OIG Work Plan for FY 2011 Released
The Office of the Inspector General (OIG) has released its Work Plan for fiscal year (FY) 2011. This document sets forth various projects planned for conducting investigations concerning programs within the Department of Health and Human Services (HHS), including Medicare and Medicaid. In the past, OIG reports have had significant impact on therapy under Medicare.
The Work Plan contains a number of sections with implications for occupational therapy, including sections on outpatient occupational therapy, home health services under Medicare and Medicaid, and medical equipment and supplies. For example, see the excerpts below:
Home Health Agencies’ Claims for Medicare Home Health Resource Groups
We will review Medicare claims submitted by HHAs to determine the extent to which claims meet Medicare coverage requirements. Federal regulations at 42 CFR § 409.42 provide that beneficiaries receiving home health services must (1) be homebound; (2) need intermittent skilled nursing care, physical or speech therapy, or occupational therapy; (3) be under the care of a physician; and (4) be under a plan of care that has been established and periodically
reviewed by a physician. The Social Security Act, § 1895, governs the payment basis and reimbursement for claims submitted by HHAs. On a prospective basis, Medicare reimburses for home health episodes using a system that categorizes beneficiaries into groups that are based on care and resource needs and that are referred to as Home Health Resource Groups
(HHRGs). HHRGs are calculated using beneficiary assessment data collected by an HHA, and each HHRG has an assigned weight that affects the payment rate. We will assess the accuracy of HHRGs submitted for Medicare home health claims in 2008 and identify characteristics of miscoded HHRGs.
(OEI; 01-08-00390; expected issue date: FY 2011; work in progress) [Page I-9]
Outpatient Physical Therapy Services Provided by Independent Therapists
We will review outpatient physical therapy services provided by independent therapists to determine whether they are in compliance with Medicare reimbursement regulations. The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or
injury or to improve the functioning of a malformed body member.” CMS’s Medicare Benefit Policy Manual, Pub. No. 100‐02, ch. 15, § 220.3, contains documentation requirements for therapy services. Previous OIG work has identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly
documented. Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, we will determine whether the services that they billed to Medicare were in accordance with federal requirements.
(OAS; W-00-11-35220; various reviews; expected issue date: FY 2011; new start) [Page I-16]
Questionable Billing for Medicare Outpatient Therapy Services
We will review paid claims data for Medicare outpatient therapy services from 2009 and identify questionable billing patterns. We will identify counties with high utilization and compare utilization in these counties to national averages. We will also determine the extent to which billing characteristics in high-utilization counties, including questionable characteristics that may indicate fraud, differed from billing characteristics nationwide.
(OEI; 04-09-00540; expected issue date: FY 2011; work in progress) [Page I-16]
Medicaid Home Health Agency Claims
We will review home health agency claims to determine whether providers have met applicable criteria to provide services and whether beneficiaries have met eligibility criteria. Federal regulations at 42 CFR § 440.70 and 42 CFR pt. 484 set standards and conditions for HHAs’ participation. Providers must meet criteria, such as minimum number of professional staff, proper licensing and certification, review of service plans of care, and proper
authorization and documentation of provided services. A doctor must determine that the beneficiary needs medical care at home and prepare a plan for that care. The care must include intermittent (not full-time) skilled nursing care and may include physical therapy or speech-language pathology services.
(OAS; W-00-09-31304; W-00-10-31304; W-00-11-31304; various reviews; expected issue date: FY 2011; work in progress) [Page III-3]
Medicaid Payments for Physical, Occupational, and Speech Therapy Services
We will review the extent to which payments for Medicaid physical, occupational, and speech therapy services comply with state standards and limits on coverage. Pursuant to the Social Security Act, § 1905(a), and regulations at 42 CFR § 440.110, states may provide physical, occupational, and speech therapy services to Medicaid beneficiaries. Previous OIG studies
found that some therapy services provided under Medicare were billed incorrectly. Through a review of selected states, we will determine whether Medicaid has similar program integrity issues.
(OEI; 07-10-00370; expected issue date: FY 2011; work in progress) [Page III-13]
Medicaid Medical Equipment
We will review Medicaid payments for medical supplies and equipment to determine whether the equipment and/or supplies billed were properly authorized by physicians, the products were received by the beneficiaries, and the amounts paid were within Medicaid payment guidelines. Federal regulations at 42 CFR pt. 440 and various provisions of CMS’s State
Medicaid Manual provide rules and guidance about necessary medical supplies and equipment for home health services; physical therapy services; occupational therapy services; services for individuals with speech, hearing, and language disorders; and home- or community-based services.
(OAS; W-00-11-31390; various reviews; expected issue date: FY 2011; new start) [Page III-14]
Medicaid School-Based Services
We will review Medicaid services provided in schools to determine whether payments for school-based health services complied with laws and regulations. The Social Security Act, § 1903(c), permits Medicaid payment for medical services provided to children under the Individuals with Disabilities Education Act of 2004 (IDEA) through a child’s plan or family plan. States are permitted to use their Medicaid programs to help pay for certain health care services, such as physical and speech therapy, delivered to children in schools. Schools also may receive Medicaid reimbursement for the costs of administrative activities, such as Medicaid outreach, application assistance, and coordination and monitoring of health services. OMB Circular A-87, Cost Principles for State, Local, and Indian Tribal Governments, permits in certain circumstances the use of substitute systems for allocation of salaries and wages to federal awards to be used in place of activity reports when employees work on multiple activities or cost objectives. Prior OIG reviews of school-based services found significant unallowable payments.
(OAS; W-00-11-31391; various reviews; expected issue date: FY 2011; new start) [Page III-14]
Medicare Qualifications of Orthotists and Prosthetists
We will review the extent to which Medicare claims for orthotics and prosthetics were paid to unqualified practitioners in 2009. We will also assess whether CMS provided guidance to state licensing boards and industry on how to define a “qualified practitioner” of orthotics and prosthetics. Pursuant to the Social Security Act, § 1834(h)(1)(F), “Special Payment Rules for
Certain Prosthetics and Custom-Fabricated Orthotics,” no payment will be made for such items unless provided by a qualified practitioner as defined in the statute. Previous OIG work found that miscoded orthotics represented $33 million in inappropriate Medicare payments in 1998 because the device did not meet the specifications billed, the device was not custom-fabricated, or the part billed was already included in the base code for a larger device.
OIG concluded that the qualifications of orthotic suppliers varied, with noncertified suppliers most likely to provide inappropriate devices and services. We will review the credentials of a sample of providers submitting orthotic and prosthetic claims and determine the extent to which CMS provides oversight of credentialing of orthotists and prosthetists.
(OEI; 07-10-00410; expected issue date: FY 2011; work in progress) [Page I-25]