OIG Eyes Unqualified Help in Incident-to

The Office of Inspector General (OIG) is worried physicians are billing for services provided by unqualified help, so it just audited Medicare incident-to claims for 2007. What it found made the agency ask the Centers for Medicare & Medicaid Services (CMS) to review its incident-to policies.

What the OIG discovered, as described in its August 2009 report entitled “Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services,” was the following:
  • When Medicare allowed physicians more than 24 hours of services in a day, half of the services were not performed personally by a physician.
  • In the first quarter of 2007, physicians who were allowed services that exceeded 24 hours of physician work time in a day personally performed approximately half of these services. Nonphysicians performed the remaining services, which physicians may have billed as incident-to services. Medicare allowed $105 million for approximately 934,000 services that the physicians personally performed and approximately $85 million for approximately 990,000 services that nonphysicians personally performed during this three-month period.
  • Nonphysicians performed almost two-thirds of the invasive services that Medicare allowed the physicians. An invasive procedure involves entry into the living body (as by incision or by insertion of an instrument). Nonphysicians performed almost half of the noninvasive services that Medicare allowed the physicians.
  • Unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally. In the first three months of 2007, Medicare allowed $12.6 million for approximately 210,000 services performed by unqualified nonphysicians. These nonphysicians did not possess the necessary licenses or certifications, had no verifiable credentials, or lacked the training to perform the service. Nonphysicians with inappropriate qualifications performed 7 percent of the invasive services that physicians did not perform.

OIG recommends the following to CMS in the report:

1. Seek revisions to the incident-to rule. The rule should require that physicians who do not personally perform the services they bill to Medicare ensure no persons except:

a. licensed physicians personally perform the services or

b. nonphysicians who have the necessary training, certification, and/or licensure, pursuant to state laws, state regulations, and Medicare regulations personally perform the services under the direct supervision of a licensed physician.

2. Require physicians who bill services to Medicare to identify the services they do not personally perform on their Medicare claims by using a service code modifier. The modifier would allow CMS to monitor claims to ensure physicians are billing for services performed by nonphysicians with appropriate qualifications.

3. Take appropriate action to address the claims for services the OIG detected that:

a. were billed by physicians and performed by nonphysicians that were, by definition, not incident-to services; and

b. were for rehabilitation therapy services performed by nonphysicians who did not have the training of a therapist.

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