The Department of Health and Human Services (HHS) Office of Inspector General (OIG) included several new items in its work plan update in January 2021. The OIG work plan outlines the projects that OIG plans to implement over the foreseeable future. Such projects typically include OIG audits and evaluations. Below are the highlights from the work plan update that providers and suppliers should take notice of.
First, OIG will perform a nationwide audit to determine whether hospitals that received Provider Relief Fund (PRF) payments and attested to the associated terms and conditions complied with the balance billing requirement for COVID – 19 inpatients. Under the PRF terms and conditions, hospitals are eligible for PRF distribution payments if they attest to specific requirements, including a requirement that providers, such as hospitals, must not pursue the collection of out-of-pocket payments from presumptive or actual COVID – 19 patients in excess of what the patients otherwise would have been required to pay if the care had been provided by in-network providers. OIG plans to assess how bills were calculated for out-of-network patients admitted for COVID-19 treatment, review supporting documentation for compliance, and assess procedural controls and monitoring to ensure compliance with the balance billing requirement.
Second, OIG will perform a nationwide review of Medicare beneficiary hospice eligibility. OIG indicated that a number of recent compliance audits have identified findings related to beneficiary eligibility. In its review, OIG plans to focus on those hospice beneficiaries that haven’t had an inpatient hospital stay or an emergency room visit in certain periods prior to their start of hospice care.
Third, OIG will review Medicare Administrative Contractors’ (MAC) conduct in accepting, auditing, and settling provider Medicare cost reports. OIG will conduct this review by first reviewing the MACs’ cost report oversight by verifying the number of desk reviews and the number of audits performed in accordance with the CMS contract and identify non-compliance issues. Then, OIG will review MAC audit findings and recommendations to determine whether the provider implemented the recommendations and took corrective action. OIG will also examine CMS’s oversight of the MAC cost report desk reviews/audits.
Lastly, OIG indicated that a prior review identified approximately 34,000 Medicare claims containing diagnosis codes that indicated Medicare beneficiaries were treated for injuries possibly caused by abuse or neglect, but that CMS had failed to properly extract this data or pursue actions in response. OIG will therefore conduct a follow-up to determine whether CMS has improved its use of Medicare data to identify incidents of potential abuse and neglect. OIG will also further assess the prevalence of incidents of potential abuse or neglect of Medicare beneficiaries, who may have perpetrated those incidents and where they occurred, and whether the incidents were reported to law enforcement.
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 firstname.lastname@example.org