The Many and Varied Types of Fraud and Abuse in Electrodiagnostic Medicine
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Transcript of The Many and Varied Types of Fraud and Abuse in Electrodiagnostic Medicine
The Many and Varied Types
of Fraud and Abuse
in Electrodiagnostic Medicine
Peter A. Grant, M.D.November 15th, 2014
A.A.P.M.&R. – San Diego.
Peter A. Grant, M.D.Past President – American Association
of Neuromuscular & Electrodiagnostic Medicine
Diplomate - American Board of Physical Medicine & Rehabilitation
Diplomate – American Board of Electrodiagnostic Medicine
Specialist in EDX Fraud & Abuse (15 years)
AANEM Accredited EDX Laboratory
DISCLAIMER
Please note that any and all comments made in
this lecture are mine and NOT the AAPM&R or the
AANEM or any other organization.
Outline of PresentationWhy EDX Fraud & Abuse?What constitutes “Quality
EDX”Types of EDX Fraud & AbuseAddressing EDX Fraud &
AbuseResourcesEDX Laboratory AccreditationFraud Trends & “Red Flags”
Reimbursement Cuts & EDX Fraud and Abuse
WHAT’S THE CONNECTION?“These cuts were, most definitely, due
to the increased utilization of the NCS codes”
(Jonathan Blum – Deputy Director CMS)
So…. The Reimbursement Cuts were a direct response to Fraud & Abuse in EDX.
Types of EDX Fraud & Abuse
LEGAL MEASURE OF QUALITY Community, regional, or national standard
of care for EDX evaluations.Current & Historical EDX practices in your
community.What AANEM (with endorsement of AAN
and AAPM&R) promotes and publishes as standards for EDX exams to be appropriate, accurate, and necessary.
Types of EDX Fraud & Abuse
THE MANY FACES OF POOR QUALITYInaccurate Diagnosis
Wrong DiagnosisMissed DiagnosisOverdiagnosis
Excessive, Inapproriate, or Insufficient Testing
Excessive or Inappropriate Charges
Types of EDX Fraud & Abuse
Common to All Abusive & Fraudulent EDX
Emphasis is on $$$ and Not on
QualityEDX Studies/Patient Care
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
Types of EDX Fraud & Abuse
MOBILE DIAGNOSTIC
LABORATORIES
A true case …
Husband & Wife involved in MVAReferred by chiropractor to have
EDXStudies performed in chiropractors
officeChiropractor bills/collects $Mobile Diagnostic Lab (MDL)
bills/collects $ for the husband and $ for the wife
Case # 1 All diagnoses made by MDL later
found to be erroneous Poor Quality / Abuses
1. Excessive Charges - $14K & $12K
2. Excessive, Unnecessary, & Inappropriate Testing - (> 20 nerves tested in each – incl Bilateral Phrenics!)
3. Inaccurate Diagnoses
Another true case…47 yr old man with R leg weaknessPrimary care MD orders EDXMDL comes into his office to
perform EDX study (NCS Only)Patient dxd with “Peroneal
mononeuropathy at fibular head involving only motor fibers” (??)
Repeat EDX study 3 weeks later (by ABEM EDX Consultant) found classic ALS (Hx, PE, & EDX)
Case # 2 Patient treated with Bob Miller
at ALS clinic in San Francisco before he died.
(MDL billed patient >$7,000!!!)
Poor Quality / Abuses1. Inaccurate Diagnosis 2. Excessive Charges3. Excessive, Unnecessary, &
Inappropriate Testing
Mobile Diagnostic Laboratories
Basics of
How They Work
Mobile Dx Labs Basics of How They Work
Marketed to Potential Referral Providers
“Why send EDX studies out when you can profit by having EDX studies performed in your own office?”
Typical Target Providers Family Physicians Internists Other MDs/DOs/FNPs/PAsChiropractors
Mobile Dx Labs Basics of How They Work
Provider Makes ReferralMVA, MC, Privates all billed now
Technician Sent to Providers Office
I have seen them sent >2000 miles!
Mobile Dx Labs Basics of How They Work
NCS Exam PerformedMost (if not all) Motor StudiesMost (if not all) Sensory StudiesMost F-waves & H-reflexesSometimes SSEPs and DSEPsSometimes MS Ultrasound
performedNo EMG performed (? Surface
EMG)No good Hx or PE performed!!!
Mobile Dx Labs Basics of How They Work
Provider bills “Technical Component”
MD at MDL “homebase” interprets NCSs
MD at MDL “homebase” charges “Professional Component”
MD at MDL “homebase” makes diagnoses and sends report to provider
Mobile Dx Labs Basics of How They Work
“New & Improved” (Mutated) MDLs
Changes to address “red flags”Marketed to potential NCS
InterpretersMDL enlists physicians to interpret
NCS for a set fee Fee is per each nerve or per whole
NCS
Mobile Dx Labs Basics of How They Work
“New & Improved” (Mutated) MDLs
MDL #2 otherwise looks and acts like #1
MDL markets to referring providersMDL sends out EDX technician to
performNo good Hx or PE performedExcessive number of nerves is norm
Features Common to
Mobile Diagnostic EDX
Labs
Features Common to Mobile Diagnostic Labs
“Shot Gun” excessive # of NCSs Templated – same nerves every
studyTechnician performs studiesPoor quality NCSsNo good HX / PE to guide examInaccurate diagnoses
Features Common to Mobile Diagnostic Labs
Poor Quality NCSs Interference very commonInaccurate marker placementInappropriate electrode placement (e.g. not on motor point)Inappropriate stimulation – too low
or too high (with volume conduction).
All lead to inaccurate and unreliable results!
Features Common to Mobile Diagnostic Labs
Inaccurate DxsOften dx radiculopathy based on F-waves (no EMG)Often see multiple diagnoses (multilevel/bilateral radiculopathies)
Often see diagnoses that make no neurophysiologic sense
Features Common to Mobile Diagnostic Labs
Emphasis on profits - not on accuracy
MDL “home base” is usually far away
Previously was mainly MVA patients
Now billing more private carriers & even Medicare/Tricare (FBI/US AG)
AMA-CPT Coding Book To address Mobile Dx Labs
Revised in 2013“Waveforms must be reviewed on
site in real time, and the technique must be adjusted, as appropriate, as the test proceeds…”
“Reports must be prepared on site by the examiner…”
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
Types of EDX Fraud & Abuse
HAND-HELDDEVICES
Hand-held Devices
Deleted 27 slides from presentation
Bigger issue 2006 – 2010.AANEM/AAPM&R/AAN addressedAs of 1/1/10 given CPT code 95905Pays much less than standard
NCSsCan be billed once per limb only
Hand-held DevicesCONTINUED PROBLEMS
Often don’t use new CPT 95905Use HHD to substantiate “need”
for surgery, injection, or other Rx ($$)
Still in wrong hands – not in offices of those that can best dx appropriately
Most diagnoses are missed (my slides)
Poorly diagnoses CTS / GPN / UN@E
Hand-held DevicesCONTINUED PROBLEMS
No info re: amp / dur / conduction block
Cannot assess prognosisDiagnose radiculopathies without
EMG!“Shotgun” - excessive number of
NCSsPreset battery of NCSs – cannot
changeNo individual results until test
completed
Hand-held DevicesCONTINUED PROBLEMS
Cannot change focus during testing
Company promotes serial “monitoring”
Slick marketing dupes providersCompany says no diagnoses –
“only interpretations” therefore no liability
Must tell providers they are legally liable when they sign bottom line of report
Hand-held DevicesTESTING FOR CARPAL TUNNEL
SYNDROME
Median Sensory to 3rd/Long ONLYNo comparison Med vs. Rad or Med vs.
UlnNo Med vs Uln MotorAbnormal by absolute values onlyNo ability to assess Conduction BlockNo EMGHow SENSITIVE would I be with
all of these limitations !?!?!?
Hand-held DevicesPROMOTES UNNECESSARY TESTING
For “non-radicular” back pain one company recommends:Bilateral Peroneal MotorsBilateral Peroneal F-WavesBilateral Tibial MotorsBilateral Tibial F-WavesLeft or Right Sural Sensory9 NCSs FOR NON-RADICULAR
LOW BACK PAIN!!
Hand-held DevicesNOT USED AS INTENDED???
Comments from CEO of HHD company:Re: their HHD being used by surgeons to
justify CTDs - “I would never argue that this technology should be used for surgical decision making.”
Re: liability issue - “We are an equipment manufacturer - we have no (medical) liability.”
“Complicated and involved cases should be referred to specialty trained Neurologists and Physiatrists”.
Hand-held DevicesNEW DEVICE
Assessment of single or bilateral surals
Gives velocity and amplitudeDon’t position correctly can get
smaller amplitude (and slowed velocity)
Make diagnosis based on only this data!
Treatment (meds & other interventions) based on only this data!
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Quantitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
Types of EDX Fraud & Abuse
Q.S.T.(Quantitative Sensory
Testing)
Q.S.T.(Quantitative Sensory
Testing)Device has changed names multiple
times (to avoid litigation and to optimize reimbursement)
Stimulation applied by probe to surface of extremity (over dermatome).
Patient response REQUIRED (as stimulus intensity ’s patient instructed to say “I feel it now”).
Also called “voltage-actuated sensory nerve conduction threshold” or vsNCT.
Q.S.T.(Quantitative Sensory
Testing)Used & promoted by Pain Medicine
ClinicsUsually have no EDX training Anesthesiologists, FPs, IMs, Peds (?),
etc.Often used to justify need for
injectionsLargest company states is “97%
sensitive while standard EMG is 37% sensitive in diagnosing radiculopathy”
Q.S.T.(Quantitative Sensory
Testing)Supporters formed organization
called “American Association of Sensory Electrodiagnostic Medicine”
When we were AAEM they were AASM
When we changed to AANEM they changed to AASEM
Logo very similar to AANEM logo(You draw your own conclusions)
Q.S.T.(Quantitative Sensory
Testing)Previously billed as 95904 (Sensory
Nerve).Does not provide amplitude, duration,
or velocity (required to bill NCSs).Even latency is confusing - ? Time to
patient response?Made additions to device when
printed waveform required (“Potentiometer”)
Q.S.T.(Quantitative Sensory
Testing)Try to make reports look like
standard NCS reports.Never use term “Q.S.T.”Use term “Nerve Conduction
Studies”Medicare and most Private Payers
deem “Investigational” and do not reimburse (if they see thru the “disguise”!!).
Q.S.T.(Quantitative Sensory
Testing)
Despite new grouped NCS codes inappropriate QST exams performed.
This is most likely due to many using results to justify injections.
Q.S.T.(Quantitative Sensory
Testing)Biggest deficiency of Q.S.T. is that
because of need for patient response it is a SUBJECTIVE TEST.
Obviously the results can be changed or biased by patient.
Important point to make to insurers or others.
Q.S.T.(Quantitative Sensory
Testing)Other Reasons QST Not Quality EDX
QST does not measure necessary response parameters of amplitude, latency, configuration, AND conduction velocity.
Those performing do not have appropriate training, education, experience, expertise, or credentials.
Make ludicrous and unsupported claims.Need to address AMA-CPT and go through the
appropriate channels to get it’s own code.
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
Types of EDX Fraud & Abuse
Manipulation of
Waveforms
Manipulation of Waveforms
Landmark case in New JerseyDigital copies of waveforms
reproduced on multiple patients charts
Possibly fictitious patientsAltering waveforms to appear to
be obtaining new/different data
Manipulation of Waveforms
Alteration of WaveformsChanges in instrumentation
Sweep speedGain
Changes in stimulationManually moving cursorsRelabeling as different sideCutting & pasting waveforms
Manipulation of Waveforms
Alteration of Waveforms
Can make changes in report of:Hardcopy waveformsDigital waveformsNumerical data in graphic form
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
Types of EDX Fraud & Abuse
“Mail Order EMG/NCS”
“Mail Order EMG/NCS” Inadequate Training
PhysiciansPTsTechnologistsChiropractorsMedical AssistantsReceptionistsYour Mailman (Allow any paying
customer)
“Mail Order EMG/NCS”
Weekend Courses (With Diploma)DVDOnline CoursesBooklets/Written Course MaterialsHalf Day in Office InstructionTeleconferences
“Mail Order EMG/NCS”
Some teach you to acquire the data and then it is sent off to be interpreted.
Others teach you to acquire and interpret the data.
Some courses include instruction in “report writing” (esp. how to make reports look like good quality report).
“Mail Order EMG/NCS”
Some companies sell small hand-held NCS device that also performs EMG.
In weekend course you are instructed in the performance and interpretation of EMG exams.
“Mail Order EMG/NCS”
Some Claims of “Mail Order” Companies
“Learn how to perform EMGs from the comfort of your home and on your schedule. - Starting at $49.99”
“Stop referring patients out! Add EMG to your practice today.”
“No cost to practice - in fact, testing can generate significant revenues.”
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
Types of EDX Fraud & Abuse
Inappropriate CPT 95937 Billing
Inappropriate CPT 95937 BillingCPT code 95937 = NMJ testing –
Repetitive Nerve Stimulation30 minutes of time needed (pre/work/post)Only NCS billed as separate units – (can be billed multiple times).Historically reimbursed higherShould only be for Myaesthenia
Gravis of Lambert-Eaton Syndrome
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
Types of EDX Fraud & Abuse
UNQUALIFIEDPRACTITIONERS
Unqualified Practitioners
Physical TherapistsAPTA goal/mandate - to have all PTs
nationwide able to legally do EDX
ChiropractorsHave “added qualifications” in
Neurophysiology / NM medicine
Other MDs/DOs (or office staff)IM, FP, Podiatrist, Rheum, Ortho,
Anes, Pain MedRecent LSBME case – Cardio, Pulm,
Pod
Types of EDX Fraud & AbuseMobile EDX Laboratories
Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”
“Enemy Within Our Ranks”
Neurology and PM&R PhysiciansParticipating in MDLs – (LSBME
case)Using HHDs, QST, “Mail-Order
EMG”Manipulating WaveformsInappropriately Supervising TechsAllowing MAs, PAs, FNPs, PTs, or
others to do part or all of NCS/EMG.
“Enemy Within Our Ranks”
Some are AANEM membersSome are AAN or AAPM&R
membersSome are ABEM certified!They often tout these
“credentials” blatantly…
Addressing EDX
Fraud & Abuse
Addressing EDX Fraud & Abuse
ResourcesEDX Laboratory
Accreditation“Red Flags” for Insurers
Addressing EDX Fraud & Abuse
Resources
Addressing EDX Fraud & Abuse
RESOURCESAANEM POSITION STATEMENTS
Proper Performance and Interpretation of Electrodiagnostic Studies
Endorsed by AAPM&R & AANBy describing what constitutes
QUALITY EDX studies it highlights inaccuracies, insufficiencies, and inappropriateness of MDLs, HHDs, and inadequately trained individuals
Addressing EDX Fraud & Abuse
RESOURCESAANEM POSITION STATEMENTS
Used by most all private insurers to draft reimbursement policies
Used by CMS to make reimbursement decisions – LCDs (NCD soon?)
Accepted authority on quality EDXUse extensively in F&A cases
Addressing EDX Fraud & Abuse
RESOURCESOTHER AANEM POSITION STATEMENTS
Recommended Policy for EDX MedicineModel Policy for Needle EMG and NCSsQuality EDX Medicine Controls CostsWho is Qualified to Practice EDX
Medicine?Credentialing of Physicians as EDX
Consultants
Addressing EDX Fraud & Abuse
RESOURCES
OTHER AANEM POSITION STATEMENTSReporting Results for Needle EMG and
NCSsGuidelines for Ethical Behavior Relating
to Clinical Practice Issues in NM and EDX Medicine
EDX services: Pay for Quality (new)Most are endorsed by AAPM&R and AAN
Addressing EDX Fraud & Abuse
EDX Laboratory Accreditation
Addressing EDX Fraud & AbuseEDX LAB ACREDITATION
Prompted by many Insurance Co. calls to AANEM office
Endorsed by AAPM&RAccreditation based on QualitySeparate from ABEMCosts will pay for program to run NOT designed as a money makerRenew every 5 years Voluntary
Addressing EDX Fraud & AbuseEDX LAB ACREDITATION
Medical DirectorCME requirementApplication procedure - onlineTraining requirements – PM&R
residencyPhysical facility requirementsReports peer reviewed (a few)Painless application process (Office Mgr
can do!)
Addressing EDX Fraud & AbuseEDX LAB ACREDITATION
Ensures quality EDX studiesMultiple mechanisms to keep out F
& AInsurance/Payers Acceptance
EDX studies authorized more easilyMore EDX referralsBetter interactions / communications?? Better reimbursement??
Addressing EDX Fraud & AbuseEDX LAB ACREDITATION
All quality labs need to become accredited!
Working with private insurers and CMS:? January 2016 DeadlineOnly reimburse EDX studies done in an
accredited lab.Possibly separate fee structure for
accredited and non-accredited labs.
Addressing EDX Fraud & Abuse
EDX LAB ACREDITATIONOur way to “take back” our
specialty!Sleep labs & Mammography are
just a few that did this with positive results.
For anyone in this room it is EASY!May need legislation – been to
Capitol Hill twice already.No Good Reason Not To Do It !!
Addressing EDX Fraud & Abuse
EDX Fraud Trends &
“Red Flags”
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGS
Presentations to FBI, OIG, CMS, NHCAA and multiple Private Insurers
I tell them what to look for – how to find EDX F&A
EDX practices that have any of these “red flags” will be at higher risk of review, audit, claim denials, or prosecution.
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSIn 2013 (and 2014) EDX studies are
on the OIG’s “Hit List” (Office of Inspector General Work Plan).
“The use of EDX testing for inappropriate financial gain poses a growing vulnerability to Medicare.”
(Not small potatoes anymore!)
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSAMA-CPT Coding Book Change for
2013“Waveforms must be reviewed on
site in real time, and the technique must be adjusted, as appropriate, as the test proceeds…”
“Reports must be prepared on site by the examiner…”
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGS
Growing movement to require physician billing EDX studies to have residency training in PM&R or Neurology.LCD’s – Medicare Regional CarriersNCD’s – Medicare nationallyPrivate health insurances coverage
policies“Scope of Practice” issue poses
problem
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGS
Limiting reimbursement toPM&R & Neuro physicans
only would have
THE LARGEST effect on EDX Fraud &
Abuse
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSBefore 1/1/13
Excess # nerve studies – esp. 95900, 95903, 95904
Excess $ charged per nerve study“Open Season” for NCS billing!!!
After 1/1/13Grouped/Bundled NCS billing
schedule
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSAfter 1/1/13
1-2 nerve conduction studies = 95907
3-4 nerve conduction studies = 95908
5-6 nerve conduction studies = 95909
7-8 nerve conduction studies = 95910
9-10 nerve conduction studies = 95911
11-12 nerve conduction studies = 95912
13 + nerve conduction studies = 95913
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSToo many NCS performed
billing 95913 > 70%
Scheduling patients to perform NCS’s on separate limbs on separate days.UE split from LE can be acceptable
Lack of appropriate training/expertise of MD/DO or NCS Technician
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSUse of inappropriate EDX
equipment (e.g. – QST device or Hand Held Device)Insurers requesting EDX equipment
brand, model and possibly serial #
Look for NCS billed without EMG<10% of time acceptable
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGS
Repeating EDX studies for “monitoring” Esp. seen with generalized neuropathyNo medical evidence to support this
practiceSometimes every 3-6 months!Can be seen with other diagnosesPossibly appropriate in nerve trauma
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSBilling CPT 95937
InappropriatelyNMJ testing – Repetitive Nerve
Stimulation30 minutes of time needed
(pre/work/post)Only NCS billed as separate
(therefore multiple) units.Historically reimbursed higherShould only be for NMJ disorders
(Myaesthenia Gravis of Lambert-Eaton)
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSLack of medical necessity for
NCS/EMGProfessional and technical
components billed separatelyPromotion to Health Care Providers
(MDs and others) as “money maker”.
Location of services not in office of NCS reviewer/biller.
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGSSurface EMG disguised and billed
as Needle/Pin EMGNCS waveforms reviewed at later
timeNCS waveforms reviewed far awayNCS waveforms being duplicated
or manipulated
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGS
What % of EDX studies billed are NCS ONLY?
PM&R = 5%Neuro = 10%IDTFs = 80%Podiatry = 100%
CBR201406: Electrodiagnostic TestingDates of Service 1/1/2013 – 12/31/2013
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGS
What % of EDX studies billed are NCS ONLY?
24 Specialties = > 30%15 Specialties = > 50%
20% cut-off excludes all providers who
inappropriately perform only NCS
Addressing EDX Fraud & Abuse
EDX FRAUD TRENDS & RED FLAGS
Average Weighted NCS Services per BeneficiaryPM&R = 7.74Neuro = 8.45IDTF = 14.07
(’s with sicker/more complicated patients –
But that is NOT why IDTFs are so high)
Addressing EDX Fraud & Abuse
If you encounter F & A or if you are asked to review cases of suspected F&A
Feel free to contact me (541) [email protected]
Contact AAPM&R or AANEM staffAAPM&R – Jennie Jackson (Manager, Health
Finance & Reimbursement)AANEM – Millie Birr (Health Policy Director)