The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released it’s 2014 Fiscal Year Work Plan. If you’ve got the stomach for the long version, click here. Around each fiscal year, the Department of Health and Human Services, Office of Inspector General publishes its annual Work Plan, which provides terrific insight into unique provider behavior and practices the OIG plans to target in 2014. Medicare providers should pay particular attention to the following targeted areas:
Home Health Agencies—failure to conduct criminal background checks on HHA applicants and employees. OIG previously found that 92% of nursing homes employed at least one person with a criminal conviction!
Anesthesia Services—OIG will review claims for personally performed anesthesia services to see if they were supported as required by Medicare requirements. OIG will also be looking at correct application of the AA modifier to make sure the claim form correctly indicates the claim was personally performed or medical directed (QK modifier).
Chiropractic Services—OIG will be completing ongoing audits and will looking at care considered to be unnecessary, inadequately documented or fraudulent. Of particular note to chiropractors undergoing audits for billing for massage, the OIG reiterates that “Part B pays only for chiropractor’s spinal manipulation of the spine to correct subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment.” OIG will also be looking to differentiate “chiropractic maintenance” (not covered) from chiropractic care which is covered. The OIG restated its previous remark that “Medicare covers chiropractic care that provides “a reasonable expectation of recovery or improvement of function.”
Ophthalmologists—OIG is targeting payments to ophthalmologists and will seek to identify geographic areas where they find questionable billing practices.
Partial Hospitalization Programs—Payments to PHPs will be investigated to ensure that Medicare payment requirements were met. Particular focus will be on proper documentation (including plans of care), physician supervision and certification.
Place of Services Scrutiny—OIG will continue to ensure proper location of service coding, especially in ASC and hospital outpatient departments.
Physical Therapy—focus will be on independent PTs and their compliance with Medicare reimbursement regulations (e.g. medical necessity and proper documentation). Get a Quick Reference PT Supervision Chart here.
Sleep Disorder Clinics—particular attention will be paid to the appropriateness of testing and documented medical necessity.
2014 doesn’t figure to be an especially unusual year for OIG activity. That said, fraud and abuse enforcement activity has clearly escalated since healthcare reform legislation (1) funded an expansion of staff and enforcement; and (2) identified healthcare recoupment is a funding mechanism for the healthcare reform.