Do Not End Up On the OIG Medicare List of Overpayment Recoveries Statistics
The following statistics may peak your interest.
From Oct. 1, 2014 to Dec.31, 2016, the Office of Inspector General (OIG) issued 153 audit reports related to the Centers of Medicare & Medicaid Services (CMS) program. The report contained 193 monetary recommendations totaling $648 million. Of the $648 million in recommended overpayment recoveries, CMS agreed to collect $566 million applicable to 190 recommendations
The Department of Health and Human Services (HHS) is responsible for resolving federal audit-report recommendations related to its activities, grantees, and contractors within six months after formal receipt of the audit report.
Effects on Dermatology Practice
When your dermatology practice’s claim submissions are not supported by medical record documentation or when services are overbilled (reporting a higher service than what was performed), your practice may be included in the statistics above.
As part of the 2019 OIG Work Plan, the following recommendations were submitted to HHS/CMS:
The extent to which CMS:
collected agreed upon Medicare overpayments identified in OIG audit reports; and
took corrective action in response to the recommendations in the OIG prior audit report examining CMS’ overpayment recoveries.
In that report, the OIG recommended that “CMS enhances its systems and procedures for recording, collecting, and reporting overpayments, as well as providing guidance to its contractors on how to document that overpayments were actually collected.”
Role of CMS Beyond the OIG Work Plan
CMS also performs many program-integrity activities to reduce fraud, waste, and abuse that are beyond the scope of the OIG Work Plan. These include, but are not limited to:
Medicare fee-for-service (MFFS) and Medicaid improper payment-rate measurement;
Medicaid program-integrity activities;
Fraud prevention system (FPS); and
Recovery audit contractor (RAC) activities.
CMS and Fraud Prevention System (FPS)
CMS uses a multifaceted approach to target all causes of fraud, waste, and abuse that result in improper payments, with an emphasis on prevention activities. It focuses on initiatives that are fundamental in addressing program integrity across the gamut, while improving payment accuracy. CMS has invested considerable resources in systems and initiatives related to data and analytics to prevent or rapidly identify fraud, waste, and abuse.
The FPS analytics technology used by CMS since 2011, runs predictive algorithms on all MFFS claims. The analytics are run continuously prior to payment to identify, prevent, and stop potentially fraudulent claims. The system helps CMS target potentially fraudulent providers and suppliers, while reducing the administrative and compliance burden on legitimate providers and suppliers.
In 2016, the FPS helped CMS identify or prevent $527.1 million in inappropriate payments, which resulted in a $6.30 to $1.00 return on investment (ROI). Since CMS implemented the original FPS technology in June 2011, the FPS has identified or prevented almost $2.0 billion in inappropriate payments by discovering new leads or contributing to existing investigations. Out of the FPS models generated in 2016, 688 of all leads were included in the zone integrity program (ZPIC).
NCCI Role
Given the volume of claims processed by Medicare each day and the significant cost associated with conducting medical review of an individual claim, CMS uses automated edits to help prevent improper payment without the need for manual intervention. As previously stated, the national correct coding initiative (NCCI) program consists of edits designed to reduce improper payments in Medicare Part B. CMS originally implemented the NCCI program in the Medicare program in January 1996 using procedure-to-procedure (PTP) edits to ensure accurate coding and reporting of services by physicians.
The PTP edits prevent inappropriate payment for billing code-pairs that should not be reported together by the same provider for the same beneficiary on the same date-of-service (DOS). In addition to PTP edits, CMS established the medically unlikely edit (MUE) program in 2007 as part of the NCCI program to reduce the Medicare Part B paid-claims improper payment rate. MUEs prevent payment for an inappropriate number/quantity of the same service on a single day.
Since October 2008, CMS has publicly posted all PTP edits and a majority of MUEs on the CMS website at https://www.cms.gov/Medicare/Coding/National-CorrectCodInitEd/index.html. To prevent misuse or manipulation by fraudulent or abusive individuals and entities, CMS does not publish certain edits. The use of PTP and MUE edits saved the Medicare program $186.9 million and $359.8 million respectively during the first nine months of FY2017.
IDR and One PI Portal
How does CMS know if your claim submission history is flawed? By using the Integrated Data Repository (IDR) and One Program Integrity (One PI) portals. CMS has continued to enhance the data available in the IDR so it can provide a comprehensive view of Medicare and Medicaid data that include claims, beneficiary data, and prescription drug information.
By using the IDR to provide broader and easier access to data, the enhanced data integration strengthens and supports CMS’ analytical capabilities. The IDR contains paid claims for Medicare Part A, Part B (including DME), Part C (encounter), and Part D from as far back as January 2006, both before and after final payment.
In addition, CMS has added shared systems location data for pre-adjudicated claims, claims submitter, and medical review utilization data. CMS then uses the One PI web-based portal in conjunction with the IDR to facilitate data sharing with program-integrity contractors and law enforcement. The portal provides a single-access point to the data within the IDR, as well as the analytic tools to review the data.
CMS has also created a command center, which provides an opportunity for Medicare and Medicaid policy experts, law enforcements officials from HHS-OIG and the DOJ, including the Federal Bureau of Investigation (FBI), state law enforcement officials, clinicians, and CMS fraud investigators, to collaborate before, during, and after the development of fraud leads in real time. The command center has advanced technologies and a collaborative environment that allows multidisciplinary teams of experts and decision makers to efficiently coordinate policies and case actions, reduce duplication of efforts, and streamline fraud investigations for more immediate administrative action.
These collaborative activities enable CMS to take administrative actions, such as revocations of Medicare billing privileges and payment suspensions, more quickly and efficiently. In FY 2017, 25 missions were conducted in the command center, which included participants from CMS, CMS partners, and even the FBI.
Do Not Be a Statistic in Medicare-Claims Review
One of CMS’s goals is to conduct provider outreach and education to reduce Medicare and Medicaid improper payment rates by giving participating providers timely and accurate information needed to bill correctly, the first time around.
Medicare administrative contractors (MACs) educate participating providers and their staff about Medicare policies and procedures, including local coverage policies, significant changes to the Medicare program, and issues identified through review of provider inquiries, claim-submission errors, medical-review data, and comprehensive error rate testing (CERT) program data.
Tip
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MACs use a variety of strategies and communication channels to offer Medicare providers and suppliers a broad spectrum of information about the Medicare program, including CMS-developed materials and contractor-developed materials.
It is important for dermatology practices to pay close attention and understand coding changes and local and national coverage determinations (LCDs/NCDs) policy updates that are published by CMS.
As the OIG continues HHS oversight with increased pressure to reduce fraud, waste, and abuse, being up to date with these resources will prevent your practice from making coding errors that will result in claim denials, payer audits, and your practice becoming part of the erroneous claim-payment statistics discussed above.
For more information, visit https://oig.hhs.gov/publi-cations/docs/hcfac/FY2017-hcfac.pdf for the HHS and DOJ’s T Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2017.
