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Prepare Your Practice for Medicare's Expanded Fraud and Abuse Program

Prepare Your Practice for Medicare's Expanded Fraud and Abuse Program

CMS is stepping up its fraud and abuse efforts, and looking closely at physicians and their practices. To mitigate the very real risks facing your practice, you should sit down with your administrative team and review all facets of your compliance plan. Ask the difficult questions, dig deep — far better that your practice finds deficiencies than Uncle Sam. While it may seem like a Herculean task, when broken down, it is a manageable process. Here are the key components to defending your practice against fraud and abuse findings.

1. The OIG work plan

The Office of Inspector General (OIG) is the financial watchdog for the federal government; charged with ensuring our tax dollars are spent wisely and properly; don't laugh. OIG is required by law to publish an annual work plan that identifies all existing and planned federal fraud, waste, and abuse initiatives.

Some of the areas being scrutinized include:

• The medical necessity of sleep studies

• A review of 2010 E&M coding and documentation to assess the presence of EHR cloning

• Non-compliance with assignment of benefit guidelines

•The medical necessity of electro-diagnostic testing

• High cumulative Part B payments

• Same-day readmissions

The OIG Work Plan will seem intimidating at first download, but it is organized rather well and has a good table of contents. Review the table of contents and probe deeper into facets that could affect your practice.

2. Medical necessity

There are several agencies that publish medical necessity guidelines with which you should be familiar. First, there is the aforementioned OIG Work Plan. Second, Medicare provides medical necessity guidance via National Carrier Determinations. Medicare also provides medical necessity guidance at the state level via Local Coverage Determinations.

Finally, there are payer- and specialty-specific guidelines regarding medical necessity, such as the ABIM Foundation's "Choosing Wisely" campaign. It is too much to take in and keep track of, but I encourage you at a minimum to understand the medical necessity guidelines for any service being targeted by OIG.

3. Recovery Audit Contractors

Recovery Audit Contractors, or RACs, are Medicare contractors charged with finding improper payments. They target incorrect payments, noncovered services (including services that are not reasonable and necessary), incorrectly coded services, and duplicate services. RACs are paid on a commission, ranging from 9 percent to 12.5 percent. The more they find in "improper" payments, the more money they make.  They are on course to find $3 billion in improper payments this year and make commissions exceeding $300 million. That is not a typo, sadly.

There are four RACs, Performant, CGI, Connolly, HealthDataInsights, and each is required to publish a list of approved work issues (aka targets) on their websites. As I noted, each RAC is required to publish a list of the areas where they will focus their energies. Their lists are long and cumbersome, but it is prudent for each practice to know of any exposures they may have. It takes only 10 minutes to 15 minutes to review your RAC's list of approved issues.


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