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MEDICARE BILLING DATA UNDER SCOPE

Patient groups hail the disclosure, but doctors say the information could be misconstrued.

Washington Post

WASHINGTON - The Medicare program is the source of a small fortune for many U.S. doctors, according to a trove of government records that reveal unprecedented details about physician billing practices across the nation.

The government insurance program for older people paid nearly 4,000 physicians in excess of $1 million each in 2012, according to the new data. Those figures do not include what the doctors billed private insurers.

The release of the information gives the public access for the first time to the billing practices of individual doctors nationwide. Consumer groups and news outlets have pressured Medicare to release the data for years. And in doing so today, Medicare officials said they hope the data will expose fraud, inform consumers and lead to improvements in care.

The American Medical Association and other physician groups have resisted the data release, arguing that the information violates doctor privacy and that the public may misconstrue details about individual doctors.

Among the highest billers were a cardiologist in Ocala, who took in $18.1 million, mainly putting in stents; a New Jersey pathologist who received $12.6 million performing tissue exams and other tests; and a Michigan vascular surgeon who got $10.1 million.

Some of the highest billing totals may simply reflect a physician who is extremely efficient or who has an unusually large number of Medicare patients.

But in some instances, the extremely high billing totals could signal fraudulent doctor behavior, as government inspectors have previously found.

Indeed, three of the top 10 earners already had drawn scrutiny from the federal government, and one of them is awaiting trial on federal fraud charges.

The specialties most common at the top ranks of the Medicare payments were ophthalmologists, oncologists and pathologists.

This information gives the public "unprecedented access to information about the number and type of health care services" doctors provided during the year, Jonathan Blum, principal deputy administrator of the Centers for Medicare and Medicaid Services, said in a blog post.

The Medicare program is the nation's largest medical insurer. By virtue of its breadth, the forthcoming billing data are expected to shed light on an array of questions that have arisen about health care costs as the nation has confronted decades of rising medical bills.

Overall, the information covers $77 billion in billing involving 880,000 practitioners in 2012.

The AMA has warned that the data could contain errors, and in some cases, one doctor's billing number may have been used by multiple support personnel for billing purposes.

But consumer and public interest groups argued that the information will help consumers make better decisions.

"This data is important because it will make it possible for consumers to identify physicians that will best meet their needs," said Robert Krughoff, president of Consumers' Checkbook, a group that began seeking the release of this information in 2005 and eventually sued for it.

The doctor at the top of the list of largest Medicare billers is Salomon Melgen, an opthalmologist in West Palm Beach, who took in $20 million from Medicare in 2012, according to the data released Wednesday.

Most of Melgen's take - about $11.8 million of it - came from injecting patients' eyes with Lucentis, a drug used for macular degeneration, the data show.

For each shot, Medicare and the patient pay a doctor about $2,000, but the drug is expensive and the doctor must then pay most of that money to the drug's manufacturer, Genentech.

What may be most interesting about Melgen's practice, however, is that he could have used a much cheaper drug than Lucentis - one called Avastin that many ophthalmologists consider an equivalent.

Had he used the cheaper alternative, his bill to Medicare for the shots would have dropped from $11.8 million to less than $500,000.

Melgen's name appeared in headlines in 2012 as result of his connection to Sen. Robert Menendez, D-N.J., a friend who received campaign contributions from the ophthalmologist.

Melgen's attorney issued a statement before the data release to try to put his client's billing in perspective.

"At all times, Dr. Melgen billed in conformity with Medicare rules," Kirk Ogrosky said. "While the amounts in the CMS data release appear large, the vast majority reflects the cost of drugs. ... Responsible analysis requires looking beyond the raw data to what was paid for pharmaceuticals and expenses."

The use of the more expensive eye drug helps explain why so many of Medicare's top billers are ophthalmologists.

The second-highest biller in 2012 was Asad U. Qamar, a cardiologist in Ocala. Qamar made headlines last year after a Reuters report detailed large donations the doctor had made to the Obama administration's agenda and a detailed federal review of his billing practices.

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