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The Inspector General posts this year’s most-wanted list

October seems a little early to be making a list and checking it twice, but October is when the Office of Inspector General publishes its annual Work Plan, giving health care providers a peek at the surprises the agency has in store for the new fiscal year. The Work Plan for fiscal 2010 contains over 350 projects. As usual, the majority of them are continuing projects or projects from prior Work Plans that have not been completed. Among the projects that are new to the list this year are several that are of particular interest to physicians.

In the area of physician payment, the OIG plans to examine the extent to which Medicare- participating physicians bill beneficiaries for amounts in excess of the allowed fees. Participating physicians are required to take assignment for all services provided to Medicare beneficiaries, and must accept the Medicare fee schedule amount as payment in full for those services. The OIG wants to determine how often physicians and other suppliers bill beneficiaries for higher amounts, and whether beneficiaries are aware of their rights under the Medicare assignment rules.

Another project that is new this year concerns charges to beneficiaries for services that are excluded from Medicare coverage by statute. Because providers are not required to notify beneficiaries in advance of charges for statutorily non-covered services, beneficiaries sometimes incur personal responsibility for unexpectedly large medical bills. The OIG will examine claims submitted to Medicare with the modifier GY, which denotes a statutorily non-covered service, to look for trends and patterns. According to the Work Plan, Medicare received over 75 million claims with the GY modifier during fiscal year 2008.

On the Stark front, the OIG will focus on physician referrals to durable medical equipment suppliers in which physicians hold ownership interests. The Stark statute and regulations prohibit almost all referrals of Medicare patients to DME suppliers in which the referring physicians have ownership interests. Some physicians in rural areas qualify for an exception to this prohibition, but there is no other Stark exception that protects these referrals. The OIG will review Medicare payments for DME to determine whether those payments are allowable under the Stark rules.

The OIG will investigate the extent to which Medicare has made payment for services ordered or referred by providers who are excluded from participation in the Medicare program. The Medicare statute prohibits payment for services ordered or referred by excluded physicians, as well as for services performed by excluded physicians. However, the edits in the claims processing systems used by Medicare Administrative Contractors flag claims only when the billing provider has been excluded, and do not check for excluded secondary providers such as ordering, referring, supervising or attending physicians. The OIG will also examine the adequacy of the mechanisms currently in place to prevent payment for services ordered or referred by excluded physicians.

The Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) and the American Recovery and Reinvestment Act of 2009 (ARRA) authorized incentive payments to health care providers for adoption of electronic health record (EHR) and electronic prescribing technologies. These incentives are the subject of several OIG initiatives for the coming year. The agency will review Medicare payments to physicians who qualify as “successful electronic prescribers” based on their e-prescribing activities during 2009. MIPPA defines a successful electronic prescriber in a physician who reports the Physician Quality Reporting Initiative e-prescribing quality measure in at least 50 percent of the cases in which that quality measure is reportable. The OIG will investigate the extent to which CMS has made erroneous payments under this statute, and the adequacy of its efforts to remedy those erroneous payments.

The OIG will conduct a similar assessment of Medicaid incentive payments to providers for adoption of EHR’s in several states. The health information technology provisions of ARRA, known as the HITECH Act, authorized these incentive payments to encourage providers to implement certified EHR technology. As with the Medicare eprescribing incentive payments, the OIG’s review will focus on determining the extent of erroneous payments and the effectiveness of remedial provisions adopted by CMS.

examine CMS’s procedures for preventing duplication of EHR incentive payments. ARRA authorizes both Medicare and state Medicaid programs to make EHR incentive payments, but provides that health care professionals may not receive incentive payments from both programs. The OIG will attempt to determine the effectiveness of CMS’s measures to prevent duplicate payments. A related OIG project will examine the health information technology improvements to CMS’s own systems, to assess the adequacy of the systems’ security controls.

As is usually the case, the 2009 Work Plan includes a number of projects that focus on specific categories of Medicare-covered services. This year, the OIG intends to examine the practice expense component of physician fee schedule payments for imaging services. The agency wishes to determine how closely Medicare payments for practice expenses correspond to the actual expenses incurred in providing covered imaging services. Among other things, the OIG wants to determine whether the assumptions about the utilization rate that underlie the practice expense calculations reflect current practices.

The OIG intends to review Part B immunosuppressive drug claims to determine whether they were billed according to their FDA-approved labels. The OIG will also examine off-label use of drugs and biologicals used in chemotherapeutic cancer regimens. To determine whether these drugs were used in a cost-effective manner, the agency will assess whether patients had trials of FDA-approved drugs before the nonapproved drugs were prescribed.

The approaching implementation of Medicare’s competitive bidding program for DME has prompted the OIG to plan a review to determine whether suppliers that are awarded competitive bidding program contracts solicit physicians to prescribe certain brands or modes of delivery in order to maximize their profits. The OIG will also examine DME suppliers’ billing patterns to determine whether those patterns change after the rollout of the competitive bidding program.

The Work Plan items that are carried over from last year include a review of Medicare payments for polysomnography. A sharp increase in Medicare payments for a particular service in a relatively short time inevitably catches the OIG’s attention and often leads to a review. Medicare expenditures for polysomnography increased from approximately $62,000,000 to $215,000,000 between 2001 in 2005, and have continued to increase since. The OIG is responding with an investigation into the appropriateness of Medicare payments for polysomnography and the factors leading to the increase in utilization.

Also carried over from the 2009 Work Plan is a study of reassignment of physicians’ right to receive Medicare payments. Based on earlier investigations in Florida, the OIG believes that some suppliers are collecting Medicare payments on the basis of fraudulently- obtained reassignments without the knowledge of the physicians. The OIG intends to examine the extent to which physicians are aware of the reassignments filed under their names.

Another continuing project concerns place-of-service codes for services provided in ambulatory surgery centers and hospital outpatient departments. The OIG will try to determine whether physicians are using inappropriate place-of-service codes for these services in order to maximize their reimbursement. Another project will examine Medicare payments for physician services provided to hospice beneficiaries. Some physician services provided to hospice beneficiaries are separately billable to Part B, while others are included in the hospice’s Part A per diem payment. The OIG is concerned about double-billing of services to both Part A and Part B.

For 2010, the OIG has once again set an ambitious agenda for itself. Providers should be certain that they understand the issues identified in the Work Plan as subjects of OIG activity in the coming year, and should take those issues into account in planning their compliance activities for the new year