Compliance guidelines will cover physicians

Rules could be in effect by summer

The Office of the Inspector General (OIG) is working on draft compliance guidance for physicians and small practices it plans to unveil for comment in either February or March, say sources. Final implementation is expected this summer.

Along with the traditional elements common to all its compliance guidance, OIG has pinpointed the following risk areas for special attention:

• unbundling (e.g., billing multichannel set of lab tests to appear as if individual tests were performed);

• soliciting, offering, or receiving a kickback, bribe, or rebate (e.g., paying for a referral of patients, getting a kickback for ordering diagnostic tests);

• routinely waiving co-pays and deductibles, regardless of need;

• billing for services not rendered ("no shows");

• upcoding;

• double-billing (Medicare and beneficiary/ insurer);

• billing for physician services rendered by nonphysicians/teaching physician requirements;

• medical necessity (documentation to support);

• misrepresenting diagnoses to justify services;

• completing certificates of medical necessity for patients not personally and professionally known by the physician;

• billing Medicare/Medicaid for investigation research, medications, and procedures without proper authorization;

• billing for a noncovered service as if it were covered.