lami oig workplan formatted · 2018-03-31 · • the mission of the oig, as mandated by public law...

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2015 OIG Work Plan

Leading Age Michigan – February 17, 2015

Your Speakers

Betsy Anderson, PresidentBetsy Anderson, PresidentFrost Healthcare111 Pfingsten Road, Suite 300Deerfield, IL 60015Main: (847) 236-1111 or (888) 377-8120Direct: (847) 282-6307banderson@frrcpas [email protected]

© 2015 Frost, Ruttenberg & Rothblatt, P.C. 2

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Your Speakers

Janet Potter, CPA, MASManager, Healthcare ResearchFrost Healthcare111 S. Pfingsten Road, Suite 300Deerfield, IL 60015Main: (847) 236-1111Direct: (847) 282-6457( )[email protected]

3© 2015 Frost, Ruttenberg & Rothblatt, P.C.

Acronyms

•ADL = Activities of Daily LivingADL = Activities of Daily Living•ADR = Additional Development Request•ALF = Assisted Living Facility•CERT = Comprehensive Error Rate Testing•CMP = Civil Monetary Penalty•CMS = Centers for Medicare and Medicaid Services•CPI = Center for Program Integrity


g g y•DME = Durable Medical Equipment•GAO = Government Accountability Office•HHS = Department of Health and Human Services

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Acronyms

•MAC = Medicare Administrative ContractorMAC = Medicare Administrative Contractor•MDS = Minimum Data Set•MedPAC = Medicare Payment Advisory Commission•MSP = Medicare as a Secondary Payer•OIG = Office of Inspector General•PSC = Program Safeguard Contractor•RA = Recovery Auditor (formerly known as RACs)


y ( y )•RUG = Resource Utilization Group•SNF = Skilled Nursing Facility•ZPIC = Zone Program Integrity Contractor

OIG WORK PLAN


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Background

• The mission of the OIG, as mandated by Public Law 95-452 is to protect the integrity of HHS programs95-452, is to protect the integrity of HHS programs, as well as the health and welfare of the beneficiaries of those programs– Investigates both Medicare and Medicaid as well as

drug safety, foster care, child support, head start, and other HHS programs


Who is the OIG?

OIG reports both to the Secretary of HHS and to Congress

OIG reports on program and management problems and makes recommendations to correct them

OIG's duties are carried out through a nationwide network of audits, investigations, evaluations and other functions


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OIG Accomplishments FY 2014

• $4.9 billion expected to be received as a result of civil$4.9 billion expected to be received as a result of civil settlements from OIG findings– Nearly $834.7 million in audit receivables

– About $4.1 billion in investigative receivables

• Including $1.1 billion from work areas such as States’ shares of Medicaid restitution

• Excluded 4,017 individuals and entities from participation in , p pFederal healthcare programs


OIG Accomplishments FY 2014

971 criminal actions against individuals or entities that engaged in crimes

against HHS programs

533 civil actions, including false claims d j t i h t l it fil iand unjust-enrichment lawsuits file in

Federal district court, civil monetary penalties (CMP) settlements, and

administrative recoveries related to provider self-disclosure matters


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OIG Leads the Way

• Studies by the OIG often are picked up by other regulatory agenciesregulatory agencies– When the OIG identifies an area as being a potential for high

fraud or abuse, other agencies (MACs, RAs) tend to review the same areas

• The annual OIG Work Plan is an outline of all the areas the OIG intends to study during the coming fiscal year


OIG Work Plan 2015

• The OIG Work Plan for fiscal year 2015 was published on October 31, 2014on October 31, 2014

• It is posted at: http://oig.hhs.gov/reports-and-publications/workplan/index.asp


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Focus Area: Quality of Care

Th OIG ill l k t h th h bThe OIG will look at areas where there have been identified gaps in program safeguards which were put in place to ensure medical necessity, patient safety, and quality of care

They also will look at access to care, including beneficiary access to durable medical equipment, prosthetics, orthotics, and supplies in the context of new programs involving competitive bidding


Focus Area: Appropriate Payments

The OIG will also focus on examining inefficient payment policies or practices, including comparison among Government programs to identify instances when Medicare paid significantly different amounts for the same or similar services or when less efficient payment methodologies were used

Including work addressing Medicare costs incurred due to deficiencies in services or defective medical devices, as well as noncompliance or other vulnerabilities in care settings with high payment error rates


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Focus Area: Oversight of Payment and Delivery Reform

The OIG is expanding its work addressing changes to Medicare programs designed toThe OIG is expanding its work addressing changes to Medicare programs designed to improve efficiency and quality of care and to promote program integrity and transparency

They will be examining the transition from volume- to value-based payments and the soundness and effectiveness of the payment structures, care coordination, and administration of these new payment models

They expect to begin work in 2015 which will include examination of data metrics to document and measure quality and performance


WORK AREAS FOR NURSING FACILITIES


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Work Area: Medicare Part A Billing by SNFs

•The OIG will look at changes in SNF billing practices from FY 2011 to 2013•Prior OIG work found that more and more SNFs billed the highest level of therapy while the general beneficiary characteristics have remained fairly constant•Additionally the OIG found a $1 5 billion error in


•Additionally, the OIG found a $1.5 billion error in inappropriate Medicare payments in 2009 due to the mistakes in the claims submitted by SNFs

The Jimmo Settlement

• The Jimmo Settlement resulted in an updated policy manual to ensure that coverage is not denied by reviewersmanual to ensure that coverage is not denied by reviewers inappropriately applying the improvement standard– The “improvement standard” means that in order for a beneficiary to

continue to receive rehabilitative Medicare services, improvement must be shown

• Many beneficiaries with chronic illnesses and conditions such as MS, Alzheimer’s, ALS, and Parkinson’s were denied therapy and other coverage by government reviewers since the beneficiaries did not meet the improvement standard– They were actually eligible for therapy for maintenance or prevention of

further deterioration


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Maintenance Therapy

• Typically 2-6 visits to establish and instruct the patient orTypically 2 6 visits to establish and instruct the patient or caregiver in a “home exercise” program– The skills of the therapist are required to develop and instruct

– The skills of a therapist are NOT required for the patient to complete the exercises once they are learned

• Exception if the skills of the therapist are required to maintain the safety of the patient

– e.g. patient with severe osteoporosis at risk of fractures when exercising


Coverage Criteria

• The decision to provide services must be made based onThe decision to provide services must be made based on the need for skilled care that must be performed or supervised by a professional nurse or therapist

• NOT based on whether or not there is potential for or actual improvement– Potential for improvement = rehabilitation

– No potential = maintenanceNo potential maintenance


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SNF Final Rule: Therapy Utilization Trends

• The SNF final rule issued August 2014 references severalThe SNF final rule issued August 2014, references several therapy utilization trends that CMS is continuing to monitor

• #1: The percentage of service dates in the ultra high RUG therapy groups has continued to climb and has increased to over 50%

• #2: The amount of therapy reported on the MDS is just enough to classify the resident into their current therapyenough to classify the resident into their current therapy RUG



Source: Observations on Therapy Utilization Trends Memo, CMS

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Work Area: Questionable Billing Patterns for Part B Services During Nursing Home Stays

•Another target the OIG will review is the Part B billing patterns of residents in nursing homes not paid under Part A•There will be a series of studies that will inspect various services across the board•Congress initiated this investigation by asking the OIG to


Congress initiated this investigation by asking the OIG to examine Part B billing for fraud and abuse during residents’ non-Part A stay to ensure that no excessive services are provided

Example: Durable Medical Equipment

• One example of a Part B service or supply that the OIGOne example of a Part B service or supply that the OIG may choose to study is Durable Medical Equipment (DME)– In 2009, the OIG released a similar study on DME to non-Part A

residents of SNFs during the year 2006

• DME is covered by Part B when prescribed by a physician for use in the home– Nursing homes are not considered a home for DME coverage g g

purposes

• Includes such items as wheelchairs, walkers, prosthetics, orthotics, oxygen and equipment, and complex items such as wound vac equipment


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Work Area: State Agency Verification of Deficiency Corrections

The OIG will monitor if state survey agencies followed up with nursing homes’ correction plans for deficiencies found during recertification surveys

Federal regulations and CMS require state survey agencies to verify the correction of identified deficiencies through on-site reviews, or by obtaining other evidence of correction


Post Survey Activities

• After a survey it is vital to have post survey action plan inAfter a survey it is vital to have post survey action plan in place– The interdisciplinary team should review all survey findings and

correction plan requirements

– Assign staff to complete any correction plans, with a due date to meet again as a team to review

– Enlist legal counsel if necessary

• Incorporate survey issues and findings into the compliance program as needed


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Work Area: Program for National Background Checks for Long Term Care Employees

Th OIG ill i th d f l t t t• The OIG will review the procedures of select states in regards to background checks for long-term care employees, and the cost of performing one

• The OIG will conclude whether or not there were any accidental outcomes to any of the states’ y yprograms


Exclusion Lists

• Remember to review exclusion lists at least monthly for allRemember to review exclusion lists at least monthly for all employees, vendors, contractors and volunteers– As we reviewed in the first compliance webinar

– SAM (System for Award Management): http://sam.gov

– LEIE (List of Excluded Individuals and Entities):

• http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp

– MDCH licensing sanctions for health facilities and professionals are g pavailable at http://michigan.gov/lara/0,4601,7-154-35299_63294_63302---,00.html and http://michigan.gov/healthlicense

– http://oig.hhs.gov/exclusions/index.asp


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Work Area: Hospitalizations of Nursing Home Residents for Manageable and Preventable

Conditions

• The Work Plan will continue the focus on theThe Work Plan will continue the focus on the hospitalization of nursing home residents with conditions that are considered “manageable or preventable” under nursing home care

• Frequent hospitalizations may be an indication of quality of care issues within the nursing home and q y gadd to the overall cost of care


Rehospitalization

• The basic formula for rehospitalizations is:The basic formula for rehospitalizations is:

• The actual readmission ratio is calculated in a complex algorithm by CMS

Excess readmission ratio = risk‐adjusted predicted readmissions

risk‐adjusted expected readmissions

• A simple calculation to track your own residents’ readmissions is:


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Specific Areas to Consider

• When you are reviewing your rehospitalization statisticsWhen you are reviewing your rehospitalization statistics, we suggest breaking down your discharges to obtain the most specific information possible

• This detailed information can then be better used in your compliance program and process reviews

• Compute rehospitalization percentage by:Payer type– Payer type

– Diagnosis

– Unit or wing

– Ancillary services received

– Other demographic or care related factors


OTHER WORK AREAS OF INTEREST


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Work Area: Hospices in Assisted Living Facilities

The Affordable Care Act requires CMS to collect relevant data to develop quality measures and revise the hospice payment system

Including length of stay, levels of care received, and common terminal illnesses of beneficiaries

The Medicare Payment Advisory Commission (MedPAC) has recommended further examination and monitoring as to why hospice patients who reside in ALFs have the longest lengths of stay compared to any other place of residence


MedPAC Report


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Work Area: Ambulance Services—Questionable Billing, Medical Necessity, and Level of

Transport

• The OIG will examine Medicare claims data to assess theThe OIG will examine Medicare claims data to assess the extent of questionable billing for ambulance services, such as transports that potentially never occurred or potentially were medically unnecessary transports to dialysis facilities

• They will also determine whether Medicare payments for ambulance services were made in accordance withambulance services were made in accordance with Medicare requirements


Ambulance Medical Necessity

Medicare does not pay for items or services that are notMedicare does not pay for items or services that are not “reasonable and necessary”

Specifically, ambulance services are covered “where the use of other methods of transportation is contraindicated by the individual’s condition…”

Many factors such as if the patient must lie flat during the transportation or requires services by an EMT go into the determination of medical necessity


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Work Area: Portable X-ray equipment—Supplier Compliance with Transportation and Setup Fee

Requirements

The OIG will review Medicare payments for the transportation andThe OIG will review Medicare payments for the transportation and setup of portable x-ray equipment to determine whether payments were accurate, and the claims were supported by documentation

They will also assess the qualifications of the technologists who performed the services, and determine whether the services were ordered by a physician

P i OIG t di f d th t M di i l id th t blPrior OIG studies found that Medicare improperly paid the portable x-ray suppliers for non-covered services like multiple trips to a nursing facility in one day, and for services ordered by non-physicians


Portable X-ray Study Results

• In 2011 the OIG issued a report on portable x-ray servicesIn 2011, the OIG issued a report on portable x ray services

• Medicare paid suppliers approximately $108 million for transportation component claims for portable x-rays furnished in 2009 while the beneficiary was in a nursing home or SNFs, according to MDS data– Approximately 12 percent of this amount, $12.8 million, was for

trips to a location already visited on the same dayp y y

– The OIG states that some return trips could be necessary, but believes that many are the result of questionable billing patterns


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THE AUDITORS


Work Area: ZPICs and PSCs—Identification and Collection Status of Medicare Overpayments

• The OIG will determine the total amount of overpaymentsThe OIG will determine the total amount of overpayments that Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) identified and referred to claims processors in 2013 and the amount of these overpayments that claims processors collected

• ZPICs and PSCs detect and deter fraud and abuse in Medicare Part A and/or Part BMedicare Part A and/or Part B – They conduct investigations; refer cases to law enforcement; and

take administrative actions, such as referring overpayments to claims processors for collection and return to the Medicare program


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ZPICs

C h b i th ZPIC f R i 3 hi h i l d th t t f Mi hi Mi tCahaba is the ZPIC for Region 3 which includes the states of: Michigan, Minnesota, Wisconsin, Illinois, Indiana, Ohio, Kentucky

Replaced the Program Safeguard Contractors (PSCs)

The primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse

Performs program integrity functions in these zones for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice and Medicare-Medicaid data matching


ZPIC Functions

Investigating potential fraud and abuse for CMS administrative action

Conducting investigations in accordance with the priorities established by Center for Program Integrity’s (CPI’s) Fraud Prevention System

Performing medical reviews


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ZPIC Functions, continued

Performing data analysis in coordination with CPI’s Fraud Prevention System

Identifying the need for administrative actions such as payment suspensions and prepayment or auto-denial edits

Referring cases to law enforcement for consideration and initiation of civil or criminal prosecution


Actions ZPICs Can Take

Request medical records and documentationRequest medical records and documentation

Conduct an interview

Conduct an onsite visit

Identify the need for prepayment or auto-denial edits and refer these edits to the MAC for installation

Withhold payments

Refer cases to CMS and/or law enforcement


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MAC Audits

MACs can opt to medically review any claim submitted to them, pre- or post-payment

Comprehensive Error Rate Testing (CERT) reviews l i b d t ti ti ll hi h fclaims based on statistically higher areas of errors

found on other claims as well as random sampling


Recovery Auditors (RAs)

• The current RA contracts have been extended while CMS finalizes the bids for the new contract period

• The awards are currently under a post-award protest being investigated by the Government Accountability Office (GAO)

• Per the CGI website:

– Beginning January 1st, 2015 the Centers for Medicare and Medicaid Services has agreed to extend the recovery program for region B and approved CGI to continue post payment automatedand approved CGI to continue post payment automated reviews, DRG Complex reviews and Drug Unit Complex reviews. Additional review issues may be added at any time through the length of this extension, solely at the discretion of CMS. The current contract is scheduled to run through December 31st, 2015.


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Recovery Auditors (RAs)

• On January 16, 2015, the RAs received notice from CMS th t th ld b i i i ADR f l di lthat they could begin issuing ADRs for manual medical review of therapy claims over the $3,700 threshold– These claims will be reviewed post-payment beginning with claims from

2014 in chronologic order from their paid date

– The first ADR will be for documentation on one claim only

– The second ADR can request documentation for up to 10% of eligible claims

Th thi d ADR t d t ti f t 25% f th i i– The third ADR can request documentation for up to 25% of the remaining eligible claims

– The fourth ADR can request documentation for up to 50% of the remaining eligible claims; and the fifth ADR can request 100% of the remaining claims


THE TRIPLE CHECK PROCESS


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Be Prepared

•We know the areas that the OIG is looking at, and we know that other auditors are likely looking at it too•But what can we do about it?•Periodic self-audits and using the triple check process can help us identify and address

b f th b th t t f th


areas before they become the target of the OIG

A Proactive Approach to Compliance

Th t i l h k i d t d t• The triple check process is a process conducted to review all data prior to submitting a claim to ensure accuracy and appropriateness of the claim– Can include both Part A and B claims as well as Medicare

Advantage and managed care

– A system that ensures all elements required for compliance and reimbursement are in place prior to billing p p p gthe specific payer


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Importance of the Triple Check

• With continued improvements and advances in ptechnology, simple off-site reviews can be conducted by contractors and third party auditors

• With great ease, conflicts or inaccuracies can be identified, resulting in repayment issues and/or further scrutiny


Triple Check Can Help Find Errors

Identify

•Technical errors, such as incorrect or missing dates•Procedural errors, such as timing issues with the MDS assessment•Documentation errors, such as under coding ADL

Identify


ADL scores•Process errors, such as missing or late beneficiary notices

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Components of the Triple Check

• Choose staff membersChoose staff members

• Identify claims for review

• Review the details of the claims and supportive documentation

• Correct errors before submitting the claim


Choose Staff Members

• Billingg

• Therapy

• MDS Coordinator

• Medical records

• Nursing

• Administrator

• Ancillary service personnel


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Identify Claims for Review

•We suggest that all payer types be reviewed initially to determine if a pattern is identified•Incorporate this process into the required monitoring and internal auditing element of your compliance program•Be sure to include claims with each type of ancillary


Be sure to include claims with each type of ancillary provided

Review the Details of the Claims and Supportive Documentation

•Each person should review the areas on the claim that are within their area of expertise, however, staff should not review their own documentation•Since the emphasis is slightly different for inpatient versus outpatient claims, the staff should be familiar with their responsibilities for each type of claim


with their responsibilities for each type of claim

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Importance of Documentation

•Paints a picture of the resident•Supports payment•Proof of services rendered•Indicates progress, lack of progress, and changes in the resident’s condition


the resident s condition

Nursing Documentation

•Document only what you know is accurate•Ensure consultants’ documentation is properly included•Ensure that CNA staff are documenting ADLs and toileting patterns•Note any change in the resident’s conditionCl l d l ibl d t i d d d


•Clearly and legibly document services rendered and resident response

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Nursing Documentation

• Notes must clearly indicate the skilled nature of theNotes must clearly indicate the skilled nature of the services being rendered

• Must support the need for SNF level of care• Notes must support the need for therapy services, if

appropriate– Any variances in resident performance should be explained


Therapy Documentation

• Prior level of functionPrior level of function• Resident response to interventions• Goal attainment and progress• Proper ICD-9 codes• Skilled level of care

– What did the therapist do?– Why could only a therapist do it?


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Correct Errors Before Submitting the Claim

If there is any area of review that is inconsistent, correct as necessary

If needed the MDS should be corrected, submitted and must be accepted prior to submitting the UB04

Check that validation reports have the same RUG category as the MDS that was submitted


Corrective Plan of Action

Did you find something in the audit that needs to be changed?

First determine the magnitude of the error

Is it something that poses the danger of a survey citation, such as incorrect procedures for beneficiary notices?as incorrect procedures for beneficiary notices?

Can the facility be held financially liable for the mistake, such as not completing or following up on the MSP form?


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Corrective Plan of Action

• Management must always be involved when a correctiveManagement must always be involved when a corrective plan of action is needed

• If there is a problem, it needs to be corrected

– Adjustment claims or cancel claims

– Document carefully

• Prevent this from occurring again

– Revise policies and procedures

– Provide updated education to staff


Questions?

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