Medical Billing

The 2017 OIG Work Plan was issued by the Office of Inspector General on November 15, 2016. Historically, we have seen the Medicare Part A & B Work Plan focus primarily on hospitals with a few items for skilled nursing, home health, and hospice. This fiscal year, a total of 24 new items were added, with five focused on nursing/skilled nursing facilities and three focused on hospice or hospice home health. The remaining 16 items are a mix of outpatient services, durable medical equipment, care management/quality of care, and inpatient rehabilitation.

The Medicare Part C & D Work Plan includes a focus on payments for service dates after a date of death, denials by Medicare Advantage Plans, Part D rebates on drugs dispensed by 340B Pharmacies, and questionable billing for compounded topical drugs.

In the Medicaid arena, the OIG focus impacting providers will be on personal care services.

The following is a list of the OIG focus for each of the new topics, and items you, as a provider or supplier, may want to consider.

As a provider, you may consider running a report of diagnoses of the patients receiving services. Verify that each diagnosis meets one of the 15 covered conditions for reimbursement. Review your medical documentation against the National Coverage Determination requirements and verify you have all the required information documented, and lastly, make sure that patients are not exceeding the medical necessity thresholds for treatments (i.e. continued treatment with hyperbaric oxygen therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment).You may wish to consider reviewing your reported Medicaid patient days, specifically to ensure that reported Medicaid days do not include S-CHIP and ARCH recipients from calculation of Medicaid patient days.Consider reviewing all inpatient psychiatric stays that resulted in outlier payments to determine if documentation and coverage requirements were met in accordance with the federal guidelines.Review all patients who are not suited for or have not received at least the minimum amount of therapy required (i.e. at least three hours of therapy, five out of seven days of the week). Determine if their admission to inpatient rehabilitation is appropriate based upon their medical condition and ability to participate.If you, as a provider, received an immediate jeopardy on a nursing home complaint, review the issues from that complaint and verify that corrective actions are still in place and functioning as intended. If a follow-up visit did not occur from the state agency, be prepared for a visit from them on the issue.Skill nursing facility (SNF) providers should review all grievances and reported incidents to determine if any of the incidents were not investigated or reported to the required agencies. If identified, providers should immediately remediate the identified incidents.SNF providers should review all patients in high therapy resource utilization groups (RUGs) to determine if the documentation in the medical record by nursing and therapy align with data as reported on the minimum data set (MDS). Areas of inconsistency should be further investigated to determine if the data reported on the MDS was appropriate or if claims should be re-filed.The OIG will be issuing this tool in FY2017 for use by all SNFs to utilize upon release. SNFs should be looking for this tool and immediately implement the tool upon release.The OIG will issue a summary fraud alert highlighting key recommendations for protecting beneficiaries and improving the Hospice program in FY2017. Facilities should review the guidance and assess whether any vulnerabilities exist relative to the reported payment, compliance oversight, and quality of care concerns.Hospice providers should review the medical record documentation for a sample of patients with long-term illness diagnoses which may not have an immediate decline (e.g. Alzheimer’s, COPD, et cetera) to verify that the medical documentation supports the appropriateness of hospice care in accordance with federal guidelines.Hospice providers of in-home care should review scheduled supervising nurse visits on admitted patients to verify that the supervising nurse is visiting at least once every 14 days to assess the quality of care and services provided. These visits should be clearly documented in the patient’s medical record.Suppliers of durable medical equipment, prosthetic, orthotic, and supplies (DMEPOS) equipment to patients in SNFs should review supporting documentation for the therapy and supplies which were provided and billed under Medicare Part B. Verify that all documentation supporting the medical necessity of the supplies are present in the file and that all claims are supported by appropriate orders.Providers of the diabetic testing strips should be aware that OIG is investigating market shares relative to the three-month period preceding the implementation of the National Mail Order Recompete, as well as two additional three-month periods to assess shifts in the market.Suppliers of items such as PAP machines, mask, tubing, headgear, and filters should review shipping and billing patterns to verify that these items are only being shipped upon a refill request from the beneficiary or caregivers, and are not automatically shipping without orders for refills and/or requests for refills from the beneficiary.Clinical diagnostic laboratories should be aware that the OIG will be looking at the top 25 laboratory tests by Medicare payments and will be assessing the market-base system payments associated with those tests.Physician practices should assess whether they appropriately filed for payments for transitional care management, and appropriately excluded filing for chronic care management, end-stage renal disease, and prolonged services without direct patient contact during the same service period.Physicians should review patients for whom chronic care management was billed to verify that the following were not also billed during that time period: transitional care management, home health care supervision/hospice care, or certain end-stage renal services.Physicians should be aware that CMS and OIG will be reviewing their prescribing patterns as it relates to drugs and orthotics for those vendors who have reported a financial relationship with the physicians to determine if there is evidence of skewing of practice patterns toward those manufacturers or group purchasing organizations.Providers of power mobility devices should be aware that an alert will be issued by OIG in FY2017 which will include recommendations to reduce vulnerabilities of medically unnecessary payments. Providers should review this document and adjust practice patterns accordingly.Providers should review documentation on wasting of single use vials to ensure that the documentation is appropriate, and to verify that the JW modifier is being utilized in an appropriate manner. The OIG will be looking a vial sizes wasted and the ability to purchase the drugs in a smaller vial to reduce the amount of waste.The OIG is focusing on the amount of savings possible if inflation-indexed rebates were required under Medicare Part B. There is no direct impact at this time to providers or manufacturers, but both entities should keep an eye on the developments from this review for potential future impacts.Providers should review their claim edit system to verify an edit is in place to catch any dates of service dated after the date of a patient’s death. If no edit is in place, providers should review any claims filed for deceased patients to verify no dates of service after the date of death were inadvertently included on the claim.This summary being prepared by the OIG and issued in FY2017 will provide a summary of the key challenges and vulnerabilities which may exist as CMS begins to implement MACRA, MIPS, and AAPMs.Medicare Advantage Plans should be aware that OIG will be looking at patterns of denials, appeals, and overturned denials to determine the extent to which the Medicare Advantage Plans are inappropriately denying services. Future work will occur, and may include medical record reviews.The OIG will be looking at the upper bound of what could be saved if pharmaceutical manufacturers paid rebates for drugs dispensed through the Medicare Part D program at 340B covered entities and contract pharmacies. Manufacturers may consider running calculations to determine the future revenue impact of a shift in coverage toward requiring rebates in order to plan for future impacts.Compounding pharmacies should review their patterns of compounding and associated relationships with the prescribers. The OIG will be targeting selected pharmacies for questionable Part D billing patterns.Medicaid managed care organizations (MCOs) should review capitation payments made to providers to determine if the reimbursement includes reimbursement for drugs which are not included on the Medicaid drug tape as provided by CMS.Providers of personal care services should be looking for the issuance of this data brief in FY2017. Upon issuance, providers should review the key data regarding investigations, patient abuse and neglect, and ensure that provider practices are designed to mitigate or eliminate the noted practices, in alignment with the practice recommendations which will be included in the data brief.Individual states will be reviewed for compliance to federal and state requirements when incentive payments were made to providers. Providers should be aware of this audit and the potential for recoupment as result of any findings.Selected accountable care organization (ACO) models in Medicaid will be reviewed for compliance with relevant state and federal requirements. ACOs should assess their level of compliance with state and federal requirements and adjust practices as necessary to ensure compliance.This review will be focused at the state level but may impact providers due to recoupments. Providers should assess policies and procedures around verification of third-party payers to ensure that Medicaid is billed as the payer of last resort.The focus in this review will be on whether states recouped required amounts from providers and properly remitted the recoupments to CMS. Providers subject to recoupment as the result of prior audits or reviews should be prepared for the recoupment to occur if it has not already been remitted to the state as required.The focus will be on states’ assignment of Medicaid-only providers to federally-designated risk categories during screening processes for fraud, waste, and abuse. Providers who have not yet been through the screening process should be prepared to participate in the process as states verify completeness.States which tax MCOs will be the focus. The focus will be on whether the tax programs meet federal hold-harmless requirements, and may impact Medicaid MCOs down the road based upon the outcome of the review.Medicaid MCOs will be targeted to determine if they continue to pay providers for inpatient hospital services related to treating certain preventable conditions. Both Medicaid MCOs and providers should be aware of this review. MCOs may want to review the provider-preventable conditions and verify they have appropriate edits in place. Providers may want to review claims filed to Medicaid or Medicaid MCOs to determine if any included the preventable conditions and calculate the amount of money owed back.

The summary above includes only those items new to the Work Plan this fiscal year. In addition, the OIG has revised 12 previously existing projects, and continues to carry forward other items from prior work plans that have on-going activity. Providers should continue to review and assess work plan areas for applicability to their operations.

If you have any questions, contact:

Adam Shewmaker: ashewmaker@ddafhealthcare.com
Shawn Stevison: sstevison@ddafhealthcare.com