WHERE IS THE GOVERNMENT GOING TO LOOK NEXT? CARE PLAN OVERSIGHT A LIKELY TARGET

Anticipating the next target of scrutiny by the Office of the Inspector General (OIG) is never easy. Under the theory that "where there is smoke, there is fire", one important indicator of what this agency intends to review may be the revealed through its audit activities. If these results are an accurate predictor, based on the findings of a recent audit of claims submitted to the Medicare program for "care plan oversight" services, the OIG appears to have identified a target for further investigation.

The OIG recently released the findings of its audit of the Medicare claims that were submitted by two physicians in Texas for care plan oversight ("CPO") activities. The agency reviewed a total of 236 GPO services for which these physicians had been paid during the twenty-four month period that ended December 31, 2002. According to the OIG, NONE of these services met the Medicare program's requirements. In 230 of these instances this agency concluded that the services had not been rendered; in the remaining 6 instances, there was no supporting documentation. As a consequence, the OIG concluded that the Medicare program had paid these physicians $15,897 in error. If the OIG's findings are upheld, these physicians will be required to repay this amount. Moreover, in light of the number of instances in which the OIG concluded the services were not rendered, it seems likely that the agency will be further scrutinizing these physicians' billing practices and considering further criminal, civil or administrative sanctions.

There are at least two lessons to be learned from this audit: First, the importance of timely and appropriate documentation that supports each claim submitted to the Medicare program or any other payer cannot be overemphasized. Second, based on the OIG's findings in this audit, it is likely that in the near future this agency will audit the claims of a number of physicians who submit claims for COP services, and Medicare carriers will begin to scrutinize these claims more closely. As a consequence, physicians who provide COP services should carefully review their documentation practices to ensure that in the event the OIG or another agency audits their claims for COP services, they will be able to demonstrate the fact that the services were rendered and that the COP services were medically reasonable, necessary and covered by that payer.