Physician Payment Data – Are You Under the Microscope?
By Sally Eggleston, MBA, RT(T)

Oh, how we hate change! Please, give us anything but change! CERTS, RAC Audits, PQRS, Meaningful Use and now Transparency—what are they going to think up next? Whether you love or hate the ACA, one of its drivers is the need for change. What makes it hard to endure is the variety of change.

CMS’s release of physician payment data on April 9, 2014 caused quite a stir. The news is still making headlines and is the buzz around the water cooler. While touted as a step toward transparency and a tool to detect fraud, the release of these numbers is causing some physicians who shouldn’t be fearful to be fearful, anyway. And while some of the follow-up articles explained that the medical oncology physicians who, in some cases, received very high Medicare payments got them as a result of the costliness of drugs, some physicians may still fret that they’ll become a target of an in-depth review of their billing and/or the loss of patient volume. It didn’t help that just a few days after the CMS release, the OIG released information about a medical oncologist—divulged by a staff whistleblower—who had fraudulently billed for drugs that patients did not receive.

Some radiation oncologists faced the same issue as the medical oncologists if, while billing in the freestanding environment for global charges, there was no consideration given to the cost of the equipment, physics, radiation therapists, etc. This occurs since, under the Medicare Physician Fee Schedule (MPFS), the CMS 1500 claim form requires a rendering physician be included on the claim if billing as a radiation oncology center.

Most physicians know it, but an industry truth continues to amaze clinical personnel when they learn that the payment systems we use are based on the honor system. Yes, the honor system. Payors don’t know whether you coded incorrectly—they will pay anyway if there isn’t an edit to prevent payment. And many times there isn’t.

If you made the list—and even if you didn’t, yet—here are some things you need to consider when evaluating your risk of a review:

  • How educated is your staff in charge capture, documentation and compliance?
  • Do you have a budget for continuing education on billing?
  • Do you have a compliance plan? If so, is it being implemented?
  • How frequently do you discuss compliance and correct coding with whoever is performing your billing?
  • What is the volume of medical records that you internally review for coding, documentation and compliance?
  • Do you receive CMS updates electronically?
  • Do you have ongoing dialogue with the clinical staff members in your office so that they know the measures being taken to be compliant?

No one likes being under scrutiny. The potential for review is real, but it doesn’t have to keep you up at night. RC Billing can help ensure that your staff is trained, your technology is up-to-date, your medical records and coding are accurate and your well-crafted compliance plan is being implemented to a T. To find out more about what RC Billing can do for you, contact us at 512-583-2000 or by email at


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