Medicare Part B pays for services that are billed by physicians but performed by nonphysicians. Known as "incident to" services, they must be performed under the supervision of a physician. The OIG commissioned a study to find out what kinds of services were being performed and by whom. The study focused on a sample of physicians who had billed Medicare for more than 24 hours in a day during the first quarter of 2007; but the report notes that its conclusions undoubtedly apply to other doctors who bill for less than 24 hours a day.
For the days on which the physicians billed for more than 24 hours, Medicare allowed $105 million for approximately 934,000 services that the physicians personally performed and about $85 million for the 990,000 services that nonphysicians performed. Nonphysicians provided two-thirds of the invasive services and nearly half of the non-invasive services.
Now here's the weird part: Unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally. None of these staff members were certified or licensed by their state or by the federal government to provide these services. Moreover, "Nonphysicians with inappropriate qualifications performed 7 percent of the invasive services that physicians did not perform," the OIG report says.
Drilling down a bit further, we are informed that unqualified nonphysicians supplied 26 percent of the evaluation & management (E&M) services that physicians did not perform. That's pretty significant, considering that E&M services include key medical decision-making and diagnostic functions.
Unqualified nonphysicians also provided a whopping 37 percent of ophthalmology services that physicians didn't perform. Those included eye examinations, diagnostic imaging, eye photography, and ophthalmoscopy.
Unqualified clinicians also performed 49 percent of the rehabilitation therapy services that physicians did not provide, including therapeutic exercises, massage therapy, ultrasound therapy, therapeutic activities, and electrical stimulation.
Overall, 11 percent of the nonphysicians who performed invasive procedures had on-the-job training, and 4 percent had no relevant qualifications.
OIG advised CMS to revise the "incident to" rule so that it would allow charges only on behalf of nonphysicians who had appropriate training and/or licensure. Second, OIG recommended that physicians identify services that they did not perform personally by using a service code modifier for billing. Third, CMS was advised to disallow the claims that were not properly billed as "incident to." CMS concurred with two of these recommendations, but declined to require physicians to identify which services were performed by nonphysicians.
Just requiring physicians to have qualified personnel perform clinical services will undoubtedly shake up the medical field when CMS gets around to revising the "incident to" definition. But the bigger question is why doctors have allowed unqualified staffers to perform these tasks up to now. Some might say that they were forced to take this step by economic pressures. But when patient safety and the quality of care are at stake, we should expect more from our physicians.