Are You Taking a Peek at Your Neighbor?

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Original story posted on: November 29, -0001

Do you know how much your healthcare “neighbors” charge? Can you believe the kind of fraud that is going on?

The recent release by the Centers for Medicare & Medicaid Services (CMS) of the 2012 Medicare Physician Payment Data has generated a lot of buzz in the popular media as well as the trade media. The professional statisticians (think RACmonitor contributing columnist and mathematician Frank Cohen) have downloaded the massive data file, converted it into a robust database, and are busy running algorithms. The rest of us amateurs are left to peek at the data through one of the portals, such as the Wall Street Journal’s Medicare Payment to Providers 2012.

Have you been there yet? Who did you look up? A colleague, a competitor, your primary care physician? Or perhaps your physical therapist or favorite ambulance company? Physicians and ancillary providers alike, if they billed Medicare in 2012, likely are all there.

If you haven’t been there yet, start a list, because it could get fun – maybe even interesting, or perhaps infuriating. A colleague of mine couldn’t resist tinkering and could not stop for even a second after she started looking at the top-billing physical therapists. She wrote a blog post, using her deductive reasoning, causing those of us in the know about therapy treatment, coding, and billing to wonder and pause about a number of things. But then again, on a weekend Twitter chat, a few individuals challenged some assumptions. Then, quickly, a second blog post followed. So infuriated was she that her browser quickly opened up Google Earth, taking a deep, deep dive to the address of the top billing therapist – and there she caught a nice shot of the strip mall where the therapy clinic was located, smack dab in the middle of a pharmacy and a paint store. In disbelief, the next check was to the state board of regulation to determine if the named therapist had a valid license to practice (maybe he had been disbarred?) And indeed, a license to practice was still in good standing. The last line of her post was a rhetorical question: Who should I contact, the FBI, OIG, or the Medicare Fraud line?

One thing we do know about the data – it is telling us how much a provider bills (charges) and how much the provider is reimbursed, per the Medicare Physician Fee Schedule for 2012. What we don’t’ know is whether the data is accurate. For this top-billing, $4 million therapist, do we know if all providers at the clinic billed under one number? Or was there only one provider billing all of the $4 million to Medicare? The data can’t tell us that. But I guess that like many top billing specialists, they clearly are now on the radar screens of auditors.

According to a recent CMS press release, this “new data set has information for over 880,000 distinct healthcare providers who collectively received $77 billion in Medicare payments in 2012 under the Medicare Part B Fee-For-Service program.” CMS further explained that with this data, “it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual healthcare providers.”

Are you ready to start peeking at your neighbors? Head on over to the CMS website, pick up the data set, and start exploring. And stay tuned to Monitor Monday, as we will continue to explore and conduct deep data dives ourselves.

About the Author

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practice. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Monday where she serves as a senior national correspondent.

Contact the Author

nancy@nancybeckley.com

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Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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