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OIG TAKING A CLOSER LOOK AT REHAB

Published on Mon Nov 17, 2003

Medical necessity and cardiac rehab top the OIG's list of hot spots. 

The 2004 Work Plan for the HHS Office of Inspector General gives rehab providers many reasons to make sure they're following Medicare rules and regs.

This Work Plan reinforces the importance of complete and accurate documentation, points out attorney Donna Thiel with Morgan Lewis & Bockius in Washington. Documentation is essential in a provider's efforts to support medical necessity, which is a "strong theme" this year, adds attorney William Sarraille with Sidley Austin Brown & Wood in Washington.

"Rehab providers would do well to design specific audit and training programs on each applicable OIG item," Saraille says.

Here are the items to which providers should pay the most attention:

  • Medical necessity of inpatient rehabilitation stays. As providers know all too well, the Centers for Medicare & Medicaid Services wants to ensure that it's not paying for therapy provided to patients in an inpatient facility if those patients could be served elsewhere.

    And the OIG is going to help ensure that only legit payments are going through: "We will assess the adequacy of controls to detect improper payments for inpatient rehabilitation facility services," the Work Plan states. Providers' best defense here is solid documentation, says attorney Robert Ramsey with Buchanan Ingersoll in Pittsburgh.

  • Inpatient rehabilitation payments. Timeliness is key here, notes Thiel. That's because the Work Plan makes clear that the OIG will be looking specifically at the accuracy of payments "when patient assessments are entered late." The OIG notes that the prospective payment system requires providers to turn in admission and discharge assessments within defined timelines to avoid having their payments cut. This priority comes as no surprise, says Ramsey. "Any time CMS rolls out a new payment system, there's a focus on whether people are gaming the system."

  • Part B payments for beneficiaries in nursing homes. "Skilled nursing facilities are reimbursed through prospective, case-mix adjusted, per diem payments that cover routine, ancillary, and capital-related costs," the OIG notes. Rehab providers should note this focus because therapy is considered a routine ancillary service, Ramsey points out.

  • Outpatient cardiac rehabilitation services. CMS is concerned that therapy provided to cardiac patients in hospital outpatient departments doesn't always meet Medicare's coverage criteria, so the OIG will be looking into it in the coming year, the Work Plan explains. Providers can expect a strong focus on whether the supervision requirements of the "incident to" rules are being met, predicts Ramsey.

  • Therapy services provided by comprehensive outpatient rehabilitation facilities. "Prior OIG reviews found that Medicare paid significant amounts for unallowable or highly questionable therapy services in outpatient rehabilitation facilities and nursing homes," the Work Plan notes. Therefore, the feds will continue to examine the situation to ferret out facilities that are breaking the rules.

    "CORFs represent a small portion of the program, but there has been a significant and growing focus on them, which reflects both the increase in those services and the fact that they provide many services that have been under the microscope for a long time," says Sarraille.

  • Payments for ancillary services in nursing homes. "Therapy service in a nursing home has been a hot topic for years," Ramsey reminds providers. And that doesn't appear to be changing in 2004.

    Finally, the OIG speaks in more general terms about continuing its crackdown on health care fraud. The final message in the Work Plan is that "enforcement efforts will continue full force next year and into the future," Ramsey concludes.

    The complete Work Plan is available at www.oig.hhs.gov/reading/workplan/2003/2-CMS%20FY03.pdf.

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