Attorneys: Data Mining to Help OIG Review Of Medicare Overpayments in Fiscal 2012

  BNA’s Health Care Fraud Report™ is the go-to source for health care fraud reporting, with in-depth information on government and private enforcement actions and strategies designed to...

By James Swann

The Department of Health and Human Services Office of Inspector General will place a greater emphasis on data mining technology to identify hospital and physician Medicare overpayments in fiscal year 2012, two attorneys said during a Nov. 16 webinar.

The BNA-sponsored webinar, What Hospitals and Physicians Should Know About the OIG's 2012 Work Plan, covered several hospital and physician issues that were in the OIG's fiscal year 2012 work plan, which was released Oct. 5 (15 HFRA 819, 10/19/11).

The work plan describes reviews that the OIG intends to initiate on HHS programs and activities.

Hospital Issues

Hospital overpayments will receive increased attention from the OIG, Francis J. Serbaroli, an attorney with Greenberg Traurig LLP, New York, said during the webinar.

“Using data mining and computer matching, the OIG will review hospitals that have the most risk [of overpayments]. During the reviews, hospital executives might be interviewed about their compliance practices,” Serbaroli said.

Data mining will also be used to identify hospitals with the least risk of overpayments, and the OIG will compare policies and procedures of hospitals with the most risk and hospitals with the least risk to develop compliance best practices, according to the work plan.

OIG officials recently spoke about the hospital overpayment reviews at the Nov. 7 Sixth National Medicare RAC Summit (15 HFRA 897, 11/16/11).

Physician Overpayments

The OIG will also review physician overpayments, including high cumulative Part B payments, Alan E. Reider, an attorney with Arnold & Porter LLP, Washington, D.C., said during the webinar.

A high cumulative payment is an unusually high payment made to a physician or a supplier over a period of time, Reider said.

Previous OIG reviews have determined that unusually high Part B payments can be an indicator of fraud and abuse, the work plan said.

Reider said the OIG is placing greater emphasis on using data mining to uncover patterns of high Part B payments.

The OIG will also review the inappropriate billing of beneficiaries in excess of the Medicare allowable amount, as well as questionable billing patterns surrounding evaluation and management services, Reider said.

In addition, the OIG will review whether beneficiaries are aware of potential excessive billings, the work plan said.

Additional Review Items

Beyond overpayments, hospitals will face multiple OIG reviews, including whether they are accurately reporting quality measure data to the Centers for Medicare & Medicaid Services, Serbaroli said.

“Hospitals are required to report on these measures, and if they don't, it can lead to reductions in Medicare payments of 2 percent,” he said.

The OIG will also be reviewing outlier payments, which are provided in addition to the regular Medicare payment for patients who are incurring high costs.

Serbaroli said outlier payments have been skyrocketing, and the OIG will review their validity.

The OIG work plan said that several hospitals have settled whistleblower lawsuits for millions of dollars for alledgedly inflating their Medicare claims to qualify for outlier payments.

In addition, the OIG will review critical access hospitals (CAHs) to determine if they are meeting the criteria and conditions of participation in Medicare.

The OIG will also review the number and type of patients treated by a CAH, the work plan said.

Reviewing Physician-Owned Distributors

On the physician side, Reider said the OIG will be reviewing physician-owned distributors of spinal implants.

“There's a real concern about overutilization of spinal implants and the impact that financial incentives might have on clinical decision-making,” Reider said.

The OIG will also review payments made for ‘incident to' services situations, which refer to services that are integral but incidental to the services of a physician.

The review will determine whether payments for ‘incident to' services have a higher error rate than non-incident to services payments, as well as look at the risks of these services being performed by non-physicians, Reider said.

Another review will focus on the impact of physicians opting out of Medicare, Reider said.

He said the review will look at whether opted out physicians are still submitting claims to Medicare, as well as whether certain areas of the country are experiencing a larger concentration of physicians opting out and how that is affecting patient care.

The OIG fiscal year 2012 work plan is at .