A recent report by the Center for Public Integrity (CPI) released in mid-September revealed that there is a growing trend in billing for higher level Medicare patient visits among doctors.
According to the report based on a review of more than 362 million claims from 2001 to 2010, at least $11 billion was spent by Medicare to cover increasingly higher levels of service billed by doctors.
These findings support the May 2012 study conducted by the Office of Inspector General which found that from 2001 to 2010, Medicare payments for Evaluation and Management services increased by 48 percent .This was explained in part by a 13 percent increase in the number of E&M services billed as well as increases in Medicare payment rates.
But the OIG also blamed the growing expenditure for patient visits on the increase in the percentage of the two highest levels of service in all types of patient visits.
For doctor’s office visits, approximately 25 percent of total visits were in the top two levels in 2001. In 2010, the two highest levels accounted for more than 40 percent. Likewise, in emergency department visits, in 2001, 59 percent of visits were in the two highest levels. In 2010, the number jumped to 77 percent.
Critics and proponents of these reports tend to point to the same factors to both support and refute the findings. The Center for Public Integrity’s report indicated that the average Medicare patient is no sicker or older, while physicians say that patients are living longer and increasingly present with more complex medical conditions. CPI also points to annual surveys by the Centers for Disease Control and Prevention which shows little increase in the amount of time physicians spend with patients, while the American Medical Association asserts that more time is required, and is therefore being billed, because of federal quality measures.
Both also point a finger at electronic health records. Just this week, Health and Human Services Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder issued a joint letter to several major healthcare provider organizations warning against the misuse of EHRs to “financially game the system,” or “upcode” various levels of service. A practice called “cloning,” where portions of a medical record are cut and pasted from one visit to another, or even from one patient to another, also are being targeted.
Cloning was mentioned specifically in the letter from Holder and Sebelius, and several Medicare Administrative Contractors (MACs) – National Government Services, Palmetto GBA, Cahaba GBA, Trailblazer Health Enterprises, and First Coast Service Options – have threatened to deny payment for services with cloned records.
Physicians, however, assert that EHRs both require more time to be spent with patients by reviewing stored information, ordering prescriptions, etc., as well as make it easier to document the information necessary to support higher levels of service. The American Hospital Association President and CEO Rich Umbdenstock, in response to the Sebelius/Holder letter, said that “more accurate documentation and coding does not necessarily equate with fraud.”
In Part 2 we look at some of the actions planned by CMS in response to these studies, as well as what physicians can do to avoid the ire of the federal government.
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