OIG April 2019 Work Plan Updates - Home Health and ESRD

PUBLISHED: Apr 19, 2019
Relevant to: Dialysis Facilities, Home Health

The Office of the Inspector General (OIG) recently released updates to their Work Plan. In 2017, OIG transition from a yearly to a monthly Work Plan with the goal of enhancing transparency around OIG's continuous work planning efforts. The OIG Work Plan provides insight into areas where government enforcement and audit officials are focusing.

For April 2019, the following selection of OIG Work Plan activities are of interest to healthcare organizations:

Review of Monthly ESRD Related Visits Billed by Physicians or Qualified Healthcare Professionals

Most physicians and other practitioners (e.g., clinical nurse specialists, nurse practitioners, or physician's assistants) who manage the care of patients who receive outpatient dialysis services at end-stage renal disease (ESRD) facilities are paid a monthly capitation payment (MCP) for ESRD-related physician services. The MCP amount is based on the number of visits provided within each month and the age of the ESRD beneficiary. The physician or other practitioner can bill only one of three current procedural terminology (CPT) codes for ESRD-related visits of one per month, two to three per month, or four or more per month (CMS, Medicare Claims Processing Manual, Pub. No. 100-04, chapter 8, § 140.1). The Comprehensive Error Rate Testing program's special study of the Healthcare Common Procedure Coding System codes for ESRD-related services found that for some codes, approximately one-third of the payments for ESRD-related services were improper payments due to insufficient documentation, incorrect coding, or no documentation submitted (CMS, Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors, volume 5, issue 3, April 2015). OIG will review whether physicians or other qualified healthcare professionals billed monthly ESRD-related visits in accordance with Federal requirements (Social Security Act, §§ 1815(a) and 1833(e)).

Medicaid Personal Care Services:

Personal care services (PCS) is a Medicaid benefit for the elderly, people with disabilities, and people with chronic or temporary conditions. It assists them with activities of daily living and helps them remain in their homes and communities. Examples of PCS include bathing, dressing, light housework, money management, meal preparation, and transportation. Prior OIG reviews identified significant problems with States' compliance with PCS requirements. Some reviews also showed that program safeguards intended to ensure medical necessity, patient safety, and quality, and prevent improper payments were often ineffective. OIG will determine whether improvements have been made to the oversight and monitoring of PCS and whether those improvements have reduced the number of PCS claims not in compliance with Federal and State requirements.

Included with today’s StayAlert! Notice are example policies that may assist with identified audit areas.

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