Precision.BI

March 2009

Table of Contents

Introducing Origin Healthcare Solutions

PresentationCenter-What to look for in the new release

Precision.BI Data Sources

SQL Tips and Tricks

Using Test Servers

What's New
Release 4.5.8030, New Additions to the PBI Team, PBI Design Group

Industry News-OIG Workplan

An introduction to FogBugz, Precision.BI’s case-tracking system

Did you know?
Documentation online

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Comments or questions about the newsletter – contact Brenda Millar at bmillar@precisionbi.com

 

 

 

 

 

Industry News:2009 OIG Work Plan Reveals Possible Risk Areas for Medicare Providers and Suppliers

By Carmen Walters, RN
Compliance and HIPAA Officer

On October 1, 2008, the Department of Health and Human Services’ Office of Inspector General (OIG) released its Work Plan for federal fiscal year 2009 (Work Plan).  The Work Plan addresses the areas and issues the OIG intends to audit, evaluate and inspect during federal fiscal year 2009. The Work Plan also provides some insight into the areas and issues that may evolve into future OIG enforcement activities. Therefore, health care providers and suppliers should consider the Work Plan in relation to their operations.  This post briefly highlights some of the Work Plan priorities for the Medicare program for physicians and other health professionals.

Place of Service Errors.
The OIG 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. The OIG will determine whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments.

Evaluation and Management Services During Global Surgery Periods.
The OIG will review industry practices related to the number of evaluation and management (E&M) services provided by physicians and reimbursed as part of the global surgery fee. The OIG will determine whether industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.

Medicare Practice Expenses Incurred by Selected Physician Specialties. 
The OIG will review the actual expenses of selected physician specialties. The OIG will determine whether Medicare payments for physician services performed by selected specialties are comparable to the actual expenses incurred by the physicians in providing services and operating their practices.

Services Performed by Clinical Social Workers.
The OIG will review services furnished by clinical social workers (CSW) to inpatients of Medicare participating hospitals or SNFs to determine whether the services were separately billed to Medicare Part B. The OIG will examine Medicare Part A and Part B claims with overlapping dates of service to determine whether services performed by CSWs in inpatient facilities were separately billed to Medicare Part B.

Outpatient Physical Therapy Services Provided by Independent Therapists.
The OIG will review outpatient physical therapy (OPT) services provided by independent therapists to determine if they are in compliance with Medicare reimbursement regulations. Focusing on independent therapists who have a high utilization rate for OPT services, the OIG will determine whether the services that they billed to Medicare were in accordance with Federal requirements.

Medicare Payments for Colonoscopy Services. 
The OIG will review the appropriateness of Medicare payments to physicians for colonoscopy services and determine whether Medicare payments for such services were properly supported, billed, and paid in accordance with Medicare requirements.

Physicians’ Medicare Services Performed by Nonphysicians. 
The OIG will review services physicians’ bill to Medicare but do not perform personally. The OIG will examine the qualifications of nonphysician staff that perform “incident to” services and assess whether these qualifications are consistent with professionally recognized standards of care.

Appropriateness of Medicare Payments for Polysomnography. 
The OIG will examine the appropriateness of Medicare payments for sleep studies. The OIG will also examine the factors contributing to the rise in Medicare payments for sleep studies and assess provider compliance with Federal program requirements.

Long-Distance Physician Claims Requiring a Face-to-Face Visit. 
The OIG will review the appropriateness of Medicare claims for long-distance E&M services and examine factors that contribute to the submission of long-distance physician claims.

Geographic Areas With a High Density of Independent Diagnostic Testing Facilities. 
The OIG will review services and billing patterns in geographic areas with high concentrations of independent diagnostic testing facilities (IDTF). In areas with a high density of IDTFs, the OIG will examine service profiles, provider profiles, beneficiary profiles, and billing patterns.

Patterns Related to High Utilization of Ultrasound Services. 
The OIG will review services and billing patterns in geographic areas with high utilization of ultrasound services paid under the Medicare physician fee schedule. In areas of high utilization of ultrasound services, the OIG will examine service profiles, provider profiles, and beneficiary profiles.

Medicare Payments for Chiropractic Services Billed With the Acute Treatment Modifier. 
The OIG will review chiropractor billings with acute treatment modifiers to determine whether they comply with Medicare coverage criteria and documentation requirements. The OIG will determine the appropriateness of Medicare payments for chiropractic claims identified as maintenance therapy.

Physician Reassignment of Benefits. 
The OIG will examine a national sample of Medicare physicians to determine the extent to which they reassign their benefits to other entities and the extent to which the physicians are aware of their reassignments.

Medicare Payments for Unlisted Procedure Codes. 
The OIG will review the accuracy of Medicare payments for services billed using unlisted procedure codes and examine provider usage of procedure codes for services not listed in the HCPCS.

Laboratory Test Unbundling by Clinical Laboratories. 
The OIG will review the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel tests to maximize Medicare payments. 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.  The OIG will also determine the extent to which the Medicare carriers have controls in place to detect and prevent inappropriate payments for laboratory tests.

Variation of Laboratory Pricing. 
The OIG will review the extent of variation in laboratory test payment rates among Medicare contractors. The OIG will analyze claims data to determine pricing variances among Medicare contractors for the most commonly performed tests.

Clotting Factor Furnishing Fee.
The OIG will review the appropriateness of the furnishing fee that Medicare pays to providers of blood clotting factor and determine whether providers performed all of the services covered by the furnishing fee.

Medicare Billings With Modifier GY. 
The OIG will review the appropriateness of providers’ use of modifier GY on claims for services that are not covered by Medicare and examine patterns and trends for physicians’ and suppliers’ use of modifier GY.

To view the entire workplan visit
www.oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf.