OIG Finds That Unqualified Nonphysicians Are Performing "Incident To" Services and Calls on CMS to Revise its Rule
Medicare Part B permits physicians to bill for services that were provided by nonphysicians “incident to” the physicians’ services. However, in a report issued by the OIG on August 6th, the Office of Inspector General (OIG) concluded that 21% of the time these “incident to” services were being performed by unqualified nonphysicians.
Nonphysicians were deemed to be unqualified when either (1) they were not properly licensed or certified under State laws, regulations, or Medicare rules, or (2) they provided rehabilitation therapy even though they had not been trained accordingly.
In conducting its research, the OIG analyzed Medicare Part B claims made during the first quarter of 2007. By randomly selecting 250 days in which physicians billed for more than 24 hours of services during a single day, it was able to identify services not provided by the physicians themselves.
When physicians’ billed hours exceeded 24 hours/day, the OIG found that half of the services were performed by nonphysicians, and that 21% of these “incident to” services were performed by nonphysicians who were not qualified to do so. During that three-month period in 2007, Medicare paid out $12.6 million for services provided by unqualified nonphysicians.
Based on these findings, the OIG recommend that the Centers for Medicare and Medicaid Services (CMS) revise its “incident to” rule in the following ways:
1. CMS should require physicians who bill for services they did not personally perform to ensure that the nonphysicians performing these services possess the appropriate training, certification and/or licensure pursuant to Medicare regulations and State law.
2. CMS should require physicians who bill Medicare for services not personally performed by them to use a service code modifier in order to identify those services on their Medicare claims.
3. CMS should address and take appropriate action in regard to those service claims that were identified as having been billed by physicians and performed by nonphysicians that were not, by definition, “incident to” services (e.g., initial patient visits). In addition, CMS should address those claims for rehabilitation services where it was found that the nonphysician did not have adequate training as a therapist.
In its response, CMS agreed with #1 and #3 of the OIG recommendations, but stated that it needed to further examine the feasibility of creating a service code modifier, as recommended in #2.
Read the full OIG report as well as CMS' response--Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services.