Audit of Medicare Part B Services Billed by Inland Physicians' Service for the Period January 1, 1994

Hhs Office Of Inspector General, Office Of Audit Services (Oas)

Informations

• Publié par: Oslu
• Nombre de lectures: 11
• Langue: English

Extrait

Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
Office of Audit Services
Region IX
AUDIT OF MEDICARE PART SERVICES
BILLED BY INLAND PHYSICIANS’
SERVICE FOR THE PERIOD
JANUARY THROUGH
DECEMBER 31, 1996
in this report represent the findings and opinions
of the HHS/OIG/OAS.
made by authorized officials of the HHS operating divisions.
Final determination on these matters will be
incurred or claimed as well as other conclusions and
questionable or a recommendation for the disallowance of costs
The designation of financial or management practices as DEPARTMENT OF HEALTH SERVICES
1 6 1998

CIN: A-09-97-00062

Mr.

Manager

Medicare Audit

1150 South Olive, T200

Dear Mr. Velasco:

Enclosed are two copies of the U.S.

Human Services (HHS),

A copy of this
1994 THROUGH DECEMBER 31, 1996." JANUARY 1,

We request

the date of this letter.

OIG, OAS reports issued to the

(See 45 CFR

Part 5.)

Act which the Department chooses to exercise.
information contained therein is not subject to exemptions in the
to members of the press and public to the extent requested,
Department's grantees and contractors are made available, if
Act (Public Law
In accordance with the principles of the Freedom of Information
bearing on the final determination.
comments or additional information that you believe may have a
Your response should present any
that you respond to the HHS action official within 30 days from
will be made by the HHS action official named below.
Final determination as to actions taken on all matters reported
her review and any action deemed necessary.
report will be forwarded to the action official noted below for
SERVICES BILLED BY INLAND PHYSICIANS' SERVICE FOR THE PERIOD
Audit Services (OAS) report entitled 'AUDIT OF MEDICARE PART B
Office of Inspector General, Office of
Department of Health and
Los Angeles, California 90015-2211
Insurance Company
Transamerica Occidental Life
Ed Velasco-
Page 2 Mr. Ed Velasco

relating to this report.

Lawrence Frelot

for Audit Services

Direct Reply to HHS Action Official:

Mrs. Alysson Blake

75 Hawthorne Street,

San Francisco, CA 94105

floor
Region IX
Health Care Financing Administration
Associate Regional Administrator for Medicare
as stated Enclosures
Regional Inspector General
Sincerely yours,
Identification Number A-09-97-00062 in all correspondence
To facilitate identification, please refer to Commoni

The review was
and abuse in the Medicare program. fraud, waste,

Insurance Company (Transamerica), a Medicare carrier.

Inland Physicians'

facilities and hospitals in the Pomona, California area.

1996 to determine if the payments were
through December 31,
appropriate for the services rendered.

SUMMARY OF FINDINGS

104 services) for which IPS was reimbursed by Medicare.

represented services which had been overpaid.

The overpayments included services which:

referred to as upcoding),
medical records,
services were rendered in different geographic areas,
subject to lower reimbursement.

supervising physician present and, therefore, were
Had been performed by physician assistants without the
and
Should have been paid at lower amounts because the
Were not supported by adequate documentation in the
than those actually performed (a condition commonly
procedure codes) that described services more complex
Had been billed using numeric coding descriptors (i.e.,
combined review disclosed that 99 of the 100 claim lines
Our
reviewed a statistical sample of 100 claim lines (representing
With the assistance of Transamerica's medical consultant, we
to IPS by Transamerica over the 3-year period January 1, 1994
Our audit examined the Medicare payments (about $2 million) made
OBJECTIVE
provides services to elderly Medicare patients in nursing
partnership of two Doctors of Osteopathy) which primarily
Service (IPS) is a group medical practice (a
jointly conducted by the OIG and Transamerica Occidental Life
Department of Health and Human Services initiative to combat
This audit was an outgrowth of Operation Restore Trust, a U.S.
BACKGROUND

one reason for the We have included a matrix (see

the overpayments for each sample item.

We are 95 percent confident that the
IPS was overpaid $752,256.
overpayment was at least $581,379.

all appearances,
reimbursement rules.

in determining the proper billing

RECOMMENDATIONS

we recommend that Transamerica:
To address these problems,
related to Medicare rules and regulations,
obtain additional provider numbers that
the various geographic areas in which corresponding to
it renders services,
prepayment review until it can
Place under
it can properly bill for services,
demonstrate that

1997, and

ldentified overpayment of $581,379 at
the
further review by our office.

IPS disagreed with the audit
In response to our draft report,
and considering IPS comments, we

remain valid.

in agreement with the findings and
Transamerica was

ii
recommendations.
this time pending
Not
Conduct an audit of IPS billings for Calendar Year
Require
Provide IPS with all pertinent educational materials
requirements.
sought the carrier's assistance
themselves of Medicare's published instructions nor had they
they had not availed From
physicians were apparently not familiar with the various Medicare
We concluded that the overpayments occurred because the IPS
Based on the results of our statistical sample, we estimate that
Appendix A) that depicts the various reasons that contributed to
Sixty-six of the 99 claim lines that were overpaid had more than.
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TABLE OF CONTENTS

EXECUTIVESUMMARY ....................

........................

Background .......................
Scope and Methodology ...........

................
FINDINGS AND RECOMMENDATIONS

Services ....................
............
Inadequately Documented Services
..
Services Performed In Lower-Priced Geographic Areas
Services Performed by Physician Assistants Without the

Supervising Physician Present ...........
................... 10
Recommendations
..................... 10
IPS Comments
.................... Comments
...............Transamerica's Comments

APPENDIX A:
Sampling Methodology
APPENDIX B:
APPENDIX C:

IPS Response
APPENDIX D:
Transamerica's Response
APPENDIX E:
Variables Projection
Reasons Contributing to the Overpayments
Objectives,
INTRODUCTION S
1

Background

In May 1995,

demonstration project,
down on Medicare fraud, waste,

home health agencies,

rendered to patients in nursing homes.

Service (IPS), a partnership created by two

physicians,

with other physicians in California.

in August 1993.

The physicians

partnership in 1995. They primarily provide medical services:

At the time of our audit, the doctors employed a staff of 12,

and 6 administrative personnel.

is a private company,

claims.

the new carrier effective December 1,
Insurance Company (NHIC),

1996.
another Medicare carrier, or National Heritage Blue Shield,
services provided at the medical office location were billed to
Group) for services provided at the medical office location. The
numbers (Inland Region Medical Group and Inland Hills Medical
The doctors also billed Medicare using two other names and
contracts with the Federal Government to process and pay Medicare
usually an existing insurance company, that
Medicare patients in nursing facilities and hospitals. A carrier
Medicare billing name and number for services rendered to
Company (Transamerica), a Medicare carrier, using the IPS
submitting claims to Transamerica Occidental Life Insurance
They billed Medicare by
), 3 medical assistants, consisting of 3 physician assistants (PA
Hills, California.
maintenance organization patients in a medical office in Chino
and around the Pomona, California area, and (2) to health
(1) to elderly patients in nursing facilities and hospitals in
originally organized IPS as a corporation but changed it to a
musculoskeletal system to all other body systems.
that places special emphasis on the interrelationship of the
Osteopathy is a school of medicine and surgery
Two doctors of osteopathic medicine formed this medical practice
aberrant billing patterns for nursing home visits when compared
for this review because one of its doctors had
Physicians'
We selected Inland
We looked at physicians in California who billed for services
project.
This audit was an outgrowth of that demonstration suppliers.
and durable medical equipment homes,
and abuse associated with nursing
known as Operation Restore Trust, to crack
the Department of Health and Human Services be