The penalties for fraudulent billing are severe and not to be taken lightly. In a 2004 landmark settlement, for example, Rush University Medical Center in Chicago paid the United States $1 million after inappropriately obtaining Medicare reimbursement for cancer trial services not covered under the NCD. These are large fines for any organization. But these penalties are nearly impossible for private physician investigators and community hospitals to pay. In those cases, it's not unusual for physician investigators to turn to the sponsoring pharma company for help—as was the case in 2002, when the University of Alabama–Birmingham subcontracted lymphoma research from Biocryst Pharmaceuticals to an independent PI, who was subsequently convicted of falsifying research data. (See "Clinical Trials Gone Bad")

Indeed, while cases of fraud and abuse are often intentional, many physician investigators in private practice or community hospitals violate the NCD through lack of detailed knowledge. And when a revised NCD policy—with potentially even more stringent limitations—comes out in July 2007, that challenge may grow even greater.

Most physicians already find it difficult to distinguish between services provided for treatment and services provided for data collection. In particular, certain treatment areas, like cancer, are particularly confusing because most treatment modalities are experimental to begin with, and payers very often won't reimburse a therapy for unapproved uses. It is here that pharma companies can help physicians avoid costly billing errors by clearly identifying the services that are reimbursable under the NCD versus those that must be borne by the sponsoring organizations.

Sponsors should disseminate the checklist to physicians to ensure accurate and appropriate claim-form completion and submission to payers, especially with respect to the correct use of modifier codes identifying services or items provided in conjunction with a trial—an area of weakness within many provider organizations. A checklist is necessary even when investigators use billing companies that code and submit bills to payers based on medical records. In reality, many billing companies are less than accurate when it comes to modifier codes. They are also at the mercy of the physician's office—without a checklist, if the PI fails to note that a patient's visit was for a clinical trial, the billing company won't know how to obtain proper reimbursement.

Even if PIs or third-party billing companies assume the responsibility of following the NCD requirements, sponsoring organizations must be aware of and monitor adherence to such regulations. After all, while the responsibility to bill appropriately rests with PIs, at the end of the day, these private physicians don't have the expertise and knowledge that pharma companies do with respect to what services are part of the clinical trial. And when push comes to shove, companies are responsible for providing this education and oversight.

Conflict of Interest

Back in February 2006, the Journal of the American Medical Association published an article by 13 psychiatrists that found that pregnant women who stopped taking antidepressants during pregnancy fell into depressive relapses. It contradicted other credible studies that advised pregnant women not to take these drugs late in pregnancy because of the risk to the fetus.

While the results were widely publicized, one aspect didn't receive as much attention—at first. But a few months later, the news broke: The study authors all had financial ties to the pharma industry but had not disclosed them to JAMA.

Payment to physicians, and other conflicts of interest, is a ripe area of concern, particularly when it raises doubt over the integrity of research findings. Because many PIs are not as sophisticated as pharma companies about the issue of conflict of interest, companies should educate PIs on full disclosure, and its importance to research integrity.