Questionable Billing for Medicare Electrodiagnostic Tests

WHY WE DID THIS STUDY

In 2011, Medicare paid approximately $486 million to 21,700 physicians who billed for electrodiagnostic tests for 877,000 beneficiaries. Electrodiagnostic tests are used to evaluate patients who may have nerve damage. Recent investigations have found that electrodiagnostic testing is an area vulnerable to fraud, waste, and abuse. For example, in 2011, following work by the Medicare Fraud Strike Force, a group of physicians was charged with fraudulently billing Medicare $113 million for false claims, including claims for electrodiagnostic tests. CMS issues comparative billing reports to providers for a variety of services, including electrodiagnostic testing. Such reports are intended to proactively educate providers and to help them identify and correct errors in their billing.

HOW WE DID THIS STUDY

We developed seven measures of questionable billing on the basis of past OIG work and input from CMS staff. We analyzed Medicare 2011 electrodiagnostic test claims to identify physicians who had unusually high billing for at least one of these measures. We also determined whether physicians with questionable billing for electrodiagnostic tests received comparative billing reports in 2011 for such tests. Finally, we identified the geographical areas with the highest amounts of questionable billing.

WHAT WE FOUND

In 2011, 4,901 physicians hadtotaling $139 million. Additionally, we found that approximately 20 percent of these physicians received comparative billing reports in 2011 on the basis of their 2010 billing for electrodiagnostic tests. Finally, physicians in the New York, Los Angeles, and Houston areas had the highest totalin 2011.

WHAT WE RECOMMEND

We recommend that CMS (1) increase its monitoring of billing for electrodiagnostic tests, (2) provide additional guidance and education to physicians regarding electrodiagnostic tests, and (3) take appropriate action regarding physicians whom we identified as having inappropriate or questionable billing. CMS partially concurred with two of our recommendations and concurred with the third recommendation.