This article is more than 5 years old. Information may no longer be current.
Office of the Inspector General unveils work plan for 2008
Although none of the physician specific areas under scrutiny focus on any particular ophthalmic service, there are four areas to be evaluated that could affect ophthalmologists.
It is that time of year again when the Office of the Inspector General issues its work plan for the upcoming year.
The Office of the Inspector General (OIG) is charged by Congress to audit and investigate government programs, recommend policies to promote economy and effectiveness of program administration, prevent and uncover fraud and abuse, and keep the Department of Health and Human Services (DHHS) and Congress informed about the need for corrective actions. To meet this mandate, the OIG undertakes a comprehensive planning process to determine the areas under its purview that warrant attention. In setting its annual priorities, the OIG considers such things as requests or concerns raised by Congress or DHHS, reviews that are required by law, reports of potentially abusive behaviors and significant challenges facing DHHS. Some of the OIG’s priorities focus on maintaining the integrity of Medicare and Medicaid payments, prescription drugs costs and the quality of care paid for by the federal government. Other initiatives focus on the quality of the work performed by the agencies that make up DHHS, such as the Centers for Medicare and Medicaid Services, the U.S. Food and Drug Administration and the National Institutes of Health.
In the past few years, the OIG work plan has included target areas specific to ophthalmology. This year, none of the physician specific areas under scrutiny focus on any particular ophthalmic service, but there are areas to be evaluated that, if problems are uncovered, could affect all physicians, including ophthalmologists.
Target areas
 Alan E. Reider |  Allison Weber Shuren |
Place of service errors. Medicare pays a fee differential to physicians based on the site of service where a physician treats a patient. The differential is to reflect that physicians incur a higher overhead cost when providing care at their office and less when providing care at a facility such as an outpatient hospital clinic or an ASC. Physicians are required to include a site of service code on claims performed in an ASC or hospital outpatient department. To ensure that physicians are properly coding claims to identify the proper site of service and consequently that Medicare is not paying higher fees than it should, the OIG is auditing a large sample of claims for place of service errors. This work is under way, and the findings will be issued in 2008. If the OIG finds a significant problem, it is reasonable to expect that carriers and other safeguard contractors will increase their auditing of individual physicians who perform services at various sites of service.
Global surgery periods. Most surgical and other invasive procedures are paid under a global fee surgery concept, whereby physicians are paid one lump sum for performing the procedure and all of the post-procedure care related to the procedure that the patient requires. Many of the global surgery periods in existence today reflect standards of care that are now outdated. For example, cataract surgery has a 90-day global surgery period that is reminiscent of the types of procedures performed 15 years ago. The importance of the global surgery period is that the physician payment for a procedure includes an estimated number of postoperative visits. The shorter the global period, the fewer office visits the physician reimbursement likely is to include.
The OIG will determine whether medical practice related to the number of post-procedure follow-up visits has changed since the global surgery fee concept was developed in 1992. The obvious concern is that the relative value of certain procedures will be decreased if the global surgical period is shortened and fewer post-procedure visits are included in the global fee calculation.
‘Incident-to’ services. Medicare pays physicians for services provided to beneficiaries’ incident-to the physician’s plan of care for the patient. The services must be of the type that generally are performed in an office or clinic setting and that are performed by a non-physician employee or independent contractor of the physician or physician practice. The physician or another physician member of the group practice must provide direct supervision of the service. Direct supervision means that the supervising physician is in the office suite at the time the incident-to service is being rendered. The physician need not oversee the actual service, however.
The OIG audit of incident-to services already is in progress, and the results will be reported in 2008. Specifically, the Office of Evaluation and Inspections, which is focused on preventing fraud, abuse and waste, is looking at the type of services being performed and billed as incident-to, the qualifications of the staff performing the services, the medical necessity and documentation of the services, and the overall quality of care of incident-to services. Physicians must be sure that staff performing incident-to services are permitted by law to perform such services, are properly trained to perform the services and are appropriately supervised.
Compliance with assignment rules. The last specific area to mention involves the OIG’s review of the extent to which Medicare providers may be billing beneficiaries’ amounts in excess of that allowed by Medicare. The investigation also includes a review of beneficiaries’ awareness of the assignment limitation and that such charges are violations of law. Providers who accept assignment must accept Medicare’s payment and the beneficiaries’ co-payment as payment in full for all covered services. In return, providers receive certain prompt pay and other benefits from the program. Thus, a physician may not “balance bill” patients – seek payment from the patient for any differential that may exist from the physician’s charges and the Medicare allowable amount. In March 2004, the OIG issued an alert to providers that additional fees charged to beneficiaries for such things as shorter wait times, coordination of care services or longer physician visits are covered services and therefore could place the physicians charging such fees at risk for civil monetary penalties. Physicians should be mindful of balance billing prohibitions imposed by all their third-party payers, not just Medicare.
The OIG 2008 work plan includes 15 areas of study directed at physician services. The results of the four projects described above have the potential to affect all physicians, and therefore it is important that ophthalmologists take the opportunity to ensure that their practice is in compliance with the rules and regulations that underlie the areas being scrutinized.
For more information:
- Allison Weber Shuren, MSN, JD, can be reached at Arent Fox LLP, 1050 Connecticut Ave. NW, Washington DC 20036-5339; 202-775-5712; fax: 202-857-6395; e-mail: shuren.allison@arentfox.com.