Medicare Compliance & Reimbursement

One State Just Says 'No' to OIG Recovery

The OIG wants New Mexico to recover $11 million from a Medicaid home care provider, but the state isn't going along with the idea. Coordinated Home Health claimed at least $11 million improperly for personal care attendant services in 2006 through 2008, the OIG maintains in a new report. Nearly half of the claims from the 100-claim sample didn't meet requirements, mostly due to attendant qualification issues, the watchdog agency says.

Nearly all the deficiencies the OIG found "involve technical or documentation problems that do not support a conclusion that payments were improperly made," the state says in its response letter to the report. To read the report, visit http://oig.hhs.gov/oas/reports/region6/60900064.pdf.

Vaccines Receive Booster Shots for 2013

Good news for physicians who administer flu shots -- CMS seems inclined to give practices a break with some of its recent updates to the seasonal influenza vaccines pricing, which CMS announced on Sept. 28. CMS boosted payment for four codes and reduced pay for one.

The Part B payment changes related to flu vaccines are as follows:

• 90654 -- Influenza virus vaccine, split virus, preservative-free, for intradermal use -- $18.981 (up from $18.383 last year)
• 90655 -- Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use -- $16.456 (up from $15.705 last year)
• 90656 -- Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use -- $12.398 (up from $12.375 last year)
• 90657 -- Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use -- $6.023 (down from $6.653 last year)
• 90660 -- Influenza virus vaccine, live, for intranasal use -- $23.456 (up from $22.316 last year)

For more on CMS's flu shot pricing, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8047.pdf

Consider These Lab Tests Officially 'CLIA-Waived'

Part B practices will benefit from 36 additional tests now classified as "CLIA-waived," thanks to a Sept. 28 CMS article on this topic.

According to MLN Matters article MM8054, CMS will consider the following tests CLIA-waived. You'll have to append modifier QW (CLIA-waived test) to these codes, which include the following, among others:

• 86803 -- OraQuick HCV Rapid Antibody Test and OraQuick Visual Reference Panel
• 87809 -- AdenoPlus (human eye fluid)
• 81003 -- McKesson 120 Urine Analyzer
• 86294 -- LifeSign Status BTA
• 82055 -- Alere Toxicology Services, iScreen Saliva Alcohol Test Strip
• G0434 -- BTNX, Inc. Rapid Response X-Press Drug Test Strip

To read the complete CMS transmittal on the new CLIA-waived tests, visit the CMS Web site at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8054.pdf.

Here's Another Reminder To Check The OIG Exclusion List

A Kansas home health provider has to pay up for employing an excluded individual. You should have lots of good reasons for taking the time to check your staff against the OIG's exclusion list " maybe more than 80,000 of them.

After it self-disclosed conduct to the HHS Office of Inspector General, Home Healthcare Connection Inc. in Wichita, Kan., agreed to pay $81,102 for allegedly violating the Civil Monetary Penalties Law, the OIG says in a new post to its website. The OIG alleges that HHCI employed an individual that it knew or should have known was excluded from participation in Federal health care programs. The OIG doesn't disclose whether the excluded employee was involved in direct patient care.

HHCI is likely far from alone. In a new study, the OIG randomly chose 500 home health agencies, hospitals, nursing facilities, and pharmacies from the population of providers enrolled in the 12 managed care entities contracted with state Medicaid programs. "Most providers reported using a variety of safeguards to ensure they do not employ excluded individuals, but identified costs and resource burdens as challenges in executing those safeguards," the OIG found. But about 7 percent of providers in the MCEs don't check the exclusions status of their employees, according to the OIG investigation.›› ›››››››› ››

Of the 248,869 individuals listed on employee rosters the OIG collected from 14 sampled providers, the watchdog agency identified 16 individuals who were excluded. "Incorrect names and failure of contractors to follow procedures contributed to the employment of the excluded individuals," found the report at oig.hhs.gov/oei/reports/oei-07-09-00632.pdf.

SNF Relationships Feature On Feds' Hospice Compliance Radar

The HHS Office of Inspector General continues to remain suspicious of hospice activities related to nursing homes and inpatient care, and the 2013 Work Plan reflects those concerns.

The OIG announces only two Medicare hospice topics for review for next year -- "Marketing Practices and Financial Relationships with Nursing Facilities" and "General Inpatient Care." Both are reviews carried over from the current year.

"In a recent report, OIG found that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements," the agency notes. Potential problems may include inappropriate enrollment and compensation to the nursing home, as well as aggressive marketing toward residents. "We will focus our review on hospices that have a high percentage of their beneficiaries in nursing facilities," the OIG notes.

The OIG has an "ongoing emphasis on marketing and relationships with NFs," says attorney Robert Markette Jr. with Benesch, Friedlander, Coplan & Aronoff in Indianapolis. "OIG has made a lot of noise about this in the past year and mentions it again in this year's work plan," he adds. "Providers need to be carefully assessing the accuracy of their marketing materials and the appropriateness of care provided in SNFs."

In its review of 2011 GIP claims, "we will review hospice medical records to address concerns that this level of hospice care is being misused," the OIG pledges.

"Some hospices have used the general inpatient care benefit as a way to pay SNFs higher amounts for residents," Markette observes. "This can be quite lucrative to the SNF and result in referrals to the hospice."

Watch out: "Providers should be aware that this creates Antikickback Statute liability," Markette warns.

In the hospital: The OIG will address another hospice topic through a hospital lens -- "Acute-Care Inpatient Transfers to Inpatient Hospice Care." The OIG doesn't want Medicare to pay hospitals a full DRG when they transfer patients to hospice after a short stay. "Medicare pays hospitals a reduced payment for shorter lengths of stay when beneficiaries are transferred to another PPS hospital or, for certain DRGs, to post-acute care settings," the OIG points out. "If appropriate, we will recommend that CMS evaluate its policy related to payment for hospital discharges to hospice facilities."

Medicare may prorate hospitals' payment for patients transferred to hospice. Many home health agencies saw hospital referrals drop dramatically for patients in DRGs that CMS began prorating. Hospices could have the same experience.

The OIG also lists a hospice topic for Medicaid -- "Compliance With Reimbursement Requirements." The review appears to focus on beneficiaries' terminal illness.

Resource: The Work Plan is at https://oig.hhs.gov/reports-and-publications/workplan/index.asp#current.

Focus For Some SNF Patients Should Be On Palliative Care

Payment for palliative care should be incorporated into Medicare's skilled nursing facility benefit, suggests a new study in the Archives of Internal Medicine.

"Almost one-third of older adults receive care in a SNF in the last 6 months of life under the Medicare" benefit, notes the abstract published in the October issue of the journal. And one out of 11 beneficiaries dies while enrolled in SNF care.

"Often our focus on these patients is trying to keep them functional or independent for as long as we can. What we may be overlooking is that they are on an end-of-life trajectory," said Dr. Katherine Aragon, the study's lead author from Lawrence General Hospital in Massachusetts, according to press reports.

The abstract is at archinte.jamanetwork.com/article.aspx?articleid=1368358.