New HHS OIG Work Plan – Same Old Stuff for Ambulance Services

The Office of the Inspector General for the Department of Health and Human Services issued the FY 2013 Work Plan today.  The Work Plan only has one specific reference to Ambulance Services; basically it is a repeat of last year’s offering:

Ambulances—Compliance With Medical Necessity and Level-of-Transport Requirements
We will examine Medicare claims data to identify questionable billing for ambulance services such as transports that were potentially not medically reasonable and necessary and potentially unnecessary billing for Advanced Life Support Services and specialty care transport. We will also examine relationships between ambulance companies and other providers. Medicare pays for emergency and nonemergency ambulance services when a beneficiary’s medical condition at the time of transport is such that other means of transportation are contraindicated (i.e., would endanger the beneficiary). (Social Security Act, § 1861(s)(7).) Medicare pays for different levels of ambulance service, including Basic Life Support and Advanced Life Support as well as specialty care transport. (42 CFR § 410.40(b).) (OEI; 09-12-00351; expected issue date: FY 2012; new start; and OAS; W-00-11-35574; W-00-12-35574; various reviews; expected issue date: FY 2013; work in progress)

Some related general sections after the jump.

Some other areas to pay attention to that may impact Ambulance Services:

Physicians and Other Suppliers—Noncompliance With Assignment Rules and Excessive
Billing of Beneficiaries
We will review the extent to which physicians and other suppliers fail to comply with assignment rules and determine to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare. We will also assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines. Physicians participating in Medicare agree to accept payment on “assignment” for all items and services furnished to individuals enrolled in
Medicare. (Social Security Act, § 1842(h)(1).) CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician or other supplier in return agrees to accept the Medicare-allowed amount indicated by the carrier as the
full charge for the items or services provided. (OEI; 07-12-00570; expected issue date: FY 2014; work in progress)

Medicare and Medicaid Security of Portable Devices Containing Personal Health
Information at Contractors and Hospitals
We will review security controls implemented by Medicare and Medicaid contractors as well as hospitals to prevent the loss of protected health information (PHI) stored on portable devices and media, such as laptops, jump drives, backup tapes, and equipment considered for disposal. Recent breaches related to
Federal computers, including one involving a CMS contractor, have heightened concerns about protecting sensitive information. We will assess and test contractors’ and hospitals’ policies and procedures for electronic health information protections, access, storage, and transport. OMB recommended that all Federal departments and agencies take action to protect sensitive information by following the National Institute of Standards and Technology’s Special Publications 800-53 and 800-53A.
(OMB Memorandum M-06-16, issued June 23, 2006.) (OAS; W-00-12-41014; various reviews; expected issue date: FY 2013; work in progress)

Medicare Integrity Program—CMS’s Overall Strategy (New)We will review CMS’s overall strategy to maintain the integrity of the Medicare. The Medicare
Integrity Program (MIP) was established through 42 U.S.C. § 1395ddd and requires CMS to contract with entities to carry out various program integrity activities to safeguard against fraud, waste, and abuse in Medicare Parts A and B. Over the past few years, Congress has submitted multiple letters to CMS questioning the effectiveness of the program integrity efforts of these contractors. We will also determine how CMS allocates funds for MIP activities and review the measures CMS uses to evaluate the performance and overall effectiveness of the MIP. (OEI-03-12-00690; expected issue date: FY 2013 work in progress)

Comprehensive Error Rate Testing Program—Fiscal Year 2012 Error Rate Oversight
We will review certain aspects of the CERT Program to evaluate CMS’s efforts to ensure the accuracy ofthe FY 2012 error rate and to reduce improper payments. Through CERT, national, contractor-specific, and service-type error rates are computed. The CERT program’s national estimated improper payments for FY 2011 were $28.8 billion (8.6 percent-error rate). In November 2003, CMS assumed responsibility for estimating and reporting improper Medicare FFS payments and national error rates. The CERT Program was established by CMS to meet the requirements of the Improper Payments Elimination and Recovery Improvement Act of 2011 (IPERA) and to monitor the accuracy with which Medicare claims are billed and paid. (CMS’s Medicare Program Integrity Manual, Pub. 100-08, ch. 12.) Effective August 1, 2008, the CERT program also samples inpatient records, replacing the Hospital Payment Monitoring Program. (OAS; W-00-13-40048; various reviews; expected issue date: FY 2013; new start)

Exclusions From Program Participation
OIG may exclude individuals and entities from participation in Medicare, Medicaid, and all other Federal health care programs for many reasons, some of which include program-related convictions, patient abuse or neglect convictions, licensing board disciplinary actions, or other actions that pose a risk to beneficiaries or programs. (Social Security Act, § 1128, § 1156, and other statutes.) Exclusions are generally based on referrals from Federal and State agencies. We work with these agencies to ensure the timely referral of convictions and licensing board and administrative actions. In fiscal year (FY) 2011, OIG excluded 2,662 individuals and entities from participation in Federal health care programs. The total for FY 2012 will be published in OIG’s Fall FY 2011 Semiannual Report to Congress. Searchable exclusion lists are available on OIG’s Web site at:

Provider Compliance Training
In spring 2011, OIG and its government partners provided in-person provider compliance training in Houston, Tampa, Kansas City, Baton Rouge, Denver, and Washington, D.C. The sessions focused on the realities of Medicare and Medicaid fraud and the importance of implementing an effective compliance program. To expand access to providers nationwide, we broadcasted a free online live Webcast of the May 18 training in Washington. These and other training materials are available on OIG’s Provider Compliance Training Web site along with corresponding slides and written handouts. Also available are 13 educational video and audio podcasts covering various topics to help prevent fraud, waste, and
abuse. Our provider compliance training effort continues.

Medicare Strike Force Teams and Other Collaboration
OIG devotes significant resources to investigating Medicare and Medicaid fraud. We conduct investigations in conjunction with other law enforcement entities, such as the Federal Bureau of Investigation (FBI), the United States Postal Inspection Service, the Internal Revenue Service (IRS), and State Medicaid Fraud Control Units (MFCU). The Health Care Fraud Prevention and Enforcement Action Team (HEAT) was started in 2009 by the Department of Health and Human Services (HHS) and DOJ to strengthen programs and invest in
new resources and technologies to prevent and combat health care fraud, waste, and abuse. Using a collaborative model, Medicare Fraud Strike Force teams coordinate law enforcement operations among Federal, State, and local law enforcement entities. These teams, now a key component of HEAT, have a record of successfully analyzing data to quickly identify and prosecute fraud. The Strike Force teams were formed in March 2007 and are operating in nine major cities. The effectiveness of the Strike Force model is enhanced by interagency collaboration within HHS. For example, we refer credible allegations of fraud to CMS so it can suspend payments to perpetrators. During Strike Force operations, OIG and CMS work to impose payment suspensions that immediately prevent losses from claims submitted by Strike Force targets.

• OIG investigates individuals, facilities, or entities that, for example, bill or are alleged to have billed Medicare and/or Medicaid for services not rendered, claims that manipulate payment codes to inflate reimbursement amounts, and false claims submitted to obtain program funds.
• We also investigate business arrangements that allegedly violate the Federal health care antikickback statute and the statutory limitation on self-referrals by physicians.
• OIG also examines quality-of-care issues in nursing facilities, institutions, community-based settings, and other care settings and instances in which the programs may have been billed for medically unnecessary services, for services either not rendered or not rendered as prescribed, or for substandard care that is so deficient that it constitutes “worthless services.”
• Other areas of investigation include Medicare and Medicaid drug benefit issues and assisting CMS in identifying program vulnerabilities and schemes, such as prescription shorting (a pharmacy’s dispensing of fewer doses of a drug than prescribed, charging the full amount, and then instructing
the customer to return to pick up the remainder).

Working with law enforcement partners at the Federal, State, and local levels, we investigate schemes to illegally market, obtain, and distribute prescription drugs. In doing so, we seek to protect Medicare and Medicaid from making improper payments, deter the illegal use of prescription drugs, and curb the danger associated with street distribution of highly addictive medications. We assist State MFCUs to investigate allegations of false claims submitted to Medicaid and will continue to strengthen coordination between OIG and organizations such as the National Association of Medicaid Fraud Control Units and the National Association for Medicaid Program Integrity. Highlights of recent enforcement actions to which OIG has contributed are posted to OIG’s Web site at:


One Response to New HHS OIG Work Plan – Same Old Stuff for Ambulance Services
  1. Rodney Johnson
    November 21, 2012 | 12:15 am

    Thank you for the information. I am working to make a change in Oklahoma. We should talk some time. I bet I could learn a lot. Thanks again.