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FL Docs Make Pricey Medicare Claims

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

When Medicare patients come in for an office visit, the doctor bills for that interaction on a scale of one to five.

A one is a relatively quick, simple office visit. A five is more complex and lengthy.

Oh, and that level five visit also pays more.

On average nationwide, only 4 percent of office visits get billed at that most complex level. But a ProPublica analysis found nearly 100 doctors in Floridawho saw at least 100 Medicare patients in 2012 billed exclusively at that highest rate.

“I find that kind of shocking,” said Cyndee Weston, executive director of the American Medical Billing Association.

She points out that some specialists do spend a lot of extra time with patients in follow-up visits: oncologists, cardiologists, psychiatrists.

“That’s one thing. But if it’s family practitioners, pediatrics, general practitioners, it’s kind of shocking that they’re billing 100 percent… they see everybody from hang nail to heart attack,” Weston said.

In Florida, cardiologists and mental health professionals were among those with the most likely to charge for intense office visits, the analysis found. 

But John Im, an emergency medicine specialist in The Villages, was the state’s most frequent biller in this category. He received $769,000 from Medicare for all treatments he conducted in 2012.

He told the Tampa Bay Times his office did inaccurately bill Medicare in 2012 for the 2,376 level five office visits, and adjustments are being made. He estimated that 90 percent, not 100 percent of his office visits qualified for the complex billing category.

Four other Florida doctors in the ProPublica analysis billed with the complex office visit category coding more than 1,100 times in 2012. They are: Sarasota psychiatrist Matthew Edlund; Sebring general practitioner George Ibrahim; Hialeah cardiologist Tomas Guerra ; and internist Jose De Olazabalof Palm Beach Gardens.

ProPublica’s analysis of the 2012 Medicare billing data looked at more than 329,000 physicians and health care providers nationwide. Of those, more than 1,200 billed exclusively for the highest-cost office visit for more than $12 billion in payments.

Medicare experts told ProPublica that watching this unusual billing patterns could help identify and cut down on wasteful spending.

"I think this is a smoking gun," Dr. Robert Berenson, a former senior Medicare official now at the Urban Institute think tank, told ProPublica. "Who's asleep at the switch here?"

Overall, Florida ranks second to California in annual Medicare payments. In 2012, health care providers nationally received $7.62 billion of the $77.3 billion distributed.

The ProPublica analysis goes far beyond looking at these office visits. Its Treatment Tracker allows consumers to see if and how often their doctors billed Medicare in 2012, what treatments they conducted, and whom they were likely to refer their patients to for more treatment.

The Florida databasealone whittles down a massive amount of information for consumers, including claims from more than 5,500 internal medicine specialists, 4,100 family practitioners and 2,800 nurse practitioners.

Mary Shedden is news director at WUSF.