Transcript for audio podcast on the following report:
Questionable Billing by Community Mental Health Centers.
From the Office of Inspector General of Department of Health and Human Services
Jaime Durley, Deputy Regional Inspector General, sits down with Latrice Rollins, Program Analyst for the Office of Evaluation and Inspections (OEI) in Atlanta, to discuss the OEI report Questionable Billing by Community Mental Health Centers.
[Jaime Durley] I'm Jaime Durley, the Deputy Regional Inspector General for HHS Region IV. I'm speaking with Latrice Rollins, a program analyst for the Office of Evaluation and Inspections, about a report called Questionable Billing by Community Mental Health Centers. Latrice, can you tell us about Community Mental Health Centers?
[Latrice Rollins] Sure. Medicare covers partial hospitalization programs that community mental health centers, or CMHCs, provide to beneficiaries. These programs are designed for beneficiaries who are at risk of being hospitalized because of their mental disorder. The concept is to provide outpatient services in a community setting, allowing beneficiaries more independence and saving money for Medicare.
During 2010, 206 CMHCs received an estimated 218 million dollars to provide partial hospitalization program services to approximately 25,000 Medicare beneficiaries.
[Jaime Durley] Why did you focus on CMHCs in this report?
[Latrice Rollins] Past OIG studies revealed Medicare payments to CMHCs for beneficiaries who were not eligible for services and for services that were not needed. Also, the Centers for Medicare and Medicaid Services, or CMS, has limited ability to oversee the quality, health, and safety of care provided in CMHCs. That's because these providers don't have "conditions of participation," which other Medicare providers have to help ensure the quality and safety of care. Past OIG studies also found that 60 percent of States don't require these centers to be licensed or certified. This gives dishonest individuals an opportunity to create CMHCs and improperly bill Medicare.
[Jaime Durley] So, what do you look for when you think a CMHC is questionably billing Medicare?
[Latrice Rollins] Our report identified claims that show certain characteristics that may hint at potential fraud, or questionable billing. It's based on nine characteristics that we developed.
One of the characteristics was the length of time that a CMHC billed for a beneficiary. In fact those that billed for more than four months of services. This is questionable because the length of services at a CMHC should resemble a short, inpatient stay, such as a few days. We also looked at how geographic location and State licensure or certification requirements played a part.
[Jaime Durley] Great. So, how did you come up with the characteristics to identify questionable billing?
[Latrice Rollins] We worked closely with our Office of Investigations to learn about on-going cases, indictments, and convictions involving CMHCs. We also had regular meetings with OIG investigators in Miami who work some of these cases. The input from these investigators was crucial in creating the questionable billing characteristics that we used in this study.
[Jaime Durley] Tell us how you did this study and what you found?
[Latrice Rollins] We used 2010 Medicare claims to identify centers that had unusually high levels of billing for at least one of our nine questionable billing characteristics. We looked at the CMHC's geographic location and whether the percentage of centers with questionable billing varied if there were State licensure or certification requirements.
We discovered that approximately half of all CMHCs had questionable billing in 2010. For example, we developed a characteristic that looked at CMHCs with a high percentage of beneficiaries who participated in the program far outside their communities. In fact more than a hundred miles away. One radical example we found was a CMHC, in Florida, that billed for a beneficiary who lived in Hawaii, over 4,000 miles away! Even when you throw out this extreme case, the other 77 beneficiaries at this CMHC lived an average of nearly 550 miles away! About one-third of all these centers had more than one of our nine questionable billing characteristics. Overall, CMHCs with any of these characteristics may be a sign that they're providing Medicare services that are NOT medically reasonable or necessary.
[Jaime Durley] Wow. What else did you find?
[Latrice Rollins] We found that approximately two-thirds of centers with questionable billing were located in eight metropolitan areas in Florida, Texas, and Louisiana. 90 percent of the centers with questionable billing were located in States that do not require CMHCs to be licensed or certified.
[Jaime Durley] So based on these findings, what is the OIG recommending to CMS?
[Latrice Rollins] We recommended four things. First, CMS should increase its monitoring of CMHCs' Medicare billing and fraud prevention controls. Second, enforce the requirement that certifying physicians be listed on a CMHCs' Medicare claim. Third, finalize and implement the proposed conditions of participation for CMHCs. And fourth, review and take appropriate action against those centers with questionable billing that we identified.
[Jaime Durley] And how has CMS responded to this report?
[Latrice Rollins] CMS agreed with all of our recommendations and acknowledged that, historically, CMHCs have been vulnerable to fraud, waste, and abuse. CMS also shared information on its efforts to address vulnerabilities in Medicare payments to CMHCs. Specifically, our questionable billing characteristics will be considered in the development of its pilot project focusing on centers in the high-risk States of Florida, Texas, and Louisiana.
[Jaime Durley] Latrice Rollins, a program analyst for the Office of Evaluation and Inspections, thank you for sharing this important work on questionable billing by community mental health centers.
[Latrice Rollins] Thank you.
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Unimplemented OIG recommendations summarized.
FY 2014 Work Plan
OIG projects planned for 2014.
Significant OIG activities in 6-month increments.