In some instances, though, those figures reflect the high price of drugs administered and not fees that go to the provider, said one top-billing physician.
The Centers for Medicare & Medicaid Services released the Part B data last week in a “huge step” toward greater transparency for how Medicare pays for services, said Jonathan Blum, the principal deputy administrator.
The $77 billion in payments were only for Medicare’s traditional fee-for-service program and did not include Medicare Advantage patients. It also did not list a service for a provider if there were fewer than 11 charges for that service to avoid providing any patient-identifying information.
“It provides much greater transparency on what the Medicare traditional program is paying for through our physician payment system,” Blum said. “For too long, this information was not made public. It was protected, which raised many questions on what the program was spending, how it was spending and the value being provided to the program’s beneficiaries.”
With its release, the public, which has a right to know, might spot anomalies that the agency should pay attention to, he said.
“We know that there is waste in the system,” Blum said. “We know that there is fraud in the system. And while we have made tremendous new investments to reduce that waste, to reduce that fraud we want the public’s help, we want reporters’ help to identify spending that doesn’t make sense, that appears to be wasteful, that appears to be fraudulent.”
In the Augusta area, the $123.7 million in payments went to 15,763 providers and covered more than 1.1 million services.
The largest single amount – more than $4.4 million – went to Gold Cross EMS, but came from nearly $11 million in charges submitted and covered 16,455 patients, an average of $269 per patient, according to the Chronicle analysis.
The ambulance service ends up appealing about a quarter of all its denied claims when Medicare decides a service wasn’t medically necessary, said CEO Vince Brogdon.
“We’ve run 911 calls where the patient was unresponsive and Medicare will deny the claim and say, ‘Patient could have gone by other means,’ ” he said. “How are they supposed to go by other means, and they are unresponsive?
“(Medicare is) one of our top sources (but) Medicare is only going to pay a certain percentage.”
Gold Cross collects payments from only about 30 percent of patients, he said.
The city of Augusta had been paying a $1.08 million annual subsidy to defray the cost of ambulance service, but when the contract was renegotiated, Gold Cross agreed to a reduction of $400,000 over the life of the three-year contract – with reductions of $120,000 the first year, $130,000 the second and $150,000 the third, Brogdon said.
“We were asked to see if we could come off some on the subsidy,” he said. “We felt that we cut as much as we could.”
Other ambulance providers were in the top five for payments in Augusta. Regional Services Ltd. got $2.7 million, and Capital City Ambulance of Georgia got just under $2 million.
Eight physicians listed at Augusta Vascular Center received a total of just over $7 million, according to the data. The center did not return a call seeking comment Friday. Eye Surgery Center of Augusta received just over $2 million, and five of its physicians were listed as receiving $2.6 million total, but it was unclear if those were different payments.
The center also did not return a call seeking comment Friday. Many Augusta physicians leave town during the week of the Masters Tournament.
Blum acknowledged that ophthalmologists and oncologists will appear higher on the payment list because by law, Medicare is required to bill for very expensive drugs that those specialties use through the Medicare Part B program, which then appears as payment.
“The reason why ophthalmologists and oncologists are high relative to other physician specialties is due to the payment system for those drugs,” he said.
That can make it appear that a lot of money is going to the ophthalmologist, when in fact the physician had to buy the very expensive drug first, maintain and store it, and then get reimbursed for about that amount from Medicare, said Dr. Dennis Marcus, of the Southeast Retina Center, who was listed as receiving $1.35 million.
“It is misleading because these are pharmaceutical profits and not physician payment profits,” he said. “The profit margin is negligible with regard to even doing it.”
In fact, ophthalmologists have lobbied to have it separated out as drug costs, but to no avail, Marcus said.
“Obviously, the drug lobby is a lot stronger than the physician lobby,” he said. “If there are concerns from the public with regard to the amount of money being spent, it really relates to the approval of drugs at those prices in this country, compared to other countries.”
Still, ophthalmologists are glad to administer those drugs if they help patients, Marcus said.
“All of these drugs are wonderful,” he said. “They save vision, and that’s what we do and fight to do every day is to save vision.”