Deeper Than the Headlines: Prepare Your Organization Using OIG Work Plan Updates

Many compliance programs rely on the OIG Work Plan when planning their own internal audit or compliance activities. Historically, the OIG Work Plan was updated annually. However, recently the OIG has been publishing periodic updates and additions more often.

In August of 2017, four new additions were included in the OIG Work Plan. So, let’s dive in and talk about these four recently added items (I know that you’re just dying to jump in there).

Medicare Part B Payments for Psychotherapy Services

Last year, Medicare Part B paid about $1.2 Billion for psychotherapy services, including both individual and group therapy. A previous OIG review concluded that Medicare paid $185 million for outpatient mental health services that should not have been paid. They found that psychotherapy services were inappropriately paid about half of the time. In that review, Medicare paid for non-covered services, inadequately documented services, or medically unnecessary services.

In past reviews and audits that I have been involved in, many providers often fail to properly and explicitly document the time component required to appropriately use the codes. Another issue that some LCDs require and that providers sometimes fail to document, is the presence of the patient. This may seem obvious, but when it comes to psychotherapy, especially in an elderly Medicare population, family members or other caretakers are often involved. And though this is fine, the codes and LCDs often require documentation of the face-to-face service and time with the patient.

LCDs may also point out what is not considered psychotherapy such as the teaching of grooming skills, monitoring activities of daily living (ADL), recreational therapy (dance, art, play) and social interaction. These services may be important for the clinical improvement of the patient, but they are not the same as psychotherapy and should not be added into the psychotherapy time.

Duplicate Drug Claims for Hospice Beneficiaries

When a Medicare patient elects hospice coverage, the hospice provider is required to render all services for the management of the patient’s terminal illness and related conditions. This includes prescription drugs. Medicare Part A pays hospice providers a daily per diem rate for each patient who has chosen hospice coverage. Thus, Medicare Part D should not be paying for prescription drugs related to the patient’s terminal illness because the per diem rate already includes payment for those drugs.

A previous OIG report found that Medicare may have paid twice for these types of drugs. Once in the hospice per diem rate and then again through Medicare Part D. OIG has added this to their work plan to determine if there is duplicate payment for drug claims for patients receiving the hospice benefit.

Review of the Patient Safety Organization Program

The Patient Safety and Quality Improvement Act of 2005 created a program known as the Patient Safety Organization (PSO) program. Under this program, federally recognized PSOs are to work with providers to improve patient care through better patient safety and quality of care. In 2008, the Agency for Healthcare Research and Quality (AHRQ) published a final rule then implemented the Act.

OIG plans to determine the value of the PSO program among hospitals. They also plan to assess AHRQ’s oversight of the PSO program and identify any hurdles the program is facing.

Ventilation Devices: Reasonableness of Medicare Payments Compared to Amounts Paid in the Open Market

OIG is interested in knowing if the Medicare program is vulnerable to potential wasteful spending as it relates to ventilation devices.  Medicare spending on ventilation devices has risen from $51 million in 2011 to $72 million in 2015. Compared to similar items for which Medicare has seen lowered costs because of the competitive bidding process, ventilation devices have not been competitively bid.

Through this review, the OIG wants to determine the “reasonableness of the fee schedule prices that Medicare and beneficiaries pay for ventilation devices compared to prices on the open market.”

How to Prepare

Not every addition to the OIG Work Plan will affect your organization, but it is always wise to stay up to date on their most recent changes to determine if they’ll be looking at areas your organization is involved in. And if they are, it would be wise to update your own internal work plan accordingly.