We talked to Lisa Maciejewski-West -- president and owner of Gold Star Medical Business Services in San Aneglo, Texas, and a faculty member of the Practice Management Institute (PMI) – about the recently released 2016 OIG Work Plan and what it might mean for practices in the new year.
Repeat offenders. There are some targets you can expect to see year after year, says Maciejewski-West: for example, “Physical Therapy Services have been under scrutiny on the Work plan in 2014, 2015 and now 2016.” She believes that repeat appearances mean the subject is costing CMS more than it wants to pay or has a high fraud-and-abuse profile or “it’s an area in which CERT and RAC audits are producing lucrative results, and it’s therefore worth the time and money to continue investigation.” Other areas under scrutiny for Part B in 2016 include Chiropractic Services (on the Work Plan for four of the last five years) and durable medical equipment, specifically power mobility devices and diabetic testing supplies, both on the Work Plan since 2012.
New faces. Among the targets making a debut in the 2016 Work Plan are physicians who order/refer for Medicare services and supplies; reasonableness of Medicare physician home visits; and reasonableness of prolonged E/M services and anesthesia services.
In general: Maciejewski-West notes the Work Plan has gotten about 10 pages shorter each year since 2013. And the recoveries have been getting smaller: “In FY 2013 expected recoveries were estimated at $5.8 billion,” she says. “In 2014 it was $4.9 billion, and in FY2015 expected recoveries were down to $3 billion -- almost half of the expected recoveries from FY 2013.”
To Maciejewski-West, this suggests OIG has been successful in stopping some of the major Medicare fraudsters. She cites a recent drop in OIG criminal actions from 971 in FY 2014 to 925 in FY 2015. At the same time, though, civil actions against providers increased by more than 150 -- from 533 in FY2014 to 682 in FY 2015 – which may mean that once the "low-hanging fruit" of major fraud is out of the way, "the OIG will be targeting the smaller practices and organizations for their investigations and recoveries.”
Maciejewski-West’s advice: Review the Work Plan; find the items in your specialty or specific billing practice, then immediately conduct an internal audit of those areas within your practice or company. “Internal monitoring and auditing is one of the key components of a compliance and ethics program for your organization,” she says.