The Office of Inspector General (OIG) has published the latest additions to its Work Plan, which includes four noteworthy items related to orthotic braces, Skilled Nursing Facility (SNF) Part D Payments, Home Health services provided via telehealth, and Part B telehealth services. PYA offers insights on each of these additions.
Background
Each month, the OIG publishes the most recent additions to its Work Plan. The Work Plan development process is dynamic and requires adjustments throughout the year to meet the OIG’s “priorities and to anticipate and respond to emerging issues with resources available.” With a goal of transparency, the OIG updates its Work Plan website monthly, outlining recently added information. The following is a summary of the latest additions, the agencies affected, and what they mean for compliance leaders in healthcare organizations.
Fraud, Waste, and Abuse Related to Orthotic Braces – CMS
According to the January OIG Work Plan Update:
Prior OIG work identified inappropriate payments for orthotic braces that were not medically necessary, not documented in accordance with Medicare requirements, or fraudulent. The OIG will compile the results of prior OIG audits, evaluations, and investigations of orthotic braces that were paid for by Medicare. The OIG will analyze data to identify trends in payment, compliance, and fraud vulnerabilities, and offer recommendations for improving detected vulnerabilities.
What You Need to Know:
The Centers for Medicare & Medicaid Services (CMS) contracts with two durable medical equipment (DME) Medicare Administrative Contractors (MACs) to process and pay Medicare Part B claims for Durable Medical Equipment, Prosthetics, Orthotics, and Suppliers (DMEPOS), including orthotic braces. Each DME MAC processes claims for two of four jurisdictions (A, B, C, and D), which include specific states and territories.
Orthotic braces are defined as “rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.” Prior to dispensing an orthotic brace, Orthotic suppliers should obtain as much documentation from the patient’s medical record as they determine necessary to assure medical necessity of the brace.
For additional insight into what the OIG looks for when auditing DMEPOS suppliers, the OIG Work Plan provides links to two past Orthotic brace supplier audit reports. Both reports outline the following documentation requirements by Local Coverage Determinations (LCDs), which must be included to be covered by the DME MAC:
- Written documentation of a verbal order or a preliminary written order from the treating physician (if applicable);
- a detailed written order from the treating physician;
- information from the treating physician concerning the beneficiary’s diagnosis;
- any information required for the use of specific modifiers; and
- proof of delivery of the orthotic brace to the beneficiary.
Medicare Part D Payments During Covered Part A SNF Stay – CMS
According to the January OIG Work Plan Update:
Medicare Part A prospective payments to skilled nursing facilities (SNFs) cover most services, including drugs and biologicals furnished by the SNF for use in the facility for the care and treatment of beneficiaries. Accordingly, Medicare Part D drug plans should not pay for prescription drugs related to post-hospital SNF care because drugs are already included in the consolidated payment for Part A SNF stays. The OIG will determine whether Medicare Part D paid for drugs that should have been paid under Part A SNF stays.
What You Need to Know:
As part of the Balanced Budget Act of 1997, most services provided to beneficiaries in a SNF stay are included in a bundled prospective payment, made through Part A. The consolidated billing package encompasses the entire continuum of care that residents receive during Part A SNF stays, including therapy services and most drugs and biologicals. There are, however, several services and items, such as chemotherapy drugs and administration services, which are excluded from the SNF consolidated billing package and are paid separately. The list of separately payable services and items can be found here. SNF providers should ensure they are only billing drugs and biologicals separately payable to Medicare Part D.
Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency – CMS
According to the January OIG Work Plan Update:
CMS amended regulations to allow home health agencies (HHAs) to use telecommunications systems in conjunction with in-person visits. The amended regulations state that: (1) the use of technology must be related to the skilled services being furnished, and (2) the use of technology must be included in the plan of care with a description of how the technology will help achieve goals without substituting for an in-person visit. The OIG will evaluate home health services provided by agencies during the COVID-19 public health emergency to determine which types of skilled services were furnished via telehealth, and whether those services were administered and billed in accordance with Medicare requirements.
What You Need to Know:
According to the CMS 2021 Final Rule, HHAs can utilize telehealth technologies to provide care to Home Health patients. The use of remote patient monitoring, audio-only services, and other telecommunication services must be documented in the patients’ plan of care. CMS has stated they will not require a description of how technology will help achieve the goals outlined in the plan or care. Rather, documentation should explain how such services will facilitate treatment outcomes. CMS has clarified that the telehealth visit cannot replace an in-person home visit, nor can it serve as a substitute for patient eligibility or payment. Using technology may result in furnishing home health services more efficiently, which may change the frequency and types of in-person visits.
The CMS 2021 Final Rule also expands the definition of telecommunications technology that HHAs can now report remote patient monitoring on the HHA cost report. CMS believes these finalized policies will ensure patient access to the latest technology and give HHAs predictability that they can continue to use telecommunications technology as part of patient care.
Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency – CMS
According to the January OIG Work Plan Update:
Because of telehealth’s changing role, the OIG will conduct a series of audits of Medicare Part B telehealth services in two phases. Phase one audits will focus on making an early assessment of whether services such as evaluation and management, opioid use order, end-stage renal disease, and psychotherapy (Work Plan number W-00-21-35801) meet Medicare requirements. Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.
What You Need to Know:
On December 1, 2020, CMS issued a final rule which includes updates on policy changes for Medicare payments under Part B, including various telehealth changes. As part of the rule, CMS finalized seven new types of services which can be provided via telehealth on a Category 1 basis. Category 1 services are classified as services similar to those already on the telehealth covered list. In addition, CMS created a temporary Category 3 list of covered services, which describes temporary services on the Medicare telehealth list for the COVID-19 public health emergency (PHE) and will remain on the list through the calendar year in which the PHE ends. The new Category 1 and Category 3 telehealth services can be found here.
According to the CMS CY2021 final rule, CMS sought comment from the public on creating a virtual check-in audio-only service for beneficiaries to avoid sources of infection, like doctor’s offices. Based on support from the public comments, CMS created on an interim final basis for calendar year 2021, HCPCS[1] code G2252. HCPCS G2252 describes a virtual medical discussion to determine the necessity of an in-person visit, the full HCPCS code description is provided below.
G2252- Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
Key Takeaways
- Evaluate the latest OIG Work Plan items and discuss relevant topics with key leaders in your organization.
- Add applicable items to your organization’s Work Plan and conduct internal audits to identify any deficiencies within your organization.
- Return any overpayments identified through internal auditing activities.
How PYA Can Help
PYA compliance consultants combine regulatory expertise with practical experience in healthcare organizations. Our compliance subject matter experts will provide a customized approach to assist you and your organization with today’s ever-changing compliance landscape.
If you would like more information about any matter involving compliance, valuation, or strategy and integration, contact one of our PYA executives below at (800) 270-9629.
[1] Healthcare Common Procedure Coding System® (HCPCS) is a registered trademark of the American Medical Association (AMA).
