Comparative Billing Reports: When to Be Concerned
Providers have many questions about Comparative Billing Reports (CBRs), one of the Centers for Medicare and Medicaid Services' (CMS) newest tools for educating providers regarding billing patters.
ROYAL OAK, MI, December 04, 2011 /24-7PressRelease/ -- Providers have many questions about Comparative Billing Reports (CBRs), one of the Centers for Medicare and Medicaid Services' (CMS) newest tools for educating providers regarding billing patters. According to CMS, the purpose of a CBR is to show individual providers how their billing patterns for various codes and procedures compare to the state average and the national average for providers within the same field (e.g. physical therapists and chiropractors). CMS has also stated that these comparative studies are designed to help providers review their coding and billing practices and utilization patterns, and take proactive compliance measures. Although CMS has stated that CBRs are for compliance purposes and not intended to be punitive or sent as an indication of fraud, providers receiving CBRs could be vulnerable to potential audit activity and could even be considered to have been put on notice of overpayments.
In the past, CMS has issued similar billing reports, such as the Program for Evaluating Payment Patterns Electronic Report (PEPPER) targeting inpatient hospitals. PEPPER focuses on several inpatient risk areas, which are used by hospitals to compare their billing practices with other hospitals across the state and nation. Although not currently available to hospitals, CBRs are much like PEPPER in that they provide comparative data to assist providers in visualizing underpayments and overpayments in an effort to show billing outliers.
CMS awarded Safeguard Services, LLC the contract for producing CBRs, and Livanta LLC the contract for distributing CBRs. CMS has recommended that CBRs be sent out to select provider types that bill for certain services identified as vulnerabilities in the Medicare Program. The first CBRs were sent out in August of 2010 to physical therapists, who were chosen due to an identified vulnerability in their billing practices. The vulnerability identified was the use of the "KX" HCPCS modifier, which is a billing requirement used to show that the beneficiary has exceeded the therapy cap, but requires additional medically necessary physical therapy services.
Since then, CMS has expanded the number of provider types to receive CBRs. To date, the provider types that have been identified to receive CBRs are chiropractors, ambulance, hospice, podiatry, sleep studies and spinal orthotics, each with its own vulnerabilities identified by CMS. A maximum of 5,000 providers in each provider class will be selected to receive CBRs. Medicare updates the data twice a year, so the reports cover one of two dates of service timeframes: January through June or July through December. Due to CBRs being based on dates of service, the reports are typically not available for at least three months in order for the claims to be finalized.
CBRs are not available to anyone but the provider who receives them. The reports do not include patient or case-specific data, but rather only contain summary billing information as a method of ensuring privacy. The providers receiving the report are directed to use the summary billing information as a tool to help them comply with Medicare billing rules and correct any current billing errors that could lead to a future audit.
CBR data analysis involves the same data-mining tools used by Medicare audit contractors to identify candidates for audit. Also, in our experience, the vulnerabilities identified in the CBR tend to be the same as those identified by CMS contractors who select providers for audit. Thus providers who are identified as outliers in CBRs will likely be subject to audits. Providers can determine whether they have been identified as an outlier compared to their peers by reviewing the graphical illustrations included in the CBR. Providers whose specialty has been identified but have not yet received a CBR may want to view a sample CBR, which can be found on Safeguard's website (http://www.safeguard-servicesllc.com/cbr/sample.asp), so that they will understand the information in the CBR should it arrive.
As discussed above, aberrant use of a code with respect to peers could also potentially be considered to put a provider on notice of an overpayment. The health care reform legislation clarified that providers have an affirmative duty to return an overpayment it has received and notify the appropriate entity (such as CMS, OIG, or the carrier) regarding the reason for the overpayment within sixty days from the date of identification. Retention of an overpayment beyond the deadline for reporting and returning creates the possibility of liability under the False Claims Act (FCA), which was recently amended to include language that creates violations for knowingly failing to return an overpayment to the government.
Upon receiving a CBR, it is vital that providers evaluate the information included and consider conducting an attorney client privileged internal compliance audit to determine whether any differences in billing patterns are attributable to billing errors or can be explained in other manners, e.g., a difference in patient population. Providers should also develop compliance policies to address any identified risk areas. Recipients of a CBR and provider types that have been identified to receive CBRs (i.e. physical therapists, chiropractors, ambulance, hospice, podiatry, sleep studies, and spinal orthotics), should consider contacting a health law attorney to discuss evaluating the CBR analysis and development of an appropriate compliance plan that will reduce audit risks going forward.
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Cheryl Sawicki
Wachler & Associates, P.C.
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