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OIG 2017 Annual Work Plan

Monday, January 23rd, 2017

OIG Annual Work Plan for 2017 – Topics Covered

The Health and Human services Office of Inspector General (OIG) recently released its 2017 Annual Work Plan.  Work planning is an ongoing project within the OIG.  Every year, the OIG publishes a work plan that consolidates the OIG audits and evaluations that are being conducted or planned within the organization.  The annual work plan has become a source that compliance officers look to as a tool for the identification of potential risk areas or areas of emphasis within their organization.  It is obviously not the only source for identifying compliance risk areas, but is certainly one reliable source that providers can draw on when setting their annual compliance priorities.

The 2017 OIG Work Plan can be download through the OIG site.

Ruder Ware’s health care group will continue to put out blogs and articles on various issues identified in the 2017 Annual Work Plan.  We will focus primarily on issues that were introduced for the first time in this year’s plan.

A listing of some of the issues addressed in the 2017 annual work plan include:

Hyperbolic Oxygen Therapy Services – Provider Reimbursement in Compliance with Federal Regulations

Incorrect Medical Assistance Days Claimed by Hospital

Inpatient Psychiatric Facility Outlier Payments

Case Review of Inpatient Rehabilitation Hospital Patients Not Suites for Intensive Therapy

Intensity-Modulated Radiation Therapy

Outpatient Outlier Payments for Short-Stay Claims

Comparison of Provider-Based and Freestanding Clinics

Reconciliation of Outlier Payments

Hospital Use of Outpatient Stays Under Medicare’s Two Midnight Rule

Case Review of Inpatient Rehabilitation Hospital Patients Not Suited for Intensive Therapy

Medicare Costs Associated with Defective Medical Device

Payment Credits for Replaced Medical Device That Were Implanted

Medicare Payment for Overlapping Part A Inpatient Claims and Part B Outpatient Claims

Selected Inpatient and Outpatient Billing Requirements

Duplicate Graduate Medical Education Payments

Indirect Medical Education Payments

Outpatient Dental Claims

Nationwide Review of Cardiac Catheterization and Endomyocardial Biopsies

Payments for Patients Diagnosed with Kwahiorkor

Use if Hospital Wage Data Used to Calculate Medicare Payments

CMS Validation of Hospital-Submitted Quality Reporting Data

Long Term Care Hospitals – Adverse Events in Post-acute-Care for Medicare Beneficiaries

Hospital Preparedness and Response to Emerging Infectious Diseases

Nursing Home Complaint Investigation Data Brief

Skilled Nursing Facilities – Unreported Incidents of Potential Abuse and Neglect

Skilled Nursing Facility Reimbursement

Skilled Nursing Facility Adverse Even Screening Tool

National Background Checks for Long Term Care Employees – Mandatory Review

Skilled Nursing Facility Prospective Payment System Requirements

Potentially Avoidable Hospitalizations of Medicare and Medicaid Eligible Nursing Facility Residents

Medicare Hospice Vulnerabilities and Recommendations for Improvement

Review of Hospices Compliance with Medicare Requirements

Hospice Home Care – Frequency of Nurse On-Site Visits to Assess Quality of Care and Services

Comparing HHS Survey Documents to Medicare Claims Data

Home Health Compliance with Medicare Requirements

Part B Services During Non Part-A Nursing Home Stays; Durable Medical Equipment

Medicare Market Share of Mail-Order Diabetics Testing Strips

Positive Airway Pressure Device Supplier – Supplier Compliance Documentation Requirements for Frequency and Medical Necessity

Orthotic Braces – Reasonableness of Medicare payments Compared to Amount Paid by Other Payors

Osteogenesis Simulators – Lump Sum Purchase Versus Rental

Power Mobility Devices – Lump Sum Purchase Versus Rental

Competitive Machines and Related Drugs – Supplier Compliance with Payment Requirements

Access to Durable Medical Equipment in Competitive Bidding Areas

Orthotic Braces – Supplier Compliance with Payment Requirements

Nebulizer Machines and Related Drugs – Supplier Compliance with Payment Requirements

Access to Durable Medical Equipment in Competitive Bidding Areas

Monitoring Medicare Payments for Clinical Diagnostic Laboratory Tests – Mandatory Review

Medicare Payments for Transitional Care Management

Medicare Payments for Chronic Care Management

Data Brief on Financial Interests Reported Under the Open Payments Program

Off-Campus Provider-Based Departments Neutrality

Friday, December 23rd, 2016

Off-Campus Provider-Based Departments Site-Neutrality

The 21st Century Cures Act contains new provisions that prohibits the Centers for Medicare & Medicaid Services (CMS) from paying different rates for services provided in for services furnished in off-campus provider-based department (PBD) of a hospital.    The CY 2015 Outpatient Prospective Payment System Final Rule (79 FR 66910-66914) created a HCPCS modifier for hospital claims that is to be reported with every code for outpatient hospital items and services furnished in an off-campus provider-based department of a hospital. This 2-digit modifier was be added to the HCPCS annual file as of January 1, 2015, with the label ‘‘PO.’’ Reporting of this new modifier was voluntary for CY 2015, with reporting required beginning on January 1, 2016.

The 21st Century Cures Act revises this policy beginning January 1, 2017, with some exceptions. One exception is for OPBDs that billed for services furnished as of November 2, 2015 (the date the law was enacted). The 21st Century Cures Act expounds on this exception and permits providers to be grandfathered under the old rules if the Secretary received a properly filed provider-based attestation for the site from the provider prior to December 2, 2015.  Furthermore, if  an off-campus provider-based department was in development as of November 2, 2015 and made a timely filing of a certification to CMS,  the old rules can be applied even though the department was not operating as of the cut-off date.

John H. Fisher, CHC, CCEP is a health care attorney at the Ruder Ware law firm.  John is actively involved representing clients on legal and compliance issues.  He has represented clients in creating compliance programs and in a variety of operational issues.  He also assists providers in addressing risk areas and potential compliance issues including preparing self-disclosure and working with the government to resolve disclosed compliance issues and overpayment.  John consults as a subject matter expert and provider legal backup to other attorneys and law firms from around the country on specialized compliance, regulatory and health care issues.  John has followed legal issues impacting health care provider for over 25 years.  As such, he is knowledgeable on the current legal standards as well as the historic perspective that is often relevant to an appropriate analysis.  

Physician Owned Hospital Expansion – CMS Approval Process

Friday, May 16th, 2014

Obtaining Approval for Expansion of Physician Owned Hospitals 

physician owned hospitalsCurrently, federal law effectively prohibits the establishment of new physician-owned hospitals.  Expansion of existing physician-owned hospitals is also effectively prohibited.  An existing hospital may request an exception from the prohibition from the Center for Medicare and Medicaid Services.  An exemption may be granted by CMS, but not without the hospital going through the formal request and review process.

Under the federal Stark Law, physicians are prohibited from owning interests or having financial relationships with entities that provide “designated health services,” including hospital services, unless an exception exists.  Previous versions of the Stark Law contained an exception for investments in the hospital itself as opposed to a subdivision of the hospital (known as the “whole hospital” exception.  The Affordable Care Act virtually eliminated the “whole hospital” exception from the Stark Law for future hospital projects and for expansion of existing projects.

Beginning in March of 2010, a physician-owned hospital is prohibited from expanding existing capacity unless it applies for and is granted an exception as either an “applicable hospital” or a “high Medicaid facility.”  Federal regulations set forth the procedures that must be complied with when submitting requests for an exception.

Physician-owned hospitals that wish to expand existing capacity must follow the regulatory process for obtaining approval.  Part of this process involves CMS obtaining input from other providers in the community.  Even if expansion is approved, expansion cannot exceed 200% of the baseline number of operating norms, procedure rooms, and beds.  Expansion must be limited to the hospital’s primary campus.

Hospital Supervision Rules – Billing “Incident To” Physician Services

Tuesday, April 22nd, 2014

Hospital Supervision Rules for “Incident To” Services

hospital supervisions incident to reimbursementPhysician supervision rules in hospital outpatient departments have continually changed over the past five years.  Those who have followed these rules cannot help but wonder whether CMS is somewhat schizophrenic on this issue.  Hospital supervision rules have been like a moving target, making compliance difficult to track and to communicate to front line physicians and staff who must comply with these changing rules.

Services of a therapeutic nature are often performed by physician extenders in a hospital department and are billed “incident to” the physician’s services.  Historically, direct supervision was required to enable the service to be billed as “incident to” the physician’s services.  The direct supervision rule generally requires the physician to be “immediately available” to assist with and direct the service.  This does not necessarily require presence in the same room where the service is being delivered.  The precise requirements that must be complied with in order to meet the “direct supervision” requirement is where CMS has given us a moving target for compliance purposes.

In the 2009 OPPS Rule, CMS provided what it considered to be “clarification” of its rules.  To most providers, the CMS guidance actually amounted to a change of position that required changes in their supervision policies.  Before the 2009 “explanation,” many providers structured their compliance efforts under the assumption that they were not required to have a physician physically present in an outpatient department to meet the direct supervision requirement.  The 2009 “clarification” indicated that physical presence of a supervision provider was required.

The 2009 comments lead to much criticism from the provider community.  This resulted in further changes in the 2010 OPPS Rule that made it sufficient for the supervising physician to be present on the same campus and immediately available rather than requiring physical presence in the department.  Off campus clinics and departments were still required to meet the more restrictive physical presence requirement.  Physical presence of off campus departments required actual physical presence in the space that is designated as the department.  The supervising physician would not meet this standard even if they were located in the same building but not in the departmental office suite.

Although the 2010 rules answered some of the open questions, the rules had a huge negative impact primarily on smaller hospitals and particularly those located in rural areas.  Small hospitals were required to meet the physician “physical presence” requirements even when there was no other activity requiring physician presence.  This necessitated small hospitals to incur costs to meet the “incident to” supervision requirement even when physician presence was not otherwise required.

At least partly to address the “small hospital” issues, the 2011 OPPS Rule made significant changes to the physician supervision requirement.  The “on the same campus” rule was abandoned in favor of a rule that focused more on the general “availability” of the physician.  The 2011 rule eliminated many of the specific physical location requirement but still maintained the more general requirement that the physician be “immediately available to furnish assistance or direction throughout the performance of the procedure.”  The standard requires the physician to be immediately available and interruptible.  The rule also opened the door for the physician to be available by telemedicine to meet “general” supervision requirements.

The 2011 rule also identified certain services for which direct supervision is always required for the initiation of the services.  Services covered by special supervision requirements includes a limited listing of non-surgical and extended duration therapeutic services.  These services include certain injections, infusion and observation services.  Chemotherapy is not included in this listing.  These services are services that can have a longer overall duration and have a low risk of requiring physician involvement after the service is initiated.

The 2011 rule set up a panel to evaluate specific therapeutic services to determine the appropriate level of supervision.  The 2012 OPPS Rule formally designated the panel as the body that reviews and recommends changes in supervision requirements relative to various therapeutic services.  The 2012 rule also took steps to assure that critical access and rural hospitals were represented on the panel.  The panel is authorized to recommend levels of supervision that are lower than “direct supervision” for specific services.  The panel does not have the ability to directly enact regulations or make policy changes.  Its role is limited to that of advising CMS on these issues.

At the present time, the hospital outpatient supervision requirements currently must meet the “general” supervision requirements.  The service must be performed under the overall direction and control of the physician.  The physical presence of the physician is not required during the performance of the “incident to” activity.  In cases where personal (as opposed to general) supervision is required, the actual presence of the physician is required in the room.  Some services only require physical presence at the inception of the service and have been found to not create a risk during the ongoing stages of the procedure.

All hospital outpatient therapeutic services are deemed to be provided “incident to” the services of the physician.  The level of supervision required in the case of these types of services (personal or general) is based upon CMS determinations following review by the panel as indicated above.

So, now that we are all clear on the rules, (insert sarcasm emotion here), can we expect them to change again the future?  Certainly the panel process will be reflected by different rules for specific therapeutic items.  Additionally, given the history of this requirement, no one would be surprised if further changes are in our future.

Two Midnight Rule Exceptions CMS Inpatient Only

Thursday, April 17th, 2014

Exceptions to Two Midnight Rule 

exceptions cms two midnight ruleCMS recently updated its frequently asked questions regarding the two midnight rule.  The two midnight rule requires a patient to require hospitalization, including two midnights, in order to qualify for inpatient hospital Medicare reimbursement.  Numerous questions have been raised about details of how the rule is applied.

CMS has recently stated two exceptions to the two midnight rule:

1.         One exception relates to patients who require mechanical ventilation that is initialed during a visit may be admitted even if the inpatient stay is not expected to remain or two midnights.  This exception does not apply as a result of anticipated intubations during minor surgery or other treatments.

2.         Procedures that are listed on the “inpatient only” list may be reimbursed even though the stay is not anticipated to meet the two midnight rule.

Providers should review the transcripts from the January 21, 2014, open door call for more details regarding the application of the two midnight rule.  The call clarified several issues of how to apply the rule.  For example:

  • Providers can assume that a patient will survive, even in cases where it is reasonably likely that the patient may not survive following admission.
  • CMS is still working on details of how to apply the role where patient transfer takes place.  Transfer cases will not be reviewed at least for the initial audits (through March 31, 2014).

CMS is requiring a 0.2% reduction to IPPS payments as part of the Final Fiscal Year 2014 IPPS rules.  Hospitals who wish to challenge the reduction amount should preserve their appeal rights by indentifying the reduced amount as being protested on their cost report.  The protest should be indicated commencing October 1, 2013, the effective date of the two midnight rules.

Two Midnight Rule Implementation Delays Announced

Tuesday, March 18th, 2014

CMS Issues Further Delays And Implementation Of The Two-Midnight Rule

In late January, the Center for Medicare/Medicaid Services announced that it will delay implementation of regulations pertaining to the two-midnight rule.  CMS announcements state that Medicare administrative contractors will not audit for compliance with the rule until October 1, 2014.

The two-midnight rule provides that an admission does not qualify for per diem reimbursement where a physician admits a patient with an expectation that treatment will require a stay of covering at least two nights.  CMS indicates that this policy merely clarifies its longstanding consideration of when admission meets criteria to be covered as an inpatient rather than as an observation or outpatient.

Under the two-midnight rule, services that are not considered to be medically necessary unless the two midnight inpatients stay rule are met.  This does not mean that there is no coverage at all.  It is possible that the service would be paid as an observation stay or as an outpatient service.  MACs will continue to perform reviews of 10-25 selected clients per hospital per admission dates between March 31 and September 30.  However, the reviews will be considered “probe and educate” reviews and will not lead to administrative sanctions.  However, providers should be completely ready and implement with the rule by October 1, 2014 date that CMS states it will use as a more formal implementation date.

 

Annual Health Care Fraud and Abuse Control Program Report

Tuesday, March 11th, 2014

Record Recovery for Health Care Fraud and Abuse

The U.S. Department of Justice (DOJ) and the U.S. Department of Health and Human Services (HHS) recently released its annual Health Care Fraud and Abuse Control Program (HCFAC) report. This report indicates that in the last three years for every dollar spent on health care related fraud and abuse investigations through HCFAC and other government programs, the government recovered $8.10. This is a record high for the 17-year old program.  HCFAC focuses on eliminating fraud, waste, and abuse in the health care industry.

A few notes on the report’s numbers:shutterstock_1766714

•      The federal government recovered a record-breaking $4.3 billion in fiscal year 2013 alone.
•      Over the last five years, the federal government recovered $19.2 billion—this is more than double the previous five-year period.
•      In fiscal year 2013, the DOJ and HHS strike force team filed 137 cases, charged 345 individuals with crimes, secured 234 guilty pleas, and achieved 46 convictions.
•      Defendants sentenced in fiscal year 2013 served an average of 52 months in prison.
•      Centers for Medicare and Medicaid Services (CMS) have banned 225,000 individuals and entities from billing Medicare between March 2011 and September 2013.

Attorney General Eric Holder states that, “With these extraordinary recoveries, and the record-high rate of return on investment we’ve achieved on our comprehensive health care fraud enforcement efforts, we’re sending a strong message to those who would take advantage of their fellow citizens, target vulnerable populations, and commit fraud on federal health care programs,” said Attorney General Eric Holder.

The return on investigation investment suggests that the federal government’s interest in investigating and prosecuting health care fraud and abuse is substantial. In short, health care compliance is more important than ever.

Telemedicine Credentialing By Proxy

Tuesday, February 12th, 2013

Telemedicine Credentialing By Proxy and Hospital Policies

telemedicine policies credentialing telehealthProvider Credentialing requirements raise important considerations in any telemedicine arrangement. The facility where care is received, renders a diagnosis, or otherwise provides clinical treatment to a patient, must assure that a telemedicine practitioner is appropriately credentialed and privileged in compliance with their credentialing process, CMS rules, and the requirements of applicable accreditation organizations.  The process for credentialing telemedicine providers should be addressed by the governing body and reflected in medical staff bylaws and formal credentialing policies.

Credentialing standards have been somewhat streamlined since CMS adopted new regulations that were effective in June of 2011.  CMS rules now permit “credentialing by proxy” provided that several conditions are met.  It remains the responsibility of the board to determine when or if it wishes to rely on “credentialing by proxy” or whether it should apply full credentialing requirements on remote providers of telemedicine services.  Even though the process has been simplified, credentialing of providers who perform telemedicine services to patients of a hospital is still an extremely important responsibility of the hospital board.

Inpatient Prospective Payment Systems Hospitals Long-Term Care Hospital Fiscal Year 2013 Rates

Friday, October 26th, 2012

IPPS Revisions Released By CMS

Link
We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. Some of the changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and other legislation. These changes will be applicable to discharges occurring on or after October 1, 2012, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits will be effective for cost reporting periods beginning on or after October 1, 2012.

 We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes made by the Affordable Care Act. Generally, these changes will be applicable to discharges occurring on or after October 1, 2012, unless otherwise specified in this final rule.

 In addition, we are implementing changes relating to determining a hospital’s full-time equivalent (FTE) resident cap for the purpose of graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or revised requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities (IPFs)) that are participating in Medicare. We also are establishing new administrative, data completeness, and extraordinary circumstance waivers or extension requests requirements, as well as a reconsideration process, for quality reporting by ambulatory surgical centers (ASCs) that are participating in Medicare.

We are establishing requirements for the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program.

 DATES: Effective date: This final rule is effective on October 1, 2012.

OIG Issues 2013 Annual Work Plan, Outlines Areas of Focus for Fiscal Year Ahead

Wednesday, October 10th, 2012

OIG 2013 Annual Work Plan Summary 

            Medical Practice Compliance Programs  The Office of Inspector General of the Department of Health of Health and Human Services (“OIG”) has published their annual work plan for the 2013 fiscal year (“2013 Work Plan”).  The Work Plan focuses on areas where OIG plans to focus significant resources during the 2013 fiscal year.  The 2013 Work Plan creates opportunities for providers to get a glimpse of what the OIG feels is important and to integrate these areas into their ongoing compliance activities.

              This update will briefly summarize some of the new issues that were added this year.  It is not a comprehensive description of all items that are on the OIG’s radar.  Providers are advised to review the entire 2013 Work Plan plus the work plans from the past several years to get a more complete picture of issues that the OIG feels are important.

Hospital-Related Issues

1.           Expansion of DRG Payment Window.  OIG states its intent is to analyze claims data to determine whether any savings could be achieved by bundling outpatient services that are delivered up to 14 days before a hospital inpatient admission.  Current Medicare policy bundles outpatient services that are delivered three days prior to inpatient admission into the “DRG window.”

2.           Provider-Based Status of Hospital on Physician Practices.  There is currently an incentive for a physician group to bill as a provider-based physician practice where there are ties to a hospital.  The OIG will be reviewing the appropriateness of physician practices who are billing as “provider-based” groups without meeting all of the necessary criteria.

3.           Medicare Transfer Policy.  The OIG will review Medicare payments made to hospitals for beneficiary discharges that should more appropriately have been coded as transfers.  Hospitals that transfer beneficiaries to another facility are not entitled to the full DRG payment that is due when a patient is properly discharged.  This creates an incentive for hospitals to code for a discharge when the patient is actually being transferred to another facility.  The OIG will be reviewing hospital billings to look for inappropriate “discharge” classifications.  Hospitals should audit their discharge and transfer practices to be certain that they are properly coding transfers where applicable.

4.           Payment for Discharges to Swing Beds and Other Hospitals.  Currently, Medicare does not reduce the DRG amount that is paid when a patient transfer is made into a “swing bed,” even when the “swing bed” is located in a separate facility.  The OIG will be reviewing this practice to determine whether any savings can come from reducing DRG payments when the swing bed transfer is made to another facility.

5.           Hospital Payments for Canceled Surgical Procedures.  The OIG will be reviewing payments that are made for canceled surgical procedures which are then followed by a second payment for a rescheduled procedure.  Current Medicare policy does not preclude payments for claims when there is an inpatient stay followed by canceled surgical procedure.  CMS will be reviewing this policy to determine whether savings can be made in this area.

6.           Payments from the Mechanical Ventilation.  CMS will be reviewing Medicare payments for mechanical ventilation.  Patients are required to receive 96 hours of mechanical ventilation in order to be eligible for payments under the DRG system.

7.           Improve An Organization Work With Hospital.  OIG will be reviewing the extent that Quality Improvement Organizations have worked with hospitals to conduct quality improvement projects and to provide technical assistance.

8.           Hospital Acquisition of Ambulatory Surgery Centers.  OIG will be reviewing hospital acquisitions of ambulatory surgery centers to determine whether these centers are being acquired as a method to increase reimbursement.  ASC services that are provided as in an outpatient department of the hospital are reimbursed at higher rates than independently owned an ambulatory surgery centers.

9.           Critical Access Hospital Payments for Swing Bed Services.  Critical access hospitals are able to designate a portion of the 25 bed allotment for use as acute care or swing bed services with CMS’s approval.  There is no limitation on the length of stay that is permitted for swing bed utilization.  The OIG will be reviewing this policy to determine whether reimbursement changes are required in this area.

Long Term Care Issues

1.           Long-Term Care Hospital Interrupted State Payments.  The OIG will be reviewing Medicare payments for interrupted stays in long-term care hospitals for the year 2011.  They will be identifying readmission patterns to determine whether the long-term care hospital’s re-admittance policies are in compliance with rules.

2.           Nursing Home Verification of State Agency Deficiency Corrections.  The OIG will be determining whether state survey agencies properly followed up and verified fulfillment of corrective action plans for deficiencies and identified during nursing home recertification surveys.  The OIG is concerned that state survey agencies may not always be verifying that identified deficiencies were properly corrected.

3.           Nursing Home Use of Atypical Antipsychotic Drugs.  The OIG will be reviewing administration of atypical antipsychotic drugs to nursing home residents.  The OIG will describe characteristics associated with nursing homes that frequently administer atypical antipsychotic drugs.

4.           Nursing Home Minimum Data Set Submissions.  OIG will determine whether CMS and state agencies oversee the accuracy and completion of minimum data sets that are submitted for nursing facilities.

Home Health Care

1.           Home Health Agency Face-To-Face Requirements.  OIG will be reviewing Medicare eligible home health services to be certain that face-to-face encounters are taking place as required under the Patient Protection and Affordable Care Act.  Previous studies indicated that only 30% of beneficiaries had at least one face-to-face visit with the physician who ordered the home health.

2.           Criminal Background Checks By Home Health Agencies.  The OIG will be reviewing home health agencies to determine whether they are complying with state requirements that require criminal background checks to be conducted on home health applicants and employees.  Federal law requires compliance with state and local laws regarding criminal background checks.  In previous OIG reviews, 92% of nursing homes employed at least one individual with criminal convictions.

Medical Equipment Suppliers

1.           Accreditation of Medical Equipment Suppliers.  OIG will be reviewing CMS procedures for conducting validation surveys of medical equipment suppliers.  CMS is required to conduct validation surveys regarding beneficiary safety and quality of care that may place Medicare beneficiaries at risk.

2.           Payments for Power Mobility Devices.  A series of reviews will be conducted relative to power mobility devices.  Reviews will focus on whether Medicare payments made to suppliers were made in accordance with federal regulations and were “reasonable and necessary.”  OIG will also be reviewing payment methods to determine whether savings can be achieved by eliminating the option of a lump sum purchase and requiring leasing of some power mobility devices.

3.           Continuous Positive Airway Pressure Supplies.  CMS will be reviewing whether scheduling of replacement supplies is appropriate and whether changing the scheduling could avoid possible wasteful spending.  There is currently no national requirement for CPAP replacement schedules.

4.           Diabetes Testing Supplies.  There are a number of new areas identified for examination relating to diabetes testing supplies.  Providers involved in these areas should carefully review the new items that relate to diabetes management and testing.

Program Integrity

1.           Onsite Visits for Medical Providers in Supplier Enrollment and Reenrollment.  CMS has the right as it deems necessary to perform onsite inspections of providers who are enrolling in the Medicare program.  CMS is authorized to expand the role of unannounced pre-enrollment visits.  Reviews found that some 33% of medical equipment suppliers in South Florida do not maintain physical facilities.  OIG will be examining these requirements to determine whether additional site visits are appropriate.

2.           Improper Use of Commercial Mailboxes.  Medicare providers are required to establish a physical business location with a permanent visible sign and a specific street addresses.  Mailboxes alone or not permitted.  Recent evidence suggests that individuals attempting to defraud Medicare may be using commercial mailbox addresses for this purpose.  OIG will be reviewing providers and suppliers to determine whether their listed addresses match commercial mailbox addresses.

3.           Provider Subject To Debt Collection.  CMS will be determining whether payment should be rechanneled relative to providers who have been reported to the Department of Treasury for collection of overpayment refunds.

Physician Billing

1.           Payment for Personally Performed Anesthesia Services.  OIG will be reviewing anesthesia claims to determine whether they are supported in accordance with Medicare requirements.  In order for a provider to be reimbursed as a personally performed anesthesia service, proper information must be included on the claim and in the medical chart to verify the claim.  Service modifier “AA” is used in connection with anesthesia services that are personally perform.  QK modifiers are used for medical direction of two, three, four concurrent anesthesia services.  Providers using “AA” modifiers must be able to support the requirement for receiving 100% of the personally performed services.

2.           Questionable Ophthalmological Service Billings for 2011.  OIG will be reviewing claims data to identify questionable billings for ophthalmologic services during 2011.  They will review geographic locations and provider patterns where questionable billings are located.  The types of billing that will be examined were not identified.

3.           Electrodiagnostic Testing.  OIG will be reviewing questionable billing for electrodiagnostic testing and will be attempting to identify Medicare utilization rates and get different rates by provider specialty, diagnosis, and geographic areas.  OIG identifies electrodiagnostic testing as an area of potential inappropriate financial gain posing significant vulnerabilities to the Medicare program.

Miscellaneous

1.           Location Requirements for Rural Health Clinics.  Rural health clinics are required to meet basic location requirements.  CMS has not promulgated final regulations allowing removal of rural health clinics that did not meet location requirements.  OIG will be reviewing this procedure.

2.           Claims Processing Areas “G” Modifiers.  The OIG will determine the extent to which Medicare improperly paid claims from 2002 to 2011 where certain “G” modifiers were used.  “G” modifiers are used to indicate that Medicare denial is expected by the provider.  It has been identified that some payments were made to providers in spite of the use of these modifier codes.

3.           Analysis of Drug Shortage in Patient Safety Concerns.  The OIG will be examining the recent trend of drug shortages to determine whether there has been an effect on pricing of pharmaceuticals.  Suspicion of industry price manipulation appears to be the motivation behind this system.

Summary

              This is a brief summary of some of the areas that were described in the recent 2013 Work Plan.  For a more comprehensive discussion of these items, visit the website for the Office of Inspector General and download the complete fiscal year 2013 annual work plan.  It is highly advisable for compliance officers to examine the document in its entirety to determine what impact, if any, it will have on their compliance efforts for fiscal year 2013.  It is also good practice to review annual work plans for several previous years as part of the risk identification process.

              If there are any questions regarding these requirements or how they impact compliance programs and detailed requirements that are generally described in this document, please do not hesitate to contact John H. Fisher, II, Esq., CCEP, CHC.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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