OIG’s 2012 Work Plan

December 8, 2011 – The following are some of the areas to be reviewed by the Office of Inspector General (OIG) as part of their Work Plan for 2012 that may affect your practice. In addition to those areas, the following general reviews will be performed by the agency.  A copy of the entire 2012 Work Plan can be found on the OIG Work Plan  website.

General Areas for Review:

• EHR Medicare and Medicaid payments from 2011 to identify payments to providers for adopting EHRs andCMS’ safeguards to prevent erroneous incentive payments.
• Compliance with Assignment Rules – beneficiaries billed in excess of amounts allowed by Medicare
• High Cumulative Part B Payments – high payment made to an individual physician, or on behalf of an individual beneficiary, over a specified period of time
• Impact of Physicians Opting out of Medicare  -  determine whether these physicians are submitting claims and whether certain areas of the country have seen higher numbers of physicians opting out of Medicare.
• Medicare Payments for Claims with G modifiers – review of G modifiers indicating that Medicare denial was expected.
• Payments for Services Ordered or Referred by Excluded Providers (providers barred from billing Federal health care programs)
• Medical claims submitted by error-prone providers to determine their validity

OIG REVIEW OF EVALUATION & MANAGMENT (E/M) SERVICES
 
Trends in Coding of Claims
Review of E/M claims to identify trends in the coding of E/M services from 2000 – 2009 and will also identify providers that exhibited questionable billing for E/M services in 2009.  Medicare paid $32 billion for E/M services in 2009, representing 19 percent of all Medicare Part B payments.  Providers are responsible for ensuring that the codes they submit for billing accurately reflect the services they provide. 
 
E/M Services Provided During the Global Surgery Periods 

• The OIG will review industry practices related to the number of E/M services provided by physicians and reimbursed as part of the global surgery fee to determine whether the practices have changed since the global surgery fee concept was developed in 1992. Under this concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E/M services provided during the global surgery period; and
   
• Review the appropriateness of the use of certain claim modifier codes during the global surgery period and determine whether Medicare paid for claims with modifiers used during the global surgery period that were in accordance with Medicare requirements.  Prior OIG reviews have shown that improper use of modifiers during the global surgery period resulted in inappropriate payments.

 E/M Services Potentially Paid Inappropriately

• There will be an assessment of the extent to whichCMSmade potentially inappropriate payments for E/M services and the consistency of E/M medical record documentation.
• Review of multiple E/M services for the same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments.  Medicare contractors (MACs) have noticed an increased frequency of medical records with identical documentation across services, instead of coding for the service based upon the content of the service and documentation to support the level of service reported.

INCIDENT-TO SERVICES
 
Medicare B pays for certain services billed by physicians that are performed by nonphysicians, incident to a physician office visit.  Incident-to services can not be identified by reviewing claims but can only be identified by reviewing medical records and comparing the medical record to the claim submitted for that patient.
 
In 2009,CMS found that:

• When Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician.
• Unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally.  The only nonphysician personnel that can bill incident-to services are certified nurse midwives, clinical psychologists, clinical social workers, physician assistants, nurse practitioners and clinical nurse specialists.

Incident-to services may also be subject to overutilization and expose Medicare beneficiaries to care that does not meet professional standards.

IMAGING & DIAGNOSTIC RADIOLOGY SERVICES 

Part B Imaging Services
The OIG will review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices.   Medicare B pays for imaging services covering the major categories of cost, including the professional component, malpractice and practice expense. (PE)  The OIG will concentrate on the PE, which includes office rent, wages of personnel, and equipment, including equipment utilization rate.
 
Diagnostic Radiology:  Excessive Payments
Review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.

SLEEP TESTING 

Payments for Polysomnography
Review  the appropriateness of Medicare payment for sleep studies and review the factors contributing to the rise in Medicare payments for sleep studies and assess provider compliance with Federal program requirements.  Medicare payments increased from $62 million in 2009 to $235 million in 2011, and coverage was recently expanded. 
 
Payments for Sleep Testing in Sleep Disorder Clinics
Reviews the appropriateness of payments for sleep test procedures provided at sleep disorder clinics and determines whether they were in accordance with Medicare requirements.  A preliminary OIG review identified improper payments when certain modifier codes are not reported with sleep test procedures.

LABORATORY TESTS
   
Glycated Hemoglobin A1C Tests
Review of Medicare contractors’ procedures for screening the frequency of clinical laboratory claims for glycated hemoglobin A1C tests and determine the appropriateness of Medicare payments for these tests.  Prior OIG work showed Medicare contractors vary in how they screen for frequency of these tests.  Medicare does not consider it reasonable and necessary to perform this test more often than every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines.
 
Trends in Laboratory Utilization
Review of trends of laboratory utilization such as the types of laboratory tests and the number of tests ordered. The OIG states there has been a 92% increase in the ordering of laboratory tests from 1998 to 2008.  The review will examine how physician specialty, diagnosis, and geographic differences in the practice of medicine affect physicians’ lab test ordering.

AMBULATORY SURGICAL CENTERS
 
Payment System
Review the appropriateness of Medicare methodology for setting ambulatory surgical center payment rates under the revised payment system.
 
Safety and Quality of Surgery and Procedures
Review the safety and quality of care for Medicare beneficiaries having surgeries and procedures in ambulatory surgical centers (ASCs) and hospital outpatient departments (HOPDS).  The OIG will assess care in preparation for and provided during surgeries and procedures in both settings and will identify adverse events in both settings.
 
Place of Service Errors
Review of services performed in ASCs and HOPDs to determine whether they properly coded the places of service.  Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than if the service is performed in an HPOD or with certain exceptions, in an ASC.

Tags: Healthcare Reform