Authored by: Elizabeth Vincenzo

On October 2, 2012, the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG) issued its Work Plan for Fiscal Year 2013, which instructs healthcare providers of some of the primary activities and practices the OIG will be targeting for enforcement action.

The coming year’s Work Plan includes multiple areas of interest to physicians, the following five of which I advise physicians to be especially aware of:

  • Assignment Rules – Medicare require physicians agree to accept payment by “assignment” for all items and services furnished to individuals enrolled in Medicare. “Assignment” is defined as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare.  Assignment allows the physician to request direct payment from Medicare for covered Part B services.  Basically, the beneficiary is assigning his or her right of reimbursement for the services to be directly paid to the physician.   In return, the physician agrees to accept the Medicare-allowed as the full charge for the items or services provided.  In 2013, the OIG will be watching for (a) the extent to which physicians and other suppliers fail to comply with assignment rules, and (b) to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare.  The OIG will also be assessing beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.
  • “Incident To” Services – These are services Medicare Part B will pay for certain services billed by physicians but performed by non-physicians that are “Incident To” a physician office visit.  According to the Work Plan, a 2009 review found (a) that when Medicare allowed physician billings for more than 24 hours of services in a day, half of the services were not performed by a physician, and (b) that unqualified non-physicians performed 21% of the services that physicians did not personally perform. Incident To services are a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.  There is also concern that Incident To services are susceptible to overutilization and can expose beneficiaries to care that does not meet professional standards of quality.
  • E&M – Medicare requires providers to select the billing code for a professional service on the basis of the content of the service and to have documentation to support the level of service reported.  OIG will be reviewing 2010 data for inappropriate payments for E&M services, including (a) the consistency of E&M medical review determinations and (b) multiple E&M services in connection with the same providers and beneficiaries in order to identify EHR documentation practices indicating potentially improper payments.  The OIG’s focus on E&M is a result of multiple MACs noting an increased frequency of medical records with identical documentation across services.
  • Imaging Services  – The Work Plan directly states that OIG “will review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices.” The focus will be on the practice expense components, including the equipment utilization rate, space lease, wages, and equipment.  Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expenses.
  • Part B Claims with G Modifiers – Physicians may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary and may use GX or GY modifiers for items or services that are statutorily excluded from Medicare payment. A new focus in 2013 will be a review of claims from 2002-2011 where bills included GA, GX, GY, or GZ service code modifiers, indicating that Medicare denial was expected.  This review is a result of a recent OIG review that found Medicare paid for 72% of pressure-reducing support surface claims with GA or GZ modifiers, estimating potentially $4 million in inappropriate payments.

Physicians should review practices and activities as they relate to the issues identified by the OIG in the 2013 Work Plan. The entire OIG 2013 Work Plan is available online at https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.


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