- Race to electronic health records may come with a price
- http://www.publicintegrity.org/health/medicare/cracking-codes
- http://www.publicintegrity.org/2012/09/15/10810/how-doctors-and-hospitals-have-collected-billions-questionable-medicare-fees
- http://www.publicintegrity.org/2012/09/18/10935/pbs-newshour-doctors-are-charging-more-medicare-patients
Provide names of other journalists involved.
Lead reporters: Fred Schulte and Joe Eaton
Data Editor: David Donald.
Data Analysis: Elizabeth Lucas, Elizabeth Caudill, Dan Tse, Lekan Wang
Web: Christine Montgomery, Sarah Whitmire.
Graphics: Timothy Meko, Ajani Winston
Fact-checking: Peter Newbatt Smith.
Project Editor: Gordon Witkin
List date(s) this work was published or aired.
Main Series: Sept. 15, 2012; Sept. 19, 2012; Sept. 20, 2012 Impact Stories: Sept. 24, 2012; Oct. 16, 2012; Oct. 24, 2012
Provide a brief synopsis of the story or stories, including any significant findings.
Cracking the Codes documented how thousands of medical professionals have steadily billed Medicare for more complex and costly health care over the past decade — adding $11 billion or more to their fees — despite little evidence elderly patients required more treatment. The series also uncovered a broad range of costly billing errors and abuses that have plagued Medicare for years — from confusion over how to pick proper payment codes to apparent overcharges in medical offices and hospital emergency rooms. The findings strongly suggest these problems, known as “upcoding,” are worsening amid lax federal oversight and the government-sponsored switch from paper to electronic medical records. This was an extremely complex topic that required deep immersion in the arcane specialties of medical coding and health information technology. Very few academics or other researchers had approached this topic using Medicare billing data, especially over such a long period of time, and so there wasn’t much in the way of roadmaps to help guide us.
Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?
We obtained 10 years of Medicare Part A and Part B claims data from the Center for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services. All totaled with supporting files, this was about 712 million claims or about 1.8 terabytes of datawhen imported into the Center’s SAN. To gain access to the data, we first filed a Freedom of Information request to CMS. When CMS didn’t respond, we called CMS. Its response was that the data were not “FOIA-able” and that we should go through the process of acquiring the data the same way researchers and consultants do, by buying data from CMS. The estimated cost for the data was about $97,000. When CMS wouldn’t budge on the price, we sued CMS in U.S. District Court under the Freedom of Information Act. This lead to a negotiated settlement in which we purchased the data we requested for $12,000. The major analysis was done on Medicare claims data from 2001-2008 from what CMS calls its “Limited Data Set,” a scientific, random 5 percent sample patients and Medicare Part B claims filed for services to those patients. Using hospital outpatient claims for the Emergency Room analysis and “carrier” files that individual doctors use for their billing, we looked at the about 133 million claims that listed one of 14 sets of Evaluation and Maintenance codes, those most prone to upcoding. We also used the CMS denominator files of all Medicare patients to give us a baseline for the entire Medicare population. To work with individual Medicare claims, researchers also need the Current Procedure Terminology Codes — purchased from the American Medical Association — ICD-9 or ICD-10 diagnostic codes and physician UPIN and NPI codes to track individual doctors in the database. The latter are public records. Many other government documents also were used to document a decade-long pattern of medical coding and billing abuses. These records included U.S. Department of Health and Human Services Inspector General audits, Medicare carrier audits, Congressional hearing testimony, federal court lawsuits and criminal prosecutions involving “upcoding” and other records. We also drew on medical journal articles and Centers for Disease Control and Prevention data indicating that Medicare patients over time have not grown sicker and older and that the amount of time doctors spent with patients has not increased. These documents cast doubt on the claims of many doctors and hospitals that higher billing is justified because patients have become more infirm and more complex to treat over time.
Explain types of human sources used.
Investigating these complex billing abuses required us to track down and interview a wide range of experts in journalist-shy fields, such as medical coding, insurance fraud, health information technology as well as government experts and numerous doctors and hospital administrators. We also interviewed a range of researchers as we sought explanations for the billing spikes that were apparent in our data analysis.
Results:
The series has been widely cited in the trade press and other media — including an excerpt in the Washington Post on page A3 of the Sun., Sept. 15 edition — and has helped spur reaction from top government officials. Less than a week after the final installment was published, Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder issued a letter sternly warning five hospital and medical groups of their intent to ramp up investigative oversight, including possible criminal prosecutions, of doctors and hospitals that use electronic health records to improperly bill for more complex and costly services than they actually deliver. Following the publication of our stories, the Obama administration’s top health information technology official has launched an internal review to determine if electronic health records are prompting some doctors and hospitals to overbill Medicare.
Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.
There have been no corrections, clarifications or challenges to the accuracy of the findings.
Advice to other journalists planning a similar story or project.
Our project was unique in its scope, with a decade worth of Medicare billing data. The data were extremely challenging to work with — and this extended our anticipated reporting timeline. Completing and conforming the analysis and making sense of it through traditional reporting required expertise and patience. The topic of billing abuses is ripe for more stories. For instance, Medicare contractors and the Centers for Medicare and Medicaid Services publish reams of data from audits conducted in various states which can be localized by reporters.