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ProPublica: Some Doctors Still Billing Medicare for the Most Complicated, Expensive Office Visits

In case you missed it: Not Massachusetts based but worth noting.

From ProPublica. Used by permission.

by Charles Ornstein and Ryann Grochowski Jones

 Dec. 27, 2017

In case you missed it: Not Massachusetts based but worth noting.

Thousands of times a year, Medicare patients file into Dr. Mark Roberts’ family practice clinic in rural Evergreen, Alabama, for standard office visits.

And almost every time they did in 2015, Roberts billed Medicare for the most complex, and most expensive, type of office visit — one that typically takes 40 minutes and for which Medicare reimbursed him an average of $94. He billed for 4,765 such high-level visits that year, according to federal data, more than any other doctor in the country. And for that, he collected nearly $450,000 from Medicare.

Roberts’ billing pattern was highly unusual compared to his peers. All told, family medicine doctors in Alabama billed for such visits only 5 percent of the time. Roberts did so 95 percent of the time. Even some doctors who had sicker patients billed for top-level visits less often, Medicare data show. Several messages left at Roberts’ office were not returned.

For years, internal government watchdogs have been warning the federal Medicare program that some doctors were overcharging for office visits. And for years, federal health officials have been promising to focus on the problem.

But a new ProPublica analysis shows very little has changed since we first wrote about the issue in 2014. ProPublica found that 1,825 health professionals, including Roberts, billed Medicare for the most expensive type of office visits for established patients at least 90 percent of the time in 2015. That was almost the same as the 1,807 that we found based on 2012 data. Some physicians that were billing Medicare this way in 2012 still were in 2015, we found.

Office visits are a staple of medicine. In 2016, Medicare paid for more than 227 million of them at a cost of $13.2 billion (including Medicare outlays and patient copayments). They are far from the most expensive services that Medicare provides, but they are ubiquitous.

While it’s possible that some physicians only treat the sickest patients who require the highest level office visits, “I don’t think it’s very probable,” said Dwayne Grant, regional inspector general for evaluation and inspections for the U.S. Department of Health and Human Services in Atlanta. Grant’s team produced reports in 2012 and 2014 that said Medicare needed to do more to address improper billing.

“We continue to believe that focusing on these high-coding physicians is going to improve oversight, reduce overpayments and really serve as a deterrent effect,” he said.

Among the 1,825 physicians who billed most often for complex office visits was Dr. Jose Prieto, an internist in Hialeah, Florida. He billed for 721 office visits in 2015, all of them at the highest level, Medicare data show. Medicare revoked Prieto’s ability to participate in the program in December 2016 for “falsified information,” according to data provided under the Freedom of Information Act.

Prieto did not respond to a phone call and email seeking comment. A woman who returned a call placed to his office said Prieto is an infectious disease doctor who treats patients with HIV and routinely spends 45 minutes with each patient. The woman disputed that Prieto exclusively bills for the highest level office visits, as Medicare data shows. “He bills for the time he spends with his patients,” she said.

Another is Dr. James Beale, an orthopedic surgeon in Warren, Michigan. All 1,150 of his Medicare office visits were billed at the highest level in 2015. Beale has been disciplined three times by Michigan’s medical board, most recently in May 2016 when he was suspended for failing to respond to a 2015 board complaint that he prescribed controlled substances for patients without adequate justification. Beale also extensively billed Medicare for psychotherapy services in 2015. He could not be reached for comment.

Also on the list is Dr. Rand Ritchie, a Pismo Beach, California, psychiatrist. He billed 1,475 visits at the highest level, or 97 percent of his Medicare office visits, in 2015. The California medical board has disciplined Ritchie twice for alcohol abuse and multiple convictions for driving under the influence of alcohol. He completed probation most recently in 2014 and currently has an unrestricted license.

Ritchie’s office manager, Darryl Schumacher, who handles billing for the practice, said Ritchie had started accepting Medicare around 2015 because no other psychiatrists in private practice in the area did so. “He was taking on many new patients and the complexity of some of these patients, because they had either gone without treatment for many years or had gone without a psychiatrist, was pretty difficult at the beginning,” Schumacher said.

Schumacher also said that no one from Medicare had contacted the practice to ask about Ritchie’s numbers and that questions from ProPublica were the first indication that his billing pattern was unlike that of his peers. As for his discipline, Schumacher said Ritchie fulfilled the requirements of his probation and is once again board certified in psychiatry.

Asked for comment, a spokeswoman for the Centers for Medicare and Medicaid Services said the agency is exploring how to make changes to its billing rules for office visits to reduce the burden on doctors and better reflect the way medicine is practiced and care is coordinated.

In a notice in the Federal Register in November, CMS said the guidelines governing how health professionals bill for office visits, more formally called Evaluation and Management visits, date to 1995 and 1997. CMS said the process for updating them could take several years.

As it stands now, doctors and their staffs decide how to bill for a patient visit based on a host of factors, including how thoroughly they review a patient’s medical history, the intensity of the physical exam and how complicated the medical decision-making was. The coding system developed by the American Medical Association gives doctors five options.

An uncomplicated visit, typically of short duration and which may not require a physician, is coded a “1”; a visit that involves more intense examination and often consumes more time is coded a “5.” The most common codes for visits are in the middle, “3” and “4.”

Most health professionals had a tiny percentage, if any, visits billed at level 5, but more than 1,250 billed only at the highest level in 2015, ProPublica found. Another 570 billed that way more than 90 percent of the time. That was very similar to what we found three years earlier.

Cyndee Weston, executive director of the American Medical Billing Association, an industry trade group, said such numbers raise red flags. “It’s not likely that every patient that comes to a doctor’s office is a level 5,” she said.

The doctors who billed at the top level in 2015 were not all the same as those who did so in 2012. Of the 1,825, 650 were on the list in both years. Another 536 billed for a lesser share of visits at the highest level in 2012. And the remaining health providers did not bill Medicare in 2012 for office visits involving at least 11 patients.

For some doctors, the shift was jarring.

In 2012, Roberts, the Evergreen, Alabama, family doctor, never billed for high-level office visits. He billed Medicare 4,681 times for level 3 visits, for which Medicare paid him an average of $43.57, less than half as much as he received per visit in 2015.

In Oak Harbor, Washington, doctors Robert Lycksell and Zayan Kanjo also didn’t bill for level 5 visits in 2012. Lycksell billed for 1,948 level 5 visits in 2015 and Kanjo 1,297 in 2015. The doctors did not return phone calls seeking comment.

Weston said it’s “disappointing” that the same problems identified years ago appear to remain today. Some of what’s happening, she said, is related to electronic medical record systems that assign billing codes based on the computer boxes doctors click during office visits.

“Those programs tend to upcode,” meaning to bill at a higher level than justified, Weston said. If doctors copy and paste phrases about a patient’s condition and their electronic medical record automatically decides how to bill for the visit, “that is worrisome.”

How We Did This Analysis

For this story, ProPublica analyzed provider billing patterns for standard office visits in Medicare. We focused on those for established patients who had been seen at least one time by the provider previously. These are among the most common services performed in the program.

We used data released by the Centers for Medicare and Medicaid Services showing the services provided by and payments made to providers in Medicare’s Part B program in 2015. Medicare redacted data on services when a provider billed for a service for fewer than 11 patients.

More than 490,000 providers billed the program for standard office visits for at least 11 patients in 2015.

Office visits are coded using the Current Procedural Terminology system devised by the American Medical Association and used by Medicare. The severity of each visit depends on three criteria: the thoroughness of the review of a patient’s medical history, the comprehensiveness of the physical exam and the complexity of medical decision-making involved.

An uncomplicated visit, typically of short duration, should be coded a 99211; a visit that involves more intense examination and often consumes more time should be coded a 99215. The most common codes for visits are in the middle, a 99213 or 99214.

To protect against variation hidden by redactions, we focused on the nearly 364,000 providers who billed for at least 100 standard visits in 2015.

We identified more than 1,250 providers who billed for every office visit using the 99215 code. We found another 570 providers who billed level 5 visits at least 90 percent of the time.

Filed under:

• Health Care

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As Trump Targets Immigrants, Elderly Brace To Lose Caregivers

Melissa Bailey, Kaiser Health News

Used by permission

BOSTON — After back-to-back, eight-hour shifts at a chiropractor’s office and a rehab center, Nirva arrived outside an elderly woman’s house just in time to help her up the front steps.

Nirva took the woman’s arm as she hoisted herself up, one step at a time, taking breaks to ease the pain in her hip. At the top, they stopped for a hug.

“Hello, bella,” Nirva said, using the word for “beautiful” in Italian.

“Hi, baby,” replied Isolina Dicenso, the 96-year-old woman she has helped care for for seven years.

The women each bear accents from their homelands: Nirva, who asked that her full name be withheld, fled here from Haiti after the 2010 earthquake. Dicenso moved here from Italy in 1949. Over the years, Nirva, 46, has helped her live independently, giving her showers, changing her clothes, washing her windows, taking her to her favorite parks and discount grocery stores.

Now Dicenso and other people living with disabilities, serious illness and the frailty of old age are bracing to lose caregivers like Nirva due to changes in federal immigration policy.

Nirva is one of about 59,000 Haitians living in the U.S. under Temporary Protected Status (TPS), a humanitarian program that gave them permission to work and live here after the January 2010 earthquake devastated their country. Many work in health care, often in grueling, low-wage jobs as nursing assistants or home health aides.

Now these workers’ days are numbered: The Trump administration decided to end TPS for Haitians, giving them until July 22, 2019, to leave the country or face deportation.

In Boston, the city with the nation’s third-highest Haitian population, the decision has prompted panic from TPS holders and pleas from health care agencies that rely on their labor. The fallout offers a glimpse into how changes in immigration policy are affecting older Americans in communities around the country, especially in large cities.

Ending TPS for Haitians “will have a devastating impact on the ability of skilled nursing facilities to provide quality care to frail and disabled residents,” warned Tara Gregorio, president of the Massachusetts Senior Care Association, which represents 400 elder care facilities, in a letter published in The Boston Globe. Nursing facilities employ about 4,300 Haitians across the state, she said.

“We are very concerned about the threat of losing these dedicated, hardworking individuals, particularly at a time when we cannot afford to lose workers,” Gregorio said in a recent interview. In Massachusetts, 1 in 7 certified nursing assistant (CNA) positions are vacant, a shortage of 3,000 workers, she said.

Nationwide, 1 million immigrants work in direct care — as CNAs, personal care attendants or home health aides — according to the Paraprofessional Healthcare Institute, a New York-based organization that studies the workforce. Immigrants make up 1 in 4 workers, said Robert Espinoza, PHI’s vice president of policy. Turnover is high, he said, because the work is difficult and wages are low. The median wage for personal care attendants and home health aides is $10.66 per hour, and $12.78 per hour for CNAs. Workers often receive little training and leave when they find higher-paying jobs at retail counters or fast-food restaurants, he said.

The country faces a severe shortage in home health aides. With 10,000 baby boomers turning 65 each day, an even more serious shortfall lies ahead, according to Paul Osterman, a professor at Massachusetts Institute of Technology’s Sloan School of Management. He predicts a national shortfall of 151,000 direct care workers by 2030, a gap that will grow to 355,000 by 2040. That shortage will escalate if immigrant workers lose work permits, or if other industries raise wages and lure away direct care workers, he said.

Nursing homes in Massachusetts are already losing immigrant workers who have left the country in fear, in response to the White House’s public remarks and immigration proposals, Gregorio said. Nationally, thousands of Haitians have fled the U.S. for Canada, some risking their lives trekking across the border through desolate prairies, after learning that TPS would likely end.

Employers are fighting to hold on to their staff: Late last year, 32 Massachusetts health care providers and advocacy groups wrote to the Department of Homeland Security urging the acting secretary to extend TPS, protecting the state’s 4,724 Haitians with that special status.

“What people don’t seem to understand is that people from other countries really are the backbone of long-term care,” said Sister Jacquelyn McCarthy, CEO of Bethany Health Care Center in Framingham, Mass., which runs a nursing home with 170 patients. She has eight Haitian and Salvadoran workers with TPS, mostly certified nursing assistants. They show up reliably for 4:30 a.m. shifts and never call out sick, she said. Many of them have worked there for over five years. She said she already has six CNA vacancies and can’t afford to lose more.

“There aren’t people to replace them if they should all be deported,” McCarthy said.

Nirva works 70 hours a week taking care of elderly, sick and disabled patients. She started working as a CNA shortly after she arrived in Boston in March 2010 with her two sons.

She chose this work because of her harrowing experience in the earthquake, which destroyed her home and killed hundreds of thousands, including her cousin and nephew. After the disaster, she walked 15 miles with her sister, a nurse, to a Red Cross medical station to try to help survivors. When she got there, she recounted, the guards wouldn’t let her in because she wasn’t a nurse. Nirva spent an entire day waiting for her sister in the hot sun, without food or water, unable to help. It was “very frustrating,” she said.

“So, when I came here — I feel, people’s life is very important,” she said. “I have to be in the medical field, just to be able to help people.”

The work of a CNA or home health aide — which includes dressing and changing patients and lifting them out of bed — was difficult, she found.

“At the beginning, it was very tough for me,” Nirva said, especially “when I have to clean their incontinence. … Some of them, they have dementia, they are fighting. They insult you. You have to be very compassionate to do this job.”

A few months ago, Nirva was injured while tending to a 285-pound patient who was lying on her side. Nirva said she was holding the patient up with one hand while she washed her with the other hand. The patient fell back on her, twisting Nirva’s wrist.

Injury rates for nursing assistants were more than triple the national average in 2016, federal labor statistics show. Common causes were falling, overexertion while lifting or lowering, and enduring violent attacks.

Nirva works with a soft voice, a bubbling laugh and disarming modesty, covering her face with both hands when receiving a compliment. She said her faith in God — and a need to pay the bills to support her two sons, now in high school and college — help her get through each week.

She started caring for Dicenso in her Boston home as the older woman was recovering from surgery in 2011. Like many older Americans, Dicenso doesn’t want to move out of her home, where she has lived for 63 years. She is able to keep living there, alone, with help from her daughter, Nirva and another in-home aide. She now sees Nirva once a week for walks, lunch outings and shopping runs. The two have grown close, bonding in part over their Catholic faith. Dicenso gushed as she described spending her 96th birthday with Nirva on a daylong adventure that included a Mass at a Haitian church. At home, Dicenso proudly displays a bedspread that Nirva gave her, emblazoned with the word LOVE.

On a recent sunny winter morning, Nirva drove Dicenso across town to a hilltop clearing called Millennium Park.

“What a beautiful day!” Dicenso declared five times, beholding the open sky and views of the Charles River. As she walked with a cane in one hand and Nirva’s hand firmly clasped in the other, Dicenso stopped several times due to pain in her hips.

“Thank God I have her on my arm,” Dicenso said. “Nirva, if I no have you on my arm, I go face-down. Thank God I met this woman.”

In addition to seeing Dicenso, Nirva works three shifts a week at a chiropractor’s office as a medical assistant. Five nights a week, she works the overnight shift, from 11 p.m. to 7 a.m., at a rehabilitation center in Boston run by Hebrew SeniorLife. CEO Louis Woolf said Hebrew SeniorLife has 40 workers with TPS, out of a total of 2,600.

It’s not clear how many direct care workers rely on TPS, but PHI calculates there are 34,600 who are non-U.S. citizens from Haiti, El Salvador, Nicaragua (for which TPS is ending next year) and Honduras, whose TPS designation expires in July. In addition, another 11,000 come from countries affected by Trump’s travel ban, primarily from Somalia and Iran, and about 69,800 are non-U.S. citizens from Mexico, PHI’s Espinoza said. Even immigrants with secure legal status may be affected when family members are deported, he noted. Under Trump, non-criminal immigration arrests have doubled.

The “totality of the anti-immigrant climate” threatens the stability of the workforce — and “the ability of older people and people with disabilities to access home health care,” Espinoza said.

Asked about the impact on the U.S. labor force, a DHS official said that “economic considerations are not legally permissible in TPS decisions.” By law, TPS designation hinges instead on whether the foreign country faces adverse conditions, such as war or environmental disaster, that make it unsafe for nationals to return to, the official said.

The biggest hit to the immigrant workforce that cares for older patients may come from another program — family reunification, said Robyn Stone, senior vice president of research at LeadingAge, an association of nonprofit groups that care for the elderly. Trump is seeking to scrap the program, which he calls “chain” migration, in favor of a “merit-based” policy.

Osterman, the MIT professor, said the sum of all of these immigration policy changes may have a serious impact. If demand for workers exceeds supply, he said, insurers may have to restrict the number of hours of care that people receive, and wages may rise, driving up costs.

“People aren’t going to be able to have quality care,” he said. “They’re not going to be able to stay at home.”

But since three-quarters of the nation’s direct care workers are U.S. citizens, then “these are clearly not ‘jobs that Americans won’t do,’” argued David Ray, spokesman for the Federation for American Immigration Reform, which supports more restrictive immigration policies. The U.S. has 6.7 million unemployed people, he noted. If the health care industry can’t find anyone to replace workers who lose TPS and DACA, he said, “then it needs to take a hard look at its recruiting practices and compensation packages. There are clearly plenty of workers here in the U.S. already who are ready and willing to do the work.”

Angelina Di Pietro, Dicenso’s daughter and primary caretaker, disagreed. “There’s not a lot of people in this country who would take care of the elderly,” she said. “Taking care of the elderly is a hard job.”

“Nirva, pray to God they let you stay,” said Dicenso, sitting back in her living-room armchair after a long walk and ravioli lunch. “What would I do without you?”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Monday night, rescheduled from earlier in March: #ConjoinedTwins: At the Crossroads of #Surgery, Medicine and Ethics.”

In order to separate these two babies, who were joined at the chest, one had to die. The doctors told their story to   a group of health writers last year. One detail stood out: when the babies were rolled into the operating room, each one was holding a rattle.

Free, but registration required. 

 

When should aging doctors retire? Does it depend on the doctor?

When should doctors retire? Depends on the doctor.

Two pieces about aging docs. One story from STAT, one column from the Globe.

 

From Medscape:

“There are many older physicians who have a wealth of experience and who are practicing very well, and the last thing on earth we want to do is discourage those physicians from continuing to practice,” Dr Dellinger said. Among the consequences of that, he added, would be worsening the physician shortage.

“On the other hand, the data are unequivocal that there is, on average, a reduction in cognitive and physical abilities with age…and we need to kindly encourage those who should be reducing their practice to do so,” he said.

According to the review, published online July 19 in JAMA Surgery, research shows that between ages 40 and 75 years, mean cognitive ability drops by more than 20%, but there is large variability individually. Dr Dellinger notes that although the journal is for surgeons, the review is meant for all physicians.