Dec. 20—The Centers for Medicare & Medicaid Services (CMS) plans to develop a dollar threshold at which physicians who prescribe Part B drugs will face greater fraud scrutiny.

The CMS plans stemmed from a new Office of Inspector General (OIG) finding that Medicare’s fraud contractors identified $34 million in overpayments over the past two years among only a subset of the 303 clinicians who charged the most under Part B in 2009. The 303 clinicians all charged Part B for at least $3 million in services that year.

Medicare administrative contactors (MACs) and Zone Program Integrity Contractors (ZPICs) reviewed payments to 104 of the highest-charging clinicians and found 77 percent of them were overpaid, three have had their medical licenses suspended, and two were indicted.

“High cumulative payments are not necessarily indicative of improper payments or fraud,” Marilyn Tavenner, administrator of CMS, wrote the OIG about its findings. “However, CMS does acknowledge that reviewing claims from providers with high cumulative payments could be a valuable screening tool and is one of many factors MACs consider when deciding whether to place a provider or supplier on manual medical review.”

The agency plans to work with its fraud contractors to indentify an appropriate “payment threshold,” which will be affected by the type of service and providers’ medical specialty.

Why the Review Took Place

The OIG review of top-charging Part B clinicians stemmed from an unrelated earlier OIG investigation of a physician who billed more than $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,” Richard Navarro, a senior auditor for OIG, said in a podcast interview. “This left us wondering if there was a way to identify the physician sooner.”

The 303 high-payment physicians mostly specialized in internal medicine, radiation oncology, and ophthalmology. Most of them practiced in Florida, California, New Jersey, Texas, New York, and Illinois.

Navarro said the $3 million threshold of charged services established by OIG for closer examination was selected “as a reasonable indicator of potentially high-billing clinicians.”

The number of clinicians exceeding the $3 million threshold grew from 268 in 2008 to 476 in 2011.

The OIG plans to identify “effective thresholds” for various provider types and specialties, Navarro said.

“We believe utilizing thresholds for high cumulative payments would be a good screening tool and helps strengthen Medicare program integrity efforts,” he said.

Publication Date: Friday, December 20, 2013