CMS: Why it isn’t Cost-Effective to Review Billings of Doctors

CMS: Why it isn’t Cost-Effective to Review Billings of Doctors

cmslogo1Medicare is the national federal insurance program for people who are over the age of 65 years. According to a recent report by the Department of Health and Human Services, Medicare issued $6.7 billion in 2010 for health-related visits that were not coded properly. The Center for Medicare and Medicaid Services (CMS) stated that it is not planning to review physician billing because it is not cost-effective to do this.

Inspector General Report

In the Inspector General’s report, there was overpayments of $32 billion (20 percent) spent on Evaluation and Management (E/M) services in 2010 alone. The E/M category includes emergency department evaluations, office visits, and inpatient hospital evaluations. One important finding is that more than half of the claims were billed at the wrong rate or with a lack of documentation to justify the service. While some physicians billed for a lower-priced service that the one given, the majority billed for a more expensive service.

In this recent review, most providers had a small percentage of visits that they charged the highest rate for, which is known as a level five. More than 1,200 providers billed exclusively at this top level, and another 600 billed for it 90 percent of the time. Also, around 20,000 healthcare providers billed at level four and five for the majority of claims. According to billing experts, these patterns are indicative of fraud and/or abuse. The physicians reported, however, that patients were now sicker than before and required more time and care.

Inside of CMS

canstockphoto4081952CMS has no plans to recoup the billions of inappropriately paid reimbursements, which has prompted some concern in Washington. The Office of Inspector General (OIG) recommends that CMS ask contractors to focus on the high-billing doctors to manage this issue. The medical reviewers previously reviewed high-coding physicians in two phases, with the first phase costing CMS quite a bit of money. The second phase has not yet been completed, but CMS believes that this will reveal whether other efforts should be taken, such as comparative billing reports.

The OIG also wants CMS to follow up with E/M service claims that were not paid appropriately. CMS has partially agreed with the recommendation, but the agency still maintains that many of the payment differences on these claims will not exceed the overpayment recovery threshold. Also, some claims are too old to recover. Out of all the claims reviewed by the OIG, 55 percent lacked proper documentation, were coded incorrectly, or both. Approximately 26 percent of reviewed claims were upcoded compared to 15 percent that were downcoded.

The OIG released a report saying that Medicare lost over $19 million related to improper inpatient claims that were associated with post-acute patient transfers between 2009 and 2012. The OIG also said that due to healthcare oversight cuts, they recovered less in 2014 than in 2013. The conclusion of all of these reports is that Medicare needs more oversight.

Level 5 Office Visit Criteria

For a level 5 office visit (99215), there are certain criteria that must be met. This code is the highest level of care for an established patient. Primary care providers and internists only billed this code around 9 percent of the time in 2012. Medicare pays approximately $144 for this office visit, and it is worth 2.11 work RVUs. The patient’s problems must be of moderate to high severity to bill 99215. The documentation for this code requires 2 out of 3 of the following:

  • A comprehensive historyfevicon
  • A comprehensive physical examination
  • High complexity medical decision-making

If the above criteria are not met, the provider must spend 40 minutes face-to-face with the patient. Also, appropriate documentation must be available and in the medical record to support this level of care.

For those practices who want to make sure the visit coding is being done correctly, MPMR has a team that will assist you. For over a decade, MPMR has been providing first rate medical billing and revenue management services along with medical practice management consulting.

Call MPMR today at (951) 757-2056 for a free consultation with the top medical billers and coders available!

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