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"OIG" & "CLIA" Articles
Click on the title to see the article summary and a link to the full article.
October 27th, 2020
OIG – Fraud and Abuse Study with COVID-19 Testing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 27th, 2020
According to the Office of Inspector General (OIG), “The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented demand for diagnostic laboratory testing to determine whether an individual has the virus. Beyond the COVID-19 tests, laboratories can also perform add-on tests, for example, to confirm or rule out diagnoses ...
July 28th, 2020
OIG Report Highlights Need to Understand Guidelines
By Wyn Staheli, Director of Research | Published July 28th, 2020
A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.
July 21st, 2020
Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately
By Aimee Wilcox | Published July 21st, 2020
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
April 20th, 2020
Now That is Fraud! Genetic Testing "Public alert"
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020
Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...
August 9th, 2019
The OIG Work Plan: What Is It and Why Should I Care?
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
May 17th, 2019
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
By Namas | Published May 17th, 2019 - Last Review/Update May 21st, 2019
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
Every year, the Department of Health and Human Services (DHS) Office of Inspector General (OIG) is required by law to release a report detailing the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such ...
April 23rd, 2019
OIG Announces New Review For Medicare Part B Payments for Podiatry and Ancillary Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 23rd, 2019
Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020. The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.
Part of the ...
May 30th, 2018
Creating a Culture of Compliance in 2018
By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...
April 23rd, 2018
Brooklyn Chiropractor OIG Report - Lessons Learned
By Wyn Staheli, ChiroCode Director of Research & Dr. Evan Gwilliam, Clinical Director PayDC Software | Published April 23rd, 2018 - Last Review/Update February 28th, 2019
In August of 2017, a Brooklyn chiropractor was ordered to repay $672,805 to Medicare because the reviewer found that 100% of the claims reviewed (from 2011-2012) did not meet medical necessity requirements. The chiropractor enlisted help from two reputable experts who disputed the findings of Medicare’s Professional Reviewer (MPR). However, the OIG maintained that the findings of the original auditor were valid.
Since none of us have ½ million in cash just laying around, it is essential to learn, understand, and make changes where appropriate to help audit-proof patient documentation.
Read here to learn more.
January 22nd, 2018
Compliance: What is it and Why is it Important
By Joan S. Hartman, RHIT | Published January 22nd, 2018 - Last Review/Update January 25th, 2018
Compliance. It is one of the buzz words in healthcare that is heard all the time but what is it really, and why is it so important?
December 21st, 2017
OIG Advisory Opinion Recinded - Lessons Learned
By Wyn Staheli, Director of Research | Published December 21st, 2017
In the compliance world, it is important to know when the OIG makes an advisory opinion on a subject. For example, the advisory on Time of Service or Prompt Pay Discounts helps to ensure that providers are creating policies and procedures which will meet the standards of the OIG in the case ...
October 23rd, 2017
Summary of OIG Reports for Chiropractic
By | Published October 23rd, 2017
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...
July 31st, 2017
Health Care Fraud - Don’t Do It!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 31st, 2017
If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely serious. I don't need to tell you this.
I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate ...
June 16th, 2017
CMS Overpaid Providers $729 Million in Incentive Payments
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 16th, 2017
Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements according to the OIG. The OIG estimated CMS inappropriately paid $729,424,395 to EPs who did not meet the requirements for meaningful use.
Eligible professional’s (EP’s) are physicians, dentists, podiatrists, optometrists or chiropractors, if ...
April 14th, 2017
The Office of Inspector General (OIG)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 14th, 2017
The Office of Inspector General (OIG) has the responsibility to identify and detect fraud, waste, and abuse for the United States Department of Health and Human Services (HHS) (also known as the Health Department). The mission of the U.S. Department of Health and Human Services is to enhance and protect ...
April 14th, 2017
Office of Inspector General (OIG) - Compliance Program Guidance
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 14th, 2017
The compliance program guidance documents are listed below.
09-30-2008Supplemental Compliance Program Guidance for Nursing Facilities (73 Fed.Reg. 56832; September 30, 2008)
Compliance Program Guidance for Nursing Facilities (65 Fed. Reg. 14289; March 16, 2000)
11-28-2005Draft Compliance Program Guidance for Recipients of PHS Research Awards (70 Fed.Reg. 71312; November 28, 2005)
NSTC Launches Government-Wide Initiative ...
October 25th, 2016
Another OIG Report on Chiropractic
By ChiroCode | Published October 25th, 2016 - Last Review/Update March 5th, 2019
On October 19 the Office of Inspector General for Health and Human Services (OIG) released another report on chiropractic. Oddly enough the Wall Street Journal had an article on that report published the day it was released (I wonder how that happened). Read hear to see the results.
July 28th, 2016
OIG adds to increased scrutiny of how patients pay for rising share of drug costs
By | Published July 28th, 2016
Charity programs that help patients pay for the rising cost-sharing obligations of needed drugs may run afoul of anti-kickback rules when the charity’s scope is so narrow that it guides the patient toward specific drugs for treatment or providers, the HHS Office of Inspector General said last week.The OIG’s Supplemental...
July 28th, 2016
OIG Work Plan to look at excessive patient billing, place of service errors
By | 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...
July 28th, 2016
OIG Work Plan 2012-Do your own review of these areas
By | Published July 28th, 2016
The Office of Inspector General released its Work Plan for 2012. As in past years, the Work Plan describes the areas of interest that the OIG will investigate in the coming year. There are sections for hospitals, nursing homes, and of course, physicians. There is a pdf file attached to...
July 28th, 2016
Cloned documentation on OIG radar screen in 2014
By | Published July 28th, 2016
One of the areas where the OIG has its sights set in 2014 is on physician documentation. The OIG plans to review documentation of E/M services looking for what it describes as “documentation vulnerabilities.” Put more specifically, the OIG reports that Medicare Administrative Contractors (MACs) have seen an increase in...
October 23rd, 2015
CLIA Categories and Subcategories
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 23rd, 2015
A laboratory may be licensed or exempted from licensure in several major categories of procedures. These major categories are listed in the Pub 100 Chapter 16-Labratory Services.
...
August 19th, 2015
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...
July 10th, 2015
Clinical Laboratory Improvement Amendments (CLIA) Requirements - Background (Rev. 3014, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 10th, 2015
The Clinical Laboratory Improvements Amendments of 1988 (CLIA), Public Law 100- 578, amended §353 of the Public Health Service Act (PHSA) to extend jurisdiction of the Department of Health and Human Services to regulate all laboratories that examine human specimens to provide information to assess, diagnose, prevent, or treat any ...
July 10th, 2015
Verifying CLIA Certification (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
CWF edits Carrier claims to ascertain that the laboratory identified by the CLIA number is certified to perform the test. (CWF uses data supplied from the certification process.) See Chapter 27 for related specifications.
Providers that bill FIs are responsible for verifying CLIA certification prior to ordering laboratory services under arrangement. ...
July 10th, 2015
CLIA Numbers (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
The structure of the CLIA number follows:
Positions 1 and 2 contain the State code (based on the laboratory’s physical location at time of registration);
Position 3 contains the letter “D"; and
Positions 4-10 contain the unique CLIA system assigned number that identifies the laboratory. (No other laboratory in the country has this ...
July 10th, 2015
CLIA Categories and Subcategories (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
A laboratory may be licensed or exempted from licensure in several major categories of procedures. These major categories are:
010 Histocompatibility
100 Microbiology
110 Bacteriology
115 Mycobacteriology
120 Mycology
130 Parasitology
140 Virology
150 Other Microbiology
200 Diagnostic Immunology
210 Syphilis Serology
220 General Immunology
300 Chemistry
310 Routine
320 Urinalysis
330 Endocrinology
340 Toxicology
350 Other
400 Hematology
500 Immuno-hematology
510 ABO Group and RH Type
520 Antibody Detection (Transfusion)
530 ...
July 10th, 2015
Certificate for Provider-Performed Microscopy Procedures (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code
Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin specimens
Q0112
All potassium hydroxide (KOH) preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, ...
July 10th, 2015
Certificate of Waiver (Rev. 1652, 01-05-09) - CLIA
By Jared Staheli | Published July 10th, 2015
Effective September 1, 1992, all laboratory testing sites (except as provided in 42 CFR 493.3(b)) must have either a CLIA certificate of waiver, certificate for providerperformed microscopy procedures, certificate of registration, certificate of compliance, or certificate of accreditation to legally perform clinical laboratory testing on specimens from individuals in the ...
July 10th, 2015
HCPCS Subject To and Excluded From CLIA Edits (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
At this time, all claims submitted for laboratory tests subject to CLIA are edited at the CLIA certificate level. However, the HCPCS codes that are considered a laboratory test under CLIA change each year. The CMS identifies the new HCPCS (non-waived, nonprovider-performed procedure) codes, including any modifiers that are subject ...
July 10th, 2015
CLIA Number Submitted on Claims from Independent Labs (Rev. 3014, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 10th, 2015
Effective with services provided October 1, 1997, any independent laboratory performing tests covered by CLIA must submit the CLIA number on the claim as provided below. The CLIA number is reported in:
• ASC X12 837 professional claim format REF segment as REF02, with qualifier of “X4” in REF01, or
• Field ...
January 23rd, 2015
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By | Published January 23rd, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses ...
December 15th, 2014
OIG Reports Success in Efforts to Prevent Fraud, Waste, and Abuse
By | Published December 15th, 2014 - Last Review/Update January 30th, 2017
The HHS OIG Work Plan for the 2015 Fiscal Year has recently been released. In this publication, the OIG addresses the accomplishments made from the previous year's Plan as well as the objectives that will be of interest for the coming new year. Accomplishments for the 2014 Fiscal Year are ...
October 16th, 2014
Is Compliance a Dirty Word?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update January 23rd, 2017
In October of 2000 in the Federal Register the Office of the Inspector General (who investigates fraud against the federal government on behalf of the Department of Health and Human Services) offered general guidelines for health care facilities to set up a “Compliance Program”. This advice has long been pushed ...
October 16th, 2014
Chiropractic is Listed as a Priority in the 2014 OIG Work Plan...Find Out Why
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published October 16th, 2014 - Last Review/Update January 30th, 2017
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 ensure compliance ...
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