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Docs collecting high payments from Medicare could be good source of information, OIG says


By Joe Carlson
Posted: December 20, 2013 - 6:30 pm ET
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Doctors who collect more than $3 million a year from treating Medicare patients aren't necessarily abusing the system. But this tiny minority deserves greater scrutiny, especially since their share of total Medicare spending has been growing in recent years, HHS' Office of the Inspector General says.

A new OIG study (PDF) concluded that 303 doctors collected $1.3 billion in Medicare payments in 2009, averaging $4.2 million per doctor. The other 878,000 doctors treating Medicare patients collected an average of $78,000 each that year, the report says.

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Of those 303 doctors, one-third of them have already been selected for focused audits by Medicare contractors, and 13 were found to have collected a total of $34 million too much from the government program. Three of the doctors ended up having their licenses suspended, and two were indicted, though they're not named in the report.

The OIG found that three medical specialties dominated the $3 million list: internal medicine (55%), radiation oncology (12%) and ophthalmology (11%). Nearly 28% of the $3 million doctors were in Florida, widely considered a hotbed of healthcare fraud and abuse, while California had 8%.

“These results illustrate that reviews of individual clinicians associated with high cumulative payments have contributed to Medicare program integrity efforts,” the OIG report says.

To underscore the urgency of the report, OIG officials noted that the number of Medicare doctors who collected more than $3 million a year grew 78% between 2008 and 2012. For Medicare Part B as a whole, both the number of doctors and total spending grew by just 13% in that period.

“High cumulative payments are not necessarily indicative of improper payment or fraud,” CMS Administrator Marilyn Tavenner wrote in response to the report. “However, CMS does acknowledge that reviewing claims from providers with high cumulative payments could be a valuable screening tool.”

She wrote that the CMS will work with its contractors to develop dollar thresholds that would trigger automatic Medicare audits, though such policies will have to take into account physician specialties and services rendered.

Follow Joe Carlson on Twitter: @MHJCarlson


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