Physician Practice

Review of Medicare payments on the OIG's Work Plan

Physician Practice Insider, November 17, 2015

The Office of Inspector General’s (OIG) Work Plan for FY 2016 details the agency’s new and ongoing reviews of HHS programs and operations. The Work Plan highlights a number of evaluations in store for physician practices, including Medicare and Medicaid services and payments. These reviews are aimed at detecting fraud, waste, and abuse, identifying areas of improvement, and holding providers who violate federal healthcare laws accountable.

Medicare payment reviews will include:

  • Home visits
  • Prolonged services
  • Referring and ordering services and supplies
  • Services provided to incarcerated beneficiaries
  • Services to beneficiaries who are unlawfully present in the country
  • Part D beneficiaries’ exposure to harmful and inappropriate drug pairs

The OIG will seek to determine if Medicare payments for home visits by physicians were reasonable and met Medicare requirements. The Work Plan notes that Medicare has paid $559 million for physician home visits since 2013. The OIG will review physician documentation for evidence to support the medical necessity of a home visit. Prolonged services will undergo a similar evaluation. The OIG will review physician documentation that supports the necessity for additional care provided and time spent after evaluation and management (E/M) services have been performed. Prolonged services should be offered only in rare and unusual circumstances, according the Work Plan.

The OIG’s review of payments for supplies and services will focus on whether the ordering physician or other practitioner is Medicare-enrolled. Medicare claims should not be paid if the ordering physician or other practitioner is not enrolled.

Prescription drug interactions will also be under scrutiny. The review “will determine whether Medicare Part D beneficiaries are being prescribed drugs that should not be prescribed in combination with other drugs,” according to the Work Plan. This will include drugs that have a severe interaction as well as drugs that shouldn’t be prescribed with component drugs.

Mandated reviews for Medicare payments made for services to incarcerated beneficiaries and beneficiaries unlawfully present in the United States aim to evaluate CMS procedures and recoup payments, the Work Plan says. “Medicare, in general, does not pay for services rendered to incarcerated beneficiaries because they do not have a legal obligation to pay (Social Security Act, § 1862); however, the regulation does permit Medicare payment where an incarcerated beneficiary has an obligation for the cost of care. (42 CFR § 411.4.)” Medicare is prohibited from paying for services and supplies provided to individuals who are not lawfully present in the country. Prior OIG reviews found that $91.6 million had been paid to providers for these services for CYs 2009 through 2011.

Other items up for review include Medicare’s fee schedule for orthotic braces, the Office for Civil Right’s oversight of ePHI security, and CMS management of ICD-10 implementation. Ongoing reviews will continue to look at chiropractor services.

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