News

We read recently of a radiation therapy provider that agreed to pay more than $3.5 million in a CMP (civil monetary penalty) settlement with the OIG (Office of Inspector General).

According to the settlement, the company submitted claims for radiation and oncology services that:

• Used incorrect CPT codes and service dates
• Weren’t provided
• Didn’t include sufficient documentation to support service necessity
• Were “unbundled”
• Contained “incomplete documentation”

In general, the AMA says, medical billing errors fall into one of two broad categories: fraud or abuse.

The AMA’s “Principles of CPT Coding” offers definitions of the terms: Fraud “involves intentional misrepresentation,” while abuse means “the falsification was an innocent mistake, but nonetheless representative.”

The organization also lists some common medical-coding errors to avoid:

• Unbundling codes: the AMA says providers should use the single code “that captures payment for the component parts of a procedure.” Don’t unbundle to increase payments.
• Upcoding: consequences for this can be “severe.”
• Failing to check NCCI edits before reporting multiple codes
• Failure to append appropriate modifiers/a

As many readers of our Michigan legal blog know, the Medicare audit appeals process has relatively small timeframes in which providers can object to claims of overpayments.

The good news for a Las Vegas hospital recently audited by the Office of the Inspector General is that its initial timely response to an audit meant that it was able to reduce the amount the OIG wants refunded for Medicare billing errors by $8,914. The reduction followed Sunrise Hospital & Medical Center’s submission of a handful of claims for reprocessing.

The bad news is that the Health and Human Services (HHS) watchdog insists on the return of the remaining portion of what it claims is $23.6 million in overpayments resulting from Medicare billing errors.

The OIG reviewed 100 inpatient and outpatient claims for the audit period from Jan. 1, 2017, through Dec. 31, 2018.

The OIG said Sunrise “complied with Medicare billing requirements for 46” of the reviewed claims, but “did not fully comply” on “the remaining 54 claims, resulting in net overpayments of $999,950 for the audit period.”

The federal office said 50 inpatient claims and four outpatient claims contained billing errors.

On the basis of the sample results, OIG estimated that Sunrise “received overpayments of at least $23.6 million for the audit period.”

In a statement on the hospital’s website, the Sunrise CEO said, “We strongly disagree with

One of the many changes the pandemic has compelled society to make is telehealth. The rapid rise of telehealth in the year-plus of the pandemic has made healthcare services more accessible, helped preserve personal protective equipment, reduced demand on healthcare facilities and helped to keep both patients and providers free of the virus.

Earlier this year, the Deputy Director for the Health and Human Services Office of Inspector General said telehealth isn’t just a matter of convenience for Medicare beneficiaries, it’s also “a matter of safety for many beneficiaries.”

Because many healthcare providers are saying they expect that telehealth will continue after the pandemic – and could even expand – the OIG Deputy Director announced plans to conduct “significant oversight” of telehealth to ensure its benefits aren’t compromised by abuse, misuse or fraud.

In fact, the OIG is already in the process of conducting several audits involving telehealth services. While the OIG’s work plan (a work plan is a list of “audits, evaluations, and inspections that are underway or planned”) indicates the focus will be on healthcare industry trends that emerged in the course of the pandemic, audits could also identify providers it believes received Medicare overpayments.

For instance, the OIG is conducting audits on the “Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care,” “Home

The Office of Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS) recently announced that it will conduct another audit to determine if acute care hospitals are being overpaid by Medicare.

The second round of audits follows up on a September 2020 audit that found that Medicare overpaid acute care hospitals $51.6 million from 2013 to 2016 for outpatient services to beneficiaries who were inpatients at other facilities such as long-term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities and critical-access hospitals.

The Detroit metro area has three acute care hospitals.

In a press statement, the OIG said: “that none of the $51.6 million we reviewed, representing 129,792 claims, should have been paid because the inpatient facilities were responsible for payments.” It added that Medicare beneficiaries also had to pay $14.3 million in “unnecessary deductibles and coinsurance” for the outpatient services.

The OIG also said the overpayments to acute care hospitals occurred because the common working file (CWF) edits that should’ve flagged overpayments weren’t working properly.

A news report stated that “acute