Office of Inspector General (OIG) Physician Work Plan 2008
Place of Service (POS) Errors
Evaluation & Management (E&M) Services
Incident-to Services
Assignment Rules by Medicare Providers
High Frequency Chiropractic Treatments
Adjustments for Graduate Medical Education (GME) Payments
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- Place of Service (POS) Errors
- Review physician coding of POS on claims performed in ambulatory surgical centers (ASC) & hospital outpatient departments
- Medicare pays a physician a higher amount when a service is performed in a non-facility setting (physician’s office)
- Evaluation & Management (E&M) Services During Global Surgery Periods
- "Incident-to" Services
- Review medical necessity, documentation & quality of care for "incident-to" services
- Assignment Rules by Medicare Providers
- Review providers that may be billing beneficiaries in excess of amounts allowed by Medicare requirements & assess beneficiary awareness of the potential violations
- Business Relationships & the Use of MRI Under the Medicare Physician Fee Schedule
- Review relationships among physicians, billing providers, & others who work together to provide imaging services & determine whether these relationships affect levels of utilization
- Interventional Pain Management Procedures
- 2005 – Medicare paid nearly $2 billion for pain management
- Will determine the appropriateness of payments for pain management & assess the oversight of these procedures
- Geographic Areas With a High Density of Independent Diagnostic Testing Facilities (IDTF)
- IDTF is a facility that performs diagnostic procedures independent of a physician’s office or hospital
- Review service profiles, provider profiles, beneficiary profiles & billing patterns
- 2006 OIG review found numerous problems
- Non-compliance with Medicare standards
- Improper payments
- High Frequency Chiropractic Treatments
- Prior OIG work found that 40% of chiropractic services were for maintenance therapy & did not meet Medicare coverage criteria
- $186 million in improper payments
- Review appropriateness of Medicare payments for high frequency chiropractic claims
- Physician Reassignment of Benefits
- Review the extent to which Medicare physicians reassign their benefits to other entities
- A large number of reassignments may be indicative of fraudulent or abusive activity
- Adjustments for Graduate Medical Education (GME) Payments
- Will review audit adjustments for direct & indirect GME that fiscal intermediaries (FI’s) make while settling Medicare cost reports
- Will determine whether the adjustments were appropriately reflected in the revised Medicare reimbursement
- Inpatient Prospective Payment System (IPPS) Wage Indices
- Will review hospital & Medicare controls over the accuracy of the hospital age data for CMS to calculate wage indices for IPPS
- Prior OIG review found hundreds of millions of dollars in misreported wage data
- Will determine whether hospitals have complied with Medicare requirements for reporting wage data & determine the effect on the Medicare program of incorrect DRG reimbursement caused by inaccurate wage data
- Inpatient Hospital Payments for New Technologies
- Will determine whether hospitals have submitted claims in accordance with the criteria & were appropriately reimbursed for costs associated with the new devices & technologies
- Long Term Care Hospital (LTCH) Payments for Interrupted Stays
- Interrupted stay occurs when a beneficiary is discharged from an LTCH to certain kinds of facilities & then returns to the same LTCH within specified periods of time
- Will determine if payments for interrupted stays made to LTCH’s were correct
- LTCH Short Stay Outliers
- Review payments for cases discharged from LTCH’s with LOS well below the average for their DRG’s, which are referred as short stay outliers (SSO)
- Provider Bad Debts
- Review Medicare bad debts claimed by acute care IP hospitals, LTCH’s, IP rehab facilities, IP psych facilities & SNF’s to determine whether they were reimbursable
- Compliance with Medicare’s Transfer Policy
- Review coding of claims submitted by hospitals for erroneously coded discharges that should have been coded as transfers
- Payments for Diagnostic X-Rays in Hospital Emergency Departments (ED)
- Review a sample of Medicare Part B paid claims & medical records for diagnostic x-rays performed in hospital ED’s to determine the appropriateness of payments
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