HHS Inspector General questions care provided by non-physicians

The HHS Office of the Inspector General has released a report expressing concern that too many services are being performed in physicians' offices by unqualified second parties.

Right now, Medicare Part B pays for services billed by physicians but performed by non-physicians, under an exception that allows doctors to bill for services "incident to" physician care. However, Medicare knows little about the individuals performing these incidental services, the OIG report notes.

To get a better feel for this issue, the OIG examined Part B Medicare National Claims History data for the first quarter of 2007, examining all days upon which Medicare allowed doctors to bill for more than 24 hours of care in a single day. Researchers then randomly selected 250 of these physician-day billing combinations, asking doctors to identify who performed each Medicare-allowed service on that day, and to submit credentials for nonphysicians involved. Nurse reviewers then looked over the data to determine whether the nonphysicians appeared to be qualified to provide the services in question.

The OIG's conclusions:

* When Medicare allowed more than 24 hours of services in a day, more than half of the services weren't performed by a physician.

* Nonphysicians performed almost-two-thirds of invasive services Medicare allowed the physicians.

* Unqualified nonphysicians performed 21 percent of services that doctors didn't perform personally.

In light of these findings, the OIG is recommending that Medicare change the "incident to" rule to demand that physicians make sure their proxies were qualified; that Medicare create a coding modifier identifying when they aren't performing the service; and that Medicare take action on claims that were filed for nonphysicians but not incident to services, or were for rehab therapy by nonqualified nonphysicians.

To learn get more data from the OIG:
- read the report (.pdf)

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