CJ Wolf
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oig work plan, OIG Work Plan Updates, Incident-To, Skin & Subcutaneous Tissue, OIG Updates 2024, OIG Work Plan 2024
The OIG has added some very significant items to their Work Plan in November 2024.
Health Risk Assessments (HRAs)
In October of 2024, the OIG released a significant report titled “Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions” (OEI-03-23-00380). They concluded that diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in Medicare Advantage (MA) risk-adjusted payments for 2023.
The OIG continued by suggesting the lack of any other follow-up visits, procedures, tests, or supplies for these diagnoses in the MA encounter data for 1.7 million MA enrollees raises concerns that either: (1) the diagnoses are inaccurate and thus the payments are improper, or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews.
With this in mind, it should not come as a surprise that in November of 2024, the OIG has added an HRA audit to their Work Plan. CMS makes monthly risk-adjusted payments to MA organizations based in part on the health characteristics of covered enrollees. Regulations require that MA organizations submit risk adjustment data, which includes diagnosis codes, to CMS in accordance with CMS instructions. Inaccurate diagnoses may cause CMS to pay MA organizations improper amounts. MA organizations use health risk assessments (HRAs) to gather information, including diagnoses, about enrollees. MA organizations can use HRAs for early identification of health risks to improve enrollees' care and health outcomes.
As their October report claimed, MA organizations may have inappropriately leveraged HRAs to maximize risk-adjusted payments. So, they announced these HRA audits focused on enrollees whose diagnoses, reported first on HRAs, mapped to hierarchical condition categories and resulted in increased risk-adjusted payments from CMS to MA organizations. The OIG plans to determine whether MA organizations complied with Federal requirements when: (1) submitting diagnoses reported on HRAs to CMS for use in CMS's risk-adjustment program and (2) taking any needed steps to ensure continuity of care and integration of services for enrollees who had received HRAs.
Skin Substitutes
An Iowa plastic surgeon paid $800,000 to the United States and the State of Iowa to resolve allegations he wrongfully billed Medicare and Medicaid, in part, for medically unnecessary and unreasonable applications of skin substitute products.
Skin substitutes help aid in wound healing and redevelopment of skin. Medicare covers skin substitutes that are reasonable and necessary for the treatment of a Medicare patient’s condition. Local coverage determinations state that Medicare Part B generally covers skin substitutes for treatment of diabetic foot ulcers and venous leg ulcers that have failed to respond to at least 4 weeks of standard wound care. However, no national or local coverage requirements apply for other wound types (e.g., pressure ulcers or trauma wounds), and coverage of skin substitutes for these wounds is determined on a case-by-case basis.
Medicare Part B pays for skin substitutes based on the number of service units billed at prices ranging from approximately $100 to more than $1,000 per square centimeter. From the calendar years 2020 through 2023, Medicare Part B payments for skin substitutes have increased substantially.
OIG is going to review Medicare Part B claims for skin substitutes to identify payments that were at risk for noncompliance with Medicare requirements.
Incident-To Services
Many medical practices struggle with compliance for ‘Incident-To’ services. One example occurred in a New York medical practice. The practice paid $600,000 to settle allegations of billing for services as incident-to when all the requirements were not met. Specifically, it was alleged services were billed in the name of the physician (at the higher rate), when the physician had not rendered the services for which reimbursement had been sought. In fact, the services had been performed by providers who had not enrolled in the Medicare or Medicaid programs. Further, the providers that had rendered the services were often not physicians, but instead nurse practitioners or physician assistants. On many such occasions, the physician had no personal involvement or supervision in the treatment of the patient as required by incident-to rules.
Medicare Part B pays for physicians' services, and services and supplies incident to a physician's services that are furnished by the physician's staff, including non-physician practitioners. Incident to services must be an integral part of the physician's services during diagnosis or treatment of an injury or illness, and, in general, must be furnished under the physician's direct supervision. Incident-to services are billed under the physician's National Provider Identifier number as if the physician personally provided the services. Medicare reimburses the incident to service at the full rate of the Medicare Physician Fee Schedule if all the requirements are met.
The OIG has performed previous work which concluded that improving the transparency of incident-to services is critical to program integrity efforts. Their objective for this Work Plan item is to determine whether Medicare Part B payments for services performed incident to physicians' services complied with Medicare requirements.
Medicaid Personal Care Services
Personal care services (PCS) are categorized as a range of human assistance provided to persons with disabilities and chronic conditions to enable them to accomplish activities of daily living or instrumental activities of daily living. PCS assists people enrolled in Medicaid with activities of daily living and helps them remain in their homes and communities. Examples of PCS include bathing, dressing, light housework, money management, meal preparation, and transportation. Prior OIG reviews identified significant problems with States' compliance with PCS requirements. Some reviews also showed that program safeguards intended to ensure medical necessity, patient safety, and quality, and prevent improper payments were often ineffective. They will determine whether PCS claims complied with Federal and State requirements.
Conclusion
If your organization is involved with any of the services discussed above, consider carefully reviewing these new Work Plan items to see how they may impact you.
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