As part of the Health Care Fraud Prevention and Enforcement Action Team’s success, the Medicare Fraud Strike Force teams will continue to report potential fraud to the OIG. Payment suspensions may occur while the investigation of credible fraud allegations proceeds. CMS focuses on false claims related to inappropriate coding, performance of medically unnecessary services, quality-of-care issues and charges for services not rendered. Investigations may also be related to the anti-kickback statute and physician self-referral as well as drug benefit issues and illegal distribution of prescription drugs.
According to the OIG FY 2013, there were 3214 individuals and entities excluded from participation in Federal health care programs, 960 criminal actions against individuals or entities for crimes against HHS programs and 472 civil actions from false claims suits, CMP settlements and provider self-disclosure recoveries. Once again, the OIG Work Plan emphasizes the importance of having an effective compliance program to prevent fraud, waste and abuse.
The 2014 Work Plan highlights the following focus areas for the Providers:
- Non-compliance with assignment rules and excessive billing of beneficiaries
- Place of service coding errors
- Documentation requirements to determine if services are “reasonable and necessary”, notably in areas of increased utilization: high cost diagnostic radiology testing, sleep-testing procedures, electrodiagnostic testing and outpatient physical therapy services by independent therapists .
- Questionable billing for ophthalmological services, personally performed anesthesia services, laboratory testing and electrodiagnostic tests (EMG and nerve conduction studies)
- Inappropriate payments for E/M services – lack of appropriate documentation to support level of service or evidence of identical documentation (copy and paste) by provider throughout medical records
- Utilization rates reflect industry practices for all imaging services
New focus areas for Providers described in the Work Plan 2014:
- Medicare enrollment and credentialing of mental health providers to verify qualifications
- Questionable billing by chiropractors for services and inappropriately billing CMS for maintenance therapy
- Medical necessity of nebulizer machines and related drugs
- Survey and certification process of dialysis facilities