Medicare Seeks to Expel Physicians from Its Program for Billing Medically Unnecessary Services

This Week Health Systems Management Network, Inc. is reporting that “Medicare seeks to fine and Expel Recalcitrant Providers”.  The reason they seek to do this is that, in their opinion, physicians are billing for “Medically Unnecessary” services.  According to CMS physicians do this despite knowing better. So a new program, “recalcitrant providers” has begun and fines as high as $10,000 will be levied even for a single office visit.

While this is a CMS based program, the “offenders” would be turned over to the Office of Inspector General (OIG) who could both fine and exclude physicians from the Medicare Program.  What kinds of offenses are included?  Physicians who order tests repeatedly even though the clinical picture is the same or up coding an office visit a level or two.  HSMN recently wrote in an article that the use of the Electronic Medical Record has seen the use of cutting and pasting notes about patients that would suggest higher levels of intensity as described by the Evaluation and Management Guidelines.  The higher the income for Medicare Providers, the more likely there will be an audit.  HSMN has been working with physician practices throughout the United States and in all settings, especially large group practices, and it has found that its clients have become so dependent on the Electronic Medical Record that they often forget that no two patients are alike and that they must be differentiated within the Clinical Documentation.

HSMN has found that in certain regions of the country, the Medicare Intermediaries are going one step further.  They are comparing physician notes to hospital notes on audits and finding discrepancies in both the levels of care and the procedures.  HSMN believes, based on the evidence to date, that for the most part these “offenses” are no more than mistakes or failures to follow the basics in Clinical Documentation.

In its almost 30 years of operation HSMN has found that physicians are still not connected to the language that supports and adequately describes levels of care or even procedures.  This has much to do with clinical training where the emphasis is on correct clinical diagnoses and excellence in performing procedures.

HSMN is advising its clients to do an audit on a prospective basis and only retrospective in conjunction with its legal counsel/compliance office.  The advice extends to hospitals with large groups operating within it who provide the bulk of the medical care.  Doing an internal audit will help both the hospitals and the physicians learn what they must do and not rely on the Electronic Medical Record only.  Furthermore, the audit should provide good information to both the facility and the physicians’ practice on how well they will do when ICD-10-CM/PCS are in place.

HSMN’s clients are beginning to ask for such reviews sooner rather than later. Those who have done are finding a very large ROI in both savings and revenue.

HSMN can be contacted through a call to its office 866-908-4226 or its website

Also see our recent article about the OIG’s recommendation regarding cutting and pasting in clinical documentation.