OIG 2012 Work Plan Targets Familiar Concerns
The U.S. Department of Health & Human Services (HHS) Office of Inspector General’s (OIG) 2012 Work Plan should look familiar to experienced coding and compliance personnel. Among those areas of investigation that carry over from previous years, the OIG will continue to review whether payments made to physicians have the proper place-of-service code, and will continue to identify providers who exhibit questionable billing of evaluation and management (E/M) codes.
The OIG’s 2012 Work Plan, released Oct. 5, identifies specific areas with respect to HHS programs (including Medicare Parts A-D), on which the OIG plans to focus its attention for the fiscal year Oct. 1, 2011 through Sept. 30, 2012. The Work Plan is a valuable tool to identify potential billing problems within your own practice or facility.
Regarding physician services, and in addition to place-of-service and E/M utilization errors, the OIG will continue to investigate the following areas in 2012:
- Compliance with Assignment Rules: The OIG will continue to review whether providers are complying with assignment rules and determine to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare.
- E/M Services Provided During Global Surgery Periods: The OIG will continue to 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 introduced.
- Part B Imaging Services: Part B imaging services will continue to be reviewed to determine whether the services reflect expenses incurred and whether the utilization rates reflect industry practices.
- Diagnostic Radiology Services (Excessive Payments): Medical necessity will continue to be reviewed as well as duplicate services.
As electronic health records (EHRs) proliferate, the OIG says it also will continue to target “cloned” E/M documentation as an area ripe for investigation.
The Work Plan isn’t all old news, however; new OIG concerns for physician services in 2012 include:
- High Cumulative Part B Payments: The OIG will review high cumulative Part B payments to determine if they are reasonable and necessary, adequately documented, and provided consistent with federal regulations.
- Incident-to Services: The OIG will review whether incident-to billing has a higher error rate than that for nonincident-to services.
- Use of Modifiers During Global Surgery Period: The OIG will review the appropriateness of the use of certain modifiers during the global surgery period to determine if Medicare payments were in accordance with Medicare requirements.
On the hospital side, many of the 2012 Work Plan objectives might also induce déjà vu, including:
- Reporting of Adverse Events
- Hospital Admissions with Conditions Coded Present-on-admission (POA)
- Hospital Inpatient Outlier Payments
- Hospital Same-Day Readmissions
- Medicare Payments for Beneficiaries with Other Insurance Coverage
- Medicare Inpatient and Outpatient Hospital Claims for the Replacement of Medical Devices
- Observation Services During Outpatient Visits
New initiatives for hospitals in the 2012 Work Plan include:
- Accuracy of Present-on-admission Indicators: The OIG will focus on the accuracy of POA indicators hospitals are reporting on inpatient claims.
- Inpatient and Outpatient Payments to Acute Care Hospitals: The OIG will be reviewing compliance with billing requirements for payments made to hospitals.
- Acute-Care Hospital Inpatient Transfers to Inpatient Hospice Care: The OIG will be reviewing the relationship between the hospital and the hospice provider, either financial or common ownership, when the beneficiary is transferred from hospital to hospice care.
- Inpatient Rehabilitation Facilities (IRF): The OIG will be reviewing the appropriateness of IRF admissions.
As in 2011, the OIG will continue to review payments to critical access hospitals (CAHs) for appropriateness, but will also be reviewing CAH profiles to determine if the hospital meets CAH criteria.
As health care expenses continue to rise, consuming an ever-greater portion of federal dollars, the OIG has become more aggressive in pursuit of noncompliance, fraud, and abuse. In 2010, $3.8 billion in expected investigative receivables were court ordered or paid through civil settlements that resulted from cases developed by OIG investigators; and HHS program managers pursued $1.1 billion in audit receivables as a result of OIG audit disallowance recommendations.
That many of the same issues remain a part of the OIG Work Plan year after year is a good indication that these are perennial problems. All practices and facilities should read the OIG Work Plan in its entirety, and take steps to identify and rectify any potential issues they may have, before the OIG does.
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