2011 OIG Work Plan

The “Office of Inspector General Work Plan for Fiscal Year 2011” provides brief descriptions of activities the OIG plans to initiate or continue in 2011 with respect to the programs and operations of the U.S. Department of Health and Human Services (HHS), such as the Centers for Medicare & Medicaid Services (CMS). Medicare Part A and Part B • Place of Service Errors Will review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers (ASC) and hospital outpatient departments. Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC. • Medicare Payments for Part B Imaging Services Will review Medicare payments for Part B imaging services. The Social Security Act, ß 1848(c)(1)(B), defines “practice expense” as the portion of the resources used in furnishing the service that reflects the general categories of expenses, such as office rent, wages of personnel, and equipment. For selected imaging services, the OIG will focus on the practice expense components, including the equipment utilization rate. They will determine whether Medicare payments reflect the expenses incurred and whether the utilization rates reflect industry practices. • Billing of Portable X-Ray Suppliers Will review providers of portable x-ray services with unusual claims patterns and identify Medicare claims that are questionable. In addition to paying suppliers for the technical and professional components of a test, Medicare pays these suppliers a setup component and transportation component. The OIG will examine the billing patterns of portable x-ray suppliers to identify those that merit additional scrutiny. • Excessive Payments for Diagnostic Tests Will review Medicare payments for high cost diagnostic tests to determine whether they were medically necessary. The Social Security Act, ß 1862 (a) (1) (A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” • Laboratory Test Unbundling by Clinical Laboratories Will review the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel tests to maximize Medicare payments. Medicare contractors must group together individual laboratory tests that clinical laboratories can perform at the same time on the same equipment and then consider the price of related profile tests. The OIG will determine whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing specimens on sequential days. They will also determine the extent to which the Medicare carriers have controls in place to detect and prevent inappropriate payments for laboratory tests. • Medicare Part B Payments for Glycated Hemoglobin A1C Tests Will review Medicare contractors’ procedures for screening the frequency of clinical laboratory claims for glycated hemoglobin A1C tests. CMS’s Medicare National Coverage Determinations Manual, states that it is not considered reasonable and necessary to perform a glycated hemoglobin test more often than every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines. • Trends in Laboratory Utilization Will review trends in laboratory utilization under the Medicare program. Medicare pays only for laboratory tests that are ordered by a physician or qualified nonphysician practitioner who is treating a beneficiary. In 2008, Medicare paid about $7 billion for clinical laboratory services, which represents a 92 percent increase from 1998. Much of the growth in laboratory spending was the result of increased volume of ordered services. The OIG will examine the types of laboratory tests and the number of laboratory tests ordered. • Lab Test Payments: Comparison of Medicare with Other Public Payers Will review the extent to which Medicare payment rates for laboratory tests vary from other public payers. Excessive payment rates for laboratory tests can be costly for the Medicare program. In 2009, Medicare paid nearly $10 billion for lab tests. The OIG will compare Medicare laboratory payment rates for the 10 most utilized lab tests with those of other public payers, including the Department of Veterans Affairs (VA) and State Medicaid programs. • Medicare Providers’ Compliance With Assignment Rules Will review the extent to which providers comply with assignment rules and determine whether and to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare requirements. CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician or other supplier in return agrees to accept the Medicare allowed amount indicated by the carrier as the full charge for the items or services provided. • Medicare Payments for Claims Deemed Not Reasonable and Necessary Will review Medicare payments for Part B claims in 2009 that providers note as not reasonable and necessary on claim submissions. The CMS Claims Processing Manual states that providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary. The OIG will determine the extent to which Medicare paid for Part B claims with these modifiers, as well as the types of providers and the types of services associated with these claims. They will also assess the policies and practices that Medicare contractors have in place with regard to these claims. • Medicare Billings With Modifier GY Will review the appropriateness of providers’ use of modifier GY on claims for services that are not covered by Medicare. Modifier GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service. Beneficiaries are liable, either personally or through other insurance, for all charges associated with the provision of these services. In FY 2008, Medicare received over 75.1 million claims with a modifier GY totaling approximately $820 million. The OIG will examine patterns and trends for physicians’ and suppliers’ use of modifier GY. • Payments for Services Ordered or Referred by Excluded Providers Will review the nature and extent of Medicare payments for services ordered or referred by excluded providers. Pursuant to the Social Security Act, ßß 1128 and 1156, and 42 CFR ß 1001.1901, no payment shall be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity. The OIG will examine CMS’s oversight mechanisms to identify and prevent improper payments for services based on orders or referrals by excluded providers. • Error Prone Providers: Medicare Part A and Part B Will review Medicare Part A and Part B claims submitted by error prone providers. CMS requires providers to submit accurate claims for services provided to Medicare beneficiaries. Error prone providers are identified using CMS’s Comprehensive Error Rate Testing (CERT) Program data. Methodology. The OIG will select the top error prone providers based on expected dollar error amounts and match selected providers against the National Claims History file to determine the total dollar amount of claims paid. They will then conduct a medical review on a sample of claims to determine their validity, project results to each provider’s population of claims, and request refunds on projected overpayments. • Comprehensive Error Rate Testing Program: FY 2010 Error Rate Oversight The Improper Payments Information Act of 2002 (IPIA) requires the head of a Federal agency with any program or activity that may be susceptible to significant improper payments to report to Congress the agency’s estimate of improper payments. The CERT Program was established by CMS to meet the requirements of the IPIA and to monitor the accuracy with which Medicare claims are billed and paid. The CERT program’s national estimated improper payments for FY 2009 were $24.1 billion (7.8 percent error rate). • Medicare Services Billed With Dates of Service After Beneficiaries’ Dates of Death Will review Medicare claims with dates of service after beneficiaries’ dates of death to assess CMS’s controls to preclude or identify and recover improper FFS payments. Entitlement to supplementary medical insurance (Part B) ends on the last day of the month in which the beneficiary dies. To monitor Medicare eligibility effectively, CMS uses several computer database systems that interface with death information on the Social Security Administration’s and the Railroad Retirement Board’s systems. Medicare Part A and Part B Contractor Operations • Accuracy of the National Provider Enumeration and Medicare Provider Enrollment Data Will review the extent to which the NPI enumeration data and Medicare Provider Enrollment, Chain and Ownership System (PECOS) data are complete, consistent, and accurate. HIPAA required the Secretary of HHS to establish a standard unique health identifier for each health care provider, health care organization, and health plan for use in the health care system. The Secretary established the NPI to address this requirement and requires providers to enroll to receive payment from Medicare, and PECOS is the system CMS uses to complete the enrollments online. • Identification and Recoupment of Improper Payments by Recovery Audit Contractors Will review the performance of the Recovery Audit Contractor (RAC) program. The RACs conduct postpayment reviews to identify overpayments and underpayments and attempt to recoup any overpayments they find. The OIG will also review CMS’s oversight of the RAC program. • Variation in Coverage of Services and Medicare Expenditures Due to Local Coverage Determinations Will review variation in Medicare spending and coverage of services due to LCDs and the evidence Medicare contractors use to develop LCDs. A contractor may establish an LCD to enforce its decision about whether a particular item or service is considered reasonable and necessary and is therefore covered under Medicare. These coverage decisions are not national, meaning Medicare could pay for a service for a beneficiary in one location, but deny payment for that service to a beneficiary elsewhere. Over 2,800 LCDs are in effect, but it is not possible to readily calculate the number of claims and the amount of Medicare spending associated with LCDs because claims do not indicate whether an LCD is involved. The OIG will also assess CMS’s monitoring and oversight of LCDs. Medicaid Reviews • Payments to Terminated and/or Excluded Medicaid Providers and Suppliers Will review Medicaid payments to providers and suppliers to determine the extent to which payments were for services provided during periods of termination or exclusion from the Medicaid program. Excluded and/or terminated providers and suppliers are not permitted to receive payments for services provided after the effective program termination date or during periods of exclusion. • Medicaid Claims With Inactive or Invalid Physician Identifier Numbers Will review Medicaid claims to determine the extent to which State agencies have controls in place to identify claims associated with inactive or invalid unique physician identifier numbers (UPIN), including claims for services alleged to have been provided after the dates of the referring physicians’ deaths. Given the vulnerabilities identified in the Medicare program, the OIG will review State Medicaid programs to determine whether States have controls in place to identify claims with inactive or invalid UPINs. • Early Results From Medicaid Integrity Contractors Will review the progress of CMS’s Medicaid Integrity Contractors (MICs) in completing program integrity tasks outlined in their contracts. MICs are tasked with preventing and detecting Medicaid fraud, waste, and abuse through the review of the actions of individuals or entities furnishing items or services under the Medicaid program. CMS began awarding contracts in April 2008 and subsequently awarded contracts covering CMS’s 10 regions. The OIG will also examine the results of the MICs’ work. • Use of Prepayment Review To Detect and Deter Fraud and Abuse in Medicaid Managed Care Will review the extent to which Medicaid MCOs use prepayment reviews to detect and deter fraud and abuse. Prepayment reviews can serve as effective fraud and abuse safeguards because they occur during the claims processing phase prior to claim payment. • Medicaid Credit Balances Will review providers to determine whether there are Medicaid overpayments in patient accounts with credit balances. The Social Security Act, 1902(a)(25), require that Medicaid be the payer of last resort and that providers identify and refund overpayments received. Prior OIG work has found Medicaid overpayments in patients’ accounts with credit balances. Legal and Investigative Activities Related to Medicare and Medicaid • Exclusions From Program Participation OIG may exclude individuals and entities from participation in Medicare, Medicaid, and all other Federal health care programs for many reasons, some of which include program related convictions, patient abuse or neglect convictions, licensing board disciplinary actions, or other actions that pose a risk to beneficiaries or programs. Exclusions are generally based on referrals from Federal and State agencies. In fiscal year (FY) 2009, OIG excluded 2,556 individuals and entities from participation in Federal health care programs. • Provider Self-Disclosure OIG encourages health care providers to promptly self disclose conduct that violates Federal health care program requirements. In October 1998, OIG announced a self disclosure protocol for all health care providers. The protocol offers steps, including a detailed audit methodology, that providers may use if they choose to work openly and cooperatively with us. Many providers, including hospitals, laboratories, and physicians, make disclosures using the protocol.