OIG Report on Incident to Billing

The Office of Inspector General (OIG) report on incident to guidelines has a shocking headline.  In the sampled claims, "Unqualified nonphysicians performed 21% of the services that that physicians did not personally perform."  That is, physician employees performed invasive and non-invasive procedures that they were not qualified to perform, for which they had no documented training or credentials, and physicians billed Medicare and received payment for the services.  This is not the type of incident to error we worry about: billing Non-Physician Practitioner services under the doctor's provider number, when it does not meet the criteria.  This report found that medical assistants, unlicensed technicians, "therapists" with no training to be a therapist and nurses were performing services outside their scope ofpractice, and/or with no training, license or certification.

What type of services?  There were a few specialties with high error rates:

• Ophthalmology: eye exams, diagnostic imaging and photographs
• Dermatology: skin grafts, skin tissue realignment and complex wound repair performed by nurses and medical assistants
• PT services: rehab services performed by therapists with no training
• E/M services: unqualified personnel performed E/M services
• Cardiology and Intervental Radiology: high error rates, type unspecified in report

Only 1% of the incident to errors were for services that should not have been billed incident to, because they didn't meet the requirements, such as new patients.  The errors were for services performed by unqualified nonphysicians.

The OIG selected the sample for review from paid claims in the first three months of 2007, for which doctors billed more than 24 hours of services for a single calendar day.  They used the typical times in the Medicare Fee Schedule to calcualate the hours of service. From that sample, they selected just over two hundred days to review.  They did not review the medical record for medical necessity, but reviewed the qualifications of the nonphysician providing the service.  They found that many of the services were provided by employees who lacked training, certification, and/or licensure, and who were not operating in their scope of practice.

The OIG has recommended that CMS revise/clarify the incident to rule, use a modifier to identify services provided incident to and take appropriate action related to these claims.

What should physician practices do?

• Asses the volume of services provided by physicians, being submitted to Medicare.  In this sample, the median billed in a single day was $9,938, with a maximum of $45,055/day.   Of course, a surgeon or other specialist who bills high dollar value procedures will exceed the median in this sample.  But, look at how many services and how much money you are billing under a single physician in a day.
• Assess the qualifications of therapists performing PT services in the physician office and billed as incident to.  They do not need to be licensed by their state but they must be qualified.
• Eye practices should review the credentials of nonphysicians who perform diagnostic services and photography.  Eye exams require a licensed professional to perform. 
• Dermatology practices should not allow nurses to perform services that are out of their scope of practice and may only be performed by MD's or NPPs.

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