As Pandemic Eases, OIG Ramps Up Audits
Date Posted: Tuesday,
August 31, 2021
With Americans having widespread access to effective vaccines, the COVID-19 pandemic is finally fading into the background for most practices, but the issue of compliance is once again rearing its multi-faceted head.
This time, after billions of dollars in federal spending as part of pandemic relief and to actively manage the country's extremely high rate of infections last year, the government is cracking down on potential fraud, waste, and abuse. That means the HHS Office of Inspector General's (OIG) Work Plan should once again be scrutinized carefully for early warning on federal audit targets. Not only is the OIG looking at its usual billing, coding, and medical necessity targets, the agency has also added several telehealth items to its hit list, as well as audits involving the disbursement of billions of dollars in federal aid to healthcare providers under the Coronavirus Aid, Relief, and Economic Security (CARES) Act.
It seems that with the crisis period of the pandemic apparently passed, program integrity – a charmingly bureaucratic phrase that covers all manner of federal audits and investigations – is once again a top priority for HHS and CMS. Remember that, midway through the Trump administration, the OIG began updating its audit targets, known as the OIG Work Plan, on a monthly rather than annual basis, which makes reviewing the Work Plan a regular task and not just a one-off exercise.
Here's a list of top OIG targets that all auditors, compliance professionals, and practice managers should have on their radar:
- Audit of CARES Act Provider Relief Funds. This refers to the $178 billion in HHS stimulus monies disbursed over three phases to healthcare providers of all sizes, and in many cases without a specific application (under the first phase's "general distribution" scheme). The OIG will be conducting audits to ensure that HHS did its job correctly in calculating payment amounts, as well as ensuring that providers that applied for funds met the specified requirements (submission of revenue information and supporting documentation).
- Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency. You knew this was coming – the OIG will be doing a two-part series of audits of telehealth services billed to Medicare Part B. The first series of audits will look at services including evaluation and management (E/M), opioid use disorder, end-stage renal disease, and psychotherapy, to determine whether telehealth versions of these services met Medicare requirements. The second series of audits will examine virtual check-in services, remote patient monitoring, annual wellness visits, and more.
- Medicare Telehealth Services During the COVID-19 Pandemic. Program Integrity Risks. The explosion of utilization of telehealth services has prompted not one, but two OIG targets. This target involves an OIG review of both traditional Medicare (Part B) as well as Medicare Advantage (Part C) claims data in order to "identify program integrity risks associated with Medicare telehealth services during the pandemic." The OIG will analyze providers' billing of telehealth services to identify any patterns that could indicate fraud or abuse.
- Audits of Medicare Part B Laboratory Services During the COVID-19 Pandemic. The OIG will look at a drop in the billing of non-COVID related lab testing, as well as "aberrant billing" of COVID-19 tests during the pandemic.
- Audit of Medicare Payments for Inpatient Discharges Billed by Hospitals for Beneficiaries Diagnosed With COVID-19. The CARES Act directed HHS to boost weighting for DRGs by 20% for patients with a diagnosis of COVID-19 who are discharged during the federal public health emergency declaration. This cost expenditure to the government is prompting the OIG review, which will look at whether payments for such cases met existing program requirements.
- CMS Oversight of the Two-Midnight Rule for Inpatient Admissions. This target is not related to the pandemic nor particularly relevant to the past year in general but is an ongoing area of review for the OIG since CMS implemented the so-called "Two-Midnight Rule" in 2014. The rule states that hospital stays not expected to last at least two midnights should not be reimbursed under the Inpatient Prospective Payment system. The OIG will audit hospital inpatient claims to see whether any "inpatient claims with short lengths of stay were incorrectly billed as inpatient and should have been billed as outpatient or outpatient with observation." The OIG also says as part of this target that it will again begin auditing short stay claims (it had stopped doing so in October 2013) and recommending overpayment collections where appropriate.
Grant Huang
Grant Huang brings extensive knowledge to his role as Director of Content at DoctorsManagement. He produces educational products that help ensure that auditors, coders, practice managers and administrators optimize their organization's revenue cycle while improving their compliance in today's complex regulatory environment. Grant is an auditor with proficiency in multiple specialties, including but not limited, to orthopedics, cardiology, neurology, general surgery, obstetrics and gynecology, internal medicine and physical and occupational therapy.
