OIG Work Plan 2006

1. codingCompliance s o l u t i o n s OIG Work Plan 2006 Georgeann Edford, RN, MBA, CCS-P Coding Compliance Solutions LLC

2. Agenda 1. Introductions 2. Medicare Hospitals 3. Investigations and Legal Counsel 4. Questions and Summary

3. 2006 OIG Work Plan Office of Audit Services Office of Evaluations and Inspections Office of Investigations Home Health Agencies Hospitals Medical Equipment Supplies Centers for Medicare and Medicaid Nursing Homes Hospice

4. Medicare Hospitals

5. Observation Services • Payments for observation versus Inpatient Admissions for Dialysis Services • Patients admitted for dialysis treatments which lasted 24 to 48 hours Typical Scenario • Patients with clotted access come in for procedure • Probable fluid overload • Patients don’t meet Medicare observation criteria • Patients admitted as inpatients Challenge • Where to put these cases and how they should be billed

6. Reimbursement – Cost Reports • Medical Education for Dental and Podiatric Services • Nursing and Allied Health Education payments • Inpatient Prospective Payment System Wage Indices • Rebates – “visit” large vendors who provide purchase credits and determine the amounts • Organ Acquisition Costs – Cost shifting?

7. New Technologies • Inpatient payments for new technologies • Focus on costs associated with new devices and technologies to determine if reimbursement is appropriate. • From a Compliance Perspective, should be viewed in same context as clinical trials. • Medicare covers routine costs associated with “qualified” clinical trials. If not part of a “qualified” trial routine costs are not covered. • Design audit program to capture new technologies and work with providers to design an approach that assures compliance with regulations.

8. LTC Hospitals • Focus on reviewing prospective payments to determine if appropriately reimbursed • Outliers • Short stay outliers • Interrupted Stays • High cost outliers LTAC reimbursement • Excluded from short term acute care Hospital PPS • Own PPS • ALOS >25 days • Own PPS system driven by: • LTC DRG • Relative weights of LTC DRGs • Payment rate

9. Psych Hospitals • Review outlier payments made to psych Hospitals as well as “interrupted” stays. • Rural psych hospitals length of stay Audit areas • “Interrupted” stays • Rural psych hospitals have unique issues • Placement • Family support • Community resources • Preadmission screening • Discharge planning on admission • Concurrent utilization review

10. Inpatient Only Procedures • Assess if inpatient only procedures performed in outpatient setting have been denied appropriately. • Two aspects • Can the service/procedure be safely performed in the outpatient setting • Have Medicare beneficiaries been inappropriately held liable for denied inpatient only claims

11. Restraint Related Deaths • Examine CMS’s early experience with reporting of Hospital related deaths that may have been caused by restraints or seclusion. • Analysis of reporting only

12. Coronary Artery Stents • Review of inpatient and outpatient claims involving arterial stent implantation to determine if Medicare payments were appropriate. Two Aspects • Data analysis • Multiple surgical procedures vs. single • Not done at same time (usually different days) • Use of modifiers • Medical necessity

13. Outpatient Outlier Payments Community Mental Health Centers ? Billed on HCFA 1500 Outpatient and Charge Issues • Two separate and distinct areas. • Appear to be disjointed thoughts

14. Unbundling Outpatient Payments • Review of payments to determine if payment for multiple procedures, reepeat procedures and global surgery were correct. • Data Analysis • Fiscal Intermediary application of payment methodologies based on modifier usage

15. Hospice

16. Hospice Providers • Hospice providers meet quality of care standards. • Provider oversight activities • Track performance including quality of care • Payment of Nursing Facilities • 46% fewer services by nurses and aides than patients living at home • Evaluate arrangements between Hospice and nursing homes

17. Excluded Providers • Part of Physician section but effects Medicare Part B services. • Home Health • DME • Outpatient radiology • Laboratories • Evaluating the extent to which Medicare is billed for Part B services ordered by providers excluded from the Medicare program.

18. DRG Coding • Analysis of “aberrant” coding patterns • ? Higher percentage of DRG with cc’s. • Analysis against self and “peer” organizations • Size • Makeup • Teaching vs non-teaching • Urban vs. rural • CMI • Current • Historical

19. Home Health

20. Outlier Payments • Long high intensity cases where episode of care costs exceed threshold amount. • Evaluate the frequency of outliers • Clustered in groups • Evaluate by geographic area or clusters Analysis • Payment is based on CMI and a historical average number of visits with for a given diagnosis • Rural areas tend to have higher number of visits per episode than urban

21. Enhanced Payment • Evaluate payment to HHA for therapy services • Number and duration of therapy services Analysis • Following certain orthopedic procedures patients are required to go home with therapy services rather than be directly admitted to rehab. • Places HHAs between rock and hard place • Accurate coding of diagnoses being treated by HHA • Completion of OASIS forms

22. Other HHA Topics • Survey certifications regarding qulaity of care • Performed by the State • ? Follow-up on deficiencies “Cyclical non-compliance” • Accuracy of data on the web-site • Mergers and Acquisitions • Closings etc

23. Skilled Nursing Facilities

24. Rehab and Infusion Therapy • Analysis of whether rehab and infusion therapy services were: • Medically necessary • Adequately supported • Actually provided Analysis • Analyze MDS assessment data • Diagnosis coding • Facility • Professional • Professional billings

25. Imaging and Laboratory Services • Evaluate the medical necessity and excessive billing for imaging and laboratory services provided to nursing home residents. • Evaluate a sample of services and examine utilization patterns Data Analysis • Diagnosis coding on claims • MDS data • ? Quality of Care

26. Other Topics • Consolidated billing • Payments for Day of Discharge • Consecutive Inpatient Stays • Deficiency Trends • Quality of Care • Enforcement Action Against Noncompliant Nursing Homes • Compliance with Complaint Investigations • Immediate jeopardy • Actual Harm

27. Medical Equipment & Supplies

28. DME for Home Health • Medical necessity of durable medical equipment and supplies Analysis • OASIS data • Post orthopedic surgery cases receiving therapy? • Relationship between HHA and DME Company

29. DME Other Topics • Medical Necessity • Therapeutic Footware • Pricing of Equipment and supplies • Home Glucose Testing supplies • Test strips • Lancets Analysis • Utilization of test strips • Based on type of diabetes • Diagnosis coding • Insuline dependent • Non-insulin dependent

30. Other Topics • Laboratory services during inpatient stays • IDTF • Therapy services provided by CORF • Part B Radiology services provided to inpatients • Separately billable lab services under ESRD • Lab proficiency testing • Quality of Care in Dialysis facilities • Ambulance Services • Ground • Hospital Inpatients

31. Summary Similarities between the OIG Work Plan and the Yellow Brick Road: 1. Provides direction 2. Once you get there you are still faced with challenges 3. You knew all along the right road to take