Best Practices

11 Questionable PSG Billing Measures, as IDed by the OIG

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Centers for Medicare & Medicaid Services will use these measures to develop algorithms to detect inappropriate billing practices and to analyze the practices of sleep medicine providers in the future. 
 
By Daniel Brown, Esq. 
 
 
In its report Questionable Billing for Polysomnography Services, the Office of Inspector General (OIG) identified 11 categories of “questionable” billing measures. It designated three as measures that address “Medicare Requirements”: improper diagnosis code, duplicate claims, and invalid NPI. All of the $16.8 million identified as erroneously paid claims are attributable to these three categories of Medicare Requirements. 
 
The remaining eight measures of questionable polysomnography (PSG) billing identified in the report didn’t trigger instances of erroneous billing. Rather these were included as instances when PSG services might be medically unnecessary, not performed, or otherwise inappropriate.
 
The OIG recommended that the Centers for Medicare & Medicaid Services (CMS) use all 11 measures of questionable billing to ferret out billing errors in future studies. CMS has agreed to adopt this suggestion. 
 
The following is the list of the eight other questionable billing measures, as identified by the OIG report: 
 
> Shared Beneficiaries. This measure represents the percentage of a provider’s beneficiaries who also had PSG claims submitted by one or more other providers. Providers with unusually high percentages for this measure may be using compromised beneficiary numbers for fraudulent billing. 
 
> Unbundling a split-night service. This measure represents the percentage of a provider’s diagnostic claims for which the provider also submitted a titration claim for the same beneficiary the next day. Providers with unusually high percentages for this measure may be routinely performing split-night services but submitting separate diagnostic and titration claims to increase reimbursement. 
 
> Double-billing for the professional component. This measure represents the percentage of a provider’s claims for global services that had a corresponding claim for the professional component. 
 
> Repeated titrations. This measure represents the percentage of a provider’s beneficiaries who had three or more titration claims within a 90-day period. According to fraud investigators and sleep medicine professionals, it’s rarely medically necessary for a beneficiary to undergo more than two titration services in such a short time. 
 
> Missing professional component. This measure represents the percentage of a provider’s claims for the technical component that had no corresponding claim for the professional component submitted by any provider. 
 
> Titration with no corresponding treatment device. This measure represents the percentage of a provider’s titration claims for which the beneficiary has no corresponding durable medical equipment (DME) claims for positive airway pressure (PAP) devices or oral appliances. According to fraud investigators and sleep medicine professionals, in almost all cases beneficiaries who require a titration service are prescribed a PAP device or oral appliance. 
 
> Missing visit with ordering provider. This measure represents the percentage of a provider’s PSG claims for which the beneficiary had no claims with the ordering provider in the preceding year. Providers with unusually high percentages for this measure may be routinely performing and billing Medicare for PSG services for which they don’t have valid orders and aren’t medically necessary. 
 
> Repeated PSG services. This measure represents the percentage of a provider’s beneficiaries who had two or more PSG claims in each of three consecutive years. Although it may be necessary in some cases for a beneficiary to undergo repeat tests, it’s rarely medically necessary for beneficiaries to receive multiple PSG services in consecutive years, according to fraud investigators and sleep medicine professionals. 
 
Daniel Brown, Esq., is an attorney at Brown, Dresevic, Gustafson, Iwrey, Kalmowitz and Pendelton, The Health Law Partners, LLC, in Atlanta.