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The Office of the Inspector General (OIG) publishes an annual Work Plan that describes its priorities for investigating and preventing fraud, waste, and abuse of federal healthcare programs. The report is available every fall, for the following fiscal year.
Reading the Work Plan should be an important, annual risk-management task for practice managers.
Before you roll your eyes at the thought of reading a government document, understand that the Work Plan is brief, refreshingly well-organized, and written in plain language. It includes a straightforward paragraph describing each area targeted for evaluation, such as hospitals, nursing homes, providers, and facilities. And it includes a combination of Medicare and Medicaid review initiatives.
Since most practice managers will only be interested in the provider and facilities sections, it will take managers about 10 minutes to read relevant sections and identify whether the annual OIG targets are something their practices should be concerned about, or not.
You'll find the full Work Plan on the OIG site. In the meantime, here are four Work Plan targets that practice managers should pay attention to this year.
1. Evaluation of Medicare's EHR adoption incentive payments
Did you apply for the Medicare or Medicaid EHR Incentive Program? So did many other practices that adopted an EHR. So this year, the OIG is evaluating all payments made to providers to confirm that the reporting criteria were truly met. If you met the criteria, and completed all appropriate requirements, there is little to worry about. OIG just wants to make sure all incentive payments made to providers were justified.
2. Prolonged service codes
The proper use of prolonged services codes (99354-99357) has caused a lot of confusion. They are intended to describe additional care provided to a patient after an evaluation and management service has been performed. They are to be billed as add-on codes to an appropriate, primary E&M code.
The necessity of prolonged services is considered to be "rare and unusual." And that's a likely reason why OIG has included the evaluation of these codes in its Work Plan. The codes are being targeted to determine whether their use was "reasonable and made in accordance with Medicare requirements." Read: OIG wants to ensure that the prolonged services Medicare and Medicaid paid for were really necessary. If not, they might ask for the payment back.
If your providers use these codes, you'd be wise to review the documentation for all prolonged services billed to Medicare or Medicaid. If the note meets payer requirements, you can rest easy. If not, it may be time for documentation refresher training.
3. Payments to providers and nonphysician practitioners who order and refer Medicare services and supplies
CMS requires that physicians and nonphysician practitioners who order certain services, supplies, and/or durable medical equipment (DME) be Medicare-enrolled physicians or nonphysician practitioners. Under this Work Plan target, the OIG will review select Medicare services, supplies, and DME to determine whether the payments made to the providers were in accordance with Medicare requirements. In other words, were the providers who billed these charges legally allowed to do so? If providers in your practice order such supplies and equipment, but are not enrolled in the Medicare program, that's a problem. If your practice has ineligible providers who have ordered and have been paid for these services and supplies, it may be at risk for an audit or payback. Be aware of the risk - and enroll any currently non-enrolled provider if he or she is ordering supplies and equipment.
4. Oversight of provider-based status and comparison of provider-based and freestanding clinics
Although this inquiry area falls under the "Hospital" directives, it may impact physician practices that are hospital owned. Provider-based status can result in higher total Medicare payments for services furnished at provider-based facilities, and may increase coinsurance liabilities for beneficiaries. The OIG will also be monitoring freestanding and provider-based physician offices to determine and compare the costs for similar procedures. Oversight of provider-based billing is typically handled by hospital administration, but physicians do need to know that this area is being scrutinized.
Sarah Wiskerchen, MBA, CPC,is a senior consultant and coding instructor with Chicago-based KarenZupko & Associates, Inc. She has extensive experience in the areas of CPT and ICD-10 coding, revenue cycle, reimbursement, and practice management.