Evaluation & Management Services
In 2009, Medicare spent nearly one fifth of its Part B payments on Evaluation and Management (E&M) Services. Providers are responsible for ensuring proper coding when submitting their claims. The OIG will review the E&M claims that have been submitted to determine if coding patterns vary by provider. Furthermore, the OIG will examine the "extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations" as a result of receiving multiple claims with identical documentation services. Finally, there will be an evaluation of whether or not the global surgery fee is still appropriate since the global surgery period's inception in 1992.
Currently, Medicare Part B pays for imaging services pursuant to the physician professional cost component, the malpractice costs, and the practice expenses. Practice expenses are resources used in furnishing the services (i.e., rent, personnel costs, equipment costs, etc.). The OIG will review whether the Medicare payments for practice expenses "reflect the expenses incurred and whether the utilization rates reflect industry practices." Furthermore, the OIG will review providers of portable x-ray services with unusual claim patterns.
The OIG will review the high-cost diagnostic tests to ensure that they were medically necessary by looking at the same diagnostic tests ordered by the primary care physician as well as the specialist. With respect to independent diagnostic testing facilities (IDTFs), federal regulations require compliance with 17 standards. The OIG will look at IDTFs to ensure compliance with all standards in addition to identifying billing patterns of non-compliant IDTFs.