For investigators billing routine care costs or drugs under a clinical trial to Medicare and Medicaid, some of the clinical areas highlighted under the 2013 work plan are:
1. Ophthalmological Services — Questionable Billing (NEW): Review Medicare claims data to identify questionable billing claims for ophthalmological services during 2011.
2. Electrodiagnostic Testing — Questionable Billing (NEW): Review Medicare claims to identify questionable billing for electrodiagnostic testing (including electromyograms and nerve conduction tests)
3. Patient Safety and Quality of Care — Claims for and Use of Atypical Antipsychotic Drugs Prescribed to Children in Medicaid (NEW): Review medical records to determine the extent to which patients 18 years of age or younger had submitted Medicaid claims for atypical antipsychotic drugs during a selected timeframe; and determine the extent to which the drug claims were submitted for off-label uses (when the drug is prescribed for a condition not listed on the product’s label) and for indications not listed in one or more of the approved drug compendia.
4. Evaluation and Management (E/M) Services — Potentially Inappropriate Payments in 2010: Determine the extent to which cms made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determination. Review multiple E/M services for the same providers and beneficiaries to identify electronic health records (documentation practices associated with potentially improper payments).
5. Diagnostic Radiology — Medical Necessity of High-Cost Tests: Review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary. Review the extent to which primary care physicians and physician specialists order the same diagnostic tests for the same treatment of a beneficiary.
6. Laboratory Tests — Billing Characteristics and Questionable Billing in 2010: Identify questionable billing for Medicare Part B (outpatient) clinical lab tests in 2010. Medicare pays only for lab tests ordered by a physician or qualified nonphysician practitioner who is treating a beneficiary.
7. Laboratory Tests — Part B Payments for Glycated Hemoglobin A1c tests: Determine the appropriateness of Medicare payments for the glycated hemoglobin test (HgbA1c). Medicare does not consider it reasonable and necessary to perform this test more often than once every 3 months on a controlled diabetic patient, unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines.
8. Patient Safety and Quality of Care — Off-Label Use of Medicare Part B Drugs: Review off-label and off-compendia use of certain outpatient Medicare (Part B) prescription drugs and determine the extent to which specified compendia provide support for coverage.
9. Drug Payments — Questionable Claims for HIV Drugs: Determine the extent of questionable billing for HIV drugs dispensed in 2010 under Medicare’s outpatient prescription plan (Part D).
10. Sleep Testing — Appropriateness of Medicare Payments for Polysomnography: Identify questionable billing patterns for Medicare sleep services provided in 2009 and 2010.
11. Sleep Disorder Clinics — High Utilization of Sleep Testing Procedures: Examine Medicare payments to physicians, hospital outpatient, and independent diagnostic testing facilities to determine whether they were “reasonable and necessary.”