The Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a report focused on clinicians generating high cumulative payments, defined as more than $3 million annually per clinician for Medicare Part B services. The OIG found that of the 303 clinicians who furnished more than $3 million in Medicare Part B services during 2009, 104 (34 percent) were identified for improper payment reviews by Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs). The MACs and ZPICs have identified $34 million in overpayments based on a review of 80 of the 104 clinicians. The OIG also found that three of the reviewed clinicians had suspended medical licenses and two had been indicted. The OIG concluded that identifying clinicians responsible for high cumulative payments provides a useful means for identifying potential improper payments.
The OIG recommended that the Centers for Medicare & Medicaid Services (CMS):
- Establish a cumulative payment threshold above which clinicians’ claims would be subject to review.
- Implement a procedure for timely identification and review of claims exceeding the cumulative payment threshold.
CMS partially concurred with each of the OIG’s recommendations. In its response, CMS indicated it intends to consider service type and provider specialty in informing the appropriate cumulative payment threshold levels.
The OIG’s report related to clinicians generating high Part B cumulative payments is available at:
Department of Health and Human Services Office of Inspector General. “Reviews of Clinicians Associated with High Cumulative Payments could Improve Medicare Program Integrity Efforts.” 19 Dec. 2013.