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June 17, 2014 Healthcare Fraud

Recently-Released Data Portrays Alarming Physician Reimbursement Rate Under Medicare Part B

Early last month, the Centers for Medicare and Medicaid services publicly released their data pertaining to reimbursement amounts provided to physicians under the Medicare Part B program – and many industry officials are not too happy about the numbers. According to the Inspector General of the Department of Health and Human Services, Medicare overpaid physicians nearly $6.7 billion for office visits in 2010. It is unclear at this point how the Department of Justice plans to proceed with this unprecedented release of information; however, overpayment and upcoding for office visits are some of the most common allegations by relators in False Claims Act litigation.

CMS Releases Data in “Interest of Transparency”

Since the controversial release of data – which historically required subpoenas to unearth – CMS has vehemently stood by its decision to share its healthcare expenditures with the general public. CMS Administrator Marilyn Tavenner defended the move as one intended to increase transparency, stating:

“In particular, we view this data release as an important first step in building greater understanding, on the part of a diverse community of policymakers, data entrepreneurs, and consumers, about the way in which Medicare pays physicians and other providers….”

General Data

According to the report, Medicare spent $32.3 billion on Evaluation and Management “E/M” services in 2010. These services include general office visits, trips to the emergency room, and inpatient consultations. Of that amount, approximately 21 percent was the result of improper billing that should not have been reimbursed by CMS.

When asked why the government is not more aggressively pursuing a reimbursement of these amounts, CMS asserted that it costs more money for investigators to uncover the improper billing than would be recovered as a result of the find. Therefore, CMS has vowed to offer providers education on proper billing procedures, as well as seek out consistent “high billers” for possible further investigation.

Backlash from Medical Community

The American Medical Association has taken great exception to the release of this data, stating:

“We believe that the broad data dump today by CMS has significant shortcomings regarding the accuracy and value of the medical services rendered by physicians. Releasing the data without context will likely lead to inaccuracies, misinterpretations, false conclusions, and other unintended consequences.”

Many in the medical community are fearful that this data may cause patients to lose confidence in their medical providers, possibly choosing to forgo necessary treatments for fear the office visit is unnecessary. Providers are also facing the possibility of increased exposure to qui tam lawsuits by patients who believe their provider is ordering unnecessary inpatient and outpatient violations – possibly resulting in a blurred perception of lawful and routine patient care versus illegal upcoding and false claims misconduct.

Contact Us to Learn More

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