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2013 Office of Inspector General Work Plan

December 12th, 2012

The Health and Human Services (HHS) Office of the Inspector General (OIG) is responsible for policing all HHS agencies, such as the Centers for Medicare and Medicaid Services. Its main focus is to detect and/or eliminate 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.

Every fall, the OIG releases its work plan for the following fiscal year. Below are direct excerpts from the 2013 OIG Work Plan that may potentially relate to an OMS office or an individual oral and maxillofacial surgeon. This area of focus may later result in policy or reimbursement changes. Being familiar with these areas in which the OIG is monitoring improper payments or abuse may help in understanding why Medicare requests overpayments to be refunded or claim audits may be performed. Being familiar of these issues also serves as a reminder to be sure that claims are coded appropriately.

Hospitals-Payments for Canceled Surgical Procedures (New)
The OIG will determine costs incurred by Medicare related to inpatient hospital claims for canceled surgical procedures. Our preliminary analysis of Medicare claims data for inpatient stays demonstrated significant occurrences of an initial PPS payment to hospitals for a canceled surgical procedure followed by a second, higher PPS payment to the same hospitals for the rescheduled surgical procedure. For these claims, the canceled surgical procedure was the principal reason for the initial hospital admission.

For these short-stay claims, few, if any, inpatient services (i.e., laboratory or diagnostic tests) were provided by the hospitals because the surgical procedure was canceled. Medicare makes two payments to hospitals that generate two bills unless the patient is readmitted to the hospital on the same day, in which case a single payment is made. Our analysis also identified inpatient claims with canceled surgical procedures for stays of less than 2 days that were not followed by subsequent inpatient admissions to the same hospitals for the rescheduled surgical procedures. Current Medicare policy does not preclude payment for these claims. (OAS; W-00-13-35626; various reviews; expected issue date: FY 2013; new start)

Hospital Outpatient Dental Claims
The OIG will review Medicare hospital outpatient payments for dental services to determine whether such payments 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). As indicated by current OIG audits, providers received Medicare reimbursement for noncovered dental services, which resulted in significant overpayments. (OAS; W-00-13-35603; various reviews; expected issue date: FY 2013; new start)

Hospitals-Outpatient Observation Services During Outpatient Visits
The OIG will describe the use of observation services from 2008 to 2011 and the characteristics of beneficiaries receiving observation services in 2011. We will also determine how much Medicare and beneficiaries paid for observation and related services in 2011 and the extent to which hospitals inform beneficiaries about observation services. Part B coverage of hospital outpatient services and reimbursement for such services under the hospital outpatient PPS are provided by the Social Security Act, §§ 1832(a) and 1833(t).) Observation services are short-term treatments and assessments that hospitals use to determine whether a beneficiary should be admitted as an inpatient or discharged. (CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 4, § 290.) Improper use of observation services may subject beneficiaries to high cost sharing. (OEI; 02-12-00040; expected issue date: FY 2013; work in progress)
Ambulatory Surgical Centers-Payment System
The OIG will review the appropriateness of Medicare’s methodology for setting ambulatory surgical center (ASC) payment rates under the revised payment system. In addition, we will determine whether a payment disparity exists between the ASC and hospital outpatient department payment rates for similar surgical procedures provided in both settings. Federal law required the Secretary to implement a revised payment system for payment of surgical services furnished in ASCs beginning January 1, 2008. (Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), § 626.) (See also 42 CFR § 416.171). (OAS; W-00-10-35423; W-00-11-35423; W-00-12-35423; various reviews; expected issue date: FY 2013; work in progress)
Ambulatory Surgical Centers and Hospital Outpatient Departments-Safety and Quality of Surgery and Procedures
The OIG will review the safety and quality of care for Medicare beneficiaries having surgeries and procedures in ASCs 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 ASCs and HOPDs. When Medicare beneficiaries require certain surgeries or procedures that do not require hospitalization, physicians generally have the option of performing such surgeries or procedures in an ASC; an HOPD; or other health care setting, such as a physician’s office. Site determinations are typically made on the basis of the type of surgery or procedure, as well as the patient’s health status and co morbidities. Surgeries and procedures performed in ASCs have risen substantially over the past decade. (OEI; 00-00-00000; expected issue date: FY 2014; new start)
Part B Imaging Services-Payments for Practice Expenses
The OIG 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. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. Practice expenses are those such as office rent, wages, and equipment. 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 expenses. (Social Security Act, § 1848(c)(1)(B).) (OAS; W-00-12-35219; W-00-13-35219; various reviews; expected issue date: FY 2013; work in progress and new start)
Physicians: Error Rate for Incident-To Services Performed by Non-physicians
The OIG 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 non-physicians 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 non-physicians 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: Place-of-Service Errors
The OIG 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 non-facility 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)
Evaluation and Management Services-Potentially Inappropriate Payments in 2010
The OIG will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 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 on the basis of 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)
Evaluation and Management Services-Use of Modifiers During the Global Surgery Period
The OIG 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 such a period were in accordance with Medicare requirements. Prior OIG work found 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-00-13-35607; various reviews; expected issue date: FY 2013; new start)
Claims Processing Errors-Medicare Payments for Part B Claims With G Modifiers (New)
The OIG will determine the extent to which Medicare improperly paid claims from 2002 to 2011 in which providers entered GA, GX, GY, or GZ service code modifiers, indicating that Medicare denial was expected. Providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary pursuant to 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 2013; work in progress)
National Provider Identifier Enumeration and Medicare Provider Enrollment Data
The OIG will review the extent to which national provider identifier (NPI) enumeration data and Medicare Provider Enrollment, Chain, and Ownership System (PECOS) data are complete, consistent, and accurate and assess CMS’s supporting processes. Federal law requires the Secretary of HHS to establish a standard unique identifier for each health care provider, health care organization, and health plan for use in the health care system. (Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Secretary established the NPI to address this requirement. Separately, Federal regulations require providers to enroll to receive payment from Medicare. (42 CFR § 424.505.) PECOS is the system CMS uses to complete the enrollments online. (OEI; 07-09-00440; expected issue date: FY 2013; work in progress)
Dental Services for Children-Inappropriate Billing (New)

The OIG will review Medicaid payments by States for dental services to determine whether States have properly claimed Federal reimbursement. Dental services are required for most Medicaid eligible individuals under age 21 as a component of the Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT) services benefit. (Social Security Act, §§ 1905(a)(4)(B) and 1905(r).) Federal regulations define "dental services" as diagnostic, preventative, or corrective procedures provided by or under the supervision of a dentist. (42 CFR § 440.100.) Services include the treatment of teeth and the associated structure of the oral cavity and disease, injury, or impairment that may affect the oral cavity or general health of the recipient. Prior work indicates that some dental providers may be inappropriately billing for services. (OAS; W-00-10-31135; W-00-11-31135; W-00-12-31135; various reviews; expected issue date: FY 2013; work in progress)

Dental Services for Children-Billing Patterns in Five States (New)

The OIG will review billing patterns of pediatric dentists and their associated clinics in five selected States. Medicaid covers comprehensive dental care for approximately 30 million low-income children through the EPSDT benefit. Under EPSDT, States must cover dental services and dental screening services for children. OIG investigations have identified numerous vulnerabilities with pediatric dental care, particularly with the care provided by certain for-profit dental chains. (OEI; 02-12-00330; expected issue date: FY 2014; work in progress)

States’ Readiness to Comply With Exchange and Medicaid Eligibility and Enrollment Requirements

The OIG will review States’ progress in complying with new eligibility and enrollment requirements for the Exchanges, Medicaid, CHIP, and health subsidy programs. We will also identify what steps States have already taken to meet these requirements, what additional steps States plan to take, and challenges or barriers that States report regarding the implementation of eligibility and enrollment systems. We will also determine the extent to which CMS has provided guidance and technical assistance to States to meet the streamlined eligibility and enrollment requirements. (OEI; 07-10-00530; expected issue date:
FY 2013; work in progress; Affordable Care Act)

Medicare-Incentive Payments for Electronic Health Records

The OIG will review Medicare incentive payments to eligible health care professionals and hospitals for adopting electronic health records (EHR) and the Centers for Medicare & Medicaid Services (CMS) safeguards to prevent erroneous incentive payments. An EHR is an electronic record of health-related information for an individual that is generated by health care providers. It may include a patient’s health history, along with other items. The American Recovery and Reinvestment Act of 2009 (Recovery Act) authorized Medicare incentive payments over a 5-year period to physicians and hospitals that demonstrate meaningful use of certified EHR technology. (§§ 4101 and 4102.) Incentive payments were scheduled to begin in 2011 and continue through 2016, with payment reductions to health care professionals who fail to become meaningful users of EHRs beginning in 2015. (§ 4101(b).) According to Congressional Budget Office (CBO) estimates, CMS’s net spending for incentives will total about $20 billion. We will review Medicare incentive payment data from 2011 to identify payments to providers that should not have received incentive payments (e.g., those not meeting selected meaningful use criteria). We will also assess CMS’s plans to oversee incentive payments for the duration of the program and actions taken to remedy erroneous incentive payments. (OEI; 05-11-00250; expected issue date: fiscal year (FY) 2013; work in progress; OAS; W-00-13-31352; expected issue date: FY 2013; new start; Recovery Act)