The Office of the Inspector General (OIG) is a 1,700-member institution within the U.S. Department of Health and Human Services (HHS) that is charged with detecting fraud and abuse and “holding accountable those who do not meet program requirements or who violate Federal laws.” In other words, the OIG is the investigative and enforcement arm of HHS and its programs, including but not limited to the Centers for Medicare & Medicaid Services and the FDA.

The OIG spends most of its time upholding the integrity of CMS by conducting audits and investigations, and imposing financial and administrative sanctions as its findings dictate. According to a recent report, in 2011 alone the OIG claimed recovery of over $5 billion from its auditing and investigative activities, excluded over 2,500 providers from health care programs, and pursued over 700 criminal and 380 civil actions. With the broad reach and impact of the OIG and the high proportion of Medicare beneficiaries in a typical practice, it is likely that more than one urologist has been or will be affected.

Now for some good news: There is considerable transparency about the intentions and operations of this federal organization. Moreover, the OIG publishes its annual “Work Plan” well in advance of actually implementing its activities. (To view the fiscal year 2013 work plan, see Among the thousands of rules and regulations in its purview, the OIG telegraphs its areas of focus and attention each year. This provides an opportunity to do a risk assessment for your practice. In this and subsequent articles in this series, I will look at some of the items identified as areas of focus in its 2013 work plan that might affect a urology practice and its physicians and patients. Unless noted, most of these focus areas are not new and have been part of previous work plans issued by the OIG.

Review of Part B claims. In 2003, CMS implemented a program called Comprehensive Error Rate Testing (CERT) to gather information on error rates (based on a sampling of claims) among participating providers ( Readers may remember receiving CERT notices from CMS in past years indicating that its review of records detected an “error” in Medicare coverage, coding, or billing rules. While an “error” detected by the CERT process does not label a claim fraudulent, the OIG intends to target the providers with the “most” errors (ie, most dollars paid “in error”) and conduct a new medical review on a sample of claims from those providers.

If you don’t know if you might be one of those “top error-prone providers,” you might wish to review your past experience with the CERT program with your office manager, billing manager, or other employee and determine whether you are on the OIG radar. In any case, now would be the time to review your procedures for ensuring that your documentation supports both the claim and the medical necessity of the care rendered.

Improper use of commercial mailboxes (new). We’ve all read the sensational headlines about fictitious patients, “patient mills,” and other egregious fraud and abuse in the Medicare system. Regulations require that providers furnish CMS with a physical street address, and the OIG claims to have evidence that renting a commercial mailbox may allow providers to circumvent this requirement and so serve as a marker of fraud. So they will be investigating providers that provided CMS a commercial mailbox address as their practice location (2011 data). You may wish to ensure that CMS has your proper physical practice location on file to avoid future problems.

High cumulative Part B payments. The OIG will “review payment system controls” that identify high cumulative payments to providers. A high cumulative payment is defined as “an unusually high payment made to an individual physician or supplier, or on behalf of an individual beneficiary.” While this focus area seems to be directed internally to evaluate its own processes, it seems clear that the OIG is serious about identifying patterns of payment that could signal errors or fraud and abuse. Urologists now have many new options available for the treatment of their patients, and some of them are expensive procedures and drugs billed under the Part B program of Medicare that could trigger a “high cumulative payment” to one provider or on behalf of one beneficiary.

You may wish to conduct your own “high cumulative payment” analysis by looking at the sum of Medicare reimbursements by patient over a certain time period, sorted by descending amount. This will simulate the process that the OIG uses to identify outliers.
Bottom line: It should come as no surprise that our nation’s largest health care insurer—the federal government—has put in place people and processes to monitor the integrity of the federal health care program. It’s important for urologists to be familiar with the rules, the entities (including the OIG) that monitor compliance with the rules, and the areas of focus and scrutiny of oversight agencies.

In the next articles in this series, I will cover other areas on the OIG radar, including imaging services, incident to services, evaluation and management coding issues, improper use of modifiers, and payments for expensive drugs.

Please view the original article written by Dr. Robert A. Dowling on the Urology Times website.