The Office of Inspector General (OIG) publishes an annual work plan that lists the issues it will look into over the coming year. The 2015 work plan—which is available at www.oig.hhs.gov—includes more than 150 areas of investigation. Here are the parts of the plan that are most important for ophthalmology.
Spotlight on Eye Care
For the third consecutive year, the OIG’s work plan states that ophthalmology will be under special scrutiny—specifically, Medicare payments from 2012 will be reviewed for inappropriate and questionable billing. Why? Because of the significant amount of money that ophthalmology receives for Part B claims. In 2012, for example, ophthalmology received $5.6 billion of the $77 billion that was paid for Part B claims.
Place-of-Service Coding Errors
Medicare’s allowable for a given CPT code is partly based on the number of Relative Value Units (RVUs) that CMS has assigned to that code. Many surgical procedures are assigned more RVUs when performed in an office setting than in a hospital or an ambulatory surgical center (ASC)—this is known as the site-of-service differential. For example, when CPT code 65778 Placement of amniotic membrane on the ocular surface is submitted for a service performed in the office, it is assigned 43.19 RVUs versus 2.17 RVUs when performed in a facility. (Note: When the procedure is performed in the office, payment for CPT code 65778 includes an allowed amount for the membrane supply.)
The OIG will review Medicare claims to make sure practices aren’t billing the place of service as office when the procedure actually took place in an ASC or hospital outpatient department.
Medicare Part B Drugs
Medicare Part B generally covers drugs used “on label” and also may cover off-label uses that are supported by clinical evidence in the literature and/or major drug compendia. This year, the OIG will review the oversight actions that “CMS and its claims processing contractors take to ensure that payments for Part B drugs meet the appropriate coverage criteria.”
The OIG will also identify challenges that Medicare Administrative Contractors (MACs) face when making coverage decisions for drugs. If Part B MACs do not have effective oversight mechanisms, Medicare and its beneficiaries may be paying for drugs with little clinical evidence of safety and effectiveness.
This OIG scrutiny might prompt changes in coverage policy and/or changes in the way current policy is implemented.
ASC Payment Rates
The OIG will review Medicare’s methodology for setting ASC payment rates. The investigators also will compare the payment rates for surgical procedures performed in ASCs with the payment rates for similar procedures performed in hospital outpatient departments.
Excluded From Medicare
If you are adding a “licensed professional” to the practice, make sure the individual hasn’t been excluded from participating in Medicare. If you don’t, the consequences could be costly. Last July, for instance, an entity that had employed three excluded individuals agreed to pay $197,839.94 as part of a settlement agreement with the OIG.
For a list of individuals who have been excluded from Medicare, visit http://exclusions.oig.hhs.gov.
The Academy's Role
The Academy has participated in several phone conferences with the OIG to explain how ophthalmology bills for exams, tests, and surgical procedures.
If your practice receives a request for records from the OIG, you are welcome to notify the Academ —e-mail firstname.lastname@example.org.