CMS and OIG discuss future Stark Law changes, inpatient rehab auditing and education focus

Wednesday, April 17, 2019

Representatives from CMS and the Office of Inspector General (OIG) discussed hot topics and focus areas at the Health Care Compliance Association’s (HCCA) 2019 Compliance Institute in Boston, including the development of interactive documentation checklists, potential changes to Stark Law this year, and methods to address the high rate of coding and documentation errors on inpatient rehabilitation facility (IRF) claims.

CMS may release a Stark Law proposed rule as soon as this summer, Kimberly Brandt, principal deputy administrator for operations at CMS, said during the first general session on April 8. In response to provider feedback, the agency is prioritizing revisions to Stark Law that would better accommodate new value-based care models and alternative payment models. In its current form, the law prohibits physicians from making referrals for certain services, payable by Medicare, to an organization with whom the physician or an immediate family member has a financial relationship. In addition, the law prohibits the organizations from filing claims with Medicare, another payer, or an individual for those services. The law does allow for some exceptions and, even in its current form, allows HHS to create regulatory exceptions. However, value-based and alternative payment models, such as the Bundled Payments for Care Improvement Advanced model, generally hinge on referrals between physicians and other organizations that may have a financial relationship due to the nature of the program. Some stakeholders have raised concerns that Stark Law could hinder these efforts toward payment and care innovation.

Brandt also discussed CMS’ Patients Over Paperwork initiatives and outlined potential future efforts to ensure documentation requirements are effective while reducing administrative burden on providers when possible. The agency will continue to look for opportunities to simplify documentation requirements, and it is investigating tools that will assist providers in completing required documentation. The list of these potential tools includes an interactive documentation checklist and a provider documentation lookup tool that could be integrated into EHRs and would allow providers to look up documentation requirements at the time of service. These documentation lookup services could be extended to public and private payers through the DaVinci Project, a program spearheaded by Health Level Seven International, Brandt said.

Representatives from the OIG emphasized the agency’s increased use of data to identify and address potential fraud, waste, and abuse. During an April 8 session, Greg Demske, chief counsel to the inspector general, and Brian Ritchie, assistant inspector general for audit services, both of the HHS OIG, outlined how the OIG is using the wealth of claims data at its disposal along with data and predictive analytics to pinpoint organizations that are at highest risk and focus resources on them. These high-risk areas and organizations include IRF services. The OIG is preparing a portfolio report on IRF services and will include recommendations to CMS on audits, education, and changes to the IRF payment system.

Editor's note: This article originally appeared in Revenue Cycle Advisor.