OIG Issues a Mid-Year Plan Update


HHS Office of Inspector General (OIG) recently issued an update to their 2015 Work Plan. The update is a summary of OIG’s planned reviews of HHS programs and billing. Providers should take note of the following planned reviews:

Anesthesia Services- Payments for personally performed services. OIG will review personally performed anesthesia service claims reported with the “AA” service code modifier to determine if they met Medicare requirements. Reporting an incorrect service code modifier on the claim indicating services were personally performed by an anesthesiologist when they were not results in higher reimbursement.

Chiropractic Services- Payments for Non-covered services and Questionable Billing. Previous reviews have shown a history of vulnerabilities relative to inappropriate payments for chiropractic services. Medicare only reimburses claims for manual manipulations of treatment of subluxations of the spine that provides “a reasonable expectation of recovery or improvement of function.” Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable.

Diagnostic Radiology- Medical necessity of high-cost tests. Payments for high-cost diagnostic radiology tests will be reviewed to determine whether the test were medically necessary and to determine the extent to which use has increased for these tests.

Opthalmologists- Inappropriate and questionable billing. Medicare claims data will be reviewed to identify potentially inappropriate and questionable billing for ophthalmology services during 2012.

Place of Service Coding Errors. Services performed in ASCs and hospital outpatient department will be reviewed to determine whether they properly coded place of service.

Physical Therapists- High use of outpatient physical therapy services. Services provided by independent therapists will be reviewed to determine whether they were in compliance with Medicare reimbursement regulations. Those therapists with a high utilization rate for outpatient PT services will be targeted. Prior history shows a pattern of claims not medically necessary and documentation not properly prepared.

Sleep Disorder Clinics- High use of sleep-testing procedures. Reviews will be conducted to determine the appropriateness of payments for high-use sleep-testing procedures, specifically 95810 and 95811. Of interest are repeated diagnostic tests on same beneficiary.

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