A Brief Summary of the OIG Work Plan Updates for January 2022

The OIG added plenty of items to their Work Plan for January. Here’s the full scoop on the items that may affect your organization or compliance program.

Provider Relief Fund Balance Billing Requirement

Remember the CARES Act, Paycheck Protection, and other laws passed in response to COVID-19? These laws appropriate over $178 billion in relief funds to hospitals and other providers. And as compliance history has always shown, the day of reckoning will follow any significant distribution of government funds. These provider relief funds are intended to reimburse eligible healthcare providers for healthcare-related expenses or lost revenue attributable to COVID-19 to ensure that Americans could get testing and treatment for COVID-19.

But to be eligible, hospitals must attest to specific requirements. One of the requirements is that hospitals must not pursue the collection of out-of-pocket payments from presumptive or actual COVID-19 patients above what the patients otherwise would have paid if in-network providers had provided the care. This is often called “surprise billing” or the “balance billing requirement.” OIG plans to perform a nationwide audit to determine whether hospitals followed this requirement for COVID-19 inpatients. They will assess how bills were calculated for out-of-network patients admitted for COVID-19 treatment, review supporting compliance documentation, and evaluate procedural controls and monitoring to ensure compliance with the balance billing requirement.

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Hospice Eligibility

Many have experienced the comfort that Hospice care can bring to patients, families, and caregivers. But to be eligible for hospice care, patients must be entitled to Medicare Part A and be certified as terminally ill. The certification of terminal illness is based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group and the beneficiaries’ attending physician if they have one.

OIG has performed several compliance audits of individual hospice providers. In each of those audits, OIG had findings of beneficiary eligibility. Given this, the OIG will now perform a nationwide review of hospice eligibility, focusing on those hospice beneficiaries that haven’t had an inpatient hospital stay or an emergency room visit in specific periods before their start of hospice care.

Data to Identify Instances of Potential Abuse or Neglect in a prior audit, the OIG identified 34,664 Medicare claims containing diagnosis codes that indicated patients were treated for injuries possibly caused by abuse or neglect. They estimated that over 30,000 of these claims were supported by medical records that contained evidence of potential abuse or neglect.

The OIG was concerned because CMS did not identify the claims that indicated potential abuse or neglect. CMS officials responded by stating it did not extract data consisting of claims with diagnosis codes related to abuse or neglect. According to the OIG, this lack of a data extract prevented CMS and other organizations’ ability to pursue legal, administrative, and other actions to ensure the safety of these patients.

This work plan item is a follow-up audit to determine whether CMS improved its use of Medicare data to identify potential abuse and neglect incidents since the OIG issued their prior report. The OIG also plans to determine:

    • the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries in 2019 and 2020,
    • who may have perpetrated those incidents and where they occurred,
    • and whether the incidents were reported to law enforcement.

Cost Report Oversight

Hospitals’ Medicare cost reports are supposed to be audited and settled by their respective Medicare administrative contractor (MAC). The MAC is supposed to perform desk reviews of all cost reports and audit cost reports as necessary before settling any cost reports.

The OIG wants to review whether MACs are appropriately overseeing cost report activity. They will check the MACs cost report oversight by verifying the number of desk reviews and the number of audits performed per the CMS contract and identify non-compliance issues.

After performing this review, the OIG plans to conduct additional reviews, including MAC audit findings and recommendations, to determine whether the provider implemented the recommendations and took corrective action. Lastly, the OIG will examine CMS’s oversight of the MAC cost report desk reviews/audits. Their objective is to determine whether the individual MACs met the requirements stated in the MAC contracts.

But if your hospital cost report has errors, they could get wrapped up in these reviews. It might make sense to proactively review your cost reports with that in mind.

COVID-19 Relief Funding, Hospice Eligibility, Data Identifying Patient Neglect or Abuse, And More.

COVID-19 relief funding, hospice eligibility, data identifying patient neglect or abuse, and cost report oversight are just some of the recently added OIG Work Plan items. Be sure to review these items as well as any others recently added. If your organization is involved in the types of services or activities outlined in the work plan, consider proactively assessing these risks in your organization.


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