4/15/14

Health Care Alert: Speculation on Potential Fall-Out Begins as CMS Releases Medicare Physician Payment Data

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On April 9, 2014, following the release of an injunction against the disclosure of the information, Centers for Medicare and Medicaid Services (CMS) posted all Medicare provider and utilization data (data) on its website.  The data reflects that in 2012, more than 880,000 providers billed $252.4 billion in charges and received $77.4 billion in payments.  CMS released the data to increase transparency. The information allows consumers to see aggregate amounts paid to physicians, as well as the types and numbers of procedures billed. 

Initial media reports focused on specific physicians who topped the lists for payments, including a Florida ophthalmologist who received $21 million.  Reports also focused on physicians high on the list who had previously been indicted for fraud.  However, a number of physicians found themselves defending their payments under media scrutiny, including many in specialties involving complex care, such as radiation oncology.  Some physicians high on the list indicated that payments made to multiple doctors in their practice were recorded under their name, leading to the appearance that they were receiving a large amount of money, when in fact, they were not. 

The American Medical Association (AMA) has been critical of the release of this data, stating that examining it without context could lead to misinterpretations and false conclusions. 

Importantly, the release of this data comes on the heels of the recent implementation of the Physician Payments Sunshine Act.  The Sunshine Act, enacted as part of the Affordable Care Act, requires disclosure of financial compensation paid to physicians by the pharmaceutical and medical device industries.  Click here to read a client alert on the Sunshine Act.

Notably, the release of this data may fuel compliance and reimbursement audits and fraud investigations at the federal and state levels.  The data may also provide additional information to potential whistleblowers (often, disgruntled current and former employees) who suspect fraudulent activity, but previously did not have access to related records.  Although recent data released by CMS is directed at physicians, such release is undoubtedly part of a larger government effort to reduce Medicare and Medicaid overpayments across all provider types.