Solo practitioners come under fire

According to Joseph Russo, president of HP3 Healthcare Concepts in Bethlehem, PA, the Department of Health and Human Services’ Office of Inspector General and Medicare Part B contractors have increased their scrutiny of solo practitioners and small group practices. "Audits by Medicare have increased significantly," he warns. "Solo practitioners and small group practices are no longer immune from the audit authority of the federal government."

According to Phoebe Moore, of the same firm, contractors may elect to conduct a "limited" medical record review, a "probe sample review," or a full RAT-STATS review when investigating these issues. Medicare utilizes a data system to capture billing and coding information and further analyze utilization patterns, she adds.

"Though designed to compare the billing practices of one carrier to another carrier or the nation, the system is also a useful tool for spotlighting trends in usage and detecting reporting errors and uncovering aberrant reporting patterns," Moore says.

While data analysis and comparison of a particular physician profile would not provide conclusive evidence of the occurrence of inappropriate billing activity, Russo says it is clear, as stated in the Program Integrity Manual, that "contractors are not meeting Medicare’s payment safeguard expectations if they react only to complaints and leads outside their environment."

The manual also states, "Contractors must proactively seek out fraud and abuse, and should review data for billing practices, patterns, or trends that may indicate abusive and/or fraudulent billing by scanning data for inexplicable aberrations from the expected and relating those aberrations to specific providers."

"Clearly, a provider with a utilization profile falling outside of that which would be normal for the particular specialty and geographic area should be aware of the potential for further review," Russo warns.

He also points out that in its Work Plan for 2002, which outlines areas of focus for the upcoming year, the OIG puts the spotlight on this area. Physician evaluation and management (E&M) codes will be reviewed to "determine whether physicians correctly code E&M services in physician offices and effectively use documentation guidelines." He says physicians should note that 1995 or 1997 documentation guidelines are utilized to make these assessments.