The future of ORT: What's next?
October 1, 1997 4 minutes read
The future of ORT: What’s next?
HCFA says measures are here to stay
In an exclusive interview with Home Infusion Therapy Management, Linda Ruiz, the direc- tor of the program integrity group for the Health Care Financing Administration (HCFA), addressed various issues regarding the federal government’s anti-fraud campaign, Operation Restore Trust (ORT). Initially viewed by the industry as a step in the right direction to weed out fraudulent providers from the Medicare system, many providers have been surprised and shocked to find the ORT spotlight placed on them.
Ruiz says the initial interpretation of ORT was too narrow and led to the confusion.
"ORT does not focus just on fraud but fraud, waste, and abuse," she says. "We find there’s as much or more abuse as there is fraud, and that’s as destructive to the program as fraud is. When we go out and we’re looking for problems, we’re not sure we’ll find fraud or at least something that can be proved as fraud, but we’re looking for any place where claims were made, and we either have the potential to make or did make a payment that is not appropriate."
Ruiz notes that fraud can be very difficult to prove, as proving fraud requires showing intent. For that reason, the agency in many cases isn’t looking for intent but instead simply instances of payments made for inappropriate claims.
"Because we find and take administrative action where we made a payment we shouldn’t have, doesn’t mean we’re treating that as fraud," she points out. "It means the program is only supposed to pay for what it covers and what is medically necessary and reasonable, and if we find instances where we made payments and those criteria were not met, we’re going to take administrative action to get our money back."
It seems, from HCFA’s point of view, ORT is not just for the blatantly fraudulent but for all providers.
However, some individuals have claimed that HCFA has used strong-arm tactics in surveying their agencies. (See related story, p. 130.) Ruiz asserts that such surprise visits are well within HCFA’s legal rights. She also asserts that HCFA’s methods of getting agencies to pay levied fines is also legal, although to understand how and why, it’s important to get a better feel for how ORT works.
Ruiz says ORT was the direct result of suggestions from HCFA surveyors.
"One of the reasons we started doing this is that surveyors often complained that they felt action should be taken [against an agency], and they didn’t know how to make that happen," says Ruiz. ORT has given surveyors just such an opportunity.
In the past, surveyors were collecting information strictly based on "quality purposes," such as information on how an agency was meeting the conditions of participation. Ruiz notes that the surveyor could "require an agency to come into compliance, or in really egregious circumstances decide to terminate" the agency’s ability to receive Medicare reimbursement.
That was the "old" survey process. Under ORT, the same surveyors are requesting and collecting additional information, but it’s not for their eyes only.
"Now they’re looking at information related to specific beneficiaries and specific claims, trying to determine whether those services should have been rendered, and they pass that information onto the intermediary who makes a separate decision about whether the payment was inappropriate based on the information the surveyor has collected," says Ruiz. "In that case, it becomes not a survey decision and a survey appeal but a decision on payment made by the intermediary."
This is admittedly in stark contrast to the way HCFA conducted surveys before.
"On the normal survey in the past and even today outside of the ORT pilot, the surveyors don’t collect that additional information and pass that onto the intermediary," says Ruiz. "We’ve created a link between the surveyors and the information they might see while doing their survey that is really information an intermediary would go on sight to collect. This is an efficiency for us where people who are out there collect information, pass it on to the intermediaries, and allow the intermediary to make a decision based on the information."
Agencies finding themselves in such a predicament say there is no cooperation or opportunity to appeal the decisions. Ruiz says that’s not true.
"For every actual claim that we looked at and made a decision that a claim should have been denied, they have the opportunity to appeal that service of denial or overpayment," says Ruiz, a process no different from normal disputes that arise when a payment is denied. This is in contrast to what some agencies claim their options are.
However, she says Medicare is offering agencies a "quick-fix" to any fines.
"In many cases, we are providing an opportunity to settle this without taking legal remedies," says Ruiz. "Instead of going to the appeals process, we say to them Here’s what we looked at, here’s the amount of money involved, and here’s the extrapolation we did. If you want to accept and pay that back, then we’ll accept that payment, and you give up your appeal rights.’ But they don’t have to accept that, and they can ask for us to look at more cases."
If you’re holding your breath ready to let loose a sigh of relief when ORT comes to a close, you’d better not wait. According to HCFA, ORT is permanent.
"This is a way of doing business," says Ruiz. "We started out with five states and added 12 more, and we will continue to add."
She notes that funding for ORT is likely to continue, as is ORT, although under a different name. When the pilot program ends, you won’t hear Operation Restore Trust, but you’ll still feel it.
"You may not hear it used with that name eventually because it will just be the way we do our business," says Ruiz.
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