The Office of Inspector General (OIG), which oversees Medicare and Medicaid enforcement, has issued its 2015 Work Plan highlighting the compliance risk areas that it will target in its review and enforcement efforts. You will see some familiar topics, which the OIG also included in last year’s plan, such as chiropractic services, place of service reporting, physical therapy, ophthalmologists, hospital staff privileging, and security of networked medical devices at hospitals.
Here’s a summary of some of the issues the OIG has said it plans to take a close look at, which may be relevant to medical offices:
Anesthesiology services. The OIG is concerned about Medicare Part B claims for “personally performed anesthesia services.” Claims submitted with an AA service code modifier must be for services personally performed by the anesthesiologist. The OIG is concerned some claims are incorrectly indicating the service was personally performed by the anesthesiologist when they weren’t. This is a concern because personally performed services get paid at a higher rate.
Chiropractic services. Once again this year, chiropractors are in the spotlight. The OIG is concerned with inappropriate payments for chiropractic services and, like last year, the Work Plan mentions manual manipulation of the spine. The OIG explains that Medicare Part B only reimburses this service if there is a “neuro-musculoskeletal condition for which such manipulation is appropriate treatment.” It also notes chiropractic maintenance therapy is not deemed medically reasonable or necessary. The OIG also notes questionable billing practices found in past reviews of chiropractic claims and reminds that Medicare only pays for manual manipulations or treatment of subluxations of the spine when there is “a reasonable expectation of recovery or improvement of function.” Finally, the OIG indicates it will be reviewing data from prior audits and reviews of chiropractic claims and identifying “trends in payment, compliance, and fraud vulnerabilities” and will make recommendations for avoiding these risks.
Diagnostic Radiology. The OIG is questioning medical necessity of high cost diagnostic radiology tests and will be reviewing whether use of these tests has increased. So if physicians are ordering such tests, they may want to be aware of this OIG concern.
Imaging Services. The OIG will be reviewing payments for these services to see if they match expenses incurred and it will be checking if utilization rates concur with industry practices. The expenses include office rent, wages, and equipment.
Ophthalmologists. Like chiropractic services, this specialty is a continuing concern for the OIG, carrying over from last years’ Work Plan. The OIG is looking for “potentially inappropriate and questionable billing” for these services.
Place of Service. Another recurring issue for the OIG is place of service. The OIG is focused on services physicians render in ambulatory surgery centers and hospital outpatient departments. The OIG wants to see that proper place of service is noted because it affects the reimbursement level. Higher payment results when the service is performed in a physician office, for example, than in a hospital outpatient department or in an ambulatory surgical center.
Physical Therapy. The OIG continues its scrutiny of outpatient physical therapy services provided by independent therapists for compliance with Medicare regulations. Prior reviews revealed to the OIG such services weren’t always reasonable or medically necessary or properly documented. Therapists with high outpatient utilization rate are a focus of their review.
Sleep disorders. The OIG will be looking at claims from physicians, hospital outpatient departments, and independent diagnostic testing facilities for sleep-testing procedures. Specifically, the OIG is concerned about high utilization for services reflected by CPT© Codes 95810 and 95811. The OIG notes repeat tests may not be reasonable and necessary.
Health Information Technology. The OIG remains concerned about networked medical devices at hospitals and how well hospitals are protecting security of information gathered by such devices. While this only applies to hospitals, it is a reminder to medical offices and all providers of the seriousness of protecting the security of patient data collected or stored on all devices.
