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.
In this Issue:
1. Review of Fee-for-Service Payments for Medicare Beneficiaries Enrolled in Managed Care Risk Plans (A-07-05-01016)
2. Review of Potential Duplicate Payments Identified by a CMS Recovery Audit Contractor (A-03-06-00004)
3. Identifying Beneficiaries Eligible for the Medicare Part D Low-Income Subsidy (OEI-03-06-00120)
4. Availability of Quality of Care Data in the Medicare End Stage Renal Disease Program (OEI-05-05-00300)
5. Medical Review of Touro Rehabilitation Center's Services for Medicare Outlier Claims for 2002 (A-04-04-00010)
1. Review of Fee-for-Service Payments for Medicare Beneficiaries Enrolled in Managed Care Risk Plans (A-07-05-01016)
OIG’s objective was to determine whether the fiscal intermediaries complied with Federal regulations in making fee-for-service payments to hospitals for inpatient services furnished to Medicare managed care organization (MCO) beneficiaries. Fiscal intermediaries did not always comply with Federal regulations in making fee-for-service payments to hospitals for inpatient services furnished to Medicare MCO beneficiaries. The intermediaries incorrectly paid 803 fee-for-service inpatient claims in calendar year 2003 and 2004 for beneficiaries who were enrolled in MCOs.
OIG recommended that CMS: (1) direct the fiscal intermediaries to recoup the $4.6 million of duplicate payments and (2) periodically compare the Group Health Plan with the Common Working File, reconcile any discrepancies in enrollment data, and have the fiscal intermediaries take necessary action on apparent duplicate payments. CMS agreed.
To access the entire article, click here: http://oig.hhs.gov/oas/reports/region7/70501016.pdf
2. Review of Potential Duplicate Payments Identified by a CMS Recovery Audit Contractor (A-03-06-00004)
OIG’s objective was to determine whether claims that the recovery audit contractor (RAC) identified as part of CMS's demonstration project were duplicate payments. None of the 241 claims that the RAC initially identified were duplicate payments. Of the 241 claims, 12 claims included overpayments, totaling $44,746, for six beneficiary stays with 1-day admissions and subsequent same-day readmissions. OIG recommended that CMS consider the performance of the RAC when reporting to Congress on the demonstration project's impact on Medicare savings and on CMS's decision to expand the project. CMS concurred with OIG’s recommendation.
To access the entire article, click here: http://oig.hhs.gov/oas/reports/region3/30600004.pdf
3. Identifying Beneficiaries Eligible for the Medicare Part D Low-Income Subsidy (OEI-03-06-00120)
Beneficiaries with limited income and assets are eligible to receive assistance to pay for the out-of-pocket costs associated with their Medicare prescription drug coverage. CMS has overall responsibility for implementing the prescription drug benefit. The Social Security Administration (SSA) was given the responsibility for processing the subsidy applications and determining eligibility. OIG found that currently, there is no way to effectively identify the pool of beneficiaries who may be eligible for the subsidy. Neither CMS nor SSA has a comprehensive source of income data to accurately identify potentially eligible beneficiaries who need to apply for the subsidy.
OIG concluded that legislation is needed to allow CMS and SSA to more effectively identify beneficiaries who are potentially eligible for the subsidy. Specifically, access to Internal Revenue Service earnings data would help CMS and SSA identify the beneficiaries most likely to be eligible for the subsidy. The identification of these beneficiaries would allow for a more targeted and effective outreach effort to ensure that all those who qualify for the subsidy receive this important assistance.
To access the entire article, click here: http://oig.hhs.gov/oei/reports/oei-03-06-00120.pdf
4. Availability of Quality of Care Data in the Medicare End Stage Renal Disease Program (OEI-05-05-00300)
Given problems with the oversight of quality of care in End Stage Renal Disease (ESRD) facilities previously identified by the Office of Inspector General and the Government Accountability Office and ongoing concerns related to quality of care, OIG assessed the extent to which data are available to ESRD Networks to assist them in identifying ESRD facilities with quality improvement needs. This study found that while Networks have access to multiple sources of data about quality of care, each has limitations as a tool to assist them in identifying facilities with quality improvement needs. Limitations include lack of facility-specific, comprehensive, and current clinical performance measures. Taken together, these sources compose a limited system of data about the quality of the ESRD program.
In 2000, CMS stated that it was developing a Core Data Set project that would collect facility-specific data on a comprehensive set of clinical performance measures regularly. If implemented as planned, the Core Data Set project could capture data currently collected from multiple sources in one national source of comprehensive facility-specific performance measures. However, CMS has faced technical and resource challenges and the implementation of the Core Data Set project is not complete.
Under the current system, Networks' abilities to ensure that all patients in all facilities receive quality care may be impaired. In addition, limitations of the current system of data about the ESRD program may have implications for the movement in health care towards linking payment to quality of care. OIG continues to support their earlier recommendation to CMS regarding development of facility-specific quality improvement information. OIG recommend that CMS increase its efforts towards regularly collecting data on all clinical performance measures identified by CMS from all patients and all facilities to address quality of care in the ESRD program, either through completing implementation of the Core Data Set project, or by some other means.
To access the entire article, click here: http://oig.hhs.gov/oei/reports/oei-05-05-00300.pdf
5. Medical Review of Touro Rehabilitation Center's Services for Medicare Outlier Claims for 2002 (A-04-04-00010)
OIG’s objective was to determine whether Touro Rehabilitation Center (Touro) submitted inpatient rehabilitation facility (IRF) outlier claims that met Medicare requirements. Touro submitted numerous IRF outlier claims during calendar year 2002 that did not meet Medicare requirements. For 69 of the 100 outlier claims in OIG’s sample, the services were not medically necessary (44 claims), were not reasonable (21 claims), or were not adequately documented (4 claims). As a result, Touro received $1,586,305 in unallowable Medicare payments on 69 claims. Based on the sample results, OIG estimate that Medicare overpaid Touro $3,309,699 for IRF outlier claims for 2002.
OIG recommended that Touro: (1) refund $3,309,699 to the Medicare program; (2) work with its fiscal intermediary to identify and refund overpayments for subsequent years' IRF outlier claims that did not meet Medicare requirements; and (3) ensure that its preadmission screening and admitting procedures provide reasonable assurance that beneficiaries who are admitted for IRF services require treatment at the IRF level of care, are capable of significant practical improvement, are able to participate in intensive rehabilitation, and are medically stable. Touro disagreed with the results of the medical determinations and took issue with many aspects of the review. Touro did not provide any additional documentation with its response nor did its comments warrant any revisions to the results of OIG’s review or to OIG’s recommendations.
To access the entire article, click here: http://oig.hhs.gov/oas/reports/region4/40400010.pdf
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