OIG: Check physicians with outsized Medicare billing

The Office of the Inspector General recommends increasing scrutiny of physicians who bill the Medicare program out of proportion to their peers.

The conclusion was made by the investigative arm of the U.S. Department of Health and Human Services in a report it released last week. OIG reviewed the billings of more than 300 physicians who received at least $3 million apiece from Medicare Part B in 2009. The billings of those doctors represented almost 2 percent of all payments for clinical services made by Medicare Part B in that year.

Overall, more than a third of those doctors were flagged for inappropriate billings by Medicare Audit Contractors, or MACs, and zone integrity payment contractors, or ZPICs. A total of 13 of those doctors overbilled Medicare by at least $34 million. Three physicians later lost their licenses to practice medicine as a result of their billing practices, and two were facing criminal charges.

In 2011, two years after the OIG scrutinized claims, 476 physicians billed Medicare for at least $3 million, up from 268 physicians in 2008.

HHS has been cracking down on potential fraud in the Medicare program, using more elaborate investigative techniques. It recovered more than $4.2 billion in fiscal 2012 in collaboration with the U.S. Justice Department--a record. In fiscal 2011, it recovered $4.1 billion. For every dollar invested in clawing back potential fraudulent claims, the federal government recovers nearly eight.

In its report, the OIG recommended that the Centers for Medicare & Medicaid Services set a threshold for cumulative payments that would trigger a review of physician claim patterns.

CMS mostly concurred with the OIG's findings and said it would implement its recommendations. It noted that it would consider such factors as physician speciality and the setting where the care is delivered for setting particular thresholds.

To Learn More:
- read the OIG report (.pdf)

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