The Many and Varied Types of Fraud and Abuse in Electrodiagnostic Medicine

1. The Many and Varied Types ofFraud and Abuse inElectrodiagnostic Medicine Peter A. Grant, M.D. November 15th, 2014 A.A.P.M.&R. – San Diego .

2. 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

3. 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.

4. Outline of Presentation • Why EDX Fraud & Abuse? • What constitutes “Quality EDX” • Types of EDX Fraud & Abuse • Addressing EDX Fraud & Abuse • Resources • EDX Laboratory Accreditation • Fraud Trends & “Red Flags”

5. 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.

6. 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.

7. Types of EDX Fraud & Abuse THE MANY FACES OF POOR QUALITY • Inaccurate Diagnosis • Wrong Diagnosis • Missed Diagnosis • Overdiagnosis • Excessive, Inapproriate, or Insufficient Testing • Excessive or Inappropriate Charges

8. Types of EDX Fraud & Abuse Common to All Abusive & Fraudulent EDX Emphasis is on $$$ and Not on Quality EDX Studies/Patient Care

9. Types of EDX Fraud & Abuse • Mobile EDX Laboratories • Hand-held Devices • QST (Qualitative Sensory Testing) • Manipulation of Waveforms • “Mail Order EMG/NCS” • Inappropriate CPT 95937 Billing • Unqualified Practitioners • “The Enemy Within Our Ranks”

10. Types of EDX Fraud & Abuse MOBILE DIAGNOSTIC LABORATORIES

11. A true case … • Husband & Wife involved in MVA • Referred by chiropractor to have EDX • Studies performed in chiropractors office • Chiropractor bills/collects $ • Mobile Diagnostic Lab (MDL) bills/collects $ for the husband and $ for the wife

12. Case # 1 • All diagnoses made by MDL later found to be erroneous • Poor Quality / Abuses • Excessive Charges - $14K & $12K • Excessive, Unnecessary, & Inappropriate Testing - (> 20 nerves tested in each – incl Bilateral Phrenics!) • Inaccurate Diagnoses

13. Another true case… • 47 yr old man with R leg weakness • Primary care MD orders EDX • MDL comes into his office to perform EDX study (NCS Only) • Patient dxd with “Peronealmononeuropathy at fibular head involving only motor fibers” (??) • Repeat EDX study 3 weeks later (by ABEM EDX Consultant) found classic ALS (Hx, PE, & EDX)

14. Case # 2 • Patient treated with Bob Miller at ALS clinic in San Francisco before he died. • (MDL billed patient >$7,000!!!) • Poor Quality / Abuses • Inaccurate Diagnosis • Excessive Charges • Excessive, Unnecessary, & Inappropriate Testing

15. Mobile Diagnostic Laboratories Basics of How They Work

16. 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/PAs • Chiropractors

17. Mobile Dx Labs Basics of How They Work • Provider Makes Referral • MVA, MC, Privates all billed now • Technician Sent to Providers Office • I have seen them sent >2000 miles!

18. Mobile Dx Labs Basics of How They Work • NCS Exam Performed • Most (if not all) Motor Studies • Most (if not all) Sensory Studies • Most F-waves & H-reflexes • Sometimes SSEPsandDSEPs • Sometimes MS Ultrasound performed • No EMG performed (? Surface EMG) • No good Hx or PE performed!!!

19. Mobile Dx Labs Basics of How They Work • 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

20. Mobile Dx Labs Basics of How They Work “New & Improved” (Mutated) MDLs • Changes to address “red flags” • Marketed to potential NCS Interpreters • MDL enlists physicians to interpret NCS for a set fee • Fee is per each nerve or per whole NCS

21. Mobile Dx Labs Basics of How They Work “New & Improved” (Mutated) MDLs • MDL #2 otherwise looks and acts like #1 • MDL markets to referring providers • MDL sends out EDX technician to perform • No good Hx or PE performed • Excessive number of nerves is norm

22. Features Common to Mobile Diagnostic EDX Labs

23. Features Common to Mobile Diagnostic Labs • “Shot Gun” excessive # of NCSs • Templated – same nerves every study • Technician performs studies • Poor quality NCSs • No good HX / PE to guide exam • Inaccurate diagnoses

24. Features Common to Mobile Diagnostic Labs • Poor Quality NCSs • Interference very common • Inaccurate marker placement • Inappropriate 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!

25. Features Common to Mobile Diagnostic Labs • Inaccurate Dxs • Oftendxradiculopathy based on F-waves (no EMG) • Often see multiple diagnoses (multilevel/bilateral radiculopathies) • Often see diagnoses that make no neurophysiologic sense

26. Features Common to Mobile Diagnostic Labs • 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)

27. 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…”

28. Types of EDX Fraud & Abuse • Mobile EDX Laboratories • Hand-held Devices • QST (Qualitative Sensory Testing) • Manipulation of Waveforms • “Mail Order EMG/NCS” • Inappropriate CPT 95937 Billing • Unqualified Practitioners • “The Enemy Within Our Ranks”

29. Types of EDX Fraud & Abuse HAND-HELD DEVICES

30. Hand-held Devices • Deleted 27 slides from presentation • Bigger issue 2006 – 2010. • AANEM/AAPM&R/AAN addressed • As of 1/1/10 given CPT code 95905 • Pays much less than standard NCSs • Can be billed once per limb only

31. Hand-held DevicesCONTINUED PROBLEMS • Often don’t use new CPT 95905 • Use 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

32. Hand-held DevicesCONTINUED PROBLEMS • No info re: amp / dur / conduction block • Cannot assess prognosis • Diagnose radiculopathies without EMG! • “Shotgun” - excessive number of NCSs • Preset battery of NCSs – cannot change • No individual results until test completed

33. Hand-held DevicesCONTINUED PROBLEMS • Cannot change focus during testing • Company promotes serial “monitoring” • Slick marketing dupes providers • Company says no diagnoses – “only interpretations” therefore no liability • Must tell providers they are legally liable when they sign bottom line of report

34. Hand-held DevicesTESTING FOR CARPAL TUNNEL SYNDROME • Median Sensory to 3rd/Long ONLY • No comparison Med vs. Rad or Med vs. Uln • No Med vsUln Motor • Abnormal by absolute values only • No ability to assess Conduction Block • No EMG • How SENSITIVE would I be with all of these limitations !?!?!?

35. Hand-held DevicesPROMOTES UNNECESSARY TESTING • For “non-radicular” back pain one company recommends: • Bilateral Peroneal Motors • Bilateral Peroneal F-Waves • Bilateral Tibial Motors • Bilateral Tibial F-Waves • Left or Right Sural Sensory 9 NCSsFOR NON-RADICULAR LOW BACK PAIN!!

36. 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”.

37. Hand-held DevicesNEW DEVICE • Assessment of single or bilateral surals • Gives velocity and amplitude • Don’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!

38. Types of EDX Fraud & Abuse • Mobile EDX Laboratories • Hand-held Devices • QST (Quantitative Sensory Testing) • Manipulation of Waveforms • “Mail Order EMG/NCS” • Inappropriate CPT 95937 Billing • Unqualified Practitioners • “The Enemy Within Our Ranks”

39. Types of EDX Fraud & Abuse Q.S.T. (Quantitative Sensory Testing)

40. Q.S.T.(Quantitative Sensory 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.

41. Q.S.T.(Quantitative Sensory Testing) • Used & promoted by Pain Medicine Clinics • Usually have no EDX training • Anesthesiologists, FPs, IMs, Peds (?), etc. • Often used to justify need for injections • Largest company states is “97% sensitive while standard EMG is 37% sensitive in diagnosing radiculopathy”

42. Q.S.T.(Quantitative Sensory 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)

43. Q.S.T.(Quantitative Sensory 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”)

44. Q.S.T.(Quantitative Sensory 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”!!).

45. Q.S.T.(Quantitative Sensory Testing) • Despite new grouped NCS codes inappropriate QST exams performed. • This is most likely due to many using results to justify injections.

46. Q.S.T.(Quantitative Sensory 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.

47. Q.S.T.(Quantitative Sensory 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.

48. Types of EDX Fraud & Abuse • Mobile EDX Laboratories • Hand-held Devices • QST (Qualitative Sensory Testing) • Manipulation of Waveforms • “Mail Order EMG/NCS” • Inappropriate CPT 95937 Billing • Unqualified Practitioners • “The Enemy Within Our Ranks”

49. Types of EDX Fraud & Abuse Manipulation of Waveforms

50. Manipulation of Waveforms • Landmark case in New Jersey • Digital copies of waveforms reproduced on multiple patients charts • Possibly fictitious patients • Altering waveforms to appear to be obtaining new/different data