What You Should Know About the OIG’s Special Fraud Alert

The OIG has been busy updating their work plan and, not surprisingly, most of its January 2021 updates were focused on COVID-19 related issues. To better understand what they’ve learned during the pandemic, and how their updates affect our compliance programs, let’s dive in and take a quick look at what’s in store by the OIG when it comes to COVID.

Home Health and COVID

Home Health Agencies have experienced special challenges while trying to deliver care during the pandemic. Some of these challenges have included obtaining equipment and supplies, treating patients remotely via telehealth, and personnel shortages. The OIG plans to perform a nationwide study to determine the extent of the challenges and the strategies Home Health Agencies took to meet these challenges. Included in the study will be a review of how well Home Health Agencies’ emergency preparedness plans helped them during the pandemic.

A second–and separate–OIG Work Plan item will include an audit of Home Health Services that were provided via telehealth during the COVID pandemic. When the United States declared a national emergency in March of 2020, CMS was allowed to take supportive steps in responding to COVID. CMS did this by issuing section 1135 waivers. Specifically, CMS waived certain requirements to expand Medicare telehealth benefits to healthcare professionals who were previously ineligible, including physical therapists, occupational therapists, speech language pathologists, and others. CMS also permitted Home Health Agencies to use telecommunications systems in conjunction with in-person visits. CMS accomplished this by amending the regulations to state that: (1) the use of technology must be related to the skilled services being furnished, and (2) the use of technology must be included in the plan of care with a description of how the technology will help achieve goals without substituting for an in-person visit.

The OIG will review Home Health services provided by agencies during the COVID pandemic to determine which types of skilled services were furnished via telehealth, and whether those services were administered and billed in accordance with Medicare requirements. Furthermore, the OIG will report overpayments of any services that were improperly billed, then make the appropriate recommendations to CMS based on the results of their review.

Audit of COVID Testing Contract Awards

Over the course of the pandemic, more than 600 COVID testing sites across the country entered into contracts with the federal government to perform testing services. These contracts totaled about $1 billion. The OIG plans to review the awarding and management of these contracts for testing in order to determine compliance with applicable Federal statutes, regulations, HHS policies and procedures, contract terms and conditions, and the allowability of claimed costs.

Specifically, the contracts utilize a Federally-bundled payment program that was paid directly to retailers that receive a flat fee for each test administered, with participating retailers responsible for coordinating the full, end-to-end testing. The Federal Acquisition Regulation (FAR) guides the acquisition process by which executive agencies of the Federal Government acquire goods and services by contract with appropriated funds. The Health and Human Services Acquisition Regulation establishes uniform HHS acquisition policies and procedures that implement and supplement FAR.

HRSA Monitoring of High-Risk COVID-19 Grantees

The Health Resources and Services Administration (HRSA) is the primary federal agency for improving healthcare to people who are isolated geographically, economically in need, or medically vulnerable. HRSA provides financial support to about 1,400 health centers that provide services to these susceptible populations.

HRSA is expected to identify and mitigate risks related to awarding grants to health centers in order to minimize the misuse of federal funds. In the spring of 2020, HRSA awarded almost $2 billion to approximately 1,380 health centers in response to the COVID pandemic. To accelerate distribution of this money, HRSA did not require that health centers apply for grants. Instead, it made the funds immediately available to health centers. Then, these health centers had 30 days to submit their grant application information (which had previously been submitted, reviewed, and approved prior to a grantee receiving funding.) The information each health center submitted included a program description, a budget and explanation, and a list of equipment expected to be purchased with the funds.

For this Work Plan item, the OIG will determine whether HRSA had an effective process for identifying and monitoring high-risk health centers that received COVID grant monies.

Part B Telehealth Services During the COVID Pandemic

As many of us have probably personally experienced, telehealth is playing an important role during the COVID pandemic. CMS is exploring how telehealth services can be expanded beyond the pandemic to provide care for Medicare beneficiaries.

Because of telehealth's evolving role in the delivery of healthcare, the OIG plans to conduct a series of audits of Medicare Part B telehealth services in two phases. Phase one audits will focus on making an early assessment of whether services such as evaluation and management, opioid use order, end-stage renal disease, and psychotherapy met Medicare requirements. The second phase of the audits will include additional reviews of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements were met.

Conclusion

Even though the pandemic is not completely over, the OIG is gearing up for a number of anticipated audits, studies, and reviews. The purpose of these are to look back at the measures that were taken to treat the pandemic, and allow for a new healthcare reality moving forward as a result. Through these audits, we’ll better understand what worked, what didn’t, and where we can improve. As always, included in this work will be a focus on “following the money,” to make sure those entities that were provided funding, read the fine print and acted in good faith.

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