What You Need to Know About the 2017 OIG Work Plan

OIG 2017 Work Plan

The 2017 HHS OIG Work Plan is out, revealing what’s in the crosshairs for special scrutiny. There’s a good chance there’s something in its 101 pages that affects you. Make sure your team’s work is up to scratch on these topics listed in the Medicare Parts A and B/Other Providers & Suppliers section of the OIG Work Plan for 2017.

Note: This list offers just a few highlights of interest to individual providers and labs. Review the complete Work Plan to be sure you’ve got all your bases covered.

Lab

  • Clinical Diagnostic Laboratory Tests: Each year, the OIG has to analyze the top 25 lab tests by Medicare payment. The review is part of seeing how CMS is doing implementing a new market-based Medicare payment system that uses rates paid by private payers.
  • Histocompatibility Labs: Labs that provide testing for bone marrow and organ transplants need to be sure their cost information supports payment, specifically being related to beneficiary care, and being reasonable, necessary, and allowable based on Medicare rules.
  • Independent Clinical Lab Billing: The OIG sees independent clinical labs as being at risk of overpayments and wants to identify those labs that submit improper claims regularly.

Transitional and Chronic Care Management

  • Transitional Care Management (TCM): The OIG wants to be sure Medicare didn’t inappropriately pay for chronic care management (CCM), end-stage renal disease (ESRD) services, and prolonged services without direct patient contact during the same service period as TCM.
  • CCM: We just saw that the OIG is checking for TCM and CCM paid during the same period. They’re also checking to make sure you didn’t get paid for CCM during the same period as home health care supervision or hospice care and certain ESRD services.

Financial Interests Reported Under Open Payments Program

  • Sunshine Act: Physician financial relationships with manufacturers and group purchasing organizations are under the microscope. To read more about the Sunshine Act, click the link for a CMS Fact Sheet.

Referring or Ordering Physician Compliance

  • Ordering Eligibility: If you aren’t eligible to order or refer for services and supplies, then Medicare shouldn’t be paying for those services and supplies. The OIG will be checking up on both physicians and nonphysician practitioners.

Anesthesia

  • Modifier: If you use the modifier indicating personal performance of anesthesia, you’d better be sure you can back it up. The OIG is checking to make sure the services weren’t just medically directed instead.

Home Visits

  • House Call: Here’s a fun fact. From 2013-2015, Medicare paid $718 million for physician home visits. The OIG wants to be sure those visits were reasonable and necessary.

Prolonged Services

  • Extra E/M Time: Prolonged services should be pretty rare, according to the OIG Work Plan. To avoid taking a hit for this audit target, make sure your coding complies with the Medicare Claims Processing Manual, Chapter 12, Section 30.6.15.1.

Chiropractic Services

  • Noncovered Services: Medicare has some pretty strict limits when it comes to covering chiropractic services, and maintenance therapy doesn’t make the cut. The OIG wants to be sure Medicare has been paying for services appropriately.
  • Trends: Chiropractic services have a history of inappropriate payments. The OIG is pulling together results of its prior work to check for patterns so the OIG can provide recommendations to Medicare on how to reduce vulnerabilities.

Physical Therapists

  • Outpatient: Finding proper documentation to support work performed by independent physical therapists was tough during a previous review, according to the OIG. This round, the OIG is checking for high utilization rates for outpatient services.

Portable X-Ray Equipment

  • Suppliers: Improper payments to portable X-ray suppliers for multiple trips to a facility in a single day are on the OIG’s radar. Technologist qualifications are getting scrutinized, too.

Sleep Disorder Clinics

  • Wrong repeat: Sleep testing procedures 95810-95811 had high utilization in a 2010 review. Now the OIG is checking up on repeated tests on the same patient.

Rx Drugs Section Bonus: Drug Waste

  • Modifier JW: In the Prescription Drugs section of the OIG Work Plan, you’ll see the OIG wants to be sure you’re using common sense (and not greed) when choosing the size of a single-use vial. They’ll be checking claims for modifier JW to see how much drug waste you’re getting paid for.

How About You?

Do you have any OIG audit experiences to share?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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