Medicare, Fraud and abuse
Some 200,000 Medicare patients will have lose their health plan options or have to find new plans because of reductions in service or withdrawals by HMOs participating in the Medicare+Choice program. In all, nine HMOs plan to withdraw next year, while 23 others and a private fee-for-service plan are reducing their service areas. The withdrawals will hit low-income, minority, and disabled beneficiaries hardest, HHS says, because those patients are most dependent on managed care plans to provide prescription drugs and other benefits not available in traditional Medicare. If Congress doesn't act to improve payment rates, HHS warns, the HMO bailout is likely to continue.
Meanwhile, beneficiaries' Part B premiums are growing more than six times as fast as their Social Security benefits. While Social Security benefits will increase a mere 1.4 percent next year, the Part B premiums will be $58.70 a month8.7 percent more than this year's $54 bill. In addition, the Part A deductible for inpatient care will rise to $840, up 3.5 percent from this year's $817.
Once again, fraud busters in the HHS Office of Inspector General plan to dig deep into doctors' billing patterns, including:
Coding. The Feds will identify doctors with aberrant coding patterns, especially disproportionately large volumes of high-level E&M codes.
Consultations. Investigators will concentrate on the appropriateness of billings for consults in general; "long-distance" claims for face-to-face physician encounters, particularly for beneficiaries who require skilled care for ongoing illnesses, will also draw greater scrutiny.
"Incident to" services. Prompted by questions about the quality and appropriateness of services billed by allied health professionalssuch as RNs, techs, and therapiststhe government will look into the conditions under which physicians bill for "incident to" services and supplies.
Nonphysician services. Concern over billings for these services hasn't abated. Expect the OIG to analyze services provided by health care providers who practice in collaboration with or under the supervision of physicians. The investigation will focus primarily on the proportion of complex procedures performed by NPs, PAs, and others, and whether they've billed for procedures not covered by their scopes of practice.
Joan Rose. ONLINE News Briefs.