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April 09. 2014 10:03PM

Federal data shows which doctors reap Medicare millions

NEW YORK — In 2012, south Florida ophthalmologist Salomon Melgen received $20.8 million in Medicare payments, the highest amount the government health plan for the elderly and disabled paid an individual provider that year, according to a Reuters analysis of federal data released Wednesday.

A California laboratory received $190 million, the most Medicare paid a single entity in 2012.

Family physician Tatiana Pavlova Greenfield, who practices in Maryland, may have received an average of more than $86,000 per patient that year, according to the Reuters review, and $3.3 million in total. That compares to an average of $2,200 per Medicare patient in 2012. Asked for comment, an employee at the office where Greenfield worked said she "had left the country."

After decades of litigation and over the strenuous objections of the American Medical Association, the leading U.S. doctors group, the federal Centers for Medicare and Medicaid Services (CMS) made public for the first time how much Medicare pays individual doctors and other providers.

The massive data release, totaling nearly 10 million lines, also includes which medical services each of more than 880,000 physicians and other health care providers nationwide billed Medicare for in 2012. In a sign of the disproportion in payments, 344 of those clinicians each received more than $3 million from Medicare Part B.

"While the data are not perfect, this is a major milestone in health care transparency," said cancer surgeon Marty Makary of Johns Hopkins School of Medicine, whose 2012 book, "Unaccountable," argues for making public more information on doctors and hospitals.

Waste and fraud

In addition to allowing patients to see which doctors perform a particular procedure most frequently often a proxy for expertise in rare and difficult surgeries such as colon operations — the data are expected to offer a road map to where waste and fraud are most rampant, not only in the Medicare program but throughout the American health care system.

"If you see that a doctor is doing a procedure hundreds or thousands of times that should be done only on a small number of patients, you wonder," said Dr. John Santa, medical director of Consumer Reports. "Are they committing fraud by billing for something they're not actually doing, doing unnecessary procedures because they're greedy, or do they practice someplace where so many people need the procedure?"

CMS urged the public, press and academics to use the data to answer such questions. "We want the public to help us, we want the press to identify outliers in spending," Jonathan Blum, CMS's principal deputy administrator, told a press conference on Wednesday.

$77 billion paid

Medicare paid physicians, physical therapists, nurse practitioners, chiropractors and other individual providers $77 billion in 2012. About two-thirds of Medicare's total $540 billion in payments that year went to hospitals and most of the rest to prescription drugs.

Outpatient office visits were among the most commonly billed services, accounting for 18 percent of all Part B spending in 2012, or $14 billion. Part B covers physician, therapist and lab services ranging from eye exams and physical therapy to knee replacements, cataract surgery and CT scans for 35 million beneficiaries.

A small number of extremely expensive procedures account for an outsized fraction of Part B spending. Medicare paid $956 million for 144,000 injections of the Roche drug Lucentis for "wet" age-related macular degeneration, an eye disease. That works out to 1.2 percent of total payments for 0.4 percent of beneficiaries. Medicare also paid $13.6 million for only 530 procedures in which men with prostate cancer received the controversial treatment Provenge, made by Dendreon.

'Complicated' cases

The data released on Wednesday include the names and addresses of physicians who submitted claims to Medicare in 2012, along with the codes for the approximately 6,000 services Medicare covers. It lists the number of times providers billed for each service, the average submitted charge and how much that deviated from the national norm.

The billing information is expected to indicate which physicians, therapists or others claim an inordinately high number of complicated cases. If a case is particularly complex, Medicare allows them to add a "modifier" to the code they use for billing and claim higher reimbursement.

"You'll be able to see back surgeons whose average bill is $50,000 because they say almost all of the spinal fusions they do are more complicated than the usual, and others whose average bill is $5,000" because they rarely classify the procedures as extra-complicated, said Santa.

That alone is not evidence of fraud, experts warned. But it can warrant additional scrutiny.

Last December, the inspector general of the Department of Health and Human Services, CMS' parent agency, found that 303 clinicians each collected more than $3 million from Medicare Part B in 2009, triggering "improper payment reviews" for 104. Those reviews identified $34 million in overpayments. Three of the clinicians had their medical licenses suspended; two were indicted.

Although CMS has had the data all along, outside health care experts are eager to scrutinize it, said healthcare analyst and Medicare expert Cristina Boccuti of the Kaiser Family Foundation. One thing they will look for is high-volume doctors. If some providers are billing for many more services per patient than others in the same community, she said, it could indicate overtreatment.

Consumer groups and media outlets have been trying to get the Medicare physician data since Jimmy Carter was in the White House. In 1979, the AMA and the Florida Medical Association convinced a judge to keep federal officials from releasing the data on the grounds that doing so would violate physicians' privacy. Last May, however, a judge in the District Court lifted the ban.


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