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2015 OIG
Work Plan
Darci Friedman
Dir. of Regulatory Products
Lynne Rinehimer
Sr. Healthcare Solutions
Consultant
February 5, 2015
Agenda
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Introduction to, and how to interpret, the OIG Work Plan
Review of new project areas
Review of project areas with new source documents
ComplyTrack Risk Assessment Manager Demonstration
Question and Answer
The OIG Work Plan
 The Office of Inspector General (OIG) is responsible for
protecting the integrity of Department of Health and Human
Services (HHS) programs through audits, investigations and
evaluations
 OIG is the enforcement agency under HHS
 OIG issues several types of documents, pursuant to its
oversight authority, including reports based upon the audits
and inspections conducted
 Work Plan provides a description of areas of focus (“project
areas”) for the OIG in the coming year to combat fraud and
abuse in HHS programs
Interpreting the Work Plan
 Describes the primary objectives for each project area in a
short paragraph
 Indicates the year in which the OIG expects one or more
reports to be issued based upon the work identified in the
project area
New Project Areas
New Project Areas
 Review of Hospital Wage Data Used to Calculate Medicare
Payments
 LTCHs: Adverse Events in Post-Acute Care for Medicare
Beneficiaries
 Selected Independent Clinical Laboratory Billing Requirements
Review of Hospital Wage Data Used to
Calculate Medicare Payments
 Must have controls in place for the collection and reporting of wage data
 Financial management system
 Review and reconciliation procedures
 Contract services generally need to be for direct patient care and top level
management services
 Excludes costs for equipment, supplies, travel expenses
 Contract is the minimum required documentation
 Deferred compensation included should be screened carefully
 GAAP and reasonable cost provisions of Medicare
 Do not include unliquidated pension costs where the hospital has not
recorded a contribution or a pension cost liability
 Do not include other postretirement benefits costs where the costs
have not yet been funded or where already fully funded
 Physician compensation should not include amounts the hospital claims
for Part B reimbursement
LTCHs: Adverse Events in Post-Acute Care
for Medicare Beneficiaries
 Similar to IRF-focused project area introduced in 2014 Work Plan
 OIG looking at adverse events and temporary harm events to
identify contributing factors, the extent to which the events were
preventable, and the associated costs to Medicare
 How LTCHs can better ensure compliance:
 Develop an ongoing, data-driven quality assessment and
performance improvement program (QAPI)
 Train employees on reporting specific types of patient harm
events
 Develop policies and procedures addressing LTCH quality
reporting measures (ex. CAUTI, CLABSI, pressure ulcers,
influenza vaccination)
Selected Independent Clinical Laboratory
Billing Requirements
 The lab must be able to provide documentation of the medical
necessity for the service it has provided
 Monitor to ensure the lab does not use information from earlier
dates of service (other than standing orders)
 Do not use computer programs that automatically insert diagnosis
codes without receipt of diagnostic information from the ordering
physician
 Monitor to ensure claims for testing services correctly identify the
services ordered by the physician and performed by the lab
 Monitor to prevent billing for the same test on the same day for the
same beneficiary
 Review 13 measures that may indicate questionable billing from OIG
Report OEI-03-11-00730 (July 2014)
Carryover Project Areas
New Inpatient Admission Criteria
 Benchmark: Establishes that inpatient admission and inpatient
payment under Part A are appropriate if a physician expects that
the patient’s stay will be at least 2 midnights
 Medical review contractors will evaluate the physician’s
expectation based on the information available to the admitting
physician at the time of the inpatient admission
 Will be looking to physician orders, certification, and medical
record documentation in determining that the inpatient stay
was reasonable and necessary and expected to span 2
midnights
 Presumption: Hospital stays spanning 2 or more midnights after
beneficiary is formally admitted as an inpatient pursuant to a
physician order will be presumed appropriate for Part A payment as
a medically necessary stay
Medicare Oversight of Provider-Based
Status
 OIG will be examining whether provider-based facilities meet CMS
criteria
 2015 OPPS – introduces a new modifier hospitals will have to use
when billing for services rendered in provider-based departments
 Hospitals will be required to append modifier PO to HCPCS
codes
 Use of the modifier is voluntary in 2015, with effective date of
Jan. 1, 2016
 2015 Physician Fee Schedule – replaces POS 22 (outpatient hospital)
with two new place of service codes for physicians
 Will be required once CMS makes them available
 October 16, 2014 – NY hospital self-disclosed provider-based
violation for $3.3 million
Duplicate Graduate Medical Education
Payments
 FTE status is based on the total time necessary to fill a residency slot
 All residents in approved programs working in all areas of the
hospital should be counted towards the number of Full Time
Equivalents (FTE)
 Do not claim the time spent by a resident training at another
hospital
 If a resident is assigned to more than one hospital, only count
them as a partial FTE based on the proportion of time worked in
the hospital to the total time worked
 No resident should be counted as more than one FTE
 Implement controls to ensure accurate recording of resident
rotations to the IRIS file
 Monitor to ensure that duplicate rotations are not recorded
Outpatient Dental Claims
 General rule is that items and services in connection with the
care, treatment, filling, removal, or replacement of teeth, or
structures directly supporting the teeth are not covered
 For dental services to be covered, they must be performed as
incident to and as an integral part of a covered procedure or
service
 Services associated with a diagnosis related to cancer or
physical trauma are generally covered
 Whether the administration of anesthesia, diagnostic x-rays or
other related procedures are covered depends upon whether
the primary procedure being performed by the dentist is
covered
 OIG Report A-06-13-00004 (February 2014)
Outpatient E&M Services Billed at the
New-Patient Rate
 For claims with dates of service prior to January 1, 2014:
 A new patient is one who had not registered as an inpatient or
outpatient of the hospital within the three years prior to a visit
 An established patient is one who had registered as an inpatient
or outpatient of the hospital within the three years prior to a
visit
 Evaluation and Management codes 99201 through 99205 (the
new patient codes) should be audited to ensure that established
patients were not billed as new patients
 For claims with dates of service after January 1, 2014:
 Clinic visits are billed with HCPCS Code G0463 (Hospital
Outpatient clinic visit for assessment and management of a
patient)
Payments for Patients Diagnosed with
Kwashiorkor
 Kwashiorkor is a form of severe protein malnutrition that generally affects
children in developing countries during times of famine
 Since the release of the 2014 OIG Work Plan, the OIG has published 10
audit reports on billing for Kwashiorkor:
 10 hospitals reviewed were in 8 different states
 Of 980 claims reviewed, 979 were billed incorrectly
 Total overpayments of $2,631,603
 How hospitals can better ensure compliance:
 Develop documentation guidelines and clinical criteria addressing
malnutrition
 Ensure appropriate documentation in medical record through education of
physicians and coders, and monitoring of records
 Develop process for coders to query physicians
 Ensure coding software is updated and has appropriate controls for billing
kwashiorkor
Oversight of Pharmaceutical Compounding
 Pharmaceutical compounding is the creation of a prescription
drug tailored to meet the needs of an individual patient
 National meningitis outbreak in 2012 linked to compounding
pharmacy – more than 700 illnesses and 64 deaths in 20 states
 Most hospitals do at least some pharmaceutical compounding
on site, while also maintaining outsourcing arrangements with
outside pharmacies
 January 8, 2014 letter from FDA Commissioner urges hospitals
to buy only from 503B outsourcing facilities
 503B facilities must abide by current good manufacturing
practice requirements, accept FDA inspections on a risk
basis, submit product information to FDA, and report
adverse events
Medicare Part A Billing by Skilled Nursing
Facilities
 January 2014 – Medicare program manuals re-worded to
clarify that coverage of therapy “does not turn on the
presence or absence of a beneficiary’s potential for
improvement from the therapy, but rather on the beneficiary’s
need for skilled care”
 When skilled services are required in order to provide care
that is reasonable and necessary to prevent or slow further
deterioration, coverage cannot be denied based on the
absence of potential for improvement or restoration (see Pub.
100-02 Ch. 8 s. 30.4.1.1)
 Increased emphasis on documentation – documentation must
justify the necessity of the skilled services provided
Hospice General Inpatient Care
 Two new OIG reports released in Aug. 2014 (A-02-11-01017) and
Sept. 2014 (A-02-11-01016)
 Issue identified in reports included:
 Beneficiary eligibility not adequately documented
 Services not supported
 Level of care not supported
 Beneficiary did not elect hospice care or had revoked election
 OIG report recommendations:
 Strengthen procedures to ensure that hospice services are
documented in accordance with Medicare requirements
 Strengthen procedures to ensure the hospice complies with
Medicare requirements for claiming hospice services
Ambulance Services – Questionable Billing,
Medical Necessity and Level of Transport
 Trip must be reasonable and medically necessary
 Medical necessity is established when the patient’s condition is such
that use of any other method of transportation is contraindicated
 Transport must be to obtain a Medicare covered service or to return from
such a service
 Transport must be to nearest facility capable of furnishing the required
level and type of care
 May not bill for entire transport when transport is to a more distant
hospital in order to see a specific physician or specialist
 May not bill for a trip to a physician office unless en route to a covered
destination and patient was in dire need of professional attention and
thereafter ambulance continues to covered destination
 Ensure ambulance crew was appropriately qualified for level of service
billed
 Appropriate documentation must be kept on file
Where to Access the Work Plan
 http://oig.hhs.gov/reports-andpublications/archives/workplan/2015/FY15-Work-Plan.pdf
 In the Compliance & Regulation Suite, OIG - FR, Reports,
Advisory Opinions, CPGs, Fraud Alerts, Work Plans Library
Q&A
Darci Friedman, JD, CHPC, CSPO
Director of Regulatory Products
[email protected]
Lynne Rinehimer, JD
Sr. Healthcare Solutions Consultant
[email protected]