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Medicare Rule Puts Patients at Risk

Cheryl Clark, for HealthLeaders Media, August 6, 2009

Millions of Medicare patients are being put at risk by a practice that allows physicians to be paid for care actually provided by non-physicians who have no verifiable credentials or appropriate training, according to a new report from the Office of Inspector General, which recommends such procedures be stopped.

"We are concerned about the potential scale of this problem," the Inspector General wrote in a 32-page report, which for the first time analyzed the issue. The investigators reviewed a random selection of 3,165 physicians, 4% of who billed Medicare during the first quarter of 2007.

Unqualified nonphysicians performed 21% of the services that physicians did not perform personally during this period. Medicare paid $12.6 million for approximately 210,000 services performed by unqualified non-physicians.

"These non-physicians did not possess the necessary licenses or certifications, had no verifiable credentials or lacked the training to perform the service," the report said.

Additionally, "non-physicians with inappropriate qualification performed 7% of the invasive services that physicians did not perform." Invasive services in particular put patients at additional risk because they involve more complex procedures that require "entry into the living body (as by incision or by insertion of an instrument)."

They involve venipuncture, surgical procedures, non-oral drug administration, and chemotherapy, according to the report.

The Inspector General examined billings for cardiovascular, diagnostic radiology, ophthalmology, and rehabilitation therapy services under a practice that allows physicians to be reimbursed for services for more than 24 hours a day, the so-called "incident to" rule, even though such services were provided by physician assistants, nurses, medical technicians, and medical assistants concurrent to the physician's billing day.

The report also said the "incident to" rule "may be vulnerable to overutilization," a key buzzword in health reform debates.

Apparently, very large amounts of taxpayer funds are spent on non-physician services. Medicare allowed $105 million for approximately 934,000 services that the physicians personally performed and approximately $85 million for approximately 990,000 services that non-physicians personally performed during this three-month period.

The report recommends that the Centers for Medicare and Medicaid Services change this "incident to" rule to require physicians who do not personally perform the services they bill to Medicare to ensure that no person–except licensed physicians or non-licensed physicians who actually have appropriate training under state laws, regulations and Medicare rules, and only under the direct supervision of a licensed physician–perform this care.

Additionally, the Inspector General recommends that whenever a physician bills CMS for services provided by a non-physician, that service be identified by a service code modifier so the federal government paying the bill can ensure that the non-physicians are appropriately qualified.

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