Physicians who bill the most for Medicare office visits continue despite warnings: 5 things to know

Written by Laura Dyrda | December 27, 2017 | Print  |

ProPublica crunched the numbers and found many of the same physicians who billed most of their Medicare cases as the most expensive type of visit in 2012 continued to do so in 2015 despite warnings that the federal government would pay more attention to those outliers in the future.


Here are five quick facts from the report:

1. In 2015, ProPublica found 1,825 healthcare professionals billed for the most complex — and most expensive — Medicare visit for 90 percent or more of their visits, nearly the same as 1,807 reported in 2012.

2. Offices currently bill based on the time spent with the patient, intensity of the exam and complicated nature of medical decision-making for each patient. Uncomplicated patients are coded as a "1" visit while the most complicated are "5"; office visits are typically coded as "3" or "4."

3. Overall, healthcare professionals typically bill a small percentage of visits as a "5" but 1,250 providers billed only level "5" visits in 2015 while 570 billed at a level "5" 90 percent of the time.

4. Around 650 of the 1,825 physicians who billed at level "5" 90 percent of the time or more in 2012 also did so in 2015. ProPublica reported that 536 physicians who billed at a high level in 2015 where responsible for billing a lesser share of the highest-level visits in 2012.

5. Some of the high billing could be attributed to EHRs, which assign codes based on boxes physicians check during the exam; others have been kicked out of the Medicare program for over billing.

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