Medicare Audits: Red Flags to Avoid This 2015

If you run a home health care business, most of your patients will probably be from Medicare. This means that there will be numerous rules and regulations to comply with for your home health care business to be admitted to the Medicare program. Private insurance plans usually have the same rules and regulations as well. These requirements cover many different aspects such as record keeping, billing procedures, and even how you screen your patients.

The Office of the Inspector General (OIG) oversees the proper administration of the Medicare program and continuously looks for ways to improve it. Each year, it comes out with a work plan enumerating what potential problem areas of the Medicare program they aim to address to streamline operations and save potentially billions of dollars for the government. Here are some of the highlights from the 2015 work plan.

Provider-Based Facilities

Medical facilities owned and operated by hospitals can be given “provider-based” status even though they are often located off-site. They operate and bill as the hospital’s outpatient departments. However, this usually means that they charge much more than freestanding clinics for the same services, a concern that was raised as far back as 2011. The OIG intends to review whether provider-based facilities actually meet the CMS criteria and whether the higher billings are justified.

Patient Classification

The OIG identified overpayments of up to millions of dollars for short in-patient stays that should have been classified as outpatient. The new criteria now require in-patient stays to be at least two nights (“two midnight rule”). The OIG also has initial findings pointing to the mislabeling of “established” outpatients as “new.” “New” patients should not have been registered as a patient of the facility within the previous three years.

Salaries and Wage Index

The OIG intends to review whether limits should be set on the salary amounts reimbursed by Medicare. While there are currently no specific limits set, they should only, to a “reasonable” extent, cover operations in line with patient care. The OIG also previously identified hundreds of millions of dollars overpaid for incorrect wage indexes for Medicare payments, leading to policy changes by the CMS. The OIG intends to assess whether these policy changes have addressed the problem, and may again review the wage index data used by facilities in their reports.

Duplicate or Excessive Education Payments
The periods between acute episodes may last cialis price brand months or even years in the early course of the disease, but seriously affect the quality of life (QOL) of the patients after gallbladder removal. A healthy cipla cialis italia libido doesn’t have to disappear as you get older. Another approach, that is not even on the table, she said. cialis generico uk Erectile dysfunction is a disorder which needs seanamic.com cheap viagra to be cured off soon and that should be a person s first priority.
 

OIG plans to review data from the CMS Intern and Resident Information System (IRIS) to assess how effective it is in identifying and preventing any duplicate or excessive payments for graduate medical education (GME). They will also review the calculation of indirect medical education (IME) payments and their compliance to set regulations and guidelines.

Compliance to Billing Requirements by Independent Clinical Laboratories

Independent clinical laboratories have been increasing exponentially, totaling over $8 billion worth in 2010. With the OIG “following the money,” so to speak, they’ve increasingly subjected these laboratories to audits and investigations. They will probably continue to do so for the foreseeable future, with a report on this expected within the year.

Specialization-Specific Claims/Payments

Dental services are generally not covered by Medicare – with some exceptions. The OIG has identified many cases of reimbursement for dental procedures that are not supposed to be covered. This includes improper record keeping or reporting. On the other hand, the OIG also aims to assess whether children with Medicaid are getting all their needed dental benefits, while also reviewing a proliferation of unnecessary procedures being carried out on them.

Anesthesia services are also being reviewed by the OIG, since services personally performed by an anesthesiologist (AA) are billed double that of services performed under an anesthesiologist’s direction (QK). Starting last year, it has been required that only services performed by the actual anesthesiologist be coded and billed as AA while QK should be used at any time the patient is left with a nurse anesthetist or other health care professional. Like dental procedures, only certain chiropractic services are covered by Medicare. These are limited only to certain conditions and only those that are necessary. This does not include, for example, maintenance procedures.

Hazzouri Accounting has over 16 years of expertise in helping local home health care businesses comply with government requirements. We specialize in Medicare / Medicaid cost report preparation for home health agencies. Call us at 734-844-1614 or use our online contact form to get started!

Visit our social media accounts to stay up to date with us:  Facebook fan page / Twitter Feed / Google+ Account