But in its reply to the findings, the Centers for Medicare and Medicaid Services, which runs Medicare, said it doesn’t plan to review the billings of doctors who almost always charge for the most-expensive visits because it isn’t cost effective to do so.
The inspector general’s report, released today, estimates that overpayments account for 21 percent of the $32.3 billion spent on evaluation and management (E&M) services in 2010. The E&M category includes office visits, emergency room assessments and inpatient hospital evaluations.
This is the second time that the inspector general has singled out this area for more scrutiny. In 2012, the watchdog said physicians had increasingly billed Medicare for more intense — and more expensive — office visits over time. But that didn’t prove the claims were improper.
“The natural question that comes out of this is: Are these physicians billing appropriately?” said Dwayne Grant, regional inspector general for evaluation and inspections in the Atlanta region, who oversaw the new report. “We don’t want to pay them too much but we don’t want to pay them too little either.”
For this review, the inspector general gathered the medical records associated with 657 Medicare claims and asked professional coders to see whether the records justified the rates charged.
Overall, more than half of the claims were billed at the wrong rate or lacked documentation to justify the service. Sometimes physicians billed for a lower-cost service than the one they delivered, but more often they billed for a higher-cost one. The inspector general extrapolated from its sample to estimate the amount Medicare overpaid on all 2010 E&M claims.
“We have to do a better job of curbing improper payments and protecting taxpayer dollars,” Sen. Bill Nelson (D-Florida), chairman of the U.S. Senate Special Committee on Aging, said in a statement.
The inspector general’s findings complement a recent review by ProPublica of data recently released by Medicare on payments to individual health professionals for services in its Part B program. We found that in 2012, more than 1,800 doctors and other health professionals almost exclusively billed Medicare for the most complicated and expensive office visits for their established patients.