Each year the U.S. Department of Health and Human Services Office of the Inspector General (OIG) produces a work plan that outlines the agency’s focus for the upcoming year. With a staff of over 1,700 professionals, the OIG, among other things, conducts provider investigations and audits. Below we discuss some of the highlights from the OIG 2013 Work Plan.
Provider Onsite Visits
The OIG will review the frequency of the Centers for Medicare and Medicaid Services (CMS) onsite provider and supplier enrollment and revalidation visits to evaluate whether additional visits will reduce program vulnerabilities. CMS is not only authorized to conduct onsite visits at any time to verify enrollment information but, pursuant to the Affordable Care Act, onsite visits are required for moderate and high risk providers.
Verifying Practice Locations
The OIG provides that Medicare providers and suppliers must have physical locations with street addresses recognized by US Postal Service, not commercial mailboxes, and the facilities must be of adequate size with permanent, visible signs. This year, the OIG will initiate a new program to verify the extent to which Part B providers and suppliers meet this location requirement. The agency has indicated that it has evidence that certain individuals attempting to defraud Medicare have established commercial mailboxes to skirt this requirement.
Focus on Physicians
The OIG will evaluate the extent to which physicians and other healthcare providers are complying with assignment rules, i.e., the extent of inappropriate billing of beneficiaries. Physician use of proper place-of-service codes will also be examined in this fiscal year.
OIG also has several reviews under way for evaluation and management codes for 2010. Providers’ use of EHR will also be examined. The agency has observed that “Medicare contractors have noted an increased frequency of medical records with identical documentation across services.”
Anesthesia And Ophthalmological Services
OIG will be analyzing Part B claims for personally performed anesthesia services for compliance with Medicare billing and reimbursement requirements. Furthermore, ophthalmological services are also on the agency’s agenda for the first time as it seeks to identify questionable billing practices.
Laboratory Tests
OIG indicated that since 1998 payments made for laboratory services increased by 92%, for a total of $7 billion in 2008. The agency attributed this growth to an increase in volume of ordered tests. This year’s workplan includes an analysis of 2010 laboratory billings to identify questionable practices.
Diagnostic Radiology
OIG will be analyzing Medicare payments made for high-cost diagnostic radiology tests for medical necessity and reasonableness.
Independent Physical Therapists With High Utilization Rates
OIG will review services of independent physical therapists with a high utilization rate for outpatient physical therapy services for medical necessity and reasonableness.
Chiropractic Services
Prompted by prior work which identified improper payments for chiropractic services, the agency indicated that it will focus its attention on chiropractic billing practices. Medicare covered chiropractic services only include treatment by means of manual manipulation of the spine to correct subluxations while chiropractic maintenance therapy is not considered to be medically reasonable or necessary.
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