Tag Archives: hospitalists

Top hospitalists use questionable billing practices

Medicare physician-payment data shows that over one thousand primary care physicians providing hospital-based services billed Medicare more than five times the average, raising questions about their billing practices.

A common explanation that Medicare permits the use of a single National Provider Identifier (NPI) fails to account for specific requirements for the four common billing scenarios that allow such use.

The Medicare physician-payment data, made public for the first time in April, has revealed unusual patterns in doctor billings in recent stories by New York TimesWall Street Journal, and ProPublica.

Data Limitations

Many of AMA’s complaints about the Medicare provider payment data release have merit. For example, care quality cannot be assessed from the information reported. It is true that billed charges and payments are not the same. The data set also does not represent the physician’s whole patient population.

previous post provided demographic, utilization, and payment insights into the fastest-growing hospitalist specialty—primary care physicians who provide hospital-based services. This post will tackle the issue of billing outliers among hospitalists.

Human Limitations

With Medicare Advantage and all private payers excluded from the data, it is not unreasonable to expect that even the most hard-working individual physician would be able to provide about 5,000 hospital-based work RVUs (wRVU) per year for Medicare patients.

Medical billingThe work RVU (wRVU) element is associated with each CPT® code and represents the relative level of time, skill, training, and intensity to provide a given service. CPT is a registered trademark of the American Medical Association and an industry-standard way of measuring physician workload.

The average for more than 79,000 primary care physicians in the data was 1,230 wRVU in hospital-based services. Physicians who provided more than 50% of their total services using the 20 CPT codes commonly associated with hospital-based services were categorized as hospitalists. The average workload for the hospitalists was higher at 1,759 wRVU.

The data reveals that the top one thousand primary care physicians providing hospital-based services averaged more than 9,300 wRVUs or 7.5 times the average for all primary care physicians and 5.3 times the average hospitalist. The top 263 physicians each billed more than 10,000 wRVU, with one hospitalist topping out at more than 40,000 wRVU!

Plausible Explanation?

One plausible explanation that is often given for the top outliers is that the services can be billed under a supervising physician’s NPI. The AMA’s letter to CMS states the following:

There also are a number of situations where it will appear that one physician has performed services that were actually delivered by many practitioners because Medicare permits the use of a single NPI without identification of the individual who delivered the service in a number of situations. These include “incident to” services provided by residents and other health care professionals who bill for their services under a supervising physicians’ NPI.

While Medicare does permit the use of a single NPI, it is not a free-for-all. There are four common scenarios that permit billing under another physician’s NPI. It is worth discussing specific requirements for each to see if the single-NPI justification can sufficiently explain the high outliers.

 1.       Billing Under a Single NPI:

The mechanism for billing a physician under another physician’s NPI, known as the Q6 modifier, is very clear. Medicare Claims Processing Manual (Chapter 1, Section 30.2.11) unequivocally states:

“The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished by a locum tenens physician) after the procedure code.”

In short, the Q6 modifier is reserved for locum tenens physicians and its use must meet several requirements, including:

  • The regular physician is unavailable to provide the visit services.
  • Locum tenens physician is not an employee of the regular physician.
  • The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis.
  • The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days.

None of these “substitute physician” requirements could be met by other physicians in the same group, thereby making the use of Q6 modifier to bill under a single physician NPI on an ongoing basis a highly questionable billing practice.

2.       Billing for Locums Tenens Physicians

As the Q6 discussion has indicated, a regular physician may submit a claim under the locum tenens arrangement using his/her own NPI and, if assignment is taken, receive payment for covered visit services assuming the specified conditions are met.

However, the substitute physician may not provide the visit/services to Medicare patients over a continuous period of longer than 60 days.

Because many locum tenens assignments in the hospitalist environment last longer than 60 days, continuing to bill locums using the Q6 modifier could result in a highly questionable billing practice.

3.       Billing for Non-Physician Providers

“A high-earner may be billing for several mid-levels” is a common refrain offered to explain high billings. There is an equally common misperception that a hospitalist can routinely bill for a non-physician practitioner (NPP) being “supervised” under the physician NPI so as to get reimbursed at 100% of the physician’s rate rather than the 85% rate if billed under the NPP’s provider number.

According to Texas Medical Association, services and supplies that would normally be covered “incident to” in an office setting, such as NPPs that the physician hires and supervises, are not billable by the physician in hospital settings.

If the physician uses the services of his/her own employees in a hospital setting and the physician merely “supervises” his/her services, the physician is not eligible for a payment from Medicare because supervision alone does not constitute a reimbursable practitioner service.

WPS, a Medicare contractor, confirms the position that “incident to” guidelines do not apply to services in an inpatient setting. Rather than “incident to” billing, the encounter must be billed as a shared/split visit.

Finally, Medicare Claims Processing Manual (Chapter 12, Section 30.6.1.B) documents specific requirements for shared/split visits with a nonphysician practitioner (NPP):

When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP  from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP’s UPIN/PIN.

In other words, to bill for NPPs under the hospitalist’s NPI as a shared/split visit, there must be: 1) documentation of the face-to-face portion of the E/M encounter between the patient and the physician and 2) the medical record should also clearly identify the part(s) of the E/M service which were personally provided by the physician and which were provided by the NPP.

In the absence of such documentation, the service may only be billed under the NPP’s provider number.

This applies to the initial history and physical examination, the discharge summary, and subsequent hospital visits. A notation of “seen and agreed” or “agree with above” does not qualify the situation as a shared/split visit.

If the face-to-face encounter and documentation requirements for a shared/split visit are not met, simultaneously billing for “several mid-levels” under the same physician’s NPI would become a highly questionable billing practice.

4.       Billing in Teaching Setting

Medicare Benefit Policy Manual’s Chapter 15 explains Part B services in a teaching setting:

Part B covers services that attending physicians (other than interns and residents) render in the teaching setting to individual patients. These include such services as reviewing the patient’s history and physical exams, personally examining the patient within a reasonable time after admission, confirming or revising diagnoses, determining the course of treatment to be followed, assuring that any supervision needed by interns or residents is furnished, and making frequent review of the patient’s progress.

Medicare Claims Processing Manual (Chapter 12, Section 100.1.1) documents specific requirements for services billed by teaching physicians as follows:

For purposes of payment, E/M services billed by teaching physicians require that they personally document at least the following:

  • That they performed the service or were physically present during the key or critical portions of the service when performed by the resident; and
  • The participation of the teaching physician in the management of the patient.

Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.

On medical review, the combined entries into the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service.

The manual further states that if the resident performs some or all of the required elements of the service in the absence of the teaching physician, the teaching physician must independently perform the critical or key portion(s) of the service with or without the resident present. The teaching physician must also document that he/she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient.

If these key teaching environment requirements are not met, billing for residents under the same attending physician’s NPI would become a questionable billing practice.

Million Dollar Doc

In an interview, one of the highest earners explained that his hospitalist group had about seven providers in 2012 and their outside biller was “Q6ing most of the doctors” under his name. The group had no idea why and didn’t understand the process well enough at the time.

The unusually high number of services under a single NPI triggered a Medicare audit. The group had to provide extensive documentation to explain the issue and also had to make sure that individual physicians were credentialed appropriately.

Based on the data analysis and requirements review, his situation hardly seems like an isolated anomaly.

Questionable Billing Practices

With online access to individual physician’s Medicare billing and payment details, the front-page ethics test has now become a reality. But it amounts to more than just salacious, break-room gossip.

The bottom line is that each of the four scenarios above has very specific billing requirements, and proper compliance with them would severely constrain the maximum workload that can be physically provided under a single NPI.

The detailed data analysis points to the presence of questionable billing practices among high-earning hospitalists because the single-NPI explanation fails to justify hospital-based workload that would be several times more than the average.

To avoid any unwanted attention and to steer clear of expensive and time-consuming audits, all hospitalists should reexamine their current billing practices for billing under another provider’s NPI.

PS: You can also see the press release on this topic at: http://www.prnewswire.com/news-releases/top-hospitalists-use-questionable-billing-practices-263052591.html

What we know about Hospitalists

Although highly-paid doctors were played up in major newspapers after the Medicare data release, a lot of useful information about hospitalists has been ignored.

After Medicare released a treasure trove of provider payment data, media outlets such as The Wall Street Journal and New York Times, published pieces focusing on the tiny sliver of doctors accounting for an outsize portion of Medicare’s 2012 payments.

CMS has already listed several data limitations on its website. Further, AMA has made its feelings known even before and soon after the data release in a letter to CMS according to the CNBC story.

While the AMA’s objections clearly have merit, in my opinion the alleged data limitations do not render the information so worthless so as to prevent drawing any meaningful conclusions.

There is a wealth of demographic, utilization, and payment related information available for the very first time in the data release, particularly as it relates to hospitalists.

Deconstructing a Hospitalist

Information related to hospitalists has always been somewhat suspect.

Until now, many things we thought we knew about hospitalists (primary care physicians who provide care to patients in the hospital) have been based on anecdotal information, statistically questionable surveys, or incomplete membership information.

HospitalistUnfortunately, there is no “hospitalist” designation in the enormous data release because physicians are listed under Internal Medicine or Family Practice or General Practice.

However, there is enough information in the Medicare data release to reliably isolate hospital-based services based on the entity code, place of service, and provider specialty along with 20 specific CPT codes (registered trademark of the American Medical Association) predominantly used by hospitalists in a hospital setting for observation, inpatient, and critical care.

Using this methodology, I compared the number of hospital-based services provided by each independent physician belonging to Internal Medicine, Family Practice, or General Practice in a facility setting to the total number of services provided by the same physician.

Physicians who provided more than 50% of their total services under the 20 CPTs commonly associated with hospitalists were categorized as “hospitalists” and the rest were classified as “traditionalists.”

Further, by overlaying physician work RVU (wRVU)—representing the relative level of time, skill, training and intensity to provide a given service—associated with each CPT code, the services were converted to a more standardized and consistent wRVU metric, which is a predominant factor in physician compensation.

Key Findings

A detailed analysis of the 2012 Medicare data using the methodology outlined above revealed the following key findings:

  • Numbers: Hospitalists were outnumbered by traditionalists. There were 37,983hospitalists and there were 41,622 traditionalists.
  • % of Services: Of the 51.6 million hospital-based services, 67% were provided by hospitalists—twice as many services as provided by traditionalists.
  • % of Work: Hospitalists often exclusively provide hospital-based services so it should come as no surprise that the 20 hospital services comprised 87% of all the services for hospitalists and only 12% for traditionalists. This bolsters the hospitalists’ claim that greater experience in a hospital setting makes them more efficient providers.
  • % of Females: The percent of hospitalists that are female stands at 35% compared to only 24% among traditionalists. The difference may exist because of the location where hospitalists may be more common or because of women’s desire not to be spread themselves too thin as a traditionalist working in both inpatient and outpatient environments.
  • Uptake by State: States with a minimum of half a million hospitalist services and 75% or greater hospitalist uptake are: Nevada, Washington, Arizona, Massachusetts, North Carolina, and Virginia. States lagging with 60% or less in hospitalist uptake are: Alabama, West Virginia, New Jersey, Mississippi, Illinois, Arkansas, Kentucky, Louisiana, and Indiana.
  • Specialty: Internal Medicine specialty dominates the hospitalists with 84% belonging to it compared to 58% of the traditionalists.
  • Workload: The average Medicare workload for a hospitalist was 910 services or1,759 wRVUs compared to 409 services and 748 wRVUS for a traditionalist. It is important to remember that this workload only represents Medicare patients and does not include Medicare Advantage or private-pay patients.
  • Coding Levels: The highest level admission code (99223) was used 66% of the time as opposed to 99221/99222. For subsequent care middle level code (99232) was used 62% of the time compared to 99231/99233. Generally, hospitalists were more prone to using higher levels codes compared to traditionalists, possibly reflecting sicker patients under their care. .
  • Charge Mark-Up: Hospitalists marked up submitted charges at 204% (more than twice) of the Medicare allowed amount compared to traditionalists who submitted charged at 171% of the Medicare allowed.
  • Paid vs. Allowed: Both hospitalists and traditionalists were reimbursed 79% of the allowed amount. In other words, the an additional payment of 21% for deductible and coinsurance amounts would have been due from other sources, including patients.
  • Paid Amount: Medicare paid $3.93 billion for hospital services provided by hospitalists and traditionalists with 68% of it going to the hospitalists. It is important to remember that Medicare payments represent only a portion of the full revenues (notprofits) because physicians also bill private insurers and other payers.
  • Payment Rate: The payment rate per service was $76. Because services can range from 99231 (at $30) to 99291 (at $174), a better way to look at the payment rate is per wRVU, which was $40. The allowed rate per wRVU was $51.
  • Gender Gap?: Despite the headlines regarding Gender Pay Gap, the amount paid per wRVU was virtually identical for female and male physicians at $40 indicating that the difference in total amount paid to men vs. women is explained by the volume or number of wRVUs submitted rather than the reimbursement rate.


The demographic, utilization, and payment data provides unprecedented insights into the heretofore loosely-defined “hospitalist” profession.