Some Illinois doctors billing Medicare top rate

A Melrose Park pain specialist charged Medicare the highest rate allowed for more than 80 percent of her established patients' office visits in 2012, government records show.

That same year, a Chicago Heights internist classified every single patient visit at the same highest rate, which Medicare says is reserved for the most intense and complex doctor/patient consultations.

Another south suburban doctor, who treats cancer patients, billed the government for nearly 3,600 of these so-called level 5 visits, which typically require 40 minutes or more of interaction and can involve multiple diagnoses, a comprehensive physical examination or intense counseling. That was twice the number of high-cost visits billed by the second-ranking physician in the state.  

While reimbursement for these complicated visits comprised less than 2 percent of Illinois' Medicare physician payments in 2012 — accounting for a little less than $50 million — these health care professionals belong to a small group of 400 across the state who billed the federal government at the highest rate for at least 70 percent of cases that year, according to a Tribune analysis of federal data.

Those outliers are "an absolute red flag," said Dr. Joel Shalowitz, director of the Health Industry Management Program at Northwestern University's Kellogg School of Management and the managing partner of a 20-physician primary care group in the northern suburbs.

These complex and expensive visits are rare enough that the vast majority of Illinois doctors did not seek to be paid for a single one in 2012. Of the 18,600 doctors who billed Medicare for a regular office visit for an established patient, fewer than 5,000 of them billed for the most-expensive category of visits, also known as a level 5.

The Tribune findings mirror national findings reported last week by ProPublica, a nonprofit investigative journalism group that shared its research with the Tribune.

The data has limitations: Doctors and health care providers say it lacks context and can be misleading without more information about their individual practices and the types of patients they treat.

But it provides a window into the vast disparities in how physicians operate their practices and how they characterize — and are paid for — the time they spend with patients.

The office visit information is part of a trove of records released last month by the federal Centers for Medicare & Medicaid Services, which detailed for the first time how doctors bill the federal health program for seniors and the disabled.

By releasing the reports, the government said it hoped to provide more transparency about a program that ranks among the nation's largest spending items, so that consumers and businesses can make better decisions on where to spend their health care dollars.

Even for patients not covered by Medicare, the data provide a valuable tool that consumers, health insurance companies, large employers and anyone else who pays for health care services can use to evaluate doctors' billing patterns to ensure they're not being overcharged.

"If physicians are doing this for Medicare, there's no reason to believe they're not doing it to private insurance," said Shalowitz, who reviews billing for his physicians' group. The practice Shalowitz was referring to, called upcoding, is an issue he encounters often in his dealings with other physicians' groups.

Such information also could take on growing importance as insurance companies and employers continue to shift more of the health spending burden to consumers via high-deductible health plans.

Instead of paying nominal copayments for office visits and other procedures, people with such plans must meet a set amount of out-of-pocket spending before their insurance benefits kick in, meaning they're often paying full freight for office visits.

With regard to office visit billing patterns, federal law enforcement officials already have taken notice. In a partnership with the U.S. Justice Department, the Department of Health and Human Services in 2009 launched a special task force that focuses solely on health care fraud.

In fiscal year 2012, the last year for which complete data were available, the government recovered a record $4.2 billion related to health care fraud and abuse, according to federal data. The same year, Medicare began screening all 1.5 million providers enrolled in the program to identify those who were ineligible or potentially committing fraud.

Scrutiny of office visit data was a factor in the decision to bring charges against a small central Illinois neurology, pain and sleep center, records show.

Dr. Naeem Kohli, a neurosurgeon based in Effingham, was indicted earlier this year by a federal grand jury for allegedly defrauding the government and an insurance company by billing for services he did not provide.

Among other things, investigators pointed to Kohli's frequent reimbursement for level 5 office visits, according to the indictment.