The Useful 5: Regulatory Roundup for Rev Cycle Leaders

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 March, including public health emergency (PHE) updates and OIG audits.

The OIG says the inability to identify denied claims in Medicare Advantage hinders its fraud oversight.

On March 2, the OIG published an issue brief regarding an evaluation into Medicare Advantage data and whether the lack of an indicator to identify payment denials in the data hinders efforts to combat fraud, waste, and abuse. CMS requires Medicare fee-for-service and Medicaid records for services to include denied claim indicators. 

Medicare Advantage organizations (MAO) do not require indicators to identify a denied claim in MA encounter data, but MAOs are required to submit claim adjustment reason codes when MAOs do not pay the actual amount billed by the provider. The OIG reviewed 2019 MA encounter records to determine how many contained adjustment codes and whether they identified records that may contain payment denials. The OIG also interviewed and sent out questionnaires to involved parties about how they identify payment denials, how the lack of a denied claim indicator could impact audits and oversight work, and to determine why CMS does not require MAOs to submit this indicator. 

The OIG found that the adjustment codes were used on almost all encounter records, but it was not possible to definitively determine which claims were denied using these adjustment codes. Oversight entities who spoke with the OIG said the denied claim indicator would make their efforts much easier and less burdensome. The CMS MA payment group said the indicator is not necessary and raised concerns about the potential burden on MAOs of requiring a denied claim indicator on encounter records.

The OIG noted, however, that the private companies which cover most MA enrollees are also involved in Medicaid managed care plans and therefore already have the ability to use denied claim indicators since they are required for Medicaid managed care plans. The OIG therefore recommends CMS require MAOs to definitively indicate on MA encounter data records when they have denied payment for a service on a claim.

There was an April 2023 update of the hospital outpatient prospective payment system (OPPS).

On March 10, CMS published a transmittal regarding the April updates to the OPPS. Updates include 23 proprietary laboratory analyses coding changes, a slew of updates to COVID-19 vaccine codes, updated language in the manual pertaining to various modifiers, and more.  

The OIG released a COVID-19 PHE flexibilities end date.

On March 10, the OIG published a post regarding the end of its COVID-19 PHE flexibilities when the PHE ends on May 11.

The OIG outlined which flexibilities it put in place, what those flexibilities allowed, and when those will end. The flexibilities include refraining from subjecting providers to administrative sanctions for reducing or waiving cost-sharing obligations for telehealth services, exercising certain enforcement discretions in order not to impose administrative sanctions for certain remuneration related to COVID-19 that was covered under blanket waivers, and more.

Medicare improperly paid physicians for spinal facet-joint interventions, the OIG says.

The OIG published a review of whether Medicare paid physicians for spinal facet-joint interventions in accordance with Medicare requirements.

The OIG had previously found that Medicare improperly paid for these services, and it noted that facet-joint interventions are at risk for overutilization. This audit was conducted as a follow-up to previous audits, and it examined interventions from August 1 through October 31, 2021.

The OIG found that Medicare did not pay physicians for selected facet-joint intervention sessions in accordance with Medicare requirements, as 66 of the 120 sampled sessions did not comply with at least one–if not more–of the requirements.

Of the 120 sampled sessions, the OIG also found that 43 had claim lines that were billed for at least one therapeutic facet-joint injection, and 33 of those sessions should have been billed for diagnostic instead of therapeutic injections. This did not result in improper payments because the payments for therapeutic injections are the same as the payment for diagnostic injections. However, the 66 sampled facet-joint intervention sessions deemed to be paid in error totaled $18,084 in improper payments. 

The OIG recommends CMS direct the MACs to recover the $18,084 in improper payments. The OIG also recommends CMS develop collaborative training programs to be used for all MAC jurisdictions and develop solutions to prevent the incorrect billing of diagnostic facet-joint injections as therapeutic facet-joint injections. CMS concurred with the OIG’s recommendations.

There was a Medicare Advantage compliance audit of Geisinger Health Plan, and it could cost Geisinger half a million dollars.

On March 20, the OIG published a review of whether select diagnosis codes that Geisinger Health Plan submitted to CMS for use in the risk adjustment program complied with federal requirements.

The OIG conducted the audit by sampling 270 unique enrollee-years across nine groups of high-risk diagnosis codes for which Geisinger received higher payments for 2016 and 2017. The OIG found that diagnosis codes for 224 of the 270 enrollee-years did not comply with federal requirements because there was not sufficient support for those codes in the medical records or Geisinger could not find the medical records to support the diagnosis codes. The OIG found that based on the results of the sample, Geisinger received at least $566,476 in net overpayments in 2016 and 2017.

The OIG recommended that Geisinger refund the federal government for the $566,476 in overpayments, identify and return similar overpayments, and examine its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes at high risk for being miscoded comply with federal requirements. Geisinger disagreed with all of the findings and recommendations in the report, but the OIG stood by its findings.