What’s Under Investigation?

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Let’s start with the good news. For the first time in years, the Office of Inspector General’s (OIG) Work Plan doesn’t single out ophthal­mology for special scrutiny. But it does list more than 200 areas of investiga­tion—many carried over from the 2015 Work Plan; others are new. The follow­ing issues are among those that might interest ophthalmic practices.

CMS management of ICD-10 implementation (new). The OIG is assessing how the transition to ICD-10 impacted claims processing, includ­ing claims resubmissions appeals and medical reviews. From ophthalmol­ogy’s perspective, the transition went smoothly whenever there was a direct crosswalk from ICD-9 codes to ICD-10 codes. When there was not, many new codes—most notably those for diabe­tes—were not initially included in Lo­cal Coverage Determination (LCD) lists of ICD-10 codes that support the use of particular CPT codes. This resulted in many denials. A number of oph­thalmologists and practice managers contacted the Academy and AAOE to report that their denials were corrected by a phone review, though some prac­tices had to go through a much longer appeals process.

Care for incarcerated beneficiaries (new). Although there are exceptions, Medicare generally should not pay for services rendered to incarcerated ben­eficiaries. The OIG has been mandated to review CMS’ procedures for preven­tion and recoupment of such payments.

Care for individuals who are not lawfully residing in the United States (new). Medicare doesn’t cover people who are “unlawfully present” in the United States. The OIG will review how CMS attempts to avert and recover these payments.

Prolonged E&M services (new). CPT codes 99354, 99355, 99356, and 99357 represent prolonged services with additional face-to-face time above and beyond the time assigned to the usual Evaluation & Management (E&M) exam codes. The OIG will review whether payments for such services—which it states are rarely needed—were billed appropriately.

Physicians referring/ordering Medicare services and supplies (new). Only Medicare-enrolled physicians are legally eligible to order—or refer pa­tients for—durable medical equipment (DME) supplies, such as postcataract glasses and aphakic contact lenses.

Pricing of prescription drugs. Since 2005, Medicare payments for most Part B drugs have been based on their average sales price (ASP). The OIG will continue comparing the ASP to the av­erage manufacturer price (AMP). The Work Plan states that when the “OIG finds that the ASP for a drug exceeds the AMP by a certain percentage (5%), OIG notifies the Secretary, who may disregard the ASP for the drug when setting reimbursement amounts.”

Part C Medicare Advantage (MA) risk adjustment data. Medicare pays MA plans a capitated amount that is adjusted based on the risk profile of enrollees, and MA plans are required to provide CMS with the necessary risk adjustment data. Consequently, many practices report that MA plans have asked them for massive amounts of records, presumably because the MA plans are looking for higher-risk diag­nosis codes, such as those for diabetes. The OIG is checking to see if the medi­cal record documentation supports the diagnoses that MA organizations gave CMS to use in its risk-score calcu­lations.

Looking ahead—new payment models. The OIG has announced that it will start expanding its focus on the effectiveness of alternate payment models, coordinated care programs, and value-based purchasing.

Before you hire, check this da­tabase. The Work Plan includes a reminder that the OIG, working with state and federal agencies, can and has excluded people from participating in Medicare and Medicaid for reasons such as program-related convictions, patient abuse or neglect convictions, and licensing board disciplinary actions. Before recruiting anyone, you should search for his or her name in the OIG’s exclusions database.

To read the entire 76-page report, visit www.oig.hhs.gov. (You also can follow the OIG on Twitter.)

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