The Cost of Unusual Medicare Physician Billing: 5 Things to Know

Medicare physician payment data reveals some providers are earning inordinate amounts from just one procedure or service, according to an analysis performed by The Wall Street Journal.

Here are five things to know about CMS’ release of physician reimbursement data and unusual billing practices.

1. The Journal’s analysis is based on data CMS released in April including information on more than 880,000 healthcare professionals across the country who received a total of $77 billion in Medicare Part B fee-for-service payments in 2012. With the data, it’s possible to compare 6,000 different types of services, procedures and payments received by individual providers, according to HHS.

2. CMS’ landmark release of physician payment data built on the agency’s decision earlier this year to evaluate Freedom of Information Act, or FOIA, requests from the media on a case-by-case basis for individual Medicare payments made to physicians, effective this past March. Previously, HHS said that “considering the two competing interests of public transparency and privacy,” Medicare physician data could not be provided through FOIA requests. The decision to disclose the data was spurred by a federal judge’s decision last year to lift a 1979 injunction that barred the release of individual physicians’ annual Medicare payments. That court decision stems from a January 2011 request from Dow Jones, publisher of Journal.

3. The Journal’s most recent analysis reveals more than 2,300 physicians received $500,000 or more in Medicare reimbursement in 2012 from a single service or procedure. For instance, the Los Angeles-based practice of physician Ronald S. Weaver, MD, received 98 percent of its $2.3 million in Medicare payments in 2012 for instances of a rarely used cardiac procedure, although Dr. Weaver is not a cardiologist. The procedure — which involves strapping the patient to a bed and using three cuffs to increase blood flow — is seen as a last resort treatment for severe chest pain, and there’s no consensus among cardiologists as to whether it has significant benefits, according to the analysis.

4. The practice of billing mostly for one service isn’t in itself unusual. Physicians can specialize in specific services and build their practices around those treatments. However, according to the Journal, a close examination of those who earn the most from few services shows they are straying from routine medical practice or operating outside their expertise. For example, urologist Evangelos G. Geraniotis, MD, of Hyannis, Mass., received $1 million out of a total of $2.1 million in Medicare payments in 2012 from a cystoscopy and fulguration procedure that isn’t deemed routine in a urological practice, according to the Journal.

5. However, the physicians in question say they aren’t driven by financial incentives and that the treatments they administer help to keep patients healthy. Dr. Weaver said the cardiac procedure he specializes in benefits his patients, and Dr. Geraniotis attributes his billing and treatment practices to a more aggressive approach that keeps patients out of the hospital, according to the Journal.