The office of the Inspector General ("OIG") recently announced areas on which it plans to focus enforcement efforts over the next two years.  The OIG is particularly interested in designated health serviced ("DHS") provided to Medicare beneficiaries by physicians in their offices.  Areas of focus will include:  

•        Review of Medicare claims for physical and occupational therapy to determine whether the services were reasonable and medically necessary and adequately documented and certified by the ordering physician;  

 •        Evaluate the appropriateness of Medicare services performed "incident to" the professional services of physicians.  The OIG will identify “incident to” services to determine the extent to which the services met Medicare standards for medical necessity, documentation and quality of care;  

•        Review whether physicians properly code the place of service on claims for services provided in ambulatory surgery centers and hospital outpatient departments; 

•        Determine whether surgeons are improperly receiving separate payments for evaluation and management services during the global surgery period; 

•        Review the appropriateness of imaging services provided in physician offices.  From 1999-2005, utilization of MRI, PET and CT scans grew, on average, 20% annually; and in 2005, Medicare paid over $7 billion for these services;  

 •        Review of medical records for durable medical equipment ("DME") items and supplies furnished to beneficiaries receiving home health services to determine whether the DME was reasonable and medically necessary;  

•        Review the relationships between billing companies and physicians and other Medicare providers using their services; and 

•        Review of Medicare payments for cardiolography and echocardiography services to determine whether physicians billed appropriately for the professional and technical components.  

On the state enforcement level, in a speech presented on October 4, 2006, Anne Murphy, senior counsel to Illinois Attorney General Lisa Madigan, noted some key Illinois enforcement initiatives, which included: 

•        Enforcement of the Consumer Fraud and Deceptive Practices Act by prosecuting providers who misrepresent or fail to disclose charges to health care consumers, fail to disclose conflicts of interest or financial incentives or issue misleading statements regarding treatment efficacy; and 

•        Investigation of complaints filed under the Illinois Whistleblower Reward and Protection Act and the Insurance Claims Fraud Protection Act, both of which have whistleblower provisions.