OIG targets sleep studies, and CMS promises crack down
Nearly $17 million of the $565 million spent on sleep studies in 2011 did not meet Medicare requirements, according to a recent report from the Office of the Inspector General (OIG). In response, the Centers for Medicare and Medicaid Services (CMS) said it would take a more critical approach to polysomnography.
OIG recommended that CMS tighten its claims processing for sleep studies and that the agency take action against providers and suppliers that might have received improper Medicare payments.
The report titled "Questionable Billing for Polysomnography Services" follows the OIG’s 2013 work plan, which indicated its intent to review and identify questionable billing patterns for Medicare-covered sleep studies. That work plan was prompted by a marked increase in Medicare spending on sleep studies. The OIG noted that from 2005 to 2011, Medicare spending on sleep studies increased 39% from $407 million in 2005 to $565 million in 2011. (The OIG report is available online at http://1.usa.gov/1gfI4su.)
Even before the report, Florida-based American Sleep Medicine agreed in March 2013 to pay a $15 million settlement to resolve allegations that it submitted false claims to Medicare and other federal payers.
For the report the OIG reviewed provider and supplier billing for sleep study services. Medicare payments for sleep study services from 2011 were analyzed under 11 measures of questionable billing. There were three Medicare requirements for reimbursement. There were eight measures independently designed through collaboration between sleep medicine professionals and fraud investigators within and outside the OIG. The OIG found that $17 million of the payments made to providers in 2011 did not meet one or more of the three Medicare requirements and that 180 providers and suppliers exhibited patterns of questionable billing practices.
The OIG found that most of the facially inappropriate claims involved wrong diagnosis codes, duplicate services for the same beneficiaries, or invalid National Provider Identifier (NPI) numbers. Eighty-five percent of the invalid claims originated from hospital outpatient departments, a disproportionately high number considering that hospital outpatient department sleep study claims represented only 53% of all such claims in 2011.
The 180 providers and suppliers exhibiting questionable sleep study billing practices exhibited one or more of the following patterns:
• same-day or duplicate claims;
• double-billing for the professional component of sleep studies;
• repeated procedures;
• missing professional component;
• multiple sleep studies performed for the same beneficiaries;
• unbundled claims (services performed over two consecutive nights usually must be bundled together and billed on the same claim);
• missing visits from ordering provider.
The OIG made these recommendations to CMS:
• Implement and improve claims processing edits and controls to prevent inappropriate payments.
• Recover payments for claims that were found not to meet Medicare requirements.
• Leverage measures of questionable billing practices identified in the study to identify providers and suppliers for further investigation.
• Take appropriate action regarding the 180 providers and suppliers that OIG found to exhibit questionable billing patterns.