OIG Work Plan 2014

The Office of Inspector General (OIG) has released its Fiscal Year 2014 Work Plan. The OIG releases a Work Plan annually to identify the investigative, enforcement and compliance activities that it will undertake in the coming fiscal year. Some areas affecting laboratory providers are identified below.

Laboratory tests—Billing characteristics and questionable billing

Will review billing characteristics for Part B clinical laboratory (lab) tests and identify questionable billing. Medicare is the largest payer of clinical lab services in the Nation. Medicare’s payments for lab services in 2008 represented an increase of 92 percent over payments in 1998. In 2010, Medicare paid about $8.2 billion for lab tests, accounting for 3 percent of all Medicare Part B payments. Much of the growth in lab spending has resulted from the increased volume of ordered services.

Physicians—Place-of-service coding errors

Will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed.

Medicare administrative contractors—Use and evaluation of local edits

Will determine the extent to which MACs used and evaluated their local claims processing system edits in 2011. Will also describe how the change in MAC error rates from 2010 to 2011 compared to MACs’ use and evaluation of local edits in 2011. Local claims processing edits are a key safeguard for identifying improper payments before Medicare payment is made and for ensuring that Part A and Part B claims are paid correctly.

Payments for incarcerated beneficiaries

Will review Medicare payments for incarcerated beneficiaries to determine whether the payments were made for beneficiaries who did not meet the criteria for exception identified in Medicare regulations.  Prior OIG reviews have identified improper Medicare payments for incarcerated beneficiaries. Medicare, in general, does not pay for services rendered to incarcerated beneficiaries.

Payments to providers subject to debt collection

Will review providers and suppliers that received Medicare payments after CMS referred them to the Department of the Treasury (Treasury) for failure to refund overpayments. Will determine the extent to which they ceased billing under one Medicare provider number but billed Medicare under a different number after being referred to Treasury.

Improper Medicare payments for beneficiaries with other insurance coverage

Will identify Medicare payments made for services to beneficiaries who have certain types of other insurance coverage to assess the effectiveness of Medicare’s controls to prevent such payments. Will determine whether selected non-Medicare health plans properly reported insurance coverage information to Medicare as required.

Recovering Medicaid overpayments—Credit balances in Medicaid patient accounts

Will review providers’ patient accounts to determine whether there are Medicaid overpayments in accounts with credit balances. Credit balances generally occur when the reimbursement that a provider receives for services provided to a Medicaid beneficiary exceeds the charges billed, such as when a provider receives a duplicate payment for the same service from the Medicaid program or another third party payer.

National Correct Coding Initiative edits and CMS oversight (new)

Will review selected States’ implementation of National Correct Coding initiative (NCCI) edits for Medicaid claims and describe CMS’s oversight of NCCI edits. Federal law required States to incorporate compatible methodologies of the NCCI for Medicaid claims filed on or after October 1, 2010.