On Friday, January 31, 2014, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released the 2014 Work Plan outlining key priorities in overseeing the health and welfare of the country.
The OIG was established to help maintain the authority, integrity, and efficacy of the HHS, and each year releases a report covering the key areas they will monitor. Specifically, those priorities seek to detect and prevent fraud, waste, and abuse; identify opportunities to improve program economy, efficiency, and effectiveness; and hold accountable those who do not meet program requirements or who violate federal law. According to the Work Plan introduction, in 2013, OIG activities resulted in $5.8 billion in expected recoveries, $19.4 billion in savings based on OIG recommendations enacted by law, 3,214 individuals and entities excluded from Federal Health Programs because of violations, 960 criminal actions, and 472 civil actions.
The new work plan covers fiscal year 2014 which technically began in October 2013. While the plan is broad in scope, a few key target areas caught our attention.
Place of Service
Several OIG priorities seek to sort out the variations in billing guidelines based on where a service happens. New in 2014, the OIG will determine the impact of new criteria for inpatient admissions, aka “the two midnight rule,” on hospital billing, as well as review how billing trends varied among hospitals. Patients needing two or more nights in the hospital may be billed as inpatient, but patients needing less than two nights in the hospital should be billed as outpatient.
Also new this year, the OIG also will review and compare Medicare payments for office visits in provider-based clinics (located in a hospital or facility) versus free-standing clinics. Because provider-based services often are reimbursed at a higher level, the OIG will scrutinize the guidelines of qualification as a “provider-based” facility.
Another new item on the OIG list relative to place of service is a review of all outpatient evaluation and management codes billed as new patients to determine if they should have been billed as established patients. Established patients are those who have been registered as an inpatient or outpatient at the hospital within the past 3 years, and they are reimbursed at a lower payment level. If patients were coded as “new” when they actually were “established” by definition, the OIG will recommend a recovery of payments.
Finally, the OIG continues to review the differences in payments between Ambulatory Surgical Centers and hospital outpatient departments to look for disparities in payment rates for the same procedures in these two different settings. Also, as in past years, the OIG is reviewing physician coding on claims for services in ambulatory surgical centers and hospital outpatient departments to ensure the proper place of service is indicated. Non-facility services, like in a physician’s office, are reimbursed at a higher rate than ASC or outpatient “facility” services.
After examining claims for ambulance services in the past to determine medical necessity, level of transport, and the viability of a transport, the OIG will now analyze and synthesize that data to identify vulnerabilities and make recommendations for improvement. Ongoing reviews of ambulance service also are planned.
After examining claims for chiropractic services in the past to determine medical necessity, proper documentation, and fraudulent activity, the OIG will now analyze and synthesize that data to identify vulnerabilities and make recommendations for improvement. Ongoing reviews of chiropractic services also are planned, specifically to look for trends suggestive of maintenance therapy which is not covered under Medicare Part B.
The OIG will continue to review Medicare Part B claims to determine whether an anesthesiologist personally performed services when reported with an AA modifier or whether the services were medically directed by the Anesthesiologist, in which case the QK modifier would have been appropriate and the payment reduced to 50 percent.
Evaluation and Management Services
Targeted in 2013, evaluation and management (E&M) services continue to be a target issue for the OIG as they consider whether the transition to electronic health records (EHR) has created documentation vulnerabilities and inflated E&M billing.
Program Management Issues
While more and more information about physicians is being made public on the Physician Compare Web site, the OIG will work to ensure the data the Centers for Medicare and Medicaid Services (CMS) publishes accurately reflects the physicians’ practices. Particularly, the OIG will monitor the accuracy of the Provider Enrollment, Chain, and Ownership System (PECOS).
Also, the OIG will work to identify any active Medicare providers who have not billed Medicare for services in more than 12 months. Federal regulations permit CMS to deactivate providers who fall into that category, but previous OIG work found many idle Medicare providers who had not billed Medicare in that time frame but were still considered active.
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