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By exposing such massive variations in
how doctors bill the nation's health program
for seniors and the disabled, experts
said, ProPublica's analysis shows Medicare
could—and should—be doing far more to
use its own data to sniff out cost-inflating
errors and fraud.
"I think this is a smoking gun," said Dr.
Robert Berenson, a former senior Medicare
official who is now a fellow at the Urban
Institute, a Washington, D.C., think tank.
"Who's asleep at the switch here?"
The Centers for Medicare and Medicaid
Services, which runs Medicare, declined an
interview request and said in a statement
that it could not comment on ProPublica's
analysis because it had not seen it.
"CMS is working to ensure that physicians
and health care providers appropriately
bill" for office visits, part of a category
known as evaluation and management
(E&M) services, the agency said. "Some
providers have sicker patients, thus are
more likely to bill at E&M coding levels
that carry higher payments. Every day we
work with providers to make patient care
the priority, and at the same time ensure
they use E&M codes that reflect the level of
service provided."
The agency also said "it would be highly
unusual for a provider to knowingly
use the highest E&M billing code for all or
nearly all of his or her outpatient visits."
American Medical Association President
Dr. Ardis Dee Hoven cautioned that billing
data can be misleading without considering
further details about doctors' practices.
Even those who handle medical billing
professionally sometimes disagree about
the right way to classify a visit.
Agomuoh, Im and Farhoomand insist
that they treat older, sicker or more difficult
patients than their peers. Agomuoh
also suggested that the Medicare data contained
errors; the agency stands behind it.
Individually, office visits for established
patients cost taxpayers little, ranging from
an average of $14 for the simplest cases to
more than $100 for the most extensive. But
collectively, they add up. Medicare shelled
out more than $12 billion for them in 2012.
Agomuoh received $174,000 for the visits
he billed at the top rate alone, tens of thousands
of dollars more than he would have
taken in if his charges were more in line
with his peers'.
In April, Medicare released data showing
2012 payments for outpatient services,
and for the first time specified how much
money went to individual health provid-
ers. Since then, most of the attention
has focused on doctors who made the
most from the program.
Looking at raw numbers, though,
can unfairly flag some doctors who
have multiple providers billing under
their IDs or who justifiably use expensive
services. It can be more revealing
to look at which procedures doctors are
performing and how frequently, and
how their billings compare with those
of their peers.
Office visits are a case in point. Doctors
or their staffs determine how to
bill for a visit based on a variety of factors,
including the thoroughness of the
review of a patient's medical history,
the comprehensiveness of the physical
exam, and the complexity of medical
decision-making involved. The AMA's
coding system gives them five options.
An uncomplicated visit, typically of
short duration, should be coded a "1"; a
visit that involves more intense examination
and often consumes more time
should be coded a "5." The most common
code for visits is in the middle, a
"3."
ProPublica focused its analysis on the
329,500 physicians and other providers
who charged for at least 100 office visits
for established patients. (Medicare
did not release data on services that a
provider performed on fewer than 11
patients.)
We found that while most providers
had a tiny percentage of level 5 cases,
more than 1,200 billed exclusively at
the highest level. Another 600 did it
more than 90 percent of the time. About
20,000 health professionals billed only
at levels 4 or 5.
The AMA's Hoven warned that the
data could reflect errors or attribute
high-priced visits to one doctor when
the services were actually provided by
another. Further, she said, because a
growing number of seniors have multiple
chronic conditions and complex
medical histories, more level 4 or 5 office
visits may be justified.
But other health industry leaders
called the billing patterns identified by
our analysis troubling.
"I can't see a situation where every
visit would be a level 5, especially on
an established patient," said Cyndee
Weston, executive director of the American
Medical Billing Association, an industry
trade group. "I was trying to talk
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