It's all right for the government to look at how teaching hospitals bill Medicare.
That's according to a 35-page report by the General Accounting Office released last week-potentially poking holes in two lawsuits aimed at halting the Physicians at Teaching Hospitals, or PATH, probe.
At issue in PATH is whether teaching physicians were present when residents provided services to patients.
"The fact that a physical presence requirement has not always been consistently communicated or enforced does not obviate the need for teaching physicians to document their personal involvement in services to legitimately bill Medicare," the GAO report said.
The probe was also expanded to determine whether teaching physicians were upcoding, or billing for a service by using an inappropriate code to get higher reimbursement. To date, four institutions have settled PATH audits for a total of $67.6 million (See chart).
U.S. Rep. William Thomas (R-Calif.), chairman of the House Ways and Means health subcommittee, requested the report in July 1997 after the Association of American Medical Colleges and the American Medical Association began lobbying heavily against the PATH initiative.
The AAMC and the AMA joined forces to sue HHS last October to halt the PATH audits as they were being conducted (Nov. 3, 1997, p. 4).
The GAO report examined the processes used by HHS' inspector general's office in three of the resolved PATH audits: Dartmouth College, Thomas Jefferson University and the University of Pennsylvania. HHS ended the Dartmouth audit last year after finding no evidence of problems.
The AMA-AAMC lawsuit alleged the inspector general was applying Medicare rules retroactively when it conducted PATH audits. But the GAO found no evidence of that.
A federal judge dismissed the lawsuit in April, ruling that the provider groups had not exhausted all their administrative remedies before taking the matter to court. The groups appealed that decision in June.
AAMC Senior Vice President Robert Dickler said the GAO report was unlikely to affect the group's pending appeal, but added that the report could be used as evidence if the case goes to trial.
"We're disappointed with the broad conclusions that there was always a clear physical presence requirement," Dickler said. "We continue to believe that there was sufficient confusion on that."
The AAMC's lawsuit also attacked the way government investigators determine the amount of PATH settlements.
This time the GAO agreed, indicating Penn and Jefferson paid settlements that were too high.
"Indeed, these estimates (of overbilling used in settlement negotiations) were not statistically valid," the GAO report said.
Meanwhile, in the other lawsuit involving PATH issues, the Greater New York Hospital Association has filed a motion for summary judgment.
The motion, filed Aug. 5 in U.S. District Court in New York, opposed the government's motion filed in June to dismiss the case.
The GNYHA contends in its federal complaint that its Medicare carrier in New York did not provide clear guidance to its teaching hospital members. Those members should be exempt from PATH audits, the GNYHA claims.
The government argues the GNYHA has no standing to bring a case until investigators have completed the audits and sued the hospitals.
No further hearing dates have been set.