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. Medicare Hospices: Certification and Centers for Medicare & Medicaid Services Oversight (OEI-06-05-00260)
2. Medicare Payments for 2003 Part B Mental Health Services: Medical Necessity, Documentation, and Coding (OEI-09-04-00220)
3. Intravenous Immune Globulin: Medicare Payment and Availability (OEI-03-05-00404)
4. OIG Publishes “Protecting Public Health and Human Services Programs: A 30-Year Retrospective”
5. Review of Medicaid Community Mental Health Center Provider Services in Indiana (A-05-05-00057)
6. Review of Inpatient Rehabilitation Facility Admissions at Whittier Rehabilitation Hospital for Calendar Year 2003 (A-01-04-00531)
7. Review of Inpatient Rehabilitation Facility Admissions at Catholic Medical Center for Calendar Year 2003 (A-01-04-00530)
8. Review of Vendor Rebates Paid to Hospitals - St. Luke's Hospital & Health Network, Bethlehem, Pennsylvania (A-05-07-00054)
9. Review of California's Controls Over Reporting of County Medicaid Administrative Expenditures (A-09-05-00057)
1. Medicare Hospices: Certification and Centers for Medicare & Medicaid Services Oversight (OEI-06-05-00260)
The study objectives were to assess, for hospices certified for Medicare by the State agencies, (1) the timeliness and results of hospice certification surveys by State agencies and (2) the extent of CMS oversight of the Medicare hospice program. The report findings are based primarily on CMS survey and certification data for 2,537 Medicare hospices as of July 5, 2005. OIG also completed a written survey of State agencies and interviewed staff of CMS headquarters and regional offices, State agencies, and professional organizations knowledgeable about hospice issues.
OIG found that 86 percent of hospices were certified within 6 years, as required by CMS policy, while 14 percent averaged 3 years past due; i.e., they were not surveyed for 9 years. Health deficiencies were cited for 46 percent of hospices surveyed and for 26 percent of hospices investigated for complaints. The most frequently cited health deficiencies centered on patient care planning and quality. Finally, CMS and State agencies rarely use methods other than certification surveys and complaint investigations to monitor and enforce hospice performance. CMS rarely includes hospices in Federal comparative surveys or annual State performance reviews. Both CMS and State agencies infrequently analyze existing hospice performance data, although CMS directed State agencies for FY 2006 to target 5 percent of hospices most at risk for having quality problems.
OIG recommended that CMS (1) provide guidance to State agencies and CMS regional offices regarding analysis of existing data and identification of at-risk hospices; (2) include hospices in Federal comparative surveys and annual State performance reviews; (3) seek regulatory or statutory changes to establish specific requirements for the frequency of hospice certification because neither law nor regulation currently specifies frequency; and (4) seek legislation to establish enforcement remedies, in addition to termination, for poor hospice performance. CMS concurred with providing increased guidance and including hospices in State performance reviews. However, it did not concur with greater inclusion of hospices in CMS validation surveys and establishing frequency requirements for hospice certification. CMS cited resource constraints. Finally, CMS neither concurred nor nonconcurred with OIG's last recommendation but is continuing to consider the recommendation.
To access the full article, click here: http://www.oig.hhs.gov/oei/reports/oei-06-05-00260.pdf
2. Medicare Payments for 2003 Part B Mental Health Services: Medical Necessity, Documentation, and Coding (OEI-09-04-00220)
This report determines the extent to which Medicare Part B mental health services met Medicare’s coverage criteria and were coded correctly in 2003. OIG found that 47 percent of the mental health services allowed by Medicare in 2003 did not meet program requirements, resulting in approximately $718 million in improper payments. Miscoded and undocumented services accounted for 26 and 19 percent of all mental health services in 2003, respectively. Medically unnecessary services and services that violated the “incident to” rule each accounted for 4 percent of all mental health services in 2003.
To address these issues, OIG recommends that CMS revise, expand, and reissue its 2003 Program Memorandum on Part B mental health services with an increased emphasis on proper documentation and coding. In addition, the memorandum should emphasize the requirements for mental health services billed “incident to.”
To access the full article, click here: http://www.oig.hhs.gov/oei/reports/oei-09-04-00220.pdf
3. Intravenous Immune Globulin: Medicare Payment and Availability (OEI-03-05-00404)
This inspection found that during the third quarter of 2006, 56 percent of IVIG sales to hospitals and 59 percent of IVIG sales to physicians by the three largest distributors occurred at prices below the Medicare payment amounts. This represents a dramatic shift from the previous three quarters, when the percentage of IVIG sold at prices below the Medicare payment amounts was as low as 23 percent for hospitals and 4 percent for physicians. In addition, most physicians and distributors reported problems with IVIG availability in 2005 and 2006. These physicians and distributors stated that problems with availability are typically related to Medicare payment. In comments to the draft report, CMS stated that this report provides initial information on the availability and pricing of IVIG and sets the stage for further review of key issues (e.g., off-label use, payment lags, and distributor markups) that can bring greater understanding of how the marketplace operates for this unique product.
To access the full article, click here: http://www.oig.hhs.gov/oei/reports/oei-03-05-00404.pdf
4. OIG Publishes “Protecting Public Health and Human Services Programs: A 30-Year Retrospective”
This publication provides highlights of the positive impact of OIG activities between 1976 and 2006 in the areas of health care integrity, quality of care, compliance/outreach, grants management, and child support enforcement. The Retrospective also identifies the critical roles that the False Claims Amendments Act of 1986 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) have played in providing OIG with statutory foundations and financial support upon which much of this work is based.
This publication recognizes three important milestones that occurred in 2006: the 30th anniversary of the establishment of the Office of Inspector General at the Department of Health and Human Services, 20th anniversary of the False Claims Amendments Act of 1986, and 10th anniversary of HIPAA.
To read the Retrospective, go to http://www.oig.hhs.gov/publications/retrospective.html
5. Review of Medicaid Community Mental Health Center Provider Services in Indiana (A-05-05-00057)
For fiscal year (FY) 2003, Indiana paid community mental health center (CMHC) providers about $226.5 million ($144 million Federal share) in total Medicaid reimbursement for Medicaid Rehabilitation Option (MRO) services. OIG’s objective was to determine whether the MRO services were provided by qualified staff, were adequately documented, and were accurately paid on behalf of eligible beneficiaries.
Based on a statistical projection of the sample results, OIG estimates that Indiana overpaid CMHC providers at least $33,407,323 ($21,298,841 Federal share) in reimbursement for services provided during FY 2003. The overpayment occurred because the services did not meet Federal and State reimbursement requirements. Indiana did not have adequate internal controls to monitor the providers to ensure that rehabilitation services were in compliance with the “State Medicaid Manual” and Federal regulations.
OIG recommended that Indiana refund $21,298,841 to the Federal Government and strengthen internal controls over the monitoring of MRO services by furnishing written notification to CMHC providers reminding them to prepare and retain complete documentation to fully support Federal and State claiming provisions. Indiana agreed with OIG’s second recommendation and partly agreed with OIG’s first recommendation.
To access the full article, click here: http://www.oig.hhs.gov/oas/reports/region5/50500057.pdf
6. Review of Inpatient Rehabilitation Facility Admissions at Whittier Rehabilitation Hospital for Calendar Year 2003 (A-01-04-00531)
The objective of OIG’s review was to determine whether Whittier Rehabilitation Hospital (the Hospital) submitted inpatient rehabilitation facility (IRF) claims that met Medicare requirements.
The Hospital submitted numerous IRF claims that did not meet Medicare requirements. For 47 of the 100 claims in OIG’s sample, an IRF was not the appropriate setting for the beneficiaries. Based on the sample results, we estimate that Medicare overpaid the Hospital approximately $4.8 million for IRF claims during 2003.
OIG recommend that the Hospital refund to the Medicare program the $4.8 million estimated overpayment for 2003; identify and refund any overpayments for subsequent years’ IRF claims that did not meet Medicare requirements; and strengthen its preadmission screening procedures to 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, and are able to participate in intensive rehabilitation. The Hospital strongly disagreed with OIG’s findings and recommendations.
To access the full article, click here: http://www.oig.hhs.gov/oas/reports/region1/10400531.pdf
7. Review of Inpatient Rehabilitation Facility Admissions at Catholic Medical Center for Calendar Year 2003 (A-01-04-00530)
The objective of OIG’s review was to determine whether Catholic Medical Center (the Hospital) submitted inpatient rehabilitation facility (IRF) claims that met Medicare requirements.
The Hospital submitted numerous IRF claims that did not meet Medicare requirements. For 44 of the 100 claims in OIG’s sample, an IRF was not the appropriate setting for the beneficiaries. Based on the sample results, we estimate that Medicare overpaid the Hospital approximately $1.7 million for IRF claims during 2003.
OIG recommended that the Hospital refund to the Medicare program the $1.7 million estimated overpayment for 2003; identify and refund any overpayments for subsequent years’ IRF claims that did not meet Medicare requirements; and strengthen its preadmission screening procedures to 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, and are able to participate in intensive rehabilitation. The Hospital strongly objected to OIG’s findings and recommendations.
To access the full article, click here: http://www.oig.hhs.gov/oas/reports/region1/10400530.pdf
8. Review of Vendor Rebates Paid to Hospitals - St. Luke's Hospital & Health Network, Bethlehem, Pennsylvania (A-05-07-00054)
The objective of OIG’s review was to determine whether St. Luke’s Hospital and Health Network (the provider) reduced costs reported on its 2004 Medicare cost report by the $34,579 vendor rebate it received. The provider did not reduce costs reported on its fiscal year 2004 cost report by the $34,579 rebate, contrary to Federal regulations and Centers for Medicare and Medicaid Services guidance.
OIG recommended that the provider (1) revise and resubmit its 2004 Medicare cost report, if not already settled, to properly reflect the $34,579 rebate as a credit reducing its health care costs; and (2) consider performing a self-assessment of its internal controls to ensure that future vendor rebates are properly credited on its Medicare cost reports. The provider agreed with OIG’s recommendations.
To access the full article, click here: http://www.oig.hhs.gov/oas/reports/region5/50700054.pdf
9. Review of California's Controls Over Reporting of County Medicaid Administrative Expenditures (A-09-05-00057)
OIG’s objective was to evaluate the adequacy of the California Department of Health Services's (the State agency) financial and compliance controls over reporting of the counties’ Medicaid administrative expenditures. OIG identified weaknesses in the State agency’s controls. Specifically, the State agency did not have financial controls to ensure that (1) the counties’ Medicaid expenditures reported on the expense claim were allowable for federal reimbursement and (2) coding instructions in and changes made to the expense claim template were reviewed for accuracy and compliance with Medicaid requirements. In addition, the State agency did not have a compliance control to ensure that it established a written agreement with the Department of Social Services (DSS) detailing their relationship and respective responsibilities for gathering, reviewing, and reporting the counties' Medicaid expenditures for eligibility determinations.
OIG recommended that the State agency establish financial controls to ensure that it (1) verifies that county Medicaid expenditures reported on the expense claim are allowable and (2) reviews coding instructions in and changes made to the expense claim template. In addition, OIG recommended that the State agency establish a written agreement with DSS detailing their relationship and respective responsibilities for gathering, reviewing, and reporting the counties’ expenditures. The State agency agreed with the recommendations and stated that it would implement necessary changes.
To access the full article, click here: http://www.oig.hhs.gov/oas/reports/region9/90500057.pdf
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