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At least 75% of services billed as consultations and paid by Medicare during 2001 did not meet program requirements, OIG said.
Of the claims studied, some did not meet Medicare's definition of a consultation (19%-$191 million), were billed as the wrong type or level of consultation (47%-$613 million), or were not substantiated by documentation (9%-$260 million).
The OIG further found that 95% of both claims billed at the highest billing level and claims for follow-up inpatient consultations were miscoded.
The OIG cautioned that it only reviewed consultations in 2001 and its conclusions should not be extrapolated to other years; however, the OIG noted that Medicare reimbursement for consultations increased from $3.3 billion in 2001 to $4.1 billion in 2004, "suggesting that at least some of the payment vulnerabilities that we identified still exist."
The OIG recommended that the Centers for Medicare and Medicaid Services (CMS) educate physicians and other healthcare practitioners through its Medicare carriers about the criteria and proper billing for all types and levels of consultations with emphasis on the highest billing levels and follow-up inpatient consultations.
In commenting on the report, CMS noted that codes for follow-up inpatient consultations and confirmatory consultations were deleted effective January 1, 2006.
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