October 16, 2012
The HHS Office of Inspector General (OIG) Work Plan for Fiscal Year 2013 has been promulgated. The Work Plan provides brief descriptions of activities that OIG plans to initiate or continue with respect to HHS programs and operations in fiscal year 2013. Why should you care? Simple – the Work Plan tells all providers what areas are being reviewed by the Federal government. Learn whether the services you provide are under review, and take the time to take preventative measures and ensure you are operating appropriately. Don't know about OIG? ABOUT OIG (from OIG Website) - "Since its 1976 establishment, the Office of Inspector General of the U.S. Department of Health & Human Services (HHS) has been at the forefront of the Nation's efforts to fight waste, fraud, and abuse in Medicare, Medicaid and more than 300 other HHS programs."
To view the Work Plan, CLICK HERE. Some areas of review that stuck out are set forth below -
Evaluation and Management Services—Use of Modifiers During the Global Surgery Period
We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements. Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. (CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40.1.) Guidance for the use of modifiers for global surgeries is in CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 30. (OAS; W-00-13-35607; various reviews; expected issue date: FY 2013; new start)
Home Health Services—Duplicate Payments by Medicare and Medicaid (New)
We will review Medicaid payments by States for Medicare-covered home health services to determine the extent to which both Medicare and Medicaid have paid for the same services. States are required to offer home health services to Medicaid beneficiaries who meet the States’ criteria for nursing home coverage. (Social Security Act, § 1902(a)(10)(D).) Medicaid is the payer of last resort, paying only after all other third-party sources have met their legal obligation to pay. (Social Security Act, § 1902(a)(25).)
(OAS; W-00-13-31305; various reviews; expected issue date: FY 2014; new start)
Nursing Homes—Questionable Billing Patterns for Part B Services During Nursing Home
Stays
We will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents. Part B services provided during a nursing home stay must be billed directly by suppliers and other providers. (CMS’s Medicare Benefits Policy Manual, Pub. 100-02, ch. 8, § 70.) Congress directed OIG to monitor these services for abuse. (Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), § 313.) A series of studies will examine podiatry, ambulance, laboratory, and imaging services. (OEI; 06-11-00280; various reviews; expected issue dates: FY 2013; work in progress)
Chiropractors—Part B Payments for Noncovered Services
We will review Medicare Part B payments for chiropractic services to determine whether such payments were in accordance with Medicare requirements. Prior OIG work identified inappropriate payments for chiropractic services furnished during calendar year (CY) 2006. Medicare-covered chiropractic services include only treatment by means of manual manipulation of the spine to correct subluxations. (42 CFR § 440.60.) Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. (CMS’s Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, § 30.5B.) Medicare will not pay for items or services that are “not reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) (OAS; W-00-12-35606; W-00-13-35606; various reviews; expected issue date: FY 2013; work in progress and new start)
Dental Services for Children—Inappropriate Billing (New)
We will review Medicaid payments by States for dental services to determine whether States have properly claimed Federal reimbursement. Dental services are required for most Medicaid ‐eligible individuals under age 21 as a component of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services benefit. (Social Security Act, §§ 1905(a)(4)(B) and 1905(r).) Federal regulations define “dental services” as diagnostic, preventative, or corrective procedures provided by or under the supervision of a dentist. (42 CFR § 440.100.) Services include the treatment of teeth and the associated structure of the oral cavity and disease, injury, or impairment that may affect the oral cavity or general health of the recipient. Prior work indicates that some dental providers may be inappropriately billing for services. (OAS; W-00-10-31135; W-00-11-31135; W‐00‐12‐31135; various reviews; expected issue date: FY 2013; work in progress)
Quality Standards—Accreditation of Medical Equipment Suppliers (New)
This review will examine accreditation organizations’ (AO) requirements and processes for granting accreditation to ensure that medical equipment suppliers meet each of Medicare’s quality standards. Failure to meet quality standards could pose a threat to beneficiary safety and quality of care as well as place Medicare resources at risk. Medical equipment suppliers must become accredited by a CMS-approved AO and must comply with quality standards to maintain their billing privileges. CMS oversees AOs through validation surveys. This review will also evaluate CMS’s procedures for conducting validation surveys. Such surveys help CMS determine whether an AO’s accreditation procedures are adequately ensuring that suppliers are complying with Medicare’s quality standards. (OEI; 00-00-00000;expected issue date: FY 2014; new start)
To view the Work Plan, CLICK HERE. Some areas of review that stuck out are set forth below -
Evaluation and Management Services—Use of Modifiers During the Global Surgery Period
We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements. Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments. The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. (CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40.1.) Guidance for the use of modifiers for global surgeries is in CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 30. (OAS; W-00-13-35607; various reviews; expected issue date: FY 2013; new start)
Home Health Services—Duplicate Payments by Medicare and Medicaid (New)
We will review Medicaid payments by States for Medicare-covered home health services to determine the extent to which both Medicare and Medicaid have paid for the same services. States are required to offer home health services to Medicaid beneficiaries who meet the States’ criteria for nursing home coverage. (Social Security Act, § 1902(a)(10)(D).) Medicaid is the payer of last resort, paying only after all other third-party sources have met their legal obligation to pay. (Social Security Act, § 1902(a)(25).)
(OAS; W-00-13-31305; various reviews; expected issue date: FY 2014; new start)
Nursing Homes—Questionable Billing Patterns for Part B Services During Nursing Home
Stays
We will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents. Part B services provided during a nursing home stay must be billed directly by suppliers and other providers. (CMS’s Medicare Benefits Policy Manual, Pub. 100-02, ch. 8, § 70.) Congress directed OIG to monitor these services for abuse. (Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), § 313.) A series of studies will examine podiatry, ambulance, laboratory, and imaging services. (OEI; 06-11-00280; various reviews; expected issue dates: FY 2013; work in progress)
Chiropractors—Part B Payments for Noncovered Services
We will review Medicare Part B payments for chiropractic services to determine whether such payments were in accordance with Medicare requirements. Prior OIG work identified inappropriate payments for chiropractic services furnished during calendar year (CY) 2006. Medicare-covered chiropractic services include only treatment by means of manual manipulation of the spine to correct subluxations. (42 CFR § 440.60.) Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. (CMS’s Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, § 30.5B.) Medicare will not pay for items or services that are “not reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) (OAS; W-00-12-35606; W-00-13-35606; various reviews; expected issue date: FY 2013; work in progress and new start)
Dental Services for Children—Inappropriate Billing (New)
We will review Medicaid payments by States for dental services to determine whether States have properly claimed Federal reimbursement. Dental services are required for most Medicaid ‐eligible individuals under age 21 as a component of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services benefit. (Social Security Act, §§ 1905(a)(4)(B) and 1905(r).) Federal regulations define “dental services” as diagnostic, preventative, or corrective procedures provided by or under the supervision of a dentist. (42 CFR § 440.100.) Services include the treatment of teeth and the associated structure of the oral cavity and disease, injury, or impairment that may affect the oral cavity or general health of the recipient. Prior work indicates that some dental providers may be inappropriately billing for services. (OAS; W-00-10-31135; W-00-11-31135; W‐00‐12‐31135; various reviews; expected issue date: FY 2013; work in progress)
Quality Standards—Accreditation of Medical Equipment Suppliers (New)
This review will examine accreditation organizations’ (AO) requirements and processes for granting accreditation to ensure that medical equipment suppliers meet each of Medicare’s quality standards. Failure to meet quality standards could pose a threat to beneficiary safety and quality of care as well as place Medicare resources at risk. Medical equipment suppliers must become accredited by a CMS-approved AO and must comply with quality standards to maintain their billing privileges. CMS oversees AOs through validation surveys. This review will also evaluate CMS’s procedures for conducting validation surveys. Such surveys help CMS determine whether an AO’s accreditation procedures are adequately ensuring that suppliers are complying with Medicare’s quality standards. (OEI; 00-00-00000;expected issue date: FY 2014; new start)
