The 2017 Office of Inspector General (OIG) Work Plan has been released by the U.S. Department of Health and Human Services (HHS). Items of interest to physicians include:
Chronic Care Management (CCM) – The OIG will determine if payments for CCM, a new benefit as of 1/1/15, were in accordance with Medicare requirements.
Transitional Care Management (TCM) – The OIG will determine if payments for TCM were in accordance with Medicare requirements and not billed during the same period as CCM services.
Open Payments Program – The OIG will determine the extent to which data in the open payments system is missing or inaccurate, the extent to which CMS oversees manufacturers’ and group purchasing organizations’ compli- ance with data reporting requirements and whether the required data for physicians and teaching hospital payments are valid.
Anesthesia Services – Non-Covered & Personally Performed – The OIG will review anesthesia claims to determine whether the beneficiary has a related Medicare service and whether claims where the anesthesiologist billed for personally performed services met the Medicare requirements.
Home Visits – Medicare paid $718 million for physician home visits between January 2013 and December 2015. The OIG will review home visit claims to determine if they met medical necessity requirements.
Prolonged Services – Prolonged services are for additional care provided to a beneficiary after an evaluation and management (E&M) service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond the time spent with a beneficiary for a usual companion E&M service. The necessity of prolonged services is considered to be rare and unusual.
Drug Waste of Single-Use Vial Drugs – Modifier JW is used to bill for discarded drugs. The OIG will review claims for modifier JW and determine the amount of waste for the 20 single-use vial drugs with the highest paid-for waste and provide specific examples of where a different size vial could significantly reduce waste.
Sleep Disorder Clinics – The OIG has identified high utilization of polysomnography; sleep staging with four or more additional parameters of sleep (95810) and polysomnography with initiation of continuous positive airway therapy or bi-level ventilation (95811), especially as it relates to retesting. The OIG will review claims for 95810 and 95811 to look for medical necessity.
Payment for Immunosuppressive Drugs Modifier KX – Modifier KX signifies that the provider retains documentation in the medical record of the beneficiary’s transplant date and that such transplant date preceded the date of service for the immunosuppressive drug. The OIG will review claims with modifier KW to insure appropriate documentation is in the medical record.
Incarcerated Beneficiaries – Medicare does not pay for services rendered to incarcerated beneficiaries. The OIG will review Medicare payments and recoup Medicare payments for items and services furnished to incarcerated Medicare beneficiaries.