Medicare Provider Enrollment
Opportunities to Enhance Program Integrity Efforts
Gao ID: GAO-03-185 March 17, 2003
Staffing companies that contract with physicians to staff hospital departments--including emergency departments--are not permitted to bill Medicare. In the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Congress directed GAO to assess the program integrity implications of enrolling these companies and allowing them to bill Medicare. GAO reviewed about 2.8 million emergency department claims for 2000 from five states and assessed whether contractor physicians retained by staffing companies billed Medicare comparably to other emergency department physicians. GAO also evaluated how the lack of information on staffing companies affects efforts to assure Medicare program integrity.
Contractor physicians associated with staffing companies billed Medicare for complex and costly, higher-level emergency department services at rates similar to emergency department physicians with other affiliations, such as those practicing in partnerships, medical groups, or employee-based staffing companies. In addition, the patients treated by contractor physicians received diagnostic tests, were admitted to the hospital, and used ambulance transport at rates similar to patients treated by other emergency department physicians. Staffing companies that retain contractor physicians remain largely invisible to the oversight efforts of the Centers for Medicare & Medicaid Services (CMS) because these companies are not enrolled in Medicare. Although CMS has information on the individual physicians, it has no information on the companies themselves. This may hinder oversight because contractor physicians provided a significant share of emergency care to Medicare beneficiaries. For example, in four of the five states studied, 27 to 58 percent of the physicians with substantial emergency department practices were contractor physicians retained by staffing companies. CMS does not permit the enrollment of staffing companies that retain contractor physicians because, under current law, these companies may not be reassigned Medicare benefits. This limits CMS's ability to monitor claims. CMS cannot identify claims submitted by these companies on behalf of their contractor physicians nor can it subject the claims to the same systematic scrutiny given to enrolled groups. Consequently, it cannot evaluate the billing patterns of specific companies nor assess the aggregate impact of these companies on Medicare program integrity.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director:
Team:
Phone:
GAO-03-185, Medicare Provider Enrollment: Opportunities to Enhance Program Integrity Efforts
This is the accessible text file for GAO report number GAO-03-185
entitled 'Medicare Provider Enrollment: Opportunities to Enhance
Program Integrity Efforts' which was released on March 17, 2003.
This text file was formatted by the U.S. General Accounting Office
(GAO) to be accessible to users with visual impairments, as part of a
longer term project to improve GAO products‘ accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
Report to Congressional Committees:
United States General Accounting Office:
GAO:
March 2003:
MEDICARE PROVIDER ENROLLMENT:
Opportunities to Enhance Program Integrity Efforts:
Medicare Provider Enrollment:
GAO-03-185:
GAO Highlights:
Highlights of GAO-03-185, a report to the Senate Committee on Finance,
the House Committee on Energy and Commerce, and the House Committee on
Ways and Means
Why GAO Did This Study:
Staffing companies that contract with physicians to staff hospital
departments--including emergency departments--are not permitted to
bill Medicare. In the Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000, Congress directed GAO to assess
the program integrity implications of enrolling these companies and
allowing them to bill Medicare. GAO reviewed about 2.8 million
emergency department claims for 2000 from five states and assessed
whether contractor physicians retained by staffing companies billed
Medicare comparably to other emergency department physicians. GAO
also evaluated how the lack of information on staffing companies
affects efforts to assure Medicare program integrity.
What GAO Found:
Contractor physicians associated with staffing companies billed
Medicare for complex and costly, higher-level emergency department
services at rates similar to emergency department physicians with
other affiliations, such as those practicing in partnerships,
medical groups, or employee-based staffing companies. In addition,
the patients treated by contractor physicians received diagnostic
tests, were admitted to the hospital, and used ambulance transport
at rates similar to patients treated by other emergency department
physicians.
Staffing companies that retain contractor physicians remain largely
invisible to the oversight efforts of the Centers for Medicare &
Medicaid Services (CMS) because these companies are not enrolled in
Medicare. Although CMS has information on the individual physicians,
it has no information on the companies themselves. This may hinder
oversight because contractor physicians provided a significant share
of emergency care to Medicare beneficiaries. For example, in four of
the five states studied, 27 to 58 percent of the physicians with
substantial emergency department practices were contractor physicians
retained by staffing companies.
CMS does not permit the enrollment of staffing companies that retain
contractor physicians because, under current law, these companies may
not be reassigned Medicare benefits. This limits CMS‘s ability to
monitor claims. CMS cannot identify claims submitted by these
companies on behalf of their contractor physicians nor can it subjec
the claims to the same systematic scrutiny given to enrolled groups.
Consequently, it cannot evaluate the billing patterns of specific
companies nor assess the aggregate impact of these companies on
Medicare program integrity.
What GAO Recommends
www.gao.gov/cgi-bin/getrpt?GAO-03-185.
To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Leslie G. Aronovitz (312) 220-7600.
Contents:
Letter:
Results in Brief:
Background:
Contractor Physicians Billed Similarly to Their Counterparts for
Emergency Department Services:
Despite Representing a Significant Share of Billings, Staffing
Companies That Retain Contractor Physicians Are Practically Invisible
to Oversight:
Conclusions:
Matters for Congressional Consideration:
Recommendation for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
State Selection Criteria:
Method for Distinguishing Contractor Physicians Associated with
Staffing Companies from Physicians with Other Affiliations:
Methods for Comparing Billing Patterns:
Appendix II: Comments from the Centers for Medicare &
Medicaid Services:
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Related GAO Products:
Tables:
Table 1: Percentage of Higher-Level E&M Services Billed by Physician
Type and State for Medicare Beneficiaries, in 2000:
Table 2: Percentage of Medicare Beneficiaries Who Received Higher-Level
E&M Emergency Services and Who Also Received Selected Services by
State, in 2000:
Table 3: Number of Emergency Department Physicians, Percentage of
Contractor Physicians, and Percentage of Related Medicare E&M Payments,
in 2000:
Table 4: Use of Medicare Emergency Department E&M Service Codes in
Selected States, in 2000 (Percentage):
Table 5: Emergency Department Physicians Billing Medicare by Staffing
Arrangement and State, in 2000:
Figure:
Figure 1: Hypothetical Example of Variations in Contractor Physician
Billing:
Abbreviations:
CMS: Centers for Medicare & Medicaid Services:
E&M: evaluation and management:
PIN: provider identification number:
This is a work of the U.S. Government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. It may contain
copyrighted graphics, images or other materials. Permission from the
copyright holder may be necessary should you wish to reproduce
copyrighted materials separately from GAO‘s product.
United States General Accounting Office:
Washington, DC 20548:
March 17, 2003:
The Honorable Charles E. Grassley
Chairman
The Honorable Max Baucus
Ranking Minority Member
Committee on Finance
United States Senate:
The Honorable W.J. ’Billy“ Tauzin
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives:
The Honorable William M. Thomas
Chairman
The Honorable Charles B. Rangel
Ranking Minority Member
Committee on Ways and Means
House of Representatives:
In 2000, Medicare--the federal health insurance program that serves the
nation‘s elderly and disabled--paid for about 16 million visits to
hospital emergency departments. Although hospitals may employ
individual physicians to provide care, they can rely on other staffing
arrangements to ensure adequate physician coverage in their emergency
departments. Some hospitals rely on medical groups, such as physician
partnerships, to ensure this coverage, while others utilize staffing
companies to provide physician services. Staffing companies are
businesses that recruit physicians, verify medical credentials, and
provide physicians to staff hospital departments, including emergency
departments. Some staffing companies are small and serve local or
regional markets, while others are large and provide physicians to
hospitals nationwide. Some staffing companies employ the physicians
that they provide to hospitals and others retain physicians on a
contractual basis.
The Centers for Medicare & Medicaid Services (CMS), the agency
responsible for administering the Medicare program, determines,
consistent with Medicare law, when and under what arrangements
physicians can enroll[Footnote 1] in, and therefore directly bill, the
program for services. Medicare law generally allows individual
physicians and physician partnerships to file claims for payment.
Medicare law also permits physicians to ’reassign“ their right to
payment to certain other entities, such as the hospitals or other
facilities where services were performed, or to their employers. CMS‘s
interpretation of this provision has had the effect, however, of
prohibiting companies that retain physicians on a contractual basis
from receiving reassigned benefits. As a consequence, such staffing
companies have not been permitted to enroll inæand therefore submit
claims directly to--Medicare. Claims for services supplied by
contractor physicians must be submitted to Medicare either by the
physicians themselves or the facilities where the services were
furnished. This determination applies to companies that retain
contractor physicians to staff hospital emergency departments, as well
as those providing physician services for other medical specialties,
such as radiology and anesthesiology.
Although staffing companies that retain contractor physicians cannot
directly bill Medicare, they nonetheless indirectly receive Medicare
funds. These staffing companies submit claims to Medicare on behalf of
their contractor physicians, who are entitled to direct payment for
their services to Medicare beneficiaries. The Medicare payments are
deposited in the contractor physicians‘ individual bank accounts.
However, the staffing companies have typically made arrangements with
these physicians to transfer their payments for these Medicare claims
to the staffing companies. Depending upon the contract provisions, the
companies and contractor physicians then share these funds.
The fiscal integrity of the Medicare program is partially dependent on
CMS‘s ability to effectively identify and investigate aberrant billing
patterns among providers to hold these providers accountable.
Contractor physicians are individually responsible for the billings
submitted on their behalf. Because staffing companies that use
contractor physicians are not enrolled in Medicare, CMS typically has
little information on these companies and cannot readily associate the
billings of individual contractor physicians with specific staffing
companies. If CMS is unable to recoup overpayments from contractor
physicians, it does not have the recourse to recoup these funds from
staffing companies. As a result, these staffing companies may have less
incentive than enrolled providers to ensure that the program is billed
properly.
Recent legislation required that we study the Medicare provider
enrollment process as it relates to contractor physicians with a
particular emphasis on hospital-based physicians, such as those
retained by emergency department staffing companies.[Footnote 2] Among
other things, it specifically directed us to assess the program
integrity implications of enrolling staffing companies that retain
contractor physicians. As agreed with the committees of jurisdiction,
we examined emergency department billings and focused this report on
(1) whether staffing companies‘ contractor physicians bill Medicare
similarly to emergency department physicians with other affiliations,
such as those practicing in partnerships, medical groups, or employee-
based staffing companies, and (2) how CMS‘s ability to monitor Medicare
billings has been affected by the lack of information linking
contractor physicians to their staffing companies.
To conduct our study, we examined Medicare emergency department
evaluation and management (E&M) services because they are an essential
component of care provided to Medicare beneficiaries by emergency
department physicians. E&M services involve a physician taking a
patient‘s medical history, performing a physical examination, and
making decisions regarding diagnosis and treatment. Medicare payments
for E&M services vary based on several factors, including the patient‘s
status and presenting diagnosis and the level of the physician‘s
medical decision making and counseling exercised during the patient‘s
examination. We analyzed about 2.8 million claims for emergency
department E&M services paid in 2000 for beneficiaries in Alabama,
Florida, Pennsylvania, Texas, and West Virginia--or about 20 percent of
Medicare emergency department E&M services paid in 2000 nationally.
To determine which physicians were contractors associated with--that
is, retained by--staffing companies, we identified physicians with
common payment addresses who were not enrolled in Medicare as part of a
medical group. For purposes of comparison, we placed all other
physicians, including those who were members of partnerships, medical
groups, or employees of hospitals or staffing companies, in a separate
category.[Footnote 3] To determine if contractor physicians associated
with emergency department staffing companies billed Medicare for more
complex services at higher rates than physicians with other
affiliations, we compared the proportions of each group‘s E&M billings
that were billed at the two highest levels. We also compared
information from Medicare claims about other services that patients
served by each group received at the time of their emergency department
visits to assess whether the groups were caring for comparable
patients. It was not feasible to obtain patients‘ medical records that
would allow a more complete comparison of the two groups‘ patients. Our
findings cannot be generalized or projected to staffing companies that
retain contractor physicians in other specialties, such as radiology or
anesthesiology, nor can our findings be projected to other states.
In addition to our claims analysis, we interviewed CMS officials to
discuss Medicare enrollment policies and procedures as well as the
program integrity implications of enrolling staffing companies that
retain contractor physicians in Medicare. We also discussed these
matters with representatives from several of the claims administration
contractors that CMS relies on to help administer the program.[Footnote
4] We obtained the views of officials from staffing companies that
employ physicians, as well as those that retain physicians on a
contractual basis and several organizations representing emergency
department physicians. Included among those officials interviewed at
CMS and staffing companies were several physicians who have experience
working in hospital emergency departments. Finally, we reviewed
applicable laws, regulations, and other guidance concerning Medicare
enrollment and claims processing. We performed our work from March 2001
through February 2003, in accordance with generally accepted government
auditing standards. (See app. I for more information on our scope and
methodology, including our criteria for selecting the states
examined.):
Results in Brief:
In four of the five states we studied, contractor physicians retained
by staffing companies billed Medicare for the higher-level emergency
department E&M services similarly to other physicians. These staffing
company physicians billed the higher-level E&M services at rates
comparable to emergency department physicians with other affiliations,
such as those associated with partnerships, medical groups, or
employee-based staffing companies. In the fifth state, contractor
physicians associated with staffing companies billed the higher-level
services substantially less often than other physicians. Our analysis
also indicated that the patients each group served were generally
similar, at least in terms of receiving services typically associated
with an emergency department visit, such as ambulance transportation,
hospital admission, and diagnostic testing. Patients treated by
contractor physicians received slightly more of these services in four
of the five states we examined. A more comprehensive comparison of the
similarities of patients of the two groups of physicians was not
feasible.
Contractor physicians associated with staffing companies provided a
substantial amount of emergency department care to Medicare
beneficiaries in four of the five states we reviewed. For example, in
these four states, contractor physicians received from 27 percent to 55
percent of the emergency department E&M payments made by Medicare on
behalf of beneficiaries in these states. Despite their strong presence,
the staffing companies are practically invisible to CMS‘s oversight.
CMS does not have information on which physicians may be contracting
with different staffing companies. Although CMS can identify the
billings of individual physicians or groups and assess whether their
billings are markedly different from the billings of their peers and
hence merit more extensive review, it cannot conduct such oversight of
claims submitted by the contractor physicians associated with a
particular staffing company. In the aggregate, emergency department
contractor physicians billed similarly to other affiliated physicians,
but differences in the billing patterns of contractor physicians
retained by specific companies cannot be detected because the companies
cannot be identified. Given the share of Medicare payments associated
with these staffing companies in the states studied, it would be
prudent if CMS could improve its ability to screen claims by requiring
such staffing companies to enroll in Medicare and identify the
physicians with which they have contracted.
To enhance program integrity, we suggest that Congress may wish to
amend the Social Security Act to permit the reassignment of benefits to
staffing companies that retain contractor physicians to treat Medicare
beneficiaries, and require these staffing companies to seek enrollment
in Medicare. We are also recommending that the CMS Administrator seek
such legislative changes. CMS agreed that a legislative amendment was
needed to permit the reassignment of benefits.
Background:
Beneficiaries are generally the only parties under Medicare statute who
are entitled to receive Medicare payments for physician
services.[Footnote 5] However, they can ’assign“ their rights to
payment to physicians, other providers, and suppliers who directly
deliver the care or service and then submit claims to Medicare. These
physicians as well as other providers and suppliers must meet criteria
for enrollment in the Medicare program. To bill Medicare, CMS requires
that physicians, other providers, and suppliers use a standardized,
five-digit coding system on the claim forms to identify the medical
services and procedures that were provided.[Footnote 6] These billing
codes describe the type of medical, surgical, and diagnostic service
rendered. For E&M services, these codes also designate the level--or
intensity--of care provided. Emergency department E&M codes range from
99281 to 99285.[Footnote 7] Typically, the higher the E&M code, the
more complex the consultation, or level of care involved, and the
higher the Medicare payment.
CMS has delegated the authority for enrolling physicians and other
entities into the Medicare program to its claims administration
contractors--the fiscal intermediaries and carriers--that help it
manage the Medicare program. As carriers are responsible for the
administration of Part B services, they are therefore tasked with
managing the enrollment of physicians in Medicare. Before enrolling
individual physicians and other entities, the carriers determine
whether applicants meet Medicare eligibility criteria and assess, based
on information provided, whether they appear to pose a potential threat
to program integrity. For example, applicants are required to disclose
their legal business names and ownership, adverse legal actions, and
outstanding Medicare debt from previous enrollment along with copies of
their medical licenses. The carriers also have the authority to request
additional documentation to validate information included in the
enrollment application, such as articles of incorporation and
partnership agreements. In addition to verifying the required
information, the carriers may access several national databases to
identify adverse reports on applicants that may affect their ability to
become enrolled in Medicare.[Footnote 8] Once physicians are enrolled,
the carriers assign each physician an individual provider
identification number (PIN), which serves as a unique identifier.
Similarly, entities that are eligible to enroll in Medicare and
therefore directly bill the program--such as physician partnerships or
staffing companies that employ physicians--obtain group PINs.
As specified by law, physicians can only ’reassign“ their payment
rights to certain other entities, such as the hospitals or other
facilities where services were performed or to their employers.
Emergency department staffing companies generally do not own the
facilities where services are performed and those that retain
contractor physicians are not considered the physicians‘ employers. As
a result, Medicare payments cannot be reassigned to emergency
department staffing companies that retain contractor physicians, and
these companies are not permitted to enroll in and directly bill
Medicare or be assigned group PINs. However, these staffing companies
may submit claims on behalf of their contractor physicians, using the
physicians‘ individual PINs. Although the physicians are ultimately
responsible for the claims submitted on their behalf, they may not be
aware of how the staffing companies code the services billed to
Medicare.
Carriers may use an individual or a group PIN to facilitate their
program integrity activities. PINs allow carriers to link the
individual physicians who actually rendered the services and the
entities with which they are affiliated. Carriers are then able to
monitor billing patterns and compare billings of both individual
physicians and groups. By analyzing the billing patterns associated
with both the PINs of individual physicians and these entities,
carriers can identify meaningful differences and detect potential
instances of improper payments or fraud. Because staffing companies
that retain contractor physicians may not be reassigned benefits and
cannot enroll in Medicare, they do not receive group PINs.
Consequently, they are not identified on Medicare claim forms and are
not subjected to such scrutiny.
Contractor Physicians Billed Similarly to Their Counterparts for
Emergency Department Services:
Our comparison of the billings by contractor physicians retained by
staffing companies to other affiliated physicians--such as those
practicing in partnerships, medical groups, and employee-based staffing
companies--showed that contractor physicians and those with other
affiliations both billed for higher-level E&M services at comparable
rates in four of the five states we reviewed and at a lower rate in the
fifth state we reviewed. Moreover, the rates at which other services--
such as ambulance transportation, hospital admission, and diagnostic
testing--were rendered in conjunction with the higher-level E&M
services were similar for contractor physicians and those with other
affiliations, providing an indication that the patients of both types
of physicians were comparable.
Higher-Level E&M Services Billed at Similar Rates:
Comparing the emergency department E&M billings of contractor
physicians with other affiliated physicians showed that physicians
involved with the two types of staffing arrangements billed Medicare
for the higher-level services at similar rates in four of the five
states we reviewed. The payment amounts for the higher-level services-
-codes 99284 and 99285--are, on average, about three times greater than
the average payment amounts for lower-level services--codes 99281,
99282, and 99283.[Footnote 9] As table 1 shows, contractor physicians
in Alabama, Florida, Pennsylvania, and Texas billed nearly the same
proportion of higher-level E&M services as their counterparts in those
states. The largest difference we identified was in West Virginia,
where contractor physicians associated with staffing companies billed
the higher-level services 55 percent of the time while other affiliated
physicians billed for these services 74 percent of the time. We were
unable to determine the cause of this variation.
Table 1: Percentage of Higher-Level E&M Services Billed by Physician
Type and State for Medicare Beneficiaries, in 2000:
State: Alabama; Contractor physicians associated with staffing
companies: 57; Other affiliated physicians: 57.
State: Florida; Contractor physicians associated with staffing
companies: 69; Other affiliated physicians: 64.
State: Pennsylvania; Contractor physicians associated with staffing
companies: 57; Other affiliated physicians: 58.
State: Texas; Contractor physicians associated with staffing companies:
66; Other affiliated physicians: 64.
State: West Virginia; Contractor physicians associated with staffing
companies: 55; Other affiliated physicians: 74.
Source: GAO.
Note: We calculated these rates by dividing the number of higher-level
(codes 99284 and 99285) billings by the total number of emergency
department E&M services billed by physician type. This information is
based on our analysis of carrier data.
[End of table]
Patients of Contractor Physicians and Other Affiliated Physicians
Received Similar Services:
Regardless of whether emergency department patients were treated by
contractor physicians or other emergency department physicians, those
receiving higher-level E&M services received other services at similar
rates in the five states we reviewed. To determine the comparability of
patients treated by both types of physicians, we examined the rates at
which patients had been transported by ambulance to the emergency
department, received diagnostic tests, or were admitted to the hospital
within 24 hours of the emergency department visit. As table 2 shows,
patients generally received ambulance, hospital admissions, and
diagnostic testing services at similar rates when higher-level E&M
services were billed, regardless of the physicians‘ staffing
arrangements.[Footnote 10]
Table 2: Percentage of Medicare Beneficiaries Who Received Higher-Level
E&M Emergency Services and Who Also Received Selected Services by
State, in 2000:
Service[A]: Ambulance; Alabama: physicians: Contractor: 38; Alabama:
Other affiliated: 35; Florida: physicians: Contractor: 38; Florida:
Other affiliated: 42; Pennsylvania: physicians: Contractor: 48;
Pennsylvania: Other affiliated: 46; Texas: physicians: Contractor: 41;
Texas: Other affiliated: 39; West Virginia: physicians: Contractor: 39;
West Virginia: Other affiliated: 37.
Service[A]: Admission; Alabama: physicians: Contractor: 59; Alabama:
Other affiliated: 53; Florida: physicians: Contractor: 64; Florida:
Other affiliated: 65; Pennsylvania: physicians: Contractor: 75;
Pennsylvania: Other affiliated: 66; Texas: physicians: Contractor: 63;
Texas: Other affiliated: 61; West Virginia: physicians: Contractor: 63;
West Virginia: Other affiliated: 53.
Service[A]: Diagnostic testing; Alabama: physicians: Contractor: 92;
Alabama: Other affiliated: 91; Florida: physicians: Contractor: 89;
Florida: Other affiliated: 91; Pennsylvania: physicians: Contractor:
96; Pennsylvania: Other affiliated: 95; Texas: physicians: Contractor:
95; Texas: Other affiliated: 93; West Virginia: physicians: Contractor:
90; West Virginia: Other affiliated: 86.
Source: GAO.
Note: This information is based on our analysis of carrier data.
[A] We used beneficiary claims data to identify whether ambulance,
hospital admission, and diagnostic services were delivered in
conjunction with a higher-level E&M service (99284 and 99285). The most
frequently ordered diagnostic tests were chest x-rays, echocardiograms,
computerized axial tomography scans, and automated blood count tests.
Contractor physicians and other affiliated physicians ordered such
tests 37 percent and 40 percent of the time, respectively.
[End of table]
Patients treated by contractor physicians in Alabama, Pennsylvania,
Texas, and West Virginia had slightly higher ambulance, hospital
admissions, and diagnostic testing rates than patients treated by other
physicians. However, as noted earlier, these physicians did not bill
for higher-level services at rates significantly greater than
physicians with other affiliations in these four states. The opposite
pattern occurred only in Florida. There, contractor physicians treated
patients who received fewer other services, but billed higher-level E&M
services slightly more often. In Florida, these physicians billed
Medicare for higher-level services 69 percent of the time as compared
to 64 percent by other affiliated physicians.
Despite Representing a Significant Share of Billings, Staffing
Companies That Retain Contractor Physicians Are Practically Invisible
to Oversight:
In four of the five states we examined, a substantial percentage of the
physicians providing emergency department care were contractor
physicians associated with staffing companies. These physicians also
received a significant share of Medicare payments for these services.
However, because the staffing companies are not subject to the
enrollment procedures that the carriers routinely conduct for
physicians and medical groups before they are allowed to bill Medicare,
CMS does not collect critical information that would enable it to
identify claims that are submitted by staffing companies on behalf of
their contractor physicians. Without such information, CMS cannot
routinely link the claims that these companies submit on behalf of
their physicians to assess the billing patterns of physicians
contracting with specific staffing companies compared to the billing
patterns of other physicians.
Contractor Physicians Account for Significant but Variable Share of
Medicare Billings:
Our five-state analysis of Medicare emergency department claims data
and physician payment information showed that contractor physicians
with staffing company affiliations accounted for a significant share of
billings overall, but this varied by state. In four of the five states
studied, from 27 to 58 percent of the physicians with substantial
emergency department practices were contractor physicians associated
with staffing companies.[Footnote 11] As table 3 shows, in Alabama, 58
percent of the 351 physicians we identified as having substantial
emergency department practices were contractor physicians. Though the
percentage of these physicians was lower in Florida, Texas, and West
Virginia, they still provided a significant portion of emergency care
for Medicare beneficiaries in those states and received a proportionate
share of Medicare E&M payments for their services. In contrast, a
considerably lower percentage of Pennsylvania physicians were
contractors associated with staffing companies. We were unable to
determine why contractor physicians had a relatively small presence in
this state.
Table 3: Number of Emergency Department Physicians, Percentage of
Contractor Physicians, and Percentage of Related Medicare E&M Payments,
in 2000:
State: Alabama; Number of physicians with substantial emergency
department practices: 351; Percentage of contractor physicians with
substantial emergency department practices: 58; Percentage of E&M
payments to contractor physicians with substantial emergency department
practices: 55.
State: Florida; Number of physicians with substantial emergency
department practices: 1,240; Percentage of contractor physicians with
substantial emergency department practices: 27; Percentage of E&M
payments to contractor physicians with substantial emergency department
practices: 27.
State: Pennsylvania; Number of physicians with substantial emergency
department practices: 1,122; Percentage of contractor physicians with
substantial emergency department practices: 4; Percentage of E&M
payments to contractor physicians with substantial emergency department
practices: 5.
State: Texas; Number of physicians with substantial emergency
department practices: 1,258; Percentage of contractor physicians with
substantial emergency department practices: 29; Percentage of E&M
payments to contractor physicians with substantial emergency department
practices: 28.
State: West Virginia; Number of physicians with substantial emergency
department practices: 253; Percentage of contractor physicians with
substantial emergency department practices: 44; Percentage of E&M
payments to contractor physicians with substantial emergency department
practices: 43.
Source: GAO.
Note: This information is based on our analysis of carrier data.
[End of table]
Program Safeguards Hindered by Lack of Information:
Despite the significant share of Medicare payments for emergency
department E&M services made to contractor physicians, the staffing
companies that retain these physicians are not subject to the screening
or systematic scrutiny that carriers impose on other entities that are
eligible to enroll in Medicare. During the enrollment process, carriers
obtain substantial information about providers that can be used to
identify applicants who may be more likely to submit improper billings.
Because staffing companies that retain contractor physicians may not be
reassigned benefits and cannot enroll in the program, they are not
assigned PINs and such information about them is not collected.
Medicare cannot identify which physicians are associated with a
specific company.
For entities that are enrolled in Medicare, carriers can track the
billings of specific providers associated with an entity over time,
compare the billings of similar provider types, and examine claims
submitted by physicians affiliated with different entities. These
analyses allow the carriers to spot billing patterns that are markedly
different from the norm, which could suggest potential improper
billing. The carriers cannot perform this analysis for staffing
companies that retain contractor physicians because these companies do
not have group PINs that would enable carriers to link physicians‘
billings to the companies. As our hypothetical example contained in
figure 1 demonstrates, important differences in billing practices
across companies can be missed when the carriers cannot identify
company affiliation.
Figure 1: Hypothetical Example of Variations in Contractor Physician
Billing:
[See PDF for image]
[End of figure]
If a carrier determines that a medical group‘s billings differ
significantly from other similar providers, the carrier may review the
entity‘s claims to identify the reasons for the variance. If the review
finds improper bills, the carrier can take corrective action, including
an assessment of amounts paid in error that must be repaid to Medicare.
For repeated billing abuses, the carrier can take steps to further
protect the Medicare program. For example, it can delay payment of some
or all claims, pending more intense screening. When the group is
enrolled in Medicare, the carrier may hold accountable, not just the
physicians responsible for the improper billings, but the group,
partnership, or entity employing those physicians as well. For example,
if the physician stops billing Medicare before the amount of the
overpayment can be withheld from subsequent payments or if the
physician is unable to return the amount of the overpayment, plus
applicable penalties and interest, the carrier may be able to recover
the funds from a partnership or staffing company that employed the
physician. Such steps cannot be taken against staffing companies that
retain contractor physicians. Because staffing companies that retain
contractor physicians may not be reassigned benefits and are not
enrolled in Medicare, CMS has no information on these companies and
cannot associate the billings of individual contractor physicians with
specific staffing companies.
Under current law, CMS lacks the capability to readily identify
contractor physicians and the staffing companies with which they
associate. We engaged in a time-consuming and labor-intensive process
that is not routinely performed by CMS or its carriers. We had to
extract and match physician information from multiple sources,
including Medicare emergency department claims data, Medicare cost
reports, a staffing company database voluntarily provided by one
staffing company, and hospitals we contacted in the five states we
reviewed.
CMS officials acknowledge the limitations in the current reassignment
and enrollment policies and the lack of information on staffing
companies that retain contractor physicians. They explained that
although Medicare statute expressly provides for certain types of
entities--such as medical groups and health care delivery systems--to
enroll and have group PINs, that law does not have comparable
provisions for staffing companies that retain contractor physicians.
CMS officials, therefore, maintain that they lack the authority to
change CMS policy to permit the enrollment of these staffing companies
and assignment of group PINs to them.
Conclusions:
Across the five states, contractor physicians billed Medicare similarly
to other affiliated physicians. While these similarities were observed
at an aggregate level, contractor physicians associated with specific
companies may nonetheless have billing patterns that differ markedly
from the norm. This, coupled with the significant share of Medicare
payments that these staffing companies receive, albeit indirectly, for
emergency services in four of the five states we studied, suggests that
it is important for CMS to be able to monitor the billing practices of
individual companies using contract physicians. However, the law
prohibiting staffing companies from being reassigned Medicare
paymentsæwith the result that they are not permitted to enroll in
Medicare and receive group PINsæhas limited CMS‘s ability to conduct
oversight. CMS‘s carriers cannot identify claims submitted by these
staffing companies and, therefore, cannot subject them to same
systematic scrutiny as those of other groups. Although our work did not
include an analysis of billings by contractor physicians who specialize
in the provision of other medical services, such as radiology or
anesthesiology, these companies remain as invisible to CMS‘s oversight
as those providing emergency department care.
Matters for Congressional Consideration:
In order to enhance Medicare‘s program integrity, Congress may wish to
amend the Social Security Act to (1) permit the reassignment of
benefits to staffing companies that retain contractor physicians to
treat Medicare beneficiaries so that CMS may enroll these companies if
they meet appropriate criteria and (2) require these staffing companies
to seek enrollment in Medicare.
Recommendation for Executive Action:
To facilitate improvements in program integrity, the CMS Administrator
should propose legislation permitting the reassignment of benefits to
staffing companies that retain contractor physicians to treat Medicare
beneficiaries and requiring that these companies seek enrollment in
Medicare.
Agency Comments:
In written comments on a draft of this report, CMS agreed that a
legislative amendment is needed. CMS recommended that we revise the
draft report to reflect that, under current law, staffing companies
that retain contractor physicians are not enrolled in Medicare because
they are generally not eligible to be reassigned benefits. We have
revised the report to fully reflect this.
We have reprinted CMS‘s letter in appendix II. CMS also provided us
with technical comments, which we have incorporated as appropriate.
We are sending copies of this report to the Administrator of CMS and
other interested parties. In addition, this report will be available at
no charge on GAO‘s Web site at http://www.gao.gov. We will also make
copies available to others upon request.
If you or your staffs have any questions about this report, please call
me at (312) 220-7600. An additional GAO contact and other staff members
who prepared this report are listed in appendix III.
Leslie G. Aronovitz
Director, Health Care--Program
Administration and Integrity Issues:
Signed by Leslie G. Aronovitz:
[End of section]
Appendix I: Scope and Methodology:
To study the billing patterns of emergency department staffing
companies that retain contractor physicians, we obtained Medicare
claims data paid in 2000 for beneficiaries in five states--Alabama,
Florida, Pennsylvania, Texas, and West Virginia. We analyzed all the
emergency department evaluation and management (E&M) claims--about 2.8
million--from the five carriers and six fiscal intermediaries that
processed Medicare claims for these states during this period. These
claims represented about 20 percent of all Medicare emergency
department E&M services paid in 2000. We interviewed representatives
from the Centers for Medicare & Medicaid Services (CMS), officials from
the five Medicare carriers and several of the fiscal intermediaries
serving the five states we reviewed, and three professional
associations that represent emergency department physicians--the
American College of Emergency Physicians, the Emergency Department
Practice Management Association, and the American Academy of Emergency
Medicine. Several of the officials from these organizations were also
physicians who have experience working in hospital emergency
departments. We also contacted hospitals in the 5 states we reviewed.
To determine how the use of staffing companies that retain contractor
physicians has affected CMS‘s ability to monitor emergency department
billings, we reviewed documentation related to the provider enrollment
process. This included criteria for qualifying for an individual or
group PIN and the processes for assessing their integrity. We reviewed
applicable laws, CMS regulations, and program guidance. We also
reviewed applicable laws and regulations on provider enrollment,
Medicare cost reports, as well as reports and other relevant materials
from staffing companies.
State Selection Criteria:
We selected the five states in our study based on several factors. We
chose Florida, Texas, and Pennsylvania because, according to 2000 U.S.
Census Bureau data, they were among the states with the largest number
of Medicare beneficiaries. Because carrier officials indicated that
billing improprieties might be more likely to occur in states that
exceed the national average for higher-level E&M services, we chose
West Virginia as one such state. As shown in table 4, Florida and Texas
also exceeded the national average in the use of higher-level codes.
Finally, we selected Alabama because the carrier serving beneficiaries
in that state had developed extensive experience identifying and
addressing provider enrollment problems. Our results cannot be
generalized to other states.
Table 4: Use of Medicare Emergency Department E&M Service Codes in
Selected States, in 2000 (Percentage):
Service codes: 99281; Alabama: 3; Florida: 1; Pennsylvania: 1; Texas:
2; West Virginia: 3; United States: 2.
Service codes: 99282; Alabama: 13; Florida: 7; Pennsylvania: 9; Texas:
8; West Virginia: 9; United States: 10.
Service codes: 99283; Alabama: 32; Florida: 28; Pennsylvania: 34;
Texas: 30; West Virginia: 27; United States: 32.
Service codes: 99284; Alabama: 30; Florida: 30; Pennsylvania: 31;
Texas: 31; West Virginia: 29; United States: 32.
Service codes: 99285; Alabama: 23; Florida: 34; Pennsylvania: 24;
Texas: 29; West Virginia: 32; United States: 24.
Service codes: Total allowed E&M services (number); Alabama: 274,660;
Florida: 840,247; Pennsylvania: 707,385; Texas: 840,193; West Virginia:
179,908; United States: 14,318,204.
Source: CMS.
Note: This information is from CMS‘s Part B Extract and Summary System
data for 2000.
[End of table]
Method for Distinguishing Contractor Physicians Associated with
Staffing Companies from Physicians with Other Affiliations:
We developed a method for categorizing physicians by their type of
staffing arrangement, based on Medicare claims data. Our analysis was
limited to physicians with substantial emergency department practices
in 2000. We defined a ’substantial practice“ as one in which at least
(1) 50 percent of the physician‘s Medicare payments were for emergency
department E&M services and (2) $20,000 in Medicare payments were for
emergency department E&M services. For physicians meeting these
criteria, carriers provided summary data containing the physicians‘
names, provider identification number (PIN), practice addresses,
payment addresses, payments received, and Medicare group numbers, where
applicable.
Using individual PINs, group PINs, and payment addresses, we placed
physicians in one of two categories--contractor physicians and other
physicians.[Footnote 12] We used a multistep process that entailed
extracting and matching information from various sources. First, we
used information from Medicare claims data to place physicians whose
individual PINs were associated with group PINs in the other physicians
category. Second, we placed physicians who did not have group PINs into
the contractor physician category if their Medicare payments were sent
to addresses used by at least one other physician or if they practiced
in rural areas. We used Medicare emergency department claims data,
private databases, and public records to identify payment addresses and
practice locations. According to CMS officials, physicians who do not
have group PINs and whose payments are sent to addresses similar to
another physician are likely to be contractors retained by staffing
companies. Third, we excluded physicians who did not have group PINs,
payment addresses in common with another physician, or who practiced in
rural locations.[Footnote 13] Less than 1 percent of the physicians
were excluded. Table 5 summarizes the results of our analysis.
Table 5: Emergency Department Physicians Billing Medicare by Staffing
Arrangement and State, in 2000:
State: Alabama; Contractor physicians: 203; Other affiliated
physicians: 148; Total physicians with substantial emergency department
practice: 351.
State: Florida; Contractor physicians: 331; Other affiliated
physicians: 909; Total physicians with substantial emergency department
practice: 1,240.
State: Pennsylvania; Contractor physicians: 47; Other affiliated
physicians: 1,075; Total physicians with substantial emergency
department practice: 1,122.
State: Texas; Contractor physicians: 362; Other affiliated physicians:
896; Total physicians with substantial emergency department practice:
1,258.
State: West Virginia; Contractor physicians: 111; Other affiliated
physicians: 142; Total physicians with substantial emergency department
practice: 253.
Source: GAO.
Note: Our method may slightly overestimate the number of physicians
because they may work in more than one emergency department or staffing
arrangement and have a different PIN for each practice location. This
information is based on our analysis of CMS data.
[End of table]
Methods for Comparing Billing Patterns:
To determine whether contractor physicians retained by staffing
companies bill Medicare for the higher-level services at rates
comparable to other emergency department physicians, we did the
following. We asked the carriers to provide us with frequency
distributions of the E&M services provided by physicians in our study.
We combined the less costly codes (99281, 99282, and 99283) to form a
lower-level service category and the more costly codes (99284 and
99285) to form a higher-level category. Of the five procedural codes,
99284 and 99285 were claimed 56 percent of the time. The carriers
derived this information from Medicare claims data.
We also used Medicare claims data to determine whether patients treated
by contractor physicians and those treated by other affiliated
physicians received comparable services. We asked carriers to identify
patients who received higher-level E&M services from physicians in both
arrangements and the dates of the E&M services. We then compared this
information with all Medicare claims paid from January 1, 2000, through
November 30, 2000.[Footnote 14] We did this to determine whether
patients receiving higher-level E&M services were also transported by
ambulance, received at least one diagnostic test, or were admitted to
the hospital. Carrier officials provided us with a list of service
codes that when present on a claim, indicate one of these three
services. Our analysis included a search for such services delivered on
the same day, 1 day before, or 1 day after the higher-level E&M service
was received.
Because carrier officials told us that it would be unusual for a
patient who received a higher-level E&M code to not receive any of the
three selected services, we analyzed such instances. We randomly
selected 15 patients in each of the five states who received a higher-
level E&M service without also receiving a selected service. The
carriers reviewed the patients‘ Medicare claims information on services
rendered within 1 week before and 1 week after the date of the higher-
level E&M service. We did not ask that the carriers conduct medical
reviews to determine whether claims were properly coded.
[End of section]
Appendix II: Comments from the Centers for Medicare & Medicaid
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Centers for Medicare & Medicaid Services:
Administrator Washington, DC 20201:
DATE: FEB 7 2003:
FROM: Thomas A. Scully Administrator:
TO: Leslie G. Aronovitz:
Director, Health Care-Program Administration and Integrity Iss:
SUBJECT: General Accounting Office (GAO) Draft Report, Medicare
Provider
Enrollment: Opportunities to Enhance Program Integrity Efforts (GAO-03-
185):
We appreciate the opportunity to review and comment on the above-
referenced report.
The General Accounting Office (GAO) reviewed about 2.8 million claims
for year 2000 from five states to assess how Medicare billing by
contractor physicians retained by emergency department staffing
companies compared with billing by other emergency department
physicians. Emergency department staffing companies are businesses that
contract with physicians to staff hospital emergency departments and
provide related support services. The GAO also evaluated how the lack
of information on staffing companies could create Medicare program
vulnerabilities that may adversely affect the Center for Medicare &
Medicaid Services“ (CMS) program integrity efforts. In order to enhance
Medicare‘s program integrity, GAO recommends that Congress amend the
Social Security Act (Act) to: 1) require staffing companies that retain
contractor physicians and submit claims to the program to apply for
enrollment in Medicare, and 2) permit CMS to enroll staffing companies
that meet enrollment criteria.
The report repeatedly characterizes the current law as prohibiting
staffing companies that retain contractor physicians from enrolling in
Medicare. We recommend that GAO revise its report to more accurately
reflect the fact that such staffing companies are not enrolled, because
they are generally not eligible to receive reassigned benefits from
contractor physicians under section 1842(b)(6) of the Act. An exception
to this general prohibition is that staffing companies (or other
entities that utilize contractor physicians) are eligible to receive
reassigned benefits for services performed on premises that they lease
or own. However, because emergency department staffing companies do not
own or lease the space in hospital emergency rooms, this exception does
not apply to them.
With respect to the conclusion drawn from the findings, the
recommendation and the matter for Congressional consideration, we agree
with GAO‘s recommendation that a legislative amendment is needed.
However, CMS believes that the recommendation should be revised to say
’based on the findings of GAO‘s analysis, the current statutory
prohibition should be revised to allow for the reassignment of benefits
for services performed by contractor physicians regardless of whether
those services are rendered on premises not owned or leased by the
contracting organization.“ Additionally, the GAO report concludes that
the program is not more vulnerable for improper billing when there is a
staffing company contract arrangement. Given that, CMS would prefer
that the entire prohibition on reassignment by contractors be
eliminated rather than trying to tailor the proposed legislative change
specifically to the attributes of a staffing company.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Geraldine Redican-Bigott, (312) 220-7678:
Acknowledgments:
Enchelle D. Bolden, Shaunessye D. Curry, Richard M. Lipinski, and Craig
Winslow made major contributions to this report.
[End of section]
Related GAO Products:
HIPAA Standards: Dual Code Sets Are Acceptable for Reporting Medical
Procedures. GAO-02-796. Washington, D.C.: August 9, 2002.
Medicare Hospital and Physician Payments: Geographic Cost Adjustments
Important to Preserve Beneficiary Access to Services.
GAO-02-968T. Washington, D.C.: July 23, 2002.
Medicare: Recent CMS Reforms Address Carrier Scrutiny of Physicians‘
Claims for Payment. GAO-02-693. Washington, D.C.: May 28, 2002.
Medicare: HCFA to Strengthen Medicare Provider Enrollment
Significantly, but Implementation Behind Schedule. GAO-01-114R.
Washington, D.C.: November 2, 2000.
FOOTNOTES
[1] ’Enrollment“ is CMS‘s term for its formal process of accepting
medical providers, including physicians, into the Medicare program. The
enrollment process helps ensure that only qualified and eligible
individuals and entities can participate in the program and receive
payment for services furnished to beneficiaries. Providers that are not
enrolled cannot directly receive payment for Medicare services.
[2] The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000, Pub. L. No. 106-554, App. F, § 413, 114 Sta.
2763, 2763A-515.
[3] We excluded a small number of physicians from our analysis who
appeared to practice emergency medicine as solo practitioners. They did
not appear to be members of partnerships or medical groups or employees
of hospitals or staffing companies and did not have payment addresses
in common with other physicians. Less than 1 percent of the physicians
who provided emergency services in the five states in 2000 were
excluded.
[4] The claims administration contractors that process Part A claims--
those covering inpatient hospital, skilled nursing facility, hospice,
and certain home health services--are known as fiscal intermediaries.
Contractors processing Part B claims--covering physician services,
diagnostic tests, and related services and supplies--are referred to as
carriers.
[5] Section 1842(b)(6) of the Social Security Act provides that
payments for Part B services, including payments for physicians‘
services, generally may be made only to the individual who received the
services. 42 U.S.C. § 1395u(b)(6) (2000). The law provides exceptions,
however, permitting payment to a physician‘s employer or to a facility,
such as a hospital, in which the services were provided. Part A
services paid under section 1814(a) of the Social Security Act include
inpatient hospital, skilled nursing facility, hospice, and certain home
health services, and generally may be made only to providers. 42 U.S.C.
§ 1395f(a) (2000).
[6] The Health Insurance Portability and Accountability Act of 1996
required the Secretary of Health and Human Services to adopt standard
code sets for describing health-related services in connection with
financial and administrative transactions, such as filing claims for
payment. Pub. L. No. 104-191, Title II, Stat. F, 110 Stat. 1936, 2021
(codified at 42 U.S.C. §§ 1320d-1320d-8 (2000)). For more information,
see U.S. General Accounting Office, HIPAA Standards: Dual Code Sets Are
Acceptable for Reporting Medical Procedures, GAO-02-796 (Washington,
D.C.: Aug. 9, 2002).
[7] There are about 8,000 codes that identify all types of medical
services, such as anesthesia, laboratory, medicine, pathology,
radiology, and surgery.
[8] Claims administration contractors compare the names of providers,
managing directors, and owners with at least 5 percent ownership
interest to those listed on several databases, specifically the (1)
Department of Health and Human Services Office of Inspector General
list of excluded providers, (2) General Services Administration
debarment list, (3) Healthcare Integrity and Protection Data Bank, (4)
Fraud Investigation Database, and
(5) ChoicePoint--a private research service that verifies medical
providers‘ personal and business information. For related information
see U.S. General Accounting Office, Medicare: HCFA to Strengthen
Medicare Provider Enrollment Significantly, but Implementation Behind
Schedule, GAO-01-114R (Washington D.C.: Nov. 2, 2000).
[9] During 2000, the national payment amounts for Medicare emergency
department E&M services were as follows: $20.14 for 99281, $31.49 for
99282, $64.07 for 99283, $98.49 for 99284, and $154.88 for 99285.
Actual payment amounts are higher or lower, depending on the labor cost
adjustment for the geographic location.
[10] Under both types of staffing arrangements, across all five states,
from 1 to 6 percent of patients did not receive at least one of the
three services. Although carrier officials told us that most patients
who received higher-level E&M services were transported to the hospital
by ambulance, admitted to the hospital, or received some diagnostic
tests, our initial analysis showed that some patients who received
higher-level E&M services did not receive any of these services. We
therefore asked carriers to review the claims of a sample of these
patients. Carrier analysis revealed that some claims contained data
entry errors that prevented them from associating these services with a
particular E&M service. They also identified other claims that were
paid in 2001, after our survey period. However, for about a third of
the patients in their sample, carrier officials could not explain why
one of the three types of services had not been rendered. Consequently,
carrier officials could not discount the possibility that the higher-
level E&M codes were improperly billed.
[11] We defined a substantial emergency department practice as one in
which at least 50 percent of the physician‘s practice involved
emergency department E&M services and at least $20,000 in Medicare
payments for E&M services were paid to the physician in 2000.
[12] We examined the billing patterns of these physicians in the
aggregate and did not analyze individual physicians, groups, or
staffing companies.
[13] We relaxed the address-matching criterion for physicians in rural
areas because we recognized that our selection criteria--50 percent of
practice and $20,000 in payments--might not adequately capture
physicians associated with staffing companies in those locations. In
rural areas where there are shortages of emergency department
physicians, practices are smaller, and physicians associated with a
staffing company might not have had sufficient Medicare payments to
meet our selection criteria. As such, the carriers would not have
identified these physicians and their Medicare payment addresses would
not be available for matching with other physicians. To ensure adequate
representation of rural contractor physicians, we included physicians
in rural areas without group numbers in the contractor physician
category. Twenty-two physicians were placed in this category as a
result of this decision.
[14] Because billing cycles and practices vary, it is possible that
some services related to an emergency department visit can be paid
weeks or months after the E&M service. To reduce the influence of
delayed billing on our analysis, we excluded E&M services that were
performed on or after December 1, 2000. This restriction allowed us to
detect admissions, ambulance, and diagnostic services that were
reimbursed up to 1 month after the E&M service was rendered. There are
some E&M services in our study that were paid in 2000, but performed in
1999. If some of the related admissions, ambulance, and diagnostic
services were paid in 1999 and not in 2000, our cross-match would not
have detected them.
GAO‘s Mission:
The General Accounting Office, the investigative arm of Congress,
exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO‘s commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO‘s Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as ’Today‘s Reports,“ on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select ’Subscribe to daily E-mail alert for newly
released products“ under the GAO Reports heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. General Accounting Office
441 G Street NW,
Room LM Washington,
D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director, NelliganJ@gao.gov (202) 512-4800 U.S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D.C.
20548: