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Medicare Compliance & Reimbursement

FRAUD & ABUSE:

Warning--Medicare Spent More Than A Billion Dollars On Improper Consults

Published on Sun May 13, 2007

Use modifiers in moderation, or face dire consequences.

Heads up: Your use of the 25 and 59 modifiers is still on the feds' watch list.

Medicare could save $538 million by reducing improper use of the 25 modifier, and $59 million by cutting back on the 59 modifier, the HHS Office of Inspector General (OIG) insists in its 2007 compendium of unimplemented recommendations.

More than a third of carriers had not examined your use of the 25 modifier when the OIG issued its report on the subject in late 2005. Also, 15 percent of the time that physicians used the 59 modifier, the services "were not distinct from each other," the OIG says.

What to expect: More scrutiny from the Centers for Medicare & Medicaid Services (CMS) and carriers on your modifier use.

Also on the OIG's hit list are:

· consults. Medicare spent $4.1 billion on consults in 2004, up from $3.3 billion in 2001, the OIG says. Three out of four consults didn't meet the definition of a consult or were the wrong type of consult, the OIG insists. What's next: Medicare will keep trying to crack down on consults without a request on file.

· allergy shots. Medicare overspent $75 million. CMS should educate physicians to make sure allergen immunotherapy is really medically necessary and properly documented, the OIG maintains.

· nail debridement. Medicare wasted $96.8 million on debridement services that weren't medically necessary or well-documented, the watchdog organization says.

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