2014 OIG Work Plan: Target Your Risk Areas
Use the latest OIG work plan to amp up your compliance plan and audit efforts.
By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO
The U.S. Department of Health & Human Services Office of Inspector General (OIG) has released its annual work plan, outlining the new and ongoing hot spots for healthcare fraud and abuse the federal agency intends to review and audit in 2014. Based on the civil and criminal sanctions that can result from noncompliance, it behooves providers to pay particular attention to the risk areas outlined in the OIG work plan and to update their compliance programs accordingly. In particular, take a good look at the new and ongoing focus areas for the Medicare Part B program.
Provider-based Freestanding Hospital-based Clinics
As a new initiative for 2014, OIG will look at the comparative payment amounts between provider-based facilities—which often receive higher payment amounts for certain services than do freestanding outpatient clinics—and their freestanding outpatient counterparts. Although there is nothing necessarily onerous or problematic with billings from hospital-based clinics, OIG will be reviewing payments. This increased scrutiny may identify outliers, which could lead to additional audit analysis.
OIG remains concerned with skilled nursing facility billing, based on a 2009 study revealing a 25 percent error rate. OIG is also concerned about questionable billing from Part B providers for services provided to nursing home residents during stays not paid under Part A benefits (such as foot care), stays during which benefits are exhausted, or due to failure to meet the three-day prior inpatient stay requirement.
OIG will focus on newly enrolling home health agencies, due to the more than $1 billion in inappropriate payments relating to home health benefits. Specific to providers who may be certifying the necessity of home health services, OIG will review compliance with documentation requirements submitted to support claims paid by Medicare. Providers are encouraged to review standards for certifying home-bound status prior to providing a certification for home health services.
ASC and Hospital Outpatient Claims
The OIG will continue to evaluate whether a payment disparity exists between reimbursement rates for services performed in an ambulatory surgical center (ASC) compared to similar surgical services performed in a hospital outpatient department. OIG will also continue to evaluate payment errors associated with place of service by Part B providers who perform surgical services in an ASC.
Rural Health Clinics
OIG is aware the Centers for Medicare & Medicaid Services (CMS) has not published regulations permitting removal of rural health program clinics that no longer meet location requirements established under the Balanced Budget Act of 1997. OIG is also aware that rural health clinics that no longer meet the location requirements necessary to qualify for enhanced Medicare reimbursement are still receiving the enhanced reimbursement amounts. Rural healthcare clinics are advised to ensure the appropriateness of any enhanced payments they received, and voluntarily refund any inappropriate payments to Medicare.
Sleep Disorder Clinics
OIG noted that an analysis of 2010 Medicare payments showed high utilization for sleep testing procedures billed under CPT® 95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist and 95811 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist. OIG will continue to examine payments to providers and facilities providing sleep testing procedures to determine the appropriateness of payments.
OIG continues to evaluate ambulance billings for transports that either did not occur or were potentially unnecessary transports to dialysis facilities. As a new initiative, OIG is reviewing and coordinating its evaluations, audits, investigations, and guidance to ensure compliance with Medicare Benefit Policy Manual requirements, which limit payment for transport services to circumstances where using other means of transport would endanger the patient’s health.
The appropriateness of personally performed anesthesia services is a continued focus area. Included in this focus is the use of modifiers AA Anesthesia services performed personally by anesthesiologist and QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.
OIG continues to identify improper payments for what CMS defines as “maintenance” care. This effort has traditionally focused on analysis of documentation for compliance with initial and subsequent visit documentation guidance contained in the Medicare Benefit Policy Manual. Of these requirements, compliance with the treatment planning elements is a particular focus, even though these elements are directory (what a plan “should” contain) in CMS guidance. In addition to those efforts, as a new initiative, the OIG intends to identify billing trends suggestive of maintenance therapy billing, given the history of problems associated with improper payments. This effort is likely to focus on visit frequency analysis, as well as the number of encounters for a reported condition (diagnosis).
OIG notes that Medicare is the largest payer of clinical lab services in the nation, with sharp increases in costs for lab testing over the past several years due to increased volume of ordered services. As a result, OIG will perform data analysis to identify questionable billing practices.
Diagnostic Radiology Services
An ongoing concern is the rapid increase of diagnostic radiology testing. The OIG continues to analyze the medical necessity of high-cost diagnostic radiology tests in an effort to understand this trend and determine the appropriateness of Medicare payments.
Portable X-ray Services
Similarly, the OIG is reviewing the appropriateness of Medicare payments associated with the transportation and setup of portable X-ray equipment. OIG is looking at the qualifications of the technicians who are performing the services, and whether the services were ordered by a medical doctor or doctor of osteopathic medicine. OIG also notes that Medicare has improperly paid portable X-ray suppliers for multiple trips to nursing facilities and for services ordered by non-physicians.
Electro-diagnostic Testing Services
OIG continues its evaluation of Medicare claims data to identify questionable billing of electro-diagnostic (EDX) testing services. EDX service providers are encouraged to review applicable local coverage determination (LCD) requirements, and ensure their documentation demonstrates conformance with applicable coverage requirements.
Documentation of E/M Services
With the advent of electronic health records (EHRs), OIG is particularly concerned with the increased frequency of medical records showing identical documentation across services. OIG is evaluating multiple records for the same provider (likely to include multiple records for each patient evaluated) to determine the extent to which documentation vulnerabilities exist (i.e. what OIG and CMS have labeled as “cloning”). Providers are cautioned to avoid EHR shortcuts that simply pull information forward, leading to the appearance of cloned documentation.
Based on 2010 data analysis, Medicare approved $6.8 billion in improper payments for ophthalmologic services. OIG is continuing its review this year, and is basing it on 2012 claims data.
OIG is reviewing compliance of participating providers with assignment rules, as well noncompliance through the billing of excess charges to Medicare beneficiaries. The OIG is using 2012 claims data for this study.
OIG continues its analysis of services performed and reported by independent therapists. OIG is anticipated to change their analysis somewhat, in the wake of the Jimmo settlement, where CMS acknowledged there is no “improvement standard” as a necessary predicate to Medicare coverage. The focus is more likely to be on whether “skilled” services were rendered (one-on-one contact) and necessary, given the patient’s condition.
Want to know more on the Jimmo v. Sebelius Settlement Agreement? Go to the Fact Sheet.
Medicare Program Management – Provider Deactivation
To prevent fraudulent claims submissions, OIG continues to review provider eligibility to identify and deactivate providers who have not billed Medicare for more than one year, following federal regulatory provisions.
These areas provide a relevant summary of the new and ongoing OIG efforts that are likely to be most applicable to outpatient providers. The OIG Work Plan for 2014 also targets various hospital services, durable medical supplies, and prescription drug benefits for both Medicare and Medicaid. You are encouraged to review the entire work plan to ensure applicable risk areas are well understood. For each applicable focus area, be certain to review appropriate CMS interpretive guidance and LCDs, as well as Medicare publications and other guidance. To ensure compliance throughout your organization, incorporate this information into your compliance plan.
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, has a Bachelor of Science degree from the United States Military Academy and a juris doctorate degree from Concord Law School, is the president of Practice Masters, Inc., and the founding partner of Miscoe Health Law, LLC. He is a past (2007-2009) and current (2013-2015) member of the AAPC National Advisory Board, is an AAPC Legal Advisory Board member, and is the chair of the AAPC Ethics Committee. Mr. Miscoe is admitted to the practice of law in California and to the bar of the U.S. Supreme Court and the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. He has over 20 years of experience in healthcare coding and over 16 years as a compliance expert, forensic coding expert, and consultant. Miscoe is a member of the Johnstown, Pa., local chapter and serves as president.
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