The OIG recommended that CMS direct contractors to recover the $34 million; that suppliers refund beneficiaries up to $8.7 million; and that the agency identify and recover any improper payments to suppliers after its audit period.
Full Answer
What is the Office of Inspector General (OIG)?
The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services has created the educational materials to assist in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse.
Why are Medicare overpayments for home health care services so high?
Hospitals improperly coding for post-discharge services contribute to hundreds of millions of dollars in Medicare overpayments. And the majority of incorrect payments are often related to home health services. That’s according to a new audit report from the Department of Health and Human Services (HHS) Office of Inspector General (OIG).
What does the OIG audit mean for Medicare?
The purpose of the OIG audit was to determine if payments met the standards of Medicare’s post-acute care transfer policy. As part of the audit, OIG examined almost 90,000 in-patient claims filed in fiscal years 2016 and 2017, totaling $948 million. Auditors took a sample of 150 claims and found that Medicare only paid three correctly.
Why are there so many Medicare payments that are inaccurate?
And the majority of incorrect payments are often related to home health services. That’s according to a new audit report from the Department of Health and Human Services (HHS) Office of Inspector General (OIG). The purpose of the OIG audit was to determine if payments met the standards of Medicare’s post-acute care transfer policy.
What does the OIG assist with in the healthcare industry?
Since its 1976 establishment, the Office of Inspector General (OIG) has been at the forefront of the Nation's efforts to fight waste, fraud and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Department of Health & Human Services (HHS) programs.
Does the OIG review claims?
We typically do not conduct claims reviews during site visits. However, OIG or a duly authorized representative does have the authority in accordance with the OIG Inspection, Audit, and Review Rights section of the CIA and IA to conduct a claims review at any time during the course of the CIA or IA.
What percentage of Medicare appeals are successful?
For the contracts we reviewed for 2014-16, beneficiaries and providers filed about 607,000 appeals for which denials were fully overturned and 42,000 appeals for which denials were partially overturned at the first level of appeal. This represents a 75 percent success rate (see exhibit 2).
What is an exclusion by the OIG?
OIG has the authority to exclude individuals and entities from Federally funded health care programs for a variety of reasons, including a conviction for Medicare or Medicaid fraud.
What is a Medicare OIG audit?
Under this authority, OIG conducts audits of internal CMS activities, as well as activities performed by CMS grantees and contractors. These audits are intended to provide independent assessments of CMS programs and operations and to help promote economy and efficiency.
What happens when OIG investigation?
Q: What happens when an investigation is complete? A: Generally, when an investigation is complete, OIG will produce a report based upon relevant witness interviews, records, and other evidence. The report will be reviewed within OIG to ensure that it is fact-based, objective, and clear.
Which health insurance company denies the most claims?
In its most recent report from 2013, the association found Medicare most frequently denied claims, at 4.92 percent of the time; followed by Aetna, with a denial rate of 1.5 percent; United Healthcare, 1.18 percent; and Cigna, 0.54 percent.
Can providers appeal denied Medicare claims?
An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can appeal if Medicare or your plan denies: A request for a health care service, supply, item, or drug you think Medicare should cover.
How often do claims get denied?
In 2020, 28 of the 144 reporting issuers had a denial rate of less than 10%, 52 issuers denied between 10% and 19% of in-network claims, 36 issuers denied 20-30%, and 28 issuers denied more than 30% of in-network claims.
What are OIG guidelines?
OIG has developed a series of voluntary compliance program guidance documents directed at various segments of the health care industry, such as hospitals, nursing homes, third-party billers, and durable medical equipment suppliers, to encourage the development and use of internal controls to monitor adherence to ...
What are the 3 statutory goals of an OIG?
OIG provides independent and objective oversight that promotes economy, efficiency, and effectiveness in the programs and operations of HHS.
What is Medicare exclusion?
What is exclusion? o Federal law prohibits Federal health care programs from paying for items or services furnished, ordered, or prescribed by an individual or entity excluded from participation by the U.S. Department of Health and Human Services.
What is OIG in healthcare?
To help healthcare providers such as hospitals and physicians comply with relevant Federal health care laws and regulations, OIG creates compliance resources, which are often tailored to particular providers.
What is the OIG?
The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services has created the educational materials to assist in teaching physicians about the Federal laws designed to protect the Medicare and Medicaid programs and program beneficiaries from fraud, waste, and abuse.
What is OIG compliance?
OIG's compliance documents include special fraud alerts, advisory bulletins, podcasts, videos, brochures, and papers providing guidance on compliance with Federal health care program standards. OIG also issues advisory opinions, which cover the application of the Federal anti-kickback statute and OIG's other fraud and abuse authorities to ...
What does the Inspector General do?
The Inspector General occasionally issues letters to health care providers alerting them to OIG policies and processes; inviting them to engage in our anti-fraud initiatives; and updating them on our ongoing projects to fight fraud, waste, and abuse in Federal health programs.
What is the purpose of the OIG audit?
The purpose of the OIG audit was to determine if payments met the standards of Medicare’s post-acute care transfer policy.
How much was improper coding of discharge?
About $218 million of that amount was related to the improper coding of a discharge directly to home, audit found. “Medicare improperly paid most in-patient claims subject to the transfer policy when beneficiaries resumed home health services within three days of discharge but the hospitals failed to code the in-patient claim as a discharge ...
What is improper coding for post discharge services?
Hospitals improperly coding for post-discharge services contribute to hundreds of millions of dollars in Medicare overpayments. And the majority of incorrect payments are often related to home health services.
Does CMS make efforts to educate health care providers on proper billing?
CMS has also made efforts to educate health care providers on proper billing.
Did CMS disagree with OIG's suggestion?
CMS disagreed with OIG’s suggestion related to reducing the need for clinical judgment.
Does CMS require Medicare contractors to recover overpayments?
In response to OIG recommendations, CMS stated it will require its Medicare contractors to recover the identified overpayments, reprocess the remaining in-patient claims and review a sample of the remaining in-patient claims.