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Some Push Medicare Coding to the Max

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.

 A group of Florida doctors has been charging Medicare at a surprisingly high rate. 

A ProPublicainvestigation analyzed a recently released Medicare database and found unusual billing patterns in Floridaand elsewhere. ProPublica used that same data to create an online tool that lets patients see how individual doctors compare to their peers when it comes to procedures and billing patterns.

Reporter Sammy Mack spoke with ProPublica’s Charles Ornstein about what he found and why it matters to Florida patients.

Q: Part of what you found is that there are some physicians who bill at an unusual rate at a really, really high level. Talk to me about that.

A: So doctors use codes to bill Medicare and sometimes there are a number of codes for the same procedure. There’ll be a level 1—which may be low intensity and therefore low cost. And a level 5—which would be high intensity and high cost.

We decided to look at routine office visits. So when you go into the doctor with a cold or with high cholesterol… And these are the most performed services in Medicare. But what we found was a huge disparity in the way that doctors were billing for this. Some doctors were billing all of their visits as level 5. But most were not. And so we wanted to look at why the ones who were so high were doing what they were doing.

Q: You spoke with one of the Florida doctors who billed at the highest rate 100 percent of the time. What’s the story with Dr. John Im?

A: Dr. Im runs an urgent care center in The Villages. And what he said is that the patients that he sees have serious ailments and are much sicker, and that his urgent care center operates much like an emergency room.

But when we looked at other urgent care centers around Florida, around Central Florida, that were run by emergency room doctors, we found very different billing patterns.

Now, he said that Medicare contacted him in 2013 and that he took an online refresher training. But he still said that somewhere around 90 percent of his visits are level 5s. By comparison, across the country, about 4percent of all visits are level 5s.

Q: And  Dr. Im was one of nearly 100 Florida Medicare providers who billed exclusively at the highest rate. What does that tell you?

A: We talked to billing professionals across the country to make sure we understood what this means. And a lot of the very senior folks in this business said that they really couldn’t envision a scenario in which a doctor would bill at exclusively the highest level; that yes, there are some doctors who care for more, sicker patients, or patients who are more critically ill. But mixed in among those are patients who are coming in for things that are less serious. And that even doctors that are in professions that are really intensive as far as illness—like oncology, which are cancer doctors—that you’re still going to see a mix of patients. So billing at 100 percent, they said, sort of is a red flag.

Q: Yeah, what exactly does this mean for a patient whose doctor looks like they might be an outlier?

A: Well many patients I’ve talked to, they pick doctors based on a recommendation from a friend, based on a referral from their doctor, or based on somebody who lives close to their house. There haven’t been a lot of tools available to you to research your doctor.

If you’re really industrious, you could go on your state’s medical board and look to see if that doctor had been disciplined. But let’s face it: most people haven’t done that.

So this new tool (called Treatment Tracker) allows folks to actually go in and see pretty easily how their doctor compares to others in the same specialty, in the same state. If you’re looking at, say, a Florida internist, we would compare him to other Florida internists. And if the procedures that he’s choosing and the volume that he’s doing doesn’t look similar to others, it’s worth asking for information from the doctor about it.