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OIG Work Plan to look at excessive patient billing, place of service errors

Published:  July 28th, 2016

The 2014 OIG Work Plan has finally been released and, while it doesn’t have a lot of new issues for physician practices, there are definitely some areas worth your attention to avoid future compliance hassles. 

If you’ve been wondering where it’s been, the OIG decided to change the timing of the work plan from its typical fall release to being released in January. And, as you might expect, the agency waited until the very end of the month for the release.

Here are some key areas of the work plan that physician practices should note:

  • Excessive E/M payments: It’s not a new item, but the sheer volume of E/M services billed makes it noteworthy. The OIG plans to look at multiple E/M services billed by the same providers for the same patients to ensure each is appropriate. The key areas of concern here are cloned notes, with the OIG targeting “identical documentation across services.”
  • Imaging services: As if practices have not suffered enough in payment cuts for imaging services, the OIG plans to see if the practice expense values for these services are appropriate when compared to actual expenses. Something to think about before expanding to add imaging services to your practice.
  • Lab tests: The OIG will look at billing for lab services to determine if the rapid growth is appropriate. The reminder here is that lab services are only covered when medically necessary. A stat that got OIG’s attention is that lab spending went up 92 percent between 1998 and 2008.
  • Ophthalmology billing: The OIG plans to analyze ophthalmology billing patterns to look for potentially inappropriate billing, particularly by geographic region. The target year for the search is 2012.
  • Excessive patient billing: Assignment rates and compliance with assignment rules will be a focus, again for 2012 claims. OIG plans to look for evidence that patients were overbilled in violation of assignment rules, which require that the provider agree to only the Medicare allowed charge when accepting assignment.
  • Place of service: OIG continues to review claims for place of service errors, which subject Medicare to potentially overpaying when a facility service is billed as a non-facility service.
  • Physical therapy services: Therapists with a high rate of utilization will be subject to potential scrutiny to determine whether those payments were appropriate. Targeted will be outpatient physical therapy services determined to be not reasonable and necessary.
  • Sleep testing: OIG plans to look for excessive utilization of sleep testing services, billed with 95810 and 95811, with a specific focus on duplicate and medically unnecessary tests.
  • Part B drugs: The OIG plans to look at whether Part B drugs are being billed appropriately, looking specifically at off-label uses of drugs.
Resources: 2014 OIG Work Plan (pdf)  



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