by Becky Amann, Director of Compliance
OIG 2016 WORK PLAN
The Office of Inspector General (OIG) has issued their Work Plan for 2016 which summarizes new and ongoing reviews and activities that they will pursue.
New investigations in 2016:
- Physicians – Referring/ordering Medicare services and supplies:
The OIG will review select Medicare services and supplies referred/ordered by physicians and non- physician practitioners to identify whether the payments were made in accordance with Medicare requirements. CMS requires that physicians and non-physician practitioners who order certain services and supplies are required to be Medicare-enrolled physicians or non-physician practitioners and legally eligible to refer/order services and supplies. If they are not eligible, Medicare should not make payment on the claims.
- Anesthesia non-covered services
The OIG will review Medicare Part B claims for anesthesia services to determine whether they were supported in accordance with Medicare requirements. Specifically, they will review anesthesia services to determine whether the beneficiary had a related Medicare service. Medicare will not pay for items or services that are not “reasonable and necessary.”
- Prolonged services – reasonableness of services
The OIG will determine whether Medicare payments to physicians for prolonged evaluation and management (E&M) services were reasonable and made in accordance with Medicare requirements. Prolonged services are for additional care provided to a beneficiary after an E&M service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond the time spent with a beneficiary for a usual companion E&M service. The necessity of prolonged services is considered to be rare and unusual.
Continuing investigations in 2016:
- Imaging Services: The OIG will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, they will focus on the practice expense components, including the equipment utilization rate. The report on their findings is expected to be issued in 2016.
- Anesthesia Services: The OIG will continue to review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will also determine whether Medicare payments for anesthesiologist services reported on a claim with the “AA” modifier met Medicare requirements. Reporting an incorrect modifier on the claim, as if services were personally performed, when they were not, will result in Medicare paying a higher amount. The report on their findings is expected to be issued in 2016.
All practices and facilities should read the OIG Work Plan in its entirety and take steps to identify and rectify any potential issues they may have, before the OIG does.
The full 2016 Work Plan can be accessed at:
For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfir