Fraud, Waste and Abuse is a Priority of OIG for Medical Providers You are on their list… to Evaluate…
by Brandy Brimhall CPC, CMCO
Each year the Office of Inspector General (OIG) issues an updated work plan which outlines the objectives and enforcement priorities for each New Year.
For Medical providers, including Chiropractic, this information is necessary to review and be familiar with so we may evaluate our own practice systems to insure compliance with the guidelines set forth.
The 2014 Work Plan specifically addresses Chiropractic services. To summarize this publication as it pertains to chiropractic practices, please read on:
E&M Payments (Evaluation & Management): The OIG will more closely evaluate the levels of E&M that are submitted for reimbursement to insure that documentation requirements are met for each level of E&M billed. This objective comes with the concern of Electronic Records too easily allowing practices to duplicate codes and records. As a result, it is expected that practices of all types will be frequently over-coding (or under-coding) the E&M code that is most necessary for individual patient visits and that is best supported within the documentation for individual patient visits.
Assignment Rules:The OIG plans to more closely evaluate those practices that are providing Medicare services. One objective is to review compliance of the strict guidelines in place particularly for providers that Accept Assignment on Medicare claims. This objective comes with the speculation and supporting evidence collected by the OIG and other reviewing agencies that Medicare providers are treating and billing Medicare for services that are not 'Medically Necessary' by Medicare guideline.
Medical Necessity and Documentation:Prior audits and research conducted by the OIG revealed payments for chiropractic services that were determined to be medically unnecessary or improperly documented (inadequate documentation to meet guidelines and/or documentation that wasn't supported with proper coding, among other findings). As a result of this, it is now listed as a priority of the OIG so they may determine the extent of such questionable billing for chiropractic services, including clearly identifying billing for maintenance therapy, which is not reimbursable by Medicare. In addition, the OIG will be examining both participating and non-participating Medicare Part B payments to verify that the claims were billed properly in accordance with Medicare rules.
While the OIG primary focus is directed in general to government related payers such as Medicare and Medicaid, it is important to understand that this publication will impact efforts on behalf other types of carriers as well. The OIG Work Plan is a foundation and guide used for all carrier types. In other words, audit and recovery efforts for both pre and post-payment claims are expected to increase as we progress through this year.
Click the following link if you would like to review the entire OIG Work Plan for 2014.
WHAT SHOULD YOU DO?
In effort to best prepare for potential records reviews and audits within your practice, the best thing to do is to educate both doctors and staff and be proactive in the steps that are taken to implement proper and required protocol for coding, documentation and for other compliance related issues.
A few immediate steps that can be taken:
-Carefully review all codes being currently used within the practice.
This includes service, codes, diagnoses codes and modifiers.
It is important that practices have knowledge and confidence in both coding
and documentation. This would be an area that I would strongly recommend
that you seek help if there is any question or concern. If you don't have current
coding books(yes, those from previous years are too old!)you need to update
those books/manuals and conduct scheduled training sessions. If your current
books are never or rarely opened I can assure you that you're probably missing
some critical information that could be costly to your practice. Click here to
order your current coding references now.
-Review documentation guidelines (from your manuals as well as Medicare LCD
(Local Coverage Determination), individual payers, and multiple of other
organizations that make this information available. Seek help! Here are the
steps to conduct your own Gap Analysis.
-Update or upgrade your software to be compliant with current guideline. This
will allow you to participate properly with PQRS Guideline as well as Meaningful
use. Be sure doctors and staff is properly trained on software to help avoid
costly errors in data entry and billing.
The suggestions that I have listed for you just above are a mere starting point for every practice but a very necessary one that cannot be overlooked or set aside. If you would like assistance with your own Gap Analysis, recommendations for upgrading software, the 2014 PQRS Guidebook for review or any other coding, documentation or compliance related questions, please reach out to me. I am here to help and I can assure you that prevention is MUCH easier than the alternative!
Brandy is available at
[email protected]. Her phone is 303-242-8901
Yours in Health and Wellness,
John W. Brimhall, BA, BS, DC, FIAMA, DIBAK