News: CMS targets physician payment errors

February 27, 2014

From calendar year 2008 to 2011, Medicare paid more than $65 billion for physician services. In each of these years, 2% of the physicians were responsible for almost 25% of all the payments—each receiving annual payments of approximately $1 million, according to a December 2013 report from the Office of the Inspector General.

The report also showed that 104 clinicians racked up $34 million in improper payments—three had their medical licenses suspended and two were indicted. It dubs these clinicians, who continuously erroneously bill Medicare despite CMS’ attempts to provide coding and documentation education, as “recalcitrant.”

“The results of these reviews demonstrate that identifying clinicians who are responsible for high cumulative payments could be a useful means of identifying possible improper payments,” the OIG report states.

Partially in response to the OIG’s findings, CMS amended its "Medicare Program Integrity Manual,” Chapter 4 (Benefit Integrity), Section 27 (Recalcitrant Providers), and published a MedLearn Matters article directing its contractors to refer cases of so-called recalcitrant providers to the OIG, encouraging the use of fines and penalties for physicians who demonstrate a pattern of inappropriate billing behavior.

One source quoted in a New York Times article on the matter stated that the real problem was federal investigators asserting that a service was not medically necessary when the physician or hospital simply did not understand the documentation requirements, or that the documentation did not adequately reflect the need for the care provided. This represents an educational opportunity for CDI.

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