Feds Set Fraud Watch List for Physicians in 2012

November 15, 2011

All of the topics on the OIG’s work plan for 2012 fall into the same advice category for physicians: Do what is right.

Ah, the playbook for the government for 2012 has been released. What always amazes me is that professional practice managers, some physicians, and most practice management consultants get really excited about The U.S. Office of the Inspector General’s (OIG) work plan for the next year. Personally, I don’t really care. Sure, I look it over and then I see that it is all about checking and making sure people are not trying to steal from the government or their patients. That translates into one of my mantras, “Do what is right.”

So, what are the main objectives for 2012? The following is a list that is not comprehensive but that is helpful:

* Compliance with assignment rules
* Physician-Owned distributors of spinal implants
* “Incident-to” services
* E/Ms (again): Coding trends, charges during global periods, modifiers used during global periods
* EMR/EHR records for overuse of templates
* Physicians who opt out of Medicare: Following rules and not punishing Medicare patients (decreasing or disrupting service)
* Place of service errors

Alright, I prevaricate a little. I do look at the work plan and have it handy to show to those who may be in need of a little prodding. For example, those physicians whose treatment probably warrants the level of service billed and the documentation does not. Physicians have been harped at about that for years. Many have changed their old habits and many have not. Therefore, the OIG still is looking at coding, billing, and documentation errors.

One new subject they are going to address this year is the “incident-to services.” The OIG wants to dig deeper into the use of incident-to. For some reason they believe that offices are billing incident-to when the rules are not being followed. I personally have not seen that happen; however with the explosion of mid-level providers being used in offices, I do see how proper billing could become an issue. Remember, if the physician is not physically in the office when the mid-level is treating a patient, it is not an incident-to service. It should be billed under the mid-level’s provider number and then it will be reimbursed properly according to CMS.

The OIG is also still looking at trends in coding of claims. This translates into the “bell curve.” If you only code one level, you will raise red flags. If your E&M levels are skewed one way or another, they are going to look at you. A practice should be aware of what its own “personal” bell-curve looks like and why. Sometimes a “skewed” bell curve is appropriate. As long as the documentation warrants the levels, no one can really argue against your “curve.”

Then there are the global period charges that the OIG wants to investigate. Many primary-care physicians, when they are submitting charges, put in as many diagnosis codes as they can. The thought process back in the 1960s and 1970s was that more ICD codes translated into higher reimbursements. That changed a long time ago but many physicians are still following that theory. That is where the OIG will get a foothold in your practice. If you are seeing a patient during the global period of a surgery for something that has nothing to do with the surgery, don’t put the diagnosis code that pertains to the surgery on your claim. Don’t elaborate on the surgery in your notes, document on what the reason is for seeing that patient during the global period.

For example, if the patient has a knee replacement and within 90 days of the surgery sees you for a sore throat, use the sore throat as the diagnosis code and document on the sore throat. Mention that the patient had the knee replacement only so that the coder can code properly and use the correct modifiers to get you reimbursed.

There is a lot more detail that I could go into, but as you can see all of their topics fall into the same category, do what is right. I believe that the vast majority of providers try very hard to do what is right. A problem arises when the physicians are doing their best and the OIG wants them to do their best, but wants them to do it the OIG way. There can be a huge disconnect between the two processes. I have heard that if the providers show that they have processes in place to monitor them and help them to follow the laws that they and the OIG can come to reasonable agreements and there are no or very low penalties. I would tend to believe that.

Again, do what is right and you won’t be penalized. Knowingly doing what is wrong in order to possibly gain more reimbursement will get you dressed in orange or stripes. Neither of those choices looks good on anyone!

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