UPfirst.com Explore the Upper Peninsula of Michigan First!
Medicare Fraud $60 Billion Per Year
and the First Line of Defense is You!
By Michaeleen OSullivan, BS, CCS, CCS-P, CMT
Copyright UPfirst.com 2011
March 21, 2011Medicare fraud and abuse is costing Americans $60 billion per year, and the first line of defense is you, the patient. All of us, including patients, providers, and healthcare professionals, will benefit from learning more about healthcare fraud and abuse. The first step for patients toward curbing healthcare fraud and abuse is for each one of us to take charge of our own healthcare.
Recent Medicare fraud arrests in Detroit and national media stories about Medicare fraud (60 Minutes) (NY Times) expose obvious instances of crime--such as providers billing claims with illegally obtained names of people who never received services. But there are many other types of not-so-obvious healthcare fraud and abuse that may only be discovered if you, the patient, pay attention and take action. Some healthcare providers and professionals knowingly or unknowingly take part in abusive or fraudulent billing. It is up to each person participating in the healthcare process to step up now and learn how to help guard against healthcare fraud and abuse.
The purpose of this article is to help shed some light on healthcare fraud and abuse so we can stand together against this devastating problem in our country. Our government’s fraud division, the Office of Inspector General, states in its “A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse” that it has functioned under the assumption that it could trust medical personnel to be honest. The “Roadmap” states: “When reimbursing physicians and hospitals for services provided to program beneficiaries, the Federal Government relies on physicians to submit accurate and truthful claims information."
“What?” you say. Yep, that’s right. The Federal Government relies on physicians and hospitals to submit accurate and truthful claims information. Unfortunately, this political/governmental assumption about healthcare providers is completely wrong. As most of us know, healthcare providers are human.
If this is news to you, please read the Institute of Medicine’s 1999 report: “To Err is Human: Building a Safer Health System.” According to the IOM, 44,000 to 98,000 deaths are attributed to medical errors each year in America. So now that we’ve established providers are human, let’s also establish that not all providers can be relied upon to submit truthful and accurate claims.
What is Medicare Fraud and Abuse?
What Is Fraud & Abuse?
Fraud occurs when someone intentionally falsifies information or deceives Medicare. Abuse occurs when doctors or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary (http://www.medicare.gov/navigation/help-and-support/fraud-and-abuse/fraud-and-abuse-overview.aspx)
A Not-So-Obvious Example - Billing Requirements for PA and NP Services
Let's look at a not-so-obvious example of Medicare fraud and/or abuse (depending on the provider's intent). When you visit your doctor's office in a private practice setting, do you sometimes see a physician assistant or nurse practitioner instead of a doctor? According to national Medicare "incident to" guidelines, if a doctor is present in the suite at the time of your visit with a PA or NP, the practice may bill under the doctor’s National Provider Identifier (NPI number) and charge 100% reimbursement. However, if a doctor is not in the suite at the time of your service, the practice must charge 85% reimbursement using the PA or NP's billing number. You are being overcharged for the visit by 15% when the physician’s NPI number is used on the claim instead of the PA or NP billing number when a physician is not present in the suite.
According to Medicare's National Coverage Provision (PHYS-004), in order for a service to be considered "incident to" a physician's services: "The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. " For more information, please see National Coverage Provision PHYS-004 "Incident to a Physician's Professional Service in the Office or Clinic."
When you schedule your doctor visit in the private office setting:
Do you ask at the time of your visit with a PA or NP if your doctor or another doctor of the same group is in the suite?
Do you ask if your service will be billed under the PA or NP billing number rather than the physician’s NPI number when a physician is not present in the suite?
Do you ask if your PA or NP service was charged at 85% when the physician is not present in the suite?
If you are a PA or NP working with a physician, do you ask your physician how your services are being billed?
In the physician office setting, Medicare regulations specify that the visit with the PA or NP must be billed under the PA or NP's billing number when a doctor is not in the suite. Others payers usually follow Medicare guidelines, but check with your individual payer for specific coverage information.
Incident-To Supervision Requirements for Hospital Outpatient Settings
To learn about incident-to supervision requirements for hospital outpatient settings, visit Medicare Benefit Policy Manual. You'll notice the requirements for hospital "outpatient therapeutic services incident to a physician's service" have changed three times in the past two years. You'll read about "general" versus "direct" supervision and about a new category for 16 "non-surgical extended duration therapeutic services."
"Direct supervision" requires the physician or NPP [non physician practitioner] to be on campus and immediately available the whole time services are provided. "General supervision" means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. CMS selected 16 services it proposes to include in the new category, including observation, intravenous infusion, subcutaneous infusion, and therapeutic, prophylactic or diagnostic injections (AHA News.com)
In the hospital outpatient setting, for the 16 non-surgical extended duration therapeutic services, "CMS requires a minimum of direct supervision during the initiation of the service which may be followed by general supervision for the remainder of the service at the discretion of the supervisory practitioner." For more information, visit the CMS Outpatient Prospective Payment System (OPPS) web site.
Therapeutic Auxiliary Service in the Physician Office Setting
Therapeutic auxiliary services provided in the physician office setting require direct supervision. For example, in Michigan, if you receive allergy immunotherapy services, the doctor must be in the suite to respond to an anaphylactic emergency. "Anaphylaxis is a severe allergic reaction that is rapid in onset and may cause death" (emedicine.net). According to the Medicare Local Coverage Determination (LCD) for Michigan:
The major risk of allergen immunotherapy is anaphylaxis. Allergen immunotherapy should, therefore, be administered under the supervision of an appropriately trained physician who can recognize early symptoms and signs of anaphylaxis and administer emergency medications where necessary. In addition, immunotherapy should be administered only in facilities equipped to treat anaphylaxis. Allergy Testing and Immunotherapy Local Coverage Determination WPS
In Michigan, direct supervision by the provider is required in all settings in regard to allergy testing, antigen preparation, and allergy immunotherapy (shot) services. According to a CMS MedLearn article, CMS does not have a national coverage determination (NCD) that identifies criteria for allergy immunotherapy services and leaves this to the local Medicare contractor's discretion. In Michigan, this means the physician must be present in the suite--not available by phone, not down the hall. The physician is not required to be in the same room at the time of the auxiliary service, but he/she must be present in the suite. If you receive your allergy services through a group practice, one doctor from the group practice must be present in the suite when nurses, technicians, or other non physicians are providing the services. Allergy services must be billed under the supervising physician's NPI number.
The Joint Council of Allergy, Asthma, and Immunology, in the Published Practice Parameters of The Joint Task Force on Practice Parameters for Allergy and Immunotherapy, describes the expectation of physician presence during allergy immunotherapy in a 2003 article:
Immunotherapy should be administered in a setting that permits the prompt recognition and management of adverse reactions. The preferred location for such administration is the prescribing physician’s office. However, patients may receive immunotherapy injections at another health care facility if the physician and staff [italics mine] at that location are equipped to recognize and manage immunotherapy reactions, in particular, anaphylaxis. Patients should wait at the physician’s office for at least 20 to 30 minutes after the immunotherapy injection(s) so that reactions can be recognized and treated promptly if they occur (Allergy Immunotherapy: A practice parameter).
Fight Healthcare Fraud and Abuse
As you can see, healthcare billing coverage issues are complex, and they vary depending on the setting, the payer, and the service being provided. It is essential that we all work together and learn as much as we can about healthcare fraud and abuse. The $60 billion in Medicare fraud annually is only part of the story. If we Americans are being robbed of $60 billion annually in Medicare fraud alone, how much are we being robbed of in toto, when all payers, including Blue Cross/Blue Shield, all other commercial payers, and private payers, are included?
Visit the Office of Inspector General's Top 10 Most Wanted Health Care Fugitives to learn more about the rampant types of criminal healthcare fraud and abuse our government is fighting.
Visit the OIG's Work Plan 2011 to learn about this year's targeted areas for fraud and abuse.
What can we do to help close the free-flowing destructive spigot of healthcare fraud and abuse? We can take charge of our own healthcare. Each time you schedule an appointment at your doctor’s office, ask who will be providing the service. If a PA or NP will be providing your service, ask if a doctor (your doctor or another of the same group) will be present in the suite. If a doctor will not be present in the suite, ask if you will be billed for 100% reimbursement under a doctor’s NPI number, or if you will be billed for 85% reimbursement under the PA or NP's number. If you are receiving ancillary therapeutic services in the physician office setting, such as allergy immunotherapy, ask if a supervising doctor will be present in the suite. If a supervising doctor will not present in the suite, ask to be rescheduled for a visit when a doctor will be available within the suite.
Taking Charge of Your Personal Health Record
Help combat medical fraud and abuse by taking charge of your personal health record and your healthcare bills and summary notices (EOBs). Request copies of your medical records at the time of service. List the reason for requesting your health records on release of information forms as for “continuity of care” and your records will mostly likely be free to obtain. Retain your health records in an organized way, either in paper or electronic form.
You can create your own free electronic personal health record at Google.com/health and at many other free sites. Learn more about how to create your personal health record at myphr.com by the American Health Information Management Association. Retain all of your insurance summary notices explaining what services have been billed and paid on your behalf. Compare your insurance summary notices to your medical record documentation to be sure that all services billed were documented. The rule is: If it wasn’t documented, it wasn’t done.
Be assertive when scheduling appointments and receiving services to guard against fraud and abuse and unsafe medical practices. If you are a Medicare or Medicaid recipient, contact the Michigan Medicare/Medicaid Assistance Program for help with understanding your medical bills. For other assistance with billing issues, contact a free volunteer medical billing advocate at Medical Billing Advocates of Michigan.
You are the first line of defense against medical fraud and abuse. Just think what $60 billion in Medicare fraud alone would do to help balance our country’s fiscal deficit. The solution you have been waiting for is you! The time for naďve reliance on healthcare provider accuracy and truthfulness is long gone.
Questions, comments, concerns? Please email mosullivan@centralbusinessschool.com.
Disclaimer: The author has made every effort to relay the information contained in this article in a truthful, responsible, and carefully researched manner. However, billing rules and guidelines are often very complicated, change frequently, and can be different from state to state and payer to payer. Therefore, the author accepts no responsibility for actions of patients, providers, or healthcare professionals based on this article. Please consult the extensive references provided for more information. Please email mosullivan@centralbusinessschool.com with questions, comments, concerns.
Michaeleen OSullivan, BS, CCS, CCS-P, CMT
For 20 years Ms. OSullivan has been actively working in the health information management field in many different capacities. Currently she is employed as a site review consultant for a national data analytics firm. In addition to her work as a review consultant, Ms. OSullivan owns Central Business School where she works as a coding and billing instructor. Some of her previous healthcare-related positions include physician practice manager, hospital coding supervisor, and coding and billing specialist. Ms. OSullivan is a member of the American Health Information Management Association (AHIMA) and the Association for Healthcare Documentation Integrity (AHDI).
Ms. OSullivan volunteers for Association for Healthcare Documentation Integrity (AHDI), Michigan Health Information Management Association (MHIMA) and Upper Peninsula Michigan Health Information Management Association (UPMHIMA) activities. She has served as president and secretary for UPMHIMA. She served on the MHIMA MyPHR campaign from 2008 to 2011. She served on the nominating committee for MHIMA in 2010.
In 2009, Ms. OSullivan created a free informational web site about medical billing issues and the personal health record at Medical Billing Advocates of Michigan.
In 2011, she created Free Coding CEUs: An Independent Study Group for Coding Education to help healthcare professionals earn free coding CEUs.
Ms. OSullivan's credentials include:
Bachelor of Science Degree, Northern Michigan University, 1989
Certified Coding Specialist Hospital, 1997-Present
Certified Coding Specialist Physician, 1998-Present
Certified Medical Transcriptionist, 1998-Present
If you have questions, comments, or concerns about this article, please contact Ms. OSullivan at her facebook account or via email.
Questions, Comments, Concerns?
Michaeleen OSullivan | Create Your Badge
AHA seeks big changes to 'onerous' 2011 outpatient supervision policy (Accessed March 25, 2011)
"Allergy Immunotherapy: A practice parameter," Joint Task force on Practice Parameters for Allergy Immunotherapy, 2003 (accessed March 26, 2011).
Allergy Services and Incident-To (accessed March 9, 2011).
Allergy Testing and Immunotherapy Local Coverage Determination WPS (accessed March 9, 2011 and March 25, 2011).
American Academy of Physician Assistants (accessed March 9, 2011).
CMS Outpatient Prospective Payment System (OPPS) web site (accessed March 25, 2011).
Coding News – Compliance Flag – Incident To (accessed March 9, 2011).
Detroit cases – February 11, 2011 (accessed March 9, 2011
Detroit Cases – February 18, 2011 (accessed March 9, 2011).
Dozens Arrested in Medicare Fraud Totaling $251 Million,
by Associated Press, Published: July 16, 2010, NYTimes (accessed March 26, 2011).
Google.com/health (accessed March 25, 2011).
How to Avoid or Prevail on a Medicare Audit (accessed March 9, 2011).
ua"> Medicare Antigen Preparation Document 2002 (essed March 9, 2011)
Medicare Benefit Policy Manual. (accessed March 25, 2011).
Medicare Fraud – $60 billion – 60 Minutes – October 25, 2009 (accessed March 9, 2011).
Medical Fraud – Washington Post – June 13, 2008 (accessed March 9, 2011).
Medicare.gov (accessed March 25, 2011).
Medical Billing Advocates of Michigan (accessed March 9, 2011).
Michigan Medicare/Medicaid Assistance Program (accessed March 9, 2011).
MyPHR by the American Health Information Management Association (accessed March 25, 2011).
Office of Inspector General, “A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse” (page 2) (accessed March 9, 2011).
OIG Guide for Physicians (accessed March 9, 2011).
OIG Report on Incident-To Services (accessed March 9, 2011).
OIG's Top 10 Most Wanted Health Care Fugitives (accessed March 25, 2011).
OIG Work Plan 2011 (accessed May 9, 2011).
Published Practice Paramaters of The Joint Task Force on Practice Parameters for Allergy and Immunotherapy, The Joint Council of Allergy, Asthma, and Immunology (accessed March 26, 2011).
Revised Physician Supervision Requirements under the 2011 Final OPPS Rule (accessed March 9, 2011.
Supervision of Hospital Outpatient Therapeutic Services Drinker Biddle (accessed March 25, 2011).
To Err is Human: Building a Safer Health System, Institute of Medicine, 1999. (accessed March 21, 2011).
WPS National Coverage Provision (PHYS-004) Incident-To Services (accessed March 9, 2011 and March 25).
Central Business School
Online Learning CenterHealth Information Coding
Certificate ProgramStart preparing for your new career
as a certified coder today!
Central Business School
Promote Your Page Too
Join Central Business School
on facebook today!
FreeCodingCEUs.com
An Independent Study Group for Coding Continuing Education
Join our FreeCodingCEUs.com independent study group today
and begin earning free CEUs for your participation now!
UPfirst.com
Copyright UPfirst.com 1996 - 2011
All Rights Reserved.
Last updated 03/27/2012
