Monday, January 22, 2018
Health

Billing to the max: Docs charge Medicare top rate for office visits

Office visits are the bread and butter of many physicians' practices. Medicare pays for more than 200 million of them a year, often to deal with routine problems like colds or high blood pressure. Most require relatively modest amounts of a doctor's time or medical know-how. Not so for Michigan obstetrician-gynecologist Obioma Agomuoh. He charged for the most complex — and expensive — office visits for virtually every one of his 201 Medicare patients in 2012, his billings show. In fact, Medicare paid Agomuoh for an average of eight such visits per patient that year, a staggering number compared with his peers.

Doctors and other health providers nationwide charged the top rate in 2012 for just 4 percent of office visits for patients they had seen before. But Agomuoh was one of more than 1,800 health professionals nationwide who billed Medicare for the most expensive type of office visits at least 90 percent of the time that year, a ProPublica analysis of newly released Medicare data found.

Dr. John Im, who runs an urgent care center in the Villages, the large retirement community near Ocala, charged the program at that level for all 2,376 visits by his established patients. Kaveh Farhoomand, an Oceanside, Calif., internist facing disciplinary charges from his state medical board, collected the highest rate to see almost all of his 301 Medicare patients an average of seven times each.

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. The agency declined to discuss individual providers but said their data may not take into account money collected by a provider and subsequently returned to CMS, or payments that "may have been withheld after claims were already processed but prior to release to the provider."

"CMS is working to ensure that physicians and health care providers appropriately bill" for office visits, also known as evaluation and management (E&M) services, the agency said.

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.

In April, Medicare released data showing 2012 payments for outpatient services, and for the first time specified how much money went to individual health providers. The data allow consumers to look at which procedures doctors are performing and how frequently, and how their billings compare with those of their peers.

Doctors or their staffs determine how to bill for routine office visits for established patients (those the provider has seen at least once before) 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.

"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 myself into it, but I just can't see it."

A May 2012 report from the U.S. Department of Health and Human Services' inspector general found that doctors are choosing higher codes more often for evaluation and management services, the broad category that includes office visits.

Agomuoh, the Michigan ob/gyn, stood out for reasons beyond his office visits. Medicare paid for an average of eight wheezing evaluations for each of his patients in 2012, at $50 a pop. Almost all of his patients received multiple ultrasounds of arteries in the legs (at $149 per test) and arms (at $144 per test), records show. Most of his peers rarely, if ever, performed these services.

Agomuoh said his billings reflect that many of his patients have asthma, chronic obstructive pulmonary disease and drug addictions.

Comments
Free clinics respond as more people head to the ER with dental problems

Free clinics respond as more people head to the ER with dental problems

Charles Lee had been dealing with an excruciating toothache for days. The pain made it hard to eat or sleep or focus on work. But Lee, 54, didnít have dental insurance. His job as a delivery truck driver offered only a supplemental policy that was to...
Published: 01/22/18
When you need a breast screening, should you get a 3-D mammogram?

When you need a breast screening, should you get a 3-D mammogram?

When I went to the imaging center for my regular mammogram last year, the woman behind the desk asked me if Iíd like to get a "3-D" mammogram instead of the standard test Iíd had in the past."Itís more accurate," she said.What do you say to that? "No...
Published: 01/22/18
Expect some pain. Thatís what hospitals are starting to tell patients as concern spreads over opioids

Expect some pain. Thatís what hospitals are starting to tell patients as concern spreads over opioids

Doctors at some of the largest U.S. hospital chains admit they went overboard with opioids to make people as pain-free as possible, and now they shoulder part of the blame for the nationís opioid crisis. In an effort to be part of the cure, theyíve b...
Published: 01/19/18
Itís flu season, and how: Hereís what you need to know

Itís flu season, and how: Hereís what you need to know

Cristi Fryberger, a fifth-grade teacher, was headed back for the first day of classes at St. Petersburg Christian School after the Christmas break but didnít feel well. She left a couple of hours later and went to an urgent care clinic, where a swab ...
Published: 01/19/18
This 66-year-old is about to run seven marathons in seven days on seven continents

This 66-year-old is about to run seven marathons in seven days on seven continents

When Robert Owensís father was 75, he gave his son some advice. "He said, ĎYou know, son, the sad part is when you get old they just put you on a shelf and you become irrelevant. Fight to stay relevant. Fight to stay in the game, otherwise they will ...
Published: 01/18/18
5 things we learned about Trump from his medical checkup

5 things we learned about Trump from his medical checkup

Five things we learned about President Donald Trump from Navy Rear Adm. Ronny Jackson, the doctor who oversaw Trumpís first medical checkup in office. SLEEP Trump doesnít get much shut-eye. Jackson guessed that Trump snoozes four to five hours a nig...
Published: 01/17/18
A century after the 1918 pandemic, science takes its best shot at flu

A century after the 1918 pandemic, science takes its best shot at flu

WASHINGTON ó The descriptions are haunting. Some victims felt fine in the morning and were dead by night. Faces turned blue as patients coughed up blood. Stacked bodies outnumbered coffins. A century after one of historyís most catastrophic disease o...
Published: 01/17/18
A popular school fundraiser is just Ďjunk-food marketing to kids,í experts say

A popular school fundraiser is just Ďjunk-food marketing to kids,í experts say

For 43 years, schoolkids and their parents have clipped the labels from cookie bags and cracker boxes as part of a popular rewards program called Labels for Education.Through this and similar programs ó think Tysonís Project A+ or General Millsí Box ...
Published: 01/17/18
Pinellas is at the center of a rise in Florida flu outbreaks

Pinellas is at the center of a rise in Florida flu outbreaks

Feeling a little sniffly or scratchy or stuffed up? It may be the flu, and you donít want to wait around to see a doctor this year. This is not the time to write off flu-like symptoms, Tampa Bay area health officials and doctors warn. The influenza v...
Published: 01/16/18

CDC says ĎThereís lots of flu in lots of places.í And itís not going away anytime soon.

A nasty flu season is in full swing across the United States, with a sharp increase in the number of older people and young children being hospitalized, federal health officials said Friday.The latest weekly data from the Centers for Disease Control ...
Published: 01/12/18