As you may or may not recall, last week I conducted a pre-Festivus airing of grievances regarding CMS’ late publication of the OIG Work Plan for the now-current fiscal year. This past Wednesday, in my daily e-mail from the OIG that documents fines, prison sentences, audit results and other assorted health care atrocities, came news that said work plan has been released. It’s 165 pages long, so let’s dive right in to the fun parts.

On the hospital side, when looking at the plan, it appears that the OIG is following the path of current controversies. Among the areas of focus are hospital reporting of adverse events, the accuracy of data submitted indicating conditions that are present on admission, and same day re-admissions. Not a week has gone by in the past 18 months where an e-mail update in my inbox hasn’t mentioned one or all of these topics.

In addition, there was one variation on a theme that caught my eye. The OIG is going to look at the replacement of medical devices billed as part of a facility claim. In some cases, when a medical device is replaced, the hospital receives credit from the manufacturer if the device was either under warranty or was recalled for some reason. In these instances, Medicare will not pay for the full cost of the device. Given that the RAC contractors have been looking at the reimbursement of DME in the inpatient setting, this work plan issue appears to be an expansion of something already identified in roughly the same universe.

I then moved onto the physician portion of the plan. There were some issues that returned for an encore. The OIG continues to look at “error-prone providers”, which are physicians who have had at least one identified CERT error for four consecutive years. Place of service errors on physician claims and E/M services in the global period have reappeared as well.

Some of the other issues, when compared to some of the shifts that are going on across the health care landscape, require some context. The OIG will continue to study coding trends for E/M services. In 2009, $32 billion was spent on E/M services by Medicare, and there has been a significant increase in utilization of CPT codes 99214 and 99215 over the past five years for established patient encounters. Looking at these numbers alone would be eye-opening, but the work plan will also be looking at inappropriate payments as they apply to EMR documentation practices. The Work Plan spelled it out fairly bluntly by making reference to “the increased frequency of medical records with identical documentation across services”. It is at this point where I do my patented pointy-finger-I-told-you-so Dance of Superiority, as I have been introducing the idea into the public sphere for some time regarding the dangers of widespread EMR documentation, most recently here (yes, that’s an old picture). As a blunt reminder, you can have the best history and examination ever documented, but medical necessity needs to be the driver of the level of service. A bug bite is a bug bite, and a complete 14-point review of systems, along with documenting that the patient is married and smokes, doesn’t change that fact. The OIG appears to now agree with me. Nyah nyah.

If you are a chiropractor, or if you bill for sleep studies, that heat you feel on the back of your neck is the sun’s rays hitting the magnifying glass that the OIG is holding over your head. The Work Plan calls for reviewing whether chiropractic claims for active treatment are actually cleverly disguised maintenance therapy. There have been some MAC probes of chiropractic claims, most notably by Palmetto GBA in California and Nevada. These probes have focused on documentation as it relates to billing. The OIG plan seems to go a step further. For sleep testing, the OIG will be looking at whether the services billed are reasonable and necessary.

With the expansion of non-physician practitioners, the OIG has decided to take a closer look at incident-to services. As a person who has a sub-specialty in practice analytics, abuses in this area are becoming easy to catch, especially when the doctor employs a physician assistant, and then subsequently reports more than 24 hours of services on one calendar day. As a subtle reminder, we do not live on Mars, and until we do, one day still equals 24 hours, and I have yet to meet the physician in the modern age whose office doubles as his or her personal boarding house.

I’d like to end with a big issue upon which to ponder. For the first time, the OIG is going to look at the impact of physicians who opt out of the Medicare program. The task is twofold, first looking at whether certain geographic areas have higher rates of physicians leaving the program and second, to insure that doctors who opt out aren’t submitting claims to Medicare for payment.

I’ve talked before about concierge/membership medicine, which is currently drawing physicians away from the traditional physician reimbursement model. The public chatter about this topic is similar to a sometimes-conspicuous drip from a faucet in an adjoining room of a house. If the OIG is looking into this for the first time, it is becoming obvious that the drip is becoming progressively more annoying. In the past year, a government report estimating that less than 1,000 physicians operate under this model nationwide has been determined to be hugely underestimated. No one disputes that we have a primary care shortage in this country. I see this Work Plan issue as the OIG’s first recognition that even one primary care physician abandoning the indentured servitude of insurance participation clearly has long-term consequences for healthcare delivery. If I’m right, we’re in for a lot of sabre-rattling and clenched fists about this topic in the very near future.

Quite obviously, there are quite a few topics under the Work Plan that I have not covered. The full plan can be found here. There is illumination in these pages, as there always tends to be. Happy reading!