Each fall, the Office of Inspector General (OIG) announces its enforcement priorities for the coming year in the form of a Work Plan. The 2007 Work Plan was released on September 26, 2006 and can be found here: http://oig.hhs.gov/publications/docs/workplan/2007/Work%20Plan%202007.pdf. As in past years, the Work Plan should be required reading for all compliance officers and others interested in getting an advance look at the feds’ playbook.

Forewarned is forearmed:

Some initial observations relevant to physician practice compliance efforts:
The OIG’s focus on services billed "incident-to physician services" is no surprise. This method allows physicians to bill for certain services performed by staffers as if the doctors had rendered them personally, but only under very tight restrictions that are poorly understood. This issue has been a source of much controversy over the years, and there have been perceptions of abuse. The reality is that Congress and CMS permitted physicians to bill for such services if certain conditions are met, and now it’s costing the system a lot more than anticipated. Practices should be certain that all components of the "incident-to" criteria are met if billing for physician extenders under this method.
The OIG is also looking at quality of care at physician-owned specialty hospitals now that studies have failed to conclusively prove that such hospitals restrict access to care in community hospitals.
"Place of service" coding will continue to be a hot issue. One reason may the ongoing growth of ambulatory surgery centers, both physician-owned and physician-hospital joint ventures. Attempts to game the system to achieve higher payment rates will be targeted.
The focus on medical necessity and quality of imaging services in physician offices is similar to what many private insurers have been doing – for instance, see the Highmark Blue Cross Blue Shield policy at https://prc.highmark.com/cgi-bin/inetcgi/prc/jsp/Home.do?site=hmbcbs
In the last year there have been a number of high-profile cases where violation of a Corporate Integrity Agreement (CIA) resulted in draconian penalties including exclusion from Medicare. This is also fertile ground for new enforcement efforts. If a provider violates a CIA, consequences will be severe. Exclusions, while still rare, may be more of a meaningful threat in 2007.
For more information, contact Bill Maruca at 412-394-5575 or wmaruca@foxrothschild.com