OIG targets home health referrals, critical care
Here are some of the key reimbursement areas the Office of the Inspector General will be examining in 2001, according to Connie Raffa, a health law attorney with Arent Fox Kitner Plotkin & Khan in New York City.
Home health: One of the areas targeted for scrutiny in 2001 is physician involvement in approving and overseeing home health services.
"The government is interested in having physicians provide more input not only in the initial orders but in the supervision of patients when they are receiving home health services," Raffa says.
Physicians should make sure that their patients are truly homebound, need skilled services, and meet other criteria for home health services. They must be able to prove that they are supervising the home health services, Raffa says.
New civil monetary penalties can be levied against physicians if their home health patients don’t meet the eligibility criteria, she adds.
However, Raffa urges her physician clients to prescribe home health for a patient if they need it. "The physician’s first concern should be what is best for the patient. If the patient meets the homebound criteria and needs skilled services, there should be a written plan of care under direction of the physician," Raffa says.
Critical care codes: The OIG has stated its intention to examine the use of critical care codes that may be billed to Medicare only if the patient is critically ill and requires constant attention by physicians.
"In this case, documentation is so important. The medical records should be such that an auditor or anyone else could pick them up and see that the level of care was medically necessary," says Darren Binder, a health law attorney in the Washington, DC, office of Arent Fox Kitner Plotkin & Khan.
In selecting critical care codes, the important element is the amount of time the doctor spends with the patient. That should be carefully documented in the records, Binder says.
Role of non-physician practitioners: The OIG intends to examine the scope of practice of nurse practitioners, clinical nurse specialists, and physician assistants to ensure that they are employees of the physician, and that they are supervised directly by the physician. While the Medicare regulations allow billing for services of allied health professionals as "incident to" physician services, the services must be provided by an employee of the physician and must be under direct supervision of a physician, Binder says.
The OIG has said it intends to look for "any potential vulnerabilities" involving the services of allied health professionals and wants to ensure that non-physician providers practice under their state’s scope-of-practice requirements.
Reassignment of physician benefits: The OIG will be looking for any abuses in the practice of allowing physicians to reassign their billing numbers to clinics, effectively shifting accountability and liability away from the physician and to the clinics.
Physicians at teaching hospitals: The purpose of this initiative is to ensure that claims at teaching hospitals accurately reflect the level of service provided to the patients.
Podiatrists’ billing and services: The OIG plan says that one state’s podiatrist claims has a 99% error rate and indicated intentions to examine a national sample of podiatry claims.
Advance beneficiary notice: Under Medicare regulations, physicians must provide advance notice to patients before they provide services that they believe Medicare will not reimburse. The work plan states the OIG’s intention to examine the wide variation in the practice.
Bone density screening: The OIG will examine the appropriateness and quality of bone density screening.
The work plan is available on the OIG web site: www.oig.hhs.gov. Just type "workplan" into the Search field.
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