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OIG work plan offers insight into critical compliance issues for physicians
The Office of the Inspector General’s published work plan includes projects that involve the eye care industry as a whole.
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 Alan E. Reider |  Allison Weber Shuren |
The start of October brought the baseball playoffs, Oktoberfest and the new Supreme Court session. It was also when the Office of the Inspector General published its work plan for the coming year.
Although you may be more apt to read this article if it was a review of the best bratwurst and Oktoberfest beers, it will instead discuss the latest insight into the current Office of the Inspector General (OIG) priorities and areas raising fraud and abuses concern.
For those who may not be familiar with the work plan, it is an annual publication of the OIG that sets forth in brief summary the areas and issues the OIG intends to audit, evaluate and inspect during the new federal fiscal year. The work plan also provides insight into the areas and issues that may evolve into future OIG enforcement activities. Therefore, health care providers and suppliers should consider the work plan in relation to their operations. Ideally, physicians will identify those areas most relevant to them and self-audit their practice’s performance in these areas as part of their practice’s internal compliance audit program.
Unlike in recent years, none of the 2009 work plan topics relate directly to ophthalmologists. Past topics such as co-management and the utilization of YAG procedures raised particular concern for eye care professionals. Nevertheless, the plan should not be given any less attention because many of the topics cut across medical specialties. Physicians also should keep an eye toward the areas of concern for non-physician providers and suppliers, such as hospitals and ASCs, because physicians could be affected by such scrutiny.
Audit review
Several of the items in the work plan that are particular to physicians are audits carried over from last year. Specifically, OIG expects to complete and issue reports on its review of physician compliance with place of service coding and global surgical periods. Under the global surgery fee, physicians are paid a single fee for all of their services usually associated with the pre-, intra- and postoperative work of a single procedure. Therefore, the fee includes payment for an average number of post-procedure office visits a typical patient will require. The audit will report on whether practice has changed since the inception of the global surgery concept in 1992. Of course, the expectation is that the number of visits has decreased. The question will be whether the related recommendation will be to decrease payments to reflect the fewer visits.
Two new audits related to physician services include reviews of:
Accuracy of Medicare practice expense assumptions: Medicare payment for physicians’ professional services is an aggregate payment that is designed to cover the physician’s actual work, the overhead cost associated with furnishing a service and payment toward the cost of malpractice premiums. The practice expense calculation is made up in part of certain assumptions drawn from data self-reported by physicians in a particular specialty. The OIG intends to determine whether Medicare payments for practice expense for services performed by selected specialties are comparable to the actual expenses incurred by the physicians in providing the services.
Medicare billings with -GY modifier: The -GY modifier signals to the Medicare contractors that the claim should be denied because the item or service represented by the claim is not covered by Medicare either because coverage is excluded by statute or because the services does not meet the definition of a covered service. In these instances, providers are not required to give the beneficiary an advanced notice of charges (ie, an Advanced Beneficiary Notice). As a result, beneficiaries can find themselves with large medical bills for which they are liable. The OIG makes note that, in 2006 alone, the program received 53 million claims with the -GY modifier that totaled more than $400 million. This audit will focus on the propriety of the use of the -GY modifier to determine if there are any notable patterns or trends in the charging of beneficiaries.
One pertinent audit involving hospitals includes hospital ownership of physician practices. In 2005, the Centers for Medicare and Medicaid Services set out rules for hospitals that purchase a physician practice to have the practice designated as provider-based. These requirements include location of the practice, the population served and degree of hospital control over the physician practice. The designation permits hospital outpatient departments to be paid under the hospital outpatient prospective payment system for the services furnished by the provider-based practice at rates greater than those paid under the physician fee schedule. It is not surprising, therefore, that the OIG is interested in knowing whether these hospital-owned practices meet the provider-based rules and whether practices that are not provider-based are improperly receiving reimbursement under the outpatient prospective payment system.
Focus of the federal government
One project related to the Part D prescription plans will look at the extent to which sponsors of plans have adopted standards for e-prescribing. These standards allow physicians and pharmacists to electronically transmit prescriptions for Part D eligible individuals. The Medicare Part D rules require Part D plans to support an e-prescribing program for those physicians who choose to adopt electronic-based communication. Given the emphasis the federal government has placed on moving the health care industry toward a paperless way of doing business, the OIG will review adoption at this level.
Finally, the work plan suggests a continued focus of the federal government on issues intersecting the authorities of the Food and Drug Administration and Medicare and Medicaid. Projects have been identified to audit Medicare claims and Medicaid claims for payments made for drugs without FDA approval. Preliminary data suggest that the federal programs may be paying for drugs that have not received FDA approval. And, in a somewhat analogous project, the OIG will look specifically at Medicaid payments made for drugs not approved for use in children. Medicaid will pay for an outpatient drug if it is prescribed for an indication approved by the FDA or supported by particular drug compendia. These projects give a clear indication of the government’s continued focus on ensuring that manufacturers complete the necessary regulatory hurdles before enjoying access to taxpayer funds through federal health program payments.
Although the work plan does not suggest any particular focus on ophthalmology in 2009, several of the items could involve the eye care industry as a whole. Physicians should meet with their compliance teams to ensure that the practice is making its best efforts to be operating consistent with the relevant rules and regulations.
- Allison Weber Shuren, MSN, JD, can be reached at Arnold & Porter LLP, 555 12th St. NW, Washington DC 20004-1206; 202-942-6525; fax: 202-942-5999; e-mail: allison.shuren@aporter.com.