OIG work plan outlines its investigatory priorities

Coding, PATH, billing on its list

The best indication of what are the Office of the Inspector General’s (OIG) priorities are — and how it plans to allocate its resources over the next year — is its annual work plan. According to the OIG’s FY 99 work plan, the office will focus on several specific areas when it comes to investigating possible physician fraud and abuse. These are:

1. Accuracy and carrier monitoring of physician visit coding.

The OIG will assess whether physicians are correctly coding evaluation and management services in locations other than teaching hospitals and whether carriers are adequately monitoring physician coding.

2. Physicians at Teaching Hospitals (PATH).

OIG plans to continue the PATH initiative to verify compliance with Medicare rules governing payment for physician services provided in the teaching setting, and to ensure that claims accurately reflect the level of service provided to the patient.

3. Billing service companies.

OIG will conduct reviews to determine:

— whether Medicare claims prepared and submitted by billing companies are properly coded in accordance with the physician services provided to beneficiaries;

— whether the agreements between providers and billing service companies meet Medicare criteria.

OIG investigators are especially interested in finding instances where billing service companies may have upcoded and/or unbundled procedure codes to maximize Medicare payments to physicians.

4. Patient billing records.

OIG will examine a sample of one state’s physicians’ patient billing records to identify and obtain refunds for Medicare and Medicaid overpayments. The review will be expanded to other states if significant problems are discovered.

5. Other physician reviews.

Studies will be made of the following issues:

— billing records of physicians with extensive visits to Medicare patients in SNFs;

— whether podiatry services were medically necessary and met Medicare coverage policy;

— improper billing of Medicare for psychiatric services;

— practice of allowing physicians to reassign their billing numbers to clinics;

— whether errors found in Medicare billing for physician services are associated with providers’ use of automated encoding software.

6. Medical equipment and supplies.

The OIG will conduct seven reviews regarding durable medical equipment (DME) in FY 1999, including medical necessity of oxygen. The OIG will compare Medicare beneficiaries’ self-reported use of home oxygen therapy with documentation supporting the medical need for such therapy. The OIG will assess the prescribing practices of physicians who order the service and how Medicare monitors utilization and medical necessity for the systems.