Make the 2012 OIG Work Plan Work for You

Follow the OIG’s lead to ensure Medicare compliance in your office.

Arguably, there has never been a more tumultuous time to be a coder or a practice manager. You are dealing not only with the daily tasks of a busy and multifaceted physician organization, but also many new and upcoming issues, such as:

Certified Professional Compliance Officer - CPCO

  • Version 5010 conversion
  • ICD-10 implementation
  • Electronic health record (EHR) adoption
  • Recovery audit contractor (RAC) demands
  • Physician Quality Reporting System (PQRS) program requirements

These, and related issues, make daily work interesting, and sometimes complicated.

At the root of all of daily activities is compliance. You must attain and maintain compliance with all federal and state rules and regulations to stay on the right side of the law. At this difficult time in the industry, that can be a tricky thing to do.

Set Forth a Compliance Plan

One way to stay compliant is to have an active auditing and monitoring program as part of a larger compliance program within your practice. In developing your auditing and monitoring plan, a great tool is the Office of Inspector General (OIG) Work Plan. This work plan is released each year in early October, and encompasses all activities the OIG plans to undertake for regularly-scheduled audits and inspections for the following federal fiscal year (not including investigation activity driven by other sources, such as whistleblowers or referrals from the Centers for Medicare & Medicaid Services (CMS)). These regularly-scheduled audits give you a glimpse into issues the OIG is concerned about, and provide you with an opportunity to find and fix issues before the government finds them for you.

Let OIG’s Plan Guide You

The OIG released its 2012 Work Plan on Oct. 5, 2011. The section of greatest concern to physician practices is Part I, Medicare Part A and Part B. If your practice sees Medicaid patients, you may be interested in Part III, Medicaid Reviews, as well. If your practice performs clinical research, look at Part V, Public Health Reviews, and specifically the portions regarding the Food and Drug Administration and the National Institutes of Health. These additional sections may be helpful in creating an auditing and monitoring plan specific to your practice.

Several items in the 2012 Work Plan appear for the first time. These include:

Physicians and Other Suppliers

High Cumulative Part B Payments – This OIG intends to review instances where a high amount of cumulative Part B payments are made to an individual physician or supplier, either over a series of payments or for a significant single payment. The OIG will examine the controls in place that ensure payments are not made for services that are not reasonable and necessary, or that do not meet the requirements for payment under the Medicare program.

Physician-Owned Distributors of Spinal Implants – Physician ownership of any device company or distributorship can cause a conflict of interest when a physician-owned distributorship (POD) is selling to hospitals where these physicians provide services or serve on the medical staff. The OIG is looking specifically at PODs of spinal implants and POD usage statistics. Congress has also raised the issue of patient safety. Based on the information in this review, you can expect to see additional investigations of this type in the future, going much further than the spinal implants mentioned in this evaluation.

Physicians

Incident-to Services – Incident-to services is a topic that appears in the work plan regularly, but the OIG is expanding their focus in this area in 2012. The OIG plans to review incident-to services to determine whether there is a higher error rate for these services than there is for non-incident-to services. They also are concerned about CMS’ ability to monitor services that are billed incident-to a physician’s service. When receiving a claim for a service billed incident-to a physician’s service, the Medicare contractor has no indication that the service was provided by a non-physician practitioner (NPP) without looking at the documentation. This is one of the many vulnerabilities of incident-to billing under the Medicare program, and why it appears in the work plan so often. Providers must have a good handle on what services they can appropriately bill as incident-to and what they cannot. Include this in your audit plan and review this documentation closely.

Impact of Opting Out of Medicare – Due to the complexities of the Medicare program, as well as the continued threats of dropping reimbursement, some physicians are choosing to opt out of the Medicare program. Alternatively, there is an option for physicians to contract directly with beneficiaries. When contracting directly with a beneficiary, physicians consign to not submit claims to Medicare. This year, the OIG is reviewing how many physicians have opted out of the program, and whether any of these “opt out” physicians are still submitting claims to the program.

Evaluation and Management (E/M) Services

Use of Modifiers During the Global Surgery Period – There are many modifiers that can be used during the global surgery period (e.g., modifiers 24, 25, 59, 79, etc.). These modifiers assist the physician practice in explaining in “code” what the complicated narrative operative or office notes often tell. Unfortunately, the OIG has identified this as an area of abuse. Many providers allegedly place various global surgery modifiers on claims without appropriate documentation to back them up. This review is not focusing on a single specific modifier, nor does the OIG specify which modifiers they will look at. It is a general review of “appropriateness of the use of certain claims modifier codes during the global surgery period,” and could include any modifier used during the postoperative period.

Physician-administered Drugs and Biologicals

The OIG is reviewing the reimbursement methodology used for both Medicare Part B and Medicaid plans. Medicare Part B currently uses a derivation of the average sales price to make payment on physician-administered drugs and biologicals. Medicaid generally gives states some latitude in determining their own reimbursement formulas, but all are based on ingredient cost in some way, and manufacturers must provide rebates on Medicaid-covered drugs. This review is a comparison of the two plans, perhaps to determine which is most cost-effective. It is also a good time to look closely at your billing and documentation for drugs and biologicals if you charge for them in your office.

Find Out More

Many more areas will affect physician practices that are not new this year, such as place of service (POS) errors, trends of coding in claims, potentially inappropriate payments, and more. Take this information, as well as other items you pull from the work plan, and build your auditing and monitoring plan around it. Examine the areas the OIG is reviewing, and learn more about the level of compliance in your organization. Use the OIG’s map to compliance to build one of your own, and stay on track during this complex time in our industry.

Next month, we’ll examine the hospital side of the OIG 2012 Work Plan.

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Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, serves as a clinical technical editor for Ingenix/OptumInsight, and has nearly 20 years of experience in the health care industry. She is a former chief compliance officer and chief privacy official. She teaches CPT® coding as an approved AAPC instructor and was a member of AAPC’s ICD-10 curriculum development team. She holds a bachelor’s degree in health care administration from Empire State College and a master’s degree in health systems administration from the Rochester Institute of Technology (RIT).

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