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FOX Facts: OIG Audit

News

03/05/2018

FOX’s OIG AUDIT: QUICK FACTS

In October 2015, FOX Rehabilitation received an audit from the OIG. The audit requested 100 cases from 100 individual patient medical records. FOX chose to submit the entire episode of care.
The purpose of the audit was to determine whether FOX claims complied with Medicare requirements and to evaluate the medical necessity of the interventions provided on a patient’s individual date of service.

FOX Vehemently Denies the OIG Audit Findings.

The physician retained to review these claims, who is an expert witness for the Office of Inspector General (OIG) as well as other expert clinical providers, stated, “FOX’s documentation is some of the best clinical documentation I have ever reviewed.”
Expert statisticians call the OIG’s extrapolation formulas and methods “faulty.”
The OIG findings violate a Federal Court Order. (Jimmo v. Sebelius)
After 2.5 years since FOX first received the audit, the OIG has passed the audit over to Centers for Medicare and Medicaid Services (CMS), where FOX is in positive communications with top CMS officials to reach a resolution and dismiss the audit.

The Audit Details

Providers of health care to Medicare Beneficiaries are naturally subject to audits at varying levels of scrutiny from numerous government agencies, rightly so. In October 2015, FOX received an audit from the OIG. The OIG contracts with individual professionals to perform various audits of medical documentation. In our case, two physicians of physical medicine and rehabilitation were the auditors.

OIG’s Faulty Findings

84 of 85 denied claims were based on auditor finding of no improvement.
These 84 findings violate the Jimmo court order.
A number of these also find numerous dates of service to be excessive despite those dates being only the second day of treatment.
The 85 disallowed claims totaled approximately $8,000. The OIG, through their formula, reported the number improperly billed as $29.9 million, through front page headlines.

Jimmo v. Sebelius: A Win for Medicare Beneficiaries Nationwide

In 2013, a constituent group representing older adults with disabilities and chronic conditions sued the U.S. Department of Health and Human Services (Jimmo v. Sebelius). The lawsuit argued that rehabilitation claims could not be denied based on a patient’s lack of improvement (also known as the Improvement Standard), but rather should be paid based on the medical necessity and skill required of the interventions provided—particularly in older adults and those with chronic conditions who demonstrate slower progress towards goals. In the end, the constituent group prevailed, resulting in a federal court order stating that rehabilitation claims should be evaluated for payment based on medical necessity and the required skill of the interventions provided, and not the patient’s improvement potential. This federal court order is now known as Jimmo. The OIG’s reliance on the Improvement Standard as a reason to deny 84 of 85 claims violates the Jimmo federal court order. This unlawful reasoning was used to justify the OIG’s extrapolation which was statistically faulty in and of itself.

FOX’s Philosophical Foundation

FOX specializes in geriatric house calls. Caring for an older adult with chronic conditions takes additional training and skill just as any other specialty in the health professions. This means that we possess skills and training to care for an older adult and the functional difficulties that older adults with chronic conditions present. We provide our interventions in our patient’s residences, where we are able to observe their functional performance first-hand and apply appropriate interventions to match. Prior to FOX making house calls, acutely ill and/or injured older adults living at home could only receive in-home therapy through the traditional models of Home Health via Medicare Part A—very reactive.* FOX provides care under Medicare Part B, similar to an outpatient clinic. We provide in-home services, because it just makes sense—“outpatient on wheels” so to speak. patients now have access to needed care. This model allows us to get involved much sooner—it’s proactive, it’s good healthcare.