High Charges By Doctors May Or May Not Be Red Flags For Fraud

Doctors who bill the federal government for a lot of services may be gaming the system, but there also may be a reasonable explanation.

hide captionDoctors who bill the federal government for a lot of services may be gaming the system, but there also may be a reasonable explanation.


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That which walks like a duck, and talks like a duck, is not always actually a duck.

That’s the argument the American Medical Association has been using for decades to block public access to doctors’ Medicare billing records. The AMA worries that people and the press will misinterpret the numbers when they see how doctors bill the government’s $500 billion health care program for the elderly and disabled, and that doctors who are doing nothing wrong could be unfairly accused of fraud.

But the medical association lost that argument last month and now doctors’ Medicare billing data is a matter of public record – dense, complicated records. And those records are beginning to tell stories.

KQED and the independent newsroom ProPublica took a look a close look at one particular type of medical service in the data.

In order to get paid, doctors have to label everything they do for a patient with a billing code. Routine visits for established patients are billed on a scale of 1 to 5. A level 1 code is for a short, easy office visit; level 5 is meant for the longest, most complicated office visits, which are also paid at a higher rate.

Office visits account for about $12 billion in Medicare spending every year.

One emergency medicine physician in Newhall, California, Dr. Gary Ordog, billed Medicare for a level 5

Article source: http://www.npr.org/2014/05/17/313125323/high-charges-by-doctors-may-or-may-not-be-red-flags-for-fraud?ft=1&f=131849999

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