Focusing on clinicians who receive high cumulative payments under Medicare Part B could be a useful means of identifying possible improper payments, according to a recent report issued by the Office of Inspector General of the Department of Health and Human Services (OIG). 

OIG reached this conclusion after determining that out of 303 clinicians—defined as physicians, nurse practitioners, and physician’s assistants—who each furnished more than $3 million in Part B services during CY 2009, Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) identified 104 of these clinicians (34 percent) for improper payment reviews.  As of December 31, 2011, the MACs and ZPICs had completed reviews of 80 of these 104 clinicians and had identified $34 million in overpayments.

Based on these findings, OIG made two recommendations to CMS.  First, OIG recommended that CMS 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.  Second, OIG recommended that CMS implement a procedure for timely identification and review of clinicians’ claims that exceed the cumulative payment threshold.

In response to OIG’s first recommendation, CMS stated that it would work with its contractors to research and develop an appropriate cumulative payment threshold that considers costs and potential benefits when determining which claims and providers should be selected for review. CMS also stated that in developing any thresholds, it would consider other factors, including service type and provider specialty, to “inform the appropriate threshold levels.” In response to OIG’s second recommendation, CMS stated that it would develop a procedure for the timely identification and review of clinicians’ claims that exceeded the cumulative payment threshold on the basis of the results of its research and OIG’s review.  CMS acknowledged that reviewing claims from providers with high cumulative payments could be a valuable screening tool and that it is one of many factors MACs consider when deciding to place a provider or supplier on manual medical review.

Review OIG’s report by clicking here.