February 13, 2014
Many clients I hear from who are the target of an audit or investigation are surprised they or their practice popped up on a radar - why me? Why now? What makes me so special or what am I doing so differently than everyone else that I am a target?
Well, sometimes the bullseye is easier to spot than others. Specifically with certain Medicare reviews, the Office of Inspector General, the arm of HHS responsible for protecting "the integrity of HHS programs" tells us exactly what and who they will be looking in to. Each year a Work Plan is published, explaining areas of review for OIG for the coming year.
CLICK HERE FOR 2014 OIG Work Plan
This year's plan mentions review of medical necessity of high cost diagnostic radiology tests, anesthesia modifier usage denoting "personally performed" as opposed to "medically directed" services, and general review of E/M services.
An area of high scrutiny is Chiropractic. The Work Plan highlights the following areas of review:
Chiropractic services — Portfolio report on Medicare Part B payments (new)
Billing and Payments. We will compile the results of prior OIG audits, evaluations, and investigations of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities. Context—Prior OIG work identified inappropriate payments for chiropractic services that were medically unnecessary, were not documented in accordance with Medicare requirements, or were fraudulent. Medicare does not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.”(Social Security Act, § 1862(a)(1)(A).)Part B pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. (42 CFR §410.21(b).)CMS’s Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, § 30.5, states that chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. Further, § 240.1.2 of the Manual establishes Medicare requirements for documenting chiropractic services. This planned portfolio document will offer new recommendations to improve Medicare chiropractic vulnerabilities detected in prior OIG work. (OAS; OIG -12-14-03; expected issue date: FY2014; work in progress)Ø
Chiropractic services—Part B payments for noncovered services
Billing and Payments. We will review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Context—Prior OIG work identified inappropriate payments for chiropractic services furnished during calendar year (CY)2006. Subsequent OIG work (CY 2013) also identified unallowable HHS OIG Work Plan | FY2014Medicare Part A and Part B Medicare payments for chiropractic services. Part B pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment.(42 CFR §410.21(b).)Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable. (CMS's Medicare Benefit Policy Manual, Pub.No.100-02, ch. 15, §30.5B.) Medicare will not pay for items or services that are “not reasonable and necessary.” (Social Security Act, §1862(a)(1)(A).) (OAS; W-00-12-35606; W-00-13-35606; various reviews; expected issue date: FY2014; work in progress)Ø
Chiropractic services — Questionable billing and maintenance therapy (new)
Billing and Payments. We will determine the extent of questionable billing for chiropractic services. We will also identify trends suggestive of maintenance therapy billing. Context—Previous OIG work has demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including recent work that identified a chiropractor with a 93-percent claim error rate and inappropriate Medicare payments of about $700,000. Although chiropractors may submit claims for any number of services, Medicare reimburses claims only for manual manipulations or treatment of subluxations of the spine that provides "a reasonable expectation of recovery or improvement of function." Moreover, Medicare does not reimburse for chiropractic maintenance therapy.(CMS’s Medicare Benefit Policy Manual, Pub. No. 10002, ch. 15, § 30.5B.) (OEI; 01-14-00200; expected issue date: FY 2015, work in progress).