Three Calif. Doctors Among Top Five Highest Medicare Billers
Three California physicians are among the top five doctors in the U.S. who most frequently billed Medicare for the most complicated -- and expensive -- office visits, according to Medicare data analyzed by KQED and ProPublica, KPCC's "Impatient" reports (Plevin, "Impatient," KPCC, 5/19).
In April, CMS publicly released Medicare payment data for the first time since 1979, showing how the program paid out $77 billion to more than 880,000 health care providers in 2012. The data included information on payments made under Medicare Part B to all participating providers.
While many stakeholders praised the increased transparency, some doctors criticized CMS for releasing the information without any additional context. For example, some physicians noted that the payments do not equate to profits but instead cover treatment costs and staff wages. In addition, some physicians noted that they are listed as the billing physician for Medicare services for an entire practice, even though they did not order the services themselves.
Physician organizations -- including the American Medical Association -- also criticized CMS for releasing the data before physicians could review it for accuracy (California Healthline, 4/10).
Details of Calif. Physicians' Billing
Three California physicians were among the top five highest billers to Medicare, according to the data released last month. Those doctors included:
- Jeffrey Mace, a cardiologist in Santa Cruz County, who ranked third in the U.S. for the number of high-level visits billed to Medicare;
- Jay Schapira, a Los Angeles cardiologist, who ranked fifth in the U.S. for the number of high-level visits billed to Medicare; and
- Louis VanderMolen, a hematologist-oncologist in Orange County, who billed Medicare for 6,340 complex visits in 2012 -- the most of any physician in the U.S.
According to KQED's "State of Health," Mace charged Medicare for high-level visits nearly 10 times more frequently than other cardiologists in the state.
Meanwhile, Schapiro's patients had an average of four complex visits annually, compared with an average of one complex visit per patients at similar specialists in the state.
VanderMolen categorized about 79% of his patient appointments at the highest level. In comparison, similar specialists billed just 12% of visits at the highest level and just 5% of doctors office visits in the state were billed at that level.
CMS did not comment directly on California doctors' billings, but the agency said, "It's our assessment that it would be highly unusual for a provider to knowingly use the highest(-level) code... for all or nearly all of his or her outpatient visits."
Coding experts have noted that the findings "do not by themselves indicate wrongdoing" by the physicians.
Lamar Blount, a Medicare billing expert with the Health Law Network consultancy, said physicians could see higher volumes of complex visits if they are associated with a teaching hospital. For example, Schapira is a professor at UCLA's School of Medicine.
In a statement to KQED, Mace said that his practice has been audited several times in the past and that CMS "has found all of the office visits reviewed to be correctly coded" (Aliferis et al., "State of Health," KQED, 5/15).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.