The Department of Health and Human Services (HHS) Office of Inspector General (OIG) regularly performs risk and priority analyses of the various HHS programs and identifies areas of focus on a monthly basis. Amongst the items released in June, OIG has included: Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes, Medicare Payments for Clinical Diagnostic Laboratory Tests in 2022, State Medicaid Agencies’ Perspectives of Managed Care Plans’ Referral of Fraud, and Audit of Selected, High-Risk Medicare Hospice General Inpatient Services. Providers should be prepared for the potential of increased audits and scrutiny based on these OIG projects.
Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes have been deemed a work plan item due to the alleged risk of improper payment amounts as a result of miscoded diagnoses. Medicare Advantage (Medicare Part C) organizations are required by law to submit risk adjustment data to CMS, and payments to these organizations are based on this data. Miscoding of diagnoses can result in increased payments to Medicare Advantage organizations. OIG states it will be focusing its audit on diagnoses that it believes are high risk for being miscoded.
OIG has identified Medicare Payments for Clinical Diagnostic Laboratory Tests in 2022 as a work plan item in order to ensure compliance with the Protecting Access to Medicare Act of 2014 (PAMA). PAMA requires CMS to set payment rates for lab tests, which are based on current private health care market rates. PAMA also requires CMS to publish annual analyses of the top 25 tests based on Medicare Part B spending. OIG plans to review the published CMS data and issue its yearly report by 2024.
State Medicaid Agencies’ Perspectives of Managed Care Plans’ Referral of Fraud has been identified by OIG as a work plan item due to OIG’s concerns regarding the efforts to combat Medicaid fraud by individual states. Medicaid managed care plans are required to report potential fraud, waste, or abuse and CMS requires states to include this requirement in their contracts with Medicaid managed car plans. OIG is concerned that not enough fraud reports are being generated by Medicaid managed care plans. This evaluation will focus specifically on how well the Medicaid managed care plans are meeting the requirements, as well as identify methods to improve the process and increase fraud referrals.
OIG has also identified a plan for Audit of Selected, High-Risk Medicare Hospice General Inpatient Services. Hospice general inpatient care (GIP) reimbursement pays the second-highest daily rate for hospice services. It is intended for short-term care to address pain control or other symptom management that is not conducive to management in other settings. These claims are at particularly high risk for inappropriate billing, as GIP care may not be appropriate for the enrollee’s needs according to Medicare requirements. This audit will concentrate on claims for enrollees who were transferred to GIP care directly following an inpatient hospital stay “during which the enrollee’s inpatient stay reached or exceeded the geometric mean length of stay for the assigned diagnosis-related group.”
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or email@example.com.