OIG Work Plan Updates For November: Everything You Need to Know About Telehealth and Severe Nutrition Claims

In November, there were many things for which to give thanks. However, some of you in the compliance industry might not have listed the newest OIG Work Plan items, added in November, as the greatest blessings for which you gave thanks. Even if you’re not grateful for these new work plan items, you should be informed. Let’s look at some of the latest items added to the OIG Work Plan.

Telehealth Services

It’s probably safe to say that all of us have had some exposure or awareness to the concept of telehealth services, especially during the COVID pandemic. Telehealth has been a way for many patients to receive care without potentially spreading the virus. Telehealth has many advantages. However, as with any increased volume of services in healthcare, there are also some accompanying compliance risks. There are even some unanswered questions in how the benefits of telehealth can be enhanced moving forward while reducing fraud, waste, and abuse risks. The OIG plans to work with the other OIG members in the leadership of the Pandemic Response Accountability Committee (PRAC) to produce a report describing the types of available telehealth services. Including those that expanded during the pandemic and key program integrity risks associated with the use of telehealth across six selected Federal health care programs. Medicare is the HHS program included in this evaluation. The resulting report is intended to provide policymakers and stakeholders with foundational information about the nature of telehealth across select Federal health care programs and related program integrity risks to inform the use of telehealth in the future.

National Background Check Program

The Affordable Care Act included a provision to establish a national background check program. CMS runs the program, and it offers grants to certain States to begin a background check program for potential employees and providers of long-term care services. The OIG is required to assess the grant program. For this work plan item, the OIG will review the program for the states of Idaho and Mississippi. They plan to determine the costs associated with each State program and determine the checks conducted during the program.

Severe Malnutrition Inpatient Hospital Claims

Hospitals bill for the treatment of malnutrition based on how severe the malnutrition is, which can be categorized as mild, moderate, or severe. From an inpatient coding and billing perspective, “severe malnutrition” is classified as a significant complication or comorbidity (MCC). Adding an MCC to a claim can increase payment by causing the claim to be coded in a higher diagnosis-related group or DRG. The OIG plans to perform statewide reviews of Medicaid hospital inpatient claims associated with severe malnutrition. Since more reimbursement is related to severe malnutrition claims, the OIG wants to discover if claims coded that way are accurate and compliant with Medicaid billing requirements.

Mechanical Ventilation Inpatient Claims

Mechanical ventilation uses a ventilator to take over active breathing for a patient. When patients admitted to the hospital require mechanical ventilation, it can affect the coding, billing, and reimbursement of those claims. OIG plans to review Medicare payments for inpatient hospital claims with certain Medicare Severity Diagnosis Related Group (MS-DRG) assignments that require mechanical ventilation to determine whether hospitals' DRG assignments and resultant Medicare payments were appropriate. A patient had to have received more than 96 hours of mechanical ventilation to qualify for Medicare coverage in some cases. The OIG will include claims for beneficiaries who received more than 96 hours of mechanical ventilation in their review. Previous OIG reviews identified improper payments made because hospitals inappropriately billed for beneficiaries who did not receive at least 96 hours of mechanical ventilation.

Conclusion

If your organization provides any of the services mentioned above or is involved in these programs, it makes sense for your compliance program to review some of these same risks proactively. Doing so helps you identify potential issues before government enforcement agencies do.

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