OIG Releases Work Plan for 2016
November 13, 2015 09:47 AM
The Office of the Inspector General (OIG) recently released its 2016 Work Plan. In the introduction it states that the OIG has focused its efforts on identifying and offering recommendations to reduce improper payments, prevent and deter fraud, and foster economical payment policies. It goes on to state that hospices can expect greater oversight, including oversight of certification surveys and hospice-worker licensure requirements. Other key focus areas include skilled nursing facility (SNF) compliance with patient admission requirements and evaluation of CMS’ Fraud Prevention System as well as reviews planned to promote the effectiveness and efficiency of the Medicaid program.
There is one area of focus listed for hospices and one area of focus listed for home health agencies; however, home health agencies will be further impacted by the OIG’s plans related to Medicaid home and community based services and hospices may be impacted. A summary for hospice and home health agencies is below as well as a summary for Medicaid-specific activities.
General Inpatient Care – the topic is the same as last year’s Work Plan but the description of activity has been revised.
We will review the use of the general inpatient care level of the Medicare hospice benefit. We will assess the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care. We will also review hospice medical records to address concerns that this level of hospice care is being billed when that level of service is not medically necessary. We will review beneficiaries’ plans of care and determine whether they meet key requirements.
Hospice care is palliative rather than curative. When a beneficiary elects hospice care, the hospice agency assumes the responsibility for medical care related to the beneficiary’s terminal illness and related conditions. Federal regulations address Medicare conditions of participation (CoP) for hospices. (42 CFR Part 418.) Beneficiaries may revoke their election of hospice care and return to standard Medicare coverage at any time. (42 CFR § 418.28.) In addition, we will also determine whether Medicare payments for hospice services were made in accordance with Medicare requirements.
To ensure compliance with the Medicare hospice election statement requirements, hospices should ensure their election statements contain the following elements, as indicated in the CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.2.
Identification of the provider: The name of the particular hospice that will provide care to the beneficiary must appear on the election statement
An understanding of the nature of hospice care: The beneficiary or representativemust acknowledge that he/she has been given a full understandingof the palliative rather than curative nature of hospice care
Waiver of certain Medicare benefits: The beneficiary or representative must acknowledge an understanding that the beneficiary has waived rights to other benefits when electing the hospice benefit for their illness
Effective date of election:The effective date of the election statement may be the first day of hospice care. Hospice care may start after the effective date, but not prior to the effective date.
Signature: A dated signature of the beneficiary or representative must appear on the document
There is no specific format for an election statement; however, all the required elements listed must be clearly evident for the election statement to be considered valid. If the acknowledgement of understanding of hospice care or the acknowledgement of waiving of the certain Medicare benefits is on a different page, send in both pages to medical review to support a valid election statement.
Commonly identified problems with election statements:
No statement indicating the beneficiary fully understands the palliative rather than curative statement of the hospice benefit present
No effective date present
No waiver of certain Medicare benefits present
The particular name of the individual hospice providing care is not identified. If the hospice belongs to a corporation or some other entity that has a different name, ensure the name of the particular hospice providing care is on the signed statement.
To ensure compliance with the general inpatient (GIP) level of care, hospices may find the Palmetto Hospice GIP Audit Tool helpful.
Home health Prospective Payment System Requirements
We will review compliance with various aspects of the home health prospective payment system (PPS), including the documentation required in support of the claims paid by Medicare. We will determine whether home health claims were paid in accordance with Federal laws and regulations. A prior OIG report found that one in four home health agencies (HHAs) had questionable billing. Further, CMS designated newly enrolling HHAs as high-risk providers, citing their record of fraud, waste, and abuse. Since 2010, nearly $1 billion in improper Medicare payments and fraud has been identified relating to the home health benefit. Home health services include part-time or intermittent skilled nursing care, as well as other skilled care services, such as physical, occupational, and speech therapy; medical social work; and home health aide services.
The Medicaid section of the Work Plan describes the range of FY 2016 reviews planned and those in progress to promote the effectiveness and efficiency of the growing Medicaid program. Focus areas include prescription drugs; billing, payment, reimbursement, quality, and safety of home health services, community-based care, and other services, equipment, and supplies; State management of Medicaid, information system controls and security; and Medicaid managed care. There is the potential for both home health and hospice agencies to be impacted in all of these areas even though home health is only mentionedand only for one topic.