Tag Archives | Oig

OIG: Acute Care Hospitals Owe Medicare $51.6M, CMS Agrees to Provider Clawbacks

A new government report finds that Medicare improperly paid acute care hospitals for outpatient services they provided to patients who were inpatients at other facilities. And now Medicare wants the money back. The Centers for Medicare and Medicaid Services has agreed to claw back the $51.6 million and require hospitals to refund patient copays and […]

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OIG Investigates Payments for Ambulance Transports of SNF Patients

Medicare’s Office of Inspector General (OIG) has issued a sixteen-question survey to many ambulance service suppliers. The survey is focused on SNF patients, and specifically why the ambulance service has billed Medicare Part B for transports while patients were in a Part A stay. During Part A stays, the nursing home receives Medicare payments that […]

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Challenging the Six Year Lookback

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently conducted an audit of Mount Sinai Hospital in New York City. After looking at a sample, the OIG found fault with about $1.4 million in claims, and projected that to an overpayment of just under $42 million. There are several […]

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Healthcare Reform Can Create Confusion Over Compliance for Providers

In 2016, the federal government recovered more than $3.3 billion in healthcare fraud judgments and settlements. On Monday, TeamHealth agreed to pay $60 million to settle allegations that a company it acquired, IPC Healthcare “knowingly and systematically encouraged false billings by its hospitalists.” The settlement is the latest in a string of False Claims Act […]

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The ICD-10 Coding Final Countdown Checklist, Coding Policies & Procedures

We are now within two weeks before ICD-10 implementation begins on Oct. 1, 2015. Going through your readiness checklist is a daily process, and at this point we all must ensure that there is nothing forgotten or skipped. The ICD-10 countdown checklist should include several key activities and areas, including but not limited to the […]

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2015 U.S. Department of Health and Human Services Office of Inspector General Work Plan is Published

As you may be aware, the 2015 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan was released on Oct. 31, 2014. This should be considered mandatory reading for all healthcare providers looking to avoid fraud charges.

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ICD-10 Medical Code Tests Yield Successful Results for CMS

The Centers for Medicare and Medicaid Services’ initial testing of updated medical diagnosis codes that will be required at health care payers and providers next year proved to be successful, according to Niall Brennan, the acting director of CMS Offices of Enterprise Management.

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OIG Finds Improper Payments Cost Medicare Billions

On May 29, 2014, the Department of Health and Human Services Office of Inspector General (OIG) released a report, Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010.

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OIG: Room To Improve Medicare Audits

Contractors hired by Medicare to audit the payment records of healthcare providers have a good track record spotting improper billing, the Department of Health and Human Services Inspector General concluded in a recent report, but legitimate concerns exist.

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Fiscal Year 2012 HHS OIG Work Plan

The HHS Office of Inspector General (OIG) Work Plan for Fiscal Year 2012 provides brief descriptions of activities that OIG plans to initiate or continue with respect to HHS programs and operations in fiscal year 2012.

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Get to Know 3 E/M Myths That Could Affect Your Practice

Hint: Just because your doctor visits the ICU doesn’t mean he can report critical care.

Most medical practices report outpatient E/M codes (99201-99215) every day, but some Part B providers are still falling victim to several of the most common E/M myths. Button up your coding processes by dispelling these three commonly-held misunderstandings.


Myth 1: When reporting 99211 “incident to” a physician, you should bill it under the name of the physician on record for that patient.

Reality: When a service such as a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of the physician) is billed incident to the physician, make sure you file the claim under the supervising physician’s name. The OIG recently found that many practices are billing incident to services under a physician’s name who was not on the premises during the encounter. Often, practice management systems use the physician of record rather than the supervising physician when billing services. This arrangement makes allotting finances between physicians easier, but it causes incident to criteria to appear to be unmet. “Incident to” requires that the supervising physician is directly available, generally considered to be in or immediately adjacent to the office suite.


Myth 2: If a patient has symptoms of a particular illness, you can count that information toward both the history of present illness (HPI) and review of systems (ROS).

Reality: You can’t “double dip” and count the same information toward two separate elements.

Example: If the patient suffered a sprain or fracture, the doctor would typically address the musculoskeletal system during a ROS. Examples of a musculoskeletal ROS might include symptoms such as poor range of motion, joint pain, dislocation, or muscle stiffness, among others. These can be…

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Overcome 3 Myths and Claim Reimbursement Opportunities using Modifier 22

Don’t fall for these common body habitus, time, and fee traps.

If you overuse Modifièr 22 (Increased procedural services), you may face increased scrutiny from your payers or even the Office of Inspector General (OIG). But if you avoid the modifièr entirely, you’re likely missing out on reimbursement your cardiologist deserves.

How it works: When a procedure requires significant additional time or effort that falls outside the normal effort of services described by a particular CPT® codè — and no other CPT® codè better describes the work involved in the procedure — you should look to modifièr 22. Modifièr 22 represents those extenuating circumstances that do not merit the use of an additional or alternative CPT® codè but do land outside the norm and may support added reimbursement for a given procedure.  Take a look at these three myths — and the realities — to ensure you don’t fall victim to these modifièr 22 trouble spots.

Myth 1: Morbid Obesity Means Automatic 22

Sometimes, an interventional cardiologist may need to spend more time than usual positioning a morbidly obese patient for a procedure and accèssing the vessels involved in that procedure. In that case, it may be appropriate to append modifièr 22 to the relevant surgical codè. However, it’s not appropriate to assume that just because the patient is morbidly obese you can always append modifièr 22.  “Modifièr 22 is about extra procedural work and, although morbid obesity might lead to extra work, it is not enough in itself,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, Manager of Compliance education for the University of Washington Physiciáns Compliance Program in Seattle.

“Unless time is significant or the intensity of the procedure is increased due to the obesity, then modifièr 22 should not be appended,” warns Maggie Mac, CPC,

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Place-of-Service Codes Caused $13 Million in Overpayments

Double check POS 11 shouldn’t be 22 — or 24.

Entering your place-of-service (POS) number on your claim form may seem routine, but a recent OIG audit found that practices are not giving POS numbers the care they deserve.
Based on a r…

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Cost of Freezing Conversion Factor is Over $6 Billion — Just for 2010

Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.

With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.

Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.

However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government… … $6.5 billion. The AMA has turned up the heat on Congress to replace the current payment method, releasing a print ad aimed at Congress to demonstrate that “more delays of permanent reform now increase the cost for taxpayers,” and that the association “calls on Congress to fix the flawed Medicare physician payment formula now.”

Congress has not yet introduced a bill to extend the payment freeze past May 31. Keep an eye on the Insider for more information as this story develops.

To read the Congressional Budget Office’s calculation sheet,visit www.cbo.gov/budget/factsheets/2010b/SGR-menu.pdf.

Part B Insider. Editor: Torrey Kim, CPC

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Gastro Coders: Be Aware of Medicare Screening Reqs Or Risk Payment Denial

Following 10-year-rule eliminates G0121 rejection.

If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.

Use this guidance to capture every screening dollar your gastroenterologist deserves.

Home in on Eligibility Requirements for

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Global Billing: Document ‘Unrelated’ for Modifier 79 Services

MACs are looking for ‘red flags’ to halt additional global period pay
Billing for additional services during a global surgery period is always tricky, but now you can expect special scrutiny for modifier 79 claims.
After the OIG got wind of fraudulent surgery billing with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period), CMS contractors have been on the hunt […]

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