Knowledge Base Article

The Office of Inspector General (OIG) has released the Spring 2018 Semiannual Report to Congress. This report summarizes work by the OIG for the reporting period covering October 1, 2017 to March 31, 2018. This Report describes work undertaken “to identify significant problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the reporting period.”

The Inspector General, Daniel R. Levinson, notes “over the 6-month reporting period OIG worked to enhance the integrity of HHS programs and operations, protect vulnerable populations, and drive value in health and human services…Looking forward, OIG will continue to leverage our staff expertise to inform Department-wide goals, including combating the opioid crises, bringing down the cost of prescription drugs, addressing the cost and availability of health insurance, and transforming our health care system to a value-based system.”

This article highlights OIG overall expected recoveries and statistics found in the report and provides examples of OIG Activities specific to the Centers for Medicare & Medicaid Services (CMS) from the first half of FY 2018.

“Fighting Fraud” by the Numbers

Highlights of Enforcement Accomplishments

• $1.46 billion is the expected investigative recoveries.
• 424 is the number of individuals or entities that engaged in crimes against HHS programs where criminal actions against them have been taken.
• 1,588 is the number of individuals and entities that have been excluded from Federal health care programs.
• 349 is the number of civil actions taken against individuals or entities.

Highlights of Accomplishments in Assessment of Mismanagement and Abuse in HHS Programs

• $187.5 million is the amount the OIG expects to recover.
• $1.5 billion is the amount of potential savings.
• $680 million is the amount of questioned costs during this time period.

Highlights from CMS Medicare Program Reports and Reviews

CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor (A-03-14-00010), November 2017

Report Highlights

• 2,145 inpatient claims at 25 providers were reviewed.
• The OIG determined that only 1 claim correctly included the diagnosis code for Kwashiorkor.
• Findings equated to overpayments in excess of $6 million.
• CMS agreed with OIGs recommendations.
• The 25 hospitals reviewed repaid $5.7 million in overpayments.

Note: In January of this year the OIG Announced the Active Work Plan Item: Hospitals Billing for Severe Malnutrition on Medicare Claims. The OIG indicated in the announcement that “this review will assess the accuracy of Medicare payments for the treatment of severe malnutrition. We will determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes for the treatment of severe types of malnutrition on inpatient hospital claims.”

Wisconsin Physicians Service Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply With Medicare Requirements (A-01-15-00515), February 2018

 Report Highlights

• Wisconsin Physicians Service (WPS) paid 73 providers for HBO therapy services that did not comply with Medicare requirements.
• OIG estimated WPS overpaid providers in Jurisdiction 5 $42.6 million.
• WPS “generally agreed” to the following OIG recommendations:
• Recover the “appropriate portion of the $300,789 in identified Medicare overpayments,
• Notify providers responsible for the 44,820 non-sampled claims with potential overpayments to investigate and return any identified overpayments, and
• To identify and recovery any improper payments after the audit and strengthen policies & procedures for making payments for HBO therapy.

Note: HBO Therapy Services is a current Targeted Probe & Educate Medical Review target for Palmetto JM. Palmetto’s May 15, 2018 Ask the Contractor Teleconference (ACT) focused on Hyperbaric Oxygen Therapy. You can find Answers to Pre-submitted Questions on Palmetto’s JM website.

While this is not an Active Medical Review for Palmetto JJ (Alabama, Georgia, Tennessee), for those providing HBO therapy services it would be worth your time to read this and ask the question, are we compliant with Medicare requirements?

Hospitals Did Not Comply With Medicare Requirements for Reporting Certain Cardiac Devices (A-05-16-00059), March 2018

 Report Highlights

• All 296 payments reviewed did not comply with Medicare requirements.
• Medicare contractors incorrectly paid hospitals $7.7 million rather than the $3.3 million they should have been paid.
• CMS agreed with the recommendation to “consider studying alternatives to implementing edits in order to eliminate the current Medicare requirements for reporting device credits.”

Note: In the Thursday, June 7, 2018 edition of the MLNConnects e-newsletter, CMS included a Provider Compliance Reminder for correct billing for device replacement procedures. The reminder provides links to resources to correctly bill and avoid overpayment recoveries.