First Coast Service Options, Inc., Paid Providers for Hyperbaric Oxygen Therapy Services That Did Not Comply with Medicare Requirements

Department of Health and Human Services OFFICE OF INSPECTOR GENERAL FIRST COAST SERVICE OPTIONS, INC., PAID PROVIDERS FOR HYPERBARIC OXYGEN THERAPY SERVICES THAT DID NOT COMPLY WITH MEDICARE REQUIREMENTS Inquiries about this report may be addressed to the Office of Public Affairs at [email protected]. Gloria L. Jarmon Deputy Inspector General for Audit Services December 2018 A-04-16-06196 Office of Inspector General https://oig.hhs.gov The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components: Office of Audit Services The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. Office of Evaluation and Inspections The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations. Office of Investigations The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. Office of Counsel to the Inspector General The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement authorities. Notices THIS REPORT IS AVAILABLE TO THE PUBLIC at https://oig.hhs.gov Section 8M of the Inspector General Act, 5 U.S.C. App., requires that OIG post its publicly available reports on the OIG website. OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS The designation of financial or management practices as questionable, a recommendation for the disallowance of costs incurred or claimed, and any other conclusions and recommendations in this report represent the findings and opinions of OAS. Authorized officials of the HHS operating divisions will make final determination on these matters. - Report in Brief U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES \ \_,, ,,/ 1 Date: December 2018 OFFICE OF INSPECTOR GENERAL \:., ·•~~ Report No. A-04-16-06196 \ V t First Coast Service Options, Inc., Paid Providers for Why OIG Did This Review Hyperbaric oxygen therapy (HBO Hyperbaric Oxygen Therapy Services That Did Not therapy) involves giving a patient high Comply With Medicare Requirements concentrations of oxygen within a pressurized chamber in which the patient intermittently breathes in What OIG Found 100-percent oxygen. A prior Office of First Coast paid 48 providers for HBO therapy services that did not comply Inspector General review identified with Medicare requirements. Of the 120 sampled outpatient claims totaling issues with Medicare payments for $415,513, First Coast made payments for HBO therapy in accordance with HBO therapy. More recently, a review Medicare requirements for 5 claims. However, First Coast made payments by a Centers for Medicare & Medicaid for HBO therapy services that did not comply with Medicare requirements for Services (CMS) contractor found that 110 claims, resulting in overpayments totaling $351,970. We treated five claims for HBO therapy services were claims as non-errors because one was canceled and the Recovery Audit denied because of a lack of medical Contractor indicated that the other four were under review by another entity. documentation. From 2015 through 2018, CMS conducted a prior First Coast made payments for HBO therapy that did not always comply with authorization demonstration program Medicare requirements because it had limited policies and procedures in for non-emergent HBO therapy to test place to ensure that it made correct payments. During the audit period, First its effectiveness. Coast did not have effective automated Medicare Part A prepayment edits in its claim processing system to monitor HBO therapy coverage. Based on our For this review, we focused on one sample results, we estimate that First Coast overpaid providers in Jurisdiction Medicare administrative contractor, N $39.7 million during the audit period for HBO therapy that did not comply First Coast Service Options, Inc. (First with Medicare requirements. Coast), because it paid the second largest amount for HBO outpatient What OIG Recommends and First Coast Comments therapy services in 2013 and 2014. We made the following recommendations to First Coast: (1) recover the appropriate portion of the $351,970 in Medicare overpayments; (2) notify the Our objective was to determine providers responsible for the 46,737 nonsampled claims with potential whether First Coast paid providers for overpayments estimated at $39.3 million so that those providers can HBO therapy services that complied investigate and return any identified overpayments; (3) identify and recover with Medicare requirements. any improper payments for HBO therapy services made after the audit period, and (4) work with CMS to the extent possible in developing more effective How OIG Did This Review automated HBO therapy prepayment edits in the claim processing system, Our review covered 46,857 outpatient which would result in millions of dollars in future cost savings. claims totaling $44.3 million for CMS Jurisdiction N that contained HBO First Coast concurred with three of our recommendations and partially therapy services provided to Medicare concurred with the fourth. In addition, First Coast questioned language in our beneficiaries during calendar years draft report stating that First Coast did not have automated Medicare Part A 2012 through 2015. We selected for prepayment edits in its claims processing system to monitor HBO therapy. review a statistical sample of 120 of We revised our report language to say that Medicare Part A these claims, submitted by 48 prepayment edits were active in First Coast’s claims processing system providers. but those edits were not effective in the prevention of improper payments for HBO therapies. The full report can be found at https://oig.hhs.gov/oas/reports/region4/41606196.asp. TABLE OF CONTENTS INTRODUCTION......................................................................................................................1 Why We Did This Review. ..........................................................................................1 Objective ....................................................................................................................2 Background ................................................................................................................2 Hyperbaric Oxygen Therapy ..........................................................................2 Medicare Coverage of Hyperbaric Oxygen Therapy......................................3 Medicare Requirements for Outpatient Claims and Payments.....................4 First Coast Service Options, Inc......................................................................4 How We Conducted This Review...............................................................................4 FINDINGS................................................................................................................................5 Payments for Hyperbaric Oxygen Therapy That Was Not Medically Necessary.......5 Causes of Improper Payments for Hyperbaric Oxygen Therapy ...............................7 RECOMMENDATIONS ............................................................................................................7 FIRST COAST COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE.......................8 Recommendations to Return Overpayments Received During Our Audit Period ...8 Recommendation to Identify and Return Overpayments Received After Our Audit Period ........................................................................................................................8

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