Medicare Data Uncovers Hospitalist Billing Trends: 7 Things to Know

Medicare physician payment data reveals more than 1,000 hospitalists — primary care physicians providing hospital-based services — billed Medicare more than five times the average amount in 2012, according to an independent analysis by healthcare consultant Abhay Padgaonkar, founder and president of Innovative Solutions Consulting.

Hospitalists should ensure they meet Medicare billing requirements, according to Mr. Padgaonkar. Here are seven things to know about his analysis and findings.

1. The analysis is based on data CMS released in April including information on more than 880,000 healthcare professionals across the country who received a total of $77 billion in Medicare Part B fee-for-service payments in 2012. With the data, it's possible to compare 6,000 different types of services, procedures and payments received by individual providers, according to HHS.

2. The average workload for more than 79,000 primary care physicians included in the CMS data was 1,230 Medicare work relative value units in hospital-based services. Physicians who provided more than 50 percent of their total services under the 20 CPT codes associated with hospital-based services were classified as hospitalists, according to the analysis. Hospitalists had an average workload of 1,759 wRVUs in 2012.

3. According to Mr. Padgaonkar, the top 1,000 hospitalists averaged more than 9,300 wRVUs — 5.3 times the average hospitalist. The top 263 physicians each billed more than 10,000 wRVUs, and one hospitalist hit the 40,000 mark.

4. There is a plausible explanation for the extremely high hospitalist wRVUs, according to the analysis. Services can be billed under a supervising physician's National Provider Identifier, so those wRVUs may actually include many clinicians instead of just one. However, a physician can only bill Medicare under another physician's NPI under certain circumstances. The regular physician must be unavailable to provide the services, the "locum tenens," or substitute, physician cannot be an employee of the regular physician, and the regular physician must pay the locum tenens on a per diem or similar fee-for-time basis. Additionally, the substitute physician can't provide the services to beneficiaries during a continuous period of more than 60 days.

5. Physicians may also bill for services provided by non-physician practitioners, but only under specific circumstances. For instance, Mr. Padgaonkar writes, "If the physician uses the services of his/her own employees in a hospital setting and the physician merely 'supervises' his/her services, the physician is not eligible for a payment from Medicare because supervision alone does not constitute a reimbursable practitioner service." Physicians may bill for NPP services under shared/split visits only if the physician provides any face-to-face portion of the evaluation/management encounter with the patient. The face-to-face encounter must also be documented, and the medical record should clearly identify which portions of the service were provided by the physician and which were administered by the NPP.

6. Teaching physicians may also bill for services administered by residents under certain circumstances, according to Mr. Padgoankar. For instance, physicians must document that they performed the service or were physically present during critical portions of a resident performing the service.

7. Overall, Mr. Padgoankar concludes compliance with the billing requirements for multiple providers billing under a single NPI would "severely constrain" the maximum workload for hospitalists. "To avoid any unwanted attention and to steer clear of expensive and time-consuming audits, all hospitalists should re-examine their current billing practices for billing under another provider's NPI," he writes.

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