In a report issued in December 2013 by the Office of Inspector General (“OIG”) of the U. S. Department of Health and Human Services (“HHS”), it was reported that 13 Medicare Part B clinicians, each of whom billed Medicare $3 million or more in 2009, were responsible for more than $34 million in Medicare overpayments. Of the 104 clinicians identified for review, 48 reviews were closed without findings and 24 reviews were ongoing as of December 31, 2011.
Medicare Part B covers two types of services: Medically Necessary Services (services or supplies that are needed to diagnose or treat medical conditions and that meet accepted standards of medical practice, such as lab tests, surgeries, and doctor visits, and supplies such as wheelchairs and walkers) and Preventive Services (health care to prevent illness or detect it at an early stage, when treatment is most likely to work best). Medicare Part B covers things like clinical research, ambulance services, durable medical equipment (“DME”), mental health (inpatient, outpatient, and partial hospitalization), second opinions before surgery, and limited outpatient prescription drugs.
The report, entitled “Reviews of Clinicians Associated With High Cumulative Payments Could Improve Medicare Program Integrity Efforts,” identified 303 clinicians who each furnished more than $3 million of Medicare Part B services during 2009 (over 5,000 clinicians were each responsible for more than $1 million in payments during 2009). The investigators identified 104 of the 303 clinicians for improper payment reviews. Three of the 104 clinicians had their medical licenses suspended and two were indicted.
Medicare paid more than $65 billion for Part B services in each calendar year from 2008 through 2011. In each of these 4 years, about 2% of clinicians were responsible for almost 25% of all Part B payments, with annual payments of more than $500,000 per clinician. The average annual payments to these clinicians was about $1 million.
Logic dictates that clinicians who receive “high cumulative payments” (defined for purposes of the OIG report as total annual payments of more than $3 million for Part B services furnished by an individual clinician) represent a greater risk to Medicare if they bill incorrectly or commit fraud. From 2008 to 2011, both the number of Medicare Part B clinicians and the total dollar amount of payments increased approximately 13%, yet the number of Medicare Part B clinicians generating high cumulative payments and the total dollar amount of those payments during the same time period both increased almost 78%.
All of the 104 clinicians who each furnished more than $3 million of Medicare Part B services in 2009 were physicians. Those physicians included specialists in internal medicine (55%), radiation oncology (12%), and ophthalmology (11%). Those physicians practiced in Florida (28%), California (8%), New Jersey (7%), Texas (7%), New York (6%), Illinois (6%), and in other states.
The OIG has generated a list of 476 clinicians who each furnished over $3 million in paid Part B services during 2011. Of the 476 clinicians identified, predictive analytics models identified 58 for further evaluation, of which eight of those providers have been preliminarily evaluated and five of those providers are considered “suspect.”
If you are aware of a Medicare provider who improperly, incorrectly, or fraudulently billed Medicare and/or received payments from Medicare that it was not entitled to, you may be entitled to share in a portion of the amount that the U.S. recovers from the wrongdoer under the federal False Claims Act.
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