Assess the effectiveness of preventing inappropriate Medicare payments for beneficiaries with other insurance coverage and identify credit balance situations, which occur when payments from Medicare and other insurers exceed the providers charges or the allowed amounts.
Based on prior OIG work, CMS implemented an edit in 2004 to reject subsequent claims on behalf of beneficiaries who were readmitted to the same hospital on the same day.
Payments for Diagnostic X Rays in Hospital Emergency Departments
Review Medicare Part B paid claims and medical records for diagnostic x rays performed in hospital emergency departments to determine the appropriateness of payments.
MedPAC, in March 2005, reported increasing cost of imaging and potential overuse of diagnostic imaging services.
Part B Services in NH
Will continue to monitor that Part B is not billed for Part A services
Laboratory Test Unbundling by Clinical Laboratories
Will review the extent to which clinical labs inappropriately unbundled laboratory profile or panel tests to maximize Medicare payments.
Will determine if labs unbundled profile or panel tests by submitting claims for multiple DOS or by drawing specimens on sequential days.
Medicare Billings With Modifier GY
Will review appropriateness of providers' use of mod -GY
GY is used for services statutorily excluded or defined as not covered.
Beneficiaries are liable for all charges.
In 2008 Medicare received ~75.1 million claims at ~$820 MM with a GY
Provider Compliance with Assignment Rules
Examine if providers comply with assignment rules and determine if beneficiaries are inappropriately billed in excess of amounts allowed.
CMS defines assignment as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare.
Payments for Services Ordered or Referred by Excluded Providers
Review Medicare payments for services ordered by excluded providers.
CMS completed its transition to the use of NPI April 2009. It is possible during this period, some referring/ordering providers, did not have NPIs.
Comprehensive Error Rate Testing Program: Fiscal Year 2008 Part A and Part B Error Rates
Review CMS's CERT methodology and medical review for determining 2008 Part A and B error rates.
Medicare Services with DOS after Death of Beneficiary
Review Medicare claims with DOS after beneficiaries' dates of death to assess CMS's controls to identify and recover improper payments.
Pursuant to 42 CFR Â§ 407.27(a) Part B entitlement ends on the last day of the month in which the beneficiary dies.
Accuracy and Completeness of the National Provider Identifier
Review the accuracy and completeness of the NPI registry.
Determine whether providers are including NPIs on claims as required.
Collection of Over Payments Referred by Program Safety Contractors
HIPAA established the Medicare Integrity Program, which requires CMS to engage contractors to review Medicare claims for possible overpayments.
PSCs identify overpayments that have been made to Medicare providers and refer them to Medicare claims processors for collection.
We will examine overpayments collected resulting form overpayment referrals and identify procedures used by the program safeguard contractors to identify and track possible fraud and abuse related to the overpayments.
Recovery Audit Contractor (RAC) Referrals of Potential Fraud and Abuse
Review CMS's oversight of RAC during a 3-year demonstration program to determine the extent to which RACs responsible for identifying Medicare overpayments, also identified and reported potential fraud and abuse.
For both the demonstration and national RACs, examine the number of cases referred to CMS, CMS's processing of those referrals, CMS's guidance and training to the demonstration RACs to identify and report potential fraud.
Transition from PSCs to ZPICs
Review the process PSCs used to transition work to Zone Program Integrity Contractors (ZPIC), which are assuming the PSCs' responsibility for ensuring integrity of Medicare claims.
Provider Education and Training (PCA)
Review the progressive corrective action provider education and training conducted by selected Medicare contractors to determine whether programs have reduced billing & payment error rates and aberrant provider behavior.
Potentially Excessive Medicaid Payments for Inpatient and Outpatient Services
Review State controls to detect potentially excessive Medicaid payments to institutional providers for inpatient and outpatient services.
Prior OIG work involving Medicare inpatient and outpatient claims found that many claims resulting in excessive payments to the hospitals were attributable to billing errors on the submitted claims, such as inaccuracies in the diagnosis codes, admission codes, discharge codes, procedure codes, charges, HCPCS codes, and number of units billed.
Medicare/Medicaid Credit Balances
Review providers, including labs and hospitals, to determine if there are Medicare/Medicaid overpayments in patient accounts with credit balances.
The SS Act, Â§ 1862(b), and 42 CFR pt. 411 requires participating providers to furnish information and to refund any Medicare moneys incorrectly paid.
Prior OIG work has identified Medicare and Medicaid overpayments in patients' accounts with credit balances
Medicaid Timely Filing
Review Medicaid payments to determine if States improperly received Federal Medicaid reimbursement for claims that exceeded timely filing requirements. Federal regulations at 42 CFR Â§ 447.45(d) provide that State Medicaid agencies require providers to submit all claims no later than 12 months from the dates of services. An OIG review in one State identified Medicaid claims exceeding the 12-month filing requirement.
Applying CCI's to Medicaid Claims
We will apply Medicare National CCI edits to Medicaid outpatient claims to estimate what could be saved if State Medicaids implemented CCI edits.
CCI edits are not required for Medicaid claims. Previous OIG work on this issue determined that 39 States paid $54 million for services that would have been denied based on CCI edits.
Medicare and Medicaid Security of Portable Devices Containing Personal Health Information at Contractors and Hospitals
Review security controls implemented by Medicare/Medicaid contractors as well as hospitals to prevent the loss of PHI stored on portable devices.
Recent breaches related to Federal computers, involving a CMS contractor heightened concerns.
Providers' Compliance With Corporate Integrity Agreements
Conduct site visits to entities that are subject to the integrity agreements to verify compliance and impose sanctions, in the form of stipulated penalties or exclusions, on providers that breach their integrity agreement.
Breach Notification and Medical Identity Theft in Medicare
Will review CMS's compliance with new breach notification requirements for personally identifiable information (PII).