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The Useful 5: Regulatory Roundup for Rev Cycle Leaders

Analysis  |  By Amanda Norris  
   October 06, 2022

HealthLeaders' regulatory round up series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more updates.

The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry.

In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in September, including multiple billing audits.

Here are the five updates you need to know.

A large payer is under scrutiny for not complying with federal regulations, and the payer cites provider coding accuracy as part of the reason.

While revenue cycle staff work diligently to report the most accurate diagnosis codes for their claims, a payer says it can't be expected that all codes received from providers are accurate.

This comment comes from the OIG's review of whether select diagnosis codes that WellCare of Florida submitted to CMS for use in the risk adjustment program complied with federal requirements.

The OIG conducted the audit by sampling 250 unique enrollee-years with high-risk diagnosis codes for which WellCare received higher payments for 2015 through 2016. The OIG found that diagnosis codes for 153 of the 250 enrollee-years did not comply with federal requirements because there was not sufficient support for those codes in the medical records.

The OIG estimated that based on the results of the sample, WellCare received at least $3.5 million in net overpayments in 2015 and 2016.

The OIG recommended that WellCare refund the federal government for the $3.5 million in net overpayments, identify and return similar overpayments, and continue its examination of its policies and procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements.

WellCare disagreed with some of the findings, the audit methodology, and the expectation that it should ensure that 100% of diagnosis codes received from providers and submitted to CMS are accurate.

The OIG revised the number of enrollee-years in error from 156 in the draft report down to 153 in this final report.

The OIG is putting the lens on telehealth billing.

Have your revenue cycle staff check Medicare claims data, review the new program integrity measures for telehealth services, and consider other telehealth-specific risks to avoid compliance issues for these services. Those are three ways that revenue cycle leaders can incorporate guidance from a recent OIG report on telehealth services into billing compliance efforts.

As background, the OIG published a data brief as part of a series of OIG analyses examining the use of telehealth in Medicare and potential program integrity concerns related to telehealth during the pandemic.

This data brief examines provider billing for telehealth services and identifies ways to safeguard Medicare from fraud, waste, and abuse. For the data brief, the OIG focused its analysis on 742,000 providers who billed for telehealth services between March 1, 2020, and February 28, 2021.

The OIG developed seven measures to identify high-risk telehealth billing (such as billing for both telehealth and a facility fee for a majority of visits, billing for both fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services, etc.) and set high thresholds for those measures in an aim to identify providers whose billing poses a high risk to Medicare.

The OIG noted that the specificity of this analysis does not capture all concerning billing related to telehealth in Medicare and said incident-to billing is hard for them to monitor in these types of reviews but can also pose a program integrity risk.

Overall, the OIG identified 1,714 providers whose telehealth billing seems to pose a high risk to Medicare. These providers received a total of $127.7 million in Medicare fee-for-service payments.

The OIG said more than half of the high-risk providers are part of a medical practice where at least one other provider's billing also seemed to pose a high risk to Medicare, suggesting that certain practices are encouraging a certain type of billing among their providers.

The OIG recommends CMS strengthen monitoring and targeted oversight of telehealth services, provide additional education to providers on appropriate billing for telehealth services, improve transparency of incident-to services when clinical staff primarily delivered the telehealth service, identify telehealth companies that bill Medicare, and follow up on providers identified in the report.

CMS concurred with recommendations to follow up with providers identified in the report but did not indicate whether it concurred with any other recommendations.

MSSP saved Medicare around $1.6 billion in 2021, so expect CMS to push more organizations into participating in the program.  

CMS published a press release regarding the Medicare shared savings program (MSSP), which CMS said saved Medicare $1.66 billion in 2021 compared to spending targets.

CMS reiterated its goal to have 100% of people with traditional Medicare participating in an accountable care relationship by 2040. The 2023 physician fee schedule proposed rule also included proposals to promote participation in the MSSP among healthcare providers in rural and underserved communities, which could in turn mean more work for your revenue cycle staff.

Insufficient documentation puts another payer in hot water this month.

The OIG published a review of whether select diagnosis codes that Regence Blue Cross Blue Shield of Oregon submitted to CMS for use in the risk adjustment program complied with federal requirements.

The OIG conducted the audit by sampling 179 unique enrollee-years with high-risk diagnosis codes for which Regence received higher payments for 2015 and 2016. The OIG found that diagnosis codes for 111 of the 179 enrollee-years did not comply with federal requirements because there was not sufficient support for those codes in the medical records. The OIG estimated that based on the results of the sample, Regence received at least $1.8 million in net overpayments in 2015 and 2016.

The OIG recommended that Regence refund the federal government for the $1.8 million in net overpayments, identify and return similar overpayments, and continue its examination of its policies and procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements.

Regence disagreed with the OIG's findings and recommendations, but the OIG maintained that its findings and recommendations were correct.

CMS' lacking system is to blame for almost $1 million in overpayments.

The OIG published a review of whether Part B payments to critical access hospitals (CAH) for professional services and payments made to healthcare practitioners for the same services complied with federal requirements.

The OIG was particularly concerned because prior survey work showed Medicare was paying both CAHs and healthcare practitioners for the same professional services. The OIG found that of the 40,026 claims reviewed, CAHs and healthcare practitioners each submitted an equal number of claims but only one claim for each date of service complied with federal requirements.

As a result, providers were paid $907,438 more than they should have, and beneficiaries had to pay $281,321 more than they should have. The OIG attributed the overpayments to CMS’ lack of claim system edits to prevent and detect duplicate professional services claims for the same date of service, beneficiary, and procedure.

The OIG recommends CMS recover payments from CAHs for which the healthcare practitioners had not reassigned their billing rights to the CAHs and recover the cost-sharing overcharges for Medicare beneficiaries within the 4-year reopening period, recover the payments from healthcare practitioners for the claims for which the practitioners had reassigned their billing rights to the CAHs and recover the beneficiary cost-sharing overcharges within the 4-year reopening period, and develop system edits or alternative means to prevent and detect overpayments for professional service payments.

CMS concurred with all recommendations except the system edits/alternative means to prevent and detect overpayments for these types of services. CMS provided a variety of reasons within the report for not concurring with that recommendation, and the OIG provided suggestions as to how CMS could better monitor this issue.

Amanda Norris is the Revenue Cycle Editor for HealthLeaders.

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