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.
The government alleges that Kohli "indiscriminately" prescribed oxycodone and other controlled substances and "spent little or no time with the patient" during those visits, according to the 15-count indictment handed down in March.
Kohli billed for such office visits more than 75 percent of the time in 2012, far outpacing his peers in Illinois, according to federal data. The average neurosurgeon in the state billed Medicare for those visits just 5 percent of the time, and records show that Kohli alone was responsible for submitting half of the most expensive office visits among all Illinois neurosurgeons in 2012.
Kohli now awaits trial in federal court. He said through an attorney that he plans to dispute the charges. His practice remains open, and it continues to see patients. The state has opened its own investigation, said Sue Hofer, a spokeswoman for the Illinois Department of Financial and Professional Regulation.
Medicare uses the five-level system to determine how much to reimburse doctors for office visits by established patients. The guidelines for choosing a level of care are based on a range of criteria.
Low-end, or level 1, visits involve a quick evaluation of a patient that takes about five minutes and may not even require a physician to be present. A case coded as level 5, on the other hand, generally represents at least 40 minutes spent examining a patient and is reserved for the most complex medical cases.
Most Illinois providers bill most frequently for level 3 office visits, which deal with medical problems of low or moderate severity. Overall, they represented 44 percent of visits and align with percentages nationally, according to the Tribune analysis.
Dr. Robert L. Wergin, president-elect of the American Academy of Family Physicians and part of a nine-doctor practice in rural Nebraska, said most office visits should fall between level 2 and level 4.
Level 5 visits, he said, usually are used when he spends an hour or more with a patient who has multiple complex medical issues. That time is spent doing an extensive medical history on a patient, interpreting lab results, reading X-rays, conducting intensive physical examinations, and counseling and consulting, Wergin said.
"To me, it's someone who really has taken a lot of work. It's not just someone with a sore throat," he said. "With level 5s, I'm really trying to decide if I can let this person go home to some sort of supervision … or whether they need to be admitted" into a hospital.
The higher the intensity of the visit, the higher the reimbursement. In Illinois, the difference is between making $50 for a level 3 office visit or $100 for a level 5, on average.
Effectively doubling a reimbursement can add up quickly — regular visits for established patients are among the most frequently billed to the government by doctors nationwide. CMS paid Illinois doctors for 9.1 million of them in 2012, at a total cost of more than $500 million.
These regular office visits made up about one-sixth of the $3.4 billion Illinois providers were reimbursed that year, records show.
A much smaller group of nearly 200 Illinois doctors billed exclusively level 5 visits. Of those, 85 were doctors who reported providing at least 100 regular office visits that year.
Dr. Charlotte Mitchell, a Chicago Heights internist, classified each of her 961 Medicare patient office visits in 2012 as level 5 visits.
Of the nearly 2,800 Illinois internists in Medicare's payment data with more than 100 office visits in 2012, Mitchell is one of six who billed exclusively for level 5 care. The average internal medicine doctor billed Medicare for level 5 visits about 5 percent of the time.
Over the course of the year, Mitchell saw nearly 200 Medicare patients an average of five times for these high-level visits, at a total cost of roughly $100,000.
Mitchell said she's "just trying to take care of my patients," and noted that most of them take longer to properly treat because they have multiple medical problems like diabetes, hypertension, heart disease and chronic obstructive pulmonary disease.
"I schedule my patients for every 30 minutes, and I'm never on time," she said. Her appointments "spill over many times, just because I'm trying to take proper care" of patients.
She said she bills Medicare based solely on the time she spends with patients and the complexity of those visits.
"I think I'm doing the right thing," Mitchell said. "I certainly don't want to start taking worse care of my patients, cutting them off because I'm worried about the numbers."
The American Medical Association, which for years has fought the release of doctor-specific data, cautioned that billing data viewed in isolation can be misleading, particularly because seniors tend to require more intensive care to treat a variety of chronic and complex medical conditions.
But other health industry leaders called some billing patterns troubling.
"I can't see a situation where every visit would be a level 5, especially on an established patient," Cyndee Weston, executive director of the American Medical Billing Association, an industry trade group, told ProPublica. "I was trying to talk myself into it, but I just can't see it."
A variety of government and private research shows that physicians are billing for more expensive office visits more frequently than in the past. The share of level 4 routine visits jumped by 15 percentage points from 2001 to 2010, while level 3 visits dropped by 8 points, according to a 2012 Department of Health and Human Services report.
That report also recommended Medicare conduct more detailed reviews of doctors who bill for more higher-level visits, but Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner balked, only committing the agency to reviewing a small number of the highest billers in different regions of the country.
A key reason, she said, is the lack of return on investment for reviewing billings for office visits. The average error cost Medicare $43, but the program paid $30 to $55 to review each claim.
Another report, released last year by Medicare, estimated that established patient visits had a 7 percent improper payment rate, accounting for about $965 million in 2012.
Still, it's impossible to determine whether a physician used the proper code for an office visit based on the Medicare data alone, Shalowitz said. "The only way you know is if you actually have all the information on the patient visit."
Dr. Refat Baridi, an oncologist with his main office at Pronger Smith Medical Care in Tinley Park, charged for the most level 5 visits among cancer doctors in 2012, eclipsing his closest peer in the field twice over.
While high charges are fairly common among cancer doctors who are providing expensive, complex and, at times, experimental treatments, more than 70 percent of Baridi's office visits were billed at level 5 in 2012, far outpacing the average of 13 percent among the many varieties of cancer doctors in Illinois, the Tribune analysis showed.
Baridi, who also was among Illinois doctors who received the most reimbursement from Medicare in 2012, receiving more than $5 million, said through a practice manager that the office visit data "is very encouraging."
"The data shows that, based on the complexity and volume of cancer patients we treat, we are in the top 15 percent of our peer groups," said Brian Wydra, the practice's manager. "I'm confident there is no upcoding going on; we subject ourselves to in-house audits, so we're very confident."
Another outlier in Illinois was Shobhana Patodia, a pain management specialist and owner of the Forum Pain Management Clinic in Melrose Park. She accounted for roughly 95 percent of the level 5 visits billed to Medicare among Illinois providers in her specialty, the Tribune found.
Among pain management specialists nationwide, she billed for more of those visits than all but one doctor.
In 2012, Patodia charged about 4 in 5 of these regular visits as the most medically complicated or time-consuming and was paid roughly $185,000 for those visits.
Moreover, she billed for her established Medicare patients at the level 5 rate an average of 6.5 times over the course of the year, records show.
Patodia could not be reached for comment.
In a statement, the federal Centers for Medicare & Medicaid Services said it "is working to ensure that physicians and health care providers appropriately bill" for office visits. It also said "it would be highly unusual for a provider to knowingly use the highest … billing code for all or nearly all of his or her outpatient visits."
ProPublica contributed.Copyright © 2015, CT Now