CJ Wolf
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In November, the U.S. Department of Health and Human Services Office of Inspector General (OIG) added 11 new items to their Work Plan. We reviewed these new items and included key updates that could affect your organization.
Medicare Trauma Claims
Last year, Kaiser Health News issued a story outlining potential concerns with hospitals that charge excessive trauma team activation fees. Many news outlets picked it up and there has been some attention on this issue in the news – and it seems the OIG has noticed too.
The OIG said, “there have been concerns about trauma centers improperly billing for trauma team activation that is not medically necessary.” Of course, they don’t take the media’s word for it, but according to the OIG, they found some providers have received trauma team activation payments without proper designation or verification. They also have concerns because currently, the Centers for Medicare and Medicaid Services (CMS) does not track which providers are designated or verified as trauma centers.
For this OIG Work Plan item, the OIG audit will be designed to determine the amount of Medicare overpayments and Medicare charges that affect future hospital payments, and they will identify providers that are not trauma centers or that billed for medically unnecessary trauma team activations.
Inpatient Rehabilitation Facilities
In the last couple of years, the OIG has issued many reports highlighting overpayments for inpatient rehabilitation services. For example, a prior audit issued by the OIG estimated that $5.7 billion was paid for inpatient rehabilitation services that were not reasonable and necessary. Additionally, many of the individual hospital compliance reviews performed by the OIG demonstrated significant error rates and overpayments because of inappropriately documented or medically unnecessary inpatient rehabilitation services. In September of 2022, the OIG added a Work Plan item declaring their intention to conduct a nationwide audit on these types of services. Now in November of 2022, they are adding another Work Plan item relating to audits of inpatient rehabilitation facilities (IRFs). According to the OIG, Medicare paid $8.7 billion to IRFs in fiscal year 2021. For this work plan item, OIG is highlighting the high error rates associated with IRF care that was not considered reasonable and necessary according to Medicare requirements.
In response to previous OIG audits, IRF stakeholders have stated that Medicare audit contractors and the OIG have misconstrued the IRF coverage regulations. In order to address these concerns and better understand any specific areas that might require clarification, OIG plans to perform an independent audit which they hope will result in more meaningful recommendations and a greater positive impact on IRF services paid for by Medicare.
National Institutes of Health Grants
The National Institutes of Health (NIH) is the largest Federal funding source for health research. Annually, the NIH disperses about $41.7 billion for medical research and development. Past work performed by the OIG identified problems with the NIH's post-award closeout processes related to grants. See this February 2022 report and another from August of 2015.
The proper closeout of a grant award is an important compliance process. During this process, the NIH determines whether all grant requirements have been completed by the grant recipient. For this particular audit, the OIG wants to determine whether NIH closed its grants in accordance with Federal requirements and departmental guidance. They also plan to determine which actions NIH took to address noncompliance with closeout requirements.
Nursing Facility Use of Medicaid Funds
Many individuals that require skilled care in nursing facilities rely on Medicaid for coverage. In addition, OIG’s efforts are often focused on improving the safety and quality of care for these patients. The OIG also prioritizes transparency of Medicaid nursing facility care to ensure that seniors, people with disabilities, and others living in nursing homes receive reliable, high-quality care.
Because Medicaid is a state-run program and states have flexibility when establishing Medicaid payment rates for nursing facility care, the OIG wants to evaluate how Medicaid dollars are being used on direct patient care in nursing facilities. To do this, they plan to select three facilities in various states to determine what percentage of Medicaid nursing facility revenue is being expended on direct patient care. The OIG has stated they will pick one facility to review from each of the following types of facilities: for-profit, not-for-profit, and governmental.
Conclusion
As always, we recommend that compliance professionals working for organizations who provide these types of services take a proactive approach to assessing your own compliance, as we know the OIG will be looking in these areas.
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