OIG Work Plan 2013 – Medical Equipment and Supplies

If you are not aware, every year the OIG ( Office of Inspector General) produces a report on what they plan to audit and review for the upcoming year. The new report does not take past items of interest off the table.

Here are some highlights for medical equipment suppliers:
1. They will review Accreditation Organization and their process for approving providers.
2. Service code modifier KX indicates the patient meets the medical criteria and upon request their is information that supports the medical need of the patient. In audits, they have found that providers have little to no documentation to support medical need. Make sure you read the medical records you obtain from physicians ordering services to ensure they include documentation that supports services you have provided.
3. In audits of lower limb prostheses, they have found in 267 providers audited no history of the patient having a lower limb amputation. I would recommend if you are providing prostheses, you obtain where the amputation was done. Medicare may not have documentation because it was not paid for by Medicare or change of physicians.
4. It appears they will be looking at reimbursement for several items and comparing it to other payor sources to see if they can reduce their reimbursement or frequency for items such as erect aids, back orthoses, parenteral nutrition, and CPAP (frequency).
5. Diabetic supplies will be reviewed for: a) see if medical records corroborate the IDDM as compared to NIDDM (making sure IDDM isn’t submitted just to bill for more supplies), b) multiple supplies, c) make sure supplies are not auto shipped, d) patients requests refill, e) the quantity of supplies left is documented at the time of request for refill, f) compares supplies provided to the competitive bid areas, g) see if “non-mail” order supplies were actually mailed, if they are in competitive bid areas, and h) IF supplies are mailed but KL not applies to indicate so the provider receives a higher rate of reimbursement.

If you have not started your compliance program audit and risk assessment protocol, these are some key areas to look at to reduce your business risk. Ask physicians to provide copies of medical records at the time of the order.

Remember, to look at the OIG Work Plan from 2012.  I outlined hightlights last year that you really need to review if you did not and continue to include those moving forward.

You may find the the OIG Work Plan details at https://oig.hhs.gov/reports-and-publications/workplan/index.asp and see Medicare Part I for Parts A & B.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller is Certified in Healthcare Compliance.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria through compliance program development, management and training.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.

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OIG Work Plan 2012

I participated in a call on Thursday January 19, 2012, on the OIG Work Plan for 2012.  Please reference the link for the full OIG Work Plan spelled out by provider type.  Many items on the Work Plan never change but there were a few points I felt important to draw your attention to for risk management purposes.  Here are a few notes I made because I think the audit risk is high since the result can be subjective:

1.  Outpatient Observation Billing

2.  Critical Access Hospitals:

A.  Distance to nearest, non-critical access hospital

B.  Herceptin and other Chemo Drug quantity

3.  Hospice because 82% of patients do not meet criteria to be admitted to hospice.

4.  Incident to Services by non-qualified personnel.  Even Blue Cross and Blue Shield is recouping and extrapolating on commercial claims for mid-level practitioner billing.  Make sure modifier is used when appropriate and the mid-level meets the licensing requirements to provide the services billed.

5.  Off Label Prescriptions.  Physicians ordering a drug that is approved for Diagnosis A but the drug is used for diagnosis B.

6.  Home Health-but not specific because they are going to review 2010 billing before they decide.

7.  Dialysis and ESRD Drug costs.  What is the drug cost to the provider versus the reimbursement.

8.  Contracts providers have with other providers/facilities.  Make sure you have a health care attorney to review the contract before executing because the health care attorneys are familiar with the Stark and Anti-Kickback provisions which typically the corporate business attorney does not have to consider.

9.  Checking employees, vendors, and providers against Sanction Databases MONTHLY.  You may find the federal links on my website.  The states have their own links.

10.  NY Medicaid reduced the annual revenues to $500K in Medicaid/Medicaid HMO/Managed Care Organizations (MCO) funds for compliance program requirement.

11.  Compliance Program Requirement under Federal Deficit Reduction Act that required all healthcare providers to have a compliance program in place by 2007 if their annual collected revenue of State reimbursement was $5M or more.  This would include Medicaid and respective Medicaid HMO or MCO.

12.  As of 2013 a healthcare compliance program is required for all providers billing Federal or State plans no matter what the annual billing revenue may be.  This would include dental practices because they bill Medicaid!

13.  Overpayments must be disclosed and refunded within 60 days of identification that it is an overpayment.  Failure to refund this money can result in “False Claims” charges and penalties.  Ensure you have someone that is accountable for working your credit balance reports monthly.  Keep documentation of these reviews and refunds issued as a result in a manner that can easily be explained and found.

The OIG Work Plan can be used to determine risk analysis, structure audit plans, and determine growth opportunities.

Do you have a Healthcare Compliance Program?

Do you review the OIG Work Plan Annually?

What else do you review to determine your audit plan?

We can help you analyze the status of your healthcare compliance program and ensure you have focused on the correct risks for your business model.  We are the compliance expert with a vast history and a cost effective way to ensure your compliance program is operating and managing your risk.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria through compliance program development, management and training.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.

Compliance Programs Required 3/25/2013

Well, we thought with Health Care Reform Act of 2010 that providers had 3 years from the signature date to have a plan implemented. With the final provisions of the Patient Protection Affordable Care Act, you have until 3/25/2013…less than 2 months to have a compliance plan in place.   They make reference to the 7 element compliance program currently recommended as a basis for the program structure. The final rule has language that reads as though they will withhold payment to providers that do not have compliance program in place.  Don’t worry, we can help you with a simple compliance program that is affordable.

A few other items that impact business decisions. This takes effect 3/25/2011 for all new providers and March 2012 for all existing providers.

1.  Moratorium on Medicare, Medicaid & CHIP provider numbers based on products and number of suppliers in the area.  This may not be as easy anymore.

2.  Application fees of $500 each for all providers excluding physicians and nurse practitioners and their group practices. If a provider applied for Medicare and Medicaid then only one fee will be required, but proof of Medicare application may be required.

3.  New screening and Fingerprinting requirements. Note Florida has had fingerprinting in place for over 8 years. You have to have a criminal record and there are many fraudulent providers that currently do not have a record. This applies to owners of 5% or more of the company, directors and officers.

4.  Unscheduled & unannounced visits to check up on suppliers.

5.  Re-enrollment for Medicare every 3 years and Medicaid annually and fees will apply plus inflation rate for CPI.

6.  New state licensing requirements to come from this also.

If you do not have a compliance program or haven’t taken your seriously, it is a requirement that could result in suspended payments.

With proven experience in the health care compliance, We can help you with a compliance program policies and procedures as well as teach you to manage your program or help you manage the program to ensure you pass the government inspection to ensure effect within 3 years of implementation. They can request random audits for privacy and security to ensure you are meeting requirements and now they have added billing compliance.

We can also help you with provider applications to ensure they are done right the first time.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, auditing, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria through compliance program development, management and training.  Ms. Miller is very experienced with Medicare & Payer audits.  Ms. Miller ran a very successful compliance program for over 5 years for the largest private held HME/Pharmacy provider in the US at the time.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back-end collections. You can visit our website at Medical Auditing Solutions LLC.