Just when you thought the water was safe . . .
Just when you thought the water was safe . . .
Da-dum, da-dum here’s more of ORT
Coming soon to a state near you a bigger, better Operation Restore Trust, along with an added action feature called the Wedge program. If this were a movie, Bruce Willis would star, but since it’s not, you may want to read on.
The Department of Health and Human Services’ Office of Inspector General, saying it has identified almost $188 million owed to the federal government, wants more.
The ORT demonstration began in 1995 with five states, which include more than a third of all Medicare and Medicaid beneficiaries: California, Florida, New York, Texas, and Illinois. ORT brought together teams to target efforts on three high-growth program areas of Medicare and Medicaid: home health agencies, nursing homes, and durable medical equipment suppliers. OIG says the $188 million identified in its investigations represents a return of more than $23 for every $1 spent on the project.
Now OIG is expanding operations into 12 more states: Arizona, Colorado, Georgia, Louisiana, Massachusetts, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, Virginia, and Washington.
Running concurrently with ORT will be the Wedge initiative in the following 14 states, some of which are already ORT target states: Connecticut, Florida, Massachusetts, Minnesota, Illinois, Indiana, Louisiana, Ohio, Oklahoma, Tennessee, Texas, Utah, Virginia, and Wyoming.
To date, the ORT probes have taken two forms:
• In the "California model," surveyors review home health compliance with the Conditions of Participation, and then act to decertify providers they say are out of compliance.
• In the "Texas/Tennessee model," surveys review 15 claims for a two-month period and demand repayment based on projection of the denial percentage of the universe of claims. A provider refusing this "consent settlement" then faces review of 100 claims from a 12-month period and repayment demands based on projection of the denial rate for the whole year.
Experts like Ann B. Howard, executive director of the American Federation of Home Health Agencies in Silver Spring, MD, say indications are "the expanded ORT program will be integrated into the standard survey process, along the lines of the California experience, while the Wedge initiative will be based on the Texas/Tennessee model."
Total HHS spending for anti-fraud, waste, and abuse efforts in Medicare and Medicaid is $599 million in FY 1997, up from $452 million five years earlier.
So far, 74 criminal convictions and 58 civil actions are attributable to ORT. In addition, 218 fraudulent health care providers have been excluded from Medicare and Medicaid. Another 210 cases stemming from the two-year ORT demonstration are being investigated.
During the next two years, the ORT expansion will include new geographic areas of concentration, as well as several new specific anti-fraud and abuse targets. "In each of these states, [investigators] will make decisions as to what they think are the important areas to focus on," says Judy Berek, HCFA’s senior adviser to the administrator for program integrity.
In addition, HHS Secretary Donna Shalala has announced that the HHS-TIPS hotline is being improved, and that HHS agencies are working with other organizations, including the American Association of Retired Persons, to make the hotline better-known and more user-friendly.
Under ORT, a hotline was established (1-800-HHS-TIPS) for the public to directly report problems that might indicate fraud, abuse, or waste. Since the hotline was activated in June 1995, it has received over 13,000 complaints related to HHS programs.
Other new approaches that have been demonstrated under the ORT initiative include:
• use of sophisticated statistical methods to identify providers for investigations and audit;
• use of interdisciplinary teams to review individual facilities with unusually high Medicare reimbursement rates (reviewers look both for facility-specific evidence and for indications of systemic problems);
• increased emphasis on concerted planning and conducting of investigations with the Department of Justice and other law enforcement agencies;
• training and empowering state and local aging organizations and ombudsmen to detect and report fraud in nursing homes and in other settings;
• use of state survey officials who regularly monitor care in home health agencies and nursing homes to help identify inappropriate and fraudulent billing.
(Editor’s note: For more information about ORT, try the HHS Web site: http://www.sba.gov/ignet/ internal/hhs/hhs.html.)
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.