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OIG Workplan Update [PODCAST]

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The Hospital Finance Podcast

In this episode, we are joined by Mary Devine, Senior Director of Revenue Cycle Services at BESLER to discuss the newest additions to the OIG Workplan.

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Highlights of this episode include:

  • What was added in the 2021 OIG workplan
  • The different components of the issues added
  • Items added related specifically to COVID
  • What providers should be doing to stay ahead of the OIG

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, senior director of Revenue Cycle Services at BESLER. Mary, welcome back to the show.

Mary Devine: Thanks, Mike.

Mike: Mary, how many items were added in 2021 to the OIG workplan, and how many of those were specific to CMS

Mary: So I think it’s important to step back and talk about the complete count of the workplan. So currently there are 286 items on the active OIG workplan. 70 have either been completed or removed, leaving 216 open items. So the OIG covers a broad spectrum of agencies. There are 186 active items for the Centers for Medicare and Medicaid Services, which we all know as CMS. 52 of them have been completed or removed, leaving 134 open items specific to CMS. So jumping into what happened in 2021, there were 31 items added in 18 of those were specific to CMS. 

Mike: What are the different components of the issues added?

Mary: So there are really two component components that the issues fall into. The issues can either be from the Office of Audit or the Office of Evaluations and Inspections. And although the the names kind of lend itself to what what they are, typically the audits are to ensure reimbursement is being made appropriate to providers. The evaluations and inspections are just that, to ensure patients are being treated and cared for appropriately. There isn’t any abuse that goes on. And so when we talk about some issues that were added – there were four items added relating to COVID-19 – three were audit and one was an evaluation and inspection. And I think when people think of the OIG, they always think of more of the audit piece than the evaluations and inspections, because that’s really genuinely focused on the overall care and outcomes of the patients.

Mike: So let’s drill into some of the detail around the issues that were added in 2021. What can you tell us about those?

Mary: Sure. So I want to start with three issues that were added regarding SNF. And two were focused on using proper reimbursement and one was inspecting employee’s background and checks. So SNFs today are reimbursed based on five care criteria, and the audit will review the reimbursement to the care provided. So basically the reimbursement is based on the level of care the patient needs. So you talk about the physical therapy and the occupational therapy, and maybe there’s wound care and the hours of nursing involved. So the higher the patient is on a on a needs scale, then the reimbursement continues. So they want to make sure that the needs of the patient and the documentation in the chart support the criteria or the level that was built. And additionally, what happens is Medicare Part D cannot be billed. And for those of you who aren’t aware – although I’m sure everyone is – Medicare Part D is prescriptions. So when a patient is in a part A SNF stay, Medicare Part D cannot be billed for any prescriptions because it’s included in that on five levels of reimbursement. So the drugs would be included in that. So they also audit to make sure that those drugs are not being separately billed outside of a part A SNF stay.

Mary: And I think one of the things that has been going on for quite some time now, there’s been a lot of focus on nursing home patient neglect and abuse. And the item that is added from a evaluation perspective is the employee background checks, and that is focused on, again, controlling, eliminating any potential neglect, abuse, making sure that employees that are hired, there’s a criminal background check done and making sure that there isn’t potential risk of the patients being neglected or abused. And then the other couple that were added, just to mention, is duplicate billing is always on the OIG work plan. And 2021 was certainly no exception. And there were two issues that were added. The first is Medicare and the VA can be billed for the same services again. So if a patient is in a VA covered stay, Medicare cannot be billed for anything that occurs. I say, because the VA should pick that up. So for this particular issue, the OIG and the VA OIG will review this together. It’ll be a joint effort between the two and they’re making sure that there isn’t any duplicate billing between the two agencies.

Mary: And then the other duplicate billing that was that is related to critical access hospitals. And one of the things about critical access hospitals is they are reimbursed on cost. So they file cost reports on an annual basis. And obviously the goal of that cost support for providers is to capture as much cost as they can. So critical access hospitals will include physicians in that cost and then that gets included in their cost and their reimbursement. If that happens, that cost– I’m sorry that physician service then cannot be billed separately to Medicare Part B, so they’ll be auditing to make sure that there are not any critical access hospitals that are collecting both from a cost perspective for their physicians as well as billing Medicare Part B.

Mike: Mary, COVID’s had a tremendous impact on the health care system. Were there any items added relating specifically to COVID?

Mary: Yep, for sure. So, as I mentioned earlier, there were four issues added relating to COVID-19. Three of the issues were from an audit perspective, and two of them were then focused on telehealth. So the first issue that was added was an audit of the home health services provided as telehealth during the COVID-19 public health emergency. And then the second telehealth was the audit of Medicare Part B telehealth services. They sound similar, but certainly a little different during the COVID-19 public health emergency. And so this is regarding the physician services, such as evaluation and management. And there really is a big focus on the ability of doctors to manage– or opioid management and control from a physician perspective. So they’re going to audit to make sure there wasn’t a lot of ordering or over ordering of the opioid drug while the patients were being managed from a telehealth perspective.

Mary: And then the other one was audits of Medicare Part B laboratory services during the COVID-19 pandemic. So. There is no cost sharing as it relates to COVID-19 testing, and so they’re going to go in and audit and make sure, number one, patients were not billed for any balances as it relates to the typical 20% that you would find. And then they’re also going to make sure that providers did not bill for other respiratory diagnoses when they should have been billing for COVID-19. So all three of these audits were for to determine a proper reimbursement was made. And this is really done through claims submitting, whether they’re accurate or not. And that’s what– so they’ll use claim data to audit.

Mary: And then the fourth is, the home health agency’s challenges and strategies in responding to the COVID-19 pandemic issue, and this is specifically to evaluate and inspect how the home health agencies dealt with the shortage of supplies and employees and utilized telehealth services. So, unfortunately, home care help was impacted greatly from a supply perspective and the availability of employees, so they want to go in and audit to see how the care was impacted due to that shortage. How did they handle that? Did they not overuse the telehealth services? And how how are the patient outcomes? So that’s what that would be focused on.

Mike: Mary, are there any items that remain on the OIG workplan worth discussing?

Mary: Oh, absolutely. So the one item that’s near and dear to my heart – and that remains on the OIG workplan since 2018 – is the Medicare hospital payments for claims involved in the acute and post acute transfer policies. Medicare’s acute and post acute transfer policies designate some discharges as transfers when beneficiaries receive care from certain post acute care facilities. And to that end, the DRG payment provides payment in full to hospitals for all inpatient services associated with a particular DRG and diagnoses. Because of the transfer policies, hospitals are paid a per diem rate for discharges when they’re below the geometric mean – and again, they’re specific to the the DRGs – and they’re transferred to another post acute facility that is impacted by PPS or paid on PPS. And then maybe they went to a skilled nursing facility as well, inpatient rehab, home health, long term care, psychiatrics hospitals and now hospice. And that is– assuming that if that is the case, then the provider should not have received the full DRG, it should have been the per diem payment. So the OIG audit is going to review Medicare for overpayments to determine whether providers billed indicating on their claim the patient did not receive post acute care, and they’re going to audit that again. It’s a data mining process and they’re going to look to see if within three days or on the date of discharge did that patient receive post acute care or while the hospital received the full DRG.

Mary: And the other thing that they did with this audit is it’s a little bit different, is that they also want to make sure that there isn’t any real cost shift. So okay, maybe Medicare didn’t pay for those post acute services, but Medicaid is paying for that post acute service. And that’s not to say that patients can’t be discharged from a hospital and go and receive services covered by Medicaid, providing it’s not a skilled level that Medicaid is not picking up, because if Medicaid is covering a skilled level, then that would be considered cost shifting and those would be considered overpayments. And in the past, CMS has recovered $54.4 million from providers based on this review. And now providers are currently receiving recoupment letters to take back that overpayment. And that one last piece of this audit that they did is they, the OIG went to the max and had them correct their edits within the [inaudible] platform. So that would ensure now that these claims won’t get paid moving forward. They actually came up with a new rejection of the C7800. So probably providers are going to begin seeing more of a C7800 rejection because these edits are now correct. And you won’t be faced with these overpayments from the OIG in two years down the road when they go back and realize this, there should be minimal overpayments.

Mike: Mary, what do you think providers should be doing to stay ahead of the OIG?

Mary: One of the biggest things is, the OIG is updated on a regular basis and should be reviewed to determine current audits and inspections. Put it on your calendar to go in and see what else was added. Read any OIG reports that come out so you can determine where your risks are. And once you determine that something new was added or you think you might be at risk, then you should take steps to review your vulnerability and perform some audits on that, whether it be just a probe or you need to do a full sample depending on where you think your risk is. And then not to mention the overpayments from the perspective of duplicate billing and telehealth and COVID-19, you want to make sure that you’re you’re reviewing those claims because those are now new items on the OIG workplan. And then finally, you always want to review your claims impacted by the transfer rule retrospectively to ensure proper payment. And if you if you’re looking at an underpayment, you want to make sure that you’re looking at overpayments as well. And you should do that either, again, using an internal process or utilizing an outside vendor.

Mike: And Mary’s team are experts at locating transfer DRG underpayments and helping hospitals understand where overpayments may exist as well. So if you’re interested in having her team provide a secondary look for your hospital, just email us at, and we’d be happy to talk with you more about that. Mary Devine, thanks so much for joining us today on the Hospital Finance podcast.

Mary: Thank you.


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