The National  Memo Logo

Smart. Sharp. Funny. Fearless.

Monday, December 09, 2019 {{ new Date().getDay() }}

by Charles Ornstein, ProPublica.

Medicare spent $6.7 billion too much for office visits and other patient evaluations in 2010, according to a new report from the inspector general of the U.S. Department of Health and Human Services.

But in its reply to the findings, the Centers for Medicare and Medicaid Services, which runs Medicare, said it doesn’t plan to review the billings of doctors who almost always charge for the most expensive visits because it isn’t cost effective to do so.

The inspector general’s report estimates that overpayments account for 21 percent of the $32.3 billion spent on evaluation and management (E&M) services in 2010. The E&M category includes office visits, emergency room assessments and inpatient hospital evaluations.

This is the second time that the inspector general has singled out this area for more scrutiny. In 2012, the watchdog said physicians had increasingly billed Medicare for more intense — and more expensive — office visits over time. But that didn’t prove the claims were improper.

“The natural question that comes out of this is: Are these physicians billing appropriately?” said Dwayne Grant, regional inspector general for evaluation and inspections in the Atlanta region, who oversaw the new report. “We don’t want to pay them too much, but we don’t want to pay them too little, either.”

For this review, the inspector general gathered the medical records associated with 657 Medicare claims and asked professional coders to see whether the records justified the rates charged.

Overall, more than half of the claims were billed at the wrong rate or lacked documentation to justify the service. Sometimes physicians billed for a lower-cost service than the one they delivered, but more often they billed for a higher-cost one. The inspector general extrapolated from its sample to estimate the amount Medicare overpaid on all 2010 E&M claims.

“We have to do a better job of curbing improper payments and protecting taxpayer dollars,” Senator Bill Nelson (D-FL), chairman of the U.S. Senate Special Committee on Aging, said in a statement.

The inspector general’s findings complement a recent review by ProPublica of data recently released by Medicare on payments to individual health professionals for services in its Part B program. We found that in 2012, more than 1,800 doctors and other health professionals almost exclusively billed Medicare for the most complicated and expensive office visits for their established patients.

Office visits are the most common services provided in the program.

While most providers had a tiny percentage of visits for which they charged the highest rate, known as level 5, more than 1,200 billed exclusively at that level. Another 600 did it more than 90 percent of the time. About 20,000 health professionals billed only at the top two levels, 4 and 5.

Experts we consulted said that these billing patterns were highly implausible and could indicate fraud. Some doctors, however, said that their patients were sicker than those of their peers and required more time and attention.

ProPublica also launched a new tool called Treatment Tracker that lets users look up their doctors and see how they compare to peers on office visits and other measures.

In its report, the inspector general’s office recommended that CMS educate doctors about proper billing practices. It also suggested that Medicare pursue doctors who consistently billed for higher-level services than they actually delivered, a practice known as upcoding.

While CMS agreed with the need for education, it disagreed with the recommendation to review the physicians’ billings. It said one of its contractors recently reviewed 5,200 medical claims of high-coding physicians and the process cost more money than it caught in overpayments.

CMS said a second phase of the review — of 13,500 claims — was nearing completion. “Based on the results of this effort, CMS will reassess the effectiveness of reviewing claims for high-coding physicians” versus other efforts, such as sending these doctors reports that compare their billings to their peers.

Grant, of the inspector general’s Atlanta office, said that while the individual E&M services do not cost much, they add up — and that if CMS declares that it won’t review outliers, it could send the wrong message.

“The challenge that CMS is trying to figure out is what is the best way to get at this,” Grant said. “We see the advantage of continuing to look at these high billers. Not only are they billing high now; it could have an impact on future billings…This is not just free rein to bill whatever you want.”

Photo: Rusty Clark via Flickr

Advertising

Start your day with National Memo Newsletter

Know first.

The opinions that matter. Delivered to your inbox every morning

Donald Trump
Youtube Screenshot

Allies of former President Donald Trump have advised members of the Republican Party to cool down their inflammatory rhetoric toward the United States Department of Justice and the Federal Bureau of Investigation following the execution of a search warrant at Trump's Mar-a-Lago estate in Palm Beach, Florida on Monday.

Trump supporters, right-wing pundits, and lawmakers have been whipped into a frenzy over what Trump called a "raid" by federal agents in pursuit of classified documents removed from the White House during Trump's departure from office.

Keep reading... Show less

Former President Donald Trump

Youtube Screenshot

On August 20, 2022, Donald Trump will have been gone from the White House for 19 months. But Trump, unlike other former presidents, hasn’t disappeared from the headlines by any means — and on Monday, August 8, the most prominent topic on cable news was the FBI executing a search warrant at Trump’s Mar-a-Lago home in South Florida. Countless Republicans, from Fox News hosts to Trump himself, have been furiously railing against the FBI and the U.S. Department of Justice (DOJ). And in an article published by Politico on August 11, reporters Kyle Cheney and Meridith McGraw describe the atmosphere of “paranoia” and suspicion that has become even worse in Trumpworld since the search.

“A wave of concern and even paranoia is gripping parts of Trumpworld as federal investigators tighten their grip on the former president and his inner circle,” Cheney and McGraw explain. “In the wake of news that the FBI agents executed a court-authorized search warrant at Donald Trump’s Mar-a-Lago residence in Florida, Trump’s allies and aides have begun buzzing about a host of potential explanations and worries. Among those being bandied about is that the search was a pretext to fish for other incriminating evidence, that the FBI doctored evidence to support its search warrant — and then planted some incriminating materials and recording devices at Mar-a-Lago for good measure — and even that the timing of the search was meant to be a historical echo of the day President Richard Nixon resigned in 1974.”

Keep reading... Show less
{{ post.roar_specific_data.api_data.analytics }}