A biweekly publication from the Healthcare Group at Feeley & Driscoll, P.C.
Please visit us at our website: www.fdcpa.com/healthcare.htm. This OIG Update is also accessible from the F&D website, by visiting www. fdcpa.com/oig.updates.htm.
1. Review of Skilled Services at Regent Care Center of Laredo, Texas (A-06-06-00047)
2. Review of Kansas's Mental Health Center Medicaid Administrative Cost for the Quarters Ended December 31, 2002, and March 31, 2003 (A-07-05-03063)
3. Medicare Part B Payments for Radiology Services Provided During Inpatient Stays: 2001 Through 2003 (A-01-04-00528)
4. Review of Selected Ohio Skilled Nursing Facilities' Minimum Data Set Reporting for Purposes of Medicare Payments to Managed Care Organizations (A-05-06-00022)
5. Cost Sharing for Older Americans Act Services (OEI-02-04-00290)
6. Home Oxygen Equipment: Cost and Servicing (OEI-09-04-00420)
7. Hospital Reporting of Deaths Related to Restraint and Seclusion (OEI-09-04-00350)
1. Review of Skilled Services at Regent Care Center of Laredo, Texas (A-06-06-00047)
OIG’s objective was to determine whether Regent Care Center (Regent) of Laredo, Texas, provided patients with skilled services, particularly infusion therapy services, that were medically necessary and adequately supported by medical documentation. A complete medical review of all skilled services on 50 claims showed that: (1) Regent was properly reimbursed for 6 claims, (2) 38 claims should either be denied or partially denied because skilled services were not medically necessary at the intense level provided in an SNF and/or the RUG level claimed, and (3) 6 claims should be denied because they were not supported by adequate documentation. Because of these errors, Medicare overpaid Regent $136,292 for services that did not meet Medicare requirements. A separate review of infusion therapy services on the 50 claims showed that 2 claims included infusion therapy services that could have been rendered in a nonskilled setting and 29 claims incorrectly included charges for infusion therapy services that Regent did not render. Though these errors did not result in overpayments, SNFs should accurately record charges for services on Medicare claims because CMS uses this information for various rate-setting and payment-refinement activities.
OIG recommended that Regent: (1) refund to the Medicare program $136,292 in overpayments, (2) provide training to its staff to ensure that it fully understands and complies with SNF medical necessity requirements so that future claims comply with these requirements, (3) ensure that its staff follows controls in place so that all Medicare claims are supported with adequate medical documentation, (4) reclassify the improperly reported pharmacy services and submit a revised Medicare cost report, and (5) establish adequate controls to ensure that claims are properly coded. In its comments to OIG’s draft report, Regent agreed with OIG’s recommendations.
To view the entire article, click here: http://oig.hhs.gov/oas/reports/region6/60600047.pdf
2. Review of Kansas's Mental Health Center Medicaid Administrative Cost for the Quarters Ended December 31, 2002, and March 31, 2003 (A-07-05-03063)
OIG’s objective was to determine whether the State agency claimed mental health center (MHC) Medicaid administrative costs for the quarters that ended December 31, 2002, and March 31, 2003, in accordance with applicable Federal requirements. OIG found that the State agency did not claim MHCs Medicaid administrative costs in accordance with applicable Federal requirements. Specifically, (1) the State agency used a statistically invalid random moment time study to allocate costs because it had inadequate oversight and the system did not have adequate capacity to process all of the time studies; (2) the State agency inappropriately claimed 75 percent Federal reimbursement instead of 50 percent for activities that did not require skilled professional medical personnel expertise because of a weakness in the claim calculator; (3) the State agency's claim for the quarter that ended March 31, 2003, was calculated by MAXIMUS with transposed time study percentages because the State agency had inadequate oversight to ensure claimed amounts were accurate; and (4) the State agency included improper amounts reported by some of the MHCs because it had inadequate oversight and did not adequately train staff at the MHCs.
OIG recommended that the State agency work with CMS to resolve the $3,060,098 in Federal reimbursement that we set aside. The State agency concurred with the findings and the recommendation.
To view the entire article, click here: http://oig.hhs.gov/oas/reports/region7/70503063.pdf
3. Medicare Part B Payments for Radiology Services Provided During Inpatient Stays: 2001 Through 2003 (A-01-04-00528)
OIG’s objective was to determine whether carriers made inappropriate Part B payments for outpatient radiology services provided to Medicare beneficiaries during inpatient stays at prospective payment system (PPS) hospitals. During calendar years 2001–2003, carriers inappropriately made Part B payments for 100,034 outpatient radiology services provided to PPS hospital inpatients. Rather than billing the hospitals for these services, radiology suppliers billed the carriers and received separate payments.
OIG recommended that CMS: (1) instruct the Medicare carriers to recover the $20 million in potential overpayments identified in OIG’s review and monitor the recovery of those overpayments, (2) establish prepayment controls to detect and prevent separate payments for Medicare Part B radiology services provided to beneficiaries during inpatient stays in PPS hospitals and/or develop postpayment review procedures to identify suppliers that submit and receive payments for inappropriate billings, and (3) alert the Medicare carriers to the most common types of payment errors and help them educate radiology suppliers about such improper billings. CMS generally agreed with OIG’s recommendations.
To view the entire article, click here: http://oig.hhs.gov/oas/reports/region1/10400528.pdf
4. Review of Selected Ohio Skilled Nursing Facilities' Minimum Data Set Reporting for Purposes of Medicare Payments to Managed Care Organizations (A-05-06-00022)
OIG’s objective was to evaluate whether nine selected skilled nursing facilities in Ohio accurately reported the long-term status of institutionalized beneficiaries to ensure proper Medicare payments to the managed care organizations. The nine selected Ohio skilled nursing facilities followed Federal regulations (42 CFR 483.20(b)(1)) and accurately and completely reported assessment information for long-term care facility residents the State specified reporting document or Resident Assessment Instrument. Minimum Data Set assessments of one hundred beneficiaries in a six-month period included discharges and re-entry assessments in compliance with the 14-day rule. OIG confirmed that the correct determinations of resident institutional status were made. As a result, the referring managed care organizations received the correct institutional payment for all one hundred beneficiaries reviewed. Therefore, no recommendations were warranted.
To view the entire article, click here: http://oig.hhs.gov/oas/reports/region5/50600022.pdf
5. Cost Sharing for Older Americans Act Services (OEI-02-04-00290)
This report assesses the extent to which States have implemented cost sharing under the Older Americans Act (OAA). The report also determines whether States implementing cost sharing do so in accordance with requirements designed to protect low-income individuals’ access to services. OIG based this study on data gathered from a written survey completed by State representatives from all 50 States, Puerto Rico, and the District of Columbia; a review of relevant State documents; a review of AoA’s participation data; and structured interviews with State Unit on Aging representatives, area agency officials, and State data officials. A total of 12 States have implemented cost sharing for at least 1 OAA service in at least 1 part of their State. OIG found that States that have implemented cost sharing do not always follow OAA requirements for cost sharing that are designed to protect low-income individuals’ access to services. Additionally, AoA has provided limited guidance to States about implementing cost sharing. Also, AoA’s participation data cannot be used to determine the impact of cost sharing on participation rates.
OIG recommend that AoA ensure that States’ cost sharing practices comply with requirements designed to protect low-income individuals’ access to services; provide additional guidance to States about implementing cost sharing in accordance with the OAA; and improve the quality of its data so that any effects of cost sharing can be measured. In its comments, AoA agrees with OIG’s findings that cost sharing is limited and that States are confused about cost sharing, but does not agree with their finding that it has provided limited guidance to States. AoA also disagrees with OIG’s finding and recommendation regarding the National Aging Program Information System/State Program Reports (NAPIS/SPR). AoA states that it will follow up on OIG’s observations and correct instances of noncompliance with the provisions of the OAA and will provide additional guidance to States.
To view the entire article, click here: http://oig.hhs.gov/oei/reports/oei-02-04-00290.pdf
6. Home Oxygen Equipment: Cost and Servicing (OEI-09-04-00420)
OIG found that based on the 2006 median fee schedule amount of $200.41, Medicare will allow $7,215 for 36 months for concentrators that cost $587 on average to purchase. Beneficiaries will incur $1,443 in coinsurance. Suppliers commonly provide used concentrators, which can last for several years. If Medicare treated concentrators like capped rental items and limited rental payments to 13 months, the program and its beneficiaries would realize considerable savings. Based on OIG’s analysis, minimal servicing and maintenance of concentrators and portable equipment are necessary. Beneficiaries are trained to perform limited routine maintenance on their concentrators, and major manufacturers recommend more comprehensive preventive maintenance annually or after several thousand hours of use. Servicing for portable equipment consists mostly of cylinder deliveries.
OIG recommends that CMS work with Congress to further reduce the rental period for oxygen equipment and determine the necessity and frequency of nonroutine maintenance and servicing for concentrators. In addition, CMS should determine if a new payment methodology is appropriate for portable oxygen.
CMS concurred with OIG’s recommendations and noted that the President’s budget for fiscal year 2007 reduces the rental period to 13 months. In addition, the CMS proposed rule of August 3, 2006, addresses our recommendations regarding nonroutine maintenance and servicing for concentrators and the payment methodology for portable oxygen.
To view the entire article, click here: http://oig.hhs.gov/oei/reports/oei-09-04-00420.pdf
7. Hospital Reporting of Deaths Related to Restraint and Seclusion (OEI-09-04-00350)
Between August 2, 1999, and December 31, 2004, hospitals failed to report to CMS 44 of 104 documented deaths related to restraint and seclusion. Among those deaths that were reported directly to CMS, less than one-third were reported timely. This study found that CMS and State survey agencies do not respond consistently to reported deaths in a timely manner, limiting their ability to address potentially harmful conditions. Although, according to CMS requirements, State survey agencies are responsible for educating hospitals about the reporting requirement, relatively few State survey agencies indicated that they provide hospitals with regular guidance. Finally, CMS does not maintain comprehensive and reliable information about hospital deaths related to restraint and seclusion.
To improve hospital reporting of deaths related to restraint and seclusion, this report recommended that CMS should seek legislation to establish intermediate sanctions for hospitals that fail to report deaths related to restraint and seclusion directly to CMS and consider regulatory changes that would require reporting of all hospital deaths related to the use of restraint and seclusion. To improve the accuracy of its data and the timely identification of deaths related to restraint and seclusion, CMS should (1) instruct its regional offices and State survey agencies to adhere to timelines, (2) encourage State survey agencies to provide ongoing training to hospitals about the mandatory reporting requirement, and (3) instruct regional offices to request periodic updates about deaths related to restraint and seclusion from other Federal and State agencies.
CMS generally concurred with OIG’s recommendations. CMS is considering changes that would simplify requirements for when a hospital is expected to report restraint and seclusion-related deaths. CMS also indicated it will issue a Survey & Certification Memorandum, and post the same information on CMS’s Web site, to ensure that regional offices and survey agencies receive written instructions that reinforce the hospital death reporting timelines. Furthermore, CMS will instruct its regional offices to contact survey agencies and other Federal agencies periodically to request information regarding restraint and seclusion-related deaths.
To view the entire article, click here: http://oig.hhs.gov/oei/reports/oei-09-04-00350.pdf
For the List of Excluded Individuals/Entities (LEIE), follow this link:
http://oig.hhs.gov/fraud/exclusions/listofexcluded.html
For the index of recent OIG Advisory Opinions, follow this link: http://oig.hhs.gov/fraud/advisoryopinions/opinions.html
To see "Frequently Asked Questions" (FAQs) on the OIG Advisory Opinion process, go here: http://oig.hhs.gov/fraud/advisoryopinions/aofaq.htm
For more information regarding the OIG's Exclusion Program, please follow this link: http://oig.hhs.gov/fraud/exclusions.html
If you have any questions or would like to discuss any of these issues with one of Feeley & Driscoll’s healthcare specialists, please contact us at (617) 742-7788 or via e-mail at info@fdcpa.com. |
