Patients Pay More, Too
These billing patterns raise questions for Medicare as a whole and for individual patients who pay a percentage copay. The higher level visits cost more. “Twenty percent of $200, for example, is obviously more than 20 percent of $100,” said Christina Melnykovych, president of Coding Continuum and an expert in insurance billing. “There’s a direct correlation between the service level billed and the paid amount, and thus the copay impacts the patient.”
All established patient office visits are coded under a category called “evaluation and management.” These visits are billed at one of five levels, with “5″ being the most complex. Established patients are people the provider has seen at least once before. First-time doctor appointments are coded differently.
The Centers for Medicare and Medicaid Services, which runs Medicare, declined to comment for this story and in a statement said they have not seen the data analysis.
“Some providers have sicker patients, thus are more likely to bill at [evaluation and management] coding levels that carry higher payments. Every day we work with providers to make patient care the priority, and at the same time ensure they use [evaluation and management] codes that reflect the level of service provided,” the agency said. “It’s our assessment that it would be highly unusual for a provider to knowingly use the highest (level) code … for all or nearly all of his or her outpatient visits.”
Only one percent of California doctors billed Medicare at the highest level for all of their office visits for their established patients.
Coding experts stress that while the numbers cited for the doctors above do not by themselves indicate wrongdoing, they do raise eyebrows.
‘I’m Not An Average Cardiologist’
We tried to reach all of the doctors named in this report, with repeated phone calls plus faxes detailing our questions. Drs. VanderMolen and Schapira did not respond to our requests.
Dr. Mace sent us a written statement in which he vigorously defended his billing patterns. “I’m not an average cardiologist,” he wrote. “I spend a great deal of time taking care of patients. I generally spend 12-16 hours per day in the practice of medicine. I do not take any lunch breaks. I am on call 24 hours a day, seven days a week and do not take vacations. By being available and devoting a great deal of resources to the patients, I hope that this comprehensive care translates to improved quality of life for my patients and hopefully, improved quantity of life (longevity).”
But billing for an individual visit is not about a physician’s dedication. Experts say it is about the patient’s complaint that day. “What was it about the patient’s clinical presentation and condition that warranted billing a level 5 service?” Melnykovych said.
Tue, May 20 2014