Takeaways From AHLA’s Institute on Medicare and Medicaid Payment Issues

AGG Healthcare attorneys Lanchi Bombalier and Charmaine Mech recently attended the American Health Law Association (AHLA)’s Institute on Medicare and Medicaid Payment Issues in Baltimore, Maryland, from March 23-25, 2022. The Institute included speakers from various government agencies including the Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), the Office of General Counsel (OGC), and the Department of Justice (DOJ) and, thus, provided valuable insights on the government’s regulatory and enforcement efforts and current objectives.

Some of AGG’s key takeaways from the programming included:

  • The OIG’s audit and enforcement activity priorities include COVID-19 provider relief funds and nursing homes
    • The new Inspector General, Christi A. Grimm, who was confirmed in February 2022, has announced that one of her primary objectives is to prevent, detect, and take swift action against COVID-19 fraud schemes and protect nursing home residents. The OIG is particularly concerned with schemes arising from or related to the Provider Relief Fund, the Uninsured Fund, and other COVID-related HHS program funding.
    • The OIG’s heightened focus on fraud related to COVID-19 and skilled nursing facilities was recently echoed in the Inspector General’s 2022 Health Care Compliance Association’s Compliance Institute keynote speech on March 29, 2022. In that speech, the Inspector General stated, “We want to raise the bar for nursing homes and nursing home oversight.”
  • Industry experts speculate possible telehealth expansion post-pandemic but also caution providers to continue to expect audit and enforcement activity
    • Given the widespread popularity and use of Medicare’s telehealth waivers during the COVID-19 public health emergency, many industry experts anticipate CMS could look to expand telehealth services post-pandemic. However, changes to the federal Medicare waivers related to telehealth may still raise issues as to who can provide telehealth services based on varying states’ positions regarding practitioner licensure requirements.
    • However, telehealth fraud has been a hotspot for audit and enforcement activity.
  • An update on the Medicare Claim Appeals process, including the status of the Administrative Law Judge hearing backlog, which is on track for elimination by FY 2022
    • Chief Administrative Law Judge (ALJ), McArthur Allen, reported that the Office of Medicare Hearings and Appeals (OMHA) has about 60,000 appeals pending as of September 30, 2021. However, as FY adjudication capacity is estimated to be approximately 107,000 appeals, stakeholders can anticipate that OMHA will be able to handle appeals within statutory deadlines within the near future.
    • OMHA’s Electronic Case Processing Environment is continuing to be expanded and developed for appeals processing. Providers, beneficiaries, and contractors may now use the e-Appeal Portal to submit ALJ hearing requests or ALJ review of dismissals, upload documentation for pending appeals, and check on the status of appeals.

For more information please contact Lanchi Bombalier or Charmaine Mech.