Physician Activity Now Under OIG Scrutiny: Revenue Impacts

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) routinely issues new Work Plan items. This year, the OIG has added two items to the Work Plan that directly impact physicians and their practices.

In December 2017, the OIG added an item focused on looking at financial relationships reported to the Open Payments Program. This project is focused on looking at what types of payments to physicians have been reported and determining if the payments have influenced the manner in which physicians practice. Specifically, the OIG is interested in whether incentives from pharmaceutical and device manufacturers have directly impacted what types of medications are prescribed and what types of devices are utilized in the care of patients. Of particular concern for the OIG is the potential that the influence of these incentives has resulted in negative impacts to patient care. This information will likely be aggregated and utilized to review claims filed by physicians to determine if there was a marked shift in prescribing or utilization patterns after receipt of incentives — whether monetary or non-monetary. As the Open Payments data is publically posted, it is recommended that physicians periodically review the information reported to the Open Payments database to verify accuracy. Physicians who note that incentives have been reported may wish to consider evaluating their practice patterns.

In July 2018, the OIG added an item focused on review of post-operative services in the global surgery period. The OIG is going to utilize the required reported data of the number of services provided in a global period to compare to claims data. Within the scope of this project, it is likely that the OIG will include a review of claims filed within the global surgery period that were inappropriately separately paid. Surgeons should be prepared to respond to inquiries as this review commences. Additionally, surgical practices may wish to conduct a proactive review of surgical cases to confirm that claims filed within the global period were appropriately coded to have prevented the receipt of a duplicate payment.

While the two above work plan items are relatively new, and are among the first few items to directly target physician practices and physician billing and coding, they will not be the last. Physician practices should consider conducting routine coding and documentation audits. Targeted reviews are recommended when the OIG issues a work plan item applicable to your practice. Proactive risk management of these areas will facilitate compliant coding and billing practices and reduce the risk of recoupments and the associated penalties and interest.

Shawn Stevison, CPA, CHC, CRMA, CGMA, Associate Director of Healthcare Consulting at Dean Dorton Allen Ford, PLLC. She can be reached at: sstevison@ddafhealthcare.com