Fraud in Anesthesia Billing

It all started during the civil war when the US government discovered it was getting sawdust instead of bullets as well as lame horses and donkeys by private suppliers. In short, the government wants to get what it pays for. This led the government to enact the False Claims Act (FCA) to protect itself against fraud. The government will prosecute those individuals who submit false claims knowingly, falsify records to get a false claim paid by the government, and or conspire to violate the FCA.

Anesthesia billing to Medicare and insurance companies is categorized in supervision using modifier QX or QK where 50% goes to the CRNA and 50% to the supervising physician.
When the QZ modifier is used, no supervision occurs. The CRNA is eligible for 100% of the fee.

The use of the QX or QK modifier requires the billing anesthesiologist to documents certain requirements to get paid. Non-compliance with this billing requirement can result in a FCA infraction. If the CRNA or AA is aware of the non-compliance they can be held responsible as well.1

There are significant criminal and civil penalties for violating the False Claims Act. Federal penalties can total three times of amount of the claim, plus fines of $5,500-$11,000 per claim.
State laws include possible imprisonment, in addition to fines of $5,000-$10,000 per claim.

So what is the Medicare billing requirement when a anesthesiologist bills for the services of resident, AA, or CRNA?

TEFRA allows anesthesiologist to bill for the services of CRNA, residents, and AA. Anesthesiologists are allowed to provide medical direction for up to 4 concurrent cases provided several conditions are met and documented.
The anesthesiologist must:

1. Perform the pre-anesthetic examination and evaluation of the patient.
2. Prescribe the anesthetic plan.
3. Personally participate in induction, emergence and other aspects of the anesthesia plan.
4. Any procedures not performed by the physician must be done by a qualified anesthesia provider.
5. Monitor the anesthesia administration at regular intervals.
6. Remain physically present and available for immediate diagnosis and treatment of emergencies.
7. Provide indicated post-operative anesthesia care.
8. Documentation in the anesthesia record of the above.

Completion and compliance of these TEFRA regulations requires strict discipline in a fluid healthcare environment. A study in 2012 determined that even with a supervision ratio of 1:2 there were lapses in supervision 37% of the time.2

In conclusion when the government pays for goods and services it expects them in return. Anesthesia providers and administrators need to be aware of these billing requirements.

1. Silberman MJ, False Claims Act Liability for CRNAs Related to Medical Direction. AANA Journal. 2014; 82:10-12
2. Epstein RH, Dexter F. Influence of supervision ratios by anesthesiologists on first- case starts and critical portions of anesthetics. Anesthesiology. 2012; 116:683-691.