Last month, it was decided that Medicare billing data would become public record. NPR recently reviewed some of the more questionable billing practices of the $500 billion program.
Doctors request reimbursement through billing codes, and NPR took a close look at how physicians charge for their office visits. Routine patient visits are charged based on a scale of 1 to 5, with a 1 being a quick, easy consultation and a 5 being the longest and most complicated visits.
NPR found that some doctors, such as a physician in Newhall, California, billed Medicare for a level 5 visit an average of 30 times per patient in 2012. These numbers, according to Patrice Morin-Spatz, a specialist in medical coding and reimbursement, represent "huge red flags, really high in the sky, waving their arms ferociously!" She claims that these types of billing practices are the main argument for healthcare cost transparency. "I think that they are trying to code based on how much money they want, as opposed to coding with a goal to satisfy the requirements of each particular level of service."
However, just because a physician regularly charges Medicare for a "5" level visit, does not mean that they could be committing fraud. Dr. Marilyn Levi of Colorado told NPR "There has to be an understanding and recognition of specialty care that is provided in only a few places. So I think it's dangerous to lump everyone together and base everything on a code." Dr. Levi works in the only academic medical center for hundreds of miles, and is regularly sent the most difficult patients for treatment.
While the data does provide much-needed additional oversight into the cost of health care, many hospitals are concerned that accurately charging for patient services could now result in them being suspected of fraud, which could lead to problems in accounts receivable practices. Health insurance claims management can outsource low value accounts to Professional Medical Services, allowing their own staff to focus on high-value Medicare and health insurance collections.