OIG fraud/abuse plan for next year will expand Stark safe harbors’

You should concentrate on areas targeted by OIG

The Health and Human Services Office of the Inspector General (OIG) has unveiled the list of the specific topics and projects it will be focusing on in its fraud and abuse efforts over the coming year.

Smart practices can use the OIG’s work plan as a kind of laundry list of items to address in their own internal compliance efforts.

First, the good news: As Physician’s Payment Update reported last summer, the OIG plans to publish soon final regulations establishing new safe harbor exemptions from the Stark anti-kickback statute. The OIG may consider adding more safe harbors later.

Besides the ongoing auditing of general coding and billing practices, OIG investigators will be paying closer attention over the next year to certain physician-related areas. You should be focusing on these areas:

• Advance beneficiary notices.

Examine the use of advance notices to Medicare beneficiaries, especially for non-covered laboratory services. By law, physicians must give seniors advance notice before they provide a service they know or believe Medicare does not consider medically necessary or for which Medicare will not reimburse. Beneficiaries who are not notified before they receive such services are not responsible for payment.

• Automated billing.

Determine what kind of billing errors can be commonly blamed on the use of automated coding software, and which cannot. OIG also will examine various billing processes to identify coding problems that occur when practices bill independently or use a third-party system.

• Reassignment of physician benefits.

Evaluate possible opportunities for fraud or abuse when, in exchange for a flat fee or salary, a physician agrees to reassign his or her billing number to clinics that handle all billing and keep all fees for services provided by the physician.

• Collection of Medicare secondary payer overpayments.

Evaluate Medicare contractors’ track records in collecting Medicare Secondary Payer overpayments from providers.

• Medicare provider numbers and unique physician identification numbers.

Determine whether Medicare provider numbers and unique physician identification number information are accurate and up to date. This follows OIG reports showing problems with the issuance of provider numbers to such providers as durable medical equipment suppliers and independent physiological laboratories, and failure to quickly deactivate unused provi der numbers.

• Routine nursing home visits by physicians.

Reacting to a five-state study that showed physicians sometimes billed for more services than they could physically perform in a normal workday, OIG will look at the need to establish controls over Medicare payments for routine nursing home visits.

• Podiatrists’ billing practices.

Recent audits of individual podiatrists found a 99% billing error rate in some instances. In response, the OIG will launch a national review to determine the extent to which podiatrists improperly bill Medicare. Included in this review will be a study of podiatry claims for nail debridements, which increased 46% between 1992 and 1995.

• Myocardial perfusion imaging.

Assess the medical appropriateness of myocardial perfusion imaging to explain the recent rise in utilization since 1997. Myocardial perfusion imaging is a cardiac imaging procedure that is used to detect coronary artery disease and determine prognoses. This type of imaging procedure accounted for a large portion of the 23% increase in billing for all nuclear imaging services between 1997 and 1998.

• Clinical laboratory proficiency testing.

The Clinical Laboratory Improvement Amend ments (CLIA) of 1988 established quality standards for all laboratory testing. This review will assess how well laboratories perform Medicare tests and adhere to CLIA standards.

• Medical appropriateness of end stage renal disease tests.

OIG will do a random medical review of end stage renal disease beneficiaries to determine if laboratory and other services they received were necessary and were provided in accordance with Medicare requirements.

• Questionable dialysis claims.

Examine claims for dialysis services to identify questionable billing patterns and aberrant providers. Dialysis treatments may be provided and billed either as single visits (common procedure codes 90935 and 90945), or, for patients with more complications, as multiple visits (codes 90937 and 90947), which are reimbursed by Medicare at a higher rate. On average, the ratio of services for the high to low codes is approximately 1 to 7.

A fraud alert has been issued to carriers to periodically determine if any nephrologist is extremely deviant from the norm.

• Duplicate payments for office visits to nephrologists.

Identify situations in which Medicare made separate payments to nephrologists for dialysis patients’ office visits, but the services were already included in the monthly capitation payment for physician services during the same period.

• Physicians at teaching hospitals.

Continue investigations of inappropriate billing for physician services at teaching hospitals.

• Billing for resident services.

Assess extent of improper Medicare billing resulting from the issuance of provider billing numbers to resident physicians at teaching hospitals. In general, Medicare regulations do not allow residents to bill Medicare for their services. The exception is if the billable services are related to "moonlighting" activities unrelated to the resident’s training program. However, OIG knows of instances where at least one hospital requested and received over 40 billing numbers for its residents over a six-year period. The residents were not involved in "moonlighting" activities, and the hospital used the numbers to improperly bill Medicare for services provided by the residents.

• OIG-excluded providers.

Examine how OIG exclusion data are used to protect federal health programs and their beneficiaries from fraudulent or poorly performing providers. Plus, identify the number of claims still being submitted by excluded providers.

• Improper Medicare fee-for-service payments.

For fiscal year 1998, the Health Care Financing Administration estimates improper fee-for-service payments totaled $12.6 billion, or 7.1% of the $176.1 billion spent on Medicare fee-for-service claims. OIG will perform another study to establish the extent of improper or inadequately documented Medicare payments.