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Release Of Medicare Doctor Payments Shows Some Huge Payouts

By Chad Terhune, Noam N. Levey and Doug Smith, Los Angeles Times

Ending decades of secrecy, Medicare is showing what the giant health care program for seniors pays individual doctors, and the figures reveal that more than a dozen physicians received in excess of $10 million each in 2012.

The Obama administration released a detailed account Wednesday of $77 billion in government payouts to more than 880,000 health care providers nationwide that year. The release of payment records involving doctors has been legally blocked since 1979, but recent court rulings removed those obstacles. No personal information on patients is disclosed.

The two highest-paid doctors listed in the Medicare data are already under government review because of suspected improper billing. They include an ophthalmologist in the retiree haven of West Palm Beach, Fla., who topped the list by taking in more than $26 million to treat fewer than 900 patients. That is 61 times the average Medicare payout of $430,000 for an ophthalmologist. A Florida cardiologist received $23 million in Medicare payments in 2012, nearly 80 times the average amount for that specialty.

The overwhelming majority of doctors billed the government very modest amounts. Overall, 2 percent of health care providers accounted for 23 percent of the Medicare fees, the federal data show.

Medicare officials said disclosing physician payment data marks an unprecedented opportunity to make the nation’s health care system more transparent for consumers and accountable to taxpayers. Many consumer advocates and employers applauded the move.

“Providing consumers with this information will help them make more informed choices about the care they receive,” Jonathan Blum, Medicare’s principal deputy administrator, said last week. Medicare plans to post the data online.

Still, federal officials cautioned against drawing sweeping conclusions about individual doctors from the numbers. High payouts do not necessarily indicate improper billing or fraud, they say. Payments could be driven higher because providers were treating sicker patients who required more treatment.

The new data reflect only Medicare Part B claims, which include doctor visits, lab tests and other treatment typically provided outside a hospital. They include what Medicare paid plus any money providers received from patients for deductibles and co-insurance. Altogether, the payouts totaled $99 billion paid to health care providers in 2012. These government figures don’t cover commercial insurance or Medicaid.

Even with those limitations, experts say, the data could serve as an early warning for potential waste and abuse.

Spending on the Medicare program, which covers about 60 million elderly and disabled Americans, is expected to exceed $600 billion this year. There is broad agreement that fraud is rampant in both Medicare and Medicaid, the government health program for the poor, but estimates of the scope vary from $20 billion annually to $100 billion.

The American Medical Association and other physician groups have long opposed the release of the Medicare data.

AMA President Dr. Ardis Dee Hoven said the group remained concerned that inaccuracies in the data or misinterpretation might unfairly tar some physicians.

She said some individual physicians might appear to be billing huge amounts to Medicare when in fact it is their entire practice that bills under a single physician’s name. In other cases, high-volume physicians may actually be experts in their field who instead will be portrayed in a bad light.

“How does a physician or a practice get their reputation back?” Hoven said.

For 2012, the top recipient of Medicare money in the country was ophthalmologist Salomon Melgen, whose billings have already been the subject of federal investigation.

Melgen has been a heavy donor to Sen. Robert Menendez (D-NJ) Last year, federal officials said a grand jury was looking into Melgen’s billing practices, and a separate investigation was examining whether Menendez had improperly intervened on his behalf.

An attorney for Melgen, Kirk Ogrosky, said the physician had billed in accordance with Medicare rules. Ogrosky said the vast majority of the money attributed to Melgen reflected the cost of drugs used in treatment and that physician reimbursement is set at 6 percent above what is paid for the medications.

“Dr. Melgen strongly supports transparency in government,” Ogrosky said, “but engaging in speculation based on raw data is irresponsible.”

Cardiologist Asad Qamar in Ocala, Fla., ranked second nationally with $22.9 million in payments for seeing Medicare patients in 2012.

He said specialists like himself who provide a variety of services inside their own medical facility have much higher bills because they reflect both the physician’s professional fee and fees to cover staffing, medical devices and supplies.

Likewise, some oncologists say their payouts appear so much higher than their peers’ because they are covering the price of expensive cancer drugs that other doctors operating inside a hospital wouldn’t bill for.

“By doing everything in your office, your numbers will be astronomical,” Qamar said. “Looking at the sheer volume of payments is a gross mistake.”

Qamar said Medicare put his billing on heightened review and delayed reimbursements more than a year ago. “I am 100 percent confident we are not doing anything wrong,” he said.

The disclosure of physician payments follows the federal government’s release last year of hospital charges that showed wild variations among medical centers for the same procedure. Increasingly, consumers and employers are demanding more transparency to avoid unnecessary medical spending and to spur more competition over cost in the nation’s $2.7 trillion health care system.

“We can’t reward high-quality care and pay for value unless we know what we’re paying for health care services now,” said Bill Kramer, executive director for national health policy at the Pacific Business Group on Health, a nonprofit coalition that represents large employers.

In December, the inspector general for the U.S. Health and Human Services Department found 303 physicians who provided more than $3 million in Medicare Part B services in 2009. Medicare’s outside billing contractors flagged 104 of those providers, or 34 percent, for additional review and identified $34 million in overpayments. The audit didn’t name the doctors.

“The results of these reviews demonstrate that identifying clinicians who are responsible for high cumulative payments could be a useful means of identifying possible improper payments,” federal auditors wrote in their report.

Photo: kbrookes via Flickr

California Gives Further Reprieve For Obamacare Sign-Ups

By Chad Terhune, Noam Levey and Soumya Karlamangla, Tribune Washington Bureau

LOS ANGELES — Overrun by last-minute demand for Obamacare coverage, California gave many consumers until April 15 to enroll as thousands of people across the nation endured long lines and website troubles.

Despite the problems, the late surge in sign-ups was a substantial boost to President Barack Obama’s signature law, particularly after such a disastrous launch in October.

The final tally from the first year of the law’s insurance expansion won’t be known until later this spring. But as the Affordable Care Act’s inaugural open-enrollment period wound down, an outpouring of interest pushed sign-ups on the new online marketplaces close to the Obama administration’s goal of seven million.

Monday had been the deadline to start signing up for coverage in California. But by Monday afternoon, state officials conceded they couldn’t handle the crowds and offered an opportunity to get coverage over the next two weeks. The state’s website went down periodically during the day while lines at enrollment events swelled into the hundreds.

“We were prepared for a last-minute surge of people coming to our website, but sometimes there’s only so much you can do operationally,” said Peter Lee, executive director of Covered California. “We can’t in good conscience turn people away who simply couldn’t get onto the website on the last day. We weren’t able to build the pipe big enough.”

Under California’s new policy, anyone who tried to enroll by Monday and faced difficulties now has until April 15 to finish an application. The state said no proof is required, so it’s essentially on the honor system.

But those applicants can no longer sign up online on their own. Officials said they must go through Covered California’s call center, an enrollment counselor, insurance agent, county office or health plan enroller.

Supporters of the health care law welcomed the additional time, given the last-minute problems.

“No Californian who tried to enroll should be frozen out of coverage, so this additional consideration is appreciated and necessary,” said Anthony Wright, executive director of Health Access, a consumer advocacy group. “It is both heartwarming to see the lines around the block and troubling because those lines and website glitches may discourage people from even trying.”

Santa Fe Springs resident Stephanie Ybarra, 52, was at the end of an enrollment line in City of Commerce around 6 p.m. Monday behind hundreds of other people when she heard about the reprieve. “I’m glad that they did that for the procrastinators like myself,” she said.

The uninsured woman said she’s eager to get health coverage because she suffers from high blood pressure and migraines.

The national rollout of the Affordable Care Act has been marked by a series of deadline extensions and abrupt policy changes, which have drawn intense criticism from the law’s opponents. Overall, public opinion nationally on the health law has remained deeply split and many Republicans continue to campaign for its repeal.

Americans who are without coverage for more than three months this year may be subject to a penalty on their 2014 taxes of $95 for a single adult or one percent of their adjusted gross income, whichever is larger.

The last-minute surge also overwhelmed the federal HealthCare.gov website, which crashed in the early-morning hours Monday. Technicians repaired it by midday, avoiding a repeat of the meltdown after the site’s Oct. 1 launch.

By 2 p.m. EDT Monday, more than 1.6 million visitors had come to HealthCare.gov; by 4 p.m., the call center had handled more than 840,000 calls.

The heavy traffic on the website triggered an automated message that alerted users that they would have to wait to set up an account or enroll in coverage. The automated queuing system, also deployed in December during a rush of consumers, enables users to enter their email address to be alerted when they can access services.

The federal website is the main portal for consumers in 36 states, including Florida, Illinois and Texas, to select health coverage on the marketplaces created by the Affordable Care Act. Fourteen states are running their own websites, with mixed results.

The surging enrollment prompted new attacks from Republican critics of Obamacare. Sen. John Barrasso of Wyoming said over the weekend that the administration was “cooking the books” on enrollment figures.

But national surveys and reports from insurance companies and state officials indicate that signs-ups for coverage had accelerated rapidly in recent weeks.

Los Angeles teaching assistant Brenda Caceres, 42, said she tried enrolling online at home three times but couldn’t get the Covered California website to work. She gave up and came to an enrollment event Monday seeking coverage for herself and her husband.

“I know a lot of people wait until the last minute,” Caceres said. “And I was one of them.”

In contrast to those in many other states, California’s exchange website had largely avoided major technical problems. But even it was hard hit Monday. To keep the state website functioning Monday, Covered California took the unusual step of logging off some online applicants so that other people could start the sign-up process. Shoppers who were kicked off were told they could return later and complete the application by April 15, officials said.

California’s exchange continued to lead those in all other states with more than 1.2 million enrollees in private health plans by early Monday. Over the weekend, 124,000 people had opened an account on the state website and started shopping for health coverage. An additional 1.5 million people have been deemed eligible for an expansion of Medi-Cal, the state’s Medicaid program.

The state said online traffic Monday at CoveredCa.com was four times as high as the previous record in late December, when applicants rushed in to get Jan. 1 coverage.

That heavy volume prompted considerable frustration for many of the state’s enrollment counselors and certified insurance agents who were trying to help people sign up.

John Anthony Costa, a state-certified insurance agent in Long Beach, said that he needed to enter insurance applications for 25 families Monday, and that he was able to get only four of them into the online system by late Monday afternoon. Meanwhile, wait times at the state’s call centers were exceeding 70 minutes in recent days.

“Every time I try to input the bare minimum, it keeps kicking me off the state website over and over,” Costa said. “This is insane.”

Sarah-Jane George, 36, arrived for an appointment midday Monday at an AltaMed enrollment center in Los Angeles. More than 300 people had shown up there by early afternoon.

An enrollment counselor went over her health plan options and she picked a Bronze plan for about $100 a month. But the state website was running so slow that she couldn’t finish signing up.

Los Angeles college student Mario Estala, 22, showed up at an enrollment event before 7 a.m. Monday and had better luck.

More than 50 people were ahead of him, and it took about three hours before he was seen by an enrollment counselor at the L.A. event sponsored by a labor union. Estala qualified for Medi-Cal and an enrollment worker rang a bell signaling another successful sign-up. Other workers cheered.

“I was relieved” to get coverage, Estala said. “I feel much more safe now.”

Will O’Neill via Flickr