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The CMS revealed Medicare physician reimbursement data Wednesday

CMS reveals Medicare physician pay data


By Joe Carlson
Posted: April 9, 2014 - 12:01 am ET
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Routine office visits accounted for the single largest share of Medicare physician billings in 2012 even though they amounted to just one-seventh of the $77 billion paid by the government for physician services through the nation's senior citizen healthcare program.

The data, released Wednesday, comes from the first-ever publication of Medicare Part B payments to individual physicians and physician practices by the CMS. The agency released the data in response to demands for transparency in the wake of court case requiring the agency to provide public access to physician billing records.

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The database includes 9.2 million lines describing transactions worth $77 billion by 880,000 physicians and physician practices certified to collect from Medicare. The data include physicians' names and office locations, the exact services for which they billed Medicare, the average payments for each service and the number of patients who received each service.

Not surprisingly, the most common Medicare physician service was the $70 doctor office visit, followed closely by the $100 office visit. Taken together, the five levels of visits known as evaluation-and-management services cost Medicare nearly $11 billion in 2012.

Analysts sifting through the data in the coming days and weeks will try to shed light on payment trends and expose outliers among services and providers. Insurers and government payers will use the data to identify high-cost providers and spot inter- and intra-regional variations in the patterns of care. Consumers groups may use the data to identify high-volume or low-volume providers in their attempts to identify physicians considered to be the best by patients and peers.

But much of the focus will eventually land on the $66 billion in physician services divvied up by providers in a huge assortment of specialty and niche services, including services offered during routine office visits.

The American Medical Association fought a 35-year battle against the release of these data, which ended with its defeat in court last year. AMA officials have repeatedly warned the data could compromise doctors' rights to privacy, and would be subject to wide misinterpretation by the public and the media.

“We believe that the broad data dump today by CMS has significant short-comings regarding the accuracy and value of the medical services rendered by physicians,” said AMA President Dr. Ardis Dee Hoven. “Releasing the data without context will likely lead to inaccuracies, misinterpretations, false conclusions and other unintended consequences.”

Billings listed under a single physician code may refer to all doctors in a large physician practice, for instance. And the billings do not equate with physician salaries since they must use the payments to pay for office space, assistants and ancillary services associated with running their practices.

Still, one of the reasons CMS officials gave for releasing the data was to aid in the search for healthcare fraud and abuse. For example, a Wall Street Journal investigation using physician payment data obtained under the Freedom of Information Act uncovered a family practice doctor in New York who received more than $2 million from Medicare through a pattern of use that strongly suggested abuse or fraud, the paper reported.

Now, the entire dataset—all payments to doctors under the Medicare Part B program—is public information. The data will keep analysts and media outlets busy for years to come as the annual releases begin to reveal changes in practice patterns over time.

Some of the early findings from a Modern Healthcare analysis of the data show:

  • On average, doctors get about 19% of their money treating Medicare patients through copayments, deductibles, and secondary-insurance. For a $70 evaluation visit, Medicare usually pays about $49 and the patient or their private insurer covers the rest.


  • Many of the highest-paying Medicare physician procedures are actually for the purchase and administration of drugs. The single highest-paying service in Medicare Part B is $25,730 for administration of prostate cancer drug Provenge for patients with “castration levels” of testosterone and evidence of tumor progression. That one code accounted for a dozen of the 20 most expensive physician procedures at practices across the country in 2012.


  • The busiest Medicare physician practice in America may be in Michigan. The data show that an Ann Arbor primary care doctor submitted bills for treating more than 207,000 Medicare patients in a single year, the highest such figure in the nation. That doctor's physician practice was reimbursed $7.6 million by Medicare, the data say. The doctor's office with the second most Medicare billings was a Rochester, Minn.-based physician who is listed as receiving more than $11 million for treating 56,000 Medicare patients. In both cases, it's likely that the figures represent the work of multiple doctors using a single provider number, even though the numbers are listed as registered to individuals, not groups.


Follow Joe Carlson on Twitter: @MHJCarlson


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