OIG Work Plan 2011 Margaret Davino Kaufman Borgeest & Ryan LLP 120 Broadway New York, NY 10271 (212)...

OIG Work Plan 2011

Margaret DavinoKaufman Borgeest & Ryan LLP

120 BroadwayNew York, NY 10271

(212) [email protected]

Margaret Davino Kaufman Borgeest & Ryan

LLP

OIG missionProtect US Department of Health and

Human Services (HHS) program integrity and beneficiary wellbeing by:- detecting and preventing waste, fraud and abuse- identifying to Congress, HHS and the public opportunities to improve program economy, efficiency and effectiveness- holding accountable those who violate Medicare requirements


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Work activities

OIG mission accomplished by:- conducting audits, investigations and inspections- providing industry guidance- imposing civil monetary penalties, assessments and sanctions- work with DOJ


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OIG componentsOIG components:Office of Audit Services (OAS)

- performs independent assessments of HHS programs and operations

Office of Investigations (OI)- conducts investigations of fraud and misconduct

Office of Evaluation & Inspections (OEI)- conducts national evaluations to provide HHS and Congress w/information and recommendations to improve program

Office of Counsel to the Inspector General (OCIG) - provides general legal services to OIG, represents OIG in fraud and abuse cases, negotiates and monitors corporate integrity agreements, renders advisory opinions, publishes fraud alerts


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OIG Workplan

Workplan identifies and prioritizes OIG’s projects for future implementation- identifies risk areas OIG will study, audit and/or investigate

2011: Looks at many of the projects in the Patient Protection and Accountable Care Act (PPACA)


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Hospital focus: provider-based statusProvider-based status: do hospitals have

provider-based status for facilities that are separate from the hospital and do those facilities meet requirements for provider-based facilities- provider-based facilities must be financially, operationally and administratively integrated w/hospital- provider-based facilities charge a facility fee- provider-based facilities must meet Emtala, reimbursement requirements

(OAS work in progress, expected date FY 2011)


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Hospital focus: payments for nonphysician outpt. services

Review: payments for non-physician outpatient services provided before hospitalization- IPPS/DRG payments to hospitals include all outpatient diagnostic services and admission-related nondiagnostic services within three days before admission

(OAS, work in progress, expected FY 2011)


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Hospital focus: Medicare DSH payments

Review: Medicare disproportionate share payments to hospitals- Medicare makes additional payments to acute care hospitals that serve a disproportionate share of low-income patients- will also examine uncompensated care by hospitals

(OAS, work in progress, FY 2011)


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Hospital focus: Medicare secondary payerFocus: Medicare payments for beneficiaries who

have other insurance should be second to the other insurance

Review: Have hospitals billed and collected from Medicare

only after collecting first from other payers if patients have insurance in addition to Medicare?

What has happened with credit balances if payments from Medicare exceed the allowed amount?

(OAS, new start, FY 2011)


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Hospital focus: hospital-reported quality data

Background: hospitals report quality measures for 10 indicators established by CMS- hospitals that don’t report have the updates to their reimbursement reduced by 2 percent

Review: is the data submitted by hospitals to CMS for Medicare reimbursement accurate?

What controls do hospitals have to ensure that their quality data are valid?

OAS, new project


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Hospital focus: readmissions

Readmission: a case where a patient is readmitted to hospital within 30 days of d/c

If a same-day readmit occurs for symptoms related to prior stay, hospital receives only one DRG payment for both admissions, but providers can override this edit

Review: are providers billing 2x for “one admit”Are QIOs appropriately reviewing hospital readmission cases to determine if the hospital services met professional standards of care


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Hospital focus: POAsReview: Which facilities are most frequently

transferring patients with certain diagnoses that were coded as present when patients were admitted (for certain diagnoses, hospitals receive a lower payment if the diagnoses were acquired in the hospital)

Whether certain providers transferred a high number of patients to hospitals with POA diagnoses



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Hospital focus: hospital-acquired conditions

Medicare’s hospital-acquired conditions (HAC) policy prevents additional IPPS payment for certain conditions or complications deemed “reasonably preventable” as of 10/08

Review: number of patient stays associated with HACs and impact on reimbursement

Review: accuracy of POA indicators used to identify HACs

(OEI, work in progress, FY 2011)


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Hospital focus: adverse eventsReview: did hospital incident reporting systems

capture adverse events and report them to external patients safety oversight entities

Review: did Medicare oversight entities investigate adverse events in hospitals and determine whether hospitals have taken corrective action

Review: Did hospitals report to CMS each death while a patient is in restraint or seclusion, & each death within 24 hours after patient removed from restraint or seclusion- & did CMS/State agencies investigate & take action

(OEI, work in progress, new start on 3rd)

Medicare brachytherapy

Review: payments for brachytherapy (radiation source placed in or next to area requiring treatment

(OAS, work in progress, FY 2011)IMRT and image-guided radiation therapy

- were safety and personnel qualification standards met

(OIE, new, FY 2012)Margaret Davino

Kaufman Borgeest & Ryan LLP

Hospital focus: observation stays

Review:Were stays properly coded as

observation staysDid hospitals’ use of observation

services affect care received

(OEI, new start, FY 2012)Margaret Davino



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Home care: payments for therapy services

Background: Therapy services furnished to Medicare beneficiaries during home health episodes are included in home health agency (HHA) prospective payment

Review: whether payments (under Part B) have been made to outside providers for therapy services that are included in the HHA prospective, and what controls agencies have to prevent outside providers from billing


Home health agency profitability

Review: HHA profitability trends under home health PPS to determine wehtehr payment methodology should be adjusted

Background: PPS for home health services started in Oct 2000, and home care expenditures have increased

OAS work in progress, FY 2011Margaret Davino Kaufman Borgeest & Ryan

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Nursing Homes: payment supported by records

Background: SNFs are paid for all covered services under Medicare Part A, using a system that categorizes each patient into a Resource Utilization Group based on care and resource needs. OIG: 26% of claims had RUGs not supported by medical records

Review: were claims medically necessary, sufficiently documented and coded correctly

(OEI work in progress, FY 2012)


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Nursing homes: Quality of care

Background: NFs must use the Resident Assessment Instrument (RAI) to assess each NF resident’s strengths and needs.

Review: whether SNFs(1)Developed care plans based on resident

assessments(2)Provided services in accordance w/care

plan(3)Planned for residents’ discharges.(OEI, work in progress, FY 2012)


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Nursing homes: oversight of poorly performing nursing homes

Background: the survey process should ensure NFs meets federal standards for Medicare/Medicaid

Review:CMS and State use of enforcement measures to

determine if they improved QC that residents received in poorly performing NFs & performance

Enforcement actions by CMS and states from survey and certification inspections

Did CMS and states follow up with poorly performing nursing homes

(OEI new project, FY 2012)

Nursing homes: hospitalization of nursing home residents

Background: OIG 2007 study found 35% of hospitalizations from SNFs due to poor quality care or fragmentation of services

Review: hospital admissions of Medicare nursing home residents & CMS oversight of NFs w/high hospitalizations

(OEI, new start, FY 2011) Margaret Davino Kaufman Borgeest & Ryan

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Nursing homes: criminal background checks

Review: Whether NFs have employed

individuals with criminal convictionsState background check programs for

prospective LTC employees mandated by PPACA 6201 (requires nationwide program)

OEI, work in progress, FY 2012Margaret Davino



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Physicians: place of service errors

Background: Medicare pays physicians a higher amount when a service is performed in a non-facility setting, than when it is performed in a hospital or ASC

Review: whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments

(OAS work in progress, FY 2011)


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Physicians: Evaluation and management services (E&M)

Review:Do E&M codes represent the type, setting

and complexity of services provided, and patient status (new or established)

Trends in coding for E&M services (MACs have noted increased frequency of medical records w/identical documentation across services)

Multiple E&M services for same providers & pts to identify EHR documentation practices


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Physicians: Medicare payments for imaging services

Background: Medicare fee schedule covers physician cost component, malpractice costs and practice expense (includes equipment utilization rate)

Review: whether Medicare payments reflecct expenses incurred (focus on practice expense component and equipment utilization rate)

(OAS, new start, FY 2011)


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All providers: excluded providers

Background: no payment made be made for items or services furnished, ordered or prescribed by an excluded individual or entity

Review: were Medicare payments made for services ordered or referred by excluded providers

OEI, new start, FY 2012


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All: error prone providers

Background: CMS’ Comprehensive Error Rate Testing (CERT) program identified providers that consistently submit claims w/errors

Review: select top error-prone providers based on dollar error amounts and match against National Claims History file to determine dollar amounts paid, then conduct a medical review on a sample of claims, project results to population and request refunds

OAS new start FY 2011

Medicare incentive payments for electronic health records

Background: ARRA authorizes Medicare incentive payments over 5 years to providers that demonstrate meaningful use of certified EHR technology (scheduled to begin 2011-2016, w/reductions in 2015 for providers who fail to become meaningful users)

Review: of Medicare incentive payments from 2011 to identify payments to providers who should not have received payment


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Information Data privacy

Review:Have Medicare and Medicaid

providers implemented privacy standards of HIPAA as strengthened by HITECH

Adequacy of OCR’s oversight of HIPAA privacy rule

OEI work in progress FY 2012Margaret Davino Kaufman Borgeest & Ryan

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Medicare billings with modifier GYBackground: Modifier GY is to be used to

code services not covered under Medicare, and patients are responsible- but providers are not required to provide patients with advance notice of charges for services excluded from Medicare by statute

Review: whether providers have appropriately used modifier GY on claims for services not covered by Medicare

(OEI work in progress)


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Medicare Part C

Medicare Advantage plans (managed care organizations licensed by States as risk-bearing that contract with CMS to provide covered services to Medicare patients). Review:

Disenrollments from plansManaged care encounter dataIdentification of potential fraud and

abuse


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Medicare Part D prescription drug programReview:Duplicate drug claims to hospice patientsDuplicate payment when patients change plansPart A and B claims included w/Part D claimsOut of pocket costsAdministrative costs included in bid submissionsAudits of pharmaciesInternal controls for fraud, waste and abuseP&T Comm. Conflicts of interest


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Medicaid reviews

Hospital outlier paymentsProvider eligibility for DSH paymentsMedicare/medicaid credit balancesMedicaid home health agency claims –

whether providers met criteriaMedicaid adult day health servicesTransparency in nursing facility

ownership

If you thought this was important before . . . .

Patient Protection and Affordable Care Act (healthcare reform law):- Access to care- Controlling costs


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One of keys to controlling costs under health reform

PROGRAM INTEGRITY


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Program integrity provisions in healthcare reform lawMandated compliance and ethics programs in

nursing facilities- to prevent violations & promote quality- shall be in effect 3/23/13- regulations due by 3/23/12, perhaps with model program- HHS evaluation of programs due within 3 years of regulations (look at deficiency citations, quality performance)


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Mandated compliance programs for Medicare providers & suppliers

As a condition of participation in Medicare, Medicaid or CHIP:

A provider or supplier shall establish a compliance program that meets certain “core elements”

No fixed dateCMS asking for comments re mandatory

compliance plans in an industryMargaret Davino


Provider disclosureApplicants and providers re-enrolling must

disclose:- current or previous affiliations with any provider or supplier with uncollected debt- if their payments have been suspended- if excluded from a healthcare program


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Provider screening & disclosure

CMS must establish procedures for screening

Proposed rule: all participating suppliers and providers classified in one of 3 risk categories, based on risk for fraud, waste and abuse- highest: new HHAs and DMEPOS- high risk if previously excluded or has overpayment, etc.


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Provider screening

Screening shall include a license checkScreening MAY include:

- criminal background check- fingerprinting- site visits- database checks

Fees assessed on institutional providersMargaret Davino


Termination of Medicaid in another state

After 1/1/11, states are required to terminate individuals or entities from Medicaid programs if they were terminated from Medicaid in another state plan

PPACA 6501


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Exclusion based upon relationships

An entity or individual may be excluded if they own, control or manage an entity that:- failed to repay overpayments- is suspended, excluded or terminated from participation in any Medicaid program- has been affiliated with a party that was excluded or suspended from Medicaid


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Mandatory reporting & repayment of overpaymentsPPACA 6402(d): “If a person has received an

overpayment, the person shall –(A) report and return the overpayment to the

Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address;

(B) Notify the Secretary, State, intermediary or carrier to whom the overpayment was returned in writing of the reason for the overpayment.”


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When must the overpayment be reported/returned?

An overpayment must be reported and returned the later of –(A) the date which is 60 days after the date on which the overpayment was identified; or(B) the date any corresponding cost report is due, if applicable


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Failure to return money is a false claim

“Any overpayment retained by a person after the deadline for reporting and returning the overpayment is an obligation as defined in Section 3729(b)(3) of title 31 USC (False Claims Act).


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What is an overpayment?

“The term ‘overpayment’ means any funds that a person receives or retains under title XVIII or XIX to which the person, after appropriate reconciliation, is not entitled.”


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Kickback as an overpayment

PPACA 6402(g): “ . . . A claim that includes items or services resulting from a violation of this section (a kickback) constitutes a false or fraudulent claim for purposes of” the False Claims Act


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What else might be “overpayments”?

NY OMIG:- payment “received or retained” in violation of Stark law- credit balances- payment received or retained for services provided or ordered by excluded providers


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Other “overpayments”?NY OMIG:

- present on admission inaccurate reporting- discharge/readmit within 30 days- drugs billed for inpatients as if outpatients- mischarged 340B drugs- transfer/discharges


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Time to return suspended

CMS Stark Law disclosure protocol- published Sept 23, 2010- limited to Stark violations (if anti-kickback law also involved, use OIG’s self-disclosure protocol)- 60 days to repay is suspended until a settlement is reached or the disclosing party withdrawsMargaret Davino


OIG Workplan focus on Medicaid

New York’s Medicaid program is larger than any other state, including California


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How OIG Workplan should affect compliance activities

Focus: ensure newly identified (and ongoing) OIG projects receive priority in establishing future compliance efforts

1. Discuss at compliance committee, with emphasis on risk areas impacting your organization

2. Add risk areas identified to risk or audit areas in your programMargaret Davino


Impact of OIG Workplan on compliance activities

3. Develop a compliance risk assessment that identifies and prioritizes institution’s compliance & business risks

4. Develop a compliance work plan5. Auditing and monitoring6. Education


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Questions

Margaret Davino(212) [email protected]

OIG Work Plan 2011 Margaret Davino Kaufman Borgeest & Ryan LLP 120 Broadway New York, NY 10271 (212)...

Documents

Transcript of OIG Work Plan 2011 Margaret Davino Kaufman Borgeest & Ryan LLP 120 Broadway New York, NY 10271 (212)...