The government's release of Medicare provider payment data led to analyses revealing questionable utilization patterns for psychotherapy and pain management benefits.
"Why are obstetricians among the top billers for group psychotherapy in Illinois?" a ProPublica headline asked. The article described a billing trend quashed by Illinois Medicaid: Nursing home residents traveled off-site several times weekly for group psychotherapy, with Medicaid paying for the sessions and travel. But providers who led the therapy--including obstetrician/gynecologists, oncologists and neurologists--"didn't have any training really in psychiatry," the article noted. Eventually the state excluded group psychotherapy benefits for nursing home residents.
A similar pattern appeared in Medicare. Three OBGYNs and a thoracic surgeon led Medicare billers for group psychotherapy in Illinois, ProPublica reported. These doctors claimed 37,864 sessions in 2012, collectively topping the claims volume for similar services rendered by all Medicare providers in California. The quartet received more than $730,000 in Medicare payments for psychotherapy in 2012, the article noted.
Medicare has no policy restricting types of providers entitled to payment for group psychotherapy, a spokesman for the Centers for Medicare & Medicaid Services told ProPublica in an email.
In another investigation revealing high utilization, USA Today asked "exactly how much pain can there be in Brooklyn?" Pain control specialists working in close proximity in the borough--including chiropractors, occupational therapists and physical therapists--shared patients at rates one expert called "staggering."
Beneficiaries saw several pain specialists on the same day, moving among providers who billed Medicare for tens of thousands of services, the article noted. Two providers saw the same patients on the same day more than 11,000 times in 18 months, USA Today found.
Cross-referring patients for financial gain is called churning, and it violates the federal anti-kickback statute, USA Today noted.
Six providers who regularly saw the same beneficiaries collected nearly $15 million from Medicare in 2012, the paper found. And two providers billed for more than 70 times the hours of the average specialist in their field.