OIG Work Plan 2016 – Impact on Physician Providers

The OIG Work Plan 2016 has been issued as of November 2, 2015, in accordance with the usual schedule for these OIG Work Plans.  We strongly encourage all physician providers to review the OIG Work Plan 2016 for timely topics that can influence their own corporate compliance work plans for next year.

The OIG Work Plan is published annually to describe the new and ongoing reviews, audits and other activities of the Office of Inspector General of the Department of Health and Human Services.  It gives insight into areas the OIG considers important to review for the coming year.  It is a great resource that should be cross-referenced with your own compliance plan.  And be sure to check out our general introduction to the OIG Work Plan 2016 you can also find on our website.

OIG Work Plan 2016 and Physician Practices and Services – Carry-over Audits

As usual, there are several carry-over topics in the OIG Work Plan 2016, some of them being carried over for a third year!

  • Anesthesia services – payments for personally provided services, as differentiated from services that were medically directed, is still on the OIG’s list of audits.  Here they are looking for the correct modifier, “AA” for services personally performed, “QK” for services medically directed.
  • Sleep Disorder Clinics – high use of sleep-testing procedures.  This is an effort to assess the appropriateness of Medicare payments for high-use sleep-testing procedures; were they were ordered and performed in accordance with Medicare requirements?
  • Imaging Services – payments for practice expenses.  This review of imaging services practice expenses can influence the amount of Medicare payments for practice expenses in the future.

OIG Work Plan 2016 New Audits related to Physician Practices and Services

There are four new audit efforts in the OIG Work Plan 2016 that relate directly to physician practices.

Physicians referring/ordering Medicare services and supplies

The OIG Work Plan 2016 is looking at the qualifications of physicians and non-physician practitioners who order supplies, equipment and other services for Medicare patients.  Such services must be ordered by physicians and non-physicians practitioners who are enrolled in Medicare and are legally eligible to refer/order the services to be payable by Medicare.

  • What might this lead to?  Claims for services/supplies for Medicare patients may be denied if they are not ordered by  qualified physicians/practitioners.
  • What should you do? Make sure providers are enrolled with Medicare before they order or refer patients for services or supplies.  Otherwise, if the practice is the entity providing the service or supply, it may not get its claims paid by Medicare in the future.

Anesthesia non-covered services

This review will look at a sample of Part B anesthesia claims to determine if they are supported with documentation in accordance with Medicare requirements.

  • What might this lead to?  Medicare may deny claims for anesthesia services that do not meet the test of being medically necessary covered benefits.
  • What should you do?  If you are providing anesthesia services, especially in an outpatient setting, make sure the service you are providing is not subject to restrictions by diagnosis or other factors due to Local Coverage Determinations or National Coverage Determinations.

Physician home visits

Costs to Medicare for physician home visits rose to $559m between January 2013 and 2015.  Documentation of the medical necessity of home visits, in lieu of an office visit, is required.

  • What might this lead to?  Physicians performing home visits may be subject to denial of payment for such claims if the medical necessity of a visit to the patient in the patient’s domicile is not established.
  • What should you do?  Review the guidelines from the local RAC for establishing the medical necessity of a home visit, and fully document other aspects of evaluation and management, e.g., history, exam and plan.

Prolonged services

Prolonged services are additional care provided by physicians after an evaluation and management service has already been performed.  Prolonged services are becoming more frequent, especially in acute care settings where coordination of care in hospitals and with other specialists is necessary and can be complicated.  CMS considers the necessity of prolonged services to be rare and unusual.

  • What might this lead to?  CMS may apply more scrutiny to such claims, possibly even instituting pre-payment reviews for physicians billing such services frequently.
  • What should you do?  Medical documentation and coding audits, done internally, that involve billing for prolonged services, is important. Making sure the necessity for prolonged services is well-documented.

While these audits of physician and other providers/suppliers are specific to physicians/practitioners, the OIG Work Plan 2016 covers several other areas as well, many involving physicians as the ordering entity.  As noted above, we recommend downloading a copy of the OIG Work Plan 2016 and reviewing it for the direct and indirect implications for your practice.



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.