Wednesday, April 23, 2014

How much does Medicare pay your Physician?

A couple of weeks ago the federal government released some disturbing data figures regarding Medicare pay-outs to Doctors. The Wall Street Journal examined many of the issues now being hotly debated in Washington and around the country. You can review the article here:   

In an effort for more transparency, The Obama Administration shared this previously unreleased data based on 2012 reimbursements to over 880,00 health care providers. These payments totaled in excess of $77 billion. Note, the data reflects only Part B Medicare payments which includes doctor visits, lab tests and other treatments provided outside a hospital that encompassed surgical procedures, chemotherapy and radiation treatments performed by physicians.  If you add what Medicare paid directly to providers, and any additional money they received from patients for deductibles and coinsurance this brings the total payout to providers to $99 billion.

Reimbursements varied by physician specialty and geographically.  While no personal patient information was disclosed in the release, you can see the list of all physicians reimbursed and their respective amounts here: 

Reimbursement by specific states is also available:

The two highest paid doctors are already under government review for suspected improper billing. One is a Florida ophthalmologist who received in excess of $26 million, more than 61 times the average for that specialty, to treat fewer than 900 patients; and the other is a Florida cardiologist who received $23 million which was 80 times the average amount for that specialty. 

So, what can we deduce from this data?  

The obvious conclusion appears this is an excellent way to identify fraud and abuse in terms of excessive and unnecessary billing.  However, this may not be a correct assumption in all cases.  According to Jonathan Blum, Medicare's principal deputy administrator, "providing consumers this information will help them make more informed choices about the care they receive."  The physicians with some of the highest reimbursements, notably ophthalmologists and radiation oncologists, contend that the reimbursements relate to very high overhead due to the cost of drugs administered to patients, and the high cost of equipment used to treat patients. Larger reimbursements may also mean that these providers have sicker patients, that they specialize in complex care or that their practice is heavily skewed toward Medicare patients.

A more comprehensive take-away from these startling numbers is that health care costs continue to surge AND there's on-going fraud in the system. Both issues need to be seriously addressed by Congress, and soon.  Remember, ObamaCare primarily addresses ACCESS and not system reform. Unfortunately, Washington lawmakers continue to singularly focus on the costs of the government run system; rather than seeking a solution to curbing actual health care costs and re-forming medical billing practices. Until this issue resolves, it doesn't matter how many people sign up under the ACA and maintain health insurance. Without developing a more effective method to lower costs within the system, financial waste and misappropriation of funds will certainly continue.

The only certainty remaining is that patients must always be diligent. Every bill received from a provider, along with every explanation of benefits received from an insurance company should be thoroughly scrutinized.  Do not accept at first glance these amounts are correct.  Don't be afraid to question a bill. Double-check you received the actual charged service on the date posted and that the insurance company paid the appropriate amount.  Understanding your benefits is key to understanding whether you were reimbursed and/or charged properly.   If you are not able to do this on your own, there is help available from professionals, like myself, whose job is to review your claims and advocate on your behalf. Most people don't even realize they've been charged incorrectly or received improper reimbursements.  Bottom line, you should only pay what you truly owe. The problem is often identifying what that amount actually is, and that is not always so transparent. 

Stay Informed. Stay Positive. Stay Healthy.
The Patient's Advocate
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