The Office of Inspector General (OIG) publishes annually a Work Plan describing new, ongoing, and revised areas within the U.S. Department of Health and Human Services (HHS) it will investigate throughout the year for potential fraud, waste, and abuse. It’s wise for providers to review this Work Plan and update their compliance plans accordingly. Here’s a summary of the areas within Medicare Part B on which the OIG plans to focus this year.
NEW!Part B services during non-Part A nursing home stays – DME: In cases where a beneficiary continues to reside in a skilled nursing facility (SNF) after 100 days (non-Part A stay), Medicare Part B may provide coverage for certain therapy and supplies. A July 2009 OIG study found that Medicare Part B made $30 million in inappropriate DME Prosthetics, Orthotics, and Supplies (DMEPOS) payments. The OIG will evaluate the extent of inappropriate payments under Part B for DMEPOS provided to nursing home residents during non-Part A stays. The OIG also intends to determine if the Centers for Medicare & Medicaid Services (CMS) has a system in place to identify and recoup such overpayments from suppliers.
NEW!Medicare market share of mail-order diabetic testing strips (DTS): The OIG will develop a required report of the market share of DTS prior to each subsequent round of the competitive bidding program.
NEW!Positive airway pressure device supplies – supplier compliance with documentation requirements for frequency and medical necessity: Medicare paid approximately $953 million for continuous positive airway pressure or respiratory assist devices (PAP). Prior OIG analysis found evidence of automatic shipping of PAP supplies when no physician orders for refills were in effect. The importance of compliance cannot be understated. Orders of certificates of medical necessity must specify the type of supplies needed and the frequency of use, replacement, or consumption consistent with the Medicare Program Integrity Manual (publication 100-8, chapter 5, sections 5.2.3, 5.9). Automatic shipment of resupplies is not permitted. The documentation must show a request for resupply by the beneficiary or caregiver before supplies are dispensed, according to the Medicare Claims Processing Manual (publication 100-4, chapter 20, section 200).
Other areas of focus include:
NEW!Monitoring Medicare payments for clinical diagnostic laboratory tests: Consistent with the requirements of section 216 of the Protecting Access to Medicare Act (PAMA) of 2014, OIG will analyze the market rates for the top 25 laboratory tests as a means of monitoring CMS’ implementation of the new payment system for these tests.
NEW!Medicare payments for transitional care management: Medicare-covered services, including chronic care management, end-stage renal disease, and prolonged services without direct patient contact cannot be billed during the same service period as transition care management (TCM). OIG will determine whether payments for TCM services were in accordance with Medicare coverage requirements.
NEW!Data brief on financial interests reported under the open payments program: Section 6002 of the Affordable Care Act, sometimes referred to as the Physician Payments Sunshine Act, requires manufacturers to disclose to CMS payments made to physicians and teaching hospitals. OIG intends to analyze the 2015 reporting data to determine the number and nature of financial interests, and will evaluate how much Medicare paid for drugs and DMEPOS ordered by physicians with financial relationships with the supplying entity. The OIG also continues to evaluate the accuracy of the data reported by manufacturers to the open payments system.
NEW!PMD equipment – Portfolio report on Medicare Part B payments: OIG previously identified inappropriate payments for PMDs that were unnecessary, not documented in accordance with Medicare requirements, cheaper to rent than purchase, or fraudulent. OIG will compile results of prior audits, evaluations, and investigations of PMD equipment paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities. OIG will make recommendations to CMS of any necessary actions.
REVISED!Ambulance services – Supplier compliance with payment requirements: The OIG found that Medicare made inappropriate payments for advanced life support (ALS) services, and based on prior work will determine whether ambulance services including basic life support (BLS), ALS, and specialty care transports were billed in compliance with Medicare requirements.
REVISED!Inpatient rehabilitation facility (IRF) payment system requirements: The OIG will determine whether IRFs nationwide have submitted claims in compliance with Medicare documentation and coverage requirements, based on prior reviews that identified substantial Medicare overpayments to IRFs.
REVISED!Histocompatibility laboratories – supplier compliance with payment requirements: From March 31, 2013, through Sept. 30, 2014, histocompatibility labs reported $131 million in reimbursable costs on their most recent cost reports. Because allowable costs must be related to the care of beneficiaries; be reasonable necessary and proper; and be an allowable cost under the regulations, the OIG will determine whether payments to histocompatibility labs were made in accordance with Medicare requirements.
Other areas the OIG is focusing on (and you should, too):
This is a summary of the Part B portion of the 2017 Work Plan; you are encouraged to review the Work Plan in its entirety to ensure applicable risk areas are well understood. For each of your focus areas, be certain to review appropriate CMS interpretive guidance and local coverage determinations, as well as any referenced regulatory provisions cited in the OIG Work Plan to ensure you completely understand and comply with CMS’ expectations, particularly with respect to documentation content and coverage limitations.
In addition to the 2017 Work Plan, the Office of Inspector General (OIG) separately published its semi-annual report to congress, in which it announced expected recoveries of $5.56 billion from its fraud and abuse efforts in 2016. This amount is up substantially from the $3.3 billion recoveries the OIG projected for 2015. OIG also reported the following statistics relative to its enforcement efforts:
| — | 2016 | 2015 | 2014 |
|---|---|---|---|
| Criminal actions against individuals or entities | 844 | 925 | 971 |
| Civil actions against individuals or entities | 708 | 682 | 533 |
| Exclusions | 3,635 | 4,112 | 4,017 |
Although criminal action and exclusion figures have fallen, civil actions — which include false claims or unjust enrichment lawsuits, civil monetary penalty settlements, and administrative recoveries relative to provider self-disclosure matters — have risen. The dramatic increase in expected recoveries suggests there is no slowdown in the government’s enforcement efforts, and the importance of compliance cannot be understated.
Source: OIG semi-annual report to Congress
2016 and 2017 OIG Work Plans: https://oig.hhs.gov/reports-and-publications/workplan/index.asp
Medicare Program Integrity Manual, pub 100-8, ch 5 – Items and Services Having Special DME Review Considerations, §§5.2.3, 5.9.
Medicare Claims Processing Manual, pub 100-4, ch 20 – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §200.