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Propublica: Doctors Overcharge Medicare For Office Visit


It's MORNING EDITION from NPR News. I'm Steve Inskeep. Medicare pays for more than 200 million office visits each year. Most visits require only a modest amount of time and expertise. But a new investigation by the nonprofit news organization ProPublica suggests that hundreds of health professionals are overcharging Medicare for office visits. ProPublica senior reporter Charles Ornstein tells us what he found.

CHARLES ORNSTEIN: So a month ago the Medicare program, which covers seniors and disabled, released a big trove of information about the services provided by doctors all across the country and how much it paid them for it. So that's the basis for this information.

INSKEEP: This wasn't known before?

ORNSTEIN: It wasn't known. A court order prevented the agency from releasing any of this.

INSKEEP: But now it has been released. You've had a number of weeks to look through it and what are you finding?

ORNSTEIN: Well, we're finding that doctors across the country practice in very different ways. And as consumers what do we have to pick a doctor on? Well, we can go by a recommendation or a referral. Maybe we look for a doctor near our house. But now there's actually tools available - and we've created one - called Treatment Tracker, that let's you see if your doctor is similar to other doctors like him.

INSKEEP: So what should people who are using Medicare do with this information? Is there some way that, for example, someone listening to this program could go find out how their doctor is charging Medicare?

ORNSTEIN: Absolutely. I think it goes beyond what they're charging Medicare. By going to Treatment Tracker you're able to look specifically at what services your doctor performs within Medicare and how that compares to others in the same specialty in their same state. And so if they look unusual, that's something worth asking questions about.

INSKEEP: OK. So we can compare doctors but let's get to this question of overcharging. How, then, would you determine that a doctor overcharged for an office visit, particularly given that every office visit must be a little different?

ORNSTEIN: Well, office visits are these things that every doctor does. There's 200 million of them across the country in a given year and on the whole, about 4 percent of these visits are classified as the most complex and the most expensive, that Medicare pays the most for.

Hundreds, if not thousands of doctors that were billing exclusively for these most complex visits, even in situations where their colleagues who have similar credentials and in similar fields, were not doing the same thing.

INSKEEP: You're telling me that there are different levels at which Medicare will pay depending on the difficulty of the visit and certain doctors you were able to find through your analysis always go for the most expensive, the gold plated visit, at least in terms of what they get from Medicare.

ORNSTEIN: Right. Medicare has certain rules about if you're going to bill for that most expensive visit, you have to meet certain criteria. And it can't just be a run-of-the-mill visit. And it's very rare to think that every patient that comes through the door every time they come to see you is going to meet that criteria in order to bill for that visit.

But yet. we found 1,200 doctors across the country that did that every single time.

INSKEEP: Were you able to call any of those 1,200 doctors and inquire about their billing practices?

ORNSTEIN: Absolutely. We talked to a whole lot of them. And they said that their patients were sicker, were more complex, or required more time. A couple of them said that they have been contacted by Medicare and have sort of reevaluated their practices. But most of them defended this.

INSKEEP: So were there doctors that you listened to their stories and said, OK, this makes perfect sense what they're saying? This is why they're charging more. And others that just had telltale signs that they were just clearly bilking the government?

ORNSTEIN: Well, the Medicare data does not give you information about the quality of care that's provided or how sick patients really are. So it's impossible to make the determination that, yes, this provider has, you know, committed fraud or this provider has done something wrong. But there are other signs that are available.

A number of these doctors have faced allegations from their state medical boards for negligence or other wrongdoing and some of the doctors similarly have other services and procedures that they provided to their patients that are also unlike their peers.

INSKEEP: So did Medicare already know before your analysis that this many people were ripping them off?

ORNSTEIN: Medicare has been warned repeatedly over the years, both by its own inspector general and its own internal reports that office visits are an area that are ripe for fraud. People have been brought up on criminal charges before for over-billing the government for office visits and there's this thing called upcoding where doctors bill for a higher level of service than they actually provide.

INSKEEP: Charles Ornstein of ProPublica. Thanks very much.

ORNSTEIN: Thanks, Steve. Transcript provided by NPR, Copyright NPR.