Breaking it down: Analysis of 2011 OIG Work Plan (Medicare Part B) Print
Written by Benjamin L. Frosch   
Friday, 03 December 2010 11:04

MEDICARE QUESTIONS AND ANSWERS

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 2011 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 work plan. With a variety of federal agencies looking closer 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 "subjects" targeted in the 2011 OIG Work Plan:

CODING AND PAYMENTS OF EVALUATION AND MANAGEMENT SERVICES                          

This is definitely going to be a subject under the microscope in 2011 and beyond.  The OIG is going to review Evaluation and Management (E&M) claims to identify issues in the coding of E&M services. Medicare paid $25 Billion dollars for E&M services in 2009 which represents 19% of all Medicare Part B payments. They will also be reviewing the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations by Medicare contractors.

Also Medicare contractors throughout the United States have noted an increase in the frequency of medical records with identical documentation across services. The OIG plans to review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.

PLACE OF SERVICE ERRORS

The OIG has decided to continue reviewing physician coding of place of service on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments. Federal regulations provide for different levels of payment to physicians depending on where the services are performed.  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 a hospital outpatient department or, with certain exceptions, in an ASC.  The OIG will continue to evaluate whether physicians properly coded the place of service on claims provided in ASC's and hospital outpatient departments.

EVALUATION AND MANAGEMENT SERVICES DURING GLOBAL SURGERY PERIOD

As we can all see E&M services are absolutely under the microscope. Under the global surgery fee 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. The OIG will evaluate whether medical practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.

EXCESSIVE PAYMENTS FOR DIAGNOSTIC TESTS

Diagnostic tests will be under scrutiny in 2011 and beyond.  The OIG will review Medicare payments for high cost diagnostic tests to determine whether they were medically necessary. The Social Security Act provides that Medicare will not pay for items or services that are "not reasonable and necessary". The OIG will address the extent in which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.   However, there will be other OIG issues for diagnostic tests. Physicians  are  paid  for services  pursuant  to  the  Medicare  physician  fee  schedule,  which  covers  the major  categories  of  costs,  including  the  physician  professional  cost component,  malpractice  costs,  and  practice  expense.  The  Social  Security Act, ยง  1848(c)(1)(B),  defines  "practice  expense"  as  the  portion  of  the resources used  in  furnishing  the  service  that  reflects  the general  categories of expenses,  such  as  office  rent, wages  of  personnel,  and  equipment.  Certain imaging services will be under focus with respect to the practice expense components. The OIG will determine whether Medicare  payments  for  Part B Imaging reflect the expenses incurred  and  utilization  rates.   

GEOGRAPHIC AREAS WITH A HIGH DENSITY OF INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTF)

While there is no doubt that the Florida is a geographic area with a high density of IDTF's, the OIG will be reviewing services and billing patterns in areas such as Florida due to high concentrations of IDTF's.   IDTFs must meet regulatory performance requirements in accordance with 42 CFR to obtain and maintain Medicare billing privileges. In 2006, the OIG concluded that there were numerous problems with IDTF's including non-compliance with Medicare standards and potential improper payments of over $70 million dollars. This issue leads into;

INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTF) COMPLIANCE WITH MEDICARE STANDARDS

The OIG is going to select certain IDTF'S that are enrolled in Medicare to determine the extent in which they comply with the ITDF Medicare standards. IDTF's received payments of almost $900 million dollars in 2009. Federal regulations require IDTF's to certify on their enrollment application that they comply with the seventeen CMS standards.  Such standards include requirements that IDTF's comply with all federal and state licensure and regulatory requirements that are applicable to the health and safety of patients, provide complete and accurate information on their Medicare enrollment application, and have the appropriate technical staff and physicians who are proficient with respect to the tests they perform.

OUTPATIENT PHYSICAL THERAPY SERVICES PROVIDED BY INDEPENDENT THERAPISTS

The OIG will evaluate if outpatient physical therapy services provided by independent therapists are in compliance with Medicare reimbursement regulations and guidelines. Previous OIG work plans have identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented.  They will focus on independent therapists who have a high utilization rate for outpatient physical therapy services and will determine whether the services that were billed to Medicare were in accordance with federal requirements.   Florida once again is one of the highest areas in the United States when it comes to providing physical therapy to Medicare beneficiaries compared to the other regions of the country.

CLINICAL LABORATORY TEST

There is a concern pertaining to the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel test to maximize Medicare payments. The OIG will look into whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing specimens on sequential days.  The OIG will also be looking at trends in laboratory utilization. In 2008, Medicare paid about $7 Billion dollars for clinical laboratory services which represent a 92% increase from 1998.

MEDICARE PAYMENT FOR SLEEP TESTS

The OIG is going to take a look at the appropriateness of Medicare payments for sleep test procedures that are provided at sleep disorder clinics. A preliminary OIG review identified improper payments when modifiers are not reported for sleep test procedures. The OIG will examine Medicare payments to physicians and Independent Diagnostic Testing Facilities for sleep test procedures to determine whether they were in accordance with Medicare requirements. 

MEDICARE SERVICES BILLED WITH DATES OF SERVICES AFTER BENEFICIARIES DATES OF DEATH

I think we can all understand why the OIG will take a look at this issue. They plan on reviewing Medicare claims with dates of service after a beneficiary's date of death to assess CMS controls to preclude or identify and recover improper payments. CMS uses several computer database systems that interface with  death  information  on  the  Social  Security  Administration's  and  the  Railroad  Retirement  Board's  systems.  

About the author:  Mr. Frosch is President of FROSCH MEDICAL CONSULTANTS, INC. in Plantation, FL.

 

Last Updated on Sunday, 14 August 2011 16:58