Doctors Abusing Medicare Face Fines and Expulsion

Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services, testifying on Capitol Hill last fall.


WASHINGTON — The Obama administration is cracking down on doctors who repeatedly overcharge Medicare patients, and for the first time in more than 30 years the government may disclose how much is paid to individual doctors treating Medicare patients.
Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services, said that “recalcitrant providers” would face civil fines and could be expelled from Medicare and other federal health programs.
In a directive that took effect on Jan. 15 but received little attention, Ms. Tavenner indicated that the agency was losing patience with habitual offenders. She ordered new steps to identify and punish such doctors.
A recalcitrant provider is defined as one who is “abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.” Cases will be referred to Daniel R. Levinson, the inspector general at the Department of Health and Human Services, who has authority to impose civil fines and exclude doctors from Medicare, Medicaid and other programs.
Federal officials estimate that 10 percent of payments in the traditional fee-for-service Medicare program are improper. That would suggest at least $6 billion a year in improper payments under Medicare’s physician fee schedule. But Malcolm K. Sparrow, a Harvard professor and an expert on health care fraud, has said the losses could be greater because the official statistics “fail to accurately capture fraud rates” in Medicare.
A new section of the Medicare manual encourages the use of fines to penalize doctors who generate a pattern of claims for goods and services that they know or “should know” are not medically necessary. Providers can also be barred from Medicare if they bill the program for “excessive charges” or for services substantially in excess of patients’ needs.
In a new report, Mr. Levinson said Medicare officials and contractors should focus on doctors with the highest Medicare billings because they often received improper payments. He said that about 300 doctors received more than $3 million each in yearly Medicare payments and that one-third of them had been singled out for special reviews because of questionable billings.
Mr. Levinson recommended that Medicare officials “establish a cumulative payment threshold” and closely examine claims filed by any doctor whose total exceeded that amount.
Ms. Tavenner, the top Medicare official, said, “High cumulative payments are not necessarily indicative of improper payments or fraud,” but she accepted the recommendation. “Reviewing claims from providers with high cumulative payments could be a valuable screening tool,” Ms. Tavenner said, and it may be appropriate to set the threshold at different levels for doctors in different specialties.
Most of the high-billing doctors specialize in internal medicine, radiation oncology or ophthalmology, investigators said.
Carrie Valiant, a lawyer who represents health care providers, said the new enforcement policy showed what she described as the administration’s “propensity to throw providers out of federal health care programs, rather than work with them to correct mistakes” in billings and claims.
In many cases, Ms. Valiant said, federal investigators assert that a service was medically unnecessary when the real problem was that a doctor or a hospital did not adequately document the need for it.
In a related action, the Obama administration this month scrapped a policy that broadly prohibited the release of federal data showing how much Medicare paid individual doctors each year. The administration said it would consider releasing payment data in response to Freedom of Information Act requests.
The policy, which goes into effect on March 18, says Medicare officials will, in each case, “weigh the balance between the privacy interest of individual physicians and the public interest in disclosure of such information.”
Thomas S. Crane, a lawyer who used to work at the Department of Health and Human Services, said, “The Medicare payment data, combined with data from other sources, could be enormously useful to consumers, researchers and whistle-blowers analyzing patterns of health spending.”
In 1979, a federal district judge in Jacksonville, Fla., issued an injunction that prohibited Medicare officials from divulging payments to individual doctors. The ruling, in a lawsuit filed by doctors, said such disclosures would violate the Privacy Act and “constitute a clearly unwarranted invasion of personal privacy.”
But in May last year, the judge now handling the decades-old case, Marcia Morales Howard, lifted the injunction. Her decision does not require the wholesale release of Medicare payment data but allows Medicare officials and courts to consider the merits of each request.
Consumer advocates, journalists, insurers and employers are urging the administration to release as much data as possible, saying it could help them evaluate providers and spot abusive billing practices.
“The compelling need for public access to physician data far outweighs privacy concerns of physicians,” said David M. Certner, legislative policy director of AARP, the lobby group for older Americans.
Doctors are urging the administration to proceed with caution.
“The unfettered release of raw data could easily result in inaccurate and misleading information that could ultimately undermine the quality of care for patients,” the American Medical Association and other physician groups wrote to Medicare officials.
The American Society for Radiation Oncology said it feared that the Medicare payment data would give a distorted picture, not showing “the substantial expenses associated with operating a radiation oncology clinic.”