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The Health and Human Services Office of Inspector General is using the weight of a dozen audits to prod a major HHS component into action At issue are overpayments made to hospitals by the Centers for Medicare and Medicaid Services (CMS). The IG has done repeated audits of that payment process and found some problems, but isn’t quite convinced it’s getting through to CMS.  The Federal Drive with Tom Temin got the details  from the Assistant Regional Inspector General Truman Mayfield.

Interview transcript:

TomTemin: And in the course of these 12 audits of hospital payments, who found 377 overpayments or payments for things that were miscoded by those hospitals? That 377 I’m presuming is out of maybe hundreds of 1000s or millions of individual payments, what was this a sample of? And do you feel that the sample was representative of? A problem that’s more widespread?

Truman Mayfield: Sure. I’ll give a little bit of background on this audit itself. This audit is a roll up of 12 previous audits. And in those 12 previous audits, we were looking at individual hospitals, the OIG has done audits of individual hospitals for a number of years, we go out and we looked at claims that are at high risk, we select a sample frame of the paid claims for those individual hospitals. And we pull a statistically valid sample from that frame. And this is not all Medicare payments to the hospitals. It’s some selected specific claims that we think are at high risk of improper payment. And then we go out, we look at those, we pull those claims, we look at the hospital’s operations, we give those claims to professional medical reviewers and make a determination on whether those claims were appropriately billed to the Medicare program. And the results for the individual audits are given back to those hospitals. And we tell them,’ hey, repay the amount to the Medicare trust fund that you’ve been overpaid’. And then we notify CMS of the findings in those individual audits. And we call CMS the action official. They’re the funding agency through Medicare for each of those individual hospitals. So it’s really incumbent on CMS to ensure that the recommendations we’ve issued to the individual hospitals are acted upon and implemented. And this audit report right here, as you said in your intro, is a roll up of 12 of those previous audits. Now, we’ve done a lot more than that, but we just picked 12 of the more recent ones that we’ve done. And this particular audit is looking at CMS rather than at the hospital specifically to see if CMS was following up and making sure the action was taken.

Tom Temin: So this is somewhere between a tap on the shoulder and a club to the back of the head to get their attention.

Truman Mayfield: We would call it communication.

Tom Temin: And just one more technical question. Do you have a sense of the cause of the overpayments? And the reason I ask is, I mean, there’s Medicare fraud that happens. But it sounds like this is mistaken coding, or some problem that is less than outright dishonesty. But there’s something in the system that’s causing these glitches?

Truman Mayfield: Correct. Yeah. And none of these underlying 12 audits could we allege any fraud at all. The OIG does look at fraud, waste, and abuse. But we’re the audit arm of that. So we’re looking at either waste or abuse, it could be mostly claims that were mis-coded for one reason or another. I mean, you can get to the fundamental basis of any claim that’s filed with Medicare, it’s the responsibility of hospital to ensure that whatever they put on that claim is supported in the medical record, you know, when they bill us for something, they need to be able to support what that claim is saying. And some types of claims are more vulnerable. They’re more complicated. They’re more vulnerable to improper payments than others.

Tom Temin: Right, because just to make an analogy, many years ago, I spoke to someone from the IRS that said, if we find that a substantial portion of people are making the same mistake on a form, it’s not them, maybe it’s a bad form. So it could be something that CMS needs to clarify. So the hospitals are clear, possibly.

Truman Mayfield: That’s a very good analogy. Yes, that works well here.

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Tom Temin: All right. And so in this particular audit, as you said, you were looking at CMS, and what did you find that they haven’t maybe quite been taking your prior advice from the first 12 audits to heart?

Truman Mayfield: Well, the first 12 audit for each of those hospitals, they generally would contain three recommendations. One is that the hospital repay money to the federal government for overpayments. The second would be that they look at other claims that are similar to the ones that we audited and do a self-audit and basically determine whether overpayments existed and then repay that additional money. And third is that they improve their internal controls to make sure that those improper payments didn’t happen again. And so each of the underlying 12 audits would have had those three recommendations and we went to CMS. And we said,’ Okay, where do you stand in following up on that?’ Now for the recovery recommendations where we’re actually telling the hospitals to repay funds, CMS has done a pretty good job. They’ve recovered approximately 91% of the amount of overpayments that they’ve agreed with us were overpayments. So we’d say that as a positive with respect to the recommendation that the hospitals do the self-audit, and then report that amount. We think there’s room for better communication between us and CMS, and possibly between CMS and the hospitals. And there’s an underlying cause for that, if you want to get into the details, but all these hospitals have appeals rights. And so they may not respond immediately to these recommendations and implement them. And the OIG doesn’t want to get in the middle of the appeals process, you know, we want to make sure the hospitals have every right they’ve got to go all the way through the system. So some of these repayments don’t happen immediately. But we want to make sure CMS was aware that we’re still tracking these recommendations. And we want to make sure that they’re tracking them through the appeals process, and they don’t get lost in the shuffle of time.

Tom Temin: We’re speaking with Truman Mayfield, assistant regional inspector general at Health and Human Services. And just to be clear, the second two recommendations to look at similar claims to make sure those are okay. And to improve internal controls, those are recommendations to the payees to the hospitals, correct?  So you want CMS to make sure that they follow up that the hospitals have done that?

Truman Mayfield: Right. Ultimately, our findings are really just recommendations, CMS is the people that hold the money. They’re the ones that are the action officials, they’re the ones that have to enforce it. They always have the opportunity to say, ‘you know, IG, you got it wrong’ and disagree with our findings. In these 12 audit reports, they agreed that with what we were finding, so now it’s just a matter of taking action and communicating that action back to us so that we can improve our audit product. To be honest, we want to know which claims are going into appeals and  where they stand on a more detailed level and what we’re getting from CMS at this point.

Tom Temin: And just while we’re at it give us a sense of the numbers involved here. How much were the total payments and how much in those 12 audits were improper that you identified just in dollar volumes?

Truman Mayfield: So total in overpayments that we found in these underlying estimated overpayments and these 12 audits was approximately $85.5 million.

Tom Temin: Yeah, so it’s not nothing.

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Truman Mayfield: Yeah. Now, I’ll have to say in the CMS world, you talk some really big dollars really quick.

Tom Temin: So yeah, a trillion or so in a given year for one of the programs? And what about the nature of the claims, were they particularly complex types of medical situations?

Truman Mayfield: They sort of span the whole gamut, one of the types of claims that we audit is really extremely complex. These are people that are in the hospital for a long period of time. And so there’s a lot that the providers have to get right to get those claims, they’re big dollar claims, frequently over $100,000 each. Some of the other types of claims that we look at is what we call it is upcoding, but it’s where a patient goes into a hospital for one type of illness, and the hospital really bills for something that’s more complex than what the patient really was showing. And that’s been a standard so that you look to see if it’s supported in the medical records. And if it’s not, no, that hospital should have been paid the lower amount and not the higher amount. And the other fairly common one that we look at is if a patient is in a hospital, and then they get released from the hospital, but instead of just going home, they’re going to another facility to get treatment, you know, like a skilled nursing facility or they’re getting home health treatment, there is supposed to be edits in the system that reduce the payment to the original discharging hospital. So because CMS don’t wanna pay twice, to make the same patient better for the same illness, so there’s coordination between the different provider types, and that’s dependent on making sure that the hospital codes these claims correctly, if they coded incorrectly, there’s a couple of things that can go wrong. There are supposed to be edits in the system that will catch some of this, but really, the hospital should be getting it right to begin with.

Tom Temin: Yeah, sounds like coding is a skill in and of itself for a hospital.

Truman Mayfield: It is. And some of the hospitals we go to frequently when they’re saying how they’ve improved and their internal controls, they’ll say that they have provided education to their coding staff, because that’s where the medical world hits the billing world. And that’s where errors can occur. So a lot of  it is teaching their people to document better so the coders themselves know what to do.

Tom Temin: Yeah, don’t code a tonsillectomy as a quintuple bypass because there’s a lot of financial applications there. And you mentioned also the issue of communication between CMS and the hospitals that you wanted to talk more about.

Truman Mayfield: That’s actually, I guess, if there was a takeaway for this particular audit, it’s that we want CMS to provide us more details. I keep using the phrase CMS for talking about the Medicare program. And CMS is not just this one building somewhere. It is a complex organization that involves numerous contractors spread throughout the country. And some of this information the individual contractors have, but it’s sort of siloed and we have an ongoing process on all of our audits where OIG and CMS, we share information back and forth. But we want more detail. We want that granular detail. So that number one, we can decide if these claims, if they’re not really being supported, or if there’s something that’s changed, we might want to move on and look at a different type of high risk claim. We’ve got limited audit resources. So we’re using this to improve our own work product as well as any oversight of the Medicare program.

Tom Temin: Right. So your philosophy or approach then is to find those claims that could give a lot of leverage, because they’re indicators of larger problems, you have to identify those. And then the issue becomes the data across the silos to get at the scope of the problem. So you expect CMS this time maybe to take a little bit more active role in getting after the ones from the previous 12 audits?

Truman Mayfield: That that’s what we’re expecting. And each year, OIG issued a number of different audits to CMS, and some of those are on big nationwide issues. Some of them were recommending that CMS implement edits in their nationwide processing system for claims, some of them were recommending that CMS may either issue new regulations or get a legislative change. In the event of one hospital, if we send in one audit that has a hospital that got some billing wrong, CMS may not know well,’ is this just a situation with that one hospital or is this a systemic problem with Medicare as a whole?’, but then we do another audit, we send them another hospital and then we do another audit, and we send them another hospital. And you know, eventually someone should be aggregating these results. The numbers add up pretty quickly. So we think CMS, someone should be aggregating these numbers and using that to improve Medicare oversight.

Tom Temin: Truman Mayfield is assistant regional inspector general at the Health and Human Services Department.

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