oig comprehensive hospital audit...

©2012 Foley & Lardner LLP

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OIG COMPREHENSIVE HOSPITAL AUDIT INITIATIVE

Maria E. Gonzalez Knavel Partner

Foley & Lardner LLP 414.297.5649

[email protected]

Association of Corporate Counsel Legal Quick Hit April 30, 2012


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Overview I.  Audit Process II.  Authority for Audits III.  Identified Risk Areas IV.  Practical Tips


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OIG Comprehensive Hospital Audit Initiative

  Use of Data Mining to Identify Hospitals –  PEPPER (Program for Evaluating Payment Patterns

Electronic Report)

  Self-Audit Letter to Hospital –  Inpatient claims –  Outpatient claims –  Areas of vulnerabilities OIG identified in prior audits –  Claims sub-divided by specific risk area –  Two weeks to complete self-audit


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OIG Comprehensive Hospital Audit Initiative (cont.)

  OIG Entrance Conference –  Explain scope/process of audit – Meeting with key hospital individuals –  OIG wants to schedule meetings with hospital’s

coders, claim processing staff, and accounting staff –  Review of additional claims

  OIG Requires Hospital to Make Presentation Regarding its Internal Controls to Assure Accurate Billing


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  OIG Exit Conference – Provides Hospital with audit findings and

Internal Controls Questionnaire – Hospital responses to findings

  OIG Final Audit Report – Hospital can appeal findings


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  OIG’s cited authority for its focused audits – – Section 1862(a)(1)(A) of the Social Security Act

(“SSA”) provides that Medicare payments may not be made for items and services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

– Section 1833(e) of the SSA precludes payment to any provider of services for other person without information necessary to determine the amount due the provider.


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– 42 C.F.R. §424.5(a)(6) states that the Provider must furnish to the Medicare contractor sufficient information to determine whether payment is due and the amount of the payment.

– Medicare Claims Processing Manual (the “Manual”), Pub. No. 100-04, Chapter 1, Section 80.3.2.2 requires providers to complete claims accurately so the Medicare contractor may process them correctly and promptly.


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–  Manual, Chapter 23, Section 20.3 states providers must use HCPCS codes for most outpatient services.


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  Survey of Issues Being Challenged –  Identified “Risk Areas” –  Inpatient

●  Short stays ●  Same day discharge and readmission ●  Transfers to post-acute care providers ●  Transfers to inpatient hospice care


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–  Inpatient (Cont.) ●  Manufacturer Medical device credits ●  Claims paid amount in excess of claims charged

amount ●  Claims with payments greater than $150,000 ●  Blood-clotting factor drugs ●  Hospital–acquired conditions and present on

admission reporting ●  Outlier payments


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– Outpatient ●  Manufacturer Medical device credits ●  Services billed with Modifier-59 ●  E&M services billed with Surgical Services ●  Claims paid amount in excess of claims charged

amount


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– Outpatient (Cont.) ●  Outpatient services billed during inpatient stays ●  72- Hour Rule ●  Surgeries billed with units greater than one ●  Services bill during skilled nursing facility stays ●  Outpatient dental services


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  Inpatient Short Stays –  Hot audit area for many years. –  Incorrectly billing an inpatient stay when

medical records support that the services should have been billed as outpatient or outpatient with observation services.

–  Implement or review internal controls for patient admission errors.

–  Case management monitoring –  Review short stays prior to patient discharge


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  Inpatient Same-Day Discharges and Readmissions

–  The Manual, Chapter 3, Section 4.2.5 states: When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms related to, or for evaluation and management of, the prior stay’s medical condition, hospitals shall adjust the original claims generated by the original stay by combining the original and subsequent stay on a single claim.

–  Review internal controls to ensure such related stays are billed on one claim.


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  Transfers to Post-Acute Care Providers –  Transfers to inpatient rehab unit, skilled

nursing facility, or home health agency coded as discharges for specified DRGs ●  Per diem rate for each day of the stay, not to

exceed the full DRG payment for a discharge. See 42 C.F.R. §§ 412.4(c)(f)

●  How do coders identify discharge status? ●  Is there a procedure to follow-up whether transfers

occurred?


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  Manufacturers Medical Device Credits –  Medicare not responsible for the full cost of

the replaced medical device in the event Hospital received partial or full credit from the manufacturer (recall/or covered under warranty) ●  Are correct modifiers used on claims to disclose

replacement device? ●  Are there internal controls for monitoring the

tracking and billing of replacement medical devices?


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  Claims Paid Amount in Excess of Claim Charged Amounts

–  Selection of incorrect procedure or diagnosis codes leads to overpayment.

–  Are controls in place to ensure the billing is based on medical record documentation?

–  Are coders properly trained in interpreting guidance for selecting a principal diagnoses?


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  Blood-clotting Factor Drugs –  The Manual, Chapter 3, Section 20.7.3(A) states that

hospitals receive an add-on payment for costs of furnishing blood clotting factor drugs to certain Medicare beneficiaries and that the provider must use revenue code 636 (drugs requiring detail coding) so that the clotting factor charges are not included in the cost outlier computations. ●  Mostly hemophilia claims, but there are other bleeding

disease which may require such drugs ●  Do not use revenue code 250 (pharmacy) which caused the

charges to be included in the claims cost outlier computation


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  Outpatient Dental Services –  Section 1862(a)(12) of the SSA states:

No payment may be made under Part A or Part B for any expenses incurred for items or services where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under Part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.

●  What controls are in place prior to inpatient admissions for dental procedures?

●  Implement Internal controls or edits to identify dental procedures prior to claims submission.


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  Services billed with Modifier-59 –  The Manual, Chapter 23, Section 20.9.1.1

states, “the -59 modifier is used to indicate a distinct procedural service. . .. This may represent a different session or patient encounter, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury (or area of injury in extensive injuries).”


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–  Does the medical record have sufficient documentation to support an unrelated service?

–  Has the coding staff been trained on the appropriate billing requirements for modifier-59?


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  Other “Risk-Areas” identified in the OIG Work Plan and Current Audit Experiences

–  Inpatient Psychiatric Facility Interrupted Stays –  Inpatient High Severity Level DRGs –  Inpatient Psychiatric Facility Emergency

Department Adjustments –  Major Complication and Co-morbidities –  Outpatient Brachytherapy Reimbursement


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  Other “Risk-Areas” identified in the OIG Work Plan and Current Audit Experiences

–  Outpatient Claims Billed Using “J” Codes –  Observation Services During Outpatient Visits –  Hemophilia Services –  Septicemia Services –  Intensity Modulated Radiation Therapy

Planning Services –  Claim Payments Greater than $25,000


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  Practical Tips – Use PEPPER data to identify hospital’s risk

areas – Review coding and billing processes in risk

areas – Take corrective actions – Ensure coding and billing staff are properly

trained and monitored –  Identify individuals likely to be interviewed – Prepare individuals for interviews


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Questions

Maria E. Gonzalez Knavel Partner

Foley & Lardner LLP 777 E. Wisconsin Avenue

Milwaukee, WI 53202-5306 414-297-5649

[email protected]

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