Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on Medicare compliance, Stark and other big-dollar issues of concern to health care compliance officers.
November 14, 2011Volume 20Issue 41
Sixty more Medicare compliance reviews are already planned or underway, underscoring the HHS Office of Inspector General’s commitment to this new multi-faceted strategy for auditing hospitals, OIG officials say.
The types of errors audited may change over time and, in fact, present-on-admission indicator reporting will be added to the usual inpatient and outpatient targets. And other types of facilities will eventually face Medicare compliance reviews, such as inpatient and psychiatric rehabilitation facilities, long-term care hospitals and perhaps even physicians.“This is an evolving initiative,” Brian Ritchie, the HHS Assistant Inspector General for CMS Audits, said at a two-part webinar on the 2012 OIG Work Plan sponsored by the Health Care Compliance Assn. on Nov. 8 and 9.“It’s a big investment in the hospital area.”
During Medicare compliance reviews, OIG simultaneously audits between eight and a dozen or two risk areas. It also evaluates a hospital’s internal controls and compliance processes to determine its capacity to prevent overpayments (RMC 7/11/11, p. 1). From a pool of 3,600 short-term acute care hospitals, Ritchie says OIG picks the lucky winners partly based on:
- Their past performance on single-issue audits;
- Where they stand compared to other hospitals’ billing volumes according to CMS’s Program for Evaluating Payment Patterns Electronic Report (PEPPER); and
- Whether there is continued “poor performance” (e.g., Medicare administrative contractors and quality improvement organizations have been to hospitals and “tried to educate them,” for example, with little success).
The risk areas reviewed include one-day stays, claims paid in excess of charges and failure to pass on manufacturers’ credits for medical devices under warranty (RMC 7/25/11, p. 1).
So far, OIG has completed six Medicare compliance reviews, with the latest subject being St. John’s Hospital in Springfield, Mo. OIG said the hospital complied with Medicare billing requirements for 166 of the 224 claims reviewed, but made mistakes on 58 claims. The net overpayment: $420,410 for 2008 through 2010, according to OIG’s Oct. 20 report (A-07-11-01098).
Medicare compliance reviews are listed on the OIG’s Work Plan under the item ”Medicare inpatient and outpatient payments to acute care hospitals.”
Here are a couple key 2012 Work Plan items covered in the webinar:
Same-day readmissions to hospitals. Generally, inpatient treatment for the same patient on the same day should be covered in the same MS-DRG, and CMS implemented an edit in 2004 to prevent duplicate payments for same-day readmissions. Hospitals can override that edit by using condition code B4 when the patient’s symptoms or evaluation and management services are unrelated to the patient’s initial admission.
But hospitals may use condition code B4 indiscriminately. “If it’s coded on the claim, the claim may go through but may not be appropriate,” Ritchie said. “This is also one of our issues in Medicare compliance reviews.” Some hospitals don’t understand the parameters of B4 use, he says, so OIG hopes to develop best practices for this area. After OIG concludes its audits, it will “roll up a report to CMS with recommendations to share with providers.”
Meanwhile, Ritchie said:
(1) “Automatic condition code entry on all readmission cases is inappropriate.” It’s important to ensure that clinical and billing staffers know the limits of B4 use.
(2) Conduct a clinical review, not just a billing review, on the appropriate use of the B4 code. Because it hinges on whether the admission was unrelated, a clinical person should be making that call.
(3) Consider the latest implications of excessive readmissions. The health reform law established a hospital readmissions-reduction program, and the final 2012 inpatient prospective payment system regulation fleshed it out. For starters, payments to hospitals will be reduced when they readmit patients for acute myocardial infarction, heart failure and pneumonia within 30 days of discharge. Readmissions also are reported on Hospital Compare, CMS’s website for reporting quality measures.
Scrutiny of compliance programs. OIG is gearing up its first-ever reviews of compliance programs aside from oversight of corporate integrity agreements. One part will be evaluations of the implementation and daily operations of compliance programs mandated by the health reform law, which start with nursing facilities. That mandate takes effect next year, “so I think we will start with evaluations in 2014,” Sue Nonemaker, OIG senior adviser for evaluations, said during the webinar.
Unrelated to the health reform law, however, OIG plans to review the effectiveness of hospital compliance programs, Nonemaker says. The reviews will include the application of the seven elements of compliance programs. Also on the drawing board: best practices for compliance programs beyond the guidance OIG has issued periodically for different industry segments since 1998. The best practices will capitalize on advances in data analysis, she notes. There will be an attempt to connect the compliance-program traits of hospitals that have the lowest error rates.
Incident-to billing. OIG is turning up the heat because Medicare allows services to be billed under the physician’s provider number even when they are performed by ancillary staffers, such as physician assistants and nurse practitioners, as long as certain conditions are met. Providers make billing errors, however, because there is no way to distinguish when the services were performed by the physician versus NPP because there’s no modifier. And some signs point to disturbing abuses with incident-to billing.
According to the Work Plan, OIG will review whether payment for incident-to services “has a higher error rate than that for non-incident-to services” and evaluate CMS’s capacity to monitor services billed incident-to, which OIG says are vulnerable to overutilization and quality problems. Because they aren’t identified by a modifier, CMS can’t audit incident-to services by a claims review and must perform medical-record reviews to determine the level of compliance.
‘There’s No Ducking Out to Starbucks’
Because this is a “target area with associated compliance risks,” health care organizations should ensure employees understand Medicare requirements for billing incident-to a physician’s services, according to Nina Tarnuzzer, assistant dean for physician billing compliance at the University of Florida College of Medicine in Gainesville. “You have to meet a long list,” she noted. For example, ancillary staffers must be employed by the physician, who must be present in the suite the whole time services are performed. “There’s no ducking out to Starbucks,” Tarnuzzer said. The physician must establish a treatment plan and see the patient the first time and as often as reasonable and necessary. If the patient presents with a new problem, then incident-to requirements are not met, she says. Otherwise, ancillary staffers can fire away, Tarnuzzer notes. Within their licensure and qualifications, pharmacists can even provide services in a practice incident-to the physician, but they are limited to the lowest level of service (CPT code 99211), she says. “There are a lot of rules and everyone needs to be aware of them,” Tarnuzzer says.View the Work Plan at www.oig.hhs.gov and click on “Reports and Publications.
No comments:
Post a Comment