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p-spencerOn Wednesday, Oct. 5 the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its work plan for the 2012 fiscal year. As with past versions of this tried-and-true compliance roadmap, there were some issues that returned for an encore and some issues that are appearing for the first time.

To begin, we will look at the repeat issues. The OIG continues to examine “error-prone providers,” which are physicians who have had at least one identified CERT error for four consecutive years. Much like the RACs, the OIG will continue to look at the financial effects of place-of-service errors on physician claims as well as E/M services in the global period.

Coding Trends for E/M Services

Some of the other issues, when considering some of the shifts going on across the healthcare landscape, require some context to digest. The OIG will continue to study coding trends for E/M services. In 2009, $32 billion was spent by Medicare on E/M services, and during the last five years there has been a significant increase in the utilization of CPT codes 99214 and 99215 for established patient encounters. Looking at these numbers alone would be eye-opening, but the work plan also touches on inappropriate payments as they apply to EMR documentation practices.

The work plan actually spelled it out fairly bluntly by making reference to “the increased frequency of medical records with identical documentation across services.” For some time I have been introducing into the public sphere my ideas as they pertain to the dangers of widespread EMR documentation. As a blunt reminder, you can have the best history and examination record ever documented, but medical necessity needs to be the driver of level of service. A bug bite is a bug bite, and a complete 14-point review of systems, along with documenting that the patient is married and smokes, doesn’t change that fact. The OIG now appears to agree with me.

If you are a chiropractor, or if you bill for sleep studies, that heat you feel on the back of your neck is the sun’s rays hitting the magnifying glass the OIG is holding over your head. The work plan calls for reviewing whether chiropractic claims for active treatment actually are being cleverly disguised as maintenance therapy.

There have been some MAC probes of chiropractic claims, most notably by Palmetto GBA in California and Nevada. These probes have focused on documentation as it relates to billing. The OIG plan seems to go a step further. For sleep testing the OIG will be looking at whether services billed are reasonable and necessary.

With the expansion of non-physician practitioners, the OIG also has decided to take a closer look at incident-to services. As a person who has a sub-specialty in practice analytics, I can report that abuses in this area are becoming easy to catch from an audit standpoint, especially when the doctor employs a physician assistant and subsequently reports more than 24 hours of services on one calendar day. As a subtle reminder, we do not live on Mars, and until we do one day still equals 24 hours (and I have yet to meet the physician in the modern age whose office doubles as his or her personal boarding house).

Physicians Opting Out

I’d like to end with a big issue upon which to ponder. For the first time the OIG is going to look at the impact of physicians who opt out of the Medicare program. The task is twofold, first looking at whether certain geographic areas have higher rates of physicians leaving the program and secondly seeking to ensure that doctors who opt out aren’t submitting claims to Medicare for payment.

I’ve been following trends in the realm of concierge/membership medicine, which currently is drawing physicians away from the traditional physician reimbursement model. The public chatter about this topic sounds similar to an occasionally conspicuous drip from a faucet in an adjoining room of a house.

If the OIG is looking into this for the first time, it is obvious that the drip is becoming progressively more annoying. In the past year a government report estimated that less than 1,000 physicians nationwide operate under this model, but that figure has been determined to be hugely underestimated. No one, however, disputes that we have a primary care shortage in this country.

It is clear that this work plan issue represents the OIG’s first recognition that even one primary-care physician abandoning the indentured servitude of insurance participation clearly may have long-term consequences for healthcare delivery. If I’m right, we’re in for a lot of saber-rattling and clenched fists about this topic in the very near future.

About the Author

Paul Spencer is the Compliance Officer for Fi-Med Management, Inc., a national physician practice financial management company based in Wauwatosa, WI. Paul has over 20 years of experience across all facets of healthcare billing, including 6 years spent with insurance carriers. In his current role with Fi-Med, he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.

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OIG Will Continue Data Mining: Highlights of the OIG Work Plan for 2012


J. Paul Spencer, CPC, COC

J. Paul Spencer is a senior healthcare consultant for DoctorsManagement. Is the national correspondent for Monitor Mondays, the live Internet radio broadcast produced by RACmonitor.

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