Medicare Compliance & Reimbursement

OIG report says. As most Part B practices know, the OIG maintains a hotline through which individuals can submit complaints or allegations of fraud and abuse -- but it's never been clear what the OIG does with those issues -- until now.

On March 21, the OIG released the results of its report, "CMS's Processing of Complaints Received Through the 1-800-HHSTIPS Hotline," and the information is promising. During its review, the OIG identified 1,427 complaints that it sent to CMS over the first six months of 2008 and followed up to determine whether CMS had resolved most of the complaints.

According to the OIG report, CMS resolved 88 percent of complaints after one year, with only 12 percent remaining unsolved at that point.

Overall, 32 percent of complaints "were confirmed as services billed in error," the report indicates. "Eleven percent of complaints involved allegations of fraud. Contractors closed 11 percent of complaints administratively. For another 32 percent, contractors researched complaints and found no problems. Two percent of complaints were referred to another agency."

Although the OIG found that CMS resolved the majority of complaints after a year, it recommended that CMS should publish written guidance for processing hotline complaints so that all contractors have a uniform set of standards. In addition, the OIG suggested that CMS should upgrade its information system for processing hotline complaints. To read the complete OIG report, visit http://oig.hhs.gov/oei/reports/oei-07-09-00020.pdf.

Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician's information is not in the MAC's claims system or in PECOS, your practice will get an informational message letting you know that the practitioner's information is missing from the system. But once CMS institutes Phase 2 of the program, you'll get a denial instead.

In December, CMS announced via Transmittal 825 that the "placeholder future implementation date" of Phase 2 would be July 5, 2011. In addition, earlier this month, the OIG printed that July 5 implementation date in its Compendium of Unimplemented Recommendations.

However, a March 21 CMS announcement states that the OIG was incorrect when it said that Phase 2 begins in July, because "CMS has not yet determined when it will begin to apply the ordering/referring provider claim edit."