Audit alert: Notable items in the 2013 OIG work plan

Oct. 1, 2012 represents the start of the federal fiscal year. That makes now a good time to look at the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) work plan for the current fiscal year, especially as it relates to physician services under the Medicare program. Knowing what the OIG is examining can sometimes provide a useful “heads up” on issues that Medicare itself may focus on during the coming 12 months.

First, OIG has no fewer than five items on its work plan aimed at diabetes testing supplies:

• Supplier compliance with payment requirements for blood glucose test strips and lancets,
• Effectiveness of system edits to prevent inappropriate payments for blood-glucose test strips and lancets to multiple suppliers,
• Potential questionable billing for test strips in 2011,
• Improper supplier billing for test strips in competitive bidding areas,
• Supplier compliance with requirements for nonmail order claims.

Although most of these items are aimed at suppliers, it is reasonable to expect that such attention may prompt those suppliers to be more demanding of physician prescribers. Given the incidence of diabetes among family medicine patients, family physicians are among the most common prescribers of such supplies.

For those practices that have office laboratories, the OIG’s work plan has at least three items of interest:

• Billing characteristics and questionable billing in 2010,
• Reasonableness of Medicare payments compared to those by state Medicaid and Federal Employees Health Benefit programs,
• Part B payments for glycated hemoglobin A1C tests.

Finally, in the particular area of physician services, the following items stand out:

• Noncompliance with assignment rules and excessive billing of beneficiaries,
• Error rate for incident-to services performed by nonphysicians,
• Place-of-service coding errors,
• Evaluation and management (E/M) services—potentially inappropriate payments in 2010.

Regarding the last item on this list, the OIG work plan states:
We will determine the extent to which the Centers for Medicare & Medicaid (CMS) made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.

The OIG’s review will focus on 2010 services, but it is reasonable to expect that this will be an area of focus going forward. Since E/M services represent the “bread and butter” of family medicine, and in light of the increasing use of EHRs in family medicine practices, this is one area that probably merits an internal review for most family medicine practices now and in the future.

Of course, the OIG’s work plan is more extensive than just the items listed above, so a scan of the table of contents for that work plan would probably be in order to see if there are other items that may be relevant to your particular practice.  Explanations of all items are included in the OIG work plan.

–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians