Medicare's Look-Up Tool for Doc Pay Reveals and Conceals

April 29, 2014

The Centers for Medicare & Medicaid Services (CMS), which sparked controversy earlier this month when it released data detailing Medicare payment of $77 billion in 2012 to more than 880,000 clinicians, has joined a small number of groups offering an online tool to look up an individual clinician's reimbursement.

Unlike what's available on the Web sites of the New York Times and the Wall Street Journal , however, the government's look-up tool is coy about disclosing how much Medicare reimbursement an individual clinician received during all of 2012. The other tools flat-out provide the dollar figure. With the government tool, which debuted last week, a user has to perform some math.This limitation might endear itself to some clinicians who don't want the public to know that they receive millions from Medicare each year. Roughly 4000 belonged to Medicare's million-dollar club in 2012, and 344 received more than $3 million apiece, according to various media analyses.

The payment information that can be harvested applies only to Medicare's Part B fee-for-service program, and then only for services rendered to 11 or more patients. Reimbursement received in Medicare Advantage programs isn't included.

Physicians Grumpy About Data Dump

The decision by CMS to open its Medicare payment database to the public has provoked strong blowback from medical societies and individual physicians. They say that this "data dump" violates physician privacy and invites misinterpretations and false conclusions because the payment information is presented out of context. Dollar amounts, it's argued, say nothing about the quality of care rendered, or the condition of the patient. Besides, payment amounts represent revenue, not income. A physician who received $7,000 for electrocardiograms in 2012, for example, might have lost money on them because it cost $8,000 to provide this service.

To be sure, media outlets offering look-up tools have included caveats that attempt to put the data in perspective. The New York Times states that "payments may also cover overhead, such as staff salaries and drug costs" and that payments shown for salaried, group-practice physicians go to their organization. The newspaper's Web page for its look-up tool also links to an article which discusses the limitations of the data in greater depth.

The payment search tool of the Wall Street Journal features a more extensive list of qualifications. It mentions, for example, that "procedures attributed to a specific physician may have been performed by other people under that doctor's supervision." It also states that physicians treating sicker patients may receive higher payments because they must perform more services. And Medicare payments "do not represent the full revenues" of a physician who also bills private insurers and other payers.

CMS takes great pains to explain how to read the Medicare payment data, linking users to an 11-page methodology document. The American Medical Association (AMA) is somewhat pleased. 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.

Do-It-Yourself Calculation

In one respect, the CMS look-up tool supplies users with more detailed information than its counterparts at the New York Times and the Wall Street Journal. Type in a physician's first and last name and location, or his or her NPI number, and the government tool digs up the following data for each billing code submitted to Medicare: The number of services, the number of beneficiaries who received these services, the average charge billed, the average payment amount allowed by Medicare — which includes the patient's 20% share — and the average Medicare payment.

In contrast, the New York Times displays only the number of patients who received a particular service, the average amount billed, and the average Medicare payment per service. The Wall Street Journal, in contrast, provides the number of services rendered under a single billing code, the average payment for them, and the grand total for each service in 2012.

However, the newspapers do one thing that CMS does not — show the grand total a physician receives from fee-for-service Medicare in 2012 for all billing codes. Visitors to the CMS Web site and its search tool can calculate that amount by multiplying the number of services rendered per billing code times the average Medicare payment per service, and then adding the grand totals for all services. For some primary-care physicians, that can mean doing the math for 20 to 30 individual billing codes.

More information on the CMS look-up tool is available on the agency's Web site.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.