Medicare Compliance & Reimbursement

OIG Cites ‘Fiscal Challenges’ for Delayed 2014 Work Plan Release

It’s that time of year again — as summer turns to autumn, the OIG typically publishes its Work Plan for the coming year, outlining all of the focus issues that the agency intends to spotlight going forward. What’s different about this autumn, however, is that the OIG doesn’t plan to release one.

Instead, the OIG notes on its website, the 2014 Work Plan won’t be issued until January 2014. The change “will better align with priorities OIG has set for the coming year, a time of continuing fiscal challenges,” the agency said in a statement.

What’s the Work Plan? If you haven’t read previous iterations of the document, the OIG’s Work Plan reveals the hot button issues that the agency plans to investigate over the course of the year. For example, the agency has been looking at “cloned notes” for E/M services, incident-to visits, and the use of “G” modifiers with ABNs over the course of the current year, according to the agency’s 2013 Work Plan.

To stay up-to-date on the agency’s focus areas and other plans, visit the OIG website at oig.hhs.gov/reports-and-publications/workplan/index.asp#2014update.

Overbilling Kyphoplasty Leads to $388,000 Settlement for One Doctor

If you’re performing kyphoplasty, make sure you’re reporting the designated codes for this procedure and not higher-level spine surgery codes — or you could face massive penalties.

This was the lesson learned by a Long Island, NY orthopedic surgeon who recently paid the government $388,000 to settle allegations that he violated the False Claims Act. The government alleged that the doctor knowingly submitted kyphoplasty claims to Medicare using CPT^® codes that were assigned to “more complicated surgeries, thereby inflating his Medicare reimbursements,” the Department of Justice noted in an Aug. 21 news release.

Reality: CPT^® includes three kyphoplasty codes (22523-22525), which you should bill based on the spinal site and the number of vertebral bodies treated. If the surgeon performs kyphoplasty and bills a code for spinal fusion or other non-kyphoplasty code, bring it to her attention that only the designated kyphoplasty codes apply to the surgery.

Lesson From Recent $750,000 Case: Repay Overpayments As Soon As Possible

If your practice accepts the fact that you received an overpayment, you can’t simply nod and agree that it was wrong — you have to send it back. That’s the lesson from a case in Maryland, where a hospital overbilled for cardiac testing and then sat on the cash even after realizing it collected more than it should have.

The hospital agreed to pay $750,000 to settle the case last week, which stemmed from overbilling cardiac perfusion studies between 2003 and 2009. The hospital was aware of the issue, but still didn’t pay the government back for the charges until a lawsuit was filed. The case was brought to the attention of the OIG and Department of Justice by a whistleblower, who will receive $119,728 for his part in raising awareness of the hospital’s wrongdoing.

To read the complete report about the case, visit www.justice.gov/usao/md/news/2013.

Senior Medicare Patrol Smaller in Numbers, But Still Producing Results

Your patients may not be giving you as much scrutiny as in previous years. So implies a new OIG report on the Senior Medicare Patrol.

The 54 Patrol projects saw their number of volunteers decrease by about 9 percent to 5,137 in 2012, the OIG says. But that doesn’t mean the projects aren’t producing results. They conducted more educational sessions despite the lower number of volunteers. And “one project provided information to Federal prosecutors for a case that eventually resulted in a $12.9 million settlement,” the OIG notes in its summary of the report, available at go.usa.gov/jBTH.

Cancel — Don’t Resubmit — RAPs With Errors

If you discover you made an error on a home health Request for Anticipated Payment that you submitted, you’ll have to bite the bullet and cancel and resubmit it. “If your RAP paid and you determine it contains incorrect information, you will need to cancel it, HHH Medicare Administrative Contractor CGS says in a frequently asked question posted on its website.

Remember: “RAPs may not be adjusted,” CGS explains. “A provider-cancelled RAP causes the episode established on the Common Working File (CWF) to be removed,” CGS adds.

Wait for the canceled RAP to process before submitting the new one, CGS advises online at www.cgsmedicare.com/hhh/education/faqs/hh_billing_faqs.html.