The Center for Public Integrity

Two senators introduced bipartisan legislation Wednesday that aims to crack down on fraud in federal health programs for the poor and the elderly.

The Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayer Dollars Act, introduced by Sens. Tom Carper, D-Del., and Tom Coburn, R-Okla., includes a provision that would require all prescriptions paid for by the Medicare Part D prescription drug plan include a valid physician identifier. That is currently not required.

In February, iWatch News reported that the use of invalid physician prescriber numbers is so common that the program cannot identify the top physician prescribers of oxycodone and Ritalin, two highly addictive drugs frequently trafficked on the street. The story also reported that some Medicare scammers have stolen the identities of dead physicians to bill Medicare for drugs under the plan.

In addition to requiring valid prescriber numbers, the Carper and Coburn bill would restrict access to the National Provider Registry, a list of physicians and their provider identification numbers that is currently open to the public online. The American Medical Association has long pushed for restricting access to the registry to combat fraud and prevent Internet surfers from stealing physician identities.

The bill includes a number of other anti-fraud provisions, including one that would phase out the so-called “pay and chase” Medicare policy, in which the government checks claims for fraud only after the claim is paid, which often allows fraudsters to stay one step ahead. Instead, the bill would require the Centers for Medicare and Medicaid Services to perform prepayment checks before paying providers.

In an effort to increase revenue for family doctors, the American Academy of Family Physicians is pushing for additional representation on a little-known committee that wields powerful influence over Medicare payments.

Dr. Lori Heim, board chair of the group that represents family doctors, said the academy sent a letter late last week to the American Medical Association/Specialty Society Relative Value Update Committee, or RUC, seeking four more seats on the panel specifically for primary care physicians, which she said would help even the playing field between family doctors and specialists.

Heim said there are currently just three primary care representatives among the 29 physicians on the RUC, a group that advises the Centers for Medicare & Medicaid Services (CMS) on the relative values of medical procedures. Family medicine groups have long said their lack of representation on the RUC has led the group to undervalue the work of family doctors while overvaluing procedures, imaging and tests performed by specialists. Primary care physicians provide more than 40 percent of Medicare-paid office visits.

Technically, the RUC simply recommends procedure values, but CMS accepts the RUC’s recommendations more than 90 percent of the time, which has led to criticism that the arrangement is a conflict of interest allowing physicians a key role in determining what Medicare pays them. The workings of the RUC and the controversy over its practices were detailed in an iWatch News piece last November.

The American Academy of Family Physicians this week declined to drop out of a little-known committee that wields powerful influence over Medicare payment to doctors,  despite pressure from some of its members to leave the group.

Late last month, Dr. Roland Goertz, the president of the academy, said its board planned to discuss giving up membership in the American Medical Association/Specialty Society Relative Value Update Committee, or RUC, a committee the family physicians’ group has long criticized for under-valuing the work of family doctors. Goertz said then the RUC issue could be decided in a board vote.

In an interview Friday, however, Goertz said the board met this week and was unable to reach a decision about its participation in the RUC. He said the issue is still on the table, but was unsure of the timetable for resolving it.

“AAFP's continued participation in the RUC is a serious decision that cannot be made lightly,” Goertz said. “We want to make sure we have investigated every conceivable impact on family medicine and primary care physicians and the patients we serve.”

The RUC is a group of 29 physicians nominated by medical specialty societies that advises the Centers for Medicare & Medicaid Services (CMS) on the relative values of medical procedures. Technically, the group simply recommends procedure values, but CMS accepts the RUC’s recommendations more than 90 percent of the time, which has led to criticism that the arrangement is a conflict of interest  allowing physicians a key role in determining what Medicare pays them. The workings of the RUC and the controversy over its practices were detailed in a Center for Public Integrity piece last November.

Pay is at root of the conflict between family physicians and the RUC.

Efforts to open Medicare billing records by doctors and other medical providers are gathering steam in the Senate. Sen. Dick Durbin, D-Ill., has introduced the third bill this session calling for a wide release Medicare billing data, a move vigorously opposed by the American Medical Association.

The Durbin bill, S-856, the Medicare Spending Transparency Act of 2011, differs from two bills introduced earlier this session by Sen. Charles Grassley, R-Iowa, and jointly by Grassley and Sen. Ron Wyden, D-Ore. Durbin’s bill would require Centers for Medicare & Medicaid Services to create on its website a list of Medicare service providers and suppliers and detailed aggregate data of their billing.

The bill would require CMS to publish the number of patients a doctor saw during the previous year, the average number of billing codes a doctor filed for each patient encounter, and how much they were paid by Medicare. It would also require CMS to publish the top 50 procedure billing codes each provider billed Medicare and the top 50 diagnosis and procedure code pairs they used. The bill would also make raw Medicare billing data available to “qualified individuals and groups.”

Public access to Medicare billing data would be a breakthrough for patients, said Rosemary Gibson, co-author of “The Treatment Trap,” a book critical of medical care overuse. “If you have someone living in a town and they see their hospital is the top hospital that bills for back surgery, they might think twice about if that hospital is performing unnecessary services,” Gibson said. “The data is out there and nobody is acting on it. The public is bearing the consequences.”

Rep. Paul Ryan’s plan to privatize Medicare would accelerate a trend started several years ago by corporate CEOs and their political allies to shift ever-increasing amounts of risk from Big Business and the government to workers and retirees.

If enacted, the Ryan plan would represent a windfall of unprecedented proportions for insurance corporations and other businesses.

For millions of average Americans, many of whom already are finding it impossible to save for retirement, it would represent financial calamity. The nation’s middle class would pay dearly for Ryan’s proposed shredding of the social safety net that Medicare currently provides.

Ryan, chairman of the House Budget Committee, wants to dismantle the Medicare program and replace it with a system of vouchers. Starting in 2022, the government would give the average 65-year-old Medicare beneficiary $8,000 a year to buy coverage from a private insurer. That’s the amount health care analysts estimate will be what the Medicare program will spend on every 65-year-old in 2022 if the government doesn’t turn it over to private insurance companies.

While that might sound fair on the surface, it would actually be a very bad deal for people who turn 65 that year, compared to those who turn 65 in 2021. That’s because commercial insurance plans are much more expensive, and operate far less efficiently, than the current Medicare program.

Journalists at iWatch News are conducting an investigation into the nation's Medicare system, highlighting some of the questionable spending that occurs in the program through our ongoing series, Manipulating Medicare.

To get a better understanding of the data we’ve obtained jointly with The Wall Street Journal, reporter Fred Schulte is interested in learning more about the process involved for patients who see doctors for the first time after being enrolled in Medicare.

Have you seen a new doctor recently? Tell us more about your experience.

Your insights will help us understand some of the billing practices and procedures for doctors who are seeing new Medicare patients, and will guide our reporting for a new story. The information you share will remain confidential to our newsroom and our trusted partners within the Public Insight Network.

Interested in learning more about the Public Insight Network? Read about how you can assist award-winning investigative journalists by sharing your expertise. If you have any questions, email Cole Goins: cgoins@publicintegrity.org.

A little-known but powerful American Medical Association committee that strongly influences how much Medicare pays doctors is catching heat both from lawmakers and family physicians who believe the panel is not representing their interests.  

In late March, Rep. Jim McDermott, D-Wash., introduced legislation targeting the American Medical Association/Specialty Society Relative Value Scale Update Committee, or RUC, a group of doctors that the Centers for Medicare and Medicaid Services (CMS) has relied on since 1991 for information it uses to price Medicare payments to physicians.

Critics of the close industry-government partnership have said that since CMS accepts more than 90 percent of the RUC’s medical procedure value recommendations, the arrangement represents a conflict of interest that essentially allows a physician interest group to set the prices its members receive from Medicare. The workings of the RUC and the controversy over its practices were detailed in a Center for Public Integrity piece last November.

McDermott’s bill, H.R. 1256, the Medicare Physician Payment Transparency and Assessment Act of 2011, would reduce the AMA committee’s influence by requiring CMS to use independent contractors to identify physician services that are believed to be incorrectly valued. The bill would also require an annual review of medical procedures that are potentially over or undervalued.

Speaking in March at a House Ways and Means health subcommittee hearing,  McDermott,  a psychiatrist himself, slammed the RUC, calling it  the “least known committee in the medical industrial complex,” and questioning why a group of doctors should be “setting their own fees.”  

Tea Party members who railed against health care reform because of the spin they were sold about how “Obamacare” would affect Medicare played a big role in returning the House of Representatives to Republican control.

I’m betting that many of them, if they're paying attention to what Rep. Paul Ryan, R-Wis., wants to do to the Medicare program, are having some serious buyer’s remorse. If Democrats are wise, they’re already drafting a strategy to remind Medicare beneficiaries, including card-carrying Tea Party members, just how fooled they were into thinking that Republicans were the protectors of the government-run program they hold so dear.

As a speaker at an especially contentious town hall meeting during the summer of 2009, I saw firsthand just how many senior citizens were snookered about how reform legislation would alter Medicare. Shortly after I testified before Congress about how the insurance industry was conducting a behind-the-scenes campaign to influence public opinion about reform, Rep. Bill Pascrell, D-N.J., invited me to share my perspective as a former insurance industry insider at his Sept. 3, 2009, town hall meeting at Montclair State University.

More than 1,000 people had crammed into the school’s auditorium, not so much to hear the speakers as to express their opinions. Reform opponents were on one side of the auditorium, and reform advocates were on the other side. I had to shout just to be heard above the insults the groups were hurling at each other. Many of the reform opponents were carrying signs that read, “Hands Off My Medicare!” They clearly had bought the lie that the Democrats planned to dismantle the program.