Eli's Hospice Insider

Published on Fri Jun 17, 2011 PDF

Plus: OIG plans to crack down on documentation requirements.

Home care providers are in the fraud and abuse enforcement hot seat these days, and it can be hard to get answers on how to resolve specific compliance problems.

The HHS Office of Inspector General discussed many of these issues during its four-hour HEAT Provider Compliance Training session on May 18 in Washington, D.C., where OIG experts offered advice on how to avoid health care fraud and abuse, and what to do if you find these issues in your organization.

The OIG reps covered a very wide range of issues during the training session. Here are some that could most help you navigate the compliance waters:

1. Mandatory compliance plans are coming soon. Although the government has not yet finalized the requirements that you'll need to follow for mandatory compliance plans, you should be aware that they are on the way.

"The health care reform law includes a requirement for providers and suppliers to have compliance plans as a condition of enrollment," said attorney Amanda Walker, senior counsel with the OIG, during the session. The implementation timeline has not yet been defined, but the Centers for Medicare & Medicaid Services has already revealed the seven elements it believes are essential to an effective compliance and ethics program, and the agency has sought comments on those elements (see box, p. 45).

2. Medicare doesn't have to pay your claim right away if abuse is suspected. Although many providers believe that Medicare contractors and the OIG only review claims on a retrospective basis, that isn't always accurate, said physician Julie Taitsman, the OIG's chief medical officer. "For suspicious providers, CMS does not have to automatically pay claims. CMS can place suspicious providers on prepayment review when they have reason to suspect fraud or abuse."

In addition, the government will be more vigilant than ever in seeking documentation to review. "Going forward, you should be aware of an increased enforcement of documentation requirements," Taitsman said. "I can point to several reasons for this. First, the administration is  pursuing an initiative to cut the improper payment rate in Medicare fee-for-service in half by 2012. Second, OIG has recommended that CMS and contractors focus on error-prone providers, and CMS is increasingly tasking Medicare contractors to review medical records to prevent improper payments."

3. Know the guidelines for returning overpayments. If you receive an overpayment from your Medicare contractor, you must return the overage within a specific time period. "Even if you make an innocent billing mistake, you must repay the government," said attorney Meredith Williams, senior counsel with the OIG. "The Affordable Care Act included a new requirement that providers must repay overpayments to Medicare and Medicaid within 60 days or be subject to penalties."

4. Ensure that your EHRs are totally secure. Electronic health records (EHRs) offer improved accessibility to providers who want to review patient charts. However, in some cases, this accessibility causes security issues, Taitsman said.

"In some of our information technology audits, we have OIG auditors who will sit in the parking lot of a hospital with a laptop computer and drop on to the hospital's wireless network and actually be able to access patient information that's supposed to be private."

Tip: Confirm that your EHRs and other systems are configured securely so that patient information stays completely confidential.