College of Medicine Office of Compliance, Gainesville, Florida
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Office of Inspector General Work Plan for Fiscal Year ending September 30, 2011

Once again the U S Department of Health & Human Services, Office of Inspector General (OIG) provides brief descriptions of activities the OIG plans to initiate or continue with respect to the programs and operations of the Department of Health & Human Services for the fiscal year ending September 30, 2011.

The entire Work Plan is 159 pages long and is available in pdf form:
http://oig.hhs.gov/publications/workplan/2011/FY11_WorkPlan-All.pdf

Pertinent excerpted topics include:

TARGETED AREAS FOR PHYSICIAN/PROVIDER SERVICES

• NEW! Payments for Evaluation and Management Services - "Cloned Notes in the Electronic Medical Record"
  CMS will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. CMS will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.
• Place-of-Service Errors
  CMS will review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers (ASC) and hospital outpatient departments. Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician's office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC. CMS will determine whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments.
• Coding of Evaluation and Management Services
  CMS will review evaluation and management (E&M) claims to identify trends in the coding of E&M services. E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. CMS will review E&M claims to determine whether coding patterns vary by provider characteristics.
• Ambulatory Surgical Center Payment System
  CMS will examine changes to the revised ASC payment system and the rate-setting methodology used to calculate ASC payment rates.
• NEW! Error-Prone Providers: Medicare Part A and Part B
  CMS will review Medicare Part A and Part B claims submitted by error-prone providers. Previous OIG work illustrated a methodology for identifying error-prone providers using CMS's Comprehensive Error Rate Testing (CERT) Program data. Using this methodology, CMS identified providers that consistently submitted claims found to be in error in a 4-year period. CMS will select the top error-prone providers based on expected dollar error amounts and match selected providers against the National Claims History file to determine the total dollar amount of claims paid. CMS will then conduct a medical review on a sample of claims to determine their validity, project our results to each provider's population of claims, and request refunds on projected overpayments.
• NEW! Partial Hospitalization Program Services
  CMS will review the appropriateness of Medicare payments for partial hospitalization program (PHP) psychiatric services. A PHP is an intensive outpatient program of psychiatric services that hospitals may provide to individuals in lieu of inpatient psychiatric care. CMS will determine whether Medicare payments for PHP psychiatric services in hospital outpatient departments and freestanding community mental health centers met Medicare requirements based on documentation supporting psychiatric services, including patient plans of care, and physician supervision and certification requirements.
• Outpatient Physical Therapy Services Provided by Independent Therapists
  CMS will review outpatient physical therapy services provided by independent therapists to determine whether they are in compliance with Medicare reimbursement regulations. Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, CMS will determine whether the services that they billed to Medicare were in accordance with Federal requirements.
• Questionable Billing for Medicare Outpatient Therapy Services
  CMS will review paid claims data for Medicare outpatient therapy services from 2009 and identify questionable billing patterns.
• Appropriateness of Medicare Payments for Polysomnography
• Medicare Payments for Sleep Testing
• Excessive Payments for Diagnostic Tests
  CMS will review Medicare payments for high-cost diagnostic tests to determine whether they were medically necessary.
• Laboratory Test Unbundling by Clinical Laboratories
  CMS will review the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel tests to maimize Medicare payments. CMS will determine whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing specimens on sequential days.
• Medicare Part B Payments for Glycated Hemoglobin A1C Tests
• Trends in Laboratory Utilization
• Lab Test Payments: Comparison of Medicare with Other Public Payers
• Geographic Areas With a High Density of Independent Diagnostic Testing Facilities
• Independent Diagnostic Testing Facilities' Compliance With Medicare Standards
• Comprehensive Outpatient Rehabilitation Facilities
  CMS will review national Medicare utilization patterns for Comprehensive Outpatient Rehabilitation Facility (CORF) services and identify CORFs in high-utilization areas CMS will conduct site visits to determine whether CORFs in high-utilization areas meet basic Medicare requirements. CMS will also identify differences in billing patterns of CORFs that met selected Medicare requirements and those that did not.
• Medicare Providers' Compliance With Assignment Rules
• Medicare Payments for Claims Deemed Not Reasonable and Necessary (GA-GZ modifiers)
• Medicare Billings With Modifier GY
  Modifier GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service.
• Payments for Services Ordered or Referred by Excluded Providers
• Payments for ESRD Beneficiaries Entitled to Medicare Under Special Provisions
• Comprehensive Error Rate Testing Program: FY 2010 Error Rate Oversight
  OMB identified CMS as an agency with high-profile programs that are susceptible to significant improper payments. In November 2003, CMS assumed responsibility for estimating and reporting improper Medicare fee-for-service payments and national error rates. The CERT Program, was established by CMS to monitor the accuracy with which Medicare claims are billed and paid. Effective August 1, 2008, the CERT program also samples inpatient records replacing the Hospital Payment Monitoring Program (HPMP).
• Medicare Services Billed With Dates of Service After Beneficiaries' Dates of Death

TARGETED AREAS FOR HOSPITAL SERVICES

• Medicare Excessive Payments
  Hospitals are required to report units of service as the number of times that a service or procedure was performed. CMS work will include certain outpatient claims in which payments exceeded charges and selected Healthcare Common Procedure Coding System (HCPCS) codes for which billings appear to be aberrant.
• Medicare Disproportionate Share Payments
  Medicare makes additional payments to acute care hospitals that serve a significantly disproportionate number of low-income patients. OIG will determine whether these payments were in accordance with Medicare methodology. CMS will also examine the total amounts of uncompensated care costs that hospitals incur.
• Medicare Outlier Payments
  CMS will review Medicare outlier payments to determine whether CMS appropriately reconciled the payments. Outliers are additional payments made for beneficiaries who incur unusually high costs.
• Duplicate Graduate Medical Education Payments
  CMS will review provider data from CMS's Intern and Resident Information System (IRIS) to determine whether duplicate graduate medical education payments have been claimed.
• Hospital Readmissions
  CMS will review Medicare claims to determine trends in the number of hospital readmission cases. A readmission is defined as a case in which the beneficiary is readmitted to a hospital less than 31 days after being discharged from a hospital.
• Hospital Admissions With Conditions Coded Present-on-Admission
  CMS will review Medicare claims to determine which types of facilities are most frequently transferring patients with certain diagnoses that were coded as being present when patients were admitted, referred to as present on admission (POA).
• Early Implementation of Medicare's Policy for Hospital-Acquired Conditions
  CMS will review the early implementation of CMS's hospital-acquired conditions (HAC) policy. CMS will review Medicare claims data to identify the number of beneficiary stays associated with HACs and determine their impact on reimbursement.
• Payments for Diagnostic Radiology Services in Hospital Emergency Departments
• Hospitals' Compliance With Medicare Conditions of Participation for Intensity-Modulated and Image-Guided Radiation Therapy Services
• Medicare Inpatient and Outpatient Hospital Claims for the Replacement of Medical Devices
  CMS will determine whether hospitals submitted inpatient and outpatient claims that included procedures for the insertion of replacement medical devices in compliance with Medicare regulations. Hospitals are required to use modifiers on their inpatient and outpatient claims when they receive credit from the manufacturer of 50 percent or more for a replacement device.
• Observation Services During Outpatient Visits
  CMS will review Medicare payments for observation services provided during outpatient visits in hospitals.
• Hospital Inpatient Outlier Payments
  CMS will review hospital inpatient outlier payments. Medicare typically reimburses hospitals for inpatient services based on a predetermined per-discharge amount, regardless of the actual costs incurred. CMS will examine trends of outlier payments nationally and identify characteristics of hospitals with high or increasing rates of outlier payments.
• Inpatient Rehabilitation Facility Transmission of Patient Assessment Instruments
  CMS will determine whether inpatient rehabilitation facilities (IRF) received reduced payments for claims with patient assessment instruments that were transmitted to CMS's National Assessment Collection Database more than 27 days after the beneficiaries' discharges. If an IRF transmits the instrument more than 27 calendar days from (and including) the beneficiary's discharge date, the IRF's payment rate should be reduced by 25 percent.

Questions?

Contact the Office of Physician Billing Compliance for the University of Florida, College of Medicine, Gainesville Campus
Phone: (352) 265-8359 or e-mail: nwt@ufl.edu

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