Medicare Compliance & Reimbursement

58 Percent of PECOS Records Are Inaccurate, OIG Says

You diligently transferred your Medicare enrollment records over from the old NPPES system to the PECOS system, but don’t pat yourself on the back just yet. The HHS Office of Inspector General (OIG) recently reviewed provider enrollment files and found that many of them were wildly inaccurate, while others were incomplete.

The OIG report, “Improvements Are Needed to Ensure Provider Enumeration and Medicare Enrollment Data Are Accurate, Complete, and Consistent,” involved reviewing a random sample of individual Medicare providers to determine how accurate the provider information was in NPPES and the more recent PECOS system. As a result, OIG found that 48 percent of NPPES records were inaccurate, but that a startling 58 percent of PECOS records were inaccurate, while another four percent were incomplete.

The OIG also found that provider data was inconsistent between NPPES and PECOS for a full 97 percent of the provider records. The main culprit? Practice addresses — which are essential for contacting providers — were the main source of inaccuracies and inconsistencies.

Part of the problem stemmed from the fact that Centers for Medicare & Medicaid Services (CMS) did not verify most provider information in either enrollment system, the OIG said. The agency urged CMS to verify more enrollment records and to detect and correct issues that it finds. Since CMS agreed with these recommendations, expect upcoming contact from your MAC if you made any errors while enrolling your practitioners.

To read the complete report, visit http://go.usa.gov/b4MC.

OIG Recovered $3.8 Billion in the First Half of FY 2013

Medicare may be cutting back on payments for some services, but the OIG is finding additional ways to save money by recouping billions from medical practices across the country. According to the OIG’s Oct. 2012 to March 2013 Semiannual Report to Congress, the agency recouped $3.8 billion through recommendations, investigative efforts, and audit recovery during that six month period.

The report outlines common enforcements, such as those on durable medical equipment (DME) suppliers, as well as new targets.

“OIG auditors, evaluators, investigators, and legal professionals joined forces to produce the first-ever OIG Portfolio, which synthesizes OIG’s work examining vulnerabilities in Medicaid personal care services (PCS) and offers recommendations for improvement,” said Inspector General Daniel R. Levinson in the report.

To read the OIG’s Semiannual Report, visit the HHS Web site at: oig.hhs.gov/reports-and-publications/archives/semiannual/2013/SAR-S13-Final.pdf.

Medicaid Data Mining Could Happen Soon

You should be paying attention to your claims and other data, because authorities certainly are — and state regulators could soon be doing it even more.

The OIG has finalized a rule that will allow State Medicaid Fraud Control Units to use Federal matching funds to “identify fraud through screening and analyzing State Medicaid data,” the OIG says in a notice in the May 17 Federal Register.

“Most commenters supported our proposal to provide Federal reimbursement for data mining activities by MFCUs, citing potential cost savings through earlier identification of Medicaid fraud, the benefit of conserving administrative resources by better targeting of antifraud investigations, and the potential for increased effectiveness in finding and eliminating fraud and abuse,” the OIG says in the final rule.

States will have to submit a request to use funds for data mining. “A data mining request must describe how data mining will be coordinated with the State Medicaid agency and OIG approval of any request will be coordinated with CMS,” the OIG explains in a notice of the regulation.

The rule is at oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp.

OIG Wants Prorated Hospital Pay For Discharges To Hospice

Hospice lengths of stay may get even shorter for patients referred by hospitals if the CMS listens to the OIG. In a new report, the OIG recommends that CMS institute a proration of the hospital DRG payment when the hospital discharges a patient “early” to hospice.

“Medicare could have saved $602.5 million for calendar years 2009 and 2010 by applying a hospital transfer payment policy for early discharges to hospice care,” the OIG estimates in the report. Hospitals already receive prorated DRG payments for some patients that transfer to home care under the post-acute care (PAC) transfer adjustment. About 30 percent of all hospital discharges to hospice were early discharges that would have received per diem payments rather than full payments under a hospital transfer payment policy, the OIG says.

“In addition, this transfer payment policy would not have caused a significant financial disadvantage for hospitals or disproportionately affected any hospital,” the watchdog agency claims.

But CMS isn’t so sure. “There is a tangible financial incentive for hospitals to initially admit hospice-bound beneficiaries as hospital inpatients,” the agency allows in its response to the report. But “adopting a transfer policy to the hospice setting would produce lower than estimated savings by discouraging hospitals from making transfers to more appropriate and cost effective care settings.”

See the report at http://oig.hhs.gov/oas/reports/region1/11200507.pdf.