims for services ordered by excluded physicians are nonallowable OIG will examine the amount of claimed Medicare services ordered by excluded physicians Note: Potential Civil Monetary Penalty (CMP) exposure for facilities or individuals that bill for services of excluded physician

24 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 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

25 PHYSICIAN PATHOLOGY, WOUND CARE, & MENTAL HEALTH SERVICES Medicare covers pathology, wound care, and mental health services performed in physician offices 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

26 PHYSICIAN CARDIOGRAPHY SERVICES Medicare covers cardiography and echocardiography services OIG will examine whether physicians properly billed for cardiography and echocardiography by using billing modifier 26 when only the professional interpretation was performed

27 LONG DISTANCE PHYSICIAN SERVICES Medicare covers physician specialist services and physician services during patient travel OIG will examine whether claimed long distance physician services for face-to to- face encounters where a significant distance separated the practice setting and the patient s s location were actually provided and accurately reported

28 PHYSICAL & OCCUPATIONAL THERAPIST SERVICES Medicare Medicare 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 OIG will examine whether claimed therapy services (especially in Comprehensive Outpatient Rehabilitation Facilities (CORFs( CORFs)) were reasonable and necessary, adequately documented, and certified by physicians

29 OTHER WORK PLAN HIGH RISK ITEMS High cost or high volume DME items Home Health Agency (HHA) DME claims Independent Diagnostic Testing Facility (IDTF) services Ambulance services

30 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 OIG will examine whether these claimed high cost or high volume DME items were medically necessary, adequately documented, and delivered to the patients

31 HOME HEALTH AGENCY DME CLAIMS Medicare covers certain DME items and supplies for patients receiving home health care OIG will examine whether these DME items and supplies were reasonable and necessary for the patients medical conditions

32 IDTF SERVICES Medicare covers IDTF diagnostic testing services if the services are medically necessary and satisfy physician supervision and technician qualification requirements OIG will examine whether IDTF services had prior approval and were performed with the designated level of physician supervision and by properly licensed technicians

33 AMBULANCE SERVICES Medicare covers outpatient ambulance services when the use of other means of transportation are contraindicated by the patient s condition OIG will examine whether claimed outpatient ambulance services were (a) medically necessary and reasonable, and (b) improperly provided to inpatients in 2001 and 2002

34 INTEGRATION OF OIG WORKPLAN INTO COMPLIANCE PLANS Compliance committee agenda Amend compliance plan Add risk areas Conduct audits Educate management, staff and physicians (distribute plan with explanation and conduct Inservices & seminars) Documentation