Medicare Compliance & Reimbursement

In the coming year, you'll want to make sure you cross all your t's and dot all your i's because the Office of Inspector General (OIG) has released its 2010 Work Plan -- which includes plans for reviewing everything from the appropriateness of the GY modifier to your e-prescribing bonus payments.

What the Work Plan is: The OIG Work Plan details issues that the Office of Audit Services, Office of Evaluations and Inspections, Office of Investigations, Office of Counsel to the Inspector General, Office of Management and Policy, and Immediate Office of the  Inspector General will address during the 2010 fiscal year.When the OIG targets an issue in its Work Plan, you can expect the agency to carefully review and audit sample claims of those services. "There is no guarantee that the OIG will specifically look at your practice's claims for the services listed in the Work Plan, but it's important to know that the OIG is looking at these services in general," advises Alli Larro, Esq., an Atlanta-based attorney.

Although the OIG usually samples claims from a prior year when it's performing its reviews, you should still make sure your coding and billing processes for these claims are on the level going forward, says Stephanie Fiedler, CPC, ACS-EM with Loeb & Troeper in New York.

"The impetus behind outpatient and inpatient departments reviewing their claims process going forward is that if they are cited, they can show that they were either processing their claims correctly, and/or they have corrected any issues going forward, which shows due diligence on their part," Fiedler says.

The OIG plans to "review a sample of Medicare Part B paid claims and medical records for diagnostic x-rays performed in hospital emergency departments to determine the appropriateness of payments." According to the report, in 2007, Medicare reimbursed physicians approximately $207 million for imaging interpretations in EDs, which caught the OIG's eye.

The OIG also intends to "review the appropriateness of providers' use of modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) on claims for services that are not covered by Medicare," the report states.

By law, Medicare excludes some medical treatments, such as many screening tests, and you might want to inform patients of this fact. Although you're not required to issue a notification to patients for excluded procedures, doing so is a courtesy to the patient and may help the process of collecting from the patient. In these cases, modifier GY applies. Medicare denied over $820 million in modifier GY claims in fiscal year 2008, and the OIG wants to further research "patterns and trends for physicians' and suppliers' use of modifier GY," the report notes.

E-Prescribing Pay Scrutinized

Interestingly, the OIG will be reviewing Medicare incentive payments made in 2010 to health care professionals for their 2009 e-prescribing activities.

The OIG will assess "whether, and, if so, the extent to which incentive payments for e-prescribing activities in 2009 were made in error." If the OIG finds that Medicare made erroneous e-prescribing payments, it will investigate how CMS remedied the overpayments.

Because the e-prescribing incentive program is just getting rolling, the investigation is an attempt for the OIG to "identify potential vulnerabilities to assist in CMS's oversight preparations."

(Editor's note: To read the entire OIG Work Plan, please visit: www.oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf.)