LW Consulting, Inc. (LWCI) serves as an Independent Review Organization (IRO) for providers and other organizations with reporting obligations under a Corporate Integrity Agreement (CIA). I currently serve as LWCI’s Engagement Director for six of these arrangements, other LWCI Directors manage about 10 others and we also have our happy graduates—yes, it does come to an end.
Most typically, we start with a review of how “Federally Paid Health Care Program” is defined in the CIA. Often, the definition is addressed in the negotiation process preceding settlement. However, CIAs generally offer a pathway to address the scope each year, prior to the end of the reporting period.
Often, we are called upon by our provider clients, to work with them, to craft annual proposals that can be submitted to the Office of Inspector General (OIG) Monitor to narrow the universe of paid claims for audit. We work with our clients in conducting analyses to determine if a limitation of payors or subsets of claims will be part of a proposal to the OIG.
Clients seek these limitations for a variety of reasons, including simplification of a complex process; decrease costs measured in both time and resources; and the education value to increase the applicability of the findings to a wider population. Limitations help to leverage the value of the resources expended to further the culture compliance in the organization.
Payor limitation is often a central theme. Whether or not the term “Federally Paid Health Care Program” is defined in the CIA, there is typically an annual opportunity for the provider and their IRO to make recommendations to limit the population by making a request in writing to the OIG Monitor. We work with our clients to gather and analyze operational factors, including payor-mix, in substantiating recommendations.
Provisions for making these recommendations are time-bound and can be found in Appendix B, "Claims Review," in the "Population" section under “Definitions” in the CIA pertaining to your agreement. The recommendations must be made at least 90 days prior to the end of the reporting period. Please note, while 90 days prior is often stipulated as the last date to provide recommendations, many monitors appreciate receiving the recommendations sooner than that.
In my experience with CIAs, I have seen a wide variation in the definition Federally Paid Health Care Program for the purposes of the claims audit. As a tip, the specific Federal programs are typically defined in the overall agreement in the "Claims Review" section in the "Terms and Scope of the CIA" and is often reiterated in Appendix A— typically titled "Independent Review Organization" under the "IRO Responsibilities" section as well as in Appendix B - typically titled "Claims Review" in the "Claims Review" section under definitions. Those sections can be used for clarification and can help provide the most narrow definition.
If it is not defined in any of those places, you are left with the broad interpretation which we have interpreted as all the Medicare and Medicaid payors including Medicare Advantage, Railroad etc. We have some engagements for which we audit all of those payors using each payor's payment rules. When multi-State Medicaid claims are involved, this must be very carefully managed - being sure to have the right National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). from the correct time period, as well as any additional guidance provided by different Medicare Administrative Contractors (MACs). I have seen CIAs, which detail in writing, that State Medicaid Rules must be used as the standard for State Medicaid claims (national scope). Even in the absence of this type of detail, I do not think that using a short cut of applying Medicare Fee-for-Service (FFS) requirements to all Federal Claims is appropriate—unless specified in writing and agreed to by the OIG Monitor.
For example, consider a scenario of a provider that operates in multiple states. The CIA stipulates “Federal Payors” without further definition. The hypothetical payor mix is 45% Medicare FFS; 20% Medicare Advantage; 4% Medicaid; 1% Tricare and the 25% balance of Commercial/Self-Pay and Other. In this scenario, assume no other Federal Payors. The provider may want to propose to limit the universe for audit to Medicare FFS only. LWCI has had much success in limiting Federal Payors using this process and providing underlying analytics and rationale. We have had success even when the term "Federal Payors" is more narrowly defined in the CIA. We also analyze clinical and operational characteristics that may lead to well-founded proposals for other limitations in the claims’ population.
For more information about LW Consulting's IRO services, call Harriett Wall at 207-613-2992 or email email@example.com.
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