What You Need to Know
Medical Economics Feature — June 2014
Tex Med. 2014;110(6):47-48.
By Catherine I. Hanson, JD
In a historic reversal of policy, on April 9, 2014, the Centers for Medicare & Medicaid Services (CMS) released extensive information about the payments it made to physicians and other providers of Part B Medicare services. The public release includes every person or organization that billed for those services in 2012 — more than 880,000 providers. The information is posted for download on the CMS website in a section titled "Medicare Provider Utilization and Payment Data."
In addition to biller demographic data, it includes the following data fields for 100 percent of the calendar year 2012 final-action, physician/supplier Part B noninstitutional line items for the Medicare fee-for-service population:
- Medicare participation (yes/no);
- Place of service (facility/outpatient);
- HCPCS (CPT) code and HCPCS description;
- Line service, unique beneficiary, and distinct beneficiary per-day service counts;
- Average Medicare allowed amount and standard deviation Medicare allowed amount;
- Average submitted charge amount and standard deviation average submitted charge amount; and
- Average Medicare paid amount and standard deviation Medicare paid amount.
For those who don't want to wade through these enormous spreadsheets, The Wall Street Journal posted an easier-to-navigate — but less complete — database. This includes physician or other provider name, address, specialty, and total Medicare payment amount. A drill-down screen shows the number of each procedure billed by CPT/HCPCS code, the average Medicare payment amount for each service, and the total paid for each service type in 2012. (To protect beneficiary identity, only services involving at least 11 beneficiaries are included.)
How hard is it to figure out what I was paid?
It takes only a few seconds to look up any physician or other Part B Medicare provider and find out what the government is reporting Medicare paid and for what services. It is also easy to see how the top physicians or other health care professionals in the aggregate — or in particular specialties — rank by total Medicare payments. And it is equally easy to do this search by state or city.
Your patients, your competitors, the managed care plans you contract with, your former or current employees, your friends, your enemies, the press, indeed anyone and everyone is now privy to your Medicare billing practices. Even worse, this is just raw claims data. With no way to put these data in context, the potential for viewers to misunderstand the raw data is significant.
What should I do?
Most important, review your data! This is not the time to put your head in the sand. The "transparency" genie is not going back in the bottle — ever. And, of course, where Medicare goes, private payers usually are not far behind.
The first step is to look at your numbers and confirm whether they are correct. Historically, there have often been major data errors in databases of this type. If CMS has it wrong, you should get the information corrected as soon as possible. Start by contacting the medical director of your Medicare carrier.
What do I do if I'm not listed?
Assuming you treated Medicare patients in 2012, the two most common reasons you won't be listed are because your services were billed under a group national provider identifier (NPI) and taxpayer identification number (TIN) or because all your patients were covered by Medicare Advantage. The database includes only fee-for-service Medicare payments; services provided to patients covered by Medicare Advantage are not included.
Again, if there is a mistake and you should have been included in the database, you may want to start by reviewing and updating your listing in the National Plan & Provider Enumeration System and then contact CMS. If you were not included and your patients are asking why, you may want to work with the organization that billed on your behalf to develop an appropriate public response.
Among other things, your employer will want to answer questions and allay any fears your patients or potential patients may express. For example, where evidence suggests physicians should perform at least a minimum number of a specific procedure to obtain optimal outcomes, you may want to be able to demonstrate that you met that threshold.
What do I do if the numbers are correct but the impression they convey is misleading?
The numbers may give your patients or the public the impression that you are making a lot more money from Medicare than others in your specialty or than you are taking home. Reasons for this may include:
- Others bill under your provider ID, such as physician assistants or nurse practitioners.
- You have been categorized incorrectly and actually practice in a different specialty or subspecialty than the one listed.
- You provide expensive drugs or other services that you pay for, such as chemotherapy drugs.
- Fee-for-service Medicare patients make up a larger-than-average portion of your practice. (You don't see many patients covered by Medicare Advantage, commercial health insurance, or other programs.)
- Your particular patient population is sicker than average because you are a subspecialist or otherwise handle more complex patients.
- Your overhead is substantial. The public generally has no idea that most physicians spend 50 percent or more of their gross income on staff, rent, equipment, supplies, health information technology, professional liability insurance, licenses, certifications and continuing medical education, education loans, etc.
You may want to develop an explanation you can share with your patients, referral sources, managed care plans, regulators, or the press that puts this information in perspective. To the extent the data demonstrate your extensive experience with a particular procedure, you may want to point that out. You also can reference the things that make your practice stand out, such as state-of-the-art equipment, foreign language competencies, and extended hours.
You also may want to take this opportunity to highlight your professional qualifications, such as successful participation in the government's e-prescribing, electronic health record meaningful use, or Physician Quality Reporting System programs. Finally, take this opportunity to review your profile on CMS's Physician Compare website. Make sure that site contains your up-to-date demographic information and correctly reflects your accomplishments.
What should I do if my numbers concern me?
Use this opportunity to compare your data with your peers. While it may be justifiable for a physician to be an outlier, there is no question that outlier status invites scrutiny. These publicly available spreadsheets have dramatically upped the stakes. Experts who have analyzed the entire public database can tell you where you rank by specialty and locality and whether your data raise particular red flags. You owe it to yourself to know where you stand and take charge of your profile.
Catherine I. Hanson, JD, is of counsel, Whatley Kallas LLP. For more information, contact the Whatley Kallas attorneys at (800) 745-8153 or email email@example.com.
Notice: The information provided in this article constitutes general commentary and information on the issues discussed herein and is not intended to provide legal advice on any specific matter. This article should not be considered legal advice, and receipt of it does not create an attorney-client relationship.