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2012 OIG Work Plan

February 14th, 2012

The Health and Human Services (HHS) Office of the Inspector General (OIG) is responsible for policing all HHS agencies including fighting fraud and abuse. The OIG conducts investigations in conjunction with other law enforcement agencies such as the Federal Bureau of Investigations (FBI), U.S. Postal Inspection Service and various state Medicaid Fraud Control units. Responsibilities include auditing, investigating and inspecting HHS programs and operations, identifying program weaknesses; leading activities to prevent fraud and abuse from occurring; finding wrongdoers and abusers of HHS programs and applying sanctions when necessary. The OIG may investigate individuals, facilities and entities for services claimed but not rendered or not medically necessary, claims that manipulate codes in an effort to inflate reimbursement amounts and other false claims submitted to obtain program funds.

Below are direct excerpts from the 2012 OIG Work Plan that potentially relate to an OMS office or an individual oral and maxillofacial surgeon.

Medicare Outpatient Dental Claims (New)

We will review Medicare hospital outpatient payments for dental services to determine whether payments for dental services were made in accordance with Medicare requirements. Dental services are generally excluded from Medicare coverage, with a few exceptions. (Social Security Act, § 1862(a)(12).) For example, Medicare reimbursement is allowed for the extraction of teeth to prepare the jaw for radiation treatment (CMS's Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, § 150). Based on current OIG audits, providers received Medicare reimbursement for noncovered dental services that resulted in significant overpayments. (OAS; W-00-12-35603; various reviews; expected issue date: FY 2012; new start)

Physicians and Other Suppliers: High Cumulative Part B Payments (New)

We will review payment systems controls that identify high cumulative Medicare Part B payments to physicians and suppliers. We will determine whether payment system controls are in place to identify such payments and assess the effectiveness of those controls. Medicare Part B services must be reasonable and necessary (Social Security Act, § 1862(a)(1)(A)), adequately documented (§ 1833(e)), and provided consistent with Federal regulations (42 CFR, § 410). A high cumulative payment is an unusually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary, over a specified period. Prior OIG work has shown that unusually high Medicare payments may indicate incorrect billing or fraud and abuse. (OAS; W-00-12-35605; various reviews; expected issue date: FY 2012; new start)

Physicians: Place-of-Service Errors

We will review physicians' coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed. (42 CFR § 414.32.) Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician's office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center. (OAS; W-00-10-35113; W-00-11-35113; various reviews; expected issue date: FY 2012; work in progress)

Physicians: Incident-To Services (New)

We will review physician billing for "incident-to" services to determine whether payment for such services had a higher error rate than that for non-incident-to services. We will also assess CMS's ability to monitor services billed as "incident-to." Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident to a physician office visit. A 2009 OIG review found that when Medicare allowed physicians' billings for more than 24 hours of services in a day, half of the services were not performed by a physician. We also found that unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally. Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose Medicare beneficiaries to care that does not meet professional standards of quality. Medicare's Part B coverage of services and supplies that are performed incident to the professional services of a physician is in the Social Security Act, § 1861(s)(2)(A). Medicare requires providers to furnish such information as may be necessary to determine the amounts due to receive payment. (Social Security Act, § 1833(e).) (OEI; 00-00-00000; expected issue date: FY 2013; new start)

Physicians: Impact of Opting Out of Medicare (New)

We will review the extent to which physicians are opting out of Medicare and determine whether physicians who have opted out of Medicare are submitting claims to Medicare. We will also examine whether specific areas of the country have seen higher numbers of physicians opting out and its potential impact on beneficiaries. Physicians are permitted to enter into private contracts with Medicare beneficiaries. (Social Security Act, § 1802(b).) As a result of entering into private contracts, physicians must commit that they will not submit a claim to Medicare for any Medicare beneficiary. (OEI; 07-11-00340; expected issue date: FY 2012; work in progress)

Ambulatory Surgical Centers and Hospital Outpatient Departments: Safety and Quality of Surgery and Procedures (New)

We will review the safety and quality of care for Medicare beneficiaries having surgeries and procedures in ambulatory surgical centers and Hospital Outpatient Departments (HOPD). We will assess care in preparation for and provided during surgeries and procedures in both settings. We will identify adverse events in both settings. CMS and stakeholders have expressed interest in the comparative safety and quality of care provided by ambulatory surgical centers and HOPDs. When Medicare beneficiaries require certain surgeries or procedures that do not require hospitalization, physicians generally have the option to perform such surgeries or procedures in an ambulatory surgical center, HOPD, or other health care setting such as a physician's office. Site determinations are typically made based on the type of surgery or procedure, as well as the patient's health status and comorbidities. The proportion of surgeries and procedures performed in ambulatory surgical centers has risen substantially over the past decade. (OEI; 00-00-00000; expected issue date: FY 2013; new start)

Evaluation and Management Services: Trends in Coding of Claims

We will review evaluation and management (E/M) claims to identify trends in the coding of E/M services from 2000-2009. We will also identify providers that exhibited questionable billing for E/M services in 2009. Medicare paid $32 billion for E/M services in 2009, representing 19 percent of all Medicare Part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. (CMS's Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. (OEI; 04-10-00180; expected issue date: FY 2012; work in progress)

Evaluation and Management Services Provided During Global Surgery Periods

We will review industry practices related to the number of E/M services provided by physicians and reimbursed as part of the global surgery fee to determine whether the practices have changed since the global surgery fee concept was developed in 1992. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E/M services provided during the global surgery period. The criteria for global surgery policy are in CMS's Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40. (OAS; W-00-09-35207; various reviews; expected issue date: FY 2012; work in progress) HHS OIG Work Plan | FY 2012 Part I: Medicare Part A and Part B Page I-20

Evaluation and Management Services: Use of Modifiers During the Global Surgery Period (New)

We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements. Prior OIG work has shown that improper use of modifiers during the global surgery period resulted in inappropriate payments. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. (CMS's Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40.1.) Guidance for the use of modifiers for global surgeries is in CMS's Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 30. (OAS; W-00-12-35607; various reviews; expected issue date: FY 2012; new start)

Evaluation and Management Services: Potentially Inappropriate Payments

We will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. (CMS's Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013; work in progress)

Part B Imaging Services: Medicare Payments

We will review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expense. Practice expenses are those such as office rent, wages of personnel, and equipment. (Social Security Act, § 1848(c)(1)(B).) For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. (OAS; W-00-11-35219; various reviews; expected issue date: FY 2012; new start)

Medicare Payments for Part B Claims with G Modifiers

We will review Medicare payments made from 2002 to 2010 for claims on which providers used certain modifier codes indicating that Medicare denial was expected. We will determine the extent to which Medicare paid claims having such modifiers. We will also identify providers and suppliers with atypically high billing related to the modifiers. Providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary. (CMS's Claims Processing Manual.) They may use GX or GY modifiers for items or services that are statutorily excluded. A recent OIG review found that Medicare paid for 72 percent of pressure-reducing support surface claims with GA or GZ modifiers, amounting to $4 million in potentially inappropriate payments. (OEI; 02-10-00160; expected issue date: FY 2012; work in progress)

Payments for Services Ordered or Referred by Excluded Providers

We will review the nature and extent of Medicare payments for services ordered or referred by excluded providers (those who have been barred from billing Federal health care programs) and examine CMS's oversight mechanisms to identify and prevent payments for such services. No payments shall be made for any items or services furnished, ordered, or prescribed by excluded individuals or entities. (Social Security Act, §§ 1128 and 1156, and 42 CFR § 1001.1901.) (OEI; 00-00-00000; expected issue date: FY 2013; new start)