OIG 2017 Work Plan – Physician Practice Impacts


Totaling over 100 pages this year, you can download the OIG 2017 Work Plan here on our website. It was issued on November 15, 2016.  This is the second year in a row the OIG has issued its plan during the usual time of year.  A Thanksgiving gift for everyone involved in healthcare!

The OIG 2017 Work Plan is published annually to describe the new and on-going reviews, audits and other activities of the Office of Inspector General of the Department of Health and Human Services.  This year, the 2017 OIG Work Plan also includes a listing of completed, new and removed audits, a first for this document!

The OIG 2017 Work Plan and Physician Practice Impacts

The OIG is undertaking two new audits of physician services in the OIG 2017 Work Plan.

Medicare Payments for Transitional Care Management (TCM)

Medicare began covering transitional care management services by physicians on January 1, 2013.  TCM services are supposed to be provided to patients whose medical and/or psychological issues require moderate or high-complexity medical decision-making during transitions from one level of care to another.  An example would be when a patient is being discharged from an acute care setting to a community setting such as home.  The OIG will look to see if physicians also billed for chronic care management, end-stage renal disease and prolonged services without patient contact during the same period as transition care management was billed.

Medicare Payments for Chronic Care Management (CCM)

Since January 1, 2015, Medicare has been paying separately for non-face-to-face services to beneficiaries who have multiple significant chronic conditions.  Examples include Alzheimer’s disease and cancer. CCM cannot be billed during the same period as TCM, home health supervision/hospice care or certain ESRD physician services are being provided.  The OIG 2017 Work Plan addresses issues about overlapping billing of these services during the CCM period of time.

The OIG 2017 Work Plan and Physician Practices – Continuing Reviews

The OIG 2017 Work Plan will continue looking at several other issues that were initiated during prior year(s) OIG Work Plan.

  • Physician orders for Medicare services, supplies and DMEPOS. Physicians and non-physicians who order such services must be enrolled in Medicare and be legally eligible to refer/order the services to be payable by Medicare.
  • Anesthesia non-covered services.  The OIG is looking at a sample of Part B anesthesia claims to determine if they are supported with documentation in accordance with Medicare requirements.
  • Physician home visits.  The OIG is looking for documentation of the medical necessity of home visits, in lieu of an office visit.
  • Prolonged services.  CMS considers the necessity of prolonged services in acute settings to be rare and unusual, but physicians are billing for such services more frequently.  The OIG will look at medical record documentation to validate the necessity of prolonged services.
  • Anesthesia Services personally performed.  Modifiers are required on claims for anesthesia services to confirm they were personally performed by a physician or were medically directed.  The OIG is looking at claims to ensure they reflect coding appropriate to the physician services performed.

What does the OIG 2017 Work Plan mean to my practice?

The OIG 2017 Work Plan covers a great many issues, some directly reflecting billing practices of hospitals, physicians and other providers, and some reflecting the performance of government departments such as the Centers for Disease Control and Prevention and the National Institutes of Health.


For physician practices, it indicates areas of focus for the OIG related to claims payment and medical record documentation.  The results of OIG audits may eventually find their way into changes in requirements for billing that meets Medicare guidelines.  Medical practices should look at the OIG 2017 Work Plan audits and reviews, and consider incorporating appropriate audits into their own Compliance Programs.

And if a medical practice does not have a Compliance Program, it should adopt one now!  The day is coming when all health care entities billing Medicare will have to have an effective Compliance Program as a condition in participating in Medicare.  So, start now, and avoid the rush!


When you need proven expertise and performance

Cindy Winn, MBA, CHSP

Ms. Cindy Winn has over 20 years of healthcare experience and expertise in operations, project management, and is certified as a HIPAA Security Professional (CHSP).

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