Medicare Compliance & Reimbursement

Telehealth misuse is now on the agency’s radar screen.

Over the last year, the feds have ramped up their enforcement against those who aim to buck the Medicare system. And a new release suggests fraudsters will find themselves charged, excluded, or behind bars.

In its Semiannual Report to Congress, released last month, the HHS Office of Inspector General (OIG) reported that enforcement and recovery activities for fiscal year (FY) 2018 were “impressive.” OIG expects audit recoveries to be around $521 million while issuing “reports with $2 billion in questioned costs,” the agency said.

Background: Collaboratively, OIG works closely with the Department of Justice (DOJ), the Medicare Fraud Strike Force teams, the Medicaid Fraud Control Units, and other federal, state, and local enforcement agencies to thwart healthcare fraud and abuse. The Semiannual Report to Congress allows the federal watchdog to alert the legislature of its financial recoveries and enforcement actions over a fiscal year related to things as varied as improper Medicare payments, Part D prescription drug abuse, and other prevalent health program issues. The brief, also, outlines the top targets, plans for future scrutiny, and money-saving tactics for federal agencies — plus, an overview of the OIG’s recommendations that departments specifically ignored.

Check out the enforcement statistics for FY 2018 from the OIG’s Semiannual Report to Congress:

• Investigative recoveries: OIG anticipates approximately $2.91 billion will be recouped from investigations for FY 2018, a significant decline from $4.13 billion investigative recovery projections in FY 2017.
• Criminal actions: The agency brought criminal actions against 764 individuals or entities.
• Civil actions: Civil cases were registered against 813 individuals or entities.
• Exclusions: OIG excluded 2,712 individuals and/or entities from participating in federal healthcare programs, 532 less than the previous fiscal year.

“OIG continues to fulfill its crucial mission for the American people by providing objective, actionable information and recommendations to improve fiscal stewardship and quality of services provided by HHS programs,” stressed Inspector General Daniel R. Levinson in the report. Moreover, the agency will hold “those who harm HHS programs accountable” and continue to focus on the “opioid epidemic, Medicaid fraud, the safety of children, and home- and community-based services, as well as emerging areas such as cybersecurity and the shift to value-based care,” he added in his message.

Review These Examples

Following is a sampling of a few of the issues and accomplishments the OIG spotlighted in the report:

• Telehealth Site Issues: After auditing Medicare claims for telehealth, OIG discovered a major location fee-discrepancy among providers. This is important since the popular service has exploded over the past decade, with Medicare payments at $61,302 in 2001 jumping to $17.6 million in 2015, the agency suggested.

“Medicare telehealth payments include a professional fee, paid to the practitioner performing the service at a distant site, and an originating-site fee, paid to the facility where the beneficiary receives the service,” the OIG noted. “We analyzed 2014 and 2015 (our audit period) telehealth claims and found that more than half of the professional telehealth claims paid by Medicare did not have matching originating-site facility fee claims.”

• Opioid Enforcement: Last June, OIG charged more than 600 individuals in the largest opioid fraud and abuse case in history.

In the “June 2018 takedown, 162 defendants, including 76 doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics,” the Semiannual Report indicated. “In addition, between July 2017 and June 2018, OIG issued exclusion notices to 587 individuals based on their conduct related to opioid diversion and abuse.”

• Senior Medicare Patrol (SMP) Project: In 2017, the 53 SMP projects had a total of 6,130 active team members who conducted 26,429 group outreach and education events, reaching an estimated 1.9 million people. The group reported $2.0 million in expected Medicare recoveries.

The SMP’s recoveries “came primarily from one project that prompted law enforcement to open an investigation that resulted in a settlement with a hospice company,” according to the report. The SMP recruits and trains retired professionals and other senior citizens to prevent, recognize, and report healthcare fraud, errors, and abuse, the OIG said.

• Replacement Positive Airway Pressure Device Claims Errors: A review of a sampling of claims from 2014 and 2015 revealed that a majority of durable medical equipment (DME) suppliers failed to comply with Medicare requirements for submissions for replacement positive airway pressure (PAP) device supplies.

“We estimated that Medicare made overpayments of almost $631.3 million for replacement PAP device supply claims that did not meet Medicare requirements,” informed the report. “These overpayments occurred because CMS oversight of replacement PAP device supplies was not sufficient to ensure that suppliers complied with Medicare requirements or to prevent payment of claims that did not meet those requirements.”

With all of the OIG recommendations leaning toward further scrutiny, now is the time to take a closer look at your Medicare billings’ practices. Putting a comprehensive coding and billing compliance plan in place ensures that you are reporting your services correctly. If you haven’t performed a self-audit in a while, consider starting 2019 off right with a checklist and review.

Resource: Read the OIG report at https://oig.hhs.gov/reports-and-publications/archives/semiannual/2018/2018-fall-sar.pdf.