1. Health

Billing to the max: Why do some Florida doctors charge Medicare far more than others?

Published May 16, 2014

When Florida doctors and other health providers billed Medicare for nearly 19 million office visits in 2012, they asked for the top fee less than 5 percent of the time.

But about 160 medical providers claimed nearly all of their visits for established patients merited the highest rate on a 1 to 5 scale, according to an analysis of Medicare data by ProPublica. Another nearly 425 providers — including doctors, nurse practitioners and physicians assistants — billed at least half their office visits at that rate.

This included Sarasota psychiatrist Matthew Edlund, who charged all his 1,415 office visits by Medicare patients in 2012 at the most expensive level. He saw each of those 188 patients an average of more than seven times, and said each visit required the most complex, time-consuming care for which Medicare will pay.

Edlund, who focuses on physical, mental and spiritual health at his Center for Circadian Medicine, said that his patients have many problems, such as insomnia, depression and poor diets.

"I happen to be doing complicated stuff," said Edlund, author of several books, including Healthy Without Health Insurance.

While many patients complain their doctors don't spend enough time with them, experts say heavy billing at the highest rate should at least raise red flags as pressure mounts to rein in waste in the public insurance program for seniors and the disabled.

Medicare typically reimburses physicians around $100 or more for the most expensive "level 5" office visit. By contrast, the more typical level 3 office visit, typically about 15 minutes, is reimbursed at about $50.

Jay Wolfson, a professor and health policy expert at the University of South Florida, said billing codes should reflect the complexity of a patient's treatment and the amount of time required from the provider. The level 5 code typically involves 40 minutes of face time with the patient.

Patients should pay attention to those codes on their Medicare statements, he said.

"If my medical records say it was a level 5 reimbursement and I'm pretty sure I got a six minute visit, well, am I that sick … or was it a mistake?" he said. "The patient has the right to know that (the visit) was complete and thorough, and not just booked as if it was."

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Dr. John Im, who runs Exceptional Urgent Care in the Villages, billed 100 percent of his Medicare visits at level 5. He said that because of his training as an emergency room physician, his center attracts sicker patients.

He said that after being contacted by Medicare officials last year, he took "voluntary tutoring and counseling" and now estimates that around 90 percent of his office visits are level 5.

"Yes it was inaccurate in 2012," he conceded, blaming his coding problems, in part, on Medicare's lack of billing categories tailored to urgent care. "Medicare gave us a call. 2013 is going to be a lot more accurate."

Experts, however, said that it was implausible that an urgent care doctor would never see patients with minor ailments. Other urgent care centers in the region, including some run by emergency specialists, have lower proportions of level 5 visits, ProPublica's analysis showed.

"Bring in the logic police," said Shelley C. Safian, who teaches medical billing and has written textbooks on the topic. "Even an emergency room in a hospital, not everybody is a level 5."

Im earned $237,600 from the government for his level 5 visits in 2012, plus patient copays.

Crystal River primary care doctor Robert Corbett billed all of his 393 Medicare office visits at the highest level, the 2012 data shows. Yet family doctors on average billed less than 5 percent of their visits at that level.

Corbett disputed his percentage was that high. Still, he said he uses that higher code often because he sees very sick patients, does a lot of the tests himself and rarely refers patients to specialists.

Just 75 miles south, in Largo, internist Kush Patel charged less than 2 percent of his 1,230 office visits at the highest level. Most of his visits were a step down at Level 4, which on average paid about $74 per visit, Medicare records show.

His office manager, Andrea McClelland, said the office has an electronic system that helps them decide which code to use. She said Patel also sees complicated patients, but that it doesn't always require the most complex services. And visits don't typically last 40 minutes. "I don't know many that do," she said.

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The issue of charging for office visits illustrates the kind of pressures faced by practices that don't perform lucrative procedures, said USF's Wolfson. Such practices can survive only if they have enough patients or use the highest codes they can justify.

In the medical billing world, it's called "optimization." A small industry has cropped up to help practices choose the highest codes possible.

"Where does that optimization end and hyperbole start?" he said.

Several Florida doctors told the Times that Medicare had asked to review their records and been satisfied by their documentation.

Private insurers also are interested. Humana, for instance, notifies providers who are "outliers" compared to their peers and sends them bill-coding education materials, said spokesman Mitch Lubitz. The insurer looks at the provider 60 to 90 days later and may request records to review whether the doctor still appears to be an outlier. A fuller audit may follow.

Corbett, the Crystal River doctor, said Blue Cross has twice requested to see his records because he had so many level 4 patients. But he said both times he was able to provide copious documentation.

"They always leave and give up," he said.

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ProPublica's analysis shows 580 medical providers in Florida billed at least half of their office visits at the highest charge.

Among them was Dr. Lodovico Balducci, a well-known geriatric oncologist at Moffitt Cancer Center in Tampa.

Around 70 percent of his Medicare office visits in 2012 were reimbursed at the highest level. On average, Florida oncologists billed only 8 percent of their office visits at that level.

Balducci said the charges reflect the complexity of his patients: an 81-year-old breast cancer patient, for instance, whom he discovers during an office visit also has anemia and a faint heart murmur. Or the nearly 20 percent of his patients with two cancers. Or those who come in with family members wanting the full scoop on their loved one's options.

Balducci said he doesn't know why oncologists typically bill far less often for complex visits. He said he limits appointments so he isn't rushed. "I want to give them as much time as I can," he said.

Medicare officials once reviewed his billing documentation, he said, but didn't suggest any changes.

Wolfson noted that providers face huge changes in coming years as Medicare stops paying them based on time or procedures and starts reimbursing them based on how healthy they keep their patients.

Already, some doctors are changing the way they bill for other reasons. Edlund, the Sarasota psychiatrist, said mental health services can now be charged under different medical codes. The next batch of Medicare data in 2013, he said, should show he had no level 5 office visits.

ProPublica and Times researcher Connie Humburg contributed to this report. Jodie Tillman can be reached at