the many and varied types of fraud and abuse in electrodiagnostic medicine

The Many and Varied Types

of Fraud and Abuse

in Electrodiagnostic Medicine

Peter A. Grant, M.D.November 15th, 2014

A.A.P.M.&R. – San Diego.

Peter A. Grant, M.D.Past President – American Association

of Neuromuscular & Electrodiagnostic Medicine

Diplomate - American Board of Physical Medicine & Rehabilitation

Diplomate – American Board of Electrodiagnostic Medicine

Specialist in EDX Fraud & Abuse (15 years)

AANEM Accredited EDX Laboratory

DISCLAIMER

Please note that any and all comments made in

this lecture are mine and NOT the AAPM&R or the

AANEM or any other organization.

Outline of PresentationWhy EDX Fraud & Abuse?What constitutes “Quality

EDX”Types of EDX Fraud & AbuseAddressing EDX Fraud &

AbuseResourcesEDX Laboratory AccreditationFraud Trends & “Red Flags”

Reimbursement Cuts & EDX Fraud and Abuse

WHAT’S THE CONNECTION?“These cuts were, most definitely, due

to the increased utilization of the NCS codes”

(Jonathan Blum – Deputy Director CMS)

So…. The Reimbursement Cuts were a direct response to Fraud & Abuse in EDX.

Types of EDX Fraud & Abuse

LEGAL MEASURE OF QUALITY Community, regional, or national standard

of care for EDX evaluations.Current & Historical EDX practices in your

community.What AANEM (with endorsement of AAN

and AAPM&R) promotes and publishes as standards for EDX exams to be appropriate, accurate, and necessary.


THE MANY FACES OF POOR QUALITYInaccurate Diagnosis

Wrong DiagnosisMissed DiagnosisOverdiagnosis

Excessive, Inapproriate, or Insufficient Testing

Excessive or Inappropriate Charges


Common to All Abusive & Fraudulent EDX

Emphasis is on $$$ and Not on

QualityEDX Studies/Patient Care

Types of EDX Fraud & AbuseMobile EDX Laboratories

Hand-held DevicesQST (Qualitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”


MOBILE DIAGNOSTIC

LABORATORIES

A true case …

Husband & Wife involved in MVAReferred by chiropractor to have

EDXStudies performed in chiropractors

officeChiropractor bills/collects $Mobile Diagnostic Lab (MDL)

bills/collects $ for the husband and $ for the wife

Case # 1 All diagnoses made by MDL later

found to be erroneous Poor Quality / Abuses

1. Excessive Charges - $14K & $12K

2. Excessive, Unnecessary, & Inappropriate Testing - (> 20 nerves tested in each – incl Bilateral Phrenics!)

3. Inaccurate Diagnoses

Another true case…47 yr old man with R leg weaknessPrimary care MD orders EDXMDL comes into his office to

perform EDX study (NCS Only)Patient dxd with “Peroneal

mononeuropathy at fibular head involving only motor fibers” (??)

Repeat EDX study 3 weeks later (by ABEM EDX Consultant) found classic ALS (Hx, PE, & EDX)

Case # 2 Patient treated with Bob Miller

at ALS clinic in San Francisco before he died.

(MDL billed patient >$7,000!!!)

Poor Quality / Abuses1. Inaccurate Diagnosis 2. Excessive Charges3. Excessive, Unnecessary, &

Inappropriate Testing

Mobile Diagnostic Laboratories

Basics of

How They Work

Mobile Dx Labs Basics of How They Work

Marketed to Potential Referral Providers

“Why send EDX studies out when you can profit by having EDX studies performed in your own office?”

Typical Target Providers Family Physicians Internists Other MDs/DOs/FNPs/PAsChiropractors


Provider Makes ReferralMVA, MC, Privates all billed now

Technician Sent to Providers Office

I have seen them sent >2000 miles!


NCS Exam PerformedMost (if not all) Motor StudiesMost (if not all) Sensory StudiesMost F-waves & H-reflexesSometimes SSEPs and DSEPsSometimes MS Ultrasound

performedNo EMG performed (? Surface

EMG)No good Hx or PE performed!!!


Provider bills “Technical Component”

MD at MDL “homebase” interprets NCSs

MD at MDL “homebase” charges “Professional Component”

MD at MDL “homebase” makes diagnoses and sends report to provider


“New & Improved” (Mutated) MDLs

Changes to address “red flags”Marketed to potential NCS

InterpretersMDL enlists physicians to interpret

NCS for a set fee Fee is per each nerve or per whole

NCS


“New & Improved” (Mutated) MDLs

MDL #2 otherwise looks and acts like #1

MDL markets to referring providersMDL sends out EDX technician to

performNo good Hx or PE performedExcessive number of nerves is norm

Features Common to

Mobile Diagnostic EDX

Labs

Features Common to Mobile Diagnostic Labs

“Shot Gun” excessive # of NCSs Templated – same nerves every

studyTechnician performs studiesPoor quality NCSsNo good HX / PE to guide examInaccurate diagnoses


Poor Quality NCSs Interference very commonInaccurate marker placementInappropriate electrode placement (e.g. not on motor point)Inappropriate stimulation – too low

or too high (with volume conduction).

All lead to inaccurate and unreliable results!


Inaccurate DxsOften dx radiculopathy based on F-waves (no EMG)Often see multiple diagnoses (multilevel/bilateral radiculopathies)

Often see diagnoses that make no neurophysiologic sense


Emphasis on profits - not on accuracy

MDL “home base” is usually far away

Previously was mainly MVA patients

Now billing more private carriers & even Medicare/Tricare (FBI/US AG)

AMA-CPT Coding Book To address Mobile Dx Labs

Revised in 2013“Waveforms must be reviewed on

site in real time, and the technique must be adjusted, as appropriate, as the test proceeds…”

“Reports must be prepared on site by the examiner…”


HAND-HELDDEVICES

Hand-held Devices

Deleted 27 slides from presentation

Bigger issue 2006 – 2010.AANEM/AAPM&R/AAN addressedAs of 1/1/10 given CPT code 95905Pays much less than standard

NCSsCan be billed once per limb only

Hand-held DevicesCONTINUED PROBLEMS

Often don’t use new CPT 95905Use HHD to substantiate “need”

for surgery, injection, or other Rx ($$)

Still in wrong hands – not in offices of those that can best dx appropriately

Most diagnoses are missed (my slides)

Poorly diagnoses CTS / GPN / UN@E


No info re: amp / dur / conduction block

Cannot assess prognosisDiagnose radiculopathies without

EMG!“Shotgun” - excessive number of

NCSsPreset battery of NCSs – cannot

changeNo individual results until test

completed


Cannot change focus during testing

Company promotes serial “monitoring”

Slick marketing dupes providersCompany says no diagnoses –

“only interpretations” therefore no liability

Must tell providers they are legally liable when they sign bottom line of report

Hand-held DevicesTESTING FOR CARPAL TUNNEL

SYNDROME

Median Sensory to 3rd/Long ONLYNo comparison Med vs. Rad or Med vs.

UlnNo Med vs Uln MotorAbnormal by absolute values onlyNo ability to assess Conduction BlockNo EMGHow SENSITIVE would I be with

all of these limitations !?!?!?

Hand-held DevicesPROMOTES UNNECESSARY TESTING

For “non-radicular” back pain one company recommends:Bilateral Peroneal MotorsBilateral Peroneal F-WavesBilateral Tibial MotorsBilateral Tibial F-WavesLeft or Right Sural Sensory9 NCSs FOR NON-RADICULAR

LOW BACK PAIN!!

Hand-held DevicesNOT USED AS INTENDED???

Comments from CEO of HHD company:Re: their HHD being used by surgeons to

justify CTDs - “I would never argue that this technology should be used for surgical decision making.”

Re: liability issue - “We are an equipment manufacturer - we have no (medical) liability.”

“Complicated and involved cases should be referred to specialty trained Neurologists and Physiatrists”.

Hand-held DevicesNEW DEVICE

Assessment of single or bilateral surals

Gives velocity and amplitudeDon’t position correctly can get

smaller amplitude (and slowed velocity)

Make diagnosis based on only this data!

Treatment (meds & other interventions) based on only this data!


Hand-held DevicesQST (Quantitative Sensory Testing)Manipulation of Waveforms“Mail Order EMG/NCS”Inappropriate CPT 95937 BillingUnqualified Practitioners“The Enemy Within Our Ranks”


Q.S.T.(Quantitative Sensory

Testing)


Testing)Device has changed names multiple

times (to avoid litigation and to optimize reimbursement)

Stimulation applied by probe to surface of extremity (over dermatome).

Patient response REQUIRED (as stimulus intensity ’s patient instructed to say “I feel it now”).

Also called “voltage-actuated sensory nerve conduction threshold” or vsNCT.


Testing)Used & promoted by Pain Medicine

ClinicsUsually have no EDX training Anesthesiologists, FPs, IMs, Peds (?),

etc.Often used to justify need for

injectionsLargest company states is “97%

sensitive while standard EMG is 37% sensitive in diagnosing radiculopathy”


Testing)Supporters formed organization

called “American Association of Sensory Electrodiagnostic Medicine”

When we were AAEM they were AASM

When we changed to AANEM they changed to AASEM

Logo very similar to AANEM logo(You draw your own conclusions)


Testing)Previously billed as 95904 (Sensory

Nerve).Does not provide amplitude, duration,

or velocity (required to bill NCSs).Even latency is confusing - ? Time to

patient response?Made additions to device when

printed waveform required (“Potentiometer”)


Testing)Try to make reports look like

standard NCS reports.Never use term “Q.S.T.”Use term “Nerve Conduction

Studies”Medicare and most Private Payers

deem “Investigational” and do not reimburse (if they see thru the “disguise”!!).


Testing)

Despite new grouped NCS codes inappropriate QST exams performed.

This is most likely due to many using results to justify injections.


Testing)Biggest deficiency of Q.S.T. is that

because of need for patient response it is a SUBJECTIVE TEST.

Obviously the results can be changed or biased by patient.

Important point to make to insurers or others.


Testing)Other Reasons QST Not Quality EDX

QST does not measure necessary response parameters of amplitude, latency, configuration, AND conduction velocity.

Those performing do not have appropriate training, education, experience, expertise, or credentials.

Make ludicrous and unsupported claims.Need to address AMA-CPT and go through the

appropriate channels to get it’s own code.


Manipulation of

Waveforms

Manipulation of Waveforms

Landmark case in New JerseyDigital copies of waveforms

reproduced on multiple patients charts

Possibly fictitious patientsAltering waveforms to appear to

be obtaining new/different data


Alteration of WaveformsChanges in instrumentation

Sweep speedGain

Changes in stimulationManually moving cursorsRelabeling as different sideCutting & pasting waveforms


Alteration of Waveforms

Can make changes in report of:Hardcopy waveformsDigital waveformsNumerical data in graphic form


“Mail Order EMG/NCS”

“Mail Order EMG/NCS” Inadequate Training

PhysiciansPTsTechnologistsChiropractorsMedical AssistantsReceptionistsYour Mailman (Allow any paying

customer)


Weekend Courses (With Diploma)DVDOnline CoursesBooklets/Written Course MaterialsHalf Day in Office InstructionTeleconferences


Some teach you to acquire the data and then it is sent off to be interpreted.

Others teach you to acquire and interpret the data.

Some courses include instruction in “report writing” (esp. how to make reports look like good quality report).


Some companies sell small hand-held NCS device that also performs EMG.

In weekend course you are instructed in the performance and interpretation of EMG exams.


Some Claims of “Mail Order” Companies

“Learn how to perform EMGs from the comfort of your home and on your schedule. - Starting at $49.99”

“Stop referring patients out! Add EMG to your practice today.”

“No cost to practice - in fact, testing can generate significant revenues.”


Inappropriate CPT 95937 Billing

Inappropriate CPT 95937 BillingCPT code 95937 = NMJ testing –

Repetitive Nerve Stimulation30 minutes of time needed (pre/work/post)Only NCS billed as separate units – (can be billed multiple times).Historically reimbursed higherShould only be for Myaesthenia

Gravis of Lambert-Eaton Syndrome


UNQUALIFIEDPRACTITIONERS

Unqualified Practitioners

Physical TherapistsAPTA goal/mandate - to have all PTs

nationwide able to legally do EDX

ChiropractorsHave “added qualifications” in

Neurophysiology / NM medicine

Other MDs/DOs (or office staff)IM, FP, Podiatrist, Rheum, Ortho,

Anes, Pain MedRecent LSBME case – Cardio, Pulm,

Pod

“Enemy Within Our Ranks”

Neurology and PM&R PhysiciansParticipating in MDLs – (LSBME

case)Using HHDs, QST, “Mail-Order

EMG”Manipulating WaveformsInappropriately Supervising TechsAllowing MAs, PAs, FNPs, PTs, or

others to do part or all of NCS/EMG.

“Enemy Within Our Ranks”

Some are AANEM membersSome are AAN or AAPM&R

membersSome are ABEM certified!They often tout these

“credentials” blatantly…

Addressing EDX

Fraud & Abuse

Addressing EDX Fraud & Abuse

ResourcesEDX Laboratory

Accreditation“Red Flags” for Insurers


Resources


RESOURCESAANEM POSITION STATEMENTS

Proper Performance and Interpretation of Electrodiagnostic Studies

Endorsed by AAPM&R & AANBy describing what constitutes

QUALITY EDX studies it highlights inaccuracies, insufficiencies, and inappropriateness of MDLs, HHDs, and inadequately trained individuals


RESOURCESAANEM POSITION STATEMENTS

Used by most all private insurers to draft reimbursement policies

Used by CMS to make reimbursement decisions – LCDs (NCD soon?)

Accepted authority on quality EDXUse extensively in F&A cases


RESOURCESOTHER AANEM POSITION STATEMENTS

Recommended Policy for EDX MedicineModel Policy for Needle EMG and NCSsQuality EDX Medicine Controls CostsWho is Qualified to Practice EDX

Medicine?Credentialing of Physicians as EDX

Consultants


RESOURCES

OTHER AANEM POSITION STATEMENTSReporting Results for Needle EMG and

NCSsGuidelines for Ethical Behavior Relating

to Clinical Practice Issues in NM and EDX Medicine

EDX services: Pay for Quality (new)Most are endorsed by AAPM&R and AAN


EDX Laboratory Accreditation

Addressing EDX Fraud & AbuseEDX LAB ACREDITATION

Prompted by many Insurance Co. calls to AANEM office

Endorsed by AAPM&RAccreditation based on QualitySeparate from ABEMCosts will pay for program to run NOT designed as a money makerRenew every 5 years Voluntary


Medical DirectorCME requirementApplication procedure - onlineTraining requirements – PM&R

residencyPhysical facility requirementsReports peer reviewed (a few)Painless application process (Office Mgr

can do!)


Ensures quality EDX studiesMultiple mechanisms to keep out F

& AInsurance/Payers Acceptance

EDX studies authorized more easilyMore EDX referralsBetter interactions / communications?? Better reimbursement??


All quality labs need to become accredited!

Working with private insurers and CMS:? January 2016 DeadlineOnly reimburse EDX studies done in an

accredited lab.Possibly separate fee structure for

accredited and non-accredited labs.


EDX LAB ACREDITATIONOur way to “take back” our

specialty!Sleep labs & Mammography are

just a few that did this with positive results.

For anyone in this room it is EASY!May need legislation – been to

Capitol Hill twice already.No Good Reason Not To Do It !!


EDX Fraud Trends &

“Red Flags”


EDX FRAUD TRENDS & RED FLAGS

Presentations to FBI, OIG, CMS, NHCAA and multiple Private Insurers

I tell them what to look for – how to find EDX F&A

EDX practices that have any of these “red flags” will be at higher risk of review, audit, claim denials, or prosecution.


EDX FRAUD TRENDS & RED FLAGSIn 2013 (and 2014) EDX studies are

on the OIG’s “Hit List” (Office of Inspector General Work Plan).

“The use of EDX testing for inappropriate financial gain poses a growing vulnerability to Medicare.”

(Not small potatoes anymore!)


EDX FRAUD TRENDS & RED FLAGSAMA-CPT Coding Book Change for

2013“Waveforms must be reviewed on

site in real time, and the technique must be adjusted, as appropriate, as the test proceeds…”

“Reports must be prepared on site by the examiner…”



Growing movement to require physician billing EDX studies to have residency training in PM&R or Neurology.LCD’s – Medicare Regional CarriersNCD’s – Medicare nationallyPrivate health insurances coverage

policies“Scope of Practice” issue poses

problem



Limiting reimbursement toPM&R & Neuro physicans

only would have

THE LARGEST effect on EDX Fraud &

Abuse


EDX FRAUD TRENDS & RED FLAGSBefore 1/1/13

Excess # nerve studies – esp. 95900, 95903, 95904

Excess $ charged per nerve study“Open Season” for NCS billing!!!

After 1/1/13Grouped/Bundled NCS billing

schedule


EDX FRAUD TRENDS & RED FLAGSAfter 1/1/13

1-2 nerve conduction studies = 95907






13 + nerve conduction studies = 95913


EDX FRAUD TRENDS & RED FLAGSToo many NCS performed

billing 95913 > 70%

Scheduling patients to perform NCS’s on separate limbs on separate days.UE split from LE can be acceptable

Lack of appropriate training/expertise of MD/DO or NCS Technician


EDX FRAUD TRENDS & RED FLAGSUse of inappropriate EDX

equipment (e.g. – QST device or Hand Held Device)Insurers requesting EDX equipment

brand, model and possibly serial #

Look for NCS billed without EMG<10% of time acceptable



Repeating EDX studies for “monitoring” Esp. seen with generalized neuropathyNo medical evidence to support this

practiceSometimes every 3-6 months!Can be seen with other diagnosesPossibly appropriate in nerve trauma


EDX FRAUD TRENDS & RED FLAGSBilling CPT 95937

InappropriatelyNMJ testing – Repetitive Nerve

Stimulation30 minutes of time needed

(pre/work/post)Only NCS billed as separate

(therefore multiple) units.Historically reimbursed higherShould only be for NMJ disorders

(Myaesthenia Gravis of Lambert-Eaton)


EDX FRAUD TRENDS & RED FLAGSLack of medical necessity for

NCS/EMGProfessional and technical

components billed separatelyPromotion to Health Care Providers

(MDs and others) as “money maker”.

Location of services not in office of NCS reviewer/biller.


EDX FRAUD TRENDS & RED FLAGSSurface EMG disguised and billed

as Needle/Pin EMGNCS waveforms reviewed at later

timeNCS waveforms reviewed far awayNCS waveforms being duplicated

or manipulated



What % of EDX studies billed are NCS ONLY?

PM&R = 5%Neuro = 10%IDTFs = 80%Podiatry = 100%

CBR201406: Electrodiagnostic TestingDates of Service 1/1/2013 – 12/31/2013



What % of EDX studies billed are NCS ONLY?

24 Specialties = > 30%15 Specialties = > 50%

20% cut-off excludes all providers who

inappropriately perform only NCS



Average Weighted NCS Services per BeneficiaryPM&R = 7.74Neuro = 8.45IDTF = 14.07

(’s with sicker/more complicated patients –

But that is NOT why IDTFs are so high)


If you encounter F & A or if you are asked to review cases of suspected F&A

Feel free to contact me (541) [email protected]

Contact AAPM&R or AANEM staffAAPM&R – Jennie Jackson (Manager, Health

Finance & Reimbursement)AANEM – Millie Birr (Health Policy Director)

the many and varied types of fraud and abuse in electrodiagnostic medicine

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