The OIG will review claims for
frequently replaced medical equipment supplies to determine whether medical
necessity, frequency, and other Medicare requirements are met. Prior OIG work found that suppliers
automatically shipped continuous positive airway pressure system and
respiratory-assist device supplies when no physician orders for refills were in
effect. Such claims are deemed
improper. For supplies and accessories
used periodically, orders or certificates of medical necessity must specify the
type of supplies needed and the frequency with which they must be replaced,
used, or consumed.
Beneficiaries or their caregivers
must specifically request refills of repetitive services and/or supplies before
suppliers dispense them. Suppliers
should not initiate refills of orders, and suppliers should not automatically
dispense a quantity of supplies on a predetermined regular basis. Medicare does not pay for items or services
that are “not reasonable and necessary."Ambulatory
Surgical Centers - Payment System
Beginning January 1, 2008, a change
in Federal law required the Secretary to implement a revised payment system for
payment of surgical services furnished in ASCs.
Accordingly, CMS implemented a revised ASC payment system modeled on the
Outpatient Prospective Payment System. The OIG will review the appropriateness
of Medicare’s methodology for setting ambulatory surgical center (ASC) payment
rates under the revised payment system.
The OIG will also determine whether a payment disparity exists between
the ASC and hospital outpatient department payment rates for similar surgical
procedures provided in both settings. Rural
Health Clinics - Compliance With Location Requirements
The Balanced Budget Act of 1997 (BBA)
authorized CMS to remove from the Rural Health Clinic (RHC) program clinics that
do not meet location requirements. In
2005, OIG recommended that CMS promulgate regulations to implement the
BBA. However, CMS has yet to promulgate
the final regulations. As a result, RHCs
that no longer meet eligibility requirements continue to receive enhanced
Medicare reimbursement. The OIG will
determine the extent to which RHCs do not meet basic location requirements and
the extent to which Medicare reimbursements to such clinics are occurring. Anesthesia
Services - Payments For Personally Performed Services
The OIG will review Medicare Part B
claims for personally performed anesthesia services to determine whether they
were supported in accordance with Medicare requirements. The OIG will also determine whether Medicare
payments for anesthesiologist services reported on a claim with the “AA”
service code modifier met Medicare requirements. Physicians report the appropriate anesthesia
modifier code to denote whether the service was personally performed or
medically directed. Reporting an incorrect
modifier on the claim as if services were personally performed when they were
not can result in Medicare’s paying a higher amount. The service code “AA” modifier is used for
anesthesia services personally performed by an anesthesiologist, whereas the QK
modifier limits payment to 50 percent of the Medicare-allowed amount for
personally performed services claimed with the AA modifier. Payments to any service provider are
precluded unless the provider has furnished the information necessary to determine
the amounts due.
Chiropractic
Services
The OIG will compile the results of
prior OIG audits, evaluations, and investigations of chiropractic services paid
by Medicare to identify trends in payment, compliance, and fraud
vulnerabilities and offer recommendations to improve detected
vulnerabilities. Prior OIG work
identified inappropriate payments for chiropractic services that were medically
unnecessary, were not documented in accordance with Medicare requirements, or
were fraudulent. Medicare will not pay
for items or services that are “not
reasonable and necessary for the diagnosis and treatment of illness or
injury or to improve the functioning of a malformed body member.” Part B will pay only for a chiropractor’s
manual manipulation of the spine to correct a subluxation if there is a
neuro-musculoskeletal condition for which such manipulation is appropriate
treatment. Similarly, chiropractic
maintenance therapy is also not considered to be medically reasonable or
necessary and is therefore not payable.
This planned portfolio document will offer new recommendations to
improve Medicare chiropractic vulnerabilities detected in prior OIG work.
Diagnostic
Radiology - Medical Necessity Of High-Cost Tests
The OIG will review Medicare payments
for high-cost diagnostic radiology tests to determine whether they were
medically necessary and the extent to which utilization has increased for these
tests. Medicare will not pay for items
or services that are not “reasonable and necessary.”
Electrodiagnostic
Testing - Questionable Billing
The OIG will review Medicare claims
data to identify questionable billing for electrodiagnostic testing and
determine the extent to which Medicare utilization rates differ by provider
specialty, diagnosis, and geographic area for these services. Electrodiagnostic testing, which assists in
the diagnosis and treatment of nerve or muscle damage, includes the needle
electromyogram and the nerve conduction test.
Coverage for diagnostic testing is provided by the Social Security Act. The use of electrodiagnostic testing for
inappropriate financial gain could pose a growing vulnerability to Medicare.
Evaluation
And Management Services - Inappropriate Payments
The OIG will determine the extent to
which selected payments for Evaluation and Management (E/M) services were
inappropriate. The OIG will also review
multiple E/M services associated with the same providers and beneficiaries to
determine the extent to which electronic or paper medical records had
documentation vulnerabilities. Medicare
contractors have noted an increased frequency of medical records with identical
documentation across services. Medicare
requires providers to select the billing code for the service on the basis of
the content of the service and to have documentation to support the level of
service reported.
Imaging
Services - Payments For Practice Expenses
The OIG will review Medicare Part B
payments for imaging services to determine whether they reflect the expenses
incurred and whether the utilization rates reflect industry practices. For selected imaging services, the OIG will
focus on the practice expense components, including the equipment utilization
rate. Practice expenses are those such
as office rent, wages, and equipment.
Physicians are paid for services pursuant to the Medicare physician fee
schedule, which covers the major categories of costs, including the physician
professional cost component, malpractice costs, and practice expenses.
Laboratory
Tests - Billing Characteristics And Questionable Billing
The OIG will review billing
characteristics for Part B clinical laboratory tests and identify questionable
billing. Medicare’s payments for lab
services in 2008 represented an increase of 92% over payments in 1998. In 2010, Medicare paid about $8.2 billion for
lab tests, accounting for 3% of all Medicare Part B payments. Much of the growth in lab spending has
resulted from the increased volume of ordered services. Part B covers most lab tests and pays 100% of
allowable charges; Medicare beneficiaries do not pay copayments or deductibles
for lab tests. Medicare should pay only
for those lab tests that are ordered by a physician or qualified nonphysician
practitioner who is treating a beneficiary.
Ophthalmologists-Questionable
Billing
The OIG will review Medicare claims
data to identify inappropriate payments and questionable billing for
ophthalmological services during 2012.
The OIG will also determine the geographic locations of providers
exhibiting questionable billing for ophthalmological services in 2012. In 2010, Medicare allowed over $6.8 billion
for services provided by ophthalmologists.
Physicians
- Place-Of-Service Coding Errors
The OIG will review physicians’
coding on Medicare Part B claims for services performed in ASCs and hospital
outpatient departments to determine whether they properly coded the places of
service. Prior OIG reviews determined
that physicians did not always correctly code nonfacility places of service on
Part B claims submitted to and paid by Medicare contractors. Federal regulations provide for different
levels of payments to physicians depending on where services are
performed. Medicare pays a physician a
higher amount when a service is performed in a nonfacility setting, such as a
physician’s office, than it does when the service is performed in a hospital
outpatient department or, with certain exceptions, in an ASC.
Sleep-Disorder
Clinics - High Utilization Of Sleep-Testing Procedures
The OIG will examine Medicare
payments to physicians, hospital outpatient departments, and independent
diagnostic testing facilities for sleep-testing procedures to assess the
appropriateness of Medicare payments for high utilization sleep-testing
procedures and determine whether they were in accordance with Medicare requirements. An OIG analysis of CY 2010 Medicare payments
for CPT Codes 95810 and 95811, which totaled approximately $415 million, showed
high utilization associated with these sleep-testing procedures. Medicare will not pay for items or services
that are not “reasonable and necessary.”
Diagnostic testing that is duplicative of previous testing done by the
attending physician to the extent the results are still pertinent is not
covered because it is not reasonable and necessary under 1862(a)(1)(A) of the Act.
Security
Of Portable Devices Containing Personal Health Information
The OIG will review security controls
implemented by Medicare and Medicaid contractors and at hospitals to prevent
the loss of Protected Health Information (PHI) stored on portable devices and
media, such as laptops, jump drives, backup tapes, and equipment considered for
disposal. Recent breaches related to
Federal computers, including one involving a CMS contractor, have heightened
concerns about protecting sensitive information. The OIG will assess and test contractors’ and
hospitals’ policies and procedures for electronic health information
protections, access, storage, and transport.
OMB recommended that all Federal departments and agencies take action to
protect sensitive information by following the National Institute of Standards
and Technology’s Special Publications 800-53 and 800-53A.
Controls
Over Networked Medical Devices At Hospitals
The OIG will determine whether
hospitals’ security controls over networked medical devices are sufficient to
effectively protect associated electronically protected health information
(ePHI) and ensure beneficiary safety.
Computerized medical devices, such as dialysis machines, radiology
systems, and medication dispensing systems that are integrated with EMRs and
the larger health network pose a growing threat to the security and privacy of
personal health information. Such
medical devices use hardware, software, and networks to monitor a patient’s medical
status and transmit and receive related data using wired or wireless
communications. To participate in the
Medicare program, providers such as hospitals are required to secure medical
records and patient information, including ePHI. Medical device manufacturers provide
Manufacturer Disclosure Statement for Medical Device Security (MDS2) forms to
assist health care providers in assessing the vulnerability and risks
associated with ePHI that is transmitted or maintained by a medical device.
Accuracy
Of The Physician Compare Web Site
The OIG will review CMS’s efforts to
ensure that the Physician Compare Web site contains accurate information on
health care providers. CMS was required
by law to create the Physician Compare Web site, which is intended to help
Medicare beneficiaries make informed choices about their health care by
providing them with information about health care providers. CMS repurposed its Provider Enrollment,
Chain, and Ownership System (PECOS) as its data source for provider information
on Physician Compare. However, prior OIG
work found that the provider information in PECOS was often inaccurate and, at
times, incomplete.
By reviewing the focus areas
identified in the Work Plan, providers can determine where to focus their
compliance program efforts. If you have
any questions regarding the Work Plan, or any issues that may impact your
organization, please contact Thomas Hutchinson at thutchinson@kdlegal.com.