Overbilling Medicare for office visits remains a problem

Male doctor in white lab coat
Some doctors continue to bill Medicare for office visits at the highest, most expensive level most of the time. (Getty/Saklakova)

Some doctors are still billing Medicare for the most expensive office visits most of the time, according to one analysis, a suspect practice that the feds have been fighting for years. 

The overbilling or upcoding for evaluation and management services has changed little from 2012 to 2015, according to a ProPublica report that analyzed data from the Centers for Medicare & Medicaid Services on services provided by and payments made to providers under Medicare’s Part B program in 2015.

The Office of Inspector General has long warned that doctors are responsible for billing Medicare at appropriate levels for office visits. 

And this kind of fraudulent billing does get doctors into legal trouble. An anesthesiology practice in New York agreed to pay almost $2 million in 2017 to resolve claims that it improperly billed for services that require a physician to spend at least 16 minutes face-to-face with a patient, for example.

But a small percentage of all physicians consistently bill at higher levels for office visits: Some 1,825 providers billed Medicare for the most complicated and expensive office visits at least 90% of the time, the report said.

That number has changed little since 2012, when 1,807 health professionals billed for office visits at level 5—indicating a visit that involves more intense examination and consumes more time—that frequently.

The numbers are indicative of a problem, Dwayne Grant, a regional inspector general for evaluation and inspections for the U.S. Department of Health and Human Services in Atlanta, told ProPublica.

While it’s possible that some doctors may treat only the sickest patients who require the highest-level office visits, Grant said that was not “very probable.”

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A CMS spokeswoman told ProPublica the agency is exploring how to update its billing rules for office visits.

Cyndee Weston, executive director of the American Medical Billing Association, told ProPublica that electronic health records that assign billing codes based on the computer boxes doctors click during office visits could be part of the problem, especially if doctors are cutting and pasting notes. 

“Those programs tend to upcode,” 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.”