The OIG has updated their work plan with its January 2018 additions. Let’s take a deep dive into the updates and what they mean for you as a compliance professional.
Questionable Billing for Off-the-Shelf Orthotic Devices
This particular item seems to have been added as a result of a MAC (Medicare Administrative Contractor) who identified high improper payment rates in their jurisdiction for three specific off-the-shelf orthotic devices. The devices and their corresponding HCPCS code are:
- L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
- L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
- L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf.
According to the OIG, the particular MAC identified improper payment rates of 79% for L0648, 88% for L0650, and 91% for L1833. The OIG appears to think similar error rates may be found in other jurisdictions for these same orthotics. They cite a 97% growth in claims for these three orthotics since 2014, while allowed charges for these orthotics have grown by 116% reaching $349 millions in 2016.
The biggest concern seems to be with substantiating documented medical necessity for these claims. According to the OIG’s work plan item they “will evaluate the extent to which Medicare beneficiaries are being supplied these orthotic devices without an encounter with the referring physician within 12 months prior to their orthotic claim and will analyze billing trends on a nationwide scale.” The MAC they referenced cited their main concern as “a lack of documentation of medical necessity in patients' medical records.”
If you bill for these orthotics, you may want to perform your own pre-emptive audit.
OIG Toolkit to Identify Patients at Risk of Opioid Misuse
The OIG continues to exert effort on the opioid problem in the country. This work plan item will focus on developing a toolkit to provide information on how the OIG performed its analysis of a large dataset of opioid claims to produce patient-level opioid data. This included they calculated a Morphine Equivalent Dose (MED) level for the patients.
This item drills home the emphasis that many federal agencies are putting on enforcement for over-prescribing and distributing opioids. It’s just one more voice in the message that your compliance program should have some plan in place to evaluate opioid distribution and/or prescribing.
Financial Impact of Health Risk Assessments and Chart Reviews on Risk Scores in Medicare Advantage
In the Medicare Part C world, CMS pays Medicare Advantage (MA) organizations for each beneficiary enrolled in the plan. To correct for patients with higher than expected costs, risk adjustments are made based on patient demographic information as well as clinical diagnoses.
Health risks assessments are visits used to evaluate a patient’s health risks. CMS includes diagnoses from these health risk assessment when they calculate the risk scores and payment adjustments.
According to the OIG, this “is allowed regardless of whether these diagnoses are supported by another service rendered to the beneficiary during that year. This study will determine the extent to which diagnoses solely generated by health risk assessments and chart reviews were associated with higher risk scores and higher MA payments.”
Other items added to the Work Plan in January include:
- States' Use of the Automated Child Welfare Information System to Monitor Medication Prescribed to Children in Foster Care
- Potential Abuse and Neglect of Medicare Beneficiaries
- States' Monitoring of Subrecipients to Ensure Program Integrity Within the Child Care Development Fund Block Grant Program
We recommend regularly reviewing the OIG Work Plan and use it as a contributing source when performing your annual compliance risk assessments as well as when you develop your compliance work plans.
CJ Wolf
Questions or Comments?