2016 OIG Work Plan Areas of Focus

The 2016 Office of Inspector General (“OIG”) Work Plan indicates the areas that will be targeted in the near future.  Be aware of these highlights from the physician portion of the work plan.

Physician home visits 

Since January 2013, Medicare has paid $559 million to physicians for evaluation and management home visits. These physicians are required to document the medical necessity for a home visit. The OIG will review documentation to see if payments for these services are “reasonable and necessary.”   

Prolonged services  

Current Procedural Terminology (“CPT®”) codes for prolonged evaluation and management services may billed when a physician spends additional time with a patient and that service is medically necessary. The Medicare Claims Processing and CPT® manuals include requirements that must be met in order to bill these services. These requirements include spending additional time that is reasonable for the specific encounter and the patient’s condition.  CMS  indicates that it is “rare and unusual” to bill these codes, and will be reviewing documentation to ensure those codes reimbursed have the appropriate supporting documentation.

Anesthesia for non-covered services 

Claims for anesthesia services will be cross-walked to ensure that a medically necessary claim for a related service was also submitted for the patient on the same date of service and at the same location. CMS will not reimburse anesthesia services for procedures that are not considered “reasonable and necessary.” 

Referring and ordering physicians

CMS requires that physicians and nonphysician practitioners be Medicare-enrolled in order to legally refer or order services, supplies and durable medical equipment for a Medicare beneficiary. The OIG will review claims for certain supplies and services to ensure that the referring or ordering provider on the claim is enrolled in the Medicare program.

Histocompatilbility laboratories

From March 2013 through September 2014, histocompatibility laboratories (facilities that perform tissue-typing and other advanced cellular services) reported $131 million in reimbursable costs.  The OIG will review these costs to ensure that they are related to the care of the beneficiaries, and are “reasonable, necessary, and proper.”

Physicians should review their documentation to ensure that the above criteria are met, or risk losing revenue for improperly documented services.