You have a lot of physician compliance changes to contend with in 2019, and you can’t slack off on your vigilance to minimize audit risk and stay out of hot water with the feds. One place you can go to uncover what the feds’ target areas might be is the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan.
Watch out: Medical coding and billing mistakes cost healthcare providers billions of dollars every year, explains medical coding and compliance expert Elin Baklid-Kunz in her audio conference, “Physician Compliance Update 2019: What You Should Know.” And with federal watchdog agencies like the OIG and Centers for Medicare & Medicaid Services (CMS) getting increasingly tough on noncompliance, you must take action now to prevent your practice from becoming the feds’ next target.
Double-Check Your Dialysis Claims
The OIG Work Plan for 2018-2019 is chock full of new (and renewed) audit target areas for physicians. And now, the OIG is issuing monthly work-planning updates, instead of just the annual plan. On the new interface, you can view a variety of work plan information, including recently added items and the archived items and reports.
Here are just a few of the latest OIG Work Plan items on the table for physicians in 2019:
- Part B Payments for Dialysis: Medicare Part B covers outpatient dialysis services for beneficiaries with end-stage renal disease (ESRD), but prior OIG reviews identified inappropriate payments for ESRD services, according to Healthicity. Specifically, the OIG has identified unallowable Medicare payments for:
- Treatments not furnished or documented
- Services for which there was insufficient documentation to support medical necessity
- Services that a physician (or the treating physician) did not order
- Claims that didn’t comply with the Medicare consolidated billing requirements, Medicare Claims Processing Manual, or Medicare Benefit Policy Manual
Hotspot: To check up on compliance with Medicare requirements, the OIG aims to review claims for Medicare Part B dialysis services provided to ESRD patients.
Pay Attention to Post-Op Services
- Medicare Advantage Denials: Medicare Advantage uses a capitated payment model based on payment per person rather than payment per service provided. Many Americans rely on payment of primary care and medical procedures through Medicare Advantage, but the payment model can become somewhat controversial due to incentives for denying access to and reimbursement for care in some circumstances, notes ProviderTrust.
The OIG will conduct medical record reviews to determine the extent to which providers and beneficiaries received denials for preauthorization or payment for medically necessary services, as well as the reasons for any inappropriate denials and the types of services involved.
- Post-Op Services in the Global Surgical Period: CMS is collecting data on post-operative services included in global surgeries, and the OIG will audit and verify a sample of the data collected. The OIG aims to determine the number of post-op services documented in the medical records and compare it to the number of post-op services reported in the data that CMS collects.
Hotspot: The OIG’s objective is to verify whether the number of post-op visits reported to CMS is accurate and determine whether global surgery fees reflect the actual number of post-op services that physicians provided to patients during the global surgery period.
Critical Care Takes the Spotlight
- Critical Care Physician Services: In August 2018, the OIG added a work item involving physicians billing for critical care evaluation and management (E/M) services. Critical care is exclusively a time-based code, and Medicare pays physicians based on the number of minutes they spend with critical care patients.
In the review, the OIG wants to determine whether Medicare payments for critical care are appropriate and paid in accordance with Medicare requirements.
Currently, critical care billing requires that the physician spend the coded time evaluating the patient, providing care, and managing the patient’s care, and the physician must be immediately available to the patient during this time.
Key takeaway: The best preparations you can make for 2019 are to boost your compliance, know where to focus your audit efforts, and anticipate the key audit target areas for physicians, stresses Elin Baklid-Kunz in her “Physician Compliance Update 2019” audio conference.