December 1, 2017
In November, the Office of the Inspector General (“OIG”) for the U.S. Department of Health & Human Services updated its 2017 Work Plan to include four issues on which it will devote particular attention in the coming months. Our hospital clients will want to be particularly vigilant with regard to billing Medicare for the treatment of severe malnutrition, while providers who receive significant Medicaid reimbursement will want to carefully examine their practices related to billing for telemedicine services and prescribing opioids to Medicaid beneficiaries.
The OIG will examine the accuracy of inpatient hospitals’ claims for reimbursement to treat severe malnutrition. Reimbursement for malnutrition treatment is based upon the severity of the condition and whether it affects patient care, with severe malnutrition being coded at a higher DRG. The OIG will analyze these claims to determine whether providers are complying with Medicare billing requirements when assigning diagnosis codes for the condition.
Turning to Medicaid, with the OIG noting a significant increase in telemedicine, telehealth, and telemonitoring Medicaid claims, it will examine providers’ claims associated with these services to determine whether those claims complied with Medicaid requirements.
Next, the OIG will examine cases in which Medicaid beneficiaries received “extreme” amounts of opioids, particularly those that appear to involve doctor or pharmacy shopping, and it will examine prescribers with questionable patterns for prescribing opioids to Medicaid patients. While the opioid epidemic is obviously a concern for the public-at-large, the OIG is particularly concerned about Medicaid patients, as they tend to have higher incidences of chronic conditions and comorbidities that require pain relief.
Last, the OIG will focus its attention on the use of funds by Medicaid Managed Care Organizations, examining the way monthly capitation payments are used to provide services to enrollees, and analyzing the amount of those payments to ensure that they are sufficient to provide services to Medicaid beneficiaries.
If you have any questions about the OIG’s updated Work Plan or if you need assistance reviewing your Medicare and Medicaid compliance program, please contact a member of HDJN’s Compliance team.
The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel, Johnson & Nagle, PC, is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel, Johnson & Nagle, PC be liable for any direct, indirect, or consequential damages resulting from the use of this material.