OIG Work Plan FY-2017 - Monitoring Claims for Potential Fraud

  • by Cindy Gallee, JD, RHIA, CHC
  • Jan 25, 2017, 12:14 PM
Monitoring Claims for Fraud-canstockphoto25652629

The Office of Inspector General (OIG) Work Plan for Fiscal Year 2017 provides useful guidance for healthcare providers and payers to monitor their claims for potential fraud and quality of care concerns.  The Work Plan (at https://oig.hhs.gov/reports-and-publications/workplan/) details areas where OIG will focus their review efforts by type of provider.  New review efforts in the areas of Skilled Nursing Facilities (SNF), Hospice, Home Health and Clinical Lab are outlined below. 

Skilled Nursing Facility reimbursement is a new area of review for the OIG.  SNF patient services are classified into resource utilization groups (RUGs) for payment purposes which encompass reporting of activities of daily living scores and therapy minutes.  Accurate documentation of therapy is required to support the RUG and the reimbursement.  OIG will be reviewing documentation to ensure that the therapy services billed were actually provided and that the therapy services were reasonable and necessary for the patient’s care.

There are several new areas of review for Hospice, one in particular being the frequency of on-site nurse visits to Hospice Home Care patients.  Medicare requires a registered nurse to visit the home hospice patient every 14 days to assess the quality of care and services provided and to ensure that the services are meeting the patient’s needs.  Documentation of this visit will be reviewed to ensure hospice patients are getting quality care.

Another new area of review for Hospice will be improper payments, where reimbursement did not meet CMS guidelines.  Medicare reimbursement for hospice is based on a prospective payment system according to level of care.

Home Health Agencies will be a subject of OIG review due in part to a CMS study which showed that the improper payment rate for home health claims in 2014 was 51.4%.  OIG will be focusing on improper payments for patients who were not homebound, and for patients who did not require skilled services.  Bills will be reviewed for compliance with the Home Health Prospective Payment System. 

Clinical Diagnostic Laboratory Tests will be reviewed annually for the top 25 tests by amount of payment for determining whether payment rates were correct.  This review was implemented according to the  Protecting Access to Medicare Act of 2014 which mandates annual review of the most expensive laboratory tests.

Many of these new areas of review concern improper payments and reimbursement errors.  It is essential that payers and providers have access to the latest fee schedules and prospective payment methodologies to adequately determine if claims are paid correctly.  Context4Healthcare’s DecisionPointTM Pricing System is an automated UCR and Medicare fee access system that allows health plans to maintain the plan’s pricing compliance by providing immediate access to the correct fees for the claim’s date of service.   Context currently provides pricing for Physician Fee Schedule, Resource Based Relative Values, Ambulance, Clinical Lab, Durable Medical Equipment, Average Sales Price Drug, End Stage Renal Disease and SNF. 

In addition to their review of proper reimbursement according to these fee schedules, OIG will also be reviewing the top clinical lab tests by payment.  Context’s FWAHawk product includes a library of reports, including a report of the highest charge procedures with provider detail and is an excellent resource for the claims that OIG is required to review annually.

Context4 Healthcare’s4 Healthcare’s FWAHawkTM Fraud, Waste & Abuse Detection Solution provides payers with a complete FWA investigation tool. FWAHawk complements the industry leading pre-payment capability of FirstPass™ with pre-built reports allowing for an analytical review of your claim data. FWAHawk can be a foundation to safeguard the health plan’s assets.

FWAHawk includes a library of reports built around current FWA topics that would help payers identify potential fraud schemes by providing insight and visibility into billing patterns. Each report provides a summary of the findings along with a capability to extract the supporting detailed data for your further analysis. Context updates the library on a regular basis to expand the pre-built scenarios. The library contents include topics such as:

  • Most frequently billed procedures by provider

  • Highest charge procedures with provider detail

  • Most frequent E/M encounters by provider

  • Most frequent procedure for outpatient facilities by provider

  • Highest charge procedure for outpatient facilities by provider


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