Medicare Compliance & Reimbursement

Federal watchdog agency's work plan will keep it busy next year.

The HHS Office of Inspector General (OIG) plans to issue a report on whether providers are following all the requirements for incident-to billing, including direct physician supervision. The OIG wants to know whether these services met the Medicare standards for medical necessity, documentation and quality of care, according to the OIG's 2007 Work Plan.

Other topics in the OIG's 2007 Work Plan include:

1) Global periods. The OIG suspects that providers may be billing for too many evaluation & management (E/M) services during the global period after a surgery. The global payment for every procedure includes a certain number of E/M visits. The OIG also wants to know whether "industry practices" have changed.

2) Assignment violations. Medicare rules prohibit so-called "balance billing," in which physicians bill patients more than the Medicare co-pays and deductibles for a service. The agency wants to know if you are overbilling patients, and also whether patients know their rights and responsibilities.

3) Imaging services. Advanced imaging services, such as MRI, CT and PET scans, increased 20 percent per year from 1999 to 2005 in physician offices. The OIG wants to know if you are billing appropriately for these services, which cost more than $7 billion in 2005.

4) Physical therapy. The Centers for Medicare & Medicaid Services (CMS) issued a fraud alert in 2004 saying that physical therapy suppliers were switching between Part A and Part B billings to maximize their income. The OIG wants to see if physical therapists are double-billing Part A and Part B for the same services.

5) Eye surgery. The OIG suspects that providers are billing for cataract and Lasik eye surgeries in ways that don't meet Medicare requirements. Also, the OIG wants to know if the carriers have adequate controls.

6) Place of service. Are you billing for services in an ambulatory surgery center when the doctor actually provided them in a hospital outpatient department, or vice versa? The OIG wants to know.

7) Inpatient psychiatric services. Medicare pays more for individual therapy than for group therapy, so physicians may have an incentive to bill for one-on-one encounters when they see a group, the OIG worries.

8) Polysomnography. Medicare payments for sleep testing increased almost 175 percent in four years, from $62 million in 2001 to $170 million in 2004. The OIG wants to know why.

9) Long-distance claims. Past reports found that physicians were billing for services for skilled nursing facility and home health patients who lived a long way away. Those services would normally require a face-to-face visit.