June 20, 2012

Return on CMS Investment in Two Medicaid Integrity Programs Lacking

By

alert-powered-by-decision-health

 

Two Medicaid integrity programs aimed at assisting states to root out fraud "are not effectively accomplishing their missions," an Office of Inspector General official testified June 14 in front of a Senate subcommittee.

Ann Maxwell, OIG regional inspector general for evaluation and inspections, said CMS' National Medicaid Audit Program and the Medicare-Medicaid Data Match Program have had "low findings of actual overpayments and, as a result, yielded negative returns on investment ... In many ways, these programs resemble a funnel through which significant federal and state resources are being poured in and limited results are trickling out."

 

CMS invested $32.1 million in review MICs and audit MICs but saw only an estimated $14 million return. CMS also spent $60 million on the Medicare-Medicaid program but recovered or avoided costs totaling $57.8 million, Maxwell testified.

 

Data shortcomings, variety in state Medicaid policies and CMS mismanagement of the programs - including not holding contractors accountable - have contributed to the problem, she said.

 

For example, review Medicaid integrity contractors (MICs) identified more than 113,000 providers with potential overpayments of $282 million, but after investigation, audit MICs found just 25 providers had actual overpayments of $285,629, Maxwell testified.

 

OIG recommended that CMS:

  • Improve Medicaid data used to conduct data analysis and mining;
  • Improve contractors' abilities to analyze Medicaid data in light of state-specific policies;
  • Consider increasing the use of collaborative audits in the Medicaid audit program;
  • Hold contractors accountable.

 

Read all of Maxwell's testimony here: http://oig.hhs.gov/testimony/docs/2012/Maxwell_testimony_06142012.pdf.

 

Region D RAC Posts Issues

 

The recovery auditors (RACs) were mostly quiet, with just one RAC, HealthDataInsights in Region D, posting issues for an "unspecified" provider type and for "other FI biller."

 

Unspecified provider type

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Facet joint denervation billed without guidance - J3

4/23/12

Ariz., Utah, S.D., Mont., Wyo., N.D.

In accordance with LCD L30813, facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance. This requirement is effective for dates of service on or after Nov. 11, 2010.

CMS Pub. 100-04 chapter 1; Noridian LCD 30813

Outpatient facility duplicates

4/13/12

RAC Region D

Duplicate payments made for services provided in an outpatient facility.

CMS Pub. 100-04 chapter 1; CMS Pub. 100-06 chapter 3

Cataract removal - excessive units

4/13/12

RAC Region D

Cataract removal can only occur once per eye for the same date of service. This issue identifies overpayments associated to outpatient hospital providers billing more than one unit of cataract removal for the same eye.

NCCI chapter 9

 


Unspecified provider type (CONT'D)

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Initial infusion and chemotherapy administration - excessive units

4/13/12

RAC Region D

When administering multiple infusions, injections or combinations, the provider should only report one "initial" service code unless protocol requires that two separate IV sites must be used.

CMS Pub. 100-04 chapter 12

 

Other FI biller

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Labs subject to consolidated billing for ESRD

4/13/12

RAC Region D

The ESRD Prospective Payment System (PPS) includes consolidated billing for limited Part B services included in the ESRD facility bundled payment. Certain laboratory services and limited drugs and supplies will be subject to the Part B consolidated billing and will no longer be separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility.

CMS Pub. 100-04 chapter 8; Change Request 7064 dated Jan. 14, 2011; MLN Matters article MM7064 dated Jan. 14, 2011

 

Unspecified provider type

 

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Facet joint denervation billed without guidance - J3

4/23/12

Ariz., Utah, S.D., Mont., Wyo., N.D.

In accordance with LCD L30813, facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance. This requirement is effective for dates of service on or after Nov. 11, 2010.

CMS Pub. 100-04 chapter 1; Noridian LCD 30813

 

About the Author

 

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

 

Contact the Author

 

KLong@decisionhealth.com

 

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