Following on the Department of Health and Human Services Office of Inspector General’s (OIG) June announcement that it would begin updating its public-facing Work Plan on a monthly basis, OIG released its first update to add 14 new topics to the Work Plan on July 17. As the health care industry knows, OIG Work Plan sets forth various projects that the OIG’s Office of Audit Services (OAS) and Office of Evaluation and Inspections (OEI) are currently undertaking or planning to undertake in the future. Previously, OIG updated its Work Plan to reflect adjustments once or twice each year. In a stated effort to increase transparency in its audit and inspection work, OIG changed its practices to begin issuing monthly updates.

The 14 topics all describe new OAS audit work, much of which is focused on Medicare and Medicaid issues. Several areas appear to lend themselves to data-mining, such cross-checking claims between Medicare Parts A and B or providers of concurrent services. For example, the OIG aims to:

  1. Evaluate whether certain Medicare Part B payments for ambulance services are subject to Medicare Part A skilled nursing facility (SNF) consolidated billing requirements (i.e. the SNF received payment for the ambulance transport as part of the Part A payment, and thus was responsible for paying the ambulance provider);
  2. Compare Medicare Part B and Part A claims to check for overlapping claims between home health agencies and/or hospices and outside providers;
  3. Investigate the validity of Medicare payments for telehealth services provided at distant sites that do not have corresponding originating site claims; and
  4. Examine Medicare payments to hospital outpatient providers for non-physician outpatient services provided under the inpatient prospective payment system.

OIG also proposed two more wide-ranging programmatic reviews. First, OIG plans to conduct a study to identify “common characteristics” of “at risk” home health agency providers in an effort to target pre-and post-payment claim reviews. This OAS study appears to be a follow-up to an OEI study issued in June 2016 of “selected characteristics commonly found in OIG-investigated cases of home health fraud.” Second, OIG plans to review hospital electronic medical record incentive payments for compliance with Medicare’s meaningful use requirements. OIG’s continued examination of EMR incentive payments follows on OAS’ June 2017 report estimating that between May 2011 and June 2014, over $729 million was paid to hospitals and physicians who did not comply with the incentive program requirements.

For a full list of the 14 additional inquiries, visit the OIG’s Work Plan website.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) annual release of a new Work Plan both summarizes the results achieved last year and highlights new areas for examination in the next. This year’s Work Plan reported rising audit results but declining investigative results, in contrast to previous years.

In examining the new topics added to the Work Plan, two themes emerge.  First, many of the new payment audits reflect OIG’s use of data mining to identify providers or suppliers who could potentially be considered “outliers” from the average use of a particular code or procedure. Data mining will also play a significant role in connection with the second theme—a notable increase in OIG’s review of significant, and some controversial, policy issues concerning changes in the country’s health care delivery system, operation of HHS programs and the effectiveness of HHS agency oversight of those changes and programs.

Based on how OIG identified new study topics, the main takeaway from the Work Plan is “know your data.” Whether the issue is Medicare claims or data reporting obligations, the OIG increasingly turns to data analytics to both generate audit or investigative leads or to study HHS program effectiveness.

To access a full analysis of the Work Plan, click here.

While the health care industry has accounted for a large portion of settlements and judgments involving fraud and False Claims Act (FCA) liability in recent years—68 percent of the United States’ $3.8 billion recovery in 2013 and 40 percent of the $5.69 billion recovery in 2014—the U.S. Department of Health and Human Services Office of Inspector General (OIG) and the U.S. Department of Justice (DOJ) have been primarily focused on hospitals, health care systems and large health care companies.  However, recent settlement and enforcement trends reiterate that individual physicians and smaller practice groups are not immune to qui tam whistleblowers and direct investigation by the OIG.

Such was the case for Garden State Cardiovascular Specialists, P.C., (Garden State) a 12-physician group in New Jersey that just last week reached a $3.6 million settlement in United States ex rel. Cheryl Mazurek v. Garden State Cardiovascular Specialists, P.C. et al., Civil Action No. 10-4734 (D.N.J.).  The settlement resolved sealed allegations that Garden State’s physicians and their NJ Medcare / NJ Heart facilities submitted claims to Medicare for various cardiology diagnostic tests and procedures (including stress tests, cardiac catheterizations and external counterpulsation).  The case against Garden State and two of its principal physicians was brought by Cheryl Mazurek, who worked for Garden State’s third-party billing and coding vendor, MediGain Inc.  Mazurek’s claims against MediGain, also filed under seal, have not yet been resolved.

The OIG Work Plan, complemented by a Mid-Year Update last month, echoes the increased focus on issues that directly implicate physicians operating independent of hospitals and larger companies.  For example, the OIG is reviewing physician coding on Medicare Part B claims for services performed in ambulatory surgical centers (ASC) and hospital outpatient departments to determine whether they properly coded the places of service.  Because Medicare reimburses physicians at a higher level when services are performed in a non-facility setting (e.g., a physician’s office) versus services performed in a hospital outpatient department or (with some exceptions) in an ASC, the OIG will be closely scrutinizing site of service this year and beyond.

Whether on the billing/coding side of the equation, medical necessity or any number of focus areas for DOJ and the OIG, physicians and practice groups (even small ones) should be keenly aware of their compliance obligations under the current FCA regime.  For a quick refresher on fraud enforcement trends for 2015 and beyond (along with some practical tips), you may find this article to be a helpful resource.