2012 OIG WORK PLAN

The Office of Inspector General (OlG) has released its Work Plan for 2012.  The OIG sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities including CMS.

The OIG plans to initiate the following NEW activities related to physician services:

1)     High Cumulative Part B Payments – The OIG will review high cumulative Part B payments to determine if they are reasonable and necessary, adequately documented, and provided consistent with Federal Regulations.

2)     Incident-to-Services – The OIG will review whether “incident to” billing has a higher error rate than that for non-incident-to-services.

3)     E/M Services: Use of Modifiers during Global Surgery Period – The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period to determine if Medicare payments were in accordance with Medicare requirements.

To avoid potential penalties in 2012, be sure that all providers in your practice are documenting exactly what they are billing out to Medicare.  Remember, if it isn't documented, it didnt happen!!!

For more information on this topic, visit http://oig.hhs.gov/reports-and-publications/workplan/index.asp

Medical Billing Services & Solutions

PREPARE FOR HIPAA 5010 NOW TO PROTECT YOUR ORGANIZATION FROM FUTURE DENIALS

Beginning on January 1, 2012, a federal mandate requires providers, health plans, and clearinghouses to use new standards when electronically conducting certain health care transactions.  Included are claims, remittances, eligibility, and claim status requests and responses.  As of March 31, 2011, claims submitted using the current HIPAA 4010 standards will start being denied by CMS.  Commercial insurance carriers may deny claims as soon as January 1, 2012.

As the deadline approaches, providers and health care organizations need to upgrade and test their claims management systems to ensure that they are prepared to accommodate 5010.  The required upgrade to 5010 was prompted by the need for a comprehensive electronic data exchange for the expanded ICD-10 code set mandated for compliance by October 1, 2013.

For more information on this topic, visit www.cms.gov/Versions5010andD0/

Medical Billing Services & Solutions

Medicare Payment Advisory Commission to Impose Pay Cut For Medicare Providers

The Medicare Payment Advisory Commission is charged with supervising $500 billion in Medicare cuts as a part of the Patient Protection and Affordable Care Act.  In September of 2011, MedPAC proposed that specialists will receive a 6% cut in their fees per year for three years followed by a 7 year freeze without any adjustment for inflation; general practitioners will face a 10 year freeze on their reimbursement fees, with no adjustment for inflation.  Despite overwhelming opposition from Medicare patients, Medicare providers, and many Health Organizations, they have recently gone ahead and voted to impose these drastic pay cuts on all doctors that accept Medicare as of January 1, 2012.

These cuts and pay freezes will equate to a 50% real pay cut for specialists and a 30% real pay cut for general practitioners over the next 10 years.  This assumes that inflation stays at a very low 3%.  Obviously, higher inflation would make the cuts in real pay even more drastic.

Consequences of this decision:

1)  Many physicians, and most specialists, will refuse to treat patients with Medicare as their primary insurance.  There are certain costs that physicians assume by practicing medicine and treating patients.  These include the obvious business overhead expenses, such as: rent, utilities, malpractice insurance, medical supplies, salaries of employees/nurses, etc.  Why would a physician want to treat a Medicare patient when they know that the reimbursement for treating that patient may not cover their expenses?

2)  More medical care will be turned over to nurses, nurse practitioners, and physician assistants.  Few people will ever get to see a doctor under the Medicare program.

3)  Medicaid will follow suit and cut their reimbursement fees as well.

4)  Many commercial insurance companies will also follow suit and cut reimbursement fees.

5)  The quality of health care in America will be drastically impacted because many students will choose to pursue careers in other fields.  The cost of medical school plus interest on student loans is always increasing.  Decreased future earnings to pay back these loans will prevent attending medical school from being a viable option.


If we do not take a stand, these cuts will drastically impact the health care industry in the United States.  I encourage you to write your Congressional Representatives and U.S. Senate Representatives to make your voice heard.