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 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).
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.
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.
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 http://oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf .
All Bloomberg BNA treatises are available on standing order, which ensures you will always receive the most current edition of the book or supplement of the title you have ordered from Bloomberg BNA’s book division. As soon as a new supplement or edition is published (usually annually) for a title you’ve previously purchased and requested to be placed on standing order, we’ll ship it to you to review for 30 days without any obligation. During this period, you can either (a) honor the invoice and receive a 5% discount (in addition to any other discounts you may qualify for) off the then-current price of the update, plus shipping and handling or (b) return the book(s), in which case, your invoice will be cancelled upon receipt of the book(s). Call us for a prepaid UPS label for your return. It’s as simple and easy as that. Most importantly, standing orders mean you will never have to worry about the timeliness of the information you’re relying on. And, you may discontinue standing orders at any time by contacting us at 1.800.960.1220 or by sending an email to firstname.lastname@example.org.
Put me on standing order at a 5% discount off list price of all future updates, in addition to any other discounts I may quality for. (Returnable within 30 days.)
Notify me when updates are available (No standing order will be created).
This Bloomberg BNA report is available on standing order, which ensures you will all receive the latest edition. This report is updated annually and we will send you the latest edition once it has been published. By signing up for standing order you will never have to worry about the timeliness of the information you need. And, you may discontinue standing orders at any time by contacting us at 1.800.372.1033, option 5, or by sending us an email to email@example.com.
Put me on standing order
Notify me when new releases are available (no standing order will be created)