Electromyography (EMG), a diagnostic procedure used to assess muscle and nerve damage, has become a major area of concern and a potential gateway for medical fraud and abuse, particularly in auto insurance.
Dr. John E. Robinton, medical director of Neurodiagnostics at One Call Care Management, presented on this topic of “EMG Fraud and Abuse” at the New Jersey Special Investigators Association’s meeting in October.
“Several factors have made auto insurance susceptible to EMG fraud and abuse,” said Dr. Robinton. “Results may be inaccurate or even fabricated, which then exposes the claim to more extensive medical fraud. For example, the test results in question could lead to unnecessary procedures, such as surgery and epidural injections, which are not only expensive to cover, but also invasive and painful for unsuspecting claimants.”
For its Neurodiagnostics program, the company admits neurologists and physiatrists into its provider network to perform these types of exams only after they undergo a rigorous credentialing process. Providers are required to meet and continually adhere to stringent EMG quality standards, providing workers’ compensation payers with confidence in the accuracy and medical usefulness of test results.
“While progress has been made in workers’ compensation, auto insurance still lacks safeguards in relation to quality and costs,” said Dr. Robinton. “On average, reimbursement for an EMG in auto insurance is 10 times higher than it is in a typical group health or Medicare claim. Lucrative fees combined with lax standards draw the type of practitioners who may be looking to take advantage of the system.”
Dr. Robinton, who has long served as a consultant to New Jersey’s attorney general regarding EMG fraud, highlighted inconsistencies that could alert investigators and lawyers to potential red flags.
“An auto accident could be relatively minor in nature, but the claimant is being treated for a long-term, debilitating injury. Attorneys may also unearth discrepancies in the claimant’s examination under oath (EUO). For example, a male claimant might say he’s being treated once a week, but unbeknownst to him, the insurer is being billed for therapy several times a week,” said Dr. Robinton.
“The goal is to get EMG providers with dubious practices out of play,” said Dr. Robinton. “Fraud and abuse hurt the legitimate providers, who are dedicated to quality but may be experiencing financial hardship as a result of unqualified and unscrupulous providers lowering overall standards of care, as well as reimbursement rates across the field of neurodiagnostic medicine.”
Source: One Call Care Management
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