Deeper Than the Headlines: OIG Work Plan Items - June 2018

In June 2018, the OIG added more items to its work plan. Here’s a quick summary of some of those newly added items:

Review of Home Health Claims for Services With 5 to 10 Skilled Visits

If a home health agency (HHA) provides four or less visits from a skilled service provider that are included under home health coverage in an episode, the HHA is paid a standardized per-visit payment based on visit type. These payment adjustments, and the episodes themselves, are known as Low Utilization Payment Adjustments (LUPA). Once a fifth visit is provided, an HHA will receive a full 60-day payment based on episode of care. The OIG is going to review supporting documentation to determine whether home health claims with 5 to 10 skilled visits in a payment episode in which the beneficiary was discharged home met the conditions for coverage and were adequately supported as required by Federal guidance. Home Health Care is big business and it’s getting bigger. Medicare paid home health agencies approximately $18.2 billion for home health services in 2016. The CERT program, however, found that the 2016 improper payment error rate for home health claims totaled 42%, or approximately $7.7 billion.

Medicare Part B Payments for End-Stage Renal Disease Dialysis Services

Medicare Part B covers outpatient dialysis services for beneficiaries diagnosed with end-stage renal disease (ESRD). Previously, the OIG’s work identified inappropriate Medicare payments for ESRD services. Specifically, OIG identified unallowable Medicare payments for treatments not furnished or documented, services for which there was insufficient documentation to support medical necessity, and services that were not ordered by a physician or ordered by a physician that was not treating the patient. Additionally, prior OIG reviews identified claims that did not comply with Medicare consolidated billing requirements. The OIG plans to review claims for Medicare Part B dialysis services provided to beneficiaries with ESRD to determine whether such services complied with Medicare requirements.

Accountable Care Organizations' Strategies Aimed at Reducing Spending and Improving Quality

The Medicare Shared Savings Program (MSSP) introduced accountable care organizations (ACOs) into the Medicare Program to promote accountability of hospitals, physicians, and other providers for a patient population; coordinate items and services; encourage investment in infrastructure; and redesign care processes for high-quality and efficient service delivery. OIG plans to identify ACOs' strategies aimed at reducing spending and improving quality. Specifically, OIG will describe ACOs' strategies intended to reduce spending and improve care in different service areas, such as hospitals and nursing homes. They will also describe strategies ACOs are using to work with physicians and engage beneficiaries; manage the care of beneficiaries needing high-cost, complex care; address behavioral health and social needs; and use data and technology.

Inappropriate Denial of Services and Payment in Medicare Advantage

Capitated payment models are based on payment per person rather than payment per service provided. A central concern about the capitated payment model used in Medicare Advantage is the incentive to inappropriately deny access to, or reimbursement for, health care services in an attempt to increase profits for managed care plans. OIG will conduct medical record reviews to determine the extent to which beneficiaries and providers were denied pre-authorization or payment for medically necessary services covered by Medicare. To the extent possible, OIG will determine the reasons for any inappropriate denials and the types of services involved.

If any of these items are similar to the services your organization provides, it may be wise for your compliance program to proactively audit or monitor these services.