Deeper Than the Headlines: October 2019 OIG Workplan Updates

This past month, the OIG has added quite a few items to their 2019 workplan. There’s a lot to unpack in there, so I thought I would do you the favor of whittling down some of the new updates that I found most interesting. So, let’s take a quick look at a few of them:

Compliance with Medicare Requirements for Replacement of Positive Airway Pressure Device Supplies

Medicare beneficiaries receiving continuous positive airway pressure, or respiratory-assisted device therapy, require replacement of supplies (e.g., mask, tubing, headgear, and filters) when they wear out or are exhausted. Medicare payments for these replacement supplies in 2017 and 2018 were approximately $945.8 million. Prior OIG work found that most Medicare claims that suppliers submitted for replacement PAP devices did not comply with Medicare requirements. For supplies and accessories used periodically, orders must specify the type of supplies needed, the frequency of use, and the quantity to be dispensed. And, suppliers must not automatically ship refills on a predetermined basis. The OIG plans to review claims for frequently-replaced devices at selected suppliers to determine whether documentation requirements for medical necessity, frequency of replacement, and other Medicare requirements are met.

Hospice Inpatient and Aggregate Cap Calculations

Hospice care can provide great comfort to beneficiaries, families, and caregivers at the end of a beneficiary's life. To ensure that hospice care does not exceed the cost of conventional medical care at the end of life, Medicare imposes two annual limits to payments made to hospice providers: 1.) The inpatient cap and, 2.) The aggregate cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20 percent of a hospice's total Medicare patient care days, and a hospice must refund to Medicare any payment amounts in excess of the inpatient cap. The aggregate cap limits the total aggregate payments that any individual hospice can receive in a cap year to an allowable amount based on an annual per-beneficiary cap amount and the number of beneficiaries served. Any amount paid to a hospice for its claims in excess of the aggregate cap is considered an overpayment and must be repaid to Medicare. Medicare administrative contractors (MACs) oversee the cap process and hospices must file their self-determined aggregate cap determination notice with their MAC no later than 5 months after the end of the cap year and remit any overpayment due at that time.

Medicare Part B Urine Drug Testing Services

Medicare covers treatment services for substance use disorders (SUDs), such as inpatient and outpatient services when they are reasonable and necessary. SUDs occur when the recurrent use of alcohol or other drugs cause clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home. Medicare also covers clinical laboratory services, including urine drug testing (UDT) under Part B. Physicians use UDT to detect the presence or absence of drugs, or to identify specific drugs in urine samples. A patient in active treatment for an SUD, or being monitored during different phases of recovery from an SUD, may undergo medical management for a variety of medical conditions. UDT results influence treatment and level-of-care decisions for individuals with SUDs. The 2018 Medicare fee-for-service improper payment data showed that laboratory testing, including UDT, had an improper payment rate of almost 30 percent, and that the overpayment rate for definitive drug testing for 22 or more drug classes was 71.7 percent. As a result of these findings, the OIG will review UDT services for Medicare beneficiaries with SUD-related diagnoses to determine whether those services were allowable, in accordance with Medicare requirements.

Medicare Part B Payments for Speech-Language Pathology

Outpatient speech therapy services are provided by speech-language pathologists and are necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities and swallowing disorders (dysphagia). When Medicare payments for a beneficiary's combined physical therapy and speech therapy exceed an annual therapy spending threshold (e.g., $2,010 in 2018), the provider must append the KX modifier to the appropriate Healthcare Common Procedure Coding System code reported on the claim. The KX modifier denotes that outpatient physical therapy and speech therapy services combined have exceeded the annual spending threshold per beneficiary, and that the services being provided are reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. The OIG will determine whether the claims using the KX modifier adhere to Federal requirements. In addition, the OIG will evaluate payment trends to identify Medicare payments for outpatient speech therapy services billed using the KX modifier that are potentially unallowable.

These workplan items are becoming more and more detailed and specific. The detail they are now providing can be very helpful, especially when compliance professionals are using the data within their own organizations to determine their level of exposure and risk under these workplan items. Taking the time now to audit or monitor these areas in your own organization is a proactive way to demonstrate your compliance program’s effectiveness.