6 Medicare Reimbursement Issues on OIG’s Radar in 2015

In 2014, the Office of the Inspector General of the U.S. Department of Health and Human Services (OIG) reported “expected recoveries of over $4.9 billion.” The agency also excluded 4,017 individuals and entities and took 971 criminal actions. Similarly, the OIG pursued 533 civil actions against individuals and entities. According to the agency’s 2015 work plan, this year promises to be just as busy for the regulators.

1. More Scrutiny of DME/Pharmacy Claims

The agency has several on-going review projects related to durable medical equipment suppliers. Some of the issues it is evaluating this year include: (a) automatic shipment of continuous positive airway pressure system and respiratory-assist device supplies when no physician order for refills were in effect (supplies provided periodically must have orders of medical necessity that specify the type of supplies needed and frequency of use or replacement); (b) payments made to multiple suppliers for test strips and lancets when LCDs state that DMEs may not dispense test strips and lancets until beneficiaries have nearly exhausted the previously dispensed supplies (and beneficiaries must specifically request refills prior to dispensing); (c) the use of appropriate modifier on claims for home blood glucose test strips and lancet supplies.

2. Personally Performed Anesthesia Services

The OIG will be evaluating Medicare claims for payments made for personally performed anesthesia services versus medically directed services. “Reporting an incorrect service code modifier on the claim as if services were personally performed by an anesthesiologist when they were not will result in Medicare’s paying higher amount,” noted OIG’s report.

3. Medical Necessity of Chiropractic Treatments

Chiropractic services continue to be the focus of OIG reviews. Medicare will only pay for manual manipulation of the spine to correct subluxation if there is a neuro-musculoskeletal condition for which such manipulation is an appropriate treatment. Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is not reimbursed by Medicare. OIG’s prior work has identified unallowable Medicare payments and questionable billing patterns for chiropractic services.

4. Unusual Claims by Independent Clinical Laboratories

Payments to independent clinical labs will also be scrutinized by the OIG who will focus its attention on outlier independent clinical labs. Prior OIG audits and investigations found independent clinical labs at risk for non compliance with Medicare billing requirements.

5. Questionable Ophthalmology Services

The OIG will be reviewing 2012 billing data for potentially inappropriate and questionable ophthalmology services. This is an on-going issue of concern for the agency in part stemming from the $6.8 billion for services paid for by Medicare to this one specialty in 2010 alone.

6. Regulatory Compliance of Outpatient Physical Therapy

Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable, not properly documented or not medically necessary. This year the OIG will continue to monitor outpatient physical therapy services billed by independent therapists for compliance with Medicare regulations.

If you have questions about the OIG’s 2015 Work plan, Medicare enrollment, revalidation, exclusion, or sanctions, or have other health law questions, please contact our office.