Medicare Compliance & Reimbursement

Plus: Master the 1P, 2P and 3P modifiers to protect your bonus.

Medicare could use "profiling" to find physicians who are providing too many services or being inefficient, said Bruce Steinwald with the Government Accountability Office at an April 3 presentation before the American Enterprise Institute.

Medicare already has a "comprehensive claims database" that would make this kind of examination possible, Steinwald noted. The database covers all the services physicians provide to patients. Also, Medicare has enough physicians in each region to allow meaningful local comparisons. And the program has some experience in using methods to account for differences in patients' health status.

CMS Unveils Quality Reporting Specs

Heads up: You have less than three months to gear up to start reporting quality indicators if you want to receive an extra 1.5 percent of your claims from July through December.

To help you prepare, the Centers for Medicare & Medicaid Services (CMS) released specifications, at www.cms.hhs.gov/PQRI/Downloads/Specifications_2007-02-04.pdf. For each quality measure, the document lists the CPT codes and diagnosis codes that go with it. If you report a particular CPT code and ICD-9 code together, you can see if the quality measure applies. Then you report on test results or other measures using Category II or "G" codes.

If the measure doesn't apply, you can use the 1P (Medical reasons), 2P (Patient reasons) and 3P (System reasons) modifiers to explain why you didn't apply it. Alternatively, you can apply modifier 8P (Unspecified reasons).

Not set in stone: CMS says it may still expand some of these specifications before the July 1 deadline, to allow the measures to apply to more specialties and providers.

In Other News...

• Medicare underpaid doctors in rural counties by $2.4 billion from 2001 to 2007, according to a complaint five California counties filed with the Department of Health & Human Services (HHS).

The counties say their doctors are paid up to 25 percent less than doctors in nearby counties for the same services ...quot; even though the neighboring areas don't have much higher costs of living. The counties claim the pay gap is forcing local doctors out of the Medicare business and forcing patients to travel long distances to find providers, according to an article in the Sacramento Bee. "We have patients who can't find doctors," Michael Reedy, a San Jose, CA attorney who helped file the HHS claim, told the Bee.

Medicare pays doctors differently depending on their geographic area, and the system is supposed to reflect geographic differences in cost.

If HHS turns down the claim, then Reedy plans to file a class-action suit in federal court.

• HHS created a "fictional patient" named Paul Watson for a Medicare sting operation. A medical equipment company owner claimed she could obtain a signed power wheelchair prescription for Watson from a doctor and "give her a couple of bucks."

The sting caught internist Zandrina Alexander, who appealed her health-care fraud conviction because of two tape recordings that were used as evidence against her. But the U.S. Court of Appeals for the Eleventh Circuit affirmed her conviction.