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Transcript for audio podcast:
Reviews of Clinicians Tied to High Cumulative Payments Could Strengthen Medicare Integrity Efforts

From the Office of Inspector General of Department of Health and Human Services

[Robert Proscia] I'm Rob Proscia, Auditor with the Office of Audit Services from Region I in Boston. Today, I'm speaking with Rick Navarro, Senior Auditor. We're talking about the recent review of payments totaling more than $3 million that Medicare paid to individual clinicians, for Part B services, in 2009. So what are "clinicians" and what types of services are we talking about?

[Richard Navarro] Well, for purposes of this report "clinicians" includes physicians, nurse practitioners, and physician's assistants. The services include office visits, diagnostic tests, and drugs.

[Robert Proscia] And how did this review come about?

[Richard Navarro] In an earlier, but unrelated review, OIG identified a physician who billed over $5 million dollars in reimbursed therapy services, in less than a year. We looked into it and found that the physician was being investigated by law enforcement. This left us wondering if there was a way to identify the physician sooner.

[Robert Proscia] Okay, so this report deals with clinicians and high cumulative payments. Could you please explain high cumulative payments?

[Richard Navarro] Again, for this review, we define it as the total amount that Medicare pays to an individual clinician, for Part B services, that is more than $3 million dollars.

[Robert Proscia] And how did OIG decide on $3 million as the threshold for the study?

[Richard Navarro] The $3 million threshold identified 303 clinicians. And we felt this was a reasonable indicator of potentially high-billing clinicians.

[Robert Proscia] So what do we know about the 303 clinicians?

[Richard Navarro] In 2009, these clinicians were all physicians, mostly specializing in internal medicine, radiation oncology, and ophthalmology. More than half of them practiced in Florida, California, New Jersey, Texas, New York and Illinois.

[Robert Proscia] How many clinicians billed Medicare over $3 million dollars for Part B services?

[Richard Navarro] Between 2008 and 2011, the number of clinicians grew from 268 to 476.

[Robert Proscia] Can the Centers for Medicare and Medicaid Services, also known as CMS, monitor these clinicians generating high payments?

[Richard Navarro] CMS does not have specific controls in place to monitor clinicians generating high cumulative payments. But, CMS does monitor provider enrollment, and works with contractors to identify improper payments from mistakes and fraud.

[Robert Proscia] Could you tell us more about CMS's contractors?

[Richard Navarro] CMS works with its contractors, to process and pay Medicare claims. The contractors identify and review potential improper payments. In some suspected fraud cases, contractors refer the case to OIG's Office of Investigations, to determine whether to pursue criminal or civil cases.

[Robert Proscia] So how many of the 303 physicians did CMS and OIG identify?

[Richard Navarro] They identified 104 physicians for improper payment review. They also found $34 million in overpayments. Three clinicians had their medical licenses suspended, and two were indicted.

[Robert Proscia] So if CMS and OIG are finding these questionable billings, why do we need this control?

[Richard Navarro] Well Rob, one challenge is how quickly can we identify questionable clinicians? It can take between 7 to 21 months before flagging a physician who is on track to bill more than $3 million for Part B services. The result is Medicare pays millions of dollars more than it should.

[Robert Proscia] How did CMS respond to the results of this review?

[Richard Navarro] CMS said that it would work with its contractors to research and develop an appropriate cumulative payment threshold, and that it would develop a procedure to quickly identify a clinician who bills above the threshold. CMS also wants to look at other factors, including service type and specialty, to set the various thresholds.

[Robert Proscia] Now for the question on everyone's mind, where does OIG go from here?

[Richard Navarro] Well, we plan to identify effective thresholds for various provider types and specialties. We believe utilizing thresholds for high cumulative payments would be a good screening tool and helps strengthen Medicare program integrity efforts.

[Robert Proscia] Thank you, Rick, for taking the time to discuss this innovative area with us.

[Richard Navarro] You're welcome.


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