Deeper Than the Headlines: OIG Workplan Additions, Aug. 2019: What You Need to Know

This August we saw a ton of additions to the OIG’s workplan. With so much to unpack, I’ve trimmed the fat down to those I believe might affect you and your organization’s compliance program the most. So, let’s dive right in. . .

Medicare Payments of Positive Airway Pressure Devices for Obstructive Sleep Apnea Without Conducting a Prior Sleep Study

An OIG analysis of the 2017 Comprehensive Error Rate Testing (CERT) program for positive airway pressure (PAP) device payments shows potential overpayments of $566 million. The overpayments come in the form of claims for PAP devices which were found to be neither reasonable nor necessary, according to Medicare standards. The OIG plans to examine Medicare payments made to durable medical equipment providers for PAP devices used to treat OSA, then determine whether those payments were in fact appropriate, Medicare-approved sleep studies were ever conducted.

Review of the Medicare DRG Window Policy

Outpatient services directly related to an inpatient admission are considered part of the inpatient payment, and thus not separately payable by Medicare. The diagnosis-related group (DRG) window policy defines when CMS considers outpatient services to be an extension of inpatient admissions, and generally includes services that are:

1. Provided within the 3 days immediately preceding an inpatient admission to an acute-care hospital
2. Diagnostic services or admission-related nondiagnostic services
3. Provided by the admitting hospital or by an entity wholly owned or operated by the admitting hospital

Building on previous work, the OIG plans to determine the number of admission-related outpatient services that were not covered by the DRG window policy in 201. This will include services that were provided prior to the start of the DRG window, as well as services provided at hospitals that shared a common owner. The OIG will also determine the amounts that Medicare and beneficiaries would have saved in 2018, had the DRG window policy been updated to include more days and other hospital ownership structures. Finally, the OIG will interview CMS staff to identify other potential payment models CMS could use to pay for outpatient services related to these inpatient admissions.

Review of Medicare Facet Joint Procedures

Facet joint injections are an interventional technique used to diagnose or treat back pain. Several previous reviews found significant billing errors in this area, including a prior OIG review. The OIG has plans to review whether payments made by Medicare for these facet joint procedures complied with Federal requirements.

Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care

Telehealth is the use of telecommunications and information technology to provide access to health assessments, diagnoses, interventions, consultations, supervisions, and other healthcare-related information from afar (i.e. The provider and the patient don’t share a room, but rather a screen or phone line). Telehealth’s value is found by increasing a beneficiary’s access to healthcare, while reducing the healthcare spend. All 50 States and the District of Columbia currently provide some coverage under Medicaid of telehealth. However, limited information is available on how States use telehealth to provide behavioral health services to Medicaid managed care enrollees. So, a review is set to be conducted by the OIG which will focus on selected States. The review will analyze how these States (and managed care organizations (MCOs)) use telehealth to provide behavioral healthcare. It will also review the selected States' monitoring and oversight of the MCOs' behavioral health services that were provided via telehealth.The review also aims to identify States' and MCOs' practices that can serve to maximize the benefits while minimizing the risks of providing behavioral healthcare via telehealth.

Medicaid Assisted Living Services

It was announced announced that Medicaid may soon provide assisted living services to individuals who are medically eligible for placement in a nursing home, but who opt for a less medically intensive service in a lower-cost setting. These services may include personal care (e.g., assistance with dressing and bathing), homemaker services (e.g., house cleaning and laundry), personal emergency response services, and therapy services (e.g., physical, speech, and occupational therapy).

A 2018 Government Accountability Office report indicated that improved Federal oversight of beneficiary health and welfare is needed in each States' administration of Medicaid assisted-living services. The OIG plans to determine whether assisted living providers are meeting quality-of-care requirements for Medicaid beneficiaries residing in their facilities and whether the providers properly claimed Medicaid reimbursement for their services, in accordance with Federal and State requirements.

Nursing Homes: CMS Oversight of State Survey Agencies

As some may know, CMS has agreements with individual State survey agencies to help determine whether nursing homes comply with Medicare requirements. What you may not know is that recent OIG reports suggest they have uncovered potential performance issues on the part of the survey agencies, including:

• Survey Agencies not verifying whether nursing homes corrected deficiencies
• Survey Agencies not investigating complaints in a timely manner

CMS evaluates each survey agencies’ performance in fulfilling their responsibilities. When there is inadequate performance, CMS may impose a sanction or remedy (e.g., provide training to survey teams, require a corrective action plan to be submitted by a survey agency, etc.).

In a forthcoming report, the OIG’s will describe CMS's efforts to work with survey agencies on improving their performance and review supporting documentation of CMS's own monitoring efforts. The report will also identify challenges impeding CMS's ability to help survey agencies improve their overall performance.

If your organization is involved in any of these kinds of services, it would be wise to perform your own proactive reviews to ensure ongoing organizational compliance.