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 Times, Wall Street Journal, and ProPublica.
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.
A 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.
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.
The 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!
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