OIG Work Plan Updates: The Notorious OIG Targets ABA Services, POS Codes, And More.

The OIG is at it again and they are not slowing down on their oversight work. So let’s take a look at some recent additions to their work plan because they might seriously impact your organization’s compliance program.

Medicaid Audit—Children with Autism

Many of us probably know someone with autism as awareness and treatment of those with autism has increased.  With increased treatment (and payment for treatment) comes increased compliance scrutiny.

Autism is a developmental disability that can cause significant social, communication, and behavioral challenges for children. According to the Centers for Disease Control, there is currently no cure for autism; however, research has shown that early intervention and treatment can improve a child's development.

One of the common treatments for autism, Applied Behavior Analysis (ABA), can help autistic children improve social interaction, learn new skills, maintain positive behaviors, and minimize negative behaviors. In the past few years, some enforcement agencies have identified billing patterns by some ABA providers that are questionable.  In addition, they’ve noticed some payments made to providers for unacceptable services.

The OIG plans to specifically audit Medicaid claims for ABA services provided to children diagnosed with autism to determine whether Medicaid payments for ABA complied with the rules and regulations accompanying ABA services.


Accuracy of Place-of-Service Codes

Place-of-Service (POS) codes can have a significant impact on the amount of reimbursement Medicare will make to providers. It’s under the fee-for-service paradigm also known as the Medicare Physician Fee Schedule. Even if physician practices accurately assign the correct CPT or HCPCS code, if the wrong POS code is assigned, providers could be overpaid.

In general, Medicare makes payments under Part B for physician services and payments under Part A for the costs of inpatient stays at inpatient facilities such as skilled nursing facilities (SNFs) and hospitals. While Medicare pays both SNFs and hospitals through prospective payment systems for the costs of inpatient stays, physician services provided to SNF and hospital inpatients are paid according to the Medicare Physician Fee Schedule.

The amount Medicare pays physician service providers (including physicians, podiatrists, and nurse practitioners for example) can vary based on where the service is provided (such as an SNF, hospital, or physician's office). Physician services can include medical and surgical procedures, office visits, and medical consultations.

To account for different practice expenses that physicians incur at different settings, Medicare designates a non-facility rate and a facility rate for each service within the fee schedule.  Because physicians generally incur higher practice expenses by performing services in their offices and other non-facility settings such as independent clinics and urgent care facilities, Medicare generally reimburses physicians at a higher non-facility rate for services performed in these settings. For services performed at a facility setting such as an SNF or hospital, Medicare generally reimburses physicians for services at a lower facility rate, and the prospective payment system payment to the facility covers the overhead expense.

Physicians indicate the applicable place of service on a Medicare claim using a two-digit POS code to ensure that Medicare properly reimburses the physician at either the non-facility rate or the facility rate. The physical setting where a physician performs a service does not always determine the appropriate place-of-service code. For example, when a beneficiary is a registered inpatient at a hospital or SNF, physician services should always be coded with a facility place-of-service code and paid at the facility rate. This is irrespective of the setting where the patient receives the face-to-face encounter.

OIG has performed preliminary data analysis which indicates that during 2018 and 2019, Medicare may have paid a significant number of Part B physician service claim lines at the non-facility rate when the beneficiary was a Part A inpatient at either a hospital or SNF.

In this audit, the OIG plans to determine whether Medicare appropriately paid claims for Part B physician services based on the correct place-of-service code when a beneficiary was an inpatient at an SNF or hospital.

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Clinical Laboratory Fee Schedule Rate-Setting

Medicare Part B pays for most clinical diagnostic laboratory tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS).  In 2018 a law was passed called the Protecting Access to Medicare Act of 2014 (PAMA).  Since 2018, CMS sets CLFS reimbursement rates based on the weighted median of private payer rates reported to CMS. A rate is set for each CDLT's HCPCS code. For new CDLTs, CMS or its Medicare administrative contractors set reimbursement rates using "cross-walking" or "gap-filling" methodologies. CMS should be determining the basis (i.e., cross-walking or gap-filling) after it solicits and receives public comments, announces and holds its CLFS annual public meeting regarding new CDLTs, and considers comments and recommendations (and accompanying data) received, including recommendations from an outside advisory panel.

For this particular audit, the OIG hopes to determine whether CMS's clinical diagnostic laboratory test rate-setting procedures could be improved for future public health emergencies. Though this audit might not directly affect your organization at this point, understanding the results and the direction OIG recommends CMS to take could have an impact on future reimbursement.  And whenever that happens compliance programs need to anticipate potential non-compliance as organizations try to make up for lost revenues.


Grantee Compliance with NIH Requirements

The National Institutes of Health (NIH) is the primary Federal agency that conducts and supports medical research. Approximately 80 percent of NIH funding goes to support research grants, including grants and subawards to support research conducted outside the United States.

OIG has previously identified NIH's oversight of grants to foreign applicants as a potential risk to meeting program goals and the appropriate use of Federal funds. NIH must monitor grantee performance and grantee use of NIH funds. Grantees are responsible for complying with all Federal award requirements, including maintaining effective internal controls over the Federal award.

Grantees that function as pass-through entities must monitor the activities of sub-recipients, including foreign subrecipients, to ensure that subawards are used for authorized purposes in compliance with relevant laws and the terms and conditions of the subaward (45 CFR § 75.352).

OIG plans to review NIH's monitoring of selected grants, and grantee use and management of NIH grant funds following Federal requirements.

If your organization is a primary or sub-recipient of NIH grants, it might be wise to proactively check compliance with grantee requirements found in 45 CFR § 75.352.


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