OIG to scrutinize eligibility for orders/referrals

Robert A. Dowling, MDThe activities of the Office of the Inspector General (OIG) are relevant to the practice of urology, and your ability to mitigate any risk associated with the OIG’s auditing and investigative activities is important. I provided tips for doing so in a series of articles in 2013 and ’14. The OIG recently released its work plan for 2016, and it’s time for an update on what is new, what is not new, and what has been removed in the scope of the office’s intended activities for the coming year and beyond. 

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As a reminder, OIG is the investigative and enforcement arm of the Department of Health and Human Services (HHS) and its programs, including but not limited to the Centers for Medicare & Medicaid Services and the FDA. Its Office of Audit Services (OAS) and Office of Evaluation and Inspections are among several branches charged with maintaining the integrity of HHS programs and watching out for those programs’ beneficiaries.

According to its website, the OIG at HHS is the largest inspector general office in the federal government. The primary tools used by the OIG are forced exclusion from HHS programs, civil monetary penalties for violations including kickback and physician self-referral issues, and criminal prosecutions of individuals and businesses for fraud and other egregious acts.

According OIG’s downloadable database as of Dec. 1, 2015, out of a total of 62,678 exclusions, 5,853 physicians and 25 urologists have been excluded from federal programs by the OIG. The top two reasons for exclusions are licensing issues (3,003) and conviction of program-related crimes (1,065).

Each year, the OIG publishes a summary of its activities and a work plan for the coming year. The work plan for fiscal year 2016 includes a number of topics of interest to urologists, which is my focus in this article. For the full report, go to http://bit.ly/OIG2016.

Next: Provider status, imaging

Provider status, imaging

Provider-based status (revised). The OIG continues its focus on “provider-based status,” as hospital-owned physician practices that bill as hospital outpatient departments “can result in higher Medicare payments for services furnished at provider-based facilities and may increase beneficiaries’ coinsurance liabilities.” This area of attention aligns with concerns expressed by the Medicare Payment Advisory Commission and changes to the definition of a hospital-owned practice announced in the recent federal budget. Urology practices that are considering acquisition by a hospital or integrated delivery system should take note.

Medical necessity of high-cost diagnostic radiology tests (removed) and imaging services payment for practice expenses (retained). In the 2016 work plan, the OIG makes no mention of continuing the focus in previous years on documenting medical necessity for high-cost radiology tests. However, in a related area of the work plan, OIG said it “will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate.”

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Urologists who own diagnostic imaging equipment and render those services to Medicare patients should remain vigilant about documenting the reasons for ordering those tests and review their own utilization rates.

Next: E&M, lab billing, referring/ordering of supplies

E&M, lab billing, referring/ordering of supplies

Evaluation and management services-inappropriate payments (removed). In its 2015 and 2016 work plans, the OIG omitted the language related to scrutiny of evaluation and management services and possible inappropriate payments. Compliant coding and avoiding fraudulent billing remain important expectations for the urology practice, but the OIG has signaled its investigative and enforcement priorities lie elsewhere.

Laboratory tests-billing characteristics and questionable billing (removed), annual analysis of Medicare clinical laboratory payments (retained), and referring/ordering Medicare services and supplies (new). According to the OIG, “Medicare pays more than other insurers for certain high-volume and high-expenditure laboratory tests.” The OIG has broadened its focus on provider ordering beyond laboratory tests, stating that “CMS requires that physicians and non-physician practitioners who order certain services, supplies and/or DME are required to be Medicare-enrolled physicians or nonphysician practitioners and legally eligible to refer/order services, supplies, and DME. If the referring/ordering physician or non-physician practitioner is not eligible to order or refer, then Medicare claims should not be paid.”

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Urology practices should review their policies for delegating and documenting “orders” and “referrals” in the electronic or paper chart to ensure they are compliant with this requirement. Practices that own and operate clinical labs should understand that this is an area of attention for the OIG as well as state and local authorities.

Next: Excessive billing of beneficiaries, prolonged services

Excessive billing of beneficiaries, prolonged services

Physicians and suppliers-Noncompliance with assignment rules and excessive billing of beneficiaries (removed), place-of-service coding errors (removed), and prolonged services/reasonableness of services (new). The OIG takes the position that “prolonged services”-those requiring time beyond the baseline evaluation and management service-should be rare and unusual. In this new focus area, the OIG announces its intention to examine whether payments for those services are appropriate. Urologists considering the use of these codes should understand the level of scrutiny they may incur and be sure to adequately document the necessity and duration of any prolonged service.

Bottom line: Urologists should be familiar with the areas of focus and scrutiny of oversight agencies like the OIG, analyze the relevance/risk to their own practice, and where appropriate, take steps to mitigate or remediate any potential problems. While it’s uncommon for urologists to be convicted of program-related crimes and/or excluded from participating in federal health programs, it can-and has-happened.

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