Home > DocuBase > Article
« All DocuBase Articles
Thursday, 23rd December 2010
Questionable Billing for Medicare Outpatient Therapy Services
Questionable Billing for Medicare Outpatient Therapy Services (PDF)
Source: U.S. Department of Health and Human Services, Office of Inspector General
We found that per-beneficiary spending on outpatient therapy in Miami-Dade County was three times the national average in 2009. We also found that Miami-Dade County had high levels of questionable billing for outpatient therapy. Nineteen additional counties also exhibited questionable billing, but to a lesser extent than Miami-Dade County.
Medicare paid $4.9 billion for outpatient therapy services provided to 4.5 million beneficiaries in 2009. South Florida, and Miami-Dade County in particular, has been the focus of efforts to combat Medicare fraud, waste, and abuse in recent years. We identified 20 high-utilization counties that had in 2009 (1) the highest average Medicare payment per beneficiary and (2) more than $1 million in total Medicare payments for outpatient therapy. Miami-Dade County had the highest average Medicare payment per beneficiary among the 20 high-utilization counties and the highest total Medicare payments for outpatient therapy services in 2009. We analyzed Medicare claims data to compare patterns of billing for outpatient therapy in Miami-Dade County, in the 19 other high-utilization counties, and nationally. We also examined claims for the presence of six questionable characteristics that may indicate fraud.
We found that Medicare per-beneficiary spending on outpatient therapy services in Miami-Dade County was three times the national average in 2009. We also found that Miami-Dade County had at least three times the national levels for five of the six questionable billing characteristics. In the 19 other high-utilization counties, Medicare's per-beneficiary payment on outpatient therapy services was 72 percent greater than the national average. These 19 counties also exhibited questionable billing but to a lesser extent than Miami-Dade County. As a group, these counties had at least twice the national level for five of the six questionable billing characteristics.
We recommend that CMS (1) target outpatient therapy claims in high-utilization areas for further review, (2) target outpatient therapy claims with questionable billing characteristics for further review, (3) review geographic areas and providers with questionable billing and take appropriate action based on results, and (4) revise the current therapy cap exception process. CMS concurred with all four recommendations.
See also: Questionable Billing for Brand-Name Inhalation Drugs in South Florida (PDF)
Please note: DocuTicker's editors collect citations for full-text PDF reports freely available on the web but we do not archive these reports. When you click a link to find and/or download the report, you are leaving the DocuTicker site. DocuTicker makes no representations regarding the ongoing availability of any report or any external resource. Links were accurate as of the date of posting.
« All DocuBase Articles
FreePint supports the value of information in the enterprise. Read more »
Latest FreePint Content:
Source Update for Factiva
Tuesday, 7th July 2015
The latest additions and takedowns in Factiva, researched and compiled by Anne Jordan.
Product Review of FirstWord Pharma PLUS (Introduction; Value; Contact Details)
Tuesday, 7th July 2015
FirstWord Pharma PLUS, the personalised news, analysis and expert opinion service for pharmaceutical industry professionals, is introduced here by Robyn Smith in the first part of her product review. As the premier information platform within the suite of FirstWord Group's bioindustry products, she considers audience, access and value.
Results from FreePint Research into Skills Part 3 - Strategy and Resources
Monday, 6th July 2015
In part three of her analysis Robin Neidorf reports further on FreePint's research into how information professionals address skills development. The research included a series of questions to understand the state of strategic planning around skills development, including: the impact of strategy, leadership and organisational culture on information skills investment, strategic planning to meet information skills needs, and budget & resource considerations. We also asked what needs to change in terms of additional or alternative resources or training for information professionals and knowledge workers.
- ... more ...
All FreePint Content »
FreePint Topics »
A FreePint Subscription delivers articles and reports that support your organisation's information practice, content and strategy.
Find out more and order a FreePint Subscription by visiting the
completing our online form: Subscription Order page.
"FreePint has lots of content that looks really interesting to read, I look forward to getting my teeth into it."
Information Officer, Law firm
Read more testimonials and supply yours »