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HHS Finds High Rate of Questionable Medicare Billings for Electrodiagnostic Tests

April 9, 2014

Physicians submitted $139 million in questionable Medicare claims for electrodiagnostic tests in 2011, according to HHS’ Office of the Inspector General.

While some of the claims may have been valid, all of the physicians — 4,910 — warrant further scrutiny, the watchdog agency says. “The majority of these physicians had an unusually high percentage of claims with modifiers, which allow physicians to receive payments for services that are typically not separately payable,” a report published Tuesday says.

OIG looked at seven measures of questionable billing, based on OIG’s work, fraud investigations relating to electrodiagnostic tests and input from the Centers for Medicare & Medicaid Services. A claim was considered unusually high if it was greater than the 75th percentile plus 1.5 times the interquartile range using any of the measures.

The study points to weaknesses in CMS’ oversight of Medicare billing for these tests, the report says, noting that about a fifth of doctors with questionable billing received comparative billing reports in 2011 based on their 2010 electrodiagnostic test billing. OIG adds that nearly half of the 4,910 physicians flagged in the study were neurologists and physiatrists, and “CMS typically does not provide CBRs on electrodiagnostic testing to neurologists and physiatrists.”

To prevent future overbilling, OIG recommends that CMS increase its monitoring of electrodiagnostic tests claims and provide more guidance and education to physicians. The report also calls on CMS to take appropriate actions against doctors whose billing practices are out of line.

CMS partially concurred with the first two recommendations and wholly agreed with the third.

Electrodiagnostic tests evaluate patients with suspected nerve damage by measuring electrical activity in muscles and nerves. Medicare Part B pays for the tests when they are medically necessary and reasonable, and conducted by a licensed practitioner.

Read the report at www.fdanews.com/ext/resources/files/04/04-08-14-OIGReport.pdf. — Lena Freund

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