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Summary: A U.S. General Accounting Office report found that consultants have been advising health care providers to perform billing practices that are not in line with federal guidance and have resulted in higher costs for the health insurance industry. |
Certain billing consultants may be encouraging providers to submit fraudulent claims information to private health insurance carriers, Medicare and Medicaid, according to a June 2001 report by the U.S. General Accounting Office (GAO).
The report was the result of an investigation request from Sen. Charles Grassley, R-Iowa, the ranking minority member of the Senate Finance Committee, which held a June 27 hearing on the report's findings. Grassley was concerned that some consultants were providing advice that could result in improper or excessive claims to Medicare, Medicaid, other federally funded health plans and private health insurance carriers.
The report noted that Medicare, Medicaid and private health insurers are vulnerable to health care fraud, which according to the Coalition Against Insurance Fraud, cost the health care industry about $54 billion in 1997 -- with $20 billion attributable to private insurers and $34 billion to Medicare and Medicaid.
Furthermore, HHS' Office of the Inspector General (OIG) has reported that provider-billing errors are significant contributors to improperly paid health insurance claims. The OIG defined billing errors as: (1) providing insufficient or no documentation; (2) reporting incorrect codes for medical services and procedures performed; and (3) billing for services that are not medically necessary or not covered -- which may result in violations of federal law.
Between July 2000 and June 2001, the GAO investigated one seminar sponsored by a physician assistants group -- which raised no concerns -- and two workshops which did raise concerns. Those workshops were ran by the same (unnamed) consulting company and advertised how to enhance revenue and avoid audits.
Specifically, the GAO found that the workshops provided certain advice that was inconsistent with HHS OIG guidance and could result in violations of both civil and criminal statutes. For example:
In conclusion, the report indicated that generally the advice at workshops and seminars could ease integrity problems in the Medicare and Medicaid programs by providing guidance on billing codes for evaluation and management services. However, integrity problems would be worsened -- and federal law violated -- if the advice provided at the two investigated workshops was followed. Furthermore, the report noted that the workshop advice raises the concern that some improperly paid health insurance claims are based on conscious decisions to submit inflated claims in an attempt to increase revenue.
Hearing Summarizes Findings
During the Senate Finance Committee hearing, Robert Hast, the managing director of GAO's office of special investigation, discussed the report's findings and how GAO has talked with OIG officials about the need to monitor similar workshops and seminars.
Furthermore, HHS has issued a special advisory bulletin on consultant practices to help providers avoid using consultants that could expose them to legal liability, added Lewis Morris, HHS assistant inspector general for legal affairs. In his written testimony, Morris emphasized that most billing consultants are honest and serve legitimate business purposes. But he noted that a "small minority" engages in improper and illegal practices and encourages the abuse of the Medicare and Medicaid programs. Here are two of his examples:
Dr. Kathryn Locatell, a private physician who assisted the GAO in its investigation, first shared in her written testimony her personal experiences with consultants. She noted that as a faculty member at a California medical center, she attended a mandatory billing and coding seminar. In her view, the goal of the consultants who ran the seminar was how to provide proper documentation to justify higher billing codes, regardless of medical necessity, to bring in more revenue for the medical center. Locatell found that this same theme "permeated" the seminars and workshops analyzed during the GAO investigation.
"The information we gathered in the course of our investigation suggests that the consultants marketing to and attracting physicians and physician groups advocate enhancing revenues in an 'audit-proof' fashion through systemic documentation efforts, regardless of medical necessity," said Locatell.
The report can be found on the GAO web site at http://www.gao.gov/cgi-bin/getrpt?gao-01-818. Or it can be ordered by calling 202/512-6000 and asking for report #GAO-01-818.
Excerpted from the August 2001 supplement to Employer's Guide to Self-Insuring Health Benefits, ©Thompson Publishing Group, Inc., 2001. All rights reserved.
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