The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its Work Plan for Fiscal Year 2015 (pdf) in late October. The Work Plan summarizes planned areas of focus for investigation and enforcement activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond.
Here are some areas pulled from the 2015 Work Plan (pdf) that affect Medicare Part B and physician services. Note: The work plan contains many other planned areas of focus. It is worth reviewing to learn about other these areas that are not mentioned in the piece.
Physicians: Place-of-service coding errors. OIG will review physicians' coding on Medicare Part B claims for services performed in ambulatory surgery centers (as well as hospital outpatient departments) to determine whether they properly coded the places of service. Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors.
Anesthesiology medical billing: Payments for personally performed services. The OIG will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. OIG indicated it will also determine whether Medicare payments for anesthesia services reported on a claim with the "AA" service code modifier met Medicare requirements. Physicians report the appropriate anesthesia modifier code to denote whether the service was personally performed or medically directed.
Reporting an incorrect service code modifier on the claim as if services were personally performed by an anesthesiologist when they were not will result in Medicare's paying a higher amount. The service code "AA" modifier is used for anesthesia services personally performed by an anesthesiologist, whereas the QK modifier limits payment to 50 percent of the Medicare-allowed amount for personally performed services claimed with the AA modifier.
Chiropractic services: Questionable billing. OIG will determine and describe the extent of questionable billing for chiropractic services. Previous OIG demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services. Although chiropractors may submit claims for any number of services, Medicare reimburses claims only for manual manipulations or treatment of subluxations of the spine that provides "a reasonable expectation of recovery or improvement of function."
OIG will also review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Prior OIG work identified inappropriate payments for chiropractic services furnished during 2006. Subsequent OIG work also identified unallowable Medicare payments for chiropractic services.
Diagnostic radiology: Medical necessity of high-cost tests. OIG will review Medicare payments for high-cost diagnostic radiology tests to determine whether thetests were medically necessary and to determine the extent to which use has increased for these tests. Medicare will not pay for items or services that are not "reasonable and necessary."
Ophthalmologists: Inappropriate and questionable billing. OIG will review Medicare claims data to identify potentially inappropriate and questionable ophthalmology billing for services during 2012. OIG will also determine the locations and specialties of providers with questionable billing.
Imaging services: Payments for practice expenses. OIG will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, OIG will focus on the practice expense components, including the equipment utilization rate. Practice expenses may include 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 insurance costs and practice expenses.
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