2016 OIG Work Plan: Part B Risk Areas
Put these OIG compliance efforts on a high priority focus list for your provider.
The Office of Inspector General’s (OIG) annual work plan for 2016 outlines significant new areas, as well as ongoing target areas, on which the federal agency will focus its reviews and audits of U.S. Department of Health and Human Services (HHS) programs and operations this year.
Let’s take a look at what’s on the OIG’s radar for Medicare Part B providers. Similar to the approach we took with Part A, published in Healthcare Business Monthly last month, we’ll review the new and revised focus areas only.
Medical Equipment and Supplies – Policies and Practices
For medical equipment and supplies, the OIG is honing in on the policies and practices of:
- Power mobility devices – lump-sum purchase versus rental
- Competitive bidding for medical equipment items and services – mandatory post-award audit
NEW! Orthotic braces – OIG will determine the reasonableness of the Medicare fee schedule by comparing Medicare payments made for orthotic braces to the amounts paid by non-Medicare payers, such as private insurance companies, to identify potentially wasteful spending.
NEW! Osteogenesis stimulators – OIG will look at lump-sum purchase versus rental. They will determine whether potential savings can be achieved by Medicare and its beneficiaries if osteogenesis stimulators are rented over a 13-month period, rather than acquired through a lump-sum purchase.
Because this is a mere summary of the Part B provider portion of the 2016 OIG Work Plan, you are encouraged to review it in its entirety to ensure applicable risk areas are well understood.
Medical Equipment and Supplies –
Billing and Payments
Regarding billing and payments of medical equipment and supplies, the OIG is focusing on:
- Power mobility devices – supplier compliance with payment requirements
- Nebulizer machines and related drugs – supplier compliance with payment requirements
- Effectiveness of system edits for diabetes testing supplies to prevent inappropriate payments for blood glucose test strips and lancets to multiple suppliers
NEW! Orthotic braces – OIG will review Medicare Part B payments for orthotic braces to determine whether durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers’ claims were medically necessary and were supported in accordance with Medicare requirements. OIG makes clear that compliance with documentation requirements and utilization guidance outlined in the local coverage determinations (LCDs) issued by the DMEPOS Medicare administrative contractor will be the focus of its analysis. DME suppliers should review published Medicare guidance to ensure compliance.
NEW! Increased billing for ventilators – OIG has noticed a significant increase in billing for ventilators (specifically, HCPCS Level II code E0464 Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask). From 2013 to 2014, OIG reports a 127 percent increase in allowed amounts for E0464. OIG believes that suppliers may be inappropriately providing/billing for ventilators for patients with non-life-threatening conditions, and not meeting the medical necessity criteria for ventilators. The Medicare National Coverage Determinations Manual, Section 280.1, stipulates that ventilators are covered for the treatment of severe conditions associated with “neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease.” Ventilators are not considered reasonable and necessary when the patient has a condition for which the relevant LCD indicates a continuous positive airway pressure or respiratory assist devices is appropriate. DME suppliers should review published LCD guidance to ensure compliance.
Medical Equipment and Supplies –
Quality of Care and Safety
OIG is reviewing quality of care and safety measures for DME in regards to:
- Access to DME in competitive bidding areas
Other Providers – Policies and Practices
For other providers’ policies and practices, the OIG is focusing on:
- Ambulatory surgical centers (ASCs) – payment system
- End-stage renal disease facilities – payment system for renal dialysis services and drugs
NEW! ASC quality oversight – OIG will review Medicare’s quality oversight of ASCs. Previous OIG work found problems with Medicare’s oversight system, including finding spans of five or more years between certification surveys for some ASCs, poor Centers for Medicare & Medicaid Services’ (CMS) oversight of state survey agencies and ASC accreditors, and little public information on the quality of ASCs. CMS requires that ASCs become Medicare certified by a state survey and certification agency or privately accredited to show they meet the conditions. Because certification is a condition of payment, payments to ASCs without proper or current certification are deemed as overpayments. For this reason, ASCs should verify compliance with state accreditation requirements.
Other Providers – Billing and Payments
For other provider billing and payments, the OIG is targeting:
- Ambulance services – questionable billing, medical necessity, and level of transport ASC anesthesia services; payments for personally performed services
- Chiropractic services – Part B payments for non-covered services
- Chiropractic services – portfolio report on Medicare Part B payments
- Imaging services – payments for practice expenses
- Selected independent clinical laboratory billing requirements
- Annual analysis of Medicare clinical laboratory payments
- Physical therapists – high use of outpatient physical therapy services by independent therapists
- Portable X-ray equipment – supplier compliance with transportation and set-up fee requirements
- Sleep disorder clinics – high use of sleep-testing procedures (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)
- Inpatient rehabilitation facility payment system requirements
- ASC versus hospital outpatient payments
NEW! Physicians referring/ordering Medicare services and supplies – OIG will review select Medicare services, supplies, and DME referred/ordered by physicians and non-physician practitioners (NPPs) to determine whether the ordering provider was a Medicare-enrolled physician or NPP. If the referring/ordering physician or NPP is not eligible to order or refer, then the claims are not compensable. You should internally validate that the ordering provider of services, supplies, and DME is currently enrolled. A review of past claims is also recommended. If the ordering provider is not an eligible (Medicare enrolled) provider, the payments associated with claims made pursuant to any order from such a provider should be disclosed and refunded.
NEW! Anesthesia services – non-covered services. OIG will review Medicare Part B claims for anesthesia services to determine whether the patient had a related and covered Medicare service. Medicare will not pay for items or services that are not reasonable and necessary. Specifically, where the anesthesia procedure was related to the performance of a non-covered procedure, the anesthesia is non-covered, as well. Anesthesia providers should review past claims for compliance, and voluntarily disclose and refund any inappropriate payments. Make necessary modification to policies and procedures to ensure compliance.
NEW! Physician home visits – reasonableness of services. OIG will determine whether Medicare payments to physicians for evaluation and management (E/M) services performed in the home were reasonable and made in accordance with Medicare requirements. Since January 2013, Medicare made $559 million in payments for physician home visits. Physicians are required to document the medical necessity of a home visit in lieu of an office or outpatient visit. Providers should review past claims for compliance and voluntarily disclose and refund any inappropriate payments. Make necessary modification to policies and procedures to ensure compliance.
NEW! Prolonged services – reasonableness of services. OIG will determine whether Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements. The necessity of prolonged services is considered by CMS to be rare and unusual. The Medicare Claims Processing Manual, publication 100-04, chapter 12, section 184.108.40.206, includes requirements that must be met to bill a prolonged E/M service. Providers should review past claims for noncompliance and voluntarily disclose and refund any inappropriate payments.
NEW! Histocompatibility laboratories – supplier compliance with payment requirements. OIG will determine whether payments to histocompatibility laboratories were made in accordance with Medicare requirements. From March 31, 2013, through September 30, 2014, histocompatibility laboratories reported $131 million in reimbursable costs. Histocompatibility laboratories are reimbursed based on reasonable costs, which must be related to the care of patients, as well as reasonable, necessary, and proper. Histocompatibility laboratories should review past claims and cost reports for noncompliance and voluntarily disclose and refund any inappropriate payments. Histocompatibility laboratories should make necessary modification to policies and procedures to ensure compliance.
Get to Know the OIG Work Plan
Because this is a mere summary of the Part B provider portion of the 2016 OIG Work Plan, you are encouraged to review it in its entirety to ensure applicable risk areas are well understood. For each focus area affecting your provider, be certain to review appropriate CMS interpretive guidance, LCDs, and any referenced regulatory provisions cited in the OIG Work Plan to ensure you completely understand and comply with CMS expectations, particularly with respect to documentation content and coverage limitations.
For details pertaining to ongoing reviews, which are listed in this article only by name, or for details regarding risk areas associated with Part C, Part D, and Medicaid programs, please refer to the 2016 OIG Work Plan.
Medicare National Coverage Determinations Manual, §280.1
Medicare Claims Processing Manual, publication 100-04, chapter 12, § 220.127.116.11
For details regarding coverage requirements for histocompatibility laboratories, see 42 CFR §§ 413.9(a), (b), and (c)(3)
For requirements pertaining to cost reporting, see 42 CFR §§ 413.24(a), (c)
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA, is president-elect of AAPC’s National Advisory Board, serves on AAPC’s Legal Advisory Board, and is AAPC Ethics Committee chair. He is admitted to the practice of law in California as well as 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. Miscoe has over 20 years of experience in healthcare coding and over 18 years as a forensic coding and compliance expert. He has provided expert analysis and testimony on coding and compliance issues in civil and criminal cases and represents healthcare providers in post-payment audits and HIPAA OCR matters. Miscoe speaks on a national level, and is published nationally on a variety of coding, compliance, and health law topics. He is a member and past president of the Johnstown, Pa., local chapter.