2014 OIG Work Plan Summary – Part 2: Physician Reviews

In the coming year, physicians will be the subject of a variety of reviews that pertain to areas of practice including billing and payments, healthcare information technology and eligibility.  As stated in the first part of the summary, physicians should pay attention to the details of each OIG review to identify areas for compliance improvement and assessment.

Billing and Payment Reviews

There are two ongoing reviews concerning physician billing and payment issues.  One considers noncompliance with assignment rules and excessive billing of beneficiaries.  Under this review, the OIG examines the extent to which physicians participated in Medicare and accepted claim assignments.  An assessment will then be done of the effects of such participation and claim assignments on the Medicare program and whether physicians “excessively” billed beneficiaries.  If a physician participates in Medicare, that physician agrees to accept payment for covered services and items from Medicare, which is considered to be payment in full.  A physician should only charge a beneficiary for permitted cost-sharing or deductibles and nothing more.

The second billing and payment issue under review by the OIG is place-of-service coding errors.  The OIG will assess claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether the place of service was properly coded.  Previous reviews found that physicians did not always properly code non-facility places of services.  Incorrect coding impacts payments because Medicare pays at different levels depending upon the place of service.  In this case, a physician receives a bigger payment for services in a non-facility setting.  Physicians should review billing to determine whether an appropriate code is used.

Health Information Technology Reviews

With the increased use of electronic medical records and other information technology, the OIG is increasingly concerned about the impact on individuals in addition to the potential for fraud and abuse.  For example, in December 2013 the OIG issued a report concluding that recommended fraud protections are not being properly utilized in electronic medical record technology.  The reviews identified in the Work Plan place a greater focus on security, but security issues can also result in the imposition of penalties.  One review concerns the security of portable devices containing personal health information.  The OIG will review security controls implemented by Medicare and Medicaid contractors and hospitals to prevent the loss of protected health information on portable devices.  The scope of portable devices includes laptops, flash drive, backup tapes and other devices.  The OIG is conducting this review in light of numerous breaches that have been reported recently.  Even though physicians are not directly the subject of the review, the same issues and concerns still apply.

A second review will look at the accuracy of information on the new Physician Compare web site.  The web site was updated with more information in 2013, but issues quickly arose.  The OIG’s review will help ensure that accurate information is posted, which is intended to assist beneficiaries in making informed choices about their healthcare providers.  Physicians are directly impacted because the information is about each individual physician.

Enrollment and Eligibility Reviews

The OIG will review the enhanced enrollment screening process for Medicare providers that was implemented pursuant to Section 6401 of the Affordable Care Act.  The OIG will determine the extent to which the Centers for Medicare and Medicaid Services and applicable contractors have actually implemented the enhanced screening.  The number of approvals and denials both before and after implementation will be compared to assess the impact.

A second review will examine whether providers continued to receive Medicare payments even after referral to the Department of the Treasury for failure to refund overpayments.  A provider can be denied enrollment if that provider has not returned an overpayment and should not be allowed to obtain a new Medicare provider number.

As the scope of reviews shows, the OIG looks at issues affecting all areas of a physician’s practice.  Each of the areas identified are believed to be potential areas for fraud and abuse that can negatively impact the Medicare program.  However, physicians can proactively audit their own practices and implement appropriate compliance policies and procedures to address an issue before the government or someone else claims a physician is violating program requirements.

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About Matt Fisher

Matt is the chair of Mirick O'Connell's Health Law Group and a partner in the firm's Business Group. Matt focuses his practice on health law and all areas of corporate transactions. Matt's health law practice includes advising clients with regulatory, fraud, abuse, and compliance issues. With regard to regulatory matters, Matt advises clients to ensure that contracts, agreements and other business arrangements meet both federal and state statutory and regulatory requirements. Matt's regulatory advice focuses on complying with requirements of the Stark Law, Anti-Kickback Statute, fraud and abuse regulations, licensing requirements and HIPAA. Matt also advises clients on compliance policies to develop appropriate monitoring and oversight of operations.
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