The 2015 Workplan of the Office of the Inspector General highlights important areas for providers including medical necessity of services billed, payment review, exclusions, and incentive payments.

Determination of the medical necessity of services billed is a primary focus of the Workplan. As stated in the Social Security Act, Medicare will not pay for items or services that are not “reasonable and necessary”. Specifically, chiropractors, radiologists, ophthalmologists and physical therapists should be aware of what issues will be reviewed regarding payments called into question. Additionally, the OIG is focusing on the following:

  • Overuse of sleep-testing procedures
  • Independent laboratory billing
  • Personally performed anesthesia services, ambulance services
  • Place-of-service coding
  • Practice expense components of imaging services including utilization rate

As part of the ACA and payment review, CMS and the contractors must have an enhanced enrollment screening process that will be assessed for its success. This screening is required for initial enrollment, re-enrollment or revalidation. This process may include site visits, fingerprinting, background checks and an automated provider screening process.

Exclusions from participation could be related to prior healthcare fraud, licensing board disciplinary actions, patient abuse or neglect, identity theft, defaulting on government loan or other program related convictions. In FY 2014, there were 4017 individuals and entities excluded from Federal healthcare programs. Some of these excluded providers could have potentially avoided exclusion as part of their settlement if they had voluntarily submitted self-disclosures of fraud, waste or abuse.

The OIG will also be reviewing Medicare and Medicaid EHR Incentive payments data from 2011 to determine if the providers met meaningful use requirements. Since the onset of the Meaningful Use program, $16 billion in Medicare Incentive payments and $8 billion in Medicaid Incentive payments have been received by the providers. Since security of the protected health information is a core objective for achieving meaningful use, CMS will be conducting audits of covered entities receiving Incentive Payments as well as their business associates to assess the adequacy of their security protection.