As is the case every year, in October the Office of Inspector General for the Department of Health and Human Services (“OIG”) released its new Work Plan for the upcoming year. This Work Plan is an important guide for physicians, hospitals and other providers to focus on areas of compliance that the OIG considers to be areas of potential risk or abuse to the Medicare program. The Work Plan provides insight not only into areas that the OIG may investigate, but also assists providers in focusing on areas where compliance is particularly important in the every day delivery of health care services. Given the continued Governmental effort to contain ever spiraling health care costs, the desire of President-elect Obama to dramatically expand the scope of healthcare insurance coverage with attendant additional costs for the taxpayer, and the stated intent of members of Congress such as Senator Baucus to focus on actual or perceived fraud and abuse among the small percentage of unscrupulous providers, attention to the 2009 Work Plan is particularly in order.
In terms of areas of focus for physicians, the Work Plan identifies several specific subjects into which the OIG will inquire. First, the OIG is going to review for place of service errors in connection with physician coding of Part B claims where the physician performs those services in an ambulatory surgical center or hospital outpatient department. In this respect, Medicare generally will pay a higher professional fee when the service is performed in a physician’s office rather than in an ambulatory surgical center or hospital The OIG will attempt to ensure that this higher fee is warranted or whether a facility setting is inappropriately being coded for professional services.
On a related note for surgical specialists, the OIG also will review the number of evaluation and management services that physicians provide and that are reimbursed as part of a global surgery fee. Under a global fee, physicians are to bill a single fee for services performed during the global surgery period. Evidently, OIG suspects that claims for evaluation and management are being routinely submitted that otherwise should be reimbursed only through the global fee.
Of significant interest to orthopedists and rehabilitation specialists, the OIG will review physical therapy services that independent therapists provide to determine whether therapy services are not reasonable, medically necessary or properly documented. In this connection, independent therapists who have a high utilization rate for outpatient physical therapy will come under scrutiny.
OIG again will provide scrutiny to billing for services that are incident to a physician’s professional services. OIG believes that these services may be at risk for overutilization or for the provision of medically unnecessary services to enhance reimbursement.
Geographic areas with a high density of independent diagnostic testing facilities will come under scrutiny. Diagnostic procedures independent of a physician’s office of hospital are performed at an IDTF. The OIG will continue its past review of these entities, referral patterns to these entities, profiles of providers utilizing these entities, and billing patterns. Though not stated in the Work Plan, it is reasonable to assume that OIG will focus attention on improper inducements to refer, physician supervision of testing at facilities, and the appropriateness of certain self reading arrangements at such facilities.
In light of the rapid increase in the provision of sleep lab studies, the OIG will focus on the appropriateness of payments for sleep lab studies. Medicare will reimburse for sleep lab studies for patients who have symptoms of sleep apnea, narcolepsy, impotence or parasomnia. The OIG will inquire to determine whether patients are being inappropriately coded for these studies when they exhibit no such symptoms.
Of significant interest to gastroenterologists and general surgeons, the OIG also will delve into reimbursement for claims for colonoscopy. This procedure usually requires that a patient be placed under sedation in a hospital outpatient setting or ambulatory surgical center. The OIG will look at the coding of these claims and particularly providers who may be outliers in terms of submission of claims for these procedures.
Additionally, the OIG will look at expenses associated with various types of practices. The issue of practice expense is a huge issue in determining the weight and attendant reimbursement that CMS will make for professional services across the specialty spectrum. In light of the anticipated battle over the next iteration of the Physician Fee Schedule this inquiry is incredibly important to physicians.
The Work Plan contains a number of additional areas of emphasis for physicians, ranging from improper reassignment of benefits, to a furnishing fee for blood clotting factor, to overutilization of ultrsonagraphy. It is incumbent upon physicians to understand the OIG’s emphasis and refocus attention to ensure compliance with the maze of regulations, as the vast majority of physicians intend.
The OIG also will make a concerted focus on certain areas of hospital operations that are of interest to physicians employed by hospitals as well as medical staff members. Among other issues, the OIG will focus on provider based reimbursement under 42 C.F.R. 413.65. In that connection, hospitals may obtain enhanced reimbursement for services provided as a department of a hospital if they meet certain strict requirements, which vary depending upon whether the services are provided on a hospital’s campus or off campus. Among these factors include clinical and financial integration, licensure, public awareness, internal reporting and supervision requirements, and additional integration requirements for off campus facilities.
The OIG also will focus on bad debts claimed by hospitals, whether hospitals meet the requirements for (and accompanying reimbursement paid to) a hospital that is designated as a critical access hospital, and whether a hospital is in fact entitled to claim disproportionate share payments made to hospitals that service a significantly disproportionate share of indigent and low income patients. Of significant additional interest is the fact that the OIG will review CMS’ oversight of hospitals’ compliance with the Emergency Medical Treatment and Labor Act of 1986 (“EMTALA”). There is significant concern about delays by CMS in investigating alleged EMTALA violations. Among the other areas of interest for hospitals is a review of never events, or serious medical errors, in the Medicare population.
This is just a short review of the many issues that the OIG indicates it will tackle in 2009. There will clearly be significant scrutiny to the submission of claims for durable medical equipment, prosthetics, orthotics and supplies across the board. It clearly is incumbent upon physicians to ensure that their ordering of such equipment is warranted. There will also be scrutiny given to payments to dialysis facilities for EPO, payments for chemotherapy drug administration services, utilization of albuterol and a host of other matters in which physician involvement is integral. Finally, there will certainly be continued, close scrutiny to the relationship between physicians and pharmaceutical and medical device companies.
