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OIG Workplan Update [PODCAST]

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The Hospital Finance Podcast

In this episode, we welcome back Mary Devine, Vice President of Revenue Integrity at BESLER, to review recent additions to the OIG workplan.

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Highlights of this episode include:

  • OIG updates – How often and What’s new?
  • COVID updates
  • Items that remain open from last update
  • Transfer DRG payments updates

Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance podcast. Each year, the OIG adds items to their workplan to deal with emerging issues. To review recent additions to the workplan, I’m joined by Mary Devine, Vice President of Revenue Integrity at BESLER. Mary, welcome back to the show.

Mary Devine: I’m glad to be back. Thanks.

Mike: So, Mary, I know the OIG updates their workplan regularly. Can you tell us how often that happens and what some of the newest updates are?

Mary: Absolutely. And I think that’s an important point to make as we talk about the updates to the OIG Workplan. It wasn’t until just a couple of years back that the OIG started updating the workplan on a monthly basis. In years past, it was always twice a year. But now, every single month, the plan is reviewed, and there are things, if it’s been completed, they’re removed off of it and put on archive, or things are added as new things come up and there’s a new priority set. So definitely it’s updated on a monthly basis. And for 2022, there were actually 16 items that were added. Certainly, I won’t go through all 16, but just to mention a few that, I think, are very important as we look at some of the updates that were made. So the first one I wanted to talk about was the follow-up audit on CMS’s use of Medicare data to identify instances of potential abuse or neglect. And a lot of times, what the OIG Workplan does is it audits what it audited before just to make sure that action items were put into place. So there was a prior audit that was done where they identified almost 35,000 Medicare claims that were containing diag codes that indicated that Medicare beneficiaries were treated for injuries possibly caused by abuse and neglect. So they worked with the Max and CMS to try and get some of corrective action put into place. And so now, with this audit, they’re following back up there on that information, and they’re looking, hey, did providers utilize this information, and are they contacting authorities the way that they’re supposed to be? Another one I wanted to mention is the MAC has oversight over the cost report. And the MACs are supposed to do desk reviews and they’re supposed to do the desk review, accepting, auditing, and settling of the Medicare cost report. Those desk reviews are really designed to determine the accuracy and the completeness at the time the cost report was settled. And so what they’re auditing to determine is if, in fact, those desk reviews really were done appropriately and did the providers implement all the recommendations and take corrective action based on the MAC desk reviews. And then finally, just one other item to talk about is the biosimilar trends in Medicare Part B. And that sounds kind of fancy, but the biologic drugs with complex molecules, they’re producing the living system and are among the most expensive drugs on the US market today. And there are biosimilar drugs that have no clinically meaningful differences and are a lot less expensive. And the OIG knows that the providers really do not have any strong financial incentives to use less expensive biosimilars. So what they’re doing is they’re going to go out and they’re going to audit that and see how many providers were using those more expensive drugs when they should have been using the biosimilars. And more importantly to that, what type of cost gets then pushed down to the beneficiaries. And that’s part of the focus on that.

Mike: Okay, great recap there, Mary. And of course, we’re all hoping that COVID is in the rearview mirror, but are there any new items on the OIG Workplan regarding COVID?

Mary: Yes, there are. Certainly not as many that were entered in ’20 and ’21, but there were new items that were put on, and there are just three of them. And most of the COVID items that are either new or that are on the OIG Workplan, they’re all kind of much more focused on the treatment and being better versus potential overpayments or fraud and abuse, although there is one that I will point out that is a little bit of looking at potential overpayments, but most of them are really geared towards the treatment and learning from it and mining that data. So one of the items that went on was the telehealth services and select federal healthcare programs. And those federal healthcare programs are really Medicare and Medicaid. And we all know that telehealth was critically important as we went through the pandemic. And what it really did was ensure access to care while reducing the risk of community spread of the virus. So what they’re trying to look for is they’re trying to look at how telehealth can best be used and meet the needs of the beneficiaries in the future. So again, this is just data gathering. And then once they have that, they’re going to take a look at can we expand that telehealth services and keep it moving? So that was one of the items that was put on, and then the next one that they put on was related to nursing home capabilities and collaboration to ensure resident care during emergencies. There was so much spread of COVID during the pandemic in nursing homes, and they’re really trying to make sure that nursing homes have the ability to deal with those challenges and have the capabilities during an emergency. Again, really focus on the treatment of the beneficiaries. And then, finally, the last one they put on is, again, related to nursing homes. There was data identified that COVID-19 infections among nursing home residents were higher in nursing homes with lower vaccination coverage among staff, and CMS went out and required all staff in nursing homes to be vaccinated. And there are certainly exceptions, as there are for individuals for certain reasons, but they have to report all their vaccinations of their staff and send that into CMS. And so they’re auditing to make sure that was done appropriately.

Mike: Okay. And so those are some of the new items. Are there any items regarding COVID that remain open from past updates?

Mary: Yeah, some of the times, it stays on the workplan and they do a little bit of a revision to it. And as I mentioned, sometimes they go back and they follow up. Well, there were definitely a couple of ones that have been on there, and then they just revised them a bit. So the first one I’ll talk about, again, just mentioning a couple of them, because they’re certainly more than, yeah, what I could ever have time to mention today. The first one is the Office of Medicare Part B laboratory services during the COVID-19 pandemic. And the concern was that, and looking at data, the number of non-COVID tests really dramatically went down during the pandemic. And there was concern that patients had conditions that needed laboratory work done and needed follow-up, and they just weren’t getting it. So this audit is following up on that to make sure that non-COVID tests are actually back being administered and patients are receiving the care that they should. And then there are going to a little bit– they’re going to make sure that there isn’t unnecessary COVID testing done, but that’s really not the main focus of the audits. It’s really focused on the non-COVID testing, making sure that, again, that went back to pre-pandemic status. And then just the other one to mention real quick is, again, about the Part B telehealth services. And this is just making sure that the telehealth services are doing what they’re supposed to do. And did any patients require services for opioid use disorder or end-stage renal disease? Were these telehealth services effective and the patients get what they needed? And so they’re just doing a phase II and following up on that and making sure that the telehealth services were really effective during the pandemic and moving forward.

Mike: Okay. It makes sense. So beyond the COVID-related items, are there any other items that remain open and if so, why do you think they’re still there?

Mary: Sure. So the purpose of the OIG is to fight fraud and abuse and ensure quality for health and human services recipients. So your Medicare and your Medicaid beneficiaries and then also excellence. So there’s items that remain out on the workplan because they really tackle one of these items. A lot of them are towards that fraud and abuse, but there are certainly plenty out there for either quality or excellence. So the first one that remains out there is certainly from a fraud and abuse perspective, so Medicare [dip?] payments during COVID Part A SNF stays. So patients that are in a SNF bed, Medicare Part A covers everything that goes on there, the medications, everything. And anything that the patient was prescribed while they were staying in the SNF, that is covered by that Part A stay. And what they found through data mining is that patients were going home and Medicare Part D was being billed for the medications that they need for their Part A stay. So they’re going through and they’re going to determine whether Medicare Part D paid for drugs on this or they shouldn’t even pay it under the Part A. And then you always have to remember that in these scenarios, there is a portion of that drug cost being given to the patient. So they are, again, focusing on that. And then another item that remains on is the, again, a little bit of fraud, abuse, and potentially even you can consider it some waste, they’re duplicate payments made by Medicare and the Department of Veterans Affairs, Veterans Community Care Program. The VA allows non-VA providers to provide hospital care and medical services to eligible veterans with non-VA providers. So maybe there’s a behavioral health center or there is a nursing home that isn’t a VA facility, but the VA contracts with them to provide services to their patients and the patient is eligible for Medicare. So what they’re finding is that claims are being billed to both Medicare and the VA program and the provider is getting double dipping there. So what they’re going to do is they’re going to, again, data mine with help from the VA and pulling the Medicare data, and making sure that there are no claims that are paid twice. And then I think, finally, one that is worth mentioning and is not so much of a fraud and abuse, but it’s certainly quality. They’re focused on quality for the beneficiaries with Health and Human Services. So they’re requiring background checks for nursing home employees, and this is required by federal regulation in their attempt to protection from abuse and neglect. So they have to do a national background check, and it was established in 2010. And what they’re doing is they’re going in, they’re going to audit to make sure that these background checks were done. And this is more worried about Medicaid beneficiaries. And were these beneficiaries adequately safeguarded from caregivers that had a criminal history of abuse, neglect, or exploitation, or mistreatment of residents? So that really is focused on quality.

Mike: That’s a great recap. Mary, is there anything else worth mentioning as a final thought?

Mary: Sure. So just a couple of things that are important to me and what I do, I always take a look at the workplan and see if there’s anything new as it relates to the Transfer DRG payments. And there was nothing new, but certainly, it’s a continued focus. And one of the focuses that they continue to keep on the workplan is they’re looking at any claim where they received the per diem amount because the patient was discharged early. So you would get a per diem payment. And sometimes, when they look at that, they’re concerned about cost-shifting over to Medicaid. So it both from a policy perspective to make sure that you receive the right payment, whether it was an underpayment or an overpayment. And there isn’t any real attempt by the Medicare program to shift it over to Medicaid. There’s an increase focus from the perspective of– and this was on– and this was added last year, but it’s continued as an item of follow-up and review, and they’re pulling more data on it, would be the impact of expanding the hospital transfer payment policy for early discharges to post-acute care for all discharges. And not right now, I think it’s 280 DRGs, so they’re now considering it to look at it if it were to impact all DRGs. And again, that is continued from last year, and it’s just going to be updated and there’s going to be more analysis with the financial impact. And then the other couple of items I wanted to mention, they were for Medicare Advantage, and there were a couple of additions, and I think they’re definitely worth mentioning as we talk about the denied claims in Medicare Advantage encounter. And then that’s a gripe of all providers and the concern for all providers. And so CMS has begun requiring Medicare Advantage organizations to submit records of all services provided to beneficiaries, and that’s not new. But now they have to include denial. So any claim that was denied, they have to submit a denial reason to CMS. And so the OIG is going in and making sure that there is that proper oversight, and they are receiving the denied claim data from the MAOs, and then they will provide corrective action back to CMS to make sure that they get that data from the Medicare Advantage program. And then, finally, this is an open item and not new, and there are some reports coming out about it very recently. Actually, one was just issued yesterday, and it’s about the inappropriate denial of services and payment in Medicare Advantage. And again, that’s a sore spot for all providers out there. And to the extent possible, they’re trying to determine the reasons for any inappropriate denials and the types of services involved. CMS just doesn’t get involved in these denials unless patient care is impacted. But they’re beginning to see that these denials are really just a slow tactic for the MAs. And they’re seeing if there’s any real reason for these claims to be denied or if it’s just slowing down because when they look at some of the claims, they see that the Medicare coverage, it met the rules first day and the claim should be paid. So I’ll be interested to see what happens with that, and that’s about it.

Mike: Well, then certainly that’s just the tip of the iceberg, right, Mary? So for those in our audience who may be interested in a more extensive discussion around the latest updates to the OIG Workplan, Mary is delivering a webinar on that topic, so you might be able to catch that live. If not, head up on up to and there will be a recording of it right there on our blog. Mary, thanks so much for joining us today on the Hospital Finance Podcast.

Mary: Thank you. 

[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit The Hospital Finance Podcast is a production of BESLER, SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.


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