OIG, Radiology, CMS, Medicare conditions of participation (CoP), EDs, The Code of Federal Regulations (Title 42, §410.33)
OIG Issues 2011 Work Plan: Several Radiology-Related Audits Planned
February 01, 2011
Each year about this time, the Department of Health and Human Services' Office of Inspector General (OIG) launches its general work plan for the next calendar year. For 2011, the OIG has seven audits (called "areas of investigation" in the report) scheduled for providers who deliver radiology services to Medicare Parts A and B beneficiaries. Of the projects announced, three of these are "new starts" and four are what the OIG calls "works in progress." In other words, if you're aware of the OIG's work plans from previous years, the works in progress below will sound familiar.
Part B Imaging Services. As you know, most physicians are paid for services through the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expenses (PE). Next year, the OIG will focus on the PE component for selected imaging services. It includes the general categories of expenses, such as office rent, personnel wages, and equipment. Its goal is to determine whether Medicare payments reflect the expenses incurred and whether the utilization rates reflect industry practices.
Radiation Therapy Services. This project focuses upon whether hospitals are complying with Medicare conditions of participation (CoP) governing the safety and quality of intensity modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT) services. In this new project, the OIG will investigate whether IMRT and IGRT meet professionally approved standards for safety and personnel, and it will also assess the oversight of these services by the Centers for Medicare & Medicaid Services (CMS).
Diagnostic Tests. High-cost diagnostic tests will come under the OIG's microscope as it reviews Medicare payments to determine whether they were medically necessary. Through the recovery audit contractor (RAC) program, much attention is being made to the following rule: Medicare will not pay for items or services that are "not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member." The OIG will determine the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.
Works in Progress Hospital Emergency Departments (EDs). In its March 2005 testimony before Congress, the Medicare Payment Advisory Commission (MedPAC) reported concerns about the increasing cost of imaging services for Medicare beneficiaries and potential overuse of diagnostic radiology services. In 2008, Medicare reimbursed physicians about $227 million for imaging interpretations performed in emergency departments.
In response to this high volume, the OIG will investigate whether diagnostic radiology interpretations and reports (x-rays, computed tomography [CTs], and magnetic resonance imaging [MRI]) contributed to the diagnoses and treatments of beneficiaries receiving care in EDs.
Billing of Portable X-Ray Suppliers. Providers of portable x-ray services with unusual billing patterns will be reviewed to identify those that merit additional scrutiny, and the OIG will identify questionable Medicare claims. This will include the four components for which suppliers are paid: technical, professional, setup, and transportation.
Independent Diagnostic Testing Facilities (IDTFs). How well do IDTFs enrolled in Medicare comply with selected Medicare standards? That's the question the OIG hopes to answer by reviewing selected IDTFs.
The Code of Federal Regulations (Title 42, §410.33) requires IDTFs to certify on their enrollment applications that they comply with 17 specific standards. As required, they must:
Comply with all of the federal and state licensure and regulatory requirements that are applicable to the health and safety of patients;
Provide complete and accurate information on their enrollment applications; and
Have on duty technical staff members who hold appropriate credentials to perform tests.
In addition to checking compliance with Medicare's standards, the OIG also will identify billing patterns.
Brachytherapy Payments. OIG will continue to review payments for brachytherapy (a form of radiotherapy where a radiation source is placed inside or next to the area requiring treatment). Its mission is to determine whether the payments are in compliance with Medicare requirements.
Jeff Majchrzak, BA, RT(R), RCC, CNMT, CIRCC, Vice President, Radiology Services is a nationally renowned radiology coding authority, Jeff has amassed an incredible breadth and depth of experience, both in the healthcare setting and in the field of consulting. His real-world experience includes work in the radiology and nuclear medicine departments of several public and private hospitals. www.medlearn.com