CMS Releases Physician Payment Tool, But It's Still Not Easy to Use

Tony Berberabe, MPH @OncBiz_Wiz
Published: Friday, May 02, 2014

MedicareThe Centers for Medicare & Medicaid Services (CMS) have released a tool to look up an individual clinician’s reimbursement record, but its ease of use remains to be seen. The new tool comes shortly after CMS received an earful of complaints from physician lobbying groups when it released details of Medicare payments for 880,000 clinicians in April.

The tool pales in comparison with other online tools provided by the New York Times and the Wall Street Journal, however. If a consumer wants to look up how much Medicare paid an individual physician in 2012, he’ll have to jump through some math hoops. The other online tools just provide the dollar figures.

The CMS tool has other limitations, including:

  • The tool only describes care delivered to Medicare beneficiaries in the fee-for-service program and, as a result, may not represent a provider’s entire practice. Providers may also see patients enrolled in Medicare Advantage, those with Medicaid coverage or private health insurance, or those who are uninsured.
  • The tool does not provide any information on the quality of care delivered by providers.
  • The information in the tool does not account for differences in the sickness of patients treated by different providers.
  • Medicare pays differently when services are provided in a physician’s office versus a facility (e.g., a hospital outpatient department). For services furnished in an office setting, this tool presents the full payment. However, if a service or procedure was furnished in a facility setting, in most cases, this data only includes the payment to the provider and not the payment to the facility.
  • In general, when a provider administers drugs to a patient, the provider purchases the drug and Medicare pays the provider 106% of the average sales price (ASP) for the drug.
  • The way CMS counts services may differ by HCPCS code. For example, if the Number of Services is 2 this may reflect two separate procedures, two 15 minute increments of a service (e.g., a 30 minute office visit), or the delivery of two units of a drug.
The agency provides a link to explain how to read the payment data, with an accompanying 11-page document about the methodology used to collect the data.

In a statement issued last week, AMA president Ardis Dee Hoven, MD, applauded CMS for prominently featuring the limitations of the Medicare claims database. "However, we believe that some of the limitations listed require better explanation and that more resources need to be spent on providing data that would actually improve care," Dr. Hoven said.

Like other medical societies, the AMA has complained that physicians did not have the opportunity to check the Medicare payment data for accuracy before it was released.

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