2011 OIG Work Plan: Things You Should Know
In an effort to promote efficiency and eliminate waste, fraud, and abuse, the Office of Inspector General (OIG) takes a look at Medicare and Medicaid programs every year. In doing so, it provides an annual work plan stipulating areas of these programs that require monitoring and investigation by components of the OIG (Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General). During the fiscal year, these offices typically audit and review Medicare Part A and B claims to determine whether providers billed appropriately for services they furnished. They also ensure that Medicare contractors and/or Medicaid programs correctly paid for these services. The OIG releases the details of its findings in reports that show the methodology for determining payment or billing errors and recommendations to the CMS to recoup erroneous payments. Also, the Medicare Recovery Audit Contractors monitor the improper payment trends identified by the OIG to use as they select new issues to audit in Medicare Parts A and B claims. AAO-HNS staff reviewed the 2011 work plan and identified key areas of focus for otolaryngologist—head and neck surgeons. The OIG will review: Medicare excessive payments to find out if they are appropriate and how effective the claims processing system edits are in identifying incorrect high payments. Medicare payments for Part B imaging services to find out whether these payments appropriately represent the practice expense components and whether the current equipment utilization rates accurately reflect current industry practices. (For 2011, the utilization assumption rate for expensive [priced over $1 million] advanced imaging equipment is 75 percent.) Medicare Part B paid claims and medical records for interpretations and reports of diagnostic radiology services (X-rays, CTs, and MRIs) performed in emergency hospital settings to determine whether the payments were appropriate. Medicare payments for observation services provided during outpatient visits in hospitals and whether hospitals’ use of observation services affects the care that Medicare beneficiaries receive and their ability to pay for out-of-pocket expenses. Medicare Part B claims to determine whether physicians appropriately reported the correct place of service codes (Medicare pays a higher amount when a service is performed in a non-facility setting [ambulatory surgical center or physician’s office] compared to when it is performed in a facility setting [in-patient hospital]). The appropriateness of the process for setting ambulatory surgical center (ASC) reimbursement rates under the revised ASC payment system. Evaluation and Management (E&M) Services to determine whether coding patterns vary by provider characteristics. How E&M services are incorrectly paid and the consistency of medical reviews for paid E&M claims. The E&M claims of providers who have identical documentation across all of their performed services to determine any electronic health record documentation practices associated with potential improper payments. Industry practices related to the number of E&M services provided by physicians and paid as part of the global surgery fee to verify whether these practices have changed since the global surgery fee concept was created. Whether Medicare appropriately paid for sleep studies, examine the factors contributing to the surge in billing, and evaluate provider compliance with the Federal requirements for sleep studies. The appropriateness of Medicare reimbursement for sleep test procedures performed in sleep disorder clinics. Medicare payments for high-cost diagnostic tests to determine whether they were medically necessary. The extent to which providers comply with assignment rules (for participating and non-participating providers) and determine whether providers are inappropriately balance-billing Medicare beneficiaries in excess of the Medicare allowed amounts. Medicare Part B claims that providers bill as “not reasonable and necessary” services (identified by modifiers GA or GZ) to determine the types of providers and services associated with these claims and evaluate the policies that Medicare contractors have for handling these types of claims. Appropriateness of providers’ use of modifier GY (services that are not covered by Medicare). Medicare Part A and B claims submitted by top error-prone providers based on expected dollar error amounts and will recoup these improper payments. Incentive payments made to eligible professionals under the Medicare and Medicaid EHR incentive program to ensure they were accurately made. Because the work plan mainly focuses on providers’ compliance to CMS’s guidelines, we cannot stress enough the importance of documentation; when submitting claims E&M services (and other procedures) make sure that your documentation supports the level of E&M service you report on your claims. Contact Healthpolicy@entnet.org for your inquiries. Contact the Academy’s coding hotline at 1-800-584-7773 for guidance before submitting your claims. Confirm whether there are edits associated with the code pairs that you are reporting, and use the appropriate modifiers if needed: (Correct Coding Initiative Edits, https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage) Ensure that you are aware of maximum units you can report for a service on the same patient on the same date of service (Medically Unlikely Edits–MUEs– https://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage). Remember global periods for procedures when submitting claims. Take advantage of the Academy’s CPT for ENT articles (http://www.entnet.org/Practice/cptENT.cfm) and other resources (http://www.entnet.org/practice/Guidelines.cfm) as you prepare claims for submission. View the complete 2011 OIG work plan at http://oig.hhs.gov/publications/workplan/2011/. Reference Office of Inspector General 2011 Work Plan. Accessed at http://oig.hhs.gov/publications/workplan/2011/ on November 9, 2010
During the fiscal year, these offices typically audit and review Medicare Part A and B claims to determine whether providers billed appropriately for services they furnished. They also ensure that Medicare contractors and/or Medicaid programs correctly paid for these services. The OIG releases the details of its findings in reports that show the methodology for determining payment or billing errors and recommendations to the CMS to recoup erroneous payments. Also, the Medicare Recovery Audit Contractors monitor the improper payment trends identified by the OIG to use as they select new issues to audit in Medicare Parts A and B claims.
AAO-HNS staff reviewed the 2011 work plan and identified key areas of focus for otolaryngologist—head and neck surgeons. The OIG will review:
- Medicare excessive payments to find out if they are appropriate and how effective the claims processing system edits are in identifying incorrect high payments.
- Medicare payments for Part B imaging services to find out whether these payments appropriately represent the practice expense components and whether the current equipment utilization rates accurately reflect current industry practices. (For 2011, the utilization assumption rate for expensive [priced over $1 million] advanced imaging equipment is 75 percent.)
- Medicare Part B paid claims and medical records for interpretations and reports of diagnostic radiology services (X-rays, CTs, and MRIs) performed in emergency hospital settings to determine whether the payments were appropriate.
- Medicare payments for observation services provided during outpatient visits in hospitals and whether hospitals’ use of observation services affects the care that Medicare beneficiaries receive and their ability to pay for out-of-pocket expenses.
- Medicare Part B claims to determine whether physicians appropriately reported the correct place of service codes (Medicare pays a higher amount when a service is performed in a non-facility setting [ambulatory surgical center or physician’s office] compared to when it is performed in a facility setting [in-patient hospital]).
- The appropriateness of the process for setting ambulatory surgical center (ASC) reimbursement rates under the revised ASC payment system.
- Evaluation and Management (E&M) Services to determine whether coding patterns vary by provider characteristics.
- How E&M services are incorrectly paid and the consistency of medical reviews for paid E&M claims.
- The E&M claims of providers who have identical documentation across all of their performed services to determine any electronic health record documentation practices associated with potential improper payments.
- Industry practices related to the number of E&M services provided by physicians and paid as part of the global surgery fee to verify whether these practices have changed since the global surgery fee concept was created.
- Whether Medicare appropriately paid for sleep studies, examine the factors contributing to the surge in billing, and evaluate provider compliance with the Federal requirements for sleep studies.
- The appropriateness of Medicare reimbursement for sleep test procedures performed in sleep disorder clinics.
- Medicare payments for high-cost diagnostic tests to determine whether they were medically necessary.
- The extent to which providers comply with assignment rules (for participating and non-participating providers) and determine whether providers are inappropriately balance-billing Medicare beneficiaries in excess of the Medicare allowed amounts.
- Medicare Part B claims that providers bill as “not reasonable and necessary” services (identified by modifiers GA or GZ) to determine the types of providers and services associated with these claims and evaluate the policies that Medicare contractors have for handling these types of claims.
- Appropriateness of providers’ use of modifier GY (services that are not covered by Medicare).
- Medicare Part A and B claims submitted by top error-prone providers based on expected dollar error amounts and will recoup these improper payments.
- Incentive payments made to eligible professionals under the Medicare and Medicaid EHR incentive program to ensure they were accurately made.
Because the work plan mainly focuses on providers’ compliance to CMS’s guidelines, we cannot stress enough the importance of documentation; when submitting claims E&M services (and other procedures) make sure that your documentation supports the level of E&M service you report on your claims.
Contact Healthpolicy@entnet.org for your inquiries. Contact the Academy’s coding hotline at 1-800-584-7773 for guidance before submitting your claims. Confirm whether there are edits associated with the code pairs that you are reporting, and use the appropriate modifiers if needed:
(Correct Coding Initiative Edits, https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage)
Ensure that you are aware of maximum units you can report for a service on the same patient on the same date of service (Medically Unlikely Edits–MUEs– https://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage).
Remember global periods for procedures when submitting claims.
Take advantage of the Academy’s CPT for ENT articles (http://www.entnet.org/Practice/cptENT.cfm) and other resources (http://www.entnet.org/practice/Guidelines.cfm) as you prepare claims for submission.
View the complete 2011 OIG work plan at http://oig.hhs.gov/publications/workplan/2011/.
Reference
- Office of Inspector General 2011 Work Plan. Accessed at http://oig.hhs.gov/publications/workplan/2011/ on November 9, 2010