Medicare Compliance & Reimbursement

100% of physician care plan oversight claims denied in preliminary audit.

The HHS Office of Inspector General is getting ready to undo the hard work home health agencies have put in on physician care plan oversight.
 
The OIG promised in its fiscal year 2004 work plan to scrutinize the area of physician CPO, to determine whether the services were billed in accordance with Medicare regulations. Although the investigation focuses on physician services, it is HHAs and hospices that will pay the price if docs are afraid to bill for CPO, and therefore make fewer home care referrals.

Many HHAs have made certification and CPO billing education a cornerstone of their physician marketing plans. If the OIG issues negative findings related to the services, it could put those agencies in a bad light, observers note.

Billing for Medicare home health and hospice CPO has been available since Jan. 1, 1995, the OIG says in a report from October 2003, "Review of Medicare Care Plan Oversight In Puerto Rico" (A-02-02-01019). Starting Jan. 1, 2001, docs have been able to bill these HCPCS codes: G0181 (physician supervision for home health) and G0182 (physician supervision for hospice).

At the same time, two codes for certification and recert of a patient's home health plan of care were introduced - G0179 (recert) and G0180 (cert).

CPO Expenditures Skyrocket 173%

Why all the fuss? The Centers for Medicare & Medicaid Services became suspicious of CPO billing when expenditures for the services jumped from $15 million in 2000 to $41 million in 2001, an OIG spokesperson tells MLR. That 173 percent surge is "quite an increase," the OIG rep says.

Thus the OIG undertook its Puerto Rico study - and generated "blockbuster" findings, notes Burtonsville, MD-based health care attorney Elizabeth Hogue.

Of the 30 CPO claims the OIG reviewed from 2000 and 2001, none of them met the Medicare requirements for CPO billing, the watchdog agency notes in its report.

The most common culprit: In 27 of the 30 claims, physicians failed to document the CPO-eligible services they performed with the date and length of time they required, the OIG found. For the other three claims, the physicians couldn't even produce a patient record at all, let alone the CPO documentation.

The physicians claimed they had no idea what was required for CPO billing, even though Puerto Rico Medicare Carrier Triple S had issued educational articles on the services in its provider bulletins.

Because none of the sample claims were valid, the OIG theorizes that most of the 37,020 claims submitted for CPO in the same time period are probably bogus as well. Those claims, submitted by 983 Puerto Rico physicians, represent $2.2 million.

CPO Investigation Gains Steam

The fallout from the OIG's findings in Puerto Rico stands to descend on HHAs nationwide -- and soon. As the OIG laid out in the FY 2004 Work Plan, it now is investigating the issue of CPO in the overall Medicare program. Sources close to the OIG say the investigation is focusing on auditing a random sample of 300 CPO claims from 2001 and 2002.

The OIG itself doesn't comment on ongoing investigations, the spokesperson says.

If the Puerto Rico audit is any indicator, the OIG won't be happy with its findings from physicians in other parts of the country. And the upshot will most likely be some kind of warning, perhaps even a special fraud alert, "that will scare physicians to death," Hogue predicts.

Even if OIG investigators merely request claims or visit physicians as part of the CPO report process, physicians will be scared off from billing for the services, Hogue expects.

Much of the increase in CPO reimbursement likely is due to the fact that the billing was "very underutilized at first," Hogue contends. Physicians just recently may have figured out how to bill for CPO, and that it is worthwhile for them to take the time to document to do so. That realization may be due in large part to HHAs' education and marketing efforts.