$21 million sounds like a lot of money, and it is. It’s also the amount Dr. Salomon Melgen, a North Palm Beach ophthalmologist, received from Medicare in 2012. More recently, he received the top Medicare biller award and 46 counts of healthcare fraud from federal prosecutors.
Of course, this begs the question of how one medical provider can receive 6,417% more in Medicare reimbursement than the average ophthalmologist ($327,239 per year). We may never know the answer, but we can learn something from this egregious example of greed.
Although there will always be outliers, as a medical provider, it’s important to ensure you do not fall into the group of innocent physicians who are in the gray data range that may be open to unfair criticism. For example, Medicare paid 344 physicians and other healthcare providers in excess of $3 million in 2012, and one-third of the top-earning providers are ophthalmologists. After a late 2013 report issued by the Inspector General of the Department of Health & Human Services, there is now greater scrutiny of physicians falling outside the Medicare payment bell-curve.
PracticeSuite, which runs the largest instance of the Oracle database in use for medical billing cloud computing, can assist providers in determining where they fall on the Medicare reimbursement curve. This type of real-time comparative data mining can help providers navigate the turbulent waters of Medicare fraud detection.
The yearly public release of payments for 880,000 individuals and organizations submitting claims to Medicare is an unprecedented milestone that brings much-needed transparency to a place where providers have always enjoyed anonymity. Providers must make sure that if they fall outside the medicare bell curve, they have the medical appropriateness backup needed to prove they are not intentionally defrauding the system.
Last Updated on April 21, 2015