Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's
leading source of news and strategic information on Medicare compliance, Stark
and other big-dollar issues of concern to health care compliance officers.
By Nina
Youngstrom, Managing Editor
January 12,
2015Volume 24Issue 1
In a false claims complaint based
partly on copay waivers, the Department of Justice alleges they led to
medically unnecessary tests and procedures at a Florida cardiology practice.
According to the complaint, which was announced on Jan. 5, interventional
cardiologist Asad Qamar, M.D., routinely waived Medicare copayments, which allegedly
encouraged some patients to submit to vascular interventions and other services
they didn’t need.
Qamar and his medical group, the
Institute for Cardiovascular Excellence (ICE), are accused of defrauding
Medicare of millions of dollars from 2008 to 2011. Some of the reimbursement
allegedly was received while Qamar was on prepayment review by the Medicare
administrative contractor (MAC) for six CPT codes for cardiac catheterization
procedures, which means his claims were reviewed before being paid. In 2012,
Medicare paid Qamar $18 million, more than any other cardiologist. “His
billings for 2012 put him second on the list of all doctors, nationwide,” the
complaint contends.
The false claims lawsuit was initially
filed by Holly Taylor, former director of client services at Partners in
Practice (PIP), which provided practice management services for Qamar and ICE.
The Department of Justice has now revealed it will take over the case.
In a YouTube video, Qamar says the
allegations are “baseless” and “fiction.” He notes that ICE serves 24,000
patients in northern central Florida, and there have been zero deaths in
connection with the 20,000 invasive procedures it has performed. The $18
million billed to Medicare has been taken out of context, a spokesman says,
because it represents services provided in six ICE locations by 10 physicians.
The complaint alleges that Qamar told
patients they did not have to pay the 20% Medicare copays, and that insurance
payments would cover their bills even if they weren’t in financial distress.
Unaware of his assurances, PIP billed patients for copays, who called to
complain that Qamar had told them they were off the hook.
There are two problems with copay
waivers, the complaint said. First, they inflate the amount Medicare pays for
services. As the HHS Office of Inspector General said in a 1994 fraud alert,
“if a supplier claims that its charge for a piece of equipment is $100, but
routinely waives the copayment, the actual charge is $80. Medicare should be
paying 80 percent of $80 (or $64), rather than 80 percent of $100 (or $80). As
a result of the supplier’s misrepresentation, the Medicare program is paying
$16 more than it should for this item.” Second, patients are less likely to
think twice about the value of a service. “Copayments are intended to eliminate
the moral hazard created when a third party (here, American taxpayers) pays for
treatment,” the complaint alleges.
Complaint Alleges Documentation Games
Copay waivers were one reason for the
medically unnecessary services, the complaint alleges. Patients allegedly did
not question the high cost of the procedures because they didn’t have to pay
their share.
For example, Qamar and ICE billed for
“an unrealistically high percentage of expensive interventional procedures; in
particular, peripheral vascular interventions and diagnostic imaging of the
renal arteries,” the complaint alleges. In the general population, about 5% of
people over age 50 have peripheral vascular disease and the same is true for
20% over age 70, yet only a small number of them need intervention. However,
almost all patients under Qamar’s care who received peripheral vascular
ultrasound diagnostic scans underwent the interventions, the complaint alleged.
Also, patients scheduled for a
catheterization often had additional, unplanned diagnostic imaging, the
complaint alleged. “Dr. Qamar would sometimes explain he had done so because he
was ‘already in there,’” the complaint alleged. “For example, patients would be
scheduled for a diagnostic heart cath and end up having diagnostic imaging done
on multiple vascular beds.”
Documentation wasn’t up to par, the
complaint alleged, which perpetuated medical necessity problems. Qamar didn’t
chart his procedures or approve the scribes’ documentation of his procedures.
Allegations of copay waivers are
unusual and hard to rebut because they are illegal on their face, unless
providers obtain documentation of the patient’s financial struggles, says
attorney Ed Gaines, chief compliance officer of Zotec Partners in Greensboro,
N.C., who is not involved in this case. “It puts a new twist on a classic
issue,” he says. “It will be interesting.”
OIG warned against copay waivers on the
same day the false claims case was announced — perhaps not coincidentally — in
the first advisory opinion issued this year (14-11). There is always the
potential for civil monetary penalties and exclusion if beneficiaries are given
remuneration that could influence their selection of a provider or supplier,
although in this case OIG said it would not sanction a charity for helping
financially needy patients who have Crohn’s disease or ulcerative colitis with
copayment obligations.
Compliance monitoring often focuses on
providers whose billing falls off a bell curve. Billing far outside the norm,
as alleged in the complaint, is a good way to get on the government’s bad side,
although it doesn’t necessarily equate to noncompliance, Gaines says. Compliance
officers in practices and hospitals that employ physicians should identify
physicians who are coding outliers as a first step. “You can go to the MAC and
get comparative billing reports,” he says. Ask for CBRs by tax identification
numbers, and compare the physicians’ billing and coding to see if anything
jumps out. But there could be a good reason for an outlier. Maybe a physician
who bills a lot of level five evaluation and management (E/M) services works in
a trauma center. Or a sudden shift from mostly level threes to level fives
reflects a change in work schedule from a rural to an urban emergency room,
Gaines says.
Read the press release at www.justice.gov and the OIG advisory opinion
at http://tinyurl.com/q7va2dd.
Watch the YouTube video at http://youtu.be/NSWC6TsuPg8.
http://aishealth.com/archive/rmc011215-04?utm_source=Real%20Magnet&utm_medium=Email&utm_campaign=63546371
