Provider groups say they're concerned about plans by HHS' inspector general's office to review the records of physicians who may have billed Medicare for excessive visits to patients in skilled-nursing facilities.
The groups say the action may discourage appropriate visits to patients in skilled-nursing facilities, or SNFs, particularly because nursing homes complain that they can't get doctors to visit often enough.
The inspector general's office outlines its plan to investigate physician SNF visits in its work plan for the 1997 federal fiscal year. The document said the agency has identified "aberrant billing patterns"-excessive visits to individual SNF patients or excessive visits in a single day-by California physicians.
The agency said it will audit physicians with the most egregious billing patterns.
Although Medicaid programs are the biggest purchasers of nursing home care, Medicare pays for at least part of 100 days of care in SNFs to treat conditions that caused beneficiaries to be hospitalized.
Medicare paid for SNF treatment for 1.1 million beneficiaries in 1994.
For all services, including office visits and procedures, inpatient care and SNF treatment, Medicare paid physicians $33 billion in fiscal 1995, according to the Congressional Budget Office. The CBO projects that number to rise to $37 billion in fiscal 1997, which began Oct. 1.
Although they support audits of doctors who intentionally defraud the government, provider groups warn that a probe by the inspector general's office could discourage doctors from making appropriate visits at a time when shortening lengths of hospital stays are increasing the healthcare needs of Medicare beneficiaries discharged to SNFs.
Nursing facility administrators often complain that doctors don't visit patients often enough because of lower Medicare reimbursement, said Dave Kyllo, spokesman for the American Health Care Association, a nursing home trade group.
Generally, physicians are required to visit patients in nursing homes once every 30 days for the first 90 days of care and once every 60 days thereafter.
An aggressive review of billing patterns also might not account for the increasing needs of Medicare beneficiaries discharged to SNFs after a hospitalization, added Susan Pettey, federal affairs director with the American Medical Directors Association, which represents nursing home medical directors.
Pettey said it's not uncommon for a physician to need to visit an SNF patient more than once a day because of instability after a hospitalization.
"We want to make sure that medically necessary visits are not thwarted," Pettey said.