There has been a lot of recent discussion about the release of physician billing and reimbursement data by the Centers for Medicare & Medicaid Services (CMS), including commentary by Frank Cohen and Mike Jamrog on last week’s Monitor Mondays broadcast.

Frank properly pointed out that there are lots of statistical issues with the data, and Mr. Jamrog noted that a very hard-working, well-respected physician on his medical staff was featured in an article in a local newspaper because his facility was on a “Top 10” list for reimbursement in his state.

The national media also made much of the political connections of some of the highest-paid physicians, implying that they may have been buying immunity, but media outlets rarely mentioned that the average reimbursement by Medicare for an office visit is about $43.

We also hear almost daily from the American Coalition for Healthcare Claims Integrity, the lobbying organization for the Recovery Auditors (RACs) and Zone Program Integrity Contractors (ZPICs). The coalition, which bills itself as “fighting waste, fraud, and abuse in the healthcare system,” has been imploring Congress to reinstate the RAC program, tweeting out the results of every OIG audit and painting all hospitals and providers as cheaters while declaring itself the savior of the Medicare Trust Fund.

Yet the OIG audit of the RAC program found that the RACs reported only eight cases of fraud between 2005 and 2012, hardly making them worthy of the title of “fraud fighter.”

The attention paid to the physician pay data and the RACs’ never-ending public relations campaign is sure to increase audit oversight of providers. But rather than attack the data as flawed, a tactic that never works, we should embrace the data for what it can help do — expose the real fraud and abuse so that those who are doing their best to follow the regulations can be left alone to take care of patients. The physician data includes data from many physicians who are clearly outliers. And while being an outlier does not mean that a physician is cheating, it certainly seems to make more sense to audit that physician than a physician whose billing is close to the norm.

Furthermore, there are many physicians whose billing data indicates aberrancies that should have been detected a long time ago by Medicare’s billing edits and not by the media. As an example, a physician in Newhall, Calif. billed for 4,495 prolonged service office visits. The prolonged service office visit codes only are to be used when face-to-face contact with a patient exceeds the normal visit time by over 60 minutes, and only when services are billed with an evaluation and management (E&M) code. Based on his billing, he spent 3,005 hours in 2012 on prolonged services beyond the normal visit times. Assuming he took no vacation at all, this means the doctor averaged 100 hours a week providing direct face-to-face patient care. Coding rules require that the prolonged service code only can be used as an add-on with an E&M code, yet this doctor only billed 1,317 E&M codes, so he should not be allowed to bill more than 1,317 prolonged services codes. Why was this doctor allowed to bill 3,178 more prolonged visits than are allowed by coding rules?

The fifth-highest paid pulmonologist in the country practices in Schaumburg, Ill., having billed 4,727 critical care visits. This means that doctor spent more than six hours a day, every day, caring for critically ill patients, yet he still had time to see about 3,000 Medicare patients in the hospital and office. This is the only doctor in the country who billed more than 2,000 critical care visits. Should this outlier not have been detected and audited before the data was released to the public?

When the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) releases its daily “What’s New at OIG,” it reports routine hospital compliance audit results intermixed with arrests of fraudsters and criminals, enabling the RACs and the media to use a broad brush to paint many as fraudsters. But that is far from the truth. CMS spent $77 million contracting with Northrup Gruman in 2011 to develop a fraud detection system, yet the physician data release has many examples of outlier data that were found within a few days of release by unpaid interested parties. Yet unfortunately, CMS has neglected to include a “report possible fraud” function on its website.

Let’s embrace this data release as a chance to encourage the discovery and investigation of the real fraudsters and to get some of the pressure off of those of us who are trying to do the right thing, yet occasionally make unintentional errors.

About the Author

Ronald Hirsch, MD, FACP, is a vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians.

Contact the Author

To comment on this article go to

Share This Article