Reviews of Clinicians Associated With High Cumulative Payments Could Improve Medicare Program Integrity Efforts

Clinicians generating high Part B payments represent a greater risk to Medicare if they bill incorrectly or commit fraud. Of the 303 clinicians who each furnished more than $3 million of Part B services during 2009, Medicare administrative contactors (MACs) and Zone Program Integrity Contractors (ZPICs) identified 104 (34 percent) for improper payment reviews. As of December 31, 2011, the MACs and ZPICs had completed reviews of 80 of the 104 clinicians and identified $34 million in overpayments. In addition, three of the clinicians had their medical licenses suspended and two were indicted. The results of these reviews demonstrate that identifying clinicians who are responsible for high cumulative payments could be a useful means of identifying possible improper payments. Although existing procedures may identify some of these clinicians for review, the procedures were not designed specifically to identify all clinicians whose payments exceed an established threshold. In addition, existing procedures may not always identify clinicians responsible for high cumulative payments in a timely manner.

We recommended that CMS (1) establish a cumulative payment threshold-taking into consideration costs and potential program integrity benefits-above which a clinician's claims would be selected for review and (2) implement a procedure for timely identification and review of clinicians' claims that exceed the cumulative payment threshold. CMS partially concurred with both of our recommendations.