The following physician reimbursement areas have been targeted by the Office of Inspector General (OIG) for audits in its 2021 work plan. We bring these to your attention for general awareness and education. Compliance will be reviewing these identified risk areas as potential topics of review for the Yale Medicine Audit Work Plan.
OIG reviews will be conducted of:
- Medicare Emergency Department Evaluation and Management Services - All E/M services reported to Medicare must be adequately documented so that medical necessity is clearly evident. This review will determine whether Medicare payments to providers for emergency department E/M services were appropriate, medically necessary, and paid in accordance with Medicare requirements.
- Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care - Limited information is available about how states use telehealth to provide behavioral health services to Medicaid enrollees. This review will describe: (1) the challenges that states face using telehealth to provide behavioral health services to Medicaid enrollees and (2) the extent to which states assess the effects of telehealth on access, cost, and quality and monitor telehealth to provide behavioral health services. The OIG collected these data points prior to states' expanding telehealth in response to the pandemic; however, this information continues to be valuable in future decisions to strengthen telehealth on a more permanent basis.
- Audits of Medicare Payments for Spinal Pain Management Services - Medicare Part B covers various spinal pain management services including facet joint injections, facet joint denervation sessions, lumbar epidural injections, and trigger point injections. Medicare Part B also covers sedation administered during these pain management services. The OIG will audit whether Medicare payments for spinal pain management services billed by physicians complied with federal requirements.
- Dermatologist Claims for Evaluation and Management Services on the Same Day as Minor Surgical Procedures - Medicare covers an E/M service when the service is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Generally, Medicare payments for global surgery procedures include payments for necessary preoperative and postoperative services related to surgery when furnished by a surgeon. In general, E/M services provided on the same day of service as a minor surgical procedure are included in the payment for the procedure.
The decision to perform a minor surgical procedure is included in the payment for a minor surgical procedure and must not be reported separately as an E/M service. An E/M service should be billed only on the same day if the provider performs a significant and separately identifiable E/M service that is unrelated to the decision to perform a minor surgical procedure. In this instance, the provider may append a modifier 25 to the appropriate E/M code. In 2019, about 56 percent of dermatologists' claims with an E/M service also included minor surgical procedures (such as lesion removals, destructions, and biopsies) on the same day. This may indicate abuse whereby the provider used modifier 25 to bill Medicare for a significant and separately identifiable E/M service when only a minor surgical procedure and related preoperative and postoperative services are supported by the patient’s medical record. The OIG will determine whether dermatologists' claims for E/M services on the same day of service as a minor surgical procedure complied with Medicare requirements. - Audits of Medicare Part B Telehealth Services during the COVID-19 Public Health Emergency - Telehealth is playing an important role during the public health emergency (PHE), and CMS is exploring how telehealth services can be expanded beyond the PHE to provide care for Medicare patients. Because of telehealth's changing role, the OIG will conduct a series of audits of Medicare Part B telehealth services in two phases. Phase one audits will focus on making an early assessment of whether services such as E/M, opioid use disorder, end- stage renal disease, and psychotherapy meet Medicare requirements. Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check- in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.