OIG 2013 Work Plan Targets New Areas of Investigation - Laboratories

Author: K. Jill Osmars

The Office of Inspector General (OIG) is the arm of the federal government that is charged with identifying, preventing and investigating fraud and abuse in Medicare and other federal programs.  Each year, the OIG publishes its Work Plan, which identifies the audits and investigations it intends to pursue during the year.

The OIG is authorized to impose monetary penalties against physicians and physician groups and may exclude individuals and medical groups from Medicare.  For these reasons, it is important for physicians to be aware of new trends in OIG enforcement activities as part of their compliance plans.

The 2013 Work Plan was published recently and identifies the following areas of interest:

Billing Characteristics and Questionable Billing:  The OIG will identify questionable billing for laboratory tests in 2010 in light of a 92 percent increase in the volume of tests ordered as compared to 1998.  Laboratories must obtain and retain all documentation sufficient to establish the medical necessity of the tests provided to beneficiaries.

Reasonableness of Medicare Payments:  As we have seen in California, Medicare will be turning its attention to the rates paid by Medicare for laboratory services.  The OIG will compare the rates paid by other public payors (Medicaid/Federal Employees Health Benefit Programs) for 20 specific laboratory tests.  The 20 tests represent the most frequently ordered for Medicare beneficiaries and the most costly paid by Medicare.

Glycated Hemoglobin A1C Tests: The OIG states that “it is not considered reasonable and necessary to perform a glycated hemoglobin test more often that every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines.”  The OIG will evaluate the various Medicare Administrative Contractors (MACs) to determine if the MACs are correctly screening for the frequency of this test.  A laboratory should audit and ensure that it has appropriate documentation of medical necessity for glycated hemoglobin A1C, particularly if performed with greater frequency than every 3 months for a beneficiary.

Laboratories should update their compliance plans and compliance programs to ensure the issues identified in the OIG’s 2013 Work Plan are being addressed. If the laboratory does not have a compliance plan and compliance program, adoption of such a program is well advised to ensure that the laboratory is not violating the various federal and state fraud and abuse laws.  If you have any compliance questions, please contact DSMW for review and advice.



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