OIG targets IMRT, chronic care payments in 2017

Each year, the Office of the Inspector General at the Department of Health and Human Services publishes a summary of its activities and a work plan for the coming year. What follows is a summary of new topics in the FY2017 work plan that may be of interest to urologists.

Dr. DowlingEach year, the Office of the Inspector General (OIG) at the Department of Health and Human Services publishes a summary of its activities and a work plan for the coming year. What follows is a summary of new topics in the FY2017 work plan that may be of interest to urologists. For the full report, go to bit.ly/OIG2017.

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As a reminder, the OIG is the investigative and enforcement arm of HHS and its programs, including but not limited to the Centers for Medicare & Medicaid Services (CMS) and the FDA. Its Office of Audit Services 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 (bit.ly/HHSOIGhome), HHS OIG is the largest Inspector General office in the federal government, with 1,600 employees devoted to fighting waste, fraud, and abuse in the agencies’ 100 or so programs-including Medicare. 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 to its downloadable database, as of December 2016, out of a total of 66,042 exclusions, 6,829 physicians and 24 urologists have been excluded from federal programs by the OIG. (One urologist who appeared in the data in 2015 has been removed from the data.) The top two reasons for exclusions are licensing issues and conviction of program-related crimes.

What follows are areas of OIG scrutiny in 2017 of which urologists should be aware.

Intensity-modulated radiation therapy

The OIG believes outpatient payments for IMRT services need to be reviewed to be sure those payments (and associated billings) were in accordance with requirements. Urologists who bill for IMRT services in their integrated practices should take note.

Next: Provider-based clinics

Provider-based clinics

Physicians practicing in clinics owned by hospitals have historically been paid under the Outpatient Prospective Payment System, while free-standing practices’ physicians are paid under the Medicare Part B Physician Fee Schedule. 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.”

Read: Medicare Part D data reveal prescriber patterns

This area of attention aligns with “site neutrality” provisions of the recently passed 21^st Century Cures Act (and provisions in the 2015 federal budget), which seek in the future to pay physicians the same regardless of setting. In the 2017 work plan, the OIG states, “We will review and compare Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments.” While this oversight would primarily affect hospitals operating “provider-based clinics,” urology practices that are considering acquisition by a hospital or integrated delivery system should take note.

Medicare payments for chronic care management (CCM)

Medicare pays for non-face-to-face services for beneficiaries with two or more significant chronic conditions. The OIG has signaled it intends to review payments made for these services since Jan. 1, 2015. This author understands some urology practices have begun billing for CCM services, and they should be aware of the OIG interest in this area.

Physician Payments Sunshine Act (“Open Payments”)

In its 2017 work plan, the OIG says it will perform its own analysis of 2015 data extracted from the Open Payments database to “determine the number and nature” of those payments to physicians by manufacturers and group purchasing organizations (GPOs) with physician ownership. (For more on Open Payments, see “Open Payments: How urology measures up.") The OIG’s analysis will include examination of individual manufacturers, drugs, and ordering habits of physicians paid under the Part B and Part D program. Finally, the OIG says it intends to examine the accuracy, validity, and required presence of data submitted by manufacturers and GPOs.

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 uncommon, urologists have been convicted of program-related crimes and/or excluded from participating in federal health programs.