2013 OIG Work Plan Includes Focus on Imaging Practice Expenses and Medical Necessity

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The Office of Inspector General has released its priorities for finding fraud and waste in Medicare and it once again includes imaging services.

According to the 2013 OIG Work Plan, it will specifically focus on two areas of diagnostic imaging. The first is the appropriateness of current practice expense payments for selected Part B imaging services. The OIG plans to study the expenses incurred by providers to see whether current assumed imaging utilization rates reflect actual industry practices.

Secondly, the OIG plans to look closely at the medical necessity of “high-cost” diagnostic radiology tests and review whether there is a difference between primary care physicians and specialists in how often they order the same diagnostic tests for the same treatment.

In addition, the OIG plans to continue making use of analytics like computer matching and data mining to detect billing irregularities that could be fraudulent. “Error-prone” Medicare providers -- providers who have consistently submitted claims found to be in error over a 4-year period -- will find their claims scrutinized especially closely. The OIG plans to “select the top error-prone providers on the basis of expected dollar error amounts and match the selected providers against the National Claims History file to determine the total dollar amount of claims paid.” It then promises to perform medical reviews on a sample of those claims to look for fraudulent billing.

Download a PDF of the 2013 OIG Work Plan.