Top Hospitalists Use Questionable Billing Practices

Medicare's physician-payment data reveals high billing outliers

PHOENIX, June 13, 2014 /PRNewswire-iReach/ -- Over one thousand primary care physicians providing hospital-based services billed Medicare more than five times the average, raising questions about their billing practices, according to a detailed analysis published by Abhay Padgaonkar, President of Innovative Solutions Consulting.


The independent billing practice analysis comes at a crucial time as the Medicare physician-payment data, made public for the first time in April, has revealed unusual patterns in doctor billings in recent stories by New York Times, Wall Street Journal, and ProPublica.

The analysis is unique in two respects. First, it focuses on isolating hospitalists—primary care physicians who provide hospital-based services. There is no "hospitalist" designation in the Medicare data because the physicians who provide hospital-based services typically belong to Internal Medicine or Family Practice specialty.

Second, the analysis standardizes hospitalist workload by converting the CPT® codes (a registered trademark of the American Medical Association) used for Medicare billing of various services to "work Relative Value Units" or wRVU. The wRVU metric represents the relative level of time, skill, training, and intensity to provide a given service; it is an industry-standard way of measuring physician workload and a predominant factor in physician compensation.

The analysis found that the top one thousand primary care providers of hospital-based services averaged more than 9,300 wRVU in 2012 or 5.3 times the workload of an average hospitalist with 1,759 wRVU, with the highest hospitalist topping out at 40,766 wRVU.

"An explanation often given for such high outlier workload is that Medicare permits the use of a single NPI for services that were actually delivered by many practitioners. But this generic explanation fails to account for specific requirements for the four common billing scenarios that allow such use. While Medicare does permit the use of a single NPI, it is not a free-for-all," said Mr. Padgaonkar.

The requirements for each of the four common billing scenarios are as follows: 

  1. Colleagues: The Q6 code modifier is often used for billing other physicians under one physician's individual NPI. The Q6 modifier, however, is reserved for services furnished by a locum tenens (substitute) physician. And its use must meet unavailability, employment, payment, and length of time criteria according to the Medicare Claims Processing Manual.
  2. Substitutes: A physician may submit a claim under his or her NPI for a substitute physician using the Q6 modifier, but it is only allowed for a continuous period of no longer than 60 days.
  3. Non-physician Providers (NPP): Incident-to services provided by NPPs in an office setting and billed under the physician's NPI are not billable by the physician in hospital settings. The encounter must be billed as a shared/split visit for which both a face-to-face encounter between the patient and the physician and a clear identification in the medical record of the part of the service personally provided by the physician are required. A notation of "seen and agreed" or "agree with above" in the patient's medical record does not qualify the situation as a shared/split visit.
  4. Residents: If the resident performs some or all of the required elements of the service in the absence of the teaching physician, the teaching physician must independently perform the key portions of the service with or without the resident present. The teaching physician must also document that he/she personally saw the patient, personally performed key portions of the service, and participated in the management of the patient.

"Compliance with these specific billing requirements would severely constrain the maximum workload that can be physically provided under a single NPI. With workloads as high as 23 times the average, it is reasonable to conclude that questionable billing practices are in use among top hospitalists," argued Mr. Padgaonkar. "To avoid any unwanted attention and to steer clear of expensive and time-consuming audits, all hospitalists should reexamine their current billing practices for billing under another provider's NPI."

About Abhay Padgaonkar

Abhay Padgaonkar is an award-winning management and healthcare consultant, author, and speaker. He is the founder and president of Innovative Solutions Consulting. Since 1999, Mr. Padgaonkar has been a trusted advisor to top management on performance improvement challenges. 

SOURCE: Innovative Solutions Consulting, LLC


Media Contact: Abhay Padgaonkar, Innovative Solutions Consulting, LLC, 602-628-1234,

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SOURCE Innovative Solutions Consulting, LLC



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