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Resources for Your Hospital Compliance Plan

Published on 

Friday, October 23, 2015

 | CERT 
 | OIG 

This week we introduce a new area of focus for our weekly Wednesday@One newsletter – Hospital Compliance. Most of what Medical Management Plus already does relates to compliance because we are all about Medicare’s rules and regulations, but a more intense focus on Compliance never hurts. The newsletter this week includes articles on Compliance 101 and hospital issues addressed in Medicare’s Quarterly Compliance Newsletter. One of the challenges of Hospital Compliance is deciding where to direct your efforts, as there are many issues to consider. One suggestion is to follow the leader - follow the lead of Medicare contractors and entities that pursue improper payments, fraud, waste, and abuse within the Medicare program.

Medicare Administrative Contractors (MACs) – In addition to processing Medicare claims, MACs perform medical reviews, provide education to providers, and establish coverage requirements. Being familiar with their medical review topics, LCDs, and education offerings will help lead you to what the MACs think are “risk” areas. MMP publishes new medical review announcements and findings from all the MACs in the Wednesday@One newsletter on the third week of the month. Recent review topics for MACs include:

  • Laboratory BNP Test (Cahaba)
  • High-cost drugs (Palmetto, Noridian JE)
  • Pulmonary Rehab (Palmetto)
  • Kwashiorkor (Novitas)
  • Joint Replacements (Cigna)
  • Facet Joint Injections (Noridian JF)

Supplemental Medical Review Contractor (SMRC) – Strategic Health Solutions is the SMRC and performs “tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.” One of their main tasks is to perform nationwide medical reviews as directed by CMS. You may want to consider their topics as your topics for addressing risks. Their website includes a list of their current projects and their completed projects. Current projects include the following topics:

  • Electrodiagnostic testing
  • Intensity Modulated Radiation Therapy (IMRT)
  • Bariatric Surgery
  • Blepharoplasty Services

Comprehensive Error Rate Testing (CERT) – CMS uses the CERT program to calculate the Medicare Fee-for-Service improper payment rate. CERT publishes an annual report that can be found on the CERT website.  The major errors identify by CERT reviews include:

  • Lack of or insufficient documentation to support services
  • Incorrect patient status
  • Failure to meet medical necessity
  • Coding errors

Program for Evaluating Payment Patterns Electronic Report (PEPPER) – A link from the CERT website labeled as “Hospital Specific Improper Payments Information and Training Resources” connects readers directly to the PEPPER Resources website. PEPPER can help guide a hospital’s auditing and monitoring activities by comparing your hospital’s statistics for discharges and services vulnerable to improper payments to the statistics of other hospitals in your state, MAC jurisdiction and nationally. This helps you identify where your hospital is an outlier. Some of the current PEPPER targets are:

  • Stroke Intracranial Hemorrhage
  • Septicemia
  • Medical/Surgical DRGs with CC or MCC
  • Excisional Debridement
  • Chronic Obstructive Pulmonary Disease
  • Syncope
  • Thirty Day Readmissions
  • One-Day and Two-Day Stays

Office of Inspector General (OIG) – The OIG protects the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. They publish an annual Work Plan that describes their target areas for the coming year and then perform audits throughout the year of the risk areas identified in the Work Plan. Compliance departments can use the Work Plan and the audit findings to select areas at risk of fraud, waste, and abuse within healthcare. Some of the topics addressed in the OIG 2015 Work Plan Mid-Year Update include:

  • Outlier payments
  • Provider-based status
  • Mechanical ventilation
  • Compliance reviews of Medicare billing requirements
  • Dental claims
  • Hospital wage data
  • Kwashiorkor
  • Intensity modulated radiation therapy (IMRT)

Recovery Auditors (RAs or RACs) – The mission of the Recovery Audit program is to identify and correct Medicare improper payments. Each RAC has their own website that list the issues they are reviewing to identify Medicare overpayments and underpayments. This is another great source for hot topics for your hospital compliance program. Although the RAC program has had to step back some lately, CMS recently released the report to Congress of the 2014 RAC activity which reported $2.39 billion of overpayments were collected, and $173.1 million of underpayments repaid to providers. For updates on the RA program, see the Medicare Recovery Audit Program webpage. We are still awaiting the Recovery Audit program to move forward to the next Scope of Work, but until then the current RACs have begun to post some new issues for review. For hospitals, these include:

  • Cardiac PET Scan (Cotiviti, formerly Connolly)
  • Sacral Nerve Stimulation for Urinary and Fecal Incontinence (Performant)
  • Rambizumab (Performant)
  • Cataract Surgery Once in a Lifetime (Performant)
  • Bariatric Surgery (Performant)
  • MS-DRG Validation: Cardiac Defibrillator Implantation (Performant)
  • MS-DRG Validation: Permanent Cardiac Pacemaker Implant (Performant)
  • Back and Neck Procedure except Spinal Fusion (CGI Federal)

Following Medicare’s lead is an easy way to begin to put together your hospital compliance plan. It gets harder, of course, as you consider what risk areas may be specific to your facility, but at least it is a place to start.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.