OIG Work Plan 2015 – Impact on Physician Providers

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Download the OIG 2015 Work Plan

The OIG Work Plan 2015 is being issued “on time” this year, unlike 2014 when it came out 4 months late.  Perhaps that’s because there are fewer new topics the OIG will consider in 2015.  In any case, all providers should review the OIG Work Plan 2015 for topics, both new and continuing, that may involve the services they provide.

The OIG Work Plan is an annual publication; it describes the new and continuing review activities the Office of Inspector General of the Health and Human Services Department will be pursuing in 2015.  Any physician practice with a formal compliance program (and that should be pretty much all of them, according to some of the US attorneys who prosecute health care fraud!) should review the OIG Work Plan 2015 and take the OIG reviews into account.   You may also be interested in a general introduction to the OIG Work Plan 2015, and the forces driving the OIG’s efforts.

OIG Work Plan 2015 and Physician Practices and Services

One of the major changes in the OIG Work Plan 2015 is the lack of a review of physician Evaluation and Management (E&M) coding, which had been an OIG focus for a few years.  Of course, there are still several areas of review covering physician services, most of which are ongoing.

Outpatient evaluation and management services billed at the new patient rate (carry over from 2014)

The OIG has not completely stopped evaluating the use of E&M coding since they are continuing their project related to billing for new patient visits in the hospital clinic setting.  In this case, they are evaluating the use of new patient visit E&M codes for patients seen in a hospital outpatient clinic.

The standard for considering a patient “new” vs. “established” is similar whether the place of service is a hospital outpatient clinic.  A new patient is one who has not been seen by the same physician – or a physician in the same group with the same specialty – in the past 3 years.  When the place of service is a hospital outpatient department, any registration of the patient as an outpatient who received professional medical services, fulfills the standard, and the patient must be considered an established patient.

  • What might this lead to? CMS may attempt to recoup payments for claims submitted for patients as new, when they have bee seen before.
  • What should you do?  Physicians and the staff who support them in hospital-based clinics should be sure to code their E&M encounters for visits properly, recognizing that a patient may be considered an established patient when they have been to a hospital outpatient clinic previously.

Place-of-Service coding errors (carry over from 2014)

Since Medicare pays a higher amount when a service is performed in a physician office vs. a facility setting, such as a hospital clinic, and since the place of service coded for such services may be inaccurate, the OIG is interested in determining how such inaccuracies may impact the costs borne by Medicare.

  • What might this lead to?  The OIG audit of these services as part of the OIG Work Plan 2015 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.

Ophthamologist – Questionable Billing (carry over from 2014)

The release of data on Medicare reimbursement in April 2014 showed payments to ophthamologists are among the largest of any medical specialty.  The OIG plans to review Medicare claims data from 2012 to identify potentially inappropriate and questionalble billing for these services in 2012.

  • What might this lead to?   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.

Sleep Disorder Clinics – high utilization of sleep-testing procedures (carry over from 2014)

An OIG analysis in 2010 showed high utilization of certain sleep-testing procedures, including CPT codes 95810 and 95811, which resulted in payments in CY 2012 of $415 million just for these two CPT codes.

  • 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.

Anesthesia Services – Payments for personally performed services (carry over from 2014)

Medicare pays a higher amount when claims contain the modifier “AA”, denoting the services were personally performed by an anesthesiologist, vs. a service that was medially directed by an anesthesiologist.

  • What might this lead to?   This may result in efforts to recoup payments deemed inappropriate based on improper coding of services.
  • What should you do?  Review your systems for coding claims with modifiers to make sure the correct modifier is  listed on each claim.

Physician Practices and other Part B providers may also be impacted by audits of other services such as ambulatory surgical centers, ESRD facilities, diagnostic imaging and several others.  We strongly recommend every physician practice download a copy of the OIG Work Plan 2015, and incorporate review of applicable practices or services identified in the Work Plan into their own compliance activities for the year

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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.