OIG wants more controls on nonphysician billing

Use of physician extenders soaring

The rapid rise in Medicare payments to nonphysician practitioners has the Office of Inspector General (OIG) worried that some of this increased spending may be the result of bogus billing. As a result, the antifraud shop is calling for added controls to determine which related services should be reimbursed.

In a recent report (OEI-02-00-00290), the OIG noted that nonphysician practitioners — nurse practitioners, clinical nurse specialists, and physician assistants — are paid through Medicare Part B. According to the report, Medicare paid for 5.2 million nonphysician practitioner services, in 1999 compared to only 1.2 million in 1997.

One reason for this jump is that enactment of the Balanced Budget Act of 1997 allowed payments for nonphysician practitioners in all geographic areas. Before then, nonphysician practitioners were only allowed reimbursement in rural areas and selected health care settings. In addition, nurse practitioners and clinical nurse specialists are now allowed to bill Medicare directly, although physician assistant services must continue to be billed by an employer.

Scopes of practice vague

One problem the OIG zeroed in on is that while individual states are responsible for setting the scopes of practice for Medicare-recognized nonphysician practitioners, most jurisdictions have only a vague definition of any related responsibilities and educational requirements.

Many states also fail to clearly identify the duties beyond a nonphysician practitioner’s scope. As a result, it is often unclear whether these caregivers are prevented from performing certain services not specifically mentioned in a scope, the report noted.

Bottom line: Look for more limits to be placed on future scopes of practice for nonphysician practitioners, plus added guidance to carriers when determining which services are reimbursable.