OIG Work Plan – Impact on Medicare Part B Providers in 2013

OIG Work Plan and Physicians

The Office of the Inspector General (OIG) released its 2013 Work Plan early in October.  This OIG Work Plan is the annual publication that contains descriptions of new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the next 12 months and beyond.  You can learn more about the layout and organization of the document in our previous post, “OIG Work Plan for 2013 – a first look“.

The OIG Work Plan for physicians and other Part B providers addresses both the common and uncommon

The OIG Work Plan always covers a wide range of topics.  Some are rather esoteric and may affect a very small range of individuals or organizations. For example, how many providers are affected by a review of the claims for equipment costs as part of NIH grants, or the audit of the President’s Emergency Plan for AIDS Relief Funds?

But other issues up for review in the OIG Work Plan may eventually affect a great many providers and organizations, especially if the OIG review reveals weaknesses in the systems CMS and its Medicare Administrative Contractors (MACs) use to process and pay claims for services.

Consequently, I strongly recommend that you download a copy of the OIG 2013 Work Plan, and do so with each and every year so that you’re able to keep informed on areas of review that may involve your own healthcare business.  I also recommend that each of those areas of OIG review that do affect your business be incorporated into your own compliance plan for internal review and auditing.

A few samples from the OIG Work Plan for 2013

The following are summaries of just a three excerpts from the OIG Work Plan for 2013 as they relate to physicians and other Part B providers.  I also address the implications for providers in the future, and what providers should do to examine their own situation.

  • Program Integrity – Medical Review of Part A and Part B Claims Submitted by Top Error-Prone Providers

This review combines two techniques that CMS and some of its MACs have used in the past to estimate and recoup provider over-payments.   The OIG will use a data-mining technique from the CMS Comprehensive Error Rate Testing (CERT) program to identify providers who consistently submitted erroneous claims to Medicare.  Then the OIG will compare these providers to claims submitted as listed in the National Claims History file, and calculate a percentage of the dollar amount of erroneous claims for the provider.  The OIG will conduct a medical records review of selected services to assess the medical record documentation that supports the claims.

What might this lead to?  Some Part B providers are already subjected to down-coding (and decreased payment) of claims by the MAC, leaving the provider to appeal the lower payment, and submitting medical record documentation to support the original claim.  Providers who became labeled as “error prone” may have a similar process applied to their claims.  Claims will simply be paid at a lower rate, and the provider left to appeal.

So what should you do?  Take a look at your percent of claims that are returned for resubmission due to errors.  A great many errors can be detected by up-to-date billing software, and by clearinghouse “claims scrubbing”.  If claims are still being denied after local and clearinghouse scrubbing, you may need to look in depth at the reasons for denials and how denials of your claims can be avoided.


  • Noncompliance with Assignment Rules and Excessive Billing of Beneficiaries

This OIG Work Plan review will focus on physicians and suppliers who do not comply with assignment rules and who may be billing beneficiaries in excess of the amounts allowed by Medicare.

What might this lead to?  Providers who come under scrutiny in this audit may be subject to requirements to refund excess amounts collected from beneficiaries.  CMS may even apply an excess collection percentage to these providers, and ask for refunds for all Medicare patients treated, on the basis that the excess collections apply to all patients billed in the last year or two.

What should you do?  Make sure your billing/accounts receivable system can track Medicare payment amounts posted to accounts, and ask for reports that demonstrate there are no excess collections from Medicare patients.  And if you bill for non-covered services, make sure an up-to-date Advance Beneficiary Notice is in use in your office, and that you are using appropriate modifiers on claims that have a mix of covered and non-covered services.


  • Error Rate for Incident-To Services Performed by Non-physicians

Incident-To services are those professional services performed by non-physicians, usually physician assistants (PAs) or nurse practitioners (NPs) but also by medical assistants, medical technologists, nurse midwives and others.  Billing government programs for these services are governed by a relatively complex set of regulations.  In some cases, the lack of understanding of these regulations (or the outright noncompliance!)  has resulted in errors in claims submission and payment for incident-to services.  The OIG Work Plan for 2013 includes a review which will attempt to determine whether payment for incident-to services had a higher error rate than non-incident-to services.

What might this lead to?  Data mining may reveal physicians who appear to be providing more services in a 24 hour period than one individual could possibly provide.  Of course this is possible for a busy physician supervising two or three PAs or NPs.  But it may point CMS or the MAC to an audit target to make sure services are medically necessary, and provided by qualified personnel who are supervised in accordance with the regulations.

What should you do?  Get information on the requirements for billing for incident-to services and make sure you are following the rules!  Medicare’s Medical Learning Network has a relatively plain English description of the Incident-to rules in its MLN SE0441, and NHIC, Corp. issued a more extensive discussion of the rules covering PAs, NPs, Clinical Nurse Specialists and Certified Nurse-Midwives.  The 2009 OIG report that found errors and use of unqualified nonphysicians is also worth reviewing.

More on the 2013 OIG Work Plan to come …

There are a total of 14 review projects covering Other Providers and Suppliers in the 2013 OIG Work Plan.  In future posts we’ll delve into some additional areas of particular interest in the coming year’s plan.  We’ll help explain some of the areas being audited, and provide you with suggestions about how you can use this information to make sure that your own organization remains proactive and compliant.  So bookmark us, and check back often … or better yet, subscribe to our feed!


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.