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Breaking it down: Analysis of 2011 OIG Work Plan (Medicare Part B) Print E-mail
Written by Benjamin L. Frosch   
Friday, 03 December 2010 11:04


With a few thousand staff members throughout the United States, the Office of Inspector General (OIG) plans and performs audits, investigations, evaluations, and legal activities pertaining to the Department of Health and Human Services (HHS).   With the Issuance of the 2011 OIG Work Plan there are a variety of important Medicare issues that they will evaluate pertaining to Medicare physicians and other health care providers.  This may be a good opportunity to evaluate compliance in your practice with respect to the following Part B subjects that are in the work plan. With a variety of federal agencies looking closer at Medicare fraud and abuse than ever before, it is very clear that there is a zero tolerance for Medicare fraud and abuse. The following is a list of what I think are some of the hottest "subjects" targeted in the 2011 OIG Work Plan:


This is definitely going to be a subject under the microscope in 2011 and beyond.  The OIG is going to review Evaluation and Management (E&M) claims to identify issues in the coding of E&M services. Medicare paid $25 Billion dollars for E&M services in 2009 which represents 19% of all Medicare Part B payments. They will also be reviewing the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations by Medicare contractors.

Also Medicare contractors throughout the United States have noted an increase in the frequency of medical records with identical documentation across services. The OIG plans to review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.


The OIG has decided to continue reviewing physician coding of place of service on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments. Federal regulations provide for different levels of payment to physicians depending on where the services are performed.  Medicare pays a physician a higher amount when a service is performed in a non-facility setting such as a physician office than it does when a service is performed in a hospital outpatient department or, with certain exceptions, in an ASC.  The OIG will continue to evaluate whether physicians properly coded the place of service on claims provided in ASC's and hospital outpatient departments.


As we can all see E&M services are absolutely under the microscope. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E&M services provided during the global surgery period. The OIG will evaluate whether medical practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.


Diagnostic tests will be under scrutiny in 2011 and beyond.  The OIG will review Medicare payments for high cost diagnostic tests to determine whether they were medically necessary. The Social Security Act provides that Medicare will not pay for items or services that are "not reasonable and necessary". The OIG will address the extent in which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.   However, there will be other OIG issues for diagnostic tests. Physicians  are  paid  for services  pursuant  to  the  Medicare  physician  fee  schedule,  which  covers  the major  categories  of  costs,  including  the  physician  professional  cost component,  malpractice  costs,  and  practice  expense.  The  Social  Security Act, §  1848(c)(1)(B),  defines  "practice  expense"  as  the  portion  of  the resources used  in  furnishing  the  service  that  reflects  the general  categories of expenses,  such  as  office  rent, wages  of  personnel,  and  equipment.  Certain imaging services will be under focus with respect to the practice expense components. The OIG will determine whether Medicare  payments  for  Part B Imaging reflect the expenses incurred  and  utilization  rates.   


While there is no doubt that the Florida is a geographic area with a high density of IDTF's, the OIG will be reviewing services and billing patterns in areas such as Florida due to high concentrations of IDTF's.   IDTFs must meet regulatory performance requirements in accordance with 42 CFR to obtain and maintain Medicare billing privileges. In 2006, the OIG concluded that there were numerous problems with IDTF's including non-compliance with Medicare standards and potential improper payments of over $70 million dollars. This issue leads into;


The OIG is going to select certain IDTF'S that are enrolled in Medicare to determine the extent in which they comply with the ITDF Medicare standards. IDTF's received payments of almost $900 million dollars in 2009. Federal regulations require IDTF's to certify on their enrollment application that they comply with the seventeen CMS standards.  Such standards include requirements that IDTF's comply with all federal and state licensure and regulatory requirements that are applicable to the health and safety of patients, provide complete and accurate information on their Medicare enrollment application, and have the appropriate technical staff and physicians who are proficient with respect to the tests they perform.


The OIG will evaluate if outpatient physical therapy services provided by independent therapists are in compliance with Medicare reimbursement regulations and guidelines. Previous OIG work plans have identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented.  They will focus on independent therapists who have a high utilization rate for outpatient physical therapy services and will determine whether the services that were billed to Medicare were in accordance with federal requirements.   Florida once again is one of the highest areas in the United States when it comes to providing physical therapy to Medicare beneficiaries compared to the other regions of the country.


There is a concern pertaining to the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel test to maximize Medicare payments. The OIG will look into whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing specimens on sequential days.  The OIG will also be looking at trends in laboratory utilization. In 2008, Medicare paid about $7 Billion dollars for clinical laboratory services which represent a 92% increase from 1998.


The OIG is going to take a look at the appropriateness of Medicare payments for sleep test procedures that are provided at sleep disorder clinics. A preliminary OIG review identified improper payments when modifiers are not reported for sleep test procedures. The OIG will examine Medicare payments to physicians and Independent Diagnostic Testing Facilities for sleep test procedures to determine whether they were in accordance with Medicare requirements. 


I think we can all understand why the OIG will take a look at this issue. They plan on reviewing Medicare claims with dates of service after a beneficiary's date of death to assess CMS controls to preclude or identify and recover improper payments. CMS uses several computer database systems that interface with  death  information  on  the  Social  Security  Administration's  and  the  Railroad  Retirement  Board's  systems.  

About the author:  Mr. Frosch is President of FROSCH MEDICAL CONSULTANTS, INC. in Plantation, FL.


Last Updated on Sunday, 14 August 2011 16:58
MEDICARE Q&A: Fall Update Print E-mail
Written by Benjamin L. Frosch   
Wednesday, 22 September 2010 21:40

Q:   I am an Administrator at a Cardiology practice that is purchasing an ultrasound machine and radiology equipment to perform procedures in our office.  We will satisfy the necessary supervision requirements with a non-radiologist, however, we will have a radiologist perform the professional interpretation off-site.  If we hire the radiologist on a part-time basis, will our group practice be allowed to bill Medicare globally for the procedures?  If not, under what circumstances can we bill globally?


Cardiology Practice

A:   There are many issues that have to be considered in your scenario.  If the radiologist is performing the professional interpretation off-site and is a purchased service, the CMS purchase interpretation rules would come into play.  The rules states: an entity that provides diagnostic tests may submit the claim and receive the Part B payment for diagnostic test interpretations which that entity purchases from the independent physician if;

  • The tests are initiated by a physician or medical group which is independent of the person or entity providing the test and of the physician or medical group providing the interpretations;
  • The physician or medical group providing the interpretation does not see the patient; and
  • The purchaser performs the technical component of the test.  The interpreting physician must be enrolled in the Medicare program and no formal reassignment is necessary.
  • The purchaser must keep on file the name, the provider identification number, and the address of the interpreting physician.

The first bullet above states that the test has to be" initiated" by a physician or medical group which is independent of the person or entity providing the test. In simple words, that means if you "ordered" the ultrasound and purchased the interpretation, you would not be able to bill Medicare globally.

With respect to the physician working on a part-time basis in lieu of purchasing the services, you may have an issue with the Stark regulations or even some state laws. The radiologist may be required to provide these interpretations on the site of your practice. You may want to check with a seasoned healthcare attorney to assure that you comply with all of these complex rules, regulations, and guidelines.

Q:  I just received a letter from Medicare informing me of a substantial overpayment. My staff researched this issue and we concluded they are correct with the overpayment determination.  The letter we received states that it is a follow-up letter. I never received the initial notification of an overpayment from Medicare.  My question addresses the interest on this overpayment.  What are the rules on Medicare assessing interest on an overpayment?


Ft. Lauderdale, Fl

A:  Medicare does not charge interest on overpayments that are received within thirty-days.  After the thirty day period, interest is assessed for the first thirty-day period and an additional thirty-day period.  Interest continues to accrue for each subsequent thirty-day period for which payment is not received by Medicare.   When money is offset (withheld from Medicare payments), it is applied to the accrued interest first and then to the principal.   The follow-up overpayment letter probably does not imply you have another thirty-day period to refund the amount nor does it prevent Medicare from withholding future payments after the thirty-day period has elapsed.  If you do not refund the overpayment within forty-days from the date of the initial refund request letter, Medicare may initiate offsets and pursue other efforts of recovery of the indentified overpayment.

The bottom line is, once you receive notification of the overpayment; return the monies as quickly as possible.  The overpayment is considered a debt owed to the United States Government and you can always appeal if you feel that Medicare is incorrect with the allegations of the overpayment or the interest payment.  

Q:  I own and operate a multi-modality Independent Diagnostic Testing Facility (IDTF).   I want to take advantage of the weak real estate market and relocate my facility to a nearby site with better street frontage and other amenities.  My administrator warned me that the move will require recertifying our provider number and may hold up Medicare reimbursements for up to six months.   Is my administrator correct about recertification and could it really delay payments for six months?    


Orlando, FL

A:  In accordance with the Medicare IDTF Standards,  changes in ownership, changes of location, changes in general supervision, and adverse legal action must be reported to Medicare Provider Enrollment within thirty-days of the change.  Should you change your location, it should not delay or hold up your Medicare reimbursement. There is a possibility that you would be required to revalidate, but that is based on other rules. All Medicare providers must revalidate every 5 years. Should you move and be required to revalidate, it would not impact your reimbursement during the process.  Should you submit the proper CMS 855 documents for only change of location, this action would also have no impact on your Medicare reimbursement.

About the author:  Mr. Frosch is the President of Frosch Medical Consultants in Plantation FL

Last Updated on Sunday, 14 August 2011 16:55
The Nine Deadly Sins of Fraud and Abuse in a Physician Practice Print E-mail
Written by Benjamin Frosch   
Sunday, 29 August 2010 12:25

In today's health-care climate, the mere hint of impropriety can lead to investigations and/or sanctions with respect to fraud and abuse. The following are nine "sins" or traps that can put a physician smack in the middle of a government false claims allegation:

1. Continue to take your time and/or ignore billing inquiries by patients or family members.

Don't make this foolish mistake. Take every phone call and inquiry pertaining to billing from patients seriously. Remember, every Medicare beneficiary gets an Explanation of Medicare Benefits (EOMB) that includes toll-free numbers to report allegations of fraud and abuse.

2. Make a foolish decision to "complete" your medical records after you've received an audit notice from Medicare or Medicaid. 

Changing and altering medical records are both illegal and unethical unless you clearly note that the change is an addendum to the original record. Then, at a minimum, record the date you entered this change or added additional information to the medical record.  Clearly make sure that Medicare and or Medicaid is aware of your modification and when it occurred.

3. Rely on information that “Charlene" at Medicare told you.   

Now that you've verbally received billing information from "Charlene" at Medicare customer service, create a paper trail confirming the information. Document the phone call and ask Charlene where you can find the information she advised you was published, i.e., in Medicare websites, Medicare bulletins, or other literature. It's a good idea to document every call you make to Medicare. Include the issue, who you spoke to, the date and time. Do not just take her word for it. Confirm her information before billing Medicare.

4. Permit staff to re-bill all denied services for medical necessity by resubmitting a "covered" ICD-9 code without any documented clinical reason.  

This policy speaks for itself and if caught could become a nightmare. Especially when your billing staff is telling government agents it was your idea.

5. Bill for someone else's services under your provider number without full compliance of the "incident to" provision.  

With respect to physician assistants, nurse practitioners or medical assistants, there is very strict and to-the-point criteria for billing services rendered "incident to" by these individuals under your provider number. Billing hospital visits performed by your PA or ARNP under your provider number is a big no-no. The "incident to" provision was not intended for the hospital setting. If it is a true "shared visit”, the services must be medically necessary.

6. Be proud of your compliance violations. 

Brag in the doctors' lunchroom about billing all of your E&M service as level four and five visits or submitting false diagnoses to get claims paid. Some colleagues within hearing shot may get angry and advise the government of your excellent billing skills.

7. Keep purchasing diagnostic services and marking them up without letting the carrier know. 

This can cause serious problems as Medicare regulation strictly prohibits marking up purchased diagnostic services. Additionally, Medicare issued regulations and guidelines that clearly indicate how the claim is to be submitted. You must indicate on the claim what the cost of the purchased service was (to avoid a mark up), who you purchased the technical component from and meet other requirements. There are also strict rules for billing purchased interpretations. Make sure you comply with all the Medicare rules when billing globally for an interpretation you did not perform 

8. Become a  Medical Director of a  Home Health Agency, Durable Medical equipment Company, or any other Designated Healthcare Service that you refer heavily to.

Make sure you are paid exceptionally well and have no documentation demonstrating your "Medical Director" services. Most important never have seasoned healthcare lawyers review these types of Medical Director relationships or other arrangements.

9. Now that Lebron James, Dwayne Wade, and Chris Bosh are all on the Miami Heat, feel comfortable taking those great (and expensive) Miami Heat playoff tickets from healthcare providers you refer to.

After all, who would ever think that those tickets are related to your referring patients to them? You will just tell the OIG agents that you only refer patients based on "quality" and those tickets would never skew your judgment.


Benjamin Frosch is President of Frosch Medical Consultants, Inc. in Plantation, FL.


Last Updated on Saturday, 04 May 2013 15:22
MEDICARE Q&A: Mid-Summer Update Print E-mail
Written by Benjamin L. Frosch   
Sunday, 25 July 2010 13:48

Q:   I am a solo practitioner who specializes in cardiology.  One of the tests that I perform in my office is echocardiography.   During very busy periods, I may not provide a full interpretation and report of my echocardiograms for a few months.  I understand that I cannot bill Medicare until the service is complete and therefore wait until I have provided a full interpretation and report.  As a result, I may not bill Medicare for those services for over a year period.  Has there been a change with respect to the time period of submitting claims to Medicare?


Tampa, FL

A:  As a result of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) will only pay for claims with dates of service on or after January 1, 2010 up to a year. Claims received later than one calendar year beyond the date of service will be denied by Medicare.  Therefore, you should not submit claims to Medicare that are more than one year old.  

Another point that you should consider is that by taking so much time to interpret these echocardiograms, Medicare could take the position that these services were not medically reasonable and necessary in treating and managing the patient.   So even if you submit claims for echocardiography on or after January 1, 2010 and forward them to Medicare months after performing the echocardiogram, you may still have an issue pertaining to why you waited so long to interpret those echocardiograms. 


Q: We have a Locum Tenens physician who next week will be with us for sixty days.  It is our understanding that sixty days is the Medicare "cutoff" for a locum tenens physician which allows us to use the Q6 modifier.   The provider enrollment process is very cumbersome and I was wondering that once our Locum Tenen physician reaches the sixty day period, can the Locum Tenens Physician take a day off and the sixty day Medicare period begin again?

Office Manager

Palm Beach, Fl

A:     If the regular physician requires services of a Locum Tenens physician for a period longer than sixty days, the substitute physician needs to enroll with the group practice.   The Locum Tenen physician should complete a CMS 855R reassigning his/her benefits to the practice.   Otherwise, the substitute physician "taking a day off" is not a consideration in the Medicare guidelines of Locum Tenens for establishing the sixty day period.  

CMS guidelines state that a regular physician may bill for the services of a Locum Tenens physician providing that the following guidelines are met:

A.    The regular physician is unable to provide visit services.

B.   The substitute physician does not provide services over a continuous period longer than sixty-days.

C.    The Medicare beneficiary has arranged for or seeks to receive services from the regular physician.

D.    The regular physician pays the Locum Tenens for services on a per diem or similar fee for time basis


Q:  I am a non-participating surgeon. I performed a surgery on a Medicare beneficiary that was very complex and time consuming.   Because the claim was submitted unassigned, the beneficiary received the payment which was very low for the surgery performed. The patient is elderly and would have difficulty filing an appeal.  Can I file the appeal on behalf of the beneficiary?


South Florida

A:  Yes,under certain circumstances. The beneficiary may complete an appointment of representation form (CMS 1696) which can be found at  This form is used to authorize an individual to act as a beneficiary's representative in connection with a Medicare appeal. As a representative, you would be able to help your Medicare patient during the processing of the claim and any subsequent appeals.


Q:  We tried to provide our patients with the highest quality of care. For our established patients, we have started to treat them on an "emergency" basis after hours at our office.  Is it necessary for us to attach modifier 25 (indicating a significant, separately identifiable E/M visit on the same date as another procedure) to our follow-up visits in order to additionally bill Medicare procedure code 99058 (services provided on an emergency basis in the office, which disrupts other scheduled office services in addition to basic service)?

Office Manager

Boca Raton, Fl

A:   CPT code 99058 is not a recognized service that is billable to the Medicare program.   The E&M follow-up visits will have to be billed according to the actual level of care that is provided to the patient.  There is no additional reimbursement by Medicare for disruption of other scheduled services or after hour services in your office.     



Last Updated on Sunday, 14 August 2011 14:11
Medicare Q&A: Early Summer Update Print E-mail
Written by Ben Frosch   
Monday, 05 July 2010 15:01


Q:  We are a group practice that uses non-physician providers such as physician assistants and nurse practitioners.  We still are unclear pertaining to appropriate billing of spilt/shared visits between a physician and non-physician practitioner.   Using Medicare guidelines can you define a split/shared visit and provide an example?

Administrator, Medical Practice

Broward County, FL

A:  According to Medicare guidelines, a spilt/shared visit is a medically necessary encounter with a patient where the physician and qualified non-physician practitioner such as a physician assistant or nurse practitioner each performs a substantive portion of the evaluation and management visit, face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, examination, and medical decision making components of the E/M service.   Simply signing off on the non-physician provider's note does not meet the criteria for a spilt/shared visit.

An example of a spilt/shared visit is a hospital inpatient E/M service that is shared between the physician and non-physician provider.  In this scenario the non-physician provider  and the physician both provide components face-to-face of the E/M encounter with the patient at separate times during the day.  This service may be billed under the physician or the non-physician provider's National Provider Identifier (NPI).

Q:  I understand that direct supervision is required to comply with "Incident-to" provision".  If a physician is in the suite, can an initial/new patient visit be billed under the physicians NPI when the service is completely provided by a nurse practitioner?


Fort Lauderdale, FL

A:  The main requirements for a provider to bill "Incident-to" are as follows:

·The services are an integral, although incidental, part of the physician's professional service;

·The service is commonly rendered without charge or included in the physician's bill;

·the service is furnished in the physician's office under the physician's direct supervision;

In order for the service to qualify as "incident-to", an initial office visit must have occurred between the physician and the patient, and a course of treatment is established by the doctor.  In the initial office visit you describe, the services are performed by the non-physician provider and do not meet the "incident-to" requirements although you are available in the suite.   You never saw the patient and therefore cannot have a plan of treatment.   Therefore, the non-physician provider would need to bill this initial encounter under their NPI number.

Q:   I employ two nurse practitioners and provide nursing home visits throughout Palm Beach County.  Can the nursing home visits provided by nurse practitioners be billed as "incident-to", a supervising physician as long as the physician is also in the facility seeing patients? 

General Practice

Palm Beach, FL

A:  The "incident-to" provision does not apply to institutional settings such as hospitals and nursinghomes. It is possible in the hospital setting for the physician and nurse practitioner to provide a shared/ spilt visit and bill it under the physicians NPI number if all the guidelines are met. Shared visits rendered in the nursing home cannot be billed to Medicare.   The only exception to this is when the physician is renting space from the nursing home and has his/her own office within the facility. In this scenario; the office space must be confided to a separately identifiable part of the facility.  Your staff may provide services in the office to out-patients and meet all of the components of the "incident-to" provision including direct supervision in order to bill under your NPI.   In the event that your non-physician provider employee provides these services outside of the office area, these services would not qualify as "incident-to" 

Q:  Last week, a patient of mine was diagnosed with hypertension and placed on a regiment of medication and diet.  I also wrote in my plan of treatment that the patient should be seen times-three (x3) in the office by my physician assistant to access the patient's progress.  I understand that if I am available and provide direct supervision, that this service can be billed under my NPI.   If I am not in the office when the service occurs but my partner is in the office, is the physician assistant visit eligible for "incident-to" billing?

Internal Medicine

Miami, FL

A:  Yes, the physician assistant visit is eligible for "incident to" billing. According to Medicare's guidelines, direct physician supervision in a clinic or office may be the responsibility of several physicians, as opposed to an individual attending physician. The physician who initiates the course of treatment doesn't need to be the same physician who oversees the physician assistant performing an incidental service.  The service you described may be billed under your partner's NPI who is physically in the office suite and providing direct supervision at the time of the service.

Benjamin L. Frosch, is the President of  Frosch Medical Consultants, Inc. in Plantation, FL

Last Updated on Sunday, 14 August 2011 16:56
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