Washington -- Medicare is paying millions of dollars for claims on services that are performed by nonphysicians who are not properly trained or qualified, according to a report released Aug. 5 by Dept. of Health and Human Services investigators.

The HHS Office of Inspector General examined Medicare Part B data for the first quarter of 2007 to determine how often the program paid for services billed by physicians but performed by nonphysicians, through a provision known as "incident to" services. Under this rule, physicians are allowed to bill for a treatment performed by a nonphysician, as long as that worker has the appropriate training, certification and licensure. Physician assistants, nurses, medical technicians and medical assistants are included in the nonphysician category.

For this study, OIG only looked at cases where a physician used the "incident to" rule to bill more than 24 hours worth of services in a single day.

Nonphysicians who were not appropriately qualified performed 21% of the services that physicians billed but did not perform personally, OIG found. Medicare paid $12.6 million for approximately 210,000 of these inappropriate services during the first three months of 2007. These nonphysicians did not possess the necessary licenses or certifications, had no verifiable credentials, or lacked the training to perform the service, the agency said. OIG also found that nonphysicians with inappropriate qualifications performed 7% of invasive services billed by physicians who did not perform them.

The "incident to" rule is a useful tool for busy physicians and "a billing mechanism that is widely used," said Abby Pendleton, a partner with Health Law Partners in Southfield, Mich. But it could place patients at risk for receiving care from someone who is not qualified.

Billing for nonphysician-provided services at the full physician fee schedule amount is allowed if those services are directly supervised by a physician. This means that the doctor must be present in the office suite and available to provide assistance, though it does not always mean he or she must be present in the room while the procedure is being performed.

The Medicare fee schedule often prompts physicians to bill under their own name rather than having a nonphysician bill for a service, Pendleton said. "They try to accomplish 'incident to' billing if they can because of the additional revenue."

American Medical Association policy supports Medicare payment to physicians for all services provided by supervised physician assistants and nurse practitioners, in accordance with applicable state laws. AMA policy adds that "the ultimate responsibility for these services rests with the physician."

For physicians who billed more than 24 hours of services in a day, half of the procedures billed were not personally performed by the physician, OIG discovered. During the three-month period in 2007, Medicare paid $105 million for approximately 934,000 services that physicians personally performed, and about $85 million for 990,000 services that nonphysicians conducted. Nonphysicians performed almost two-thirds of the invasive treatments that physicians billed to Medicare.

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