MEDICARE QUESTIONS AND ANSWERS
With the passage the Affordable Health Care Act (Health Care Reform) and the Medicare program in financial jeopardy, the OIG 2014 Work Plan is possibly more important than any of their previous work plans. I would say it is one of the most detailed OIG work plans, which explains the 3 month delay of the OIG issuing the 2014 work plan. With a few thousand staff members throughout the United States, the Office of Inspector General (OIG) plans and performs audits, investigations, evaluations, and legal activities pertaining to the Department of Health and Human Services (HHS). With the Issuance of the 2014 OIG Work Plan there are a variety of important Medicare issues that they will evaluate pertaining to Medicare physicians and other health care providers. This may be a good opportunity to evaluate compliance in your practice with respect to the following Part B subjects that are in the OIG Work Plan. With more federal agencies taking a closer look at Medicare fraud and abuse than ever before, it is very clear that there is a zero tolerance for Medicare fraud and abuse.
The following is a list of what I think are some of the hottest physician subjects targeted in the 2014 OIG Work Plan:
EVLAUATION AND MANAGEMENT SERVICES- Inappropriate payments
This is going to be a subject under the microscope in 2014 and beyond. The OIG will be identifying providers that exhibit questionable billing for E/M services in 2010. Medicare payments for E&M services in 2010 represented 19% of all Medicare Part B payments. The OIG will review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare has noted an increased frequency of medical records with identical documentation across services. Providers are responsible for ensuring that the E/M codes that they submit accurately reflect the services actually provided and were medically necessary. E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established.
PLACE OF SERVICE ERRORS
The OIG has and will continue to review physician coding on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments to determine whether they are coded properly with the correct place of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed. Prior OIG reviews determined that physicians did not always correctly code non-facility places of service submitted to and paid by Medicare. Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician office, than it does when a service is performed in hospital outpatient department or, with certain exceptions, in Ambulatory Surgical Centers.
PART B IMAGING SERVICES
The OIG will continue to evaluate Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. Physicians are paid for services pursuant to the Medicare Fee Schedule, which covers the major categories of cost, including the physician professional cost component, malpractice cost, and practice expenses. Practice expenses are those such as office rent, wages of personnel, and equipment. For selected imaging services, the OIG will focus on the practice expense components, including the equipment utilization rate.
DIAGNOSTIC RADIOLOGY-Medical Necessity of High Cost tests
The OIG will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which utilization has increased for theses diagnostic tests. They will also look again at imaging services ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.
ANESTHESIA SERVICES-Payments for personally performed services
The OIG will review the appropriateness of Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will review whether Medicare payments for anesthesiologist services reported on a claim with the “AA” service code modifier met Medicare regulations. Physicians report the appropriate anesthesia modifier code to denote whether the service was personally performed or medically directed. Reporting an incorrect modifier on the claim as if services were personally performed when they were not will result in Medicare paying a higher amount.
OPHTHALMOLOGISTS – Questionable billing
Billing and payment issues - The OIG plans on reviewing claims data to identify inappropriate payments and/or questionable billing for ophthalmological services during 2012. They will determine the geographic locations of providers exhibiting questionable billing for ophthalmological services in 2012. In 2010, Medicare allowed over $6.8 billion for services provided by ophthalmologists.
SLEEP DISORDER CLINICS – High utilization of sleep-testing procedures
The OIG will take a closer look at Medicare payments to physicians, hospital outpatient departments, and Independent diagnostic testing facilities (IDTF’s) for sleep–testing procedures to assess the appropriateness of Medicare payments for high utilization sleep-testing procedures and determine whether they were in accordance with Medicare requirements. An OIG analysis of CY 2010 payments for CPT codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep-testing procedure. Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not medically reasonable and necessary under the Medicare program.
OUTPATIENT PHYSICAL THERAPY SERVICES
The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. In the past, the OIG has identified claims for therapy services provided by independent physical therapists that were not, medically reasonable and necessary, or properly documented. The OIG will focus on independent therapists who have a high utilization rate for outpatient physical therapy services because of their concern that they may not be medically reasonable and necessary.
CLINICAL LABORATORY SERVICES
The OIG will take a look at and review trends in laboratory utilization under Medicare, such as in the types of laboratory tests and the number of tests ordered and identify questionable billing. Medicare is the largest payer of clinical lab tests in the nation. Medicare’s payments for lab tests in 2008 represented an increase of 92 percent over payments in 1998. In 2010, Medicare paid about $8.2 billion for lab tests, accounting for 3 percent of all Medicare Part B payments.
CHIROPRATIC SERVICES - Part B payments for non covered services
The OIG will be reviewing billing and payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Prior OIG reviews identified inappropriate payments for chiropractic services during calendar year 2006. In 2013, the OIG identified unallowable Medicare payments for chiropractic services. Medicare pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is no neuro - musculoskeletal condition for which such manipulation is appropriate treatment. Chiropractic maintenance therapy is not considered medically reasonable or necessary, and is therefore not payable under the Medicare program.
ELECTRO DIAGNOSTIC TESTING- Questionable Billing
The OIG will review Medicare claims data to identify questionable billing for electrodiagnostic testing. They will evaluate the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services. Electrodiagnostic testing, which assists in the diagnosis and treatment of nerve or muscle damage, includes the needle electromyogram and the nerve conduction test. The OIG is concerned about the use of electrodiagnostic testing for inappropriate financial gain poses a growing vulnerability to Medicare.
ASCs and HOSPITAL OUTPATIENT DEPARTMENTS-Safety and Quality of Surgery and Procedures
The OIG will review the safety and quality of care for Medicare beneficiaries having surgeries and procedures in ASCs and Hospital outpatient departments. They will assess care in preparation for and provided during surgeries and procedures in both settings. The OIG will identify adverse events in both settings. Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL. Got a Question for Ben? Click Ask Ben.