On Monday, July 17, the Office of Inspector General for the U.S. Department of Health and Human Services announced 14 new inquiries into potentially fraudulent billing of Medicare and Medicaid. The OIG announcement is part of a new policy to update its investigative Work Plan every month rather than once or twice per year. The inquiries announced Monday join over 200 pending reviews the agency watchdog is conducting.
Telehealth patients must be in a medical facility, not at home.
1. OIG will review whether Medicare claims for telehealth services, physician checkups conducted via video chat, met Medicare requirements. Medicare Part B pays for qualifying telehealth services to support access to care for beneficiaries in rural areas. In order to qualify, beneficiaries must conduct the video call from a specified medical facility, such as a hospital or rural health center, not at their home or office.
Ambulance companies should bill SNFs directly for stays covered by Medicare Part A.
2. OIG will look into whether ambulance companies are billing appropriately for services provided to skilled nursing facilities. When a beneficiary’s SNF stay is covered under Medicare Part A, ambulances should bill the SNF directly rather than bill Medicare Part B.
Hospitals charging for outpatient nonphysician services are possibly duplicating payments.
3. OIG has identified “significant overpayment to hospital outpatient providers for nonphysician services” furnished shortly before or during inpatient hospital stays. These costs are included as part of the Medicare Part A inpatient prospective payment system. Thus, according to OIG, a duplicate payment is made if charged separately under Medicare Part B.
Home health and hospice services will receive additional scrutiny.
4. OIG will take a closer look at home health agencies using data from the Comprehensive Error Rate Testing (CERT) program to identify common “risk factors” in order to target pre- and post-payment review of claims. The CERT program determined that “the 2016 improper payment error rate for home health claims was 42 percent, or about $7.7 billion.”
5. OIG will also review unallowable overlaps between home health claims and Part B claims.
6. OIG will examine possible duplicate payments for hospice claims and related Part B claims.
Additionally, OIG will review:
7. Whether hospitals were overpaid Medicare incentive payments for adopting electronic health record technology.
8. Whether adult day centers, which provide nonresidential services to functionally impaired adults, are complying with applicable health and safety regulations.
9. Whether States erred in calculating the enrollment of children in Medicaid resulting in unallowable bonus payments made to States under the Children’s Health Insurance Program Reauthorization Act of 2009.
10. Whether States reported and returned the Federal Government’s share of settlement and judgment amounts States received as a result of harms to the States’ Medicaid programs.
11. Whether State agencies complied with Federal and State requirements when claiming Medicaid reimbursement for Opioid Treatment Program services.
12. Whether select States made Medicaid payments for targeted case management services in according with Federal requirements.
13. Whether select States made payments in accordance with Federal and State regulations for Consumer-Directed Personal Assistance programs, which allow consumers to select and schedule home care aids rather than assigning a home care agency.
14. Whether States are meeting Federal requirements in setting payment rates for Assertive Community Treatment programs, which provide person-centered, recover-based services in a community setting to those with severe and persistent mental illness.
*We would like to thank Matt Wood, a summer associate in the Austin, TX office, for his assistance with the preparation of this post.