OI G 2007 Work Plan OI G 2007 Work Plan Part II: Physician Focus - - PDF document

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OI G 2007 Work Plan OI G 2007 Work Plan

Part II: Physician Focus Part II: Physician Focus

HCCA Audio Conference Series November 2, 2006 12:00 Central Time

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Speakers Speakers

Kimberly Zeoli, CPA Kimberly Zeoli, CPA

Partner, National Life Sciences & Health Care Regulatory Consult Partner, National Life Sciences & Health Care Regulatory Consulting Practice ing Practice Deloitte & Touche LLP Deloitte & Touche LLP 200 Berkeley Street, Boston, MA 02118 200 Berkeley Street, Boston, MA 02118 617 617-

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437-

• 3467

3467 Email: kzeoli@deloitte.com Email: kzeoli@deloitte.com

Paul C. Levy, MD Paul C. Levy, MD

Compliance Program Medical Director & Acting Chairman, Departmen Compliance Program Medical Director & Acting Chairman, Department of Medicine t of Medicine University of Rochester Medical Center University of Rochester Medical Center 601 Elmwood Avenue, Box 520, Rochester, NY 14642 601 Elmwood Avenue, Box 520, Rochester, NY 14642 585 585-

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275-

• 8538

8538 Email: Paul_Levy@URMC.Rochester.edu Email: Paul_Levy@URMC.Rochester.edu

Howard J. Young, Esq. Howard J. Young, Esq.

Partner, Health Care Practice Group Partner, Health Care Practice Group Sonnenschein Nath & Rosenthal LLP Sonnenschein Nath & Rosenthal LLP 1301 K Street, N.W. Suite 600, East Tower, Washington, DC 20005 1301 K Street, N.W. Suite 600, East Tower, Washington, DC 20005 202 202-

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408-

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9210 Email: hyoung@sonneschein.com Email: hyoung@sonneschein.com 2

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Session Agenda Session Agenda

Overview of the OIG Overview of the OIG Overview of the 2007 Work Plan Overview of the 2007 Work Plan

• Risk Areas for Physicians and Physician

Risk Areas for Physicians and Physician Practices: Practices:

• Recurring Work Plan Studies

Recurring Work Plan Studies

• What

What’ ’s New s New

• Q&A

Q&A

Closing Remarks Closing Remarks

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Overview of the OIG Overview of the OIG

Counsel to the I nspector General (OCI G) –coordinates OIG’s role in the judicial and administrative resolution of fraud and abuse cases involving HHS programs. OCIG also develops and promotes industry specific voluntary compliance program guidance. OCIG issues special fraud alerts to the public, special advisory bulletins, and advisory

• pinions regarding the application of the OIG’s sanction authorities. OCIG is

responsible for developing new, and modifying existing, safe harbor regulations under the anti-kickback statute.

Legal Counsel Focus Areas

Office of I nvestigations (OI ) – conducts investigations of fraud and misconduct to safeguard HHS’s programs and protect its beneficiaries. OI concentrates its resources

• n criminal investigations, but its activities are also aimed at deterring fraud and

abuse by identifying systemic weaknesses and vulnerabilities that can be mitigated through corrective management actions, regulation, or legislation.

I nvestigative Focus Areas

Office of Evaluation and I nspections (OEI ) – seeks to improve HHS program effectiveness and efficiency by conducting inspections to provide timely, useful, and reliable information and advice to decision makers. These inspections are program and management evaluations that focus on specific issues of concern to the Department, Congress, and the public.

Program I nspections

Office of Audit Services (OAS) – conducts financial and performance audits of HHS programs and operations to determine whether objectives are being achieved, which aspects of programs need to be performed more efficiently, and to identify systemic weaknesses that give rise to fraud, waste or abuse.

Program Audits HY

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Significance of the Work Plan Significance of the Work Plan

• Work Plan is a Valuable Tool as indication

Work Plan is a Valuable Tool as indication

• f areas of potential concern
• f areas of potential concern
• Not necessarily a

Not necessarily a “ “Fraud Fraud” ” Roadmap Roadmap

• A

A “ “Plan Plan” ” for where OIG will invest its for where OIG will invest its resources in coming year (may change) resources in coming year (may change)

• Audit or Evaluation plans get cancelled

Audit or Evaluation plans get cancelled

Overview of the 2007 Work Plan Overview of the 2007 Work Plan

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Overview of the 2007 Work Plan Overview of the 2007 Work Plan

• 93 pages, published 9/25/06

93 pages, published 9/25/06

• Four sections:

Four sections: 1. Centers for Medicare & Medicaid Services 2. Public Health Agencies: Agency for Health Care Research & Quality (AHRQ), Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Health Resources and Services Administration (HRSA), Indian Health Service (IHS), National Institutes of Health (NIH), and Substance Abuse and Mental Health Services Administration (SAMHSA) 3. Administration for Children & Families (ACF) and Administration on Aging (AoA) 4. Department-wide Projects that cut across programs, including State and local government use of Federal funds, and the functional areas of the Office of the Secretary

Number of Work Plan Projects (359 total) 253 48 47 11 CMS PHA ACF/AoA Dept-wide

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Overview of the 2007 Work Plan Overview of the 2007 Work Plan

CMS CMS

• Information System Controls (18)

Information System Controls (18)

• Medicare/Medicaid Hurricane Response (9)

Medicare/Medicaid Hurricane Response (9)

• Legal Counsel (7)

Legal Counsel (7)

• General Administration (5)

General Administration (5)

• Investigations (2)

Investigations (2)

• Administration (34)

Administration (34)

• Prescription Drugs (15)

Prescription Drugs (15)

• Other Services (13)

Other Services (13)

• Long Term and Community Care (11)

Long Term and Community Care (11)

• Mental Health Services (7)

Mental Health Services (7)

• Hospitals (3)

Hospitals (3)

• State Children

State Children’ ’s Health Insurance s Health Insurance Program (3) Program (3)

• Hospitals (25)

Hospitals (25)

• Part D Administration (19)

Part D Administration (19)

• Contractor Operations (18)

Contractor Operations (18)

• Physicians and Other Health

Physicians and Other Health Professionals (17) Professionals (17)

• Nursing Homes (10)

Nursing Homes (10)

• Part B Drug Reimbursement (10)

Part B Drug Reimbursement (10)

• Managed Care (9)

Managed Care (9)

• Other Services (7)

Other Services (7)

• Home Health (6)

Home Health (6)

• Medical Equipment and Supplies (5)

Medical Equipment and Supplies (5)

• Hospice (2)

Hospice (2)

Other (41) Other (41) Medicaid (86) Medicaid (86) Medicare (126) Medicare (126)

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Compliance Retrospective: Compliance Retrospective: Where have we been? Where have we been?

Key Events: Key Events:

• 1995

1995 -

• University of Pennsylvania $30 million

University of Pennsylvania $30 million PATH settlement PATH settlement

• Clarification of components of E/M codes

Clarification of components of E/M codes

• Compliance Program Guidance:

Compliance Program Guidance: Laboratories, Hospitals, Laboratories, Hospitals, Third Third-

• Party Billing

Party Billing Companies, etc. Companies, etc.

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Compliance Efforts: Compliance Efforts: Where are things headed? Where are things headed?

Shift in themes of audits Shift in themes of audits

• Less attention to

Less attention to “ “what what” ”

• More attention to

More attention to “ “why why” ”

• Medical necessity reviews

Medical necessity reviews

Quality and Outcome Assessments: Quality and Outcome Assessments:

• Hospital

Hospital

• Physician

Physician

• Pay for Performance

Pay for Performance

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Recurring Work Plan Studies Recurring Work Plan Studies

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Risk Areas for Physicians and Risk Areas for Physicians and Physician Practices Physician Practices

Overview of Recurring Work Plan Studies Overview of Recurring Work Plan Studies

1. 1. Propriety of contractual relationships between billing companies Propriety of contractual relationships between billing companies and physicians and and physicians and their impact on physicians their impact on physicians’ ’ billings billings 2. 2. Compliance of in Compliance of in-

• office pathology services with Medicare Part B
• ffice pathology services with Medicare Part B

3. 3. Appropriateness of professional and technical component billing Appropriateness of professional and technical component billing for cardiography for cardiography and echocardiography services and echocardiography services 4. 4. Appropriateness of payments to providers of care for initial pre Appropriateness of payments to providers of care for initial preventative physical ventative physical examinations examinations 5. 5. Evaluation of medical necessity and billing for Part B mental he Evaluation of medical necessity and billing for Part B mental health services alth services provided in physicians provided in physicians’ ’ offices

• ffices

6. 6. Medical necessity, adequate documentation, and physician certifi Medical necessity, adequate documentation, and physician certification statements cation statements for physical and occupational therapy services for physical and occupational therapy services 7. 7. Assessment of medical necessity and billing compliance for wound Assessment of medical necessity and billing compliance for wound care services care services billed by physicians billed by physicians

“R”

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• 1. Billing Service Companies
• 1. Billing Service Companies

Work Plan

We will identify and review the relationships between billing companies and the physicians and

• ther Medicare providers who use their
• services. We will identify the types of

arrangements that physicians and

• ther Medicare providers have with

billing services and determine the impact of these arrangements on physicians’ billings. (OAS; W-00-05-35162; various reviews; expected issue date: FY 2007; work in progress)

Key Points Key Points

• OIG Compliance Program Guidance for Third

OIG Compliance Program Guidance for Third-

• Party

Party Medical Billing Companies (MBCs) issued in 1998 Medical Billing Companies (MBCs) issued in 1998

• Providers remain responsible for any errors made

Providers remain responsible for any errors made by MBCs by MBCs

• One of the most common risk areas

One of the most common risk areas -

• physician

physician practices contracting with billing services on a practices contracting with billing services on a percentage basis percentage basis -

• the OIG has a longstanding

the OIG has a longstanding concern that such arrangements may increase the concern that such arrangements may increase the risk of intentional upcoding and similar abusive risk of intentional upcoding and similar abusive billing practices billing practices

• R

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• 2. Physician Pathology Services
• 2. Physician Pathology Services

Work Plan

We will determine whether the billings for pathology laboratory services comply with Medicare Part B

• requirements. We will focus on

pathology services performed in physicians’ offices. Medicare pays more than $1 billion annually to physicians for pathology services. We will also identify and review the relation-ships between physicians who furnish pathology services in their

• ffices and outside pathology

companies. (OAS; W-00-05-35164; various reviews; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Focus on path lab services furnished in physician

Focus on path lab services furnished in physician

• ffice labs; not in an independent or clinical
• ffice labs; not in an independent or clinical

pathology lab pathology lab − − TC and interpretation TC and interpretation − − Must be billed on an assigned basis Must be billed on an assigned basis – – can can’ ’t bill t bill the patient the patient − − Clinical Laboratory Improvements Clinical Laboratory Improvements Amendments (CLIA) certificate/waiver issues Amendments (CLIA) certificate/waiver issues

• If service furnished to hospital inpatient, no direct

If service furnished to hospital inpatient, no direct billing to Medicare billing to Medicare

• In recent years, a sharp increase in

In recent years, a sharp increase in “ “turnkey turnkey” ” path path lab arrangements (so lab arrangements (so-

• called

called “ “pod labs pod labs” ”) ) − − Stark Law In Stark Law In-

• office ancillary service exception
• ffice ancillary service exception

− − CMS proposed to change definition of CMS proposed to change definition of “ “centralized building centralized building” ” to eliminate pod lab to eliminate pod lab arrangement (rental of cubicles) arrangement (rental of cubicles)

• R

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• 3. Cardiography and
• 3. Cardiography and

Echocardiography Services Echocardiography Services

Work Plan

We will review Medicare payments for cardiography and echocardiography services to determine whether physicians billed appropriately for the professional and the technical components of the services. Like many physician services, cardiography and echo-cardiography include both technical and professional

• components. When a physician

performs the interpretation separately, the modifier 26 should be used to bill Medicare. (OAS; W-00-06-35165; various reviews; expected issue date: FY 2007; work in progress)

Key Points Key Points

• These services can be performed either in a

These services can be performed either in a hospital setting or in physician clinics hospital setting or in physician clinics

• If the physician does not own/lease the equipment

If the physician does not own/lease the equipment

• r the service is performed in the hospital setting
• r the service is performed in the hospital setting

the physician should bill with modifier 26 to the physician should bill with modifier 26 to indicate the services is the professional indicate the services is the professional (interpretation) only (interpretation) only

• Overpayment will result if modifier 26 is not

Overpayment will result if modifier 26 is not applied when applicable applied when applicable

• R

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• 4. Payment to Providers of Care for
• 4. Payment to Providers of Care for

Initial Preventative Physician Exam Initial Preventative Physician Exam

Work Plan

We will evaluate the impact of the initial preventive physical examination (IPPE) on Medicare payments and physician billing

• practices. Section 611 of the MMA

provides for coverage under Part B of an IPPE, including a screening electrocardiogram (EKG) for new Medicare beneficiaries, effective January 1, 2005. In addition to the screening EKG, the IPPE must include a measurement of height, weight, and blood pressure; a review of medical and social history; assessment of the potential for depression; and evaluation of functioning

• ability. For new Medicare beneficiaries

with established relationships, the physician is presented with the

• pportunity to claim a higher payment for

the IPPE under a new Healthcare Common Procedure Coding System (HCPCS) code, G0344, for services that may already have been performed in a past evaluation and management visit. (OAS; W-00-06-35195; A-02-06-01014; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Section 611 of the MMA provides coverage under

Section 611 of the MMA provides coverage under Part B for an initial preventative physical Part B for an initial preventative physical examination (IPPE) for new beneficiaries, effective examination (IPPE) for new beneficiaries, effective 1/1/05 1/1/05

• Focus on documentation to indicate that all

Focus on documentation to indicate that all components of this service have been provided components of this service have been provided

• The IPPE includes services provided by a physician

The IPPE includes services provided by a physician

• r qualified non
• r qualified non-
• physician practitioner & consist of:

physician practitioner & consist of:

• 1. A physical examination (including measurement
• f height, weight, blood pressure, and an

electrocardiogram, but excluding clinical laboratory tests) with the goal of health promotion and disease detection

• 2. Education, counseling and referral for screening

and other covered preventive benefits separately authorized under Medicare Part B – (e.g., pneumococcal, influenza and hepatitis B vaccine and their administration)

R

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• 5. Part B Mental Health Services
• 5. Part B Mental Health Services

Work Plan

We will determine whether Medicare Part B mental health services provided in physicians’ offices were medically necessary and billed in accordance with Medicare requirements. Payments for mental health services provided in the physician’s office setting accounted for approximately 55 percent of the $1.3 billion in Medicare payments for Part B mental health services in 2002. In a prior report, we found that Medicare allowed $185 million in 1998 for inappropriate mental health services in the outpatient setting. We will also determine the financial impact

• f claims that do not meet Medicare

requirements. (OEI; 09-04-00220; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Outpatient Mental Health Therapeutic Treatment

Outpatient Mental Health Therapeutic Treatment Limitation (Medicare pays only 50%, not 80%) Limitation (Medicare pays only 50%, not 80%) − − Diagnostic services not subject to limitation Diagnostic services not subject to limitation

• Local Coverage Decisions (LCDs) specify

Local Coverage Decisions (LCDs) specify − − Documentation requirements Documentation requirements − − Covered diagnoses Covered diagnoses − − Coding guidelines Coding guidelines

• Includes psychologists, NPs, PAs, CSWs

Includes psychologists, NPs, PAs, CSWs

• In past OIG reports, psychotherapy, group therapy

In past OIG reports, psychotherapy, group therapy and psychological testing found particularly and psychological testing found particularly problematic problematic

• OIG advised CMS/carriers to institute pre

OIG advised CMS/carriers to institute pre-

• pay edits

pay edits and post and post-

• pay reviews

pay reviews

R

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• 6. Physical and Occupational
• 6. Physical and Occupational

Therapy Services Therapy Services

Work Plan

We will review Medicare claims for therapy services provided by physical and occupational therapists to determine whether the services were reasonable and medically necessary, adequately documented, and certified by physician certification statements. Physical and occupational therapies are medically prescribed treatments concerned with improving or restoring functions, preventing further disability, and relieving symptoms. (OAS; W-00-06-35159; various reviews; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Therapy services not properly authorized or non

Therapy services not properly authorized or non-

• covered services billed as covered

covered services billed as covered

• Therapy services not provided as ordered

Therapy services not provided as ordered

• Coding/billing issues

Coding/billing issues

• Inappropriate billing of supervision

Inappropriate billing of supervision

• Inappropriate site of service

Inappropriate site of service

• Inappropriate CPT coding

Inappropriate CPT coding

• Billing for multiple patients receiving therapy

Billing for multiple patients receiving therapy at the same time inappropriately at the same time inappropriately

• Incomplete medical records/services billed that

Incomplete medical records/services billed that were not properly documented were not properly documented

• Therapy services billed that were provided by

Therapy services billed that were provided by inappropriate or unlicensed staff inappropriate or unlicensed staff

R

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• 7. Wound Care Services
• 7. Wound Care Services

Work Plan

We will determine whether claims for wound care services were medically necessary and billed in accordance with Medicare requirements. Medicare- allowed amounts for certain wound care services billed by physicians increased from approximately $98 million in 1998 to $147 million in 2002. We will also examine the adequacy of controls to prevent inappropriate payments for wound care services. (OEI; 02-04-00410; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Multiple NCD

Multiple NCD’ ’s and LCD s and LCD’ ’s for wound care s for wound care

• Documentation is key

Documentation is key − − Support for medical necessity Support for medical necessity − − Detailed notes on services provided Detailed notes on services provided − − Separate note for E/M services same day Separate note for E/M services same day

R

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What What’ ’s New s New

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Risk Areas for Physicians and Risk Areas for Physicians and Physician Practices Physician Practices

Overview of What Overview of What’ ’s New s New

1. 1. Accuracy of billing for ophthalmology services related to catara Accuracy of billing for ophthalmology services related to cataract and lasik eye ct and lasik eye surgery (take out) surgery (take out) 2. 2. Appropriateness of Medicare services performed Appropriateness of Medicare services performed “ “incident to incident to” ” the professional the professional services of physicians services of physicians 3. 3. Propriety of imaging services, such as MRI, PET and CT scans pro Propriety of imaging services, such as MRI, PET and CT scans provided in vided in physicians physicians’ ’ offices

• ffices

4. 4. Improper coding of the Improper coding of the “ “place of service place of service” ” on claims for services provided in ASCs

• n claims for services provided in ASCs

and hospital outpatient departments and hospital outpatient departments 5. 5. Whether physicians received separate payments for evaluation and Whether physicians received separate payments for evaluation and management management services provided during the global surgery period and whether i services provided during the global surgery period and whether industry practices ndustry practices related to the number of evaluation and management services prov related to the number of evaluation and management services provided during the ided during the global surgery period have changed since the advent of the globa global surgery period have changed since the advent of the global surgery fee l surgery fee concept concept 6. 6. Factors contributing to the rise in Medicare reimbursement for p Factors contributing to the rise in Medicare reimbursement for polysomnography

• lysomnography

(expected issued date of FY2008) (expected issued date of FY2008) 7. 7. Improper billing of psychiatric services in an inpatient setting Improper billing of psychiatric services in an inpatient setting 8. 8. Appropriateness of billing Medicare Part B long distance physici Appropriateness of billing Medicare Part B long distance physician services for an services for beneficiaries of home health and skilled nursing facilities serv beneficiaries of home health and skilled nursing facilities services ices 9. 9. Appropriateness of Medicare payments for Botox treatments provid Appropriateness of Medicare payments for Botox treatments provided to ed to beneficiaries beneficiaries

“N”

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Risk Areas for Physicians and Risk Areas for Physicians and Physician Practices Physician Practices

Overview of What Overview of What’ ’s New (continued) s New (continued)

10. 10. The extent to which providers are billing beneficiaries in exces The extent to which providers are billing beneficiaries in excess of amounts allowed s of amounts allowed by Medicare requirements by Medicare requirements 11. 11. Medical necessity of the anemia drug Epogen that is ordered by p Medical necessity of the anemia drug Epogen that is ordered by physicians and hysicians and billed to Medicare by independent dialysis facilities billed to Medicare by independent dialysis facilities

“N”

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• 1. Eye Surgeries
• 1. Eye Surgeries

Work Plan

We will determine whether Medicare payments for ophthalmology services related to cataract and lasik eye surgery were billed in accordance with Medicare requirements. We will also examine the adequacy of carrier claims processing controls to prevent inappropriate payments for these services. (OAS; W-00-06-3521; A-05-06-00054; expected issue date: FY 2007; work in progress)

Key Points Key Points

• National Coverage Decisions (NCDs) for eye

National Coverage Decisions (NCDs) for eye procedures procedures

• Additional Local Coverage Decisions (LCDs)

Additional Local Coverage Decisions (LCDs)

• Ophthalmologists should be aware of all applicable

Ophthalmologists should be aware of all applicable coverage, coding and documentation requirements coverage, coding and documentation requirements

• LASIK to correct vision is not covered except to

LASIK to correct vision is not covered except to repair surgically induced astigmatism and/or repair surgically induced astigmatism and/or anisometropia and when patient is unable to wear anisometropia and when patient is unable to wear glasses or contacts. glasses or contacts.

• One eye at a time or both?

One eye at a time or both?

• N

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• 2. Evaluation of
• 2. Evaluation of “

“Incident to Incident to” ” Services Services

Work Plan

The purpose of this study is to evaluate the appropriateness of Medicare services performed “incident to” the professional services of

• physicians. We will identify services

performed “incident to” physicians’ professional services and will determine the extent to which the services met Medicare standards for medical necessity, documentation, and quality of care. (OEI; 09-06-00430; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Some aspect of

Some aspect of “ “incident to incident to” ” services has been services has been included in the OIG included in the OIG’ ’s Work Plan since 2001 s Work Plan since 2001

• Must be part of the patient's normal course of

Must be part of the patient's normal course of treatment during which a physician personally treatment during which a physician personally performed an initial service and remains actively performed an initial service and remains actively involved in the course of treatment involved in the course of treatment

• Must be provided under direct supervision

Must be provided under direct supervision

• Caregiver providing "incident to" services must

Caregiver providing "incident to" services must represent a financial expense to the billing represent a financial expense to the billing physician physician

• Documentation of link with supervising physician

Documentation of link with supervising physician

N

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• 3. Advanced Imaging Services in
• 3. Advanced Imaging Services in

Physician Offices Physician Offices

Work Plan

This review will examine the appropriateness of imaging services provided in physician offices. From 1999 to 2005, utilization of advanced imaging services, such as MRI, PET, and CT scans, has grown on average by 20 percent per year. In 2005 Medicare allowed charges of over $7 billion for these services. This review will examine the nature of the growth

• f these services over this period

including examination of billing patterns in certain geographic areas and practice settings. (OEI; 01-06-00260; expected issue date: FY 2007; work in progress)

Key Points Key Points

• In

In-

• office ancillary services exception to self
• ffice ancillary services exception to self-
• referral

referral

• Concerns include:

Concerns include: − − Opportunity for additional income Opportunity for additional income − − Quality of equipment Quality of equipment − − Excessive imaging services Excessive imaging services

• N

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• 4. Place of Service Errors
• 4. Place of Service Errors

Work Plan

• This review will determine whether

physicians properly coded the place of service on claims for services provided in ambulatory surgical centers and hospital outpatient departments. Medicare regulations provide for different levels of payments to physicians depending on where the service is performed. Medicare makes higher payments for physician office services.

• (OAS; W-00-06-35113; various

reviews; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Three components to RVU for a physician

Three components to RVU for a physician’ ’s service s service − − Work component Work component − − Practice Expense component (PE) Practice Expense component (PE) − − Malpractice component Malpractice component

• Separate PE RVUs established for procedures that

Separate PE RVUs established for procedures that can be performed in both a facility and nonfacility can be performed in both a facility and nonfacility (office) setting (office) setting

• When coded with P.O.S. of a facility, physician gets

When coded with P.O.S. of a facility, physician gets reduced payment; P.O.S. of office (11), receives reduced payment; P.O.S. of office (11), receives higher payment. higher payment.

• Multiple OIG audits have found high P.O.S.

Multiple OIG audits have found high P.O.S. reporting error rates and overpayments reporting error rates and overpayments

• Most at risk are services in provider

Most at risk are services in provider-

• based

based physician clinics physician clinics

• N

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• 5. Review of E&M Services During
• 5. Review of E&M Services During

Global Surgery Periods Global Surgery Periods

Work Plan

We will determine whether (1) physicians received separate payments for evaluation and management (E&M) services provided during the global surgery period and (2) industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was initially developed in

• 1992. Under the global surgery fee concept,

physicians bill a single fee for all their services usually associated with a surgical procedure and related E&M services provided during the global surgery period. E&M services related to the surgery provided during the global period should not be billed for and paid separately by Medicare. The global surgery fee includes payment for a certain number of E&M services provided during the global surgery period. OAS; W-00-06-35207; A-05-06-00040; expected issue date: FY 2007; work in progress)

Key Points Key Points

• Understand what

Understand what is is included and what included and what is not is not included in global surgery payment included in global surgery payment

• Components typically included in global surgery

Components typically included in global surgery payment payment − − Pre Pre-

• op visits day before and day of surgery
• p visits day before and day of surgery

− − After decision for surgery has been made After decision for surgery has been made − − Inter Inter-

• op services that are normally a usual
• p services that are normally a usual

and necessary part of the surgical procedure and necessary part of the surgical procedure − − Post Post-

• op visits within global period
• p visits within global period

− − Complications not requiring return to OR Complications not requiring return to OR

• Appropriate use of modifiers is key to indicate

Appropriate use of modifiers is key to indicate services not included in global payment services not included in global payment

N

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• 6. Medicare Reimbursement for
• 6. Medicare Reimbursement for

Sleep Studies Sleep Studies

Work Plan

• This study will determine the factors

contributing to the rise in Medicare reimbursement for polysomnography. Medicare reimbursement for polysomnograpy increased nearly 175 percent in 4 years, rising from $62 million in 2001 to $170 million in 2004. The study will also examine the appropriateness of services billed to Medicare.

• (OEI; 00-00-00000; expected issue

date: FY 2008; new start)

Key Points Key Points

• Understand documentation requirements

Understand documentation requirements − − Most states have LCDs for sleep studies Most states have LCDs for sleep studies

• Covered service only for specific diagnoses

Covered service only for specific diagnoses

• Documentation must include:

Documentation must include: − − Physician order Physician order − − Symptoms/signs to support diagnosis Symptoms/signs to support diagnosis reported reported − − Patient Patient’ ’s history and level of functional s history and level of functional impairment impairment − − Results and interpretation of tests performed Results and interpretation of tests performed

• N

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• 7. Psychiatric Services Provided in
• 7. Psychiatric Services Provided in

an Inpatient Setting an Inpatient Setting

Work Plan

We will determine whether psychiatric services provided in an inpatient setting are being properly billed to

• Medicare. Medicare makes payments

to physicians and certain nonphysician practitioners for therapy sessions provided to beneficiaries, including individual and group therapy sessions, based on a fee schedule. Because a group therapy session is reimbursed at a lower rate than an individual session, physicians may have an incentive to bill Medicare for an individual session when a group therapy session was provided to receive a higher reimbursement. (OAS; W-00-07-35304; A-04-07- 00000; expected issue date: FY 2007; new start)

Key Points Key Points

• Covered inpatient psychiatric services must be:

Covered inpatient psychiatric services must be:

− −

Provided under an individualized plan Provided under an individualized plan

− −

Reasonably expected to improve patient Reasonably expected to improve patient’ ’s s condition or for the purpose of diagnosis condition or for the purpose of diagnosis

− −

Supervised and evaluated by a physician Supervised and evaluated by a physician

• Group versus individual therapy

Group versus individual therapy

• Documentation requirements for progress notes

Documentation requirements for progress notes

N

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• 8. Long Distance Physician Claims Associated
• 8. Long Distance Physician Claims Associated

with Home Health and SNF Services with Home Health and SNF Services

Work Plan

• We will determine if Medicare Part B

long distance physician services are inappropriately billed for beneficiaries

• f home health and skilled nursing

facility services. Previous inspections identified instances of physicians

• rdering or billing for services that

would normally require

• face-to-face examination for

beneficiaries who live a significant distance from the physician’s office.

• (OEI; 00-00-00000; expected issue

date: FY 2007; new start)

Key Points Key Points

• Historically, perceived lack of physician

Historically, perceived lack of physician involvement in the care of home health patients involvement in the care of home health patients and nursing home residents and nursing home residents − − 1992 OEI report, Part B Services in Nursing 1992 OEI report, Part B Services in Nursing Homes Homes

( (http://oig.hhs.gov/oei/reports/oei http://oig.hhs.gov/oei/reports/oei-

• 06

06-

• 92

92-

• 00865.pdf

00865.pdf) )

− 2001 OEI report, The Physician’s Role in Medicare Home Health

(http://oig.hhs.gov/oei/reports/oei-02-00-00620.pdf)

• Physicians and non

Physicians and non-

• physician practitioners with

physician practitioners with UPINs should keep in mind that the OIG could use UPINs should keep in mind that the OIG could use the location data fields in CMS the location data fields in CMS’ ’s Active UPIN s Active UPIN database to identify questionable database to identify questionable “ “long distance long distance physician claims physician claims” ” (i.e., where there is a significant (i.e., where there is a significant distance separated the practice setting and the distance separated the practice setting and the beneficiary beneficiary’ ’s location) s location)

• N

KZ

29

• 9. Review of Botulinum Toxin
• 9. Review of Botulinum Toxin

(Botox) Treatments (Botox) Treatments

Work Plan

We will assess the appropriateness of Medicare payments for Botox treatments provided to Medicare

• beneficiaries. Section 1862(a)(1)(A) of

the Social Security Act prohibits payment of claims for items or services that are not reasonable or necessary for the diagnosis or treatment of illness or injury or improvement of the function of a malformed body part. Medicare coverage for Botox includes specific spastic conditions associated with certain diagnoses that are supported by medical necessity. Use of Botox for conditions other than what is covered by Medicare is unallowable. (OAS; W-00-07-35318; A-02-07- 00000; expected issue date: FY 2007; new start)

Key Points Key Points

• Covered service for specific conditions

Covered service for specific conditions

• Cosmetic use not medically necessary

Cosmetic use not medically necessary

• Refer to Local Coverage Decisions (LCDs) for

Refer to Local Coverage Decisions (LCDs) for indications and limitations of coverage indications and limitations of coverage

• Specific documentation requirements

Specific documentation requirements

N

PL

30

SLIDE 16

16

• 10. Violation of Assignment Rules
• 10. Violation of Assignment Rules

by Medicare Providers by Medicare Providers

Work Plan

We will examine the extent to which providers are billing beneficiaries in excess of amounts allowed by Medicare requirements. Providers must accept Medicare’s payment and beneficiary co-payment, known as the Medicare allowed amount, as payment in full for all covered services. Providers cannot bill beneficiaries for amounts in excess of the Medicare allowed amount. We will also assess beneficiary awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines. (OEI; 00-00-00000; expected issue date: FY 2007; new start)

Key Points Key Points

• Three contractual options for physicians:

Three contractual options for physicians: − − Participation (PAR) Participation (PAR) -

• Accept physician fee

Accept physician fee schedule allowed charge as payment in full schedule allowed charge as payment in full − − Non Non-

• participation (non

participation (non-

• PAR)

PAR) -

• −

− Medicare payment based on 95% of PFS Medicare payment based on 95% of PFS − − May charge up to 115% of fee schedule (PFS) May charge up to 115% of fee schedule (PFS) (limiting charge) (limiting charge) − − Some states prohibit balance billing Some states prohibit balance billing

− − Private contracting Private contracting – – physician opts out physician opts out

− − May not be on a patient May not be on a patient-

• to

to-

• patient basis

patient basis − − Must meet specific requirements Must meet specific requirements − − Physician may not submit Medicare claims for 2 Physician may not submit Medicare claims for 2 years after opting out years after opting out

• Physicians may change from PAR to non

Physicians may change from PAR to non-

• PAR or

PAR or vice vice-

• versa annually

versa annually

N

HY

31

• 11. Payments to Independent
• 11. Payments to Independent

Dialysis Facilities for Epogen Dialysis Facilities for Epogen

Work Plan

• We will determine whether independent dialysis

facilities are billing Medicare for administering the anemia drug Epogen beyond what is medically necessary and ordered by physicians. Epogen is a biologically engineered protein that is used to treat anemia associated with chronic renal failure. Patients who receive Epogen should have a hematocrit level between 30 percent and 36

• percent. Medicare policy requires that FIs identify

dialysis facilities with an atypical number of patients with hematocrit levels above a 90-day rolling average of 37.5 percent for routine medical review activities. Dialysis facilities are paid a composite rate per treatment for providing dialysis services to patients with end-stage renal disease (ESRD). These facilities receive a separate payment for administering Epogen that is not a part of the composite rate. We will identify for review dialysis facilities that bill Medicare for Epogen and have an atypical number of patients with a 90-day rolling average hematocrit level greater than 37.5 percent.

• (OAS; W-00-07-35306; A-03-07-00000; expected

issue date: FY 2007; new start)

Key Points Key Points

• Independent Dialysis Facilities

Independent Dialysis Facilities – – those that are not those that are not hospital based; a number of independent facilities hospital based; a number of independent facilities are owned by one or more physicians are owned by one or more physicians

• Effective 4/1/2006, Medicare implemented a

Effective 4/1/2006, Medicare implemented a national monitoring policy to for Medicare national monitoring policy to for Medicare contractors to conduct medical review on EPO contractors to conduct medical review on EPO claims claims

• CMS web

CMS web-

• site:

site: http://www.cms.hhs.gov/CoverageGenInfo/07_epo http://www.cms.hhs.gov/CoverageGenInfo/07_epo policies.asp# TopOfPage policies.asp# TopOfPage

• If dosages exceed certain thresholds, Medicare

If dosages exceed certain thresholds, Medicare contractors will return the claim to the provider as contractors will return the claim to the provider as a medically unbelievable error a medically unbelievable error

• Dosing methodology (Medicare billable increment

Dosing methodology (Medicare billable increment

• f EPO 100 mcgs)
• f EPO 100 mcgs)
• Medical necessity documentation

Medical necessity documentation

N

KZ

32

SLIDE 17

17

Q&A

KZ

33

Closing Remarks

HY

34

SLIDE 18

18

34

The information presented and discussed represents the

• pinions of the authors/presenters and, although

descriptive of general activities, they do not necessarily reflect the views of either University of Rochester Medical Center, Sonnenschein Nath & Rosenthal LLP

• r Deloitte & Touche LLP and is not intended to be

legal, regulatory, or accounting advice of any kind.