Resident billing is biggest problem found in audits
Resident billing is biggest problem found in audits
Even though some of the hospitals audited by the federal government were fined millions of dollars, the list of billing errors is short. The same problems were found at almost all of the hospitals, and the government alleges that the providers just did not follow the advice provided by their carriers and intermediaries.
Two billing errors were found at all three of the five audited hospitals that had to pay penalties. Improperly billing for the services provided by residents was cited at the University of Pennsylvania, Thomas Jefferson University, and the University of Virginia. Billing for faculty physicians at levels unsupported by the medical records also was found at all three. The University of Pennsylvania also was cited for incomplete documentation.
Though the same three billing errors were common to all the hospitals penalized after their audits, avoiding those errors is not necessarily so easy. To better understand the intricacies of those billing errors, Healthcare Risk Management sought advice from Michael Mangano, principal deputy inspector general of the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services. There is little explanation available for the citation for insufficient documentation; if auditors find that the medical records are incomplete in a way that may affect the billing justification, they can penalize you for insufficient documentation.
Drawing on his recent testimony before the U.S. Senate Committee on Appropriations, Mangano provides this advice on the two errors that make up almost all the problems found in PATH audits:
o Billing by faculty physicians for services actually performed by residents.
The government takes a hard stand on this issue because Medicare supports the costs of training residents and interns through the graduate medical education (GME) program. It also pays for other indirect medical education (IME) costs by increasing the normal reimbursement rates for each DRG. Teaching hospitals can easily receive more than $100,000 per resident per year from the government. At the University of Pennsylvania, Medicare had paid over $126,000 per resident in GME and IME payments for physician training.
"In light of these direct and indirect payments for training, the teaching physicians may not submit claims for payment to Medicare Part B for the same general supervision of residents and interns already paid for under Part A," Mangano says. "Teaching physicians seeking reimbursement under Part B must do more."
A 1967 regulation, 42 CFR 405.521 (1992 version), allows teaching physicians to bill the program when they personally provide services and "when the attending physician furnishes personal and identifiable direction to interns or residents who are participating in the care of the patient. A clarification in 1969, Intermediary Letter 372, added that teaching physicians must "render personal and identifiable medical services" after establishing themselves as the attending physician. To qualify as the attending physician, the clarification says the doctor must meet these criteria: reviewing the patient’s history, personally examining the patient, confirming or revising the diagnosis and determining the course of treatment, performing the physician’s services or supervising the treatment, and being present for all complex or dangerous procedures.
Over the years, Medicare provided more policy documents that required teaching physicians to provide "personal and identifiable services" or "personal and identifiable direction" in order to bill. The physical presence of the teaching physician is one clear indication of a more patient- specific level of involvement that may entitle him or her to Part B reimbursement. "Working elbow-to-elbow" with the resident is a phrase often used by the OIG.
"What was clear was that teaching physicians had to have a personal role in delivering the medical service, and it had to be far more direct than the general supervision already compensated under GME," Mangano says.
An OIG review of carrier policies and directives found that more than 75% of the providers with teaching programs received guidance that conditioned Part B reimbursement on either personally furnishing a service or being present when it was furnished by an intern or resident. In 1977, the Medicare Regional Office responsible for Pennsylvania issued Regional Intermediary Letter 20-77, stating that "it will suffice for either the intern, resident or nurse to note in the record that the physician was personally involved in the particular service billed for. A physician countersignature of notes entered by a resident, intern, or nurse is not in itself evidence that a covered service was rendered unless the notes indicate that the physician was present."
In the completed PATH audits, auditors found that a physician billed Medicare for hospital care provided during a three-day period in which his travel schedule placed him out of town, another billed for one hour of critical care on each of two days when he was out of town at a conference, and another billed for a hospital visit on each day of a weeklong leave.
o Billing for improper levels of service.
Codes for patient visits, known as evaluation and management codes, have levels ranging from the least complex and time-consuming to the most complex. The audits are designed to detect abusive patterns or practices of improperly selecting codes that overstate the actual level of service provided. The OIG looks for patterns of abuse rather than isolated inadvertent mistakes.
"You would normally expect to find coding errors that are mixed, that is, some in favor of the hospital and some in favor of Medicare," Mangano says. "When an audit demonstrates that the overwhelming majority of coding errors favor the provider, it is an indicator of billing abuse."
At one teaching hospital, auditors found that very few consultations and hospital visits were billed at the two lowest levels. Further investigation revealed that the preprinted forms used by teaching physicians to record the level of service omitted the two lowest codes for these services as choices. As a result, the physicians rarely billed for a less expensive patient visit even though the medical record clearly showed that as the level of service provided.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.