Who and What is the OIG?
The Office of Inspector General (OIG) Health & Human Services (HHS) of was established 1976 and has been at the forefront of the Nation’s efforts to fight waste, fraud, and abuse in Medicare, Medicaid, and more than 300 other HHS programs. The majority of OIG’s resources go toward overseeing of Medicare and Medicaid, and they develop and distribute resources to assist the health care industry in its efforts to comply with the Nation’s fraud and abuse laws and to educate the public about fraudulent schemes.
In order to fulfill their mission, the OIG:
- Conducts investigations, audits, and evaluations of all HHS programs (including Medicare and Medicaid);
- Identifies weaknesses in HHS programs that provide opportunities for fraud and abuse;
- Leads and coordinates activities to prevent fraud and abuse;
- Detects abusers of HHS programs;
- Assists in the development of cases for criminal, civil and administrative enforcement; and
- Keeps the Secretary of HHS and Congress informed of problems and deficiencies
In addition, the OIG handles all False Claim Act violations included Qui Tam cases in conjunction with the Attorney General and the DOJ (See January 2012 IL advantage). The office is responsible for proposing and litigating Civil Monetary Penalties and for maintaining the OIG Exclusion list. The OIG develops and publishes compliance programs guidelines to assist healthcare providers to stay in compliance with current healthcare laws and regulations (See May 2011 IL Advantage). The OIG website posts fraud alerts and bulletins provide advisory opinions and list the OIG Most Wanted.
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Each October, the OIG publishes its annual Work Plan. This plan summarizes new and ongoing audits and activities the OIG plans to focus on during the following year. The document is over 112 pages long and only a small portion is relevant to chiropractors. You can read the full OIG Work Plan at www.oig.hhs.gov. Chiropractors should be aware of the following items in the 2013 Plan:
Chiropractors-Part B Payments for Non-covered Services
The OIG will review Medicare Part B payments for chiropractic services to determine whether such payments were in accordance with Medicare requirements. Prior OIG work identified inappropriate payments for chiropractic services. Medicare-covered chiropractic services include only treatment by means of manual manipulation of the spine to correct subluxations (42 CFR § 440.60), and chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable (CMS’s Medicare Benefit Policy Manual, Pub. 100-02, ch. 15,§ 30.5B). Additionally, Medicare will not pay for items or services that are “not reasonable and necessary” (Social Security Act, § 1862(a)(1)(A) and OAS; W-00-12-35606; W-00-13-35606 and HHS OIG Work Plan / FY 2013 Part I Medicare Part A and Part B, P.26).
It is important that your documentation shows medical necessity for care including your E/M, treatment plan and daily notes. Pay close attention to your onset date, diagnosis codes and modifiers you list on your CMS 1500 Claim Form. Medicare’s definition of medical necessity states that a patient must have a significant health problem in the form of a neuromusculoskeletal condition that necessitates treatment; that the CMT must have a direct relationship to the patient’s condition; there must be a reasonable expectation of recovery or improvement in function. In short, Medicare does not pay for pain, and the patient must have a subluxation of the spine as demonstrated by x-ray or physical exam (PART). If care is wellness/maintenance, do not bill the service using the AT modifier.
Independent Therapist-High Utilization of Outpatient Physical Therapy Services
The OIG states that they will review outpatient PT services provided by independent therapists to determine if claims are in compliance with Medicare reimbursement requirements. Prior, the OIG found that claims provided by independent physical therapists were not reasonable, necessary, or properly documented. Again, Medicare will not pay for items or services that are not reasonably necessary (Social Security Act,§ 1862 (a)(1)(A)). Documentation requirements for therapy services are in CMS’ Medical Benefit Policy Manual, Pub. 100-02, ch. 15,§ 220.03 (HHS OIG Work Plan / FY 2013 Part I Medicare Part A and Part B, P.20).
If you employ a PT, pay close attention that his or her documentation for services follow Medicare’s requirements and notes show medical necessity for care. Review claims to determine that your therapists are properly billing and coding.
Noncompliance with Assignment Rules and Excessive Billing of Beneficiaries
The OIG will audit physicians and suppliers to determine if they are in compliance with assignment rules. Remember, chiropractors who participate in Medicare agree to accept Medicare allowed amount for covered services (HHS OIG Work Plan / FY 2013 Part I Medicare Part A and Part B, P.24).
It is important to look past OIG Work Plans since many of the items listed in prior plans are still being focused on today. To receive regular updates on OIG activities I recommend signing up for OIG email updates at www.oig.hhs.gov.
