OIG and CMS Audits Current New Spherical of Compliance Issues for Healthcare Suppliers: McBrayer PLLC

[ad_1]

You can view the original post here

OIG and CMS Audits Current New Spherical of Compliance Issues for Healthcare Suppliers

Because the starting of the Public Well being Emergency, Facilities for Medicare and Medicaid Companies (“CMS”) and the Facilities for Illness Management and Prevention (“CDC”) knowledge mirror over 44 million COVID-19 instances, 3 million COVID-19 associated hospitalizations, and 720,000 COVID-19 deaths. COVID-19 has positioned monumental stress on our healthcare system. Federal and state responses to COVID-19 have woven a fancy and sophisticated security web by easing regulatory necessities via waivers and funneling billions of {dollars} to suppliers amongst many different actions. Simply because the pandemic might lastly be easing, federal concentrate on use of COVID-19 assets guarantees to extend healthcare suppliers’ stress.

In mild of the $1.5 billion[1] {dollars} Medicare spent on COVID-19 testing, the Workplace of the Inspector Basic (“OIG”) has introduced a strategic shift from creating a security web to assist suppliers to evaluating suppliers’ use of COVID-19 assets. The OIG has introduced a “series of audits” in addition to a “trend analysis” for Medicare lab billing associated to COVID-19 testing to id potential cases of fraud and abuse. The OIG ’s development evaluation of Medicare lab billing will goal COVID-19 add-on testing.[2]

When conducting COVID-19 testing, laboratories may also carry out add-on diagnostic laboratory testing to verify or rule out diagnoses apart from COVID-19. Nevertheless, the OIG has program integrity considerations about add-on assessments when carried out together with COVID-19 assessments, notably associated to probably fraudulent billing for the next add-on testing: respiratory pathogen panel (“RPP”) assessments, allergy assessments, and genetic assessments.[3] Add-on testing is a focus in mild of CMS’ leisure of guidelines associated to COVID-19 testing, which eradicated the requirement for an order from a doctor or non-physician supplier in the course of the public well being emergency.

The OIG has acknowledged, “relaxation of the physician ordering/nonphysician practitioner rules could allow unscrupulous actors more leeway for fraudulent billing of unnecessary add-on testing.”[4] The OIG’s “trend analysis” will look at Medicare claims knowledge for laboratory testing to determine tendencies in using RPP, allergy, and genetic testing and determine patterns of billing by laboratories that the OIG believes might point out fraud and abuse.[5]

For healthcare suppliers this solely means one factor: prepare.

What to Anticipate and Methods to Put together

Many practices, rural well being clinics, ambulatory clinics, and different suppliers have expanded their laboratory capabilities to accommodate the necessity for COVID-19 testing and may be topic to audit. To organize for these audits and development evaluation, suppliers ought to start asking themselves the exact same questions the OIG will ask about COVID-19 take a look at billing: (1) Have been the assessments eligible to be coated by Medicare? (2) Was it applicable to invoice Medicare for journey and assortment of specimens? (3) Do we have now the best documentation?

Have been the assessments eligible to be coated by Medicare?

Medicare doesn't present protection for all COVID-19 assessments. In reality, Medicare solely covers diagnostic assessments, i.e., ones administered to a affected person who has displayed COVID-19 signs or was uncovered to COVID-19. Medicare doesn't cowl non-diagnostic assessments, i.e., these carried out solely to observe public ranges of the virus for well being surveillance. Importantly, Medicare solely pays for lab assessments that are medically vital—if the COVID-19 take a look at was accompanied by one other lab take a look at, every take a look at could also be reviewed to find out whether or not it was medically vital, and due to this fact billable to Medicare. The OIG audits will concentrate on COVID-19 assessments and accompanying assessments carried out and submitted for fee, making use of scrutiny as to whether every take a look at was medically vital.

This opens up the hypothetical “gates” to a far reaching and thorough audit by the OIG.

Was it applicable to invoice Medicare for journey and assortment of specimens?

In lots of cases, an entity (maybe the lab itself or a specimen assortment firm) will journey to healthcare amenities to gather samples for diagnostic assessments. Medicare pays for journey if an entity should go to a different location to gather samples from Half B inpatients who're homebound or non-hospital. Nevertheless, if the take a look at is carried out in the identical location that the take a look at pattern is collected, Medicare won't pay for any journey bills. Thus, it's improper for a healthcare facility or supplier to request reimbursement for journey bills which can be inaccurate or inflated. If a supplier has billed Medicare for specimen assortment associated journey, it's required to have logs supporting the mileage traveled (whether or not in paper or digital format). If no such logs exist, fee for journey could also be in jeopardy.

Does Correct Documentation Exist?

As with each service billed, a supplier should have a medical document that helps the claims filed. COVID-19 testing, nonetheless, is completely different as a result of an order for a take a look at is just not all the time medically vital. For protection, nonetheless, the medical document should mirror that the take a look at was medically vital which means the affected person’s document ought to mirror that the affected person was reporting signs and/or had been uncovered to COVID-19. The medical document ought to include pertinent info, equivalent to when the affected person was uncovered, and an in depth define of what signs the affected person was displaying. Thus, the supplier ought to have correct data documenting the medical necessity for the take a look at in addition to for any add-on take a look at that was carried out on the identical time. Suppliers ought to evaluate their data to make sure that COVID-19 assessments have been correctly documented by way of their efficiency and billing, to keep away from compliance points. Beforehand billed COVID-19 assessments needs to be reviewed to make sure correct coding was used. Gathering and organizing such info is a very powerful step in making ready for any audit and avoiding legal responsibility.

As a part of a supplier’s routine compliance evaluate, samples of sufferers’ medical data the place COVID-19 testing was carried out needs to be reviewed, notably if extra testing was carried out on the identical time. Data needs to be reviewed to guarantee {that a} Subjective, Goal, Evaluation and Plan (“SOAP”) word exists that helps the testing carried out. Typically, a SOAP word displays ample medical reasoning to evaluate, diagnose, and deal with a affected person primarily based on the knowledge offered to them by the affected person and captures medical necessity. Utilizing a SOAP as a guidelines serves as a cognitive help and a possible index to retrieve info from the document.[6] It's important to take advantage of clinically related knowledge within the medical document simpler to seek out and extra instantly obtainable previous to being inspected or audited by a third-party.

Conclusion

Federal audits are a demanding prospect for the already overwhelmed healthcare amenities and suppliers. Incorporating a evaluate of medical data as a part of routine compliance actions is a accountable solution to deal with points earlier than they change into the topic of an audit or investigation. Any facility or apply performing COVID-19 testing ought to decide whether or not add-on testing was additionally carried out. We're right here to assist our shoppers guarantee compliance with all regulatory and statutory directives. For help with these or some other healthcare issues, contact your McBrayer legal professional in the present day.

Lisa English Hinkle is a Member of McBrayer legislation. Ms. Hinkle chairs the healthcare legislation apply and is situated within the agency’s Lexington workplace. Contact Ms. Hinkle at [email protected] or (859) 231-8780, ext. 1256.

Jonas Bastien is an Affiliate of McBrayer Legislation. He practices with the healthcare and litigation teams within the agency's Lexington workplace. Mr. Bastien may be reached at [email protected] or (859) 231-8780, ext. 1029.