HHS has issued its 2012 OIG Work Plan. Following are some particular areas of concern for physicians:
Physician-Owned Distributors of Spinal Implants: OIG will determine the extent to which physician-owned distributors (PODs) provide spinal implants purchased by hospitals and whether PODs are associated with high use of spinal implants. The Work Plan notes that Congress has expressed concern the PODs could create conflicts of interest and safety concerns for patients.
Incident-To Services: OIG will review physician billing for incident-to services to determine whether payment for such services has a higher error rate than that for non-incident-to services. OIG will assess the Centers for Medicare & Medicaid Services’ (CMS’) ability to monitor incident-to services. OIG expresses concern that the incident-to services may be performed by unqualified individuals, may expose beneficiaries to care that does not meet professional standards of quality, and may be vulnerable to overutilization.
Evaluation and Management Services–Use of Modifiers During the Global Surgery Period: OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims where modifiers were used during the global surgery period were in compliance with Medicare requirements. Prior OIG review indicates that improper use of modifiers during this time resulted in improper payments for Evaluation and Management (E/M) services that were otherwise included in the global payment.
Physician-Administered Drugs and Biologicals: OIG launches a new initiative to compare Medicare and Medicaid payments for commonly used physician-administered drugs and biological to assess current reimbursement of ASP plus 6% and opportunities for savings through changes to Part B.
Compliance with Assignment Rules: OIG remains interested in the extent to which providers comply with assignment rules and the extent to which beneficiaries may be being inappropriately billed in excess of Medicare-allowed amounts.
Medicare Payments for Part B Imaging Services: OIG continues to assess whether Medicare payments for Part B imaging services reflect expenses incurred and whether utilization rates reflect industry practices. OIG is particularly interested in the practice expense component and equipment utilization rate.
Excessive Payments for Diagnostic Radiology: OIG continues to review high-cost diagnostic radiology tests to assess medical necessity to deny payment (or request a refund for overpayment) for the unnecessary tests. OIG continues to assess ordering patterns by primary care physicians versus specialists for the same treatment.
Medicare Payments for Sleep Testing and Appropriateness of Medicare Payments for Polysomnography: OIG continues its interest in the appropriateness of Medicare payments for sleep test procedures, including payments to physicians and independent diagnostic testing facilities for these tests. Unnecessary tests are not covered and subject a provider to refund any overpayment.
Comprehensive Outpatient Rehabilitation Facilities (CORFs): OIG is concerned about “potentially inappropriate” lease arrangements between physician landlords and CORFs. Expect the OIG to perform site visits and review of associated arrangements.