The items contained in the OIG 2002 Work Plan of which physicians should take particular notice are as follows:

"Incident To" Services. The OIG intends to focus on the manner in which physicians bill "incident to" services and supplies. A physician may bill for services provided by allied health professionals, such as nurses, technicians and therapists, "incident to" the physician’s professional services and receive 100 percent of the Medicare physician fee schedule payment for such service. However, applicable Medicare requirements as to the performance as such services must be satisfied (including, but not limited to, having the service performed under the direct supervision of a physician). The OIG notes that questions persist about the quality and appropriateness of these billings because insufficient information is available on types of services being billed.

Reassignment of Benefits. The OIG intends to examine staffing companies and their relationships with emergency room physicians, identifying problems in connection with Medicare reassignment rules. The OIG notes that hospitals commonly contract with billing and staffing companies to staff their emergency room and handle administrative functions. Under some of these arrangements, emergency room physicians work for the staffing companies as either employees or independent contractors; the OIG states that these physicians may reassign Medicare benefits to the staffing company only if they are employees of the staffing company. Reassignment issues outside of the emergency room will also continue to be of interest to the OIG.

Use of Evaluation and Management Codes. The OIG intends to continue to look at whether physicians correctly code evaluation and management services and effectively use existing documentation guidelines. The OIG notes that Medicare payments for evaluation and management codes total approximately $18 billion per year and account for almost half of Medicare spending for physician services. Physicians are currently permitted to use either the 1995 guidelines or the 1997 guidelines developed by the American Medical Association in selecting evaluation and management codes, and new billing guidelines are currently under development.

Consultations. The OIG is going to focus on the appropriateness of billings for physician consultation services as well as attempt to determine the primary reasons for inappropriate billing in this area.

Advanced Beneficiary Notices. The OIG intends to examine the use of advanced beneficiary notices by physicians. Physicians must provide advance notice before providing services that they know or believe Medicare does not consider medically necessary or that Medicare will not reimburse. Medicare beneficiaries who do not receive such a notice before they receive such services are not responsible for payment.

Physicians at Teaching Hospitals. The OIG is continuing an initiative designed to verify compliance with Medicare rules governing payment for physician services provided in the teaching hospital setting in order to insure that the claims accurately reflect the level of service provided to patients. Previous efforts by the OIG in this area provided it with information that many providers were not in compliance with applicable Medicare reimbursement policies in this area.

Billing for Residents’ Services. The OIG intends to look into the billing of residents for "moonlighting" services. The OIG intends to make sure that hospitals and physicians are properly using physicians’ identification numbers to bill Medicare only in instances meeting its "moonlighting" rules.

Inpatient Dialysis Services. The OIG intends to conduct a review to determine whether Medicare payments for inpatient dialysis services meet Medicare’s billing requirements. The focus of this review will be whether or not Medicare’s requirements with regard to presence of a physician during a patient’s dialysis treatment are being satisfied.

Procedure Coding of Outpatient and Physician Services. The OIG intends to review the procedure coding of outpatient services billed by a hospital and a physician for the same service. In a previous nationwide study, the OIG discovered that the coding used by hospital outpatient departments and physicians for the same service differed 23 percent of the time. The OIG intends to review these inconsistencies and determine their effect on the Medicare program.

Clinical Laboratory Improvement Amendments Certifications. The OIG intends to look at whether laboratories are conducting tests and billing Medicare within the scope of their certifications under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The tests that a laboratory is permitted to perform under CLIA are limited by the lab’s certification, and the OIG intends to use Medicare billing records to make sure that labs are properly qualified to perform the tests for which they are billing.

Health Care Fraud. The OIG indicates that they will continue to investigate individuals, facilities or entities that bill Medicaid and/or Medicare programs for services not rendered, claims that manipulate payment codes in an effort to increase reimbursement amounts and other false claims submitted to obtain improper payment. Special focus areas in 2002 include pharmaceutical fraud and quality of care issues for beneficiaries residing in care facilities. The OIG will also continue to investigate business arrangements that violate the Federal Anti-Kickback Statute. However, as it has said in the past, the OIG indicates that it will not conduct investigations on individuals, facilities or entities that merely commit errors or mistakes on claims submitted to the Medicare or Medicaid programs. The OIG also notes that it has a voluntary self-disclosure program that providers may avail themselves of where a potential violation of the law has occurred that threatens a Federal health care program.

The foregoing items highlight the areas upon which the OIG will focus in 2002. While most of these areas are not new areas of concern for the OIG, the OIG 2002 Work Plan does highlight the fact that the OIG is still focusing on problems that arrive in connection with these highlighted areas. As such, physicians would be wise to take a closer look at the foregoing areas as part of their overall efforts in complying with the rules and regulations published by Medicare and Medicaid. If you have any specific questions as to how the rules in a specific area impact your practice, you should consult with a health care attorney who is knowledgeable in these areas.