Feds Offer Road Map For Medicare Investigative Stories

To find great Medicare stories, look no further than the federal Office of Inspector General.

Trudy Lieberman wrote a piece last week about Medicare being the most important health story of 2012. Journalists wanting to cover that story should read the Department of Health and Human Services' OIG work plan for the coming year.

And, if the whole report seems a little daunting on deadline, you can read Emily Walker's nice summary of it in MedPage Today.

There were three particular story ideas that caught my eye.

1. Doctors milking Medicare while pretending to opt out. Every health writer has heard physicians complain about low reimbursement rates from Medicare, and yet nearly every physician continues to bill Medicare for payments because the patient population is so large. What's interesting here is that OIG is apparently trying to see if any of that bluster is bad for patients (and taxpayers).

We will review the extent to which physicians are opting out of Medicare and determine whether physicians who have opted out of Medicare are submitting claims to Medicare. We will also examine whether specific areas of the country have seen higher numbers of physicians opting out and its potential impact on beneficiaries. Physicians are permitted to enter into private contracts with Medicare beneficiaries. (Social Security Act, § 1802(b).) As a result of entering into private contracts, physicians must commit that they will not submit a claim to Medicare for any Medicare beneficiary.

Is there a physician group in your area that has recently declared it won't take Medicare? Talk with patients in waiting rooms or parking lots to see what forms they are being asked to sign and how much of their treatments are showing up on their bills. (Doctors may be double billing, too!)

2. Ambulances transporting the able bodied. This appears to be in direct response to Terri Langford's great series at The Houston Chronicle. She actually chased ambulances to see how frequently they were making the same trips and what types of patients they were carrying.

We will examine Medicare claims data to identify questionable billing for ambulance services such as transports that were potentially not medically reasonable and necessary and potentially unnecessary billing for Advanced Life Support Services and speciality care transport. We will also examine relationships between ambulance companies and other providers. Medicare pays for emergency and nonemergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation are contraindicated (i.e., would endanger the beneficiary). (Social Security Act, § 1861(s)(7).) Medicare pays for different levels of ambulance service, including Basic Life Support and Advanced Life Support as well as specialty care transport.

It's unlikely that Houston is the only pocket of Medicare fraudsters-on-wheels. Take a look at the number of transport companies in your area and see if you might have a story.

3. Conflicted advisors picking the drugs Medicare should buy. If you don't spend much time writing about Medicare, you might not understand how its formularies work. Under Medicare Part D – the prescription drug benefit – the government contracts with private insurers to provide pharmaceutical coverage. Each company is supposed to form a committee that chooses the drugs that will be covered by the plan. Theoretically, you might have one plan cover Lipitor and another plan refuse to cover it. OIG thinks that some members of these committees may be motivated by their ties to industry to include drugs that should not be covered.

We will review Part D Pharmacy and Therapeutics committees' disclosed potential conflicts of interest and describe the nature of such conflicts. Sponsors using formularies must have Pharmacy and Therapeutics committees that select the drugs on sponsors' formularies and determine cost sharing, prior authorization, quantity limits, generic substitution, and other issues affecting drug access. (42 CFR § 423.120(b)(1).) Each committee must have at least one physician and one pharmacist who are free of conflicts of interest.

Find the companies offering Part D in your area. (Medicare allows you to search by zip and even to check which drugs are covered by which plans.)Ask them for a list of their committee members and their conflict of interest statements. Then, if you find conflicts, check the formularies to see if there are any interesting discrepancies. OIG already has identified one red flag medication: Revatio. It's supposed to only be covered in the case of hypertension, but OIG thinks it may be prescribed – and paid by Medicare – more frequently for erectile dysfunction.

There are tons of great tips for stories in the report. Give it a read or scan Walker's synopsis. Also, send me your thoughts at askantidote@gmail.com.