Medicare Update: OIG Work Plan Identifies Possible Areas of Concern for Home Health Agencies and DMEPOS Suppliers

On October 1, 2009, the Department of Health and Human Services' Office of Inspector General (OIG) released its Work Plan for fiscal year 2010 (Work Plan).

As stated in a previous post, the Work Plan addresses the areas and issues the OIG intends to audit, evaluate and inspect during fiscal year 2010. The Work Plan also provides some insight into the areas and issues that may evolve into future OIG enforcement activities. Therefore, home health agencies (HHA) and suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) should consider the Work Plan in relation to their operations.

This post briefly highlights some of the Work Plan priorities for HHAs and DMEPOS suppliers.

Home Health Agencies

Part B Payments for Home Health Beneficiaries. The OIG will review Part B payments for services and medical supplies provided to beneficiaries in home health episodes. The OIG will identify Part B payments made to outside suppliers for services and medical supplies included in the HHA prospective payment and examine the adequacy of controls established to prevent inappropriate Part B payments for services and medical supplies.
Accurately Coding Claims for Medicare HHRGs. The OIG will review Medicare claims submitted by HHAs to determine the extent to which the billing codes for home health resource groups (HHRG) are used in determining whether payments to HHAs are accurate and supported by documentation in the medical record. The OIG will assess the accuracy of HHRG assignment and identify patterns of miscoded HHRGs.
Medicare Home Health Payments for Insulin Injections. The OIG will review the incidence of Medicare home health services outlier payments for insulin injections. The OIG will also examine billing patterns in geographic areas with high rates of home health visits for insulin injections.
HHA Outlier Payments. The OIG will review the Centers for Medicare & Medicaid Services' (CMS) methodology for calculating outlier payments to determine whether the methodology reimburses HHAs as intended for high cost episodes.
Home Health Prospective Payment System Controls. The OIG will review compliance with various aspects of the home health prospective payment system (PPS), including billings for the appropriate location of the services provided. The OIG will also analyze various trends in HHA activities, including the number of claims submitted to Medicare, number of visits provided to beneficiaries, arrangements with other facilities, and ownership information.
HHA Profitability. The OIG will review cost report data to analyze HHA profitability trends under home health PPS to determine whether the payment methodology should be adjusted. The OIG will examine various trends, including profitability trends in Medicare and the overall profitability trends of freestanding and hospital-based HHAs.
Medicare Home Health Payment for Diabetes Self-Management Training Services. The OIG will review Medicare home health payments for diabetes self-management training services and examine billing patterns in geographic areas with high utilization of such services.
Oversight of HHA OASIS Data. The OIG will review CMS's oversight of Outcome and Assessment Information Set (OASIS) data submitted by Medicare certified HHAs. The OIG will review CMS's process for ensuring that HHAs submit accurate and complete OASIS data.

DMEPOS Suppliers

Physician Self-Referral for DME Services. The OIG will review Medicare payments for durable medical equipment (DME) services to determine their allowability in context of Federal requirements for physician self-referral prohibitions. In particular, the OIG will determine the allowability of physician self-referrals to DME suppliers in which physicians held ownership interests.
Medicare Payments for Various Categories of DME. The OIG will review the appropriateness of Medicare Part B payment to DME suppliers of power mobility devices (e.g., scooters), hospital beds and accessories, oxygen concentrators, and enteral/parenteral nutrition. The OIG will identify DME suppliers in selected geographic areas with high volume claims and reimbursement to determine whether payments were made in accordance with Medicare requirements.
Medicare Payments for DME Claims With Modifiers. The OIG will review the appropriateness of Medicare Part B payments to DME suppliers that submitted claims with modifiers and determine whether payments were made in accordance with Medicare requirements.
Comprehensive Error Rate Testing Program (CERT): DME Corrective Actions. The OIG will review CMS's corrective actions in response to recommendations in the OIG's final report dated August 22, 2008, regarding the medical review claims for the FY 2006 CERT program DME review. The OIG will verify actions taken by CMS to implement the OIG's recommendations.
Appropriateness of DME Categorization. The OIG will review the appropriateness of DME categorization in the Medicare fee schedule for selected DME items. Using the DME suppliers' records and information from beneficiaries, the OIG will determine whether DME items are properly classified according to current payment methodologies.
Enteral Nutrition Therapy Services in Nursing Homes. The OIG will review Part B enteral nutrition therapy (ENT) to assess the medical necessity, adequacy of documentation, and coding accuracy of claims submitted for Medicare beneficiaries during a nursing home stay that is not covered under the Part A skilled nursing facility benefit. The OIG will also examine the characteristics of inappropriately allowed ENT claims.
Medicare Pricing for Parenteral Nutrition. The OIG will review Medicare's fee schedule for parenteral nutrition in comparison with fees paid by other sources of reimbursement.
Medicare Part B Payments for Home Blood Glucose Testing Supplies. The OIG will review Medicare Part B payments made for home blood glucose test strips and lancet supplies and determine the appropriateness of payments for such supplies.
Medicare Payment for Power Wheelchairs. The OIG will review documentation supporting claims for power wheelchairs paid for by Medicare and determine whether beneficiaries received the required face-to-face examinations from the referring practitioners prior to receipt of the wheelchairs.
Medicare Payments to DME Suppliers for Power Wheelchairs. The OIG will review documentation for payments to DME suppliers for standard and complex rehabilitation power wheelchairs to determine whether suppliers meet Medicare's coverage criteria and medical necessity documentation requirements. The OIG will also determine whether suppliers had documentation from the beneficiaries' medical records (as required) that clearly supported the medical necessity of the power wheelchairs.
Medicare Enrollment and Monitoring of DMEPOS Suppliers and HHAs. The OIG will review Medicare contractors' processes for enrolling and monitoring DME suppliers and HHAs. In particular, the OIG will assess Medicare contractors' use of enrollment screening mechanisms and post enrollment monitoring activities to identify DME and HHA applicants that pose fraud risks to Medicare and the extent to which applicants omitted ownership information on enrollment applications.