5 OIG Work Plan Updates Added in June 2024

The OIG added many new items to their work plan in June. We’ve highlighted a select number of them below. 

Peripheral Vascular Procedures Audits

Many of us are familiar with diagnostic and therapeutic procedures related to heart vessels when those vessels are suspected of having disease or blockage. Other vessels in the body can also be affected by the process of plaque formation or other conditions. Specifically, the vessels of the lower extremity are often affected and medical services for these vessels are referred to as peripheral vascular procedures. These procedures can be performed in hospitals, but more and more of them are being performed in the office setting. 

In fact, the performance of in-office peripheral vascular procedures has increased among Medicare beneficiaries over the past decade. In the two calendar years for 2022 and 2023, Medicare paid approximately $1.16 billion for lower extremity peripheral vascular procedures in office settings.  

These procedures can help improve blood flow but are generally only recommended after more conservative treatment has failed. Included in these treatments are medical therapy, exercise therapy, and lifestyle changes. 

There have been many enforcement cases by the OIG and DOJ involving these procedures. They can be vulnerable to improper payment. The OIG plans to analyze Medicare fee-for-service for peripheral vascular procedures for questionable characteristics and review the program integrity activities of CMS and its contractors to combat fraud, waste, and abuse specific to these procedures. Additionally, they will assess whether these procedures complied with CMS requirements and met applicable treatment guidelines. 

Nursing Homes

Nursing homes are under a lot of scrutiny for different reasons. There are reports and programs aimed at measuring good care in nursing homes. To improve quality of care for the poorest performing nursing homes, CMS established the Special Focus Facility (SFF) Program. CMS and State survey agencies conduct increased oversight of nursing homes in the SFF Program by surveying these facilities twice per year, about twice as often as required for other nursing homes.  

The program was updated by CMS in Fall 2022. The goal was to shorten the time nursing homes spent in the program and increase the number of nursing homes that can go through it. 

OIG plans to evaluate CMS' and state survey agencies' implementation of the SFF Program, including implementation program updates. Additionally, OIG hopes to identify factors that have aided graduated SFFs with sustaining quality improvements and will assess the extent to which CMS and states incorporate these factors into the SFF Program. Lastly, OIG hopes this review with result in their sharing descriptive information about nursing homes that participated in the SFF Program. 

Leaving Against Medical Advice

Most patients admitted to a hospital listen and follow the recommendations of their clinical care team, including agreeing to stay in the hospital as recommended by medical personnel.  

However, there are several patients who decide to leave the hospital against medical advice (AMA). When this happens, hospitals indicate it on a claim with a specific patient discharge status code-"07," which stands for "left against medical advice or discontinued care."  

There have been some researchers who have published work indicating that patients who leave AMA might indicate a higher risk that a patient experienced poor quality health care. The researchers also note that hospital stays coded with the AMA designation may be associated with increased patient morbidity and mortality percentage rates. Additionally, the research suggests that those who have historically been medically underserved are more likely than other groups to receive the AMA designation.  

The percentage rates that hospitals have been designating that Medicare enrollees left AMA have increased over the past three decades. The OIG intends to create a data brief that will analyze the percentage rates and outcomes for enrollees that hospitals designate as left AMA as well as provide CMS and other stakeholders with information that can be used to address health disparities and improve enrollee outcomes. 

Durable Medical Equipment

Durable Medical Equipment (DME) is big business that has not been immune from fraud, waste, and abuse. Hardly a month goes by where there has not been a multi-million-dollar settlement related to DME. Two examples include: 

1. $2.1 million settlement https://www.justice.gov/usao-sc/pr/durable-medical-equipment-companies-pay-millions-false-claims-settlement 
2. $25.5 million settlement https://www.justice.gov/usao-sdny/pr/us-attorney-announces-255-million-settlement-durable-medical-equipment-supplier  

For traditional Medicare alone, the payment made for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) each year exceeds $7 billion.  

There are many safeguards in place to try and reduce fraud, waste, and abuse in DMEPOS, but fraudulent billing continues to be a major issue. Recent cases, such as those shared above, demonstrate that DMEPOS continues to be a target of fraudulent billing and that new schemes have developed.  

The OIG plans to review and provide information about current fraud schemes and the safeguards and monitoring that CMS has implemented to prevent fraud, waste, and abuse. OIG anticipates their findings will result in multiple products. The first will look at billing for DMEPOS in Medicare Advantage, specifically by suppliers that are not enrolled in Medicare fee-for-service. 

Conclusion

If your organization is involved with any of the areas mentioned above, you should review and stay updated on evolving compliance requirements in these areas.

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