Medicare doc data release a mixed blessing


The government's release of Medicare provider payment data is a giant step forward. Taxpayers and consumer advocates have the right to know how public funds are spent. When I think of the horrified reactions some beneficiaries have after reading their Explanation of Medicare Benefits forms, I can only imagine the read 'em and weep shock waves that will move through the country when people see their doctors' annual earnings. 

The Centers for Medicare & Medicaid Services payment data may shine a floodlight in dark corners where healthcare fraud hides. Payers may see for the first time how much providers earn from Medicare as a whole. This larger picture may flag impossible claims patterns, such as filing for 25 hourly office visits a day. Maybe the data will expose fraud and abuse hidden by claims filed with multiple carriers, and that may help us find regional vulnerabilities.          

Certainly there are lawyers celebrating. "When I was prosecuting Medicare fraud cases years ago, it was often difficult for us as prosecutors to get Medicare data in a timely fashion," former U.S. Department of Justice employee Jay Darden told Bloomberg. "So the notion that now it's not only being released, but released to the public, that could very well signal a recognition from CMS that it's had a problem in the past and it needs to do something about it."

And I wasn't surprised to see two of Medicare's millionaire doctors stand accused of overbilling and fraud, with one in prison on federal fraud charges and the other a party to two ongoing government investigations. Michigan physician Farid Fata received more than $10 million from Medicare in 2012; he was the highest paid oncologist out of more than 7,300 specialists in his field. And Florida ophthalmologist Salomon Melgen collected 64 times the specialty average in 2012.

Special investigations unit analysts often see wild deviations like these; but now the public does too. So the chickens of accountability may finally be coming home to roost for the government as steward of Medicare dollars, for insurers as distributors of these and for providers as claimants. It's all good.

But news about how some groups are approaching the data concerns me: The leader of a nonprofit group of whistleblower attorneys sent Medicare's payment database link to hundreds of group members under the heading "Have Fun!" Shortly afterward, a Pennsylvania lawyer was reportedly "having a ball" after spending hours combing the data in light of several pending fraud lawsuits. I read this and thought of how some people devour the tabloids.

Of course we vigorously pursue abusive providers, but a "gotcha!" approach to the Medicare data is counterproductive and off purpose. We need to use them with care.  

Fraud fighting isn't a work of tearing down. It's ultimately about building program integrity, and that won't happen without a partnership of respect with doctors and hospitals. We're on the same side, though it often seems otherwise. The best interests of the healthcare system aren't served by flying at the throats of dedicated medical professionals, even though payers must monitor their claims and recoup overpayments.

There's a big difference between a doctor who dilutes chemotherapy drugs to boost revenue and a doctor who unintentionally upcodes routine office visits. It's the larger threats to patient safety and program funding that merit deep scrutiny, and thankfully those threats come from a small subset of the provider base. While finding these cases is necessary, important and evidence of hard work, it's not fun. From a program and customer standpoint, it's quite sad. - Jane (@HealthPayer)       

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