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In the News: OIG Reports

(April 6, 2012) Fraud prevention and enforcement activities continue at the top of the Office of the Inspector General’s (OIG) focus areas. Just recently, the Attorney General and Department of Health and Human Services (HHS) released its fiscal year 2011 report, which revealed that healthcare fraud prevention and enforcement efforts recovered the most taxpayer dollars (i.e. nearly $4.1 billion) in any fiscal year to date. This annual report, titled the Health Care Fraud and Abuse Control Program (HCFAC) Report, summarizes the Health Care Fraud Prevention and Enforcement Action Team (HEAT) efforts. The report notes that the Affordable Care Act provided additional tools and resources to enhance activities, which resulted in record annual funds being recovered.


Skilled Nursing Facilities (SNF)

Scrutiny continues on all aspects of health care provision, with all health care providers being a prime focus of investigations. The OIG presents providers with its plan of action each year in the annual HHS OIG work plan. In recent years and in 2012 the OIG’s focus on the skilled nursing industry continues to be potential billing practice problems.hospice patient with nurse

The ongoing audits being conducted by the Recovery Audit Contractor (RAC) to approve consolidated SNF billing resulted in a study to determine if Medicare billing separately is in compliance with consolidated Medicare billing requirements and standards. Consolidated billing uses the strategy that all services provided during an SNF stay should be bundled, billed and reimbursed as one lump sum. This bundled billing should not include any excluded services, such as physician and other non-physician provider services. The RAC region provider determines and announces new audit issues identified and approved.

Among SNF issues identified was high therapy service utilization, which received increased audit focus and scrutiny. CMS permits RACs to request no more than 10 records to audit as test claims to determine the value of including the specific type of claim in future audits. Region B’s RAC obtained approval to conduct test claims of ultra-high therapy Resource Utilization Groups (RUGs) and based upon test claim audit findings, ultra-high therapy utilization was added to the approved audit issues list.

Key risk areas for providers to include in compliance plans are those internal and external areas that RACs are targeting in audits. Issues under scrutiny include beneficiaries' qualifying three-day hospital stay verified and documented, certification by physicians completed within allowable time frame and timely therapy service sessions that are clearly documented and demonstrate progress towards goals and billing using the appropriate RUG code.

Home Health

In March, the OIG released its study of home health claims relative to recipients complying with Medicare home health coverage criteria. This review was conducted on 495 beneficiary records receiving services during 2008 and validated that only two percent of those served did not meet Medicare home health coverage requirements. That meant 98 percent of beneficiaries were found to meet coverage requirements. There were three coverage criteria reviewed (i.e. homebound status, skilled or therapy service need and under a physician’s care). In evaluating billing practices it appeared that a higher level was billed than delivered about 10 percent of the time and that claims were billed at lower level than care delivered about 10 percent of the time. Most billing mistakes occurred due to coding errors. The study also found documentation was present to demonstrate that skilled nursing care and therapy services were reasonable and necessary. The 2 pecent not found to be in compliance with Medicare home health service eligibility requirements was due to lack of documentation that demonstrated the beneficiary was homebound.

Despite these good results relative to Medicare home health criteria, there were other findings where improvement was recommended. This included deficiency in the plan of care (36 percent), discharge plan not present (15 percent), rehabilitation potential not documented (9 percent) and signature dates lacking for plan of care physician signatures (21 percent). A cautionary note was provided in that all physician orders must be signed and dated prior to billing Medicare for services.

In other HHA activities, OASIS data submission was studied and findings were not overly positive. The study revealed that in 2009, 6 percent of claims (i.e. 392,180) did not submit the required OASIS data, but that only 199 HHAs were penalized with a two percent CMS payment reduction from 2007 through 2010. In addition, some states conducted only a limited review of the OASIS data resulting in CMS non-validation of the states’ processes. The recommendation resulting from this study, supported by CMS, was to identify all HHAs that failed to submit OASIS data and apply the two percent payment reduction to all (Report OEI- OEI-01-10-00460).

Personal Care

An OIG review of New Mexico Medicaid personal care found that claims did not always comply with all federal and state requirements. This occurred in 23 percent of the random record reviews with the most frequent deficiency findings being attendant training, number of units claimed for attendant services and prior approval for personal care services provided by a legal guardian. It was recommended to the New Mexico State Medicaid to reimburse the federal government the $889,000 paid for unallowable personal care services and establish a process that assures all personal care service providers comply with federal and state requirements. Providers must also be able to provide supporting documentation to this effect.

It is anticipated that similar OIG review audits will be forthcoming for other state Medicaid personal care provider programs and that providers should proactively review and address these areas.

Other Work Plan 2012 Focus Areas: DME, Home Health and Hospice

Both Medicare and Medicaid programs are increasing audit activities focused on community-based health care provider services billing. This includes Medicaid home health and hospice services provided, billed and paid, as well as Durable Medical Equipment (DME) and transportation services provided and billed. The continued emphasis on hospice nursing home beneficiaries impacts both skilled nursing and hospice providers. In addition the OIG is focused on compliance plans established and followed within the skilled nursing facility as well as trends in hospital admissions, followed by skilled nursing facility admissions for repeat beneficiaries. Hospice marketing practices and financial relationships are also under closer scrutiny, along with drug claims that are billed to Medicare Part D instead of being bundled into the hospice per diem rate (Dumm, 2011).



Colagiovanni, J and J Lange. Feb 15, 2012. Increased Audit Scrutiny Aimed at Skilled Nursing Facilities. Retrieved here on March 18, 2012

Dumm, M. November 2011. OIG Work Plan Outlines Audit Area Focus for 2012. Retrieved here in March 2012

Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion. Retrieved here on Feb. 14, 2012.

Limited Oversight of Home Health Agency OASIS Data. 02-27-2012. Report OEI-01-10-00460. Retrieved here on March 20, 2012.

OIG Home Health Study Finds 98% of Beneficiaries Were Homebound and Needed Skilled Nursing or Therapy Services. Retrieved here on March 13, 2012.

Review of New Mexico Medicaid Personal Care Services Provided by Ambercare Home Health. 03-12-2012. Audit (A-06-09-00062). Retrieved here on March 20, 2012.

SNF Consolidated Billing, Approved on July 26, 2011. Retrieved here on March 19, 2012.





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