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March 27, 2018

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OIG 2014 Work Plan: Part 2

February 13, 2014:

Karen Kachur, Clinical/Technical Editor

Physician services are not the only things the Office of Inspector General will scrutinize in its 2014 work plan: the agency will also target services covered under Medicare Part B.

Three separate reviews will continue to focus on chiropractic services due to the previous discovery of payments for fraudulent services. The agency’s main focus will be on maintenance therapy as well as other inappropriate payments, compliance, and noncovered services. OIG will continue to investigate trends and vulnerabilities and to determine ways to detect fraudulent activity. While Medicare does cover chiropractic services in accordance with strict regulations, it does not cover maintenance therapy.

In past reviews, the OIG found claims for outpatient therapy services provided by independent physical therapists that were not medically necessary or not documented correctly. The agency will continue to look at outpatient physical therapy services provided by independent therapists to determine if they comply with Medicare reimbursement regulations, particularly focusing on independent therapists with high utilization rates for outpatient physical therapy services.

Also in the OIG’s sights will be electrodiagnostic testing. The agency will examine questionable billing and inappropriate financial profit, and evaluate the extent to which Medicare utilization rates vary according to provider specialty, diagnosis, and geographic area.

Another area of diagnostic testing under review is questionable billing of Part B clinical laboratory tests, which now represent 3 percent of the total Medicare Part B payments. Medicare covers lab tests only when they are ordered by a physician or qualified nonphysician practitioner who is treating a beneficiary.

Prior OIG analysis of Medicare payments for the transportation and setup of portable x-ray equipment exposed incorrect payment to portable x-ray suppliers for return trips to nursing homes and for services ordered by ineligible providers. The current review will determine whether payments were correct, supported by documentation, and ordered by a physician. The agency will also review the qualifications of the technologists performing the services.

Payments for imaging services will be reviewed to determine whether they reflect the expenses incurred and whether utilization rates reflect industry practices. The agency will focus on select imaging services, concentrating on the practice expense components, which include rent, wages, and the utilization rate for equipment. High-cost diagnostic radiology services are another area of scrutiny, with the agency examining the medical necessity of these tests and the extent to which utilization of them has increased.

OIG will also continue to review ambulance services, concentrating on transports to dialysis facilities that were medically unnecessary or transports that perhaps never occurred. In the past, OIG has discovered payments for advanced life support services that were not appropriate.

Another area of interest to the OIG is whether mental health professionals are meeting Medicare provider enrollment standards in addition to specific standards for licensure or certification in the states where they practice. With the goal of promoting safety and health care quality, the agency will review current Medicare mental health provider enrollment and credentialing requirements and evaluate the agency’s efforts to verify the qualifications of these providers, including psychiatrists, other physicians, clinical psychologists, clinical social workers, and clinical nurse specialists.

Also in the interest of safety and high-quality care, the agency will investigate Medicare’s survey process for dialysis facilities. Currently state agencies are responsible for conducting dialysis facility surveys for the Centers for Medicare and Medicaid Services (CMS), but there is concern that this process is inadequate for identifying those facilities failing statutory or regulatory requirements.

Click here to read the work plan in its entirety, including the issues relevant to hospitals, nursing homes, home health agencies, and durable medical equipment and supplies.


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