Medicare Compliance & Reimbursement

Medicare benes’ opioid use went up during the reporting period.

Just because the feds are currently hyper-focused on COVID-19 fallout doesn’t mean that other fraud and abuse concerns are going to fall by the wayside. In fact, you would be wise to clean up other compliance gaffes at your practice, a recent report suggests.

Reminder: There are still other enforcement hot zones that the HHS Office of Inspector General (OIG) is zeroing in on — and many of them involve Medicare providers, according to the latest Semiannual Report to Congress. During the October 1, 2020 through March 31, 2021 reporting, OIG racked up an unusually large number of reports under its audit services division.

Here’s a brief list of what’s in the OIG’s crosshairs:

Home health: The Semiannual Report outlines seven HHA audits the OIG released during the reporting period. The agency estimates overpayments for the seven agencies ranging up to $3.3 million, based on review of a 100-claim sample for each. Though it didn’t specify its justification in the report, the OIG’s determinations were largely based on homebound and medical necessity criteria. Plus, the national watchdog continues to churn out more HHA reports since the reporting period ended.

Hospices: The report to Congress also tallies the OIG’s hospice audits, listing three hospice audit reports from the October-to-March time period with estimated overpayments reaching as high as $8.3 million. The OIG report details the problems the agency found with the hospice claims, mainly related to terminal prognosis, care level documentation, and Notices of Election. As with HHAs, the OIG has issued multiple hospice audit reports since that time period as well.

Nursing homes: CMS tweaked its nursing home survey requirements to prevent the spread of COVID-19, but the report suggests this may have done more harm than good.

“These changes have resulted in less comprehensive oversight of nursing homes and residents,” the report says. OIG recommends that CMS reevaluate current infection controls and surveys, “work with States to help overcome challenges with PPE and staffing,” and ensure the States understand that standard survey backlogs and “high-priority complaint surveys” are expected ASAP.

Opioids: The report shows that the pandemic only compounded opioid misuse and prescription fraud. “During the first 8 months of 2020 — and the onset of the COVID-19 pandemic — at least 5,000 Part D beneficiaries per month suffered opioid overdoses and almost a quarter of a million received high amounts of opioids,” the report says. OIG advised both CMS and HHS to be extra vigilant in “monitor[ing] trends in prescriptions for drugs for MAT and naloxone and take appropriate action.”

Hospital stays: OIG highlights recent trends toward more expensive hospital stays and related upcoding issues. According to the report, “CMS should conduct targeted reviews of Medicare Severity Diagnosis Related Groups (MS-DRGs) and stays that are vulnerable to upcoding, as well as the hospitals that bill them more frequently,” explains attorneys with King & Spalding LLP in online legal analysis.

Tip: “The OIG’s semiannual reports indicate the current areas of concern for the OIG. Health care providers can utilize the insight offered by the report to review their own practices as they relate to the OIG’s investigative focus issues and thereby ensure they are not on a path to becoming a statistic on the next report,” maintains attorney Jonell B. Beeler with Baker Donelson in Jackson, Mississippi, in online analysis.

Resource: View the report at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2021/2021-spring-sar.pdf.