Insights by Engage

Earlier this week, the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the distribution of approximately $9 billion in Provider Relief Fund (PRF) Phase 4 payments, from a pool of $17 billion, to health care providers who have experienced revenue losses and expenses related to the COVID-19 pandemic. (Provider Relief Fund Payments ) Phase 4 funding is being distributed based on expenses and decreased revenues from July 1, 2020, to March 31, 2021. The average payment for small providers is $58,000, for medium providers is $289,000, and for large providers is $1.7 million. HRSA is reimbursing a higher percentage of losses and expenses for smaller providers, who typically care for vulnerable populations and historically operate on smaller financial margins.

In the 34^th Edition of the User’s Guide for Short-Term Acute Care Program for Evaluating Payment Patterns Electronic Report (PEPPER)(ST PEPPER User’s Guide), the Centers for Medicare and Medicaid Services (CMS) has included a new target area – Severe Malnutrition. Also effective with the Q3FY21 release, CMS is discontinuing the Transient Ischemic Attack target area.

There are a couple of powerful auditors looking at fraud, waste, and abuse in the healthcare arena with whom you hope to never have the pleasure of interacting. One is the Health and Human Services (HHS) Office of Inspector General (OIG). It is the largest inspector general’s office in the Federal Government and the majority of their resources and activities are focused upon the Medicare and Medicaid programs. The OIG operates under a Work Plan (OIG Work Plan). The Work Plan, which is updated monthly, advises the public about various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections. Of course, those audits and evaluations could include time consuming activities on the part of providers and suppliers.

The Medicare Program Integrity Manual (MPIM)(Pub. 100-08) is a 15-chapter manual addressing all sorts of behavior by the CMS contractors charged with protecting the Medicare Trust Fund. Chapter 3, entitled “Verifying Potential Errors and Taking Corrective Actions” (MPIM Chapter 3) has set forth the following as one of its goals:

The Centers for Medicare and Medicaid Services (CMS), on November 2, 2021, issued the CY2022 Outpatient Prospective Payment System (OPPS) Final Rule (OPPS Final Rule) which, in part, paused the elimination of the Inpatient Only (IPO) list. In the CY2021 OPPS Final Rule, CMS finalized a plan to eliminate the IPO list; a list of services that CMS deemed so complex that Medicare would only pay for when they were performed in an inpatient setting because of the nature of the procedure, the underlying physical condition of the patient, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged (70 FR 68695). The plan was to fully eliminate the full list over a three (3) year period. The initial elimination for CY2021 had CMS dropping 298 services from the IPO list. There were many comments throughout the rulemaking process as well as post final rule by interested stakeholders concerned that CMS was creating a patient safety concern by eliminating a program which safeguarded many complex services.