By Harriet Franklin, Esq. & Kirsten McAuliffe Raleigh, Esq.
Each year the The Department of Health and Human Services, Office of Inspector General (OIG) publishes a “WorkPlan” setting forth its planned activities. The 1998 WorkPlan describes numerous projects, including program audits, program inspections and investigative focuses it plans to perform, during 1998. This article summarizes those OIG projects set forth in the OIG WorkPlan for fiscal year 1998 that could affect physicians.
Physicians at Teaching Hospitals (PATH)
The OIG plans to verify compliance with the Medicare rules governing payment for physician services provided in the teaching setting, and to insure that claims accurately reflect the level of service provided to the patient.
Physician Perspectives on Medicare HMOs
Based on concerns about the impact of HMOs on the access and quality of health care provided to Medicare beneficiaries, the OIG plans to obtain the experiences and perspectives of physicians who work with Medicare HMOs.
Physician Certification of Durable Medical Equipment
The OIG will study whether physicians are meeting Medicare expectations, that they act as controls against unnecessary use of non-physician services and supplies, including home health, and that they complete certificates of medical necessity.
Hospital Ownership of Physician Practices
A study will be conducted of Medicare billing practices and utilization of hospital owned physician practices, including an examination of whether there are inappropriate referrals (in either direction) between hospitals and physicians, excessive costs and billings, and over-utilization of services when hospitals bill the Medicare program.
Another study aimed at determining what vulnerabilities to Medicare result from the growing trend of hospitals’ purchases of physician practices will examine the number and types of physician practices owned by hospitals, physician compensation arrangements and hospitals’ business objectives in pursuing physician practices.
Accuracy of and Carrier Monitoring of Physician Visit Coding
The OIG will build on a previous study to further assess whether physicians are correctly coding evaluation and management services in locations other than teaching hospitals and whether carriers are adequately monitoring physician coding.
Use of Surgical Modifier
The OIG will determine whether physicians are improperly using Modifier 25 (used to claim “Significant, Separately Identifiable Evaluation and Management Service on the Day of Surgery”) on their Medicare Part B claims to increase reimbursements.
Physician and Other Service Provider Use of Diagnosis Codes
Following up on a previous study that found that physicians and other providers of imaging services do not follow HCFA’s guidance on use of diagnosis codes, the OIG will compare Medicare claims to beneficiary medical records to determine the extent to which diagnosis codes on claims match the reason for ordering and providing various services.
Physician Credit Balances
The OIG will perform a study to determine whether physicians are reviewing their records for Medicare credit balances (when a provider receives and records higher reimbursement than the amount actually charged to a specific Medicare beneficiary) and refunding to their carriers those indicating an overpayment.
Discharge day management can only be billed by the admitting physician. The OIG will develop a computer application to identify those beneficiaries whose discharge day management was billed by more than one physician during a single inpatient stay, to determine whether duplicate payments have been made for day of discharge patient management services.
Based on the OIG’s finding that anesthesiologists were improperly billing for supervising residents in three or more operating rooms at the same time, this review will identify anesthesiologists who bill for personally performed services and determine if these services were in compliance with Medicare regulations.
Critical Care Services
Critical care is usually provided in a critical care area, such as a coronary care unit, intensive care unit, respiratory care unit or an emergency care facility. Physician services for patients who are not critically ill but happen to be in a critical care unit are to be claimed using “Subsequent Care” hospital codes. The OIG study will focus on those providers who incorrectly bill Medicare for critical care based on the location of the patient and not the actual services provided by the physician.
Billing for Services Rendered by Physician Assistants
Medicare allows physician assistants to render certain services as “incident to” services, which are billed by the employing physician as if the service was personally rendered by the physician. If the services do not fall under the “incident to” criteria, the employing physician must bill using a modifier which reduces the Medicare payment. The OIG will determine whether physicians are improperly billing for services rendered by physician assistants and are therefore being overpaid.
Billing Service Companies
Medicare allows providers to contract with billing service companies that provide billing and payment collection services. The contractual agreements between the provider and the billing service company must meet certain Medicare criteria and a copy of the agreement must be provided to the applicable Medicare carrier. Previous OIG investigations showed that billing service companies may upcode and/or unbundle procedure codes to maximize Medicare payments to physicians. This review will further study whether Medicare claims prepared and submitted by billing service companies are properly coded in accordance with the physician services provided to beneficiaries. It will also study whether the agreements between providers and billing service companies meet Medicare criteria.
Improper Billing of Psychiatric Services
The OIG will study whether providers are properly billing Medicare for psychiatric services in the following three areas: providers’ billing Medicare for individual psychotherapy rather than inpatient hospital care, resulting in Medicare overpayments; providers’ billing Medicare for psychological testing code on a per test basis rather than a per hour basis, as required; or providers’ billing Medicare for group psychotherapy in cases which do not qualify for Medicare payment because either the group sessions do not involve actual psychotherapy services or the patients cannot benefit by group psychotherapy.
Physician Referrals to Self-Owned Laboratory Services
OIG will review and analyze HCFA’s enforcement of the self-referral prohibition involving physicians and clinical laboratory services to determine whether HCFA has adequate information (i.e., ownership and compensation data) to enforce the law with respect to clinical laboratory services and document the actions taken to date.
Provider Billing Numbers Issued to Resident Physicians
Generally, residents may not bill Medicare for their services unless the billable services are related to “moonlighting activities” at another institution separate from the institution where the resident is pursuing his/her medical studies. OIG will study whether hospitals requesting and receiving billing numbers for their residents are improperly billing Medicare for services provided by residents.
Physician Incentive Plans in Managed Care Contracts
OIG will review physician incentive plans that are included in contracts that physicians enter into with managed care plans to insure that any arrangement that financially rewards or penalizes physicians based on the utilization levels is disclosed to HCFA and beneficiaries pursuant to HCFA’s final rule dated March 1996. In addition, the OIG will look at other clauses in these contracts that may impact the quality of care provided.
Dialysis Procedures/Evaluation and Management Code Double Billing
The Medicare Carriers Manual states that a dialysis procedure cannot be paid on the same day as evaluation and management services, unless the services are unrelated to the dialysis, as dialysis and any related physician services are included in the monthly capitation payment. OIG will study whether renal/nephrology physicians are billing for a dialysis evaluation on the same day that they bill for evaluation and management services.
Medical Necessity of Oxygen
OIG will assess the prescribing practices of physicians who order home oxygen therapy and how Medicare monitors utilization and medical necessity for the systems.
Physician Case Management Billings
Payment of physicians for plan care oversight is to be recovered when a claim did not meet Medicare criteria for home health services. OIG’s review will determine if, when a home health claim has been denied by the regional home health intermediary, the Part B carrier also denies any related payments submitted by the physician for oversight of the plan of care.
Duplicate Billing of Outpatient Hospital Services
Services rendered in a hospital-based outpatient clinic are billed under Medicare Part B but through a fiscal intermediary. The physicians providing services in these clinics may be billing for the same services under Part B, but submitting their claims to the carrier. OIG will compare the billing practices of hospital-based outpatient clinics and physicians who bill for similar services in the clinics to determine if there are duplicate payments.
Physicians with Excessive Nursing Home Visits
The OIG nursing home project identified trends in Medicare and Medicaid payments and populations and identified aberrant providers of nursing home services by type of service. Using this data as well as other computer screening techniques, the OIG identified physicians with aberrant billing patterns for visits to skilled nursing facilities (SNF) patients, such as an excessive number of visits in a given day and excessive visits to the same beneficiaries. The OIG will identify and audit physicians with excessive visits to Medicare patients in SNFs. Individual reviews will be conducted for those physicians with the most egregious billing patterns. The OIG will further determine how the carriers could better identify and prevent such billings.
Financial Conflicts of Interest
The OIG will examine nursing homes that have been purchased, either partially or wholly, by durable medical equipment supplier chains and/or physician groups. This review will look at claims submitted for Medicare beneficiaries in these homes and identify any aberrant billing patterns for services and supplies provided by owners with a substantial financial interest.
Harriet Franklin, Esq. & Kirsten McAuliffe Raleigh, Esq., are with the law firm of Stevens and Lee, P.C., in their Wayne, Pennsylvania office.