Every practice knows that the Department of Health and Human Services (HHS) assigns its watchdog agency, the OIG, to review problematic issues at medical offices, and to investigate when warranted. Investigations may end up resulting in fines and penalties for practices, which is why it’s important to avoid these reviews if at all possible. One way the HHS shares the issues it’s scrutinizing is through its OIG Work Plan document.
While the OIG Work Plan is constantly being updated, it’s a good idea to check it a few times a year to ensure you’re on top of its open investigations. Check out three issues that were added to the document within the past few months.
1. Diagnosis Miscoding in Medicare Advantage
In September 2023, the OIG began auditing Medicare Part C unlinked chart review diagnosis codes. Also known as Medicare Advantage (MA), Part C claims are expected to include diagnosis codes to help support medical necessity. But ICD-10-CM codes have a secondary purpose in MA — to adjust the risk scores of beneficiaries, which lead directly to the amount of money the MA firms receive.
“Miscoded diagnoses may cause CMS to pay MA organizations improper amounts,” the OIG Work Plan notification said. “For these audits, we will focus on enrollees who had diagnoses identified from unlinked chart reviews that resulted in increased risk-adjusted payments from CMS to MA organizations.” The agency will evaluate whether the ICD-10-CM codes that the Medicare Advantage firms sent to CMS as part of its risk adjustment program complied with federal requirements.
Shore up your claims: If you haven’t been self-auditing your diagnosis code use, now is the time to review them and ensure you haven’t made any errors.
2. Remote Patient Monitoring for Medicare Patients
Remote patient monitoring is a relatively new phenomenon that Medicare will reimburse — if you follow every guideline to the letter. And while many practices are careful about doing so, others grew slightly lax about it during recent years. Now, HHS is taking a closer look at these claims, thanks to a newly added issue to the OIG Work Plan.
The OIG plans to start reviewing remote patient monitoring for both Medicare fee-for-service claims and Medicare Advantage claims. The agency will “look at the extent to which the use of remote patient monitoring services has changed, the nature of remote patient monitoring services being used by Medicare enrollees, and the characteristics of enrollees using remote patient monitoring services. This review will also determine the extent to which provider billing for remote patient monitoring services may indicate fraud, waste, or abuse.”
Shore up your claims: Whether you’re just starting to report remote patient monitoring or you’ve been at it for quite some time, take a close look at your claims and ensure that you are following all the payer guidelines, submitting the right codes and confirming that patients qualify for these services before you bill.
3. MA Payments That Weren’t Confirmed on Inpatient Stays
When Medicare Advantage plans receive risk-adjusted payments based on beneficiaries’ diagnoses, CMS tends to trust that the diagnosis codes are accurate. However, the agency wants to confirm that, and has added an issue to the latest OIG Work Plan that focuses on beneficiaries “who had a diagnosis on a physician or outpatient claim that did not appear on a concurrent inpatient claim.”
If it finds such diagnoses, it could mean that practices misrepresented the health status of patients and the MA plan got extra money even though it shouldn’t have.
Shore up your claims: Once again, self-audits can help you find this issue before it becomes a major problem. Your best bet is to use an audit schedule to review your claims and evaluate whether you’ve made any errors in this category.
The OIG is leveling record fines and penalties against medical practices, and it’s important to stay out of the agency’s crosshairs. Attorney Lynn M. Adam, Esq. can show you how during her 60-minute online training event, DME Fraud Alert, Avoid Severe OIG Stark & Anti-Kickback Fines. Register today!
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