The document is the 2011 OIG Workplan for Physicians. It outlines the Office of Inspector General's investigative priorities for 2011, which include evaluating payments for evaluation and management services, diagnostic testing, medical necessity of claims, and compliance with Medicare rules. The Workplan is released annually and provides guidance for healthcare providers to identify areas of focus for compliance audits and taking corrective actions if issues are found.

1. 12/17/2010
2011 OIG Work Plan for Physicians
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INCREASING REVENUES IN THE BUSINESS OFFICE
Presented by Jennifer Hume, CPC, CPMA, CEMC
Richard S. Blauvelt, BA, MHSM
President/CEO
PRO-DOC SOLUTIONS
2011 OIG WORKPLAN FOR PHYSICIANS
OIG WORKPLAN
• Released on October 1 of each year
• Coincides with the start of the new fiscal year for the
government
• Lists key investigative priorities.
• Multiple “parts”
-Part 1 addresses Medicare Part A and Part B services.
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2. 12/17/2010
2011 OIG WORKPLAN FOR PHYSICIANS
OIG WORKPLAN—PART 1
Addresses many different provider types
Provider Types
Home Health
Hospitals Nursing Facilities
Agencies
Other Providers & Medical Equipment Part B Payments for
Suppliers & Supplies Prescription Drugs
Medicare Part A and Part B Contractor Operations
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2011 OIG WORKPLAN FOR PHYSICIANS
OIG WORKPLAN—PART 1
• Evaluation and Management Services
• Diagnostic Testing
• Medicare Program – General
• Medical Necessity
• Comprehensive Error Rate Testing
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3. 12/17/2010
2011 OIG WORKPLAN FOR PHYSICIANS
OTHER PROVIDERS AND SUPPLIES
Evaluation and Management Services
• Coding of E/M services
• Payments for E/M services
• E/M services during global surgery periods
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2011 OIG WORKPLAN FOR PHYSICIANS
OTHER PROVIDERS AND SUPPLIES
Diagnostic Testing
• Appropriatness of Medicare payments for
polysomnography
• Medicare payments for sleep testing
• Excessive payments for diagnostic tests
• Medicare payments for Part B imaging services
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4. 12/17/2010
2011 OIG WORKPLAN FOR PHYSICIANS
OTHER PROVIDERS AND SUPPLIERS
Medicare Program – General
• Medicare providers’ compliance with assignment rules
• Payments for services ordered or referred by excluded
providers
• Medicare services billed with dates of service after
beneficiary’s date of death
• Place of service errors
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2011 OIG WORKPLAN FOR PHYSICIANS
OTHER PROVIDERS AND SUPPLIERS
Medical Necessity
• Medicare payments for claims deemed not reasonable
and necessary
• Medicare billings with modifier GY
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5. 12/17/2010
2011 OIG WORKPLAN FOR PHYSICIANS
OTHER PROVIDERS AND SUPPLIERS
Comprehensive Error Rate Testing
• Comprehensive Error Rate Testing (CERT) Program:
FY2010 error rate oversight
• Error-prone providers: Medicare Part A and Part B
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2011 OIG WORKPLAN FOR PHYSICIANS
OTHER PROVIDERS AND SUPPLIES
Providers other than physicians
Therapists Hospice
Independent Diagnostic Comprehensive Outpatient
Testing Facilities (IDTFs) Rehabilitation Facilities
(CORF)
Portable x-ray suppliers Clinical laboratories
ESRD services Clinical Social Workers
Ambulatory surgery centers Partial Hospitalization
Services
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6. 12/17/2010
2011 OIG WORKPLAN FOR PHYSICIANS
OTHER WORKPLAN PARTS
Don’t limit workplan reviews to just the other providers and suppliers
section
• Hospital:
Medicare Secondary Payer/Other Insurance Coverage: We will
review Medicare payments for beneficiaries who have other
insurance. Pursuant to the Social Security Act, § 1862(b),
Medicare payments for such beneficiaries are required to be
secondary to certain types of insurance coverage. We will assess
the effectiveness of procedures in preventing inappropriate
Medicare payments for beneficiaries with other insurance
coverage. For example, we will evaluate procedures for
identifying and resolving credit balance situations, which occur
when payments from Medicare and other insurers exceed the
providers’ charges or the allowed amounts. (OAS;
W‐00‐11‐35317; various reviews; expected issue date: FY 2011;
new start)
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2011 OIG WORKPLAN FOR PHYSICIANS
HOW TO USE THE WORKPLAN
• Review when issued
• Identify key investigative priorities that may affect your
practice
• Incorporate into your annual compliance audit plan
Example: General surgical practice and E/M services
during the global surgical package
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7. 12/17/2010
2011 OIG WORKPLAN FOR PHYSICIANS
DEMONSTRATE COMPLIANCE
• Document your efforts
• Identify issues and take corrective action
• Document
—Issue
—Findings
—Corrective actions
—Resolution
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2011 OIG WORKPLAN FOR PHYSICIANS
QUESTIONS
Thank you for attending!
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