Monday, January 27, 2014

Government Sets Their Sights on Clinicians with High Medicare Part B Reimbursements

The Office of the Inspector General (OIG) recently released a study detailing overpayments to clinicians who provide Medicare Part B services. "High cumulative payment clinicians" were defined as those who are receiving total annual payments of more than $3 million for Part B services.  This threshold poses a greater risk for improper payment or fraud in the Medicare system. The OIG will seek to implement new programs and policies to detect those problems, and CMS agrees with its essential recommendations. Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessarry to treat a disease or condition.
Part B covers 2 types of services
  • Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  • Preventive Services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work
The study found that both the number of Medicare Part B clinicians generating high cumulative payments, as well as the total amount of those payments, increased almost 78% from 2008-2011. Most importantly, the study identified 303 clinicians who supplied more than $3 million in Part B services in 2009, with Medicare Administrative Contractors (MACs) identifying 104 of the 303 (34%) for improper payment reviews. Some clinicians faced suspended licenses, mandatory prepayment reviews, and even two indictments. The OIG recommends that CMS establish a cumulative payment threshold above which a clinician's claims would be selected for review as well as implementing a procedure for timely identification and review of clinicians' claims that exceed this threshold. One problem with the threshold is that a violator would tailor their reimbursements strategically to that threshold. On the other hand, high Medicare earnings could be indicators of a bustling and successful practice and not necessarily a red flag as to Medicare fraud. As a result of this study, clinicians who are reimbursed through Medicare Part B should ensure that their billing practices are in compliance with Medicare documentation and reimbursement rules. A copy of the study can be found at: