Medicare data review throws office visit billing into question

Analysis finds many docs who bill at top levels for most or all patient visits

Medicare pays for more than 200 million office visits a year, but at what cost? In 2012, more than 1,800 healthcare professionals billed Medicare for the most expensive type of doctor visit at least 90 percent of the time, according to a ProPublica analysis of Medicare data.

Last month, data released by the Centers for Medicare & Medicaid Services showed just how much doctors collect from Medicare. For example, an ophthalmologist in Florida received $20.8 million from Medicare in 2012, FierceHealthFinance previously reported.

The American Medical Association coding system, which rates visits from short and uncomplicated to long and intense, exposes massive discrepancies in how doctors bill the program. More than 1,200 physicians out of 329,500 billed exclusively at the highest level, according to the analysis.   

"I can't see a situation where every visit would be a level 5, especially on an established patient," Cyndee Weston, executive director of the American Medical Billing Association, an industry trade group, told ProPublica. "I was trying to talk myself into it, but I just can't see it."

The CMS data highlights the real and present dangers of healthcare fraud. The government recovered $4.3 billion in healthcare fraud judgments last year, but that may be a fraction of the estimated $30 to 98 billion lost every year.

To fight overbilling, the U.S. Department of Health and Human Services' inspector general recommends that Medicare educate doctors, ask contractors to review evaluation and management billings and has said it might get more aggressive about reviewing physicians who charge at high levels.

To learn more:
- here's the ProPublica piece

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