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myself into it, but I just can't see it."
She said such providers "would be ripe
for audit," because they are outliers.
Medicare has long known that office
visits are susceptible to fraud and what's
known as "upcoding," or billing for a
more expensive service than was actually
performed.
A May 2012 report from the U.S. Department
of Health and Human Services'
inspector general found that doctors are
choosing higher codes more often for
evaluation and management services, the
broad category that includes office visits.
The proportion of level 4 visits by established
patients increased by 15 percentage
points from 2001 to 2010, while level
3 visits dropped by 8 points.
The HHS inspector general recommended
that Medicare educate doctors,
ask its contractors to review E&M billings,
and conduct detailed reviews of
physicians who consistently bill for higher-level
visits. CMS administrator Marilyn
Tavenner agreed with the first two
recommendations but only committed
the agency to reviewing a small number
of the highest billers.
She noted that the return on investment
to check billings for visits wasn't
great. The average error cost Medicare
$43, but the program paid $30 to $55 to
review each claim.
Using a sample of Medicare data, nonprofit
investigative group the Center for
Public Integrity found a similar trend in
upcoding office and emergency room
visits across the country in an analysis
it published in September 2012. And a
Medicare report from 2013estimated that
established patient visits had a 7 percent
improper payment rate, accounting for
approximately $965 million in 2012.
"That's real money coming out of the
Treasury," the Urban Institute's Berenson
said. "Some doctors are robbing the commons
for themselves."
By looking at provider-level data, patients
can evaluate their doctors' billing
patterns. The providers flagged by Pro-
Publica stand out from others in their
specialties and states. Some were senior
doctors at prominent teaching hospitals
who may disproportionately care for
complex cases; most were not.
Explore Obioma Agomuoh's provider profile
Agomuoh was one of 790 Michigan
obstetrician-gynecologists who billed
Medicare for established patient visits
in 2012. Together, these doctors billed
THE SUIT MAGAZINE - NOV 2014
for about 61,000 office visits, of which
7 percent were classified as level 5. By
contrast, 97 percent of Agomuoh's office
visits were at the highest level. His level
5 visits accounted for 35 percent of those
for all ob-gyns in Michigan.
In an interview, Agomuoh said he does
not believe the data is accurate, even
though Medicare says it is. Agomuoh
also said he takes on tough patients other
providers won't see in the impoverished
community of Hamtramck, Michigan,
outside Detroit.
"Most of these patients have been rejected
by other doctors," he said. "I'm
probably the only one taking care of
them."
But Agomuoh's Medicare billings were
unusual in other ways, too, ProPublica's
analysis showed.
The program paid for wheezing evaluations
for every one of his patients in
2012, at $50 a pop. On average, each of
his patients was checked for wheezing
eight times. Almost all of his patients
also received an average of seven ultrasounds
of arteries in the legs (at $149 per
test) and seven ultrasounds of arteries in
the arms (at $144 per test). Most of his
peers rarely, if ever, billed for these services.
All told, Medicare paid Agomuoh
$769,000 in 2012.
Agomuoh has a long history of discipline
against his medical licenses and
has been sanctioned for negligence, making
false statements, failing to pay child
support and lying about it. He has surrendered
his license in New York, agreed
not to renew his license inConnecticut,
withdrawn his application for a license in
Ohio and was once on probation in Michigan.
Agomuoh, who is running for governor
of a state in Nigeria, where he was
born, said his billings reflect that many
of his patients have asthma, chronic obstructive
pulmonary disease and drug
addictions. He initially said a reporter
could visit his office but then changed his
mind a day later, referring further questions
to his lawyer, Fred Freeman.
"Why are you bothering him?" Freeman
asked. "You're not being fair to him
at all. He has nothing to say to you."
Medicare declined to answer questions
about Agomuoh, or about other
individual practitioners, and there's no
indication that program officials have
challenged his billings. Medicare officials
have said that their data may not take
into account money collected by a provider
and subsequently returned to CMS,
or payments that "may have been withheld
after claims were already processed
but prior to release to the provider."
Medicare did question the billing practices
of Im, the doctor who coded 100 percent
of his visitsas level 5. Im runs Exceptional
Urgent Care in The Villages, a huge
retirement community in central Florida,
and said that because of his training as an
emergency room physician, his center attracts
sicker patients than others do.
He said that after being contacted by
Medicare officials last year, he took "voluntary
tutoring and counseling" and now