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2014 Work Plan Highlights for Physicians

On January 31, 2014, the Office of Inspector General (“OIG”) finally released its Work Plan for fiscal year 2014. The Work Plan is a dense summary of the OIG’s various enforcement priorities for the year. This overview is specifically for physicians, hospitals, and other health care providers. Some of this year’s plan’s significant focus areas are discussed below.

Place-of-service coding errors

Federal reimbursement regulations, including Medicare regulations, provide different levels of payment depending on the setting of the performed services. Non-facility or physician clinic payments are higher than many hospital-based payments. Specifically, OIG will be looking at the services provided in ambulatory surgical centers and hospital outpatient departments to see whether miscoding with respect to the site of services is a source of Medicare overpayment and as such can be recovered from providers.

Inappropriate E&M payments

The OIG will be analyzing whether payments for physician’s evaluation and management services are correct. Because electronic medical records present the opportunity to “cut and paste,” OIG will be specifically examining whether electronic records have diminished the accuracy and, in some cases, the appropriateness of billing for E&M services. 

Utilization of laboratory tests, diagnostic radiology, and sleep disorder clinics

According to OIG, there has been a high utilization rate of lab tests, diagnostic testing, and independent diagnostic facilities for sleep-testing procedures. The OIG plans to review the appropriateness of test ordering, billing, and payment practices.

Chiropractic services

Prior audits and research conducted by the OIG revealed payments for chiropractic services that were medically unnecessary or improperly documented. One of OIG’s new initiatives is to determine the extent of such questionable billing for chiropractic services, including identifying chiropractic maintenance therapy billing, which Medicare does not reimburse. In addition, the OIG will be examining Medicare Part B payments to verify that the claims were billed properly in accordance with Medicare rules.

Ophthalmological services

The 2012 Medicare claims data will be reviewed with respect to ophthalmological services (and their geographic location) in order to identify questionable billing practices and/or inappropriate payments.

Assignment rules

Physicians participating in Medicare receive payment on “assignment” for all services provided to Medicare beneficiaries. The OIG plans to examine physicians’ non-compliance with assignment rules and excessive billing of beneficiaries.

Physician Compare website

The Physician Compare website, which helps Medicare beneficiaries choose a health care provider, will be examined for informational accuracy.

On Thursday, the OIG’s initiatives for nursing facilities, hospice, and home health services will be discussed, so be sure to check back if you are involved with one of these entities.

This article is intended as a summary of newly enacted federal and state law and does not constitute legal advice.

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