Compliance plans are critical to making sure your organization is mitigating risk. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recommends that you audit a minimum of 10 professional encounters per year, per physician – but if you’re not going above and beyond that by performing focused audits, you’re putting your practice at risk by ignoring everything else (not to mention, you may be missing opportunities by under-coding).
Each year OIG publishes its Work Plan, detailing exactly what they will be focusing on in the coming year. This is a goldmine of information to help compliance officers stay ahead of the game. However, because the Work Plan is so extensive, too many compliance officers simply don’t know where to start and ignore this valuable resource.
To give you a jump-start and make sure 2021 is the year you make the most of your compliance efforts, we’ve narrowed down the OIG Work Plan to 12 key categories in the professional arena. These categories give you a valuable starting point for building a compliance plan that protects your organization in areas the government is particularly concerned with examining this year.
What’s the best way to use this list of 12 categories? Consider your billing volume. Do you bill a significant amount within any of these categories? If so, they should be a part of your focused compliance plan, as they will be areas of particular audit focus for the OIG this year. Do you have more than one category with significant billing? Prioritize your audit efforts based on the area with the highest billing first, and attack them one by one until you’ve tackled them all.
By taking an intentional, focused approach to your compliance planning, you can make the most of your efforts. Now, on to the 12 key categories!
#1: Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency
In response to the COVID-19 pandemic, CMS amended regulations to allow home health agencies to use telecommunications systems in conjunction with in-person visits. OIG will evaluate home health services provided by agencies during the continuing COVID-19 public health emergency (PHE) to determine which types of skilled services were furnished via telehealth, and whether those services were administered and billed in accordance with the amended Medicare requirements.
#2: Audit of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency
CMS is currently exploring how telehealth services can be expanded beyond the PHE to provide care for Medicare beneficiaries. As such, OIG will conduct a series of audits of Part B telehealth services in two phases; audits in the first phase will focus on making an early assessment of whether services such as evaluation and management (E&M), opioid use disorder, end-stage renal disease, and psychotherapy meet Medicare requirements, while the second phase will include additional reviews of services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth, and annual wellness visits.
#3: Follow-up Review on Medicare Claims for Outpatient Services Provided During Inpatient Stays
A prior OIG review identified that Medicare inappropriately paid acute-care hospitals millions for outpatient services provided to beneficiaries who were inpatients of other facilities, i.e. long-term care hospitals, (LTCHs), inpatient rehabilitation facilities (IRFs), inpatient psychiatric facilities (IPFs), and critical access hospitals (CAHs). Specifically, it was found that Medicare overpaid acute-care hospitals because the common working file (CWF) edits that should have prevented or detected the overpayments were not working properly. The OIG’s upcoming audit is a follow-up to determine whether CMS corrected the CWF edits and ensured that they were working properly.
#4: Medicare Part B Payments for Psychotherapy Services (Including Services Provided via Telehealth During the Public Health Emergency)
Pursuant to authority granted under the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 and Section 1135 of the Social Security Act, CMS was authorized to temporarily implement waivers and modifications to Medicare program requirements, making Medicare beneficiaries eligible to receive psychotherapy services through telehealth. OIG will conduct multiple audits of Medicare Part B payments for such services to determine whether they were allowable.
#5: Use of Medicare Telehealth Services During the COVID-19 Pandemic
As referenced above, in response to the COVID-19 pandemic, CMS made a number of changes that allowed Medicare beneficiaries to access a wider range of telehealth services without having to travel to a healthcare facility. CMS is now proposing to make some of these changes permanent. An OIG review will be based on Medicare Parts B and C data, focusing on telehealth use and prevalence, how such services compare to the same services delivered in person, and the various types of providers and beneficiaries using telehealth.
#6: Advanced Care Planning Services: Compliance with Medicare Requirements
In 2016, Medicare began paying for advanced care planning (ACP), face-to-face services through which a qualified healthcare professional and a patient discuss the patient’s wishes for healthcare if he or she becomes unable to make decisions about their care. Previous reviews of ACP have shown improper payments due to lack of clinical documentation to support face-to-face services, clinical documentation of time spent discussing ACP, or both. OIG plans to perform a nationwide audit to determine whether Medicare providers for ACP services complied with federal regulations.
#7: Assessing Inpatient Hospital Billing for Medicare Beneficiaries
CMS and OIG have identified problems with “upcoding” in inpatient hospital billing: the practice of mis-coding or over-coding to increase payment. OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing; OIG will also determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. OIG will then use the results of the analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.
#8: Medicare Part B Payments to Physicians for Co-Surgery Procedures
Under Medicare Part B, when the individual skills of two surgeons are necessary to perform a specific surgical procedure or distinct parts of a surgical procedure (or procedures) simultaneously on the same patient during the same operative session, each surgeon should report the specific procedure(s) by billing the same procedure code(s) with a modifier -62. OIG plans to audit a sample of claim line items, specifically under this scenario.
#9: Medicare Payments for Stelara
Since 2016, total Medicare Part B payments to physicians for Stelara have increased substantially. OIG will conduct a study to a) determine whether versions of Stelara that are typically self-injected meet the criteria for Medicare Part B coverage; b) identify factors that may be causing the substantial growth in payments; and c) determine whether claims for Stelara show evidence of improper billing by physicians.
#10: Medicare Part B Payments for Speech-Language Pathology
When Medicare payments for a beneficiary’s combined physical therapy and speech therapy exceed an annual spending threshold, the provider must append the -KX modifier to the appropriate Healthcare Common Procedure Coding System reported on the claim, denoting that despite the threshold being exceeded, the services being provided are still reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. The OIG will determine whether the claims using this modifier adhere to federal requirements.
#11: Medicare Part B Services to Medicare Beneficiaries Residing in Nursing Homes During Non-Part A Stays
Since the 1990s, OIG has identified problems with Part B payments for services provided to nursing home residents; officials have said that unique opportunity for fraudulent, excessive, or unnecessary Part B billing exists in this arena. OIG will determine whether Part B payments to Medicare beneficiaries in nursing homes are appropriate, and whether the facilities have effective compliance programs and adequate control over the care provided to their residents.
#12: Review of Medicare Facet Joint Procedures
Facet joint injections are an interventional technique used to diagnose or treat back pain. Several previous reviews found significant billing errors in this aera, including a prior OIG review. OIG will review whether payments made by Medicare for facet joint procedures billed by physicians complied with federal requirements.
There you have it! As you’re building your 2021 compliance plan, remember the 12 key professional services areas from the OIG Work Plan to ensure you’re focusing your attention on the same areas as the OIG.
Randomly auditing 10-25 professional encounters per physician each year does little to minimize your risk if you don’t have specific items for which you’re looking. This year, build a compliance plan that intentionally checks those areas to which we know OIG is paying particular attention.
For more information on how Panacea is assisting providers nationwide with preparations for these and other changes, go online to https://www.panaceainc.com or call us at 866-926-5933, or contact us by email at firstname.lastname@example.org.
By: Becky Rodrian-Jacobsen, CCS-P, CPC, CBCS, MBS, CEMC, CPEDC, BSN