OIG Work Plan 2014 – Impact on Physician Providers

OIG Work Plan 2014 for Physicians

The OIG Work Plan 2014, after four months of delay, has finally been issued, and it has several areas of focus that should be of interest for physician providers.  The OIG Work Plan is the annual publication that contains descriptions of both new and ongoing reviews and activities that Office of the Inspector General of the Health and Human Services Department plans to pursue during 2014. It’s a great resource that should be cross-referenced with your own compliance plan. And with that in mind, each year we provide a review for the benefit of physicians.  You may also be interested in a general introduction to the OIG Work Plan, and forces that are driving the OIG’s diligence.

The OIG Work Plan 2014 covers several area of interest to physician providers

Here are several of the more notable projects that the OIG is focusing on in their Work Plan for 2014 as they pertain to physicians, along with some additional insights that you should consider and be proactive about.

Physicians – Place-of-service coding errors

Part B providers such as physicians receive higher payment for professional services rendered in non-facility settings.  Facility settings, like hospital outpatient departments and ambulatory surgery centers, carry a lower payment rate for the professional component of services.  Previously, the OIG has determined that physicians have not always coded the place of service correctly.

  • What might this lead to?  The OIG audit of these services as part of the OIG Work Plan 2014 will provide the OIG and CMS with an estimate of the scope of the problem, and may result in provider audits for providers with modest rates of facility services where the service reported (or the associated diagnosis) is commonly performed in a facility.
  • What should you do?  If you are a Part B provider who renders services in a facility setting some of the time or even all of the time, make sure your system for identifying the place of service for billing purposes is airtight.  And make sure your billing staff questions the place of service when the diagnosis is inconsistent with the location.

Evaluation and Management Services – Inappropriate payments

So-called “inappropriate payments” for E&M services has long been a topic for CMS.  RACs and other review organizations have been reviewing E&M services for several years now, but the emphasis on this aspect of the OIG Work Plan 2014 is documentation using electronic health records.  In particular, Medicare contractors are noting identical documentation in patient records from the same provider.

  • What might this lead to?  The OIG will attempt to identify vulnerabilities in medical record documentation related to use of electronic or paper health records.  They will also evaluate the payment for E&M services based on medical record documentation.
  • What should you do?  One of the most important aspects of an effective compliance program is conducting internal monitoring and auditing.  If you have not done it recently, you should conduct or commission a medical records/billing audit, where your medical record documentation is compared to the E&M code submitted to payors.  Further, if you use an electronic health record system where you can “cut and paste” descriptions of patient conditions, assessments and/or treatment plans, make sure the documentation is pertinent to the patient you are recording it for.  It is very easy when using this technique to gloss over words or phrases that do not apply to the next patient, making you vulnerable to charges of violating Medicare requirements for accurate documentation that supports the level of service reported.

Ophthamologists – Questionable Billing

In 2010, Medicare allowed over $6.8 billion for services provided by opthamologists.

  • What might this lead to?  The OIG will survey Medicare claims data to identify inappropriate billing and/or questionable payments for ophthalmological services in 2012.  This may result in efforts to recoup payments deemed inappropriate based on medical necessity.
  • What should you do?  The best defense against audits by outside entities besides responding to the audit request is to perform your own internal review of medical record documentation as part of an effective compliance program.

Electrodiagnostic Testing – Questionable Billing

Electrodiagnostic testing includes services designed to diagnose and treat nerve or muscle damage.  The specific tests include needle electromyograms (EMG) and nerve conduction tests.  The OIG will attempt to identify divergent patterns of use of these tests, by provider specialty, diagnosis and geographic area.

  • What might this lead to?  To the extent the OIG finds what it considers inappropriate use of these tests, there may be follow-up audits that focus on very specific geographic areas and providers.
  • What should you do?  It may be sounding like a broken record, but an internal audit conducted as part of a an effective compliance program is the best way to discover if you have a problem that may surface as the OIG or a RAC starts asking for medical records.

Sleep disorder clinics – high utilization of sleep-testing procedures

An OIG analysis in 2010 showed high utilization of certain sleep-testing procedures, including CPT codes 95810 and 95811.

  • What might this lead to?  OIG is looking at the issue of duplicative testing done after an initial test is performed, and where the results of the initial test are still clinically pertinent.  In such cases, Medicare may not consider additional testing medically necessary.
  • What should you do?  Physicians ordering or performing sleep studies should ensure they are not duplicating testing where the results of previous testing are still clinically relevant.  Claims for such testing may be denied and CMS may even consider such testing and billing to be an abusive billing process, leading to sanctions against the provider.

The OIG Work Plan 2014 also includes audit topics from 2013

In 2013, the OIG Work Plan identified Noncompliance with assignment rules and excessive billing of beneficiaries as an issue for audit and review.  This topic is carried over to the OIG Work Plan 2014, so Part B providers should examine their internal practices for following those rules.

Physician Practices and other Part B providers may also be impacted by audits of other services such as ambulance services, anesthesia services, diagnostic radiology and imaging and several others.  We strongly recommend every physician practice download a copy of the OIG Work Plan 2014, and incorporate review of applicable practices or services identified in the Work Plan into their own compliance activities for the year.

When you need proven expertise and performance

Jim Hook, MPH

Mr. James D. Hook has over 30 years of healthcare executive management and consulting experience in medical groups, hospitals, IPA’s, MSO’s, and other healthcare organizations.