WASHINGTON - Most community mental health centers employ at least one questionable billing practice, a government report has found.
More than half of community mental health centers (52%) were found to have employed at least one of nine predetermined questionable billing practices, the Department of Health and Human Services Office of Inspector General (OIG) found in a report released Tuesday. About a third of the 195 centers (35%) it reviewed exceeded thresholds for unusually high billing in at least two of the nine areas.
The OIG report focused on the centers' practices in billing for partial hospitalization programs. Medicare Part B reimburses community mental health centers for providing such programs, which are intense, structured outpatient mental health treatment programs.
To combat possible billing fraud, the OIG recommended that the Centers for Medicare and Medicaid Services (CMS) increase monitoring of the mental health centers' billing and fraud prevention, take appropriate action against questionable billing, finalize proposed conditions of participation, and enforce the requirement that certifying doctors be listed on partial hospitalization program services claims.
Enforcing the requirement that physicians be listed on the claims "provides additional information for CMS to use to verify whether the [partial hospitalization program] services billed were medically reasonable and necessary," the report stated.
CMS has already agreed with all of the OIG's recommendations, the report said.
In 2010, 206 centers received $218.6 million for providing partial hospitalization services to 25,000 Medicare beneficiaries. In 2011, four community mental health center owners and managers were convicted of fraudulently billing Medicare for roughly $200 million for medically unnecessary partial hospitalization services from 2002 to 2010.
To find out more about the problem, the investigative wing of HHS developed nine questionable billing characteristics, then reviewed 2009 and 2010 Medicare claims to spot community mental health centers with one of the characteristics to help identify areas of possible waste.
Questionable characteristics included:
- Beneficiaries who received only group psychotherapy during participation
- Beneficiaries who were not evaluated by physicians during participation
- Beneficiaries with no mental health diagnoses 1 year before participation
- Beneficiaries with cognitive disorders such as Alzheimer's disease
- Beneficiaries who were readmitted to inpatient treatment
The OIG found that in 2010, eight of 11 metropolitan areas with at least three mental health centers had a higher percentage of questionable billing than the national average; areas with the highest percentages of centers employing questionable practices included Houston, Miami, and Baton Rouge, La.
In addition, 90% of centers with questionable billing were located in states that don't require mental health centers to be licensed or certified.
CMS expects to publish a final rule for conditions of participation for community mental health centers in spring 2013.
Source: David Pittman, Washington Correspondent, MedPage Today-Published: August 22, 2012