The Department of Health and Human Services Office of Inspector General (OIG) recently released a report on Medicare's improper payments to physicians for co-surgery and assistant-at-surgery services. The report, conducted by the Office of Audit Services (OAS), found that Medicare made overpayments of $1.1 million for the audit period of calendar years 2017 through 2019 due to noncompliance with Federal requirements. The OIG's statutory mission is to safeguard the integrity of HHS programs and the well-being of beneficiaries served by those programs. Through a nationwide network of audits, investigations, and inspections, the OIG aims to reduce waste, abuse, and mismanagement, as well as promote economy and efficiency throughout HHS. This report highlights the importance of ensuring the proper use of Medicare funds and protecting the interests of program beneficiaries.
Key Findings of the Report
Impact of Medicare Improper Payments on Healthcare System
The OIG's report on Medicare's improper payments to physicians for co-surgery and assistant-at-surgery services provides valuable insights into the need for effective controls to prevent improper payments. The audit conducted by the OAS covered $15.4 million in Medicare Part B payments for services performed during calendar years 2017 through 2019. The audit focused on cases in which two different providers separately billed an identical procedure code for the same beneficiary and on the same day. The OAS selected a stratified random sample of 100 services for review that were billed by one of the providers from the sampling frame without a co-surgery or assistant-at-surgery modifier. The OAS also identified and reviewed 127 corresponding services that were billed by providers with the same procedure code for the same beneficiary on the same day as the sampled services.
The OAS used the OIG/OAS statistical software to estimate the improper co-surgery payments, improper assistant-at-surgery and duplicate service payments, and overall improper payment amounts in the sampling frame. The OAS calculated the point estimate and the corresponding two-sided 90-percent confidence interval for each of these estimates. From the 100 statistically sampled services, the OAS found that 69 did not comply with Federal requirements. These noncompliant services resulted in overpayments of $1.1 million for the audit period.
The OIG's report highlights the importance of implementing effective controls to prevent improper payments. Medicare's co-surgery and assistant-at-surgery payment policies are designed to ensure that physicians are reimbursed appropriately for their services. However, the OIG's findings suggest that these policies are not always followed, resulting in overpayments and potential waste of Medicare funds. The report emphasizes the need for Medicare to implement effective controls to prevent improper payments and ensure that physicians are billing for co-surgery and assistant-at-surgery services with the appropriate payment modifiers.
The OIG's report also underscores the importance of ongoing monitoring and oversight to ensure that Medicare payments are made only for services that are reasonable and necessary.
The OAS's audit identified a significant number of noncompliant services, indicating that there may be a need for additional education and training for physicians and billing staff. Medicare must continue to monitor its payment policies and procedures to ensure that they are effective in preventing improper payments and protecting the interests of program beneficiaries.
In conclusion, the OIG's report on Medicare's improper payments to physicians for co-surgery and assistant-at-surgery services highlights the need for effective controls to prevent improper payments. The report's findings underscore the importance of ongoing monitoring and oversight to ensure that Medicare payments are made only for services that are reasonable and necessary. Medicare must continue to work to improve its payment policies and procedures to protect the interests of program beneficiaries and ensure the proper use of Medicare funds.
The OIG's Operating Components
Analyzing the Causes of Medicare Improper Payments
The Office of Inspector General (OIG) operates through a nationwide network of audits, investigations, and inspections aimed at promoting economy and efficiency throughout the Department of Health and Human Services (HHS) and reducing waste, abuse, and mismanagement. The OIG's operating components play crucial roles in fulfilling its statutory mission to protect the integrity of HHS programs and the health and welfare of beneficiaries.
The Office of Audit Services (OAS) is responsible for providing auditing services for HHS, either by conducting audits with its own resources or by overseeing audit work done by others. OAS audits examine the performance of HHS programs, grantees, and contractors to provide independent assessments and help reduce waste, abuse, and mismanagement.
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. OEI reports also present practical recommendations for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. OI's investigative efforts often lead to criminal convictions, administrative sanctions, and civil monetary penalties, actively coordinating with law enforcement authorities to protect the integrity of HHS programs.
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and operations. OCIG represents OIG in civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. OCIG also provides guidance to the health care industry concerning OIG enforcement authorities.
The OIG's operating components collectively contribute to the OIG's efforts to ensure the integrity of HHS programs and the well-being of beneficiaries, promoting economy and efficiency while reducing waste, abuse, and mismanagement.
CMS Response to the Report
Strategies to Address Medicare Improper Payments
In response to the OIG's report on Medicare's improper payments to physicians for co-surgery and assistant-at-surgery services, the Centers for Medicare & Medicaid Services (CMS) has acknowledged the importance of providing people with Medicare access to medically necessary services while protecting the Medicare Trust Funds from improper payments. CMS has emphasized its commitment to ensuring that Medicare payments are made only for services that are reasonable and necessary, reflecting its dedication to upholding the integrity of the Medicare program.
CMS has outlined initiatives aimed at preventing improper payments, such as the Comprehensive Error Rate Testing program and the Targeted Probe and Educate program. These initiatives demonstrate CMS's proactive approach to identifying and addressing improper payments, ensuring that Medicare funds are used appropriately and that beneficiaries receive the necessary care.
Recommendations and Future Steps for Medicare Compliance
The response from CMS underscores the agency's commitment to addressing the issues identified in the OIG's report and implementing measures to prevent future improper payments. By working collaboratively with the OIG and other stakeholders, CMS aims to strengthen the integrity of the Medicare program and uphold its responsibility to beneficiaries and taxpayers alike.
In conclusion, the OIG's report on Medicare's improper payments to physicians for co-surgery and assistant-at-surgery services highlights the need for effective controls to prevent improper payments. The report's findings underscore the importance of ongoing monitoring and oversight to ensure that Medicare payments are made only for services that are reasonable and necessary. The OIG's operating components play crucial roles in fulfilling its statutory mission to protect the integrity of HHS programs and the health and welfare of beneficiaries.
The report emphasizes the importance of implementing effective controls to prevent improper payments and ensuring that physicians are billing for co-surgery and assistant-at-surgery services with the appropriate payment modifiers. Medicare must continue to work to improve its payment policies and procedures to protect the interests of program beneficiaries and ensure the proper use of Medicare funds.
The response from CMS underscores the agency's commitment to addressing the issues identified in the OIG's report and implementing measures to prevent future improper payments. By working collaboratively with the OIG and other stakeholders, CMS aims to strengthen the integrity of the Medicare program and uphold its responsibility to beneficiaries and taxpayers alike.
In summary, the OIG's report highlights the importance of ensuring the proper use of Medicare funds and protecting the interests of program beneficiaries. The report's findings and recommendations provide valuable insights into the need for effective controls to prevent improper payments and promote the integrity of the Medicare program. By implementing these recommendations, Medicare can continue to provide high-quality care to beneficiaries while safeguarding the program's financial resources.
In light of the OIG's revealing report on Medicare Improper Payments, it's evident that meticulous attention to medical coding and billing compliance is more critical than ever. Navigating the complexities of Medicare regulations demands not only expertise but also a proactive approach to ensure accuracy and adherence to evolving standards. This is where our team at Coder on Call excels. With our deep understanding of medical coding intricacies and a steadfast commitment to precision, we offer services that not only mitigate the risk of improper payments but also optimize your billing processes. Partner with us to safeguard your practice against compliance pitfalls and to secure the financial health of your business. contact us today and get a consultation started - your trusted ally in navigating the ever-changing landscape of medical coding and billing