HHS-OIG has Identified “Partial Hospitalization Program Services” as a New Audit Area of Interest in its 2011 Work Plan

October 1, 2010 by  
Filed under Medicare Audits

(October 1, 2010):  This afternoon, HHS-OIG issued its 2011 Work Plan setting out new and continuing areas of interest where the investigative agency plans to initiate new audit reviews or continue their assessment of other areas of interest.  Depending on the ultimate findings made by HHS-OIG’s Office of Audit Services, there may very well be increased scrutiny in the future by ZPICs and RACs of partial hospitalization billings to the Medicare program.  Specific areas of interest for HHS-OIG’s Office of Audit Services include:

(1) Patient plans of Care, (2) Physician supervision and (3) Certification requirements.

 As the 2011 Work Plan sets out:

“We will review the appropriateness of Medicare payments for partial hospitalization program (PHP) psychiatric services. The Social Security Act, § 1832(a)(2)(J), provides for coverage of PHP services, and conditions for payment are in CMS’s Medicare Claims Processing Manual, Pub. No. 10004, ch. 4, § 260, and at 42 CFR §§ 410.43 and 424.24(e). A PHP is an intensive outpatient program of psychiatric services that hospitals may provide to individuals in lieu of inpatient psychiatric care. The program is to provide individuals who have mental health conditions with an individualized, coordinated, comprehensive, and multidisciplinary treatment involving nurses, psychiatrists, psychologists, and social workers. Medicare spending for PHP services has increased over the years. We will determine whether Medicare payments for PHP psychiatric services in hospital outpatient departments and freestanding community mental health centers met Medicare requirements based on documentation supporting psychiatric services, including patient plans of care, and physician supervision and certification requirements. (OAS; W001135453; various reviews; expected issue date: FY 2011; new start).”

 Once again, it is highly recommended that CMHCs review their documentation and billing practices to better ensure full compliance with applicable regulations. 

Liles Parker attorneys have extensive experience representing Medicare providers in administrative appeals.   Should you have any questions regarding these issues, contact Liles Parker for a free consultation at: 1 (800) 475-1906.

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