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A Requiem for ICD-11 & Perspective on Physician Compensation

Posted by J. Paul Spencer, CPC, CPC-H

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Hot Topics

It has been my habit in the past to begin my weekly dissertations in this space with amusing anecdotes and random thoughts blurted out from a brain long since “modified” by a habit of sleeping roughly 4 hours per night for many years. Instead, in order to jolt you into the content about to follow, I shall precede the guts of today’s post with this brief but powerful musical interlude, which features Donald “Duck ” Dunn, bass player extraordinaire (easily in my top 5), who passed away this week.

Now that we have that out of the way, let’s talk about the latest in a long line of proposed rules for an ICD-10 compliance date, the comment period for which expired last night at 11:59 PM.  As promised, I submitted my comments yesterday afternoon, which I have decided to post in this space as well as on regulations.gov. It is a healthy mix of seasoned opinion and “poking the bear” that states my views on the proposed, revised compliance date of October 1, 2014:

RE: CMS Proposed Rule, File Code CMS-0040-P, Docket ID: CMS-2012-0043

I wish to submit the following comment on the above proposed rule. Specifically, I would like to address the portion of the Proposed Rule regarding the revision of the compliance date of ICD-10 from October 1, 2013 to October 1, 2014.

It is with particular disappointment that upon reviewing the Proposed Rule, one again CMS is committed to a path that will lead to the United States being on a lower tier internationally with regard to symptom, disease and morphology reporting.

As was stated in the Proposed Rule, CMS rejected the idea of moving directly from ICD-9 to ICD-11, scheduled for release by the World Health Organization in May of 2015, which is notable for being only 8 months after the new proposed date for ICD-10 compliance. This two-paragraph rejection of such a move was footnoted by two recent industry articles, which indicated that a clinical and procedural modification would “take anywhere from 5 to 7 years for the United states to develop its own ICD-11-CM and ICD-11-PCS versions”.

During the original Proposed Rule comment period in late-2008, leading up to the Final Rule in January, 2009, I submitted a comment regarding the oncoming implementation of ICD-10 (then slated for October 1, 2011 in the Proposed Rule). Commenting on the original proposed date of October 1, 2011, I stated that the United States “will have finally caught up to the rest of the world in its reporting structure, only to see that disappear within three years as the world begins to use ICD-11”. With the proposed release date for ICD-11 now appearing a mere 8 months after the proposed date, I again state that I am in favor of moving directly to ICD-11 from the current outdated standard.

The industry articles cited in the new Proposed Rule under footnote 48 had arguments that fell into two lines of thought, the first being the expense and time already spent planning for ICD-10 implementation, and the processes that would need to happen to move our current system to ICD-11. I would like to address the first of these two articles, which involved the costs and time already dedicated to ICD-10. The article states that work first began in 1993, and concludes with the statement “We could have skipped ICD-10 in 1993-it’s a bit late now”. This appears to me to be a facetious argument, as the planning for the succeeding code set, ICD-11, did not begin until roughly a decade later. If the overarching argument of the article is that the amount of time and dollar investment now necessitates the country staying behind the global health care curve, I am having a hard time fathoming why CMS finds the article worth quoting, if CMS’ current mission to modernize our health care system is in earnest.   

The other main argument against ICD-11 implementation appears to be the idea of being unable to bring forth a “clinical modification” acceptable to stakeholders in the American health care system. The original final rule for ICD-10 released in January of 2009 offered an implementation date of 2020. There are now estimates being put forward of ICD-11, after American clinical modification, not being released until as late as 2030. The previously quoted article in the new proposed rule offers an implementation date of 2024.

CMS has stated very clearly, both with words and with a host of payment reform initiatives that the Centers wish to connect reimbursement for services with patient outcomes. Given that ICD-11 interfaces with SNOMED-CT as part of its design, and given that a global clinical modification will be part of the ICD-11 code set upon release, I see little reason to attempt to modify ICD-11 after release in order to make it fit into the current payment models in the United States if CMS’ goal remains as stated. ICD-10 has been modified for our current payment model, and based on its design dating back to the late-1980’s, allows for better reporting for reimbursement, rather than better reporting for clinical outcome. I posit that it is time to abandon the idea of a uniquely American clinical modification so that we as a country can begin to report diseases, symptoms and morphology in a way that is conducive to bringing forward better outcomes.

I am more in agreement with another recent article on this subject, which was penned by five physicians, one of whom happens to be a member of the ICD-11 Revision Steering Group for the World Health Organization. The opinion of this article is that if ICD-10 is to be the standard for the immediate future, that a delay of one to three years in the implementation date be enacted, but with the understanding that planning for ICD-11 implementation begin immediately. I would like to go a step further and state categorically that in order to stay true to CMS’ goal of aligning payment with outcomes, the ICD-11 code set, as scheduled for release by the World Health Organization, should be accepted without further modification as the reporting standard for the United States.

I then signed off, with name, rank, serial number, shoe measurements and other pertinent information.

Originally, ICD-10/ICD-11 was going to be my only topic today, but I came across a study yesterday in my daily search for new information that is instructive with regard to one of many sore subjects in the healthcare debate. According to a joint survey by the Overseas Employment Development Board (who?) and a private company called Jackson Healthcare, physician compensation in the United States is equal to 8.6% of total healthcare spending in this country. Compared to the healthcare systems of seven other industrialized nations, only Sweden and New Zealand, at 8.5% and 7.35% respectively, had a lower percentage of healthcare spending going to physicians.

On the surface, one might be tempted to cry for the poor American physicians, until we take a closer look at the numbers, as well as the populations of the countries listed in the survey. There were eight countries measured in the survey, with data from Australia, Canada, France, Germany, New Zealand, Sweden and the United Kingdom joining that of the U. S. When we look at total healthcare spending, we see that the combined healthcare expenditures of these countries equals only 38% of the total healthcare spending of the United States. For more perspective on the numbers, I also notice that the $216 billion dollars paid to American physicians is higher than the combined healthcare expenditures of Australia, Canada and New Zealand.

Yet population differences tend to cleanse these figures somewhat. The United States is the third largest country in the world in terms of population, trailing China and India by a good distance. The closest country in terms of population in the survey was Germany, but the total population of Germany only represents roughly 26% of that of the United States. In fact, the United States is roughly ten to fifteen percent higher in population than all seven countries combined. By virtue of our size and dollars spent, the 8.6% number could almost be admirable, but the amount of waste in our system, coupled with the knowledge that 13.9% of America’s gross domestic product is spent on healthcare, makes any admiration fleeting.

As I try to gain control of these and other random thoughts, I leave you with the above points to ponder as the weekend approaches.

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10:29 am, May 18th, 2012 | 1 Comment »

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The RAConteur: Another Opinion on Government Audits

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
The RAConteur™

Given the increasing incompetence in our society, I feel that with each passing day there are more jobs that I myself could perform. Yet there is one exception, and that would be the job of sports referee. It takes either a special level of off-the-chart arrogance regarding your own skills or a deep-seeded self-hatred to be a referee. Every decision that a referee makes guarantees that one-half of the participants in the sporting contest will come away hating you.

In the world of government audits in the last week, we heard from one such policy referee, that being the General Accounting Office (GAO).

The GAO is officially the investigative arm of Congress. It operates as the actuarial governor on Congressional legislation, reviewing the receipt and payment of public funds to gage the financial impact of legislation. Much like a referee, the reports released by the GAO tend to briefly alienate political factions based on whether the reports fit a particular party narrative. A report released last Wednesday was no exception.

The GAO chastised the Department of Health & Human Services for not implementing past recommendations to reduce improper payments from the Medicare program. The most prominent of the GAO’s recommendations was CMS demanding automated prepayment edits of the Medicare Administrative Contractors (MACs) in order to identify improper claims. This recommendation was first brought forward in 2007 and remains an illusive goal.

In addition, the GAO wants to see payments to Medicare Advantage plans to reflect the correct health status of the beneficiary in question. Risk Adjustment Data Validation (RADV) audits have revealed that the Medicare Part C plans have been claiming more dollars than they are entitled to based on patient condition, so this GAO recommendation should gain some traction. In addition, the GAO wants to see the current Medicare Advantage Quality Bonus Payment Demonstration halted, as it claims the design of the program precludes it from yielding meaningful results.  

It is one thing for the Senate Finance Committee to request input from stakeholders on how to avoid waste, fraud and abuse in the Medicare program. It is quite another for the GAO to state that there is more that CMS could do to fight improper payments, in addition to RACs, ZPICs and predictive modeling technology, all of which have been shown to be failing in their own unique ways. The injection of the GAO as an impartial observer into the debate should be welcomed by a provider community left shell-shocked from audit activity. For this one time, everyone should rejoice in the arrival of the referee.

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5:13 pm, May 16th, 2012 | 1 Comment »

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Who Will Best Prepare You For ICD-10?

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
Industry Updates

I stopped reading the local newspaper’s Op-Ed page, as well as viewing Sunday opinion shows, a long time ago. It wasn’t the constant back and forth between factions of opinion that turned me off. What irked me was the very idea of the people offering their opinions being regarded as “experts” simply by their presence in a certain forum, when in fact what they actually had were good industry connections in order to be able to spout off any kind of nonsense imaginable. As time passes, a resigned acceptance takes hold within the reader / viewer that a particular person stands as an expert in their field, when in actuality they are nothing more than a human embodiment of a long-existing restaurant in a good location.

I have been thinking about this as it relates to my chosen profession lately. At the root of my experience is my 14-year-old coding certification. Medical billing and coding has become the “hot” job in America over the last two years. Twenty years ago, if you had a day off or a sick day and you were watching afternoon TV, the three main commercials you would see were “Have you been hurt in an accident?”, “I’ve fallen and I CAN’T GET UP!” and “Are you looking for an exciting career in trucking/hair styling/graphic design?”. Today, between scenes of “The Rockford Files”, you still get the ambulance-chasing attorneys, but the latter two choices have been replaced by commercials for Medicare Part C plans and technical schools offering courses in medical billing and coding.

As a result, there has been a significant influx of people in my profession who are just entering my occupational universe. This comes at a time when a paradigm shift is about to occur in the basic tasks of a coder, that being the looming implementation of ICD-10. When I sat in a hospital meeting room in Pennsylvania in 1998 to take my 5-hour certification examination, I had been involved in the administrative side of health care for over 8 years. I passed that examination, as well as a subsequent one a few months later, which gave me a couple of spiffy acronyms after my name conveying the imprimatur of expertise in my field. In the succeeding decade and a half, I have worked hard to continually improve the work product of myself and others in my chosen field.

If only I could say the same for my certification body.

About 5 weeks ago, I traveled to Las Vegas and attended the annual national conference of the American Academy of Professional Coders (AAPC), the organization that oversees my two coding certifications. The AAPC has been in existence since 1988, but went through a change in stewardship in the middle of the last decade in the wake of separate controversies regarding the founder and his estranged spouse, who was the president at the time of the takeover. As a result of this purchase, the AAPC is now a for-profit certifying entity. While the new owners did have some positive immediate impact upon acquisition, their actions since, as embodied by the national conference I recently attended, couldn’t come at a worse time.

I have a few beefs with the AAPC that I was unable to move up the chain of command in Las Vegas, thanks to the coding game shows, simplistic, beginner-level presentations and the ongoing abomination that is modern popular music being blasted over the speakers during every general session. Lucky for my readers, they get a dose of my attitude here, and it comes with better music.

A cursory look at the AAPC website shows that in addition to their most important core credential of Certified Professional Coder (CPC), they list twenty-five additional certifications. Twenty of these deal with individual areas of coding expertise, with the remaining five being certifications in hospital outpatient facility, auditing, “payer perspective coding”, interventional radiology and compliance. A majority of these certifications have come into being in the last five years. In creating this alphabet soup of credentials, the AAPC has created the unintended consequence of weakening their core CPC credential for physician practice coding.

Which leads me to everyone’s favorite topic, ICD-10. With the exception of the first presentation I attended by Michael Arrigo of No World Borders, who expertly connected the dots between ICD-10, payment reform and the revenue cycle, the balance of the information presented on ICD-10 at the Las Vegas conference consisted of “prepare now”, “it’s coming” and “it will affect things here and here”. This approach came complete with a guy dressed up like some mutated form of Elvis and an ICD-10-CM book (I wish I was kidding). Instructing the 2,200 coders and other professionals who attended just how to prepare and how things will be affected was conspicuously absent.

It helps to contrast the approach of the AAPC towards ICD-10 with that of the American Health Information Management Association (AHIMA). Because AHIMA certifications have more to do with hospital billing and coding, AHIMA has been engaged in the ICD-10 implementation process for over a decade. This included the 36 days of field testing that was done back in 2003 that is now seen as sufficient for implementation of the code set. As this recent article points out, AHIMA vigorously defends the need for the code set, has no tolerance for outside opinion to the contrary and is leading the charge toward a smooth transition.

Meanwhile, last week, the AAPC created yet another new certification and has taken the position that training in the code set should be undertaken no more than one year before the implementation date, which is set to move again soon after the CMS comment period on the latest proposed rule closes next week.

With the number of coders suddenly multiplying thanks to afternoon TV advertising, we now have an army of new AAPC-certified coders who not only are brand new to the administrative side of the industry, but who were proficiency-tested on ICD-9, which won’t be around 2 1/2 years from now. Meanwhile, the AAPC page on LinkedIn.com consists mostly of postings from newly certified coders who are still looking for work months (or even years) after attaining certification. The AAPC’s answer to this is to have a membership count proudly displayed on the home page of their website.

While I do plan to submit some rather pointed and mocking comments to CMS regarding the lost opportunity about to be undertaken so close to worldwide release of ICD-11, I am resigned to the fact that ICD-10 is a reality that is best planned for sooner rather than later. To those who took a break from afternoon TV and happened upon this article, might I suggest that rather than entering the overpopulated world of medical billing and coding at a high tuition cost to you, maybe instead try to draw Tippy the Turtle for an art school scholarship. A brand new CPC certification from the AAPC, in its current form, will mark you as an expert two years from now about as much as anyone on a Sunday afternoon talk show. Trust me when I say that’s not saying much. Do yourself a favor and try a new restaurant.

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1:02 pm, May 11th, 2012 | 1 Comment »

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The RAConteur: An OIG Preview Of Coming Attractions

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
The RAConteur™

I’m going to start out today’s post with a confession of a personal shortcoming. I am much more dynamic on paper than I am in person. When I discuss a subject face-to-face with people, I have a tendency to obsess on one topic, much to the detriment of a random listener. I tend to blurt out thoughts without thinking, and based on my fund of bar knowledge, some of those random thoughts are downright frightening and have led to bans in several social circles across the United States.

There are some issues from which I squeeze the life in print, as many of my regular readers will certainly attest. If I had to select one topic which I have revisited more than others in my professional life (restricting our universe to the world of health care), it would be the billing and documentation of evaluation and management (E/M) services. Thanks to the majesty and splendor of the OIG Work Plan, I get another opportunity to write about it again today.

When the latest Work Plan was released last October, the OIG indicated that they would be reviewing trends in E/M coding for claims submitted between 2000 and 2009. In particular, the work plan stated that the OIG would “also identify providers that exhibited questionable billing for E/M services in 2009″. This morning, as I was searching the macabre depths of my mind for today’s topic, I received an e-mail stating that this review has been conducted and finalized.

There were two slight changes from the Work Plan and the released report, that being that the years of E/M data being reviewed was 2001-2010, and the identification of physicians with aberrant patterns being based on 2010 data. The findings of the report should come as no surprise to anyone who has been involved in medical billing consistently over the last decade. In the years surveyed, physicians “increased their billing of higher level E/M codes in all types of E/M services”. The analysis of the billing data identified approximately 1,700 physicians “who consistently billed higher level E/M codes in 2010″. Based on the report, the OIG recommended continued education, encouraging contractors to review physicians’ billing for E/M services and to commence review of physicians “who bill higher level E/M codes for appropriate action”. For those not studied in Apparatchik language, that means audits. Dr. X, meet Mr. ZPIC.

For the last 30 years, physicians in private practice have been feeling the reimbursement squeeze from government and commercial payers. In this environment, the physicians who care most about their reimbursement have been searching for ways to stop the bleeding. One of the easiest ways to do this is to increase reimbursement for the most common service of the practice, which is the face-to-face encounter with the patient. As a result of this philosophy coming to the fore, a cottage industry of consultants promising to increase reimbursement for E/M services by “strengthening” documentation has popped up, often focusing too much on “bullets” and not enough on medical necessity. In the world of the electronic medical record, this type of approach by practices is fraught with risk, especially if the physician is more receptive to a financial message rather than a message centered around compliant documentation. With ICD-10 poised to be shoved down our throats like a Turkish scimitar, documenting for reimbursement is a habit that is best broken sooner rather than later.

In the eyes of CMS and the OIG, the roughly 1,700 providers identified as outliers by this OIG analysis are about to have a rude awakening. Having reviewed tens of thousands of pieces of E/M documentation in my career, and having seen nine years of CERT results that have consistently identified high level E/M services as being coded improperly, there is absolutely no excuse for not knowing the documentation rules for E/M services. I have heard every physician canard (“…but I spend a lot of time with my patients…”, “…but my patients are sicker than others…”, “…these rules are so arbitrary…”, “…how am I supposed to keep my doors open…”, etc.) multiple times from multiple sources, and none of them make sense if your documentation of services is not a true reflection of the scope of the patient encounter. From personal experience, I can tell you that the instances where assumptions made by physicians about the care they are rendering being accurately reflected in their documentation upon initial review are few and far between.

Those of us who exist on the side of physicians have been waiting for the RAC contractors to announce their entry into the E/M universe. The RACs are surrounded on all sides with evidence from other audit entities that E/M services should be targeted. Based on the poor quality of the RAC work product up to this point, it is something of a blessing that the RACs have stayed on the sidelines. There should be no illusions that the RACs will continue with this indifference indefinitely.

I have written and spoken about E/M services in one way, shape or form on just about every day of my health care career. Those who know me are sick of hearing me talk about it, and future acquaintances will respond the same way given time. The OIG report is but another warning shot across the bow of providers who have been taught to game the system through creative coding and documentation techniques. My wife can tell you that I often repeat myself, but this is one topic that must be consistently reiterated based on rampant errors that exist.

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12:42 pm, May 9th, 2012 | 1 Comment »

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A Heavy Week For The Police Blotter

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
Health Care Fraud

When I was growing up, there used to be a phrase for a person or a business enterprise that could be trusted to do the right thing. That phrase was “on the level”. In the grand scheme of things, my life experience to date is fairly short, so it is distressing to me that the idea of someone being “on the level” seems to be some kind of quaint notion from yesteryear. Once upon a time, it was fairly easy to distinguish what was legitimate and what was too good to be true.

Unfortunately, in modern times, we are surrounded on a daily basis with scams. From the spam in our e-mail inbox to the “price rollbacks” offered by virtually every retailer, there is very little that I see across the landscape as “on the level”. Even adding something to your meal from the fast food menu for “another dollar” seems like an honest bargain, until you realize two years later that you can’t fit through the doorway without coating your hips and shoulders with margarine.

After a while, what tends to happen is people become numb to the ugliness around them and get consumed by it, rather than feeling like they are spending their lives swimming upstream under the delusion of something wonderful greeting you at the river’s source, even though it never comes into view. Maybe it’s all the psychedelic music I’ve cheerfully listened to in my life, or maybe it’s my love of oceans, lakes and rivers, but I’m here to tell you that I’ll keep swimming for the rest of us.

I read two stories this week that make me believe that the idea of “on the level” is poised for a comeback. The first news came to me this past Wednesday, when the latest wide-ranging HEAT teams busts were announced in a joint statement by the Department of Justice and the Department of Health and Human Services. In all, 107 people at various levels of decision making in the health care chain were charged with false billing to the Medicare program totalling $452 million. Fifty-nine of those charged were from (say it with me!) South Florida, with the majority of the remainder coming from the high fraud areas of Baton Rouge, Los Angeles, Houston, Chicago and Detroit. We even had one defendant from Alabama, so let me take this opportunity to welcome those in the Yellowhammer State (yes, I had to look that up) to the world of Medicare Fraud arrests.

In addition to the “perp walks” in many cities, Medicare suspended payments to 52 providers based on aberrant billing patterns and what they called “credible allegations of fraud”. I find this to be the most interesting announcement by the team, as this indicates to me that the predictive modeling technology implemented by CMS last July is beginning to prove it’s worth, albeit on a small scale thus far. There is still a long way to go to expunge the Medicare program of fraud (as indicated by this insightful comment from my blog posting this past Wednesday that begs for a larger audience), but anytime providers of ill repute are led away in handcuffs, my soul does a Daffy Duck “Woo Hoo” Dance.

The other bit of news from the true crime files came in this morning, and has a connection to one of the many places I’ve lived in my life. In 2010, a pharmaceutical distribution center for drug giant Eli Lilly located in Enfield, Connecticut (past home base number 2 of 12) was robbed of over $70 million of Prozac and Zyprexa in a sophisticated heist. Thanks to a long investigation by local and federal authorities, 12 arrests were made in Florida this week against individuals who ran a cargo heist ring up and down the East Coast. In addition to the Eli Lilly robbery, the same ring was involved in cargo thefts at truck stops in Pennsylvania, Ohio and Tennessee, as well as a similar heist at a GlaxoSmithKline warehouse in Virginia. A statement from Eli Lilly indicated that the remaining drugs recovered as part of the arrests will eventually be destroyed. 

While two news releases will not completely restore the idea of entities being “on the level”, it is to the benefit of those in the medical field who are working hard to do the right thing that those players acting in bad faith are removed from the field. It continues to be a swim upstream, but for a small window of time, the rocks we encountered on this part of our journey were made of Styrofoam.

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10:27 am, May 4th, 2012 | No Comments »

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The RAConteur: Other (Wide) Shoes Begin To Drop

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
The RAConteur™

I thought I’d begin today’s rumination by dispensing a bit of just-uncovered wisdom; having wide feet in and of itself does not guarantee that one is standing on steady ground. Allow me to offer one literal and one figurative example.

This morning, I was making my usual run to purchase a 44-ounce unsweetened iced tea at my local Speedway store (a Midwestern gas station-mini-mart chain) against the backdrop of rainfall in the Greater Milwaukee region. I took about four steps into the store and promptly slipped on a wet spot on the floor, quickly losing footing under my size 12 wides. I was able to catch myself before I made any more of a rush hour spectacle of myself. To Speedway’s credit, this morning’s iced tea was complimentary due to the apologetic clerk’s self-flagellation for not putting down a mat across the floor, thereby keeping my lifetime record of never hiring an ambulance-chasing attorney intact. Little did she know I’m a singer and not a dancer…

Upon my arrival at the office this morning, I was greeted by an article that should be of great interest to all providers adversely affected by government audits. A representative of the Senate Finance Committee told an audience at the just-concluded Health Care Compliance Association conference in Las Vegas that the Committee will soon be issuing an open letter to healthcare providers. The purpose of the communique is to solicit advice on the best ways to prevent waste, fraud and abuse in Medicare, Medicaid and their many offshoots.

On April 24th, this same committee held a hearing entitled “Anatomy of a Fraud Bust: From Investigation to Conviction”. It was at this hearing that Senator Orrin Hatch (R-Utah), the ranking minority member of the Finance Committee, announced his intention to solicit provider input. In the absence of the letter, the Committee has apparently been inundated with complaints from providers regarding auditing tactics. The bulk of the ire has been focused on the Zone Program Integrity Contractors (ZPIC) and that less-than-popular ongoing scourge of the hospital community, the RACs.

As the reader knows, I’m more than happy to share clearly defined opinions of both of these outside contractors. Bluntly, gathering the organized input of the provider community is overdue. Yet I would caution the reader, as I did with another such open letter issued last week, to consider the source of the request and the backdrop under which it occurs. The committee hearing from the 24th was commenced with two agendas. On one side was Senator Max Baucus (D-Montana), attempting to point to successes of government audits in the hope of propping up the thesis that states that fraud & abuse collections will pay for health care reform. On the other side is Senator Hatch, whose party’s ultimate mission is to vastly redesign the Medicare program into some kind of an amorphous voucher program.

Given this, there are reasons not to trust the motives of the minority portion of the Committee on this particular subject, but we are all fully aware that the RAC and ZPIC processes appear to be deliberately designed so that providers are at a disadvantage. The RAC program in particular has been problematic in that CMS continues to tweak the program to make it harder for providers to respond to incorrect audit findings in a cost-effective manner. As the majority of the contentious issues revolve around short hospital stays and observation status, it would appear that the RAC program could be formally concluded if CMS would only clarify these standards. It would be much more cost-effective for all concerned than the current model. To complicate matters, the boastful and glowing quarterly reports on RAC results that have been released by CMS thus far crumble under the realities of provider appeal results.

Yet something is missing. One set of entities that is more responsible than any other for Medicare’s haphazard payment practices appears once again to be avoiding the spotlight. I speak of the Medicare Administrative Contractors, who have been allowing Medicare benefits on claims that had no business being paid for decades, all without consequence. If the effect of a set of policies is studied in the absence of studying the cause, only half of the story has been written. Providers would be wise to consider this in any testimony or remarks submitted to the committee.

While this announcement was being made, I came across interesting news on a live broadcast by the RACMonitor team from the same conference. They had a guest on their broadcast yesterday afternoon stating that she has now seen Medicaid RAC activity in the states on New Jersey and Kansas. While the fate of the Medicaid RAC program now hangs on the looming Supreme Court decision regarding PPACA, it is no less distressing to learn that activity that has done very little for the Medicare Trust Fund is now reaching into Medicaid with their error-prone tentacles.

I saw more than just my own wide feet drop in the last day and a half, and only my own dealt directly with rain and iced tea. With regard to the other two, I am less than thrilled at the beginnings of the Medicaid RAC program given recent history, but I couldn’t be happier that the RAC and ZPIC contractors and their processes are finally being put under a credible and critical microscope.

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4:47 pm, May 2nd, 2012 | 3 Comments »

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Surprise! It’s A Sternly-Worded Letter!

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
Industry Updates

Another birthday weekend is upon me.

This coming Sunday will mark yet another anniversary of my birth. Coming up on 46, for me birthdays are no longer a celebration of my birth, but rather another mile marker on the (hopefully long) highway leading to my cremation. This is a somewhat dark way of looking at it, but as one of my living musical heroes, Robyn Hitchcock, so eloquently put it, “God finds you naked and he leaves you dying / What happens in between is up to you”.

As I get older, I find that I am making less and less time for politics in my life. There are many reasons for this, but the biggest reason is simply that every politician that I come across on the state and national stage lacks imagination. Just once, I would like to turn on C-SPAN during a Special Orders session in the House of Representatives and see a member of Congress painting a seascape, singing a new song that they’ve written or doing an interpretive dance in honor of the planet Jupiter. It would assure me that at least someone with their hands on the levers of power had the ability to think outside of the box.

In the absence of my grand vision, we are left with the oft-repeated habits of the Beltway Set; grandstanding for the cameras, filling their pockets with lobbying dollars and (my personal favorite in terms of absurdity) taking advantage of Congressional free mail to fill people’s mail boxes with letters that combine the worst of the two previous activities just listed. So much for elected leaders representing “public servants” or the “best of the best”.

If it’s another week in Washington, then someone must have sent a sternly-worded letter, and this week’s is a doozy.

Anyone who reads my missives in this space knows that I have a dim view of government audits, mainly because they are shifting the blame for abuse in the system to the wrong people, namely well-meaning hospitals and physicians who have a hard time understanding federal rules of documentation and reimbursement. We all know who the thieves are when it comes to healthcare delivery, and pelting hospitals with thousands of requests for documentation per year rarely smokes these rats out of their lairs. Claims are paid badly by MACs and subsequently reviewed poorly by RACs based on complexity built into the system by CMS. Shifting the administrative burden of such a system on providers is short-sighted and does nothing to improve the care being administered.

With all of that being said, you would think that I would be in favor of this week’s sternly-worded letter from a subcommittee of the House Ways and Means Committee to Marilyn Tavenner, the Acting Administrator of CMS. After a short preamble, the letter asks for every statement of work, performance report, case referral and contractor fee paid relating to Medicare and Medicaid program integrity efforts for every contractor involved in such activities.

You should all know by now that I’ll sprint to the front of the opinion line to talk about government audits, and I have always been a fan of full disclosure. As it applies to the Recovery Auditor Program, every quarterly report that has been issued by CMS on RAC performance is either a collection of half-truths or (in the case of the first provider accuracy scores issues by the RAC Validation Contractor) bald-faced lies. I am encouraged that CMS will be called onto the carpet regarding RAC appeal rates, as any provider that has been affected by RAC audits can tell you that a look at that aspect of the program is well overdue.

With all of that being said, it helps to consider the source of the letter to CMS. Charles Boustany, the Louisiana Congressman who chairs the oversight committee has quite the revealing report when it comes to an analysis of his biggest campaign donors. The list includes Blue Cross and Blue Shield and an organization known as the LHC Group, a nationwide provider of home health, hospice and long-term acute care services. That list of LHC’s services looks a lot like the list of the types of providers often caught in the HEAT team net. In all, Congressman Boustany has taken in over $350,000 in campaign contributions from entities involved in health care, including nearly $170,000 from various factions of the insurance industry.

Whenever a legislative opponent mugs for the camera, they do so hoping for a knowledge vacuum by the viewer. This latest in a string of sternly-worded letters that bounce back and forth within the Beltway is part of the never-ending gamesmanship that has led to the system we currently have in place. If I believed that anyone in Washington, DC cared for my opinion, I would issue my own correspondence to those in power. I can guarantee that there would be just enough in every letter to anger everyone on both sides. I can also promise you that unlike this blog, it would be unexpurgated.

I am happy with the long-overdue demands made in this letter, but I simply know better than to trust this particular messenger. It takes no imagination whatsoever to take action simply because someone pays you to do so. Sometimes, you have to do it because no one else will and it is the right thing to do. By this standard, the letter is a failure.

So if you want an uncensored and uncompensated opinion, and you’re not doing anything tomorrow night, come out and celebrate my birthday at 7:30 and I’ll be happy to impart some wisdom, but take this latest sternly-worded letter with a grain of salt until we see a response from CMS.

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11:32 am, April 27th, 2012 | 4 Comments »

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The RAConteur: Medicaid Integrity Update and A Notable Sale

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
The RAConteur™

Covering the world of government audits in a continuing series of ruminations has the feel of yelling at the ocean. It is an exhilarating feeling until you realize that the ocean is always going to be louder than you are and you’re always going to end up smelling vaguely of dead marine life and salt. Until last week, I had a mostly walled-in desk, so pity my poor co-workers going forward.

Today I have some updates with regard to government audits that, while not related to the RACs, give us small windows into where government audits are going, and, more importantly, who’s pulling the strings.

I covered two recent OIG reports on the Medicaid Integrity Program on a recent episode of Monitor Monday podcast, but I’ll give you a quick synopsis for purposes of brevity. There was an OIG report released back in February with regard to how well the Review Medicaid Integrity Contractors (MICs) were performing their tasks. The report found that the review MICs completed 81% of their assignments, but had limited input into what specific leads were forwarded to the audit MICs. The review MICs created 114 reports identifying 113,378 unique providers. CMS then filtered that information and targeted 244 providers for audit. The report recommended that the quality of data given to the review MICs improve, as well as allowing the review MICs more input in the selection of audit leads.

This first report led into another, released roughly one month later, regarding audit MIC performance. The report showed that 81% of review audits conducted between January 1 and June 30, 2010 did not lead to the identification of an overpayment. Additionally, 11% of assigned audits were completed and $6.9 million in overpayments were identified, with $6.2 of that coming from collaborative audits between the review MICs, audit MICs, state fraud control units and CMS. The report recommended that further collaborative audits be initiated.

This past Monday, the OIG issued a 5-page addendum to the February report on the Review MICs to further clarify the status of the 244 providers targeted for audit by CMS. It turns out that in the second half of 2011, CMS assigned 161 of the 244 providers targeted to the audit MICs. As of February 1, 2012, 127 of these proposed audits have been completed. From this universe of targets, only 25 audits uncovered overpayments, totalling $285,629. This number represents less than 1% of the estimated $33.5 million in potential overpayments identified by the review MICs at the time of referral of these cases from CMS to the audit MICs.

Once again, we see clear and compelling evidence that a CMS audit initiative is plagued by poor data and substandard execution. It is also worth remembering that some portion of the minuscule amount identified as overpaid will be appealed by providers successfully, which further decreases the total amount of overpayment collections under the Medicaid Integrity Program.

Switching gears, I took note of an interesting financial transaction that affects government health care audits in a small fashion. It was announced on Monday that Thompson Reuters reached agreement on a sale of their health care division to Veritas Capital for $1.25 billion in cash. Thompson Reuters had been previously identified as the Medicaid RAC contractor for the state of Indiana. This is an interesting purchase for Veritas, a company that has made a rather salutary living in the world of government contracting (mostly in areas of defense) since 1992. Some of Veritas’ owned entities have had a less-than-sparkling record with contracted tasks in war zones over the last decade. If some of these patterns repeat, the health care providers in Indiana are owed our collective sympathies.

As the waves continue to crash, and as the salt sea air continues to invade my nostrils as my voice grows weak against the tide, I leave the reader to ponder the intricacies of the world of government audits. I recommend having some tequila handy, as it’s not a gentle subject.

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4:40 pm, April 25th, 2012 | 1 Comment »

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A One-Day Diversion To Music

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
J. Paul Spencer, CPC CPC-H

The general state of the American health care system isn’t on my mind today.

Perhaps I am in the throws of an extended “information cool-down” from the Fi-Med RAC Summit that concluded on Tuesday. Maybe I am burned out on the hot topics of the day, which are the ICD-10 proposed rule and the Supreme Court deciding the fate of PPACA. It could be that I really didn’t want to get out of bed this morning on a cloudy, rainy day, as a day of sleep with my dog and cat nearby sounds better than writing about another study, opinion or semi-breakthrough in the world of medicine.

More than likely, it’s because I lost one of my musical heroes yesterday.

Those who have read my pieces in this space know that one of my bigger areas of interest is music, both listening and performing. Any musician with any value will look you right in the eye and tell you that they are only the sum total of musical heroes that have gone before. As a singer, I would be nothing without the previous vocal contributions of the likes of Tim Buckley, Van Morrison and Paul McCartney. As a songwriter, I wouldn’t have much to offer lyrically without the craft displayed by Richard Thompson, David Ackles, Graham Parker or Bob Dylan.

And then there was The Band.

When I was in high school, I was in an enviable position, as my high school had a functioning, licensed radio station. For two years in the early ’80s, I had the coveted Friday night on-air slot. While I have some regrets about not being on the air with my current music collection, it was a great laboratory for pointing me in the right direction in the realm of both listening and composing. I discovered the bulk of The Band’s catalog during those years, and as time has passed, I have come to consider them to be the greatest band that North America ever produced. They are also the centerpiece of The Last Waltz, the greatest musical documentary ever filmed.

In the middle of The Band’s music was drummer and singer Levon Helm, an Arkansas native tasked with keeping the beat behind four Canadians. On Tuesday, a notice was released to the world that Levon was in the final stages of his 14-year battle with cancer. Yesterday, that battle concluded. He was 71.  

I never had the chance to see him in concert. My friend Curtis did, as he states here. Yet having occupied a unique musical space for nearly 50 years, everyone who came across him had a story about his calming and welcoming presence that went along with his first rate musicianship.

My favorite story about Levon Helm has nothing to do with music at all. There used to be a morning DJ in Philadelphia by the name of John DeBella, who had previously been employed in New York. One morning, he told a story about having interviewed Levon Helm on-air during his days in New York. When the interview concluded and the microphones were turned off, Levon turned to him and in his gentlemanly Southern drawl said, “John, if you ever find yourself in Woodstock on a Sunday, just drop on by. We’ll have the game on”. Some time later, DeBella found himself around Woodstock, New York on a Sunday afternoon and thought to himself, “He probably doesn’t remember me, but what the hell? Let me try it”. He found Levon’s house in Woodstock, parked the car, walked up and knocked on the door. Levon answered the door, amazed and said “JOHN! HOW ARE YOU? COME ON IN! WE’VE GOT THE GAME ON!”.

There is a local band in Milwaukee called the Flood Brothers that do a mix of originals and covers. Sometimes, when I’m in the audience, they invite me up onstage to do a song, and invariably, the song we choose is “The Weight” by The Band. There are only a few songs in existence in this day and age that when played, the bulk of the audience feels compelled to sing along with the chorus. Mostly thanks to Levon’s vocal tone, mixing a storyteller’s care for narrative with a weariness of a traveler wanting only “some place where I could lay my head”, “The Weight” is a song that never gets old. The Flood Brothers play in town tomorrow night, and the urge is striking me to sing one more chorus.

Yet isn’t that the magic of all art, especially music? A song has a way of transporting you back in time to a moment when for a brief few minutes, it was the center of your existence. The listener never realizes that the song has just become a part of that person’s oral history until time passes. For me and my fan’s relationship with The Band, it is the vision of a 10-year-old kid, up late on a Saturday in 1976, watching the Band’s last television appearance on “Saturday Night Live” and listening as “The Night They Drove Old Dixie Down” spilled out of the television and into my mind for the first time, never to vacate since. At the center of the music was Levon Helm as drummer and one of three rotating lead and harmony vocals, presenting a story so seemingly real that I could picture him as a Confederate soldier. I remember buying The Band’s greatest hits on vinyl when my teenage years hit and being similarly ignited.

My childhood and high school days have disappeared with a combination of time, weight, acne medications and a pressing need to live in the moment. If the truth is told, all time prior to my introduction to my wife Leslie (half-Canadian; coincidence?) can be accurately described as my Dark Ages. Yet the music from as far back as AM radio in 1971 to the present day always resonates with a memory in tow in ways that my first encounter with a CPT book never can. Levon Helm has danced on the edges of my memory – consistently as a positive one – for over 35 years, and will continue to for many years to come thanks to his significant musical contributions. I am left with being able to only say “Thank you” to him from a distance.  

This space is supposed to be dedicated to medicine, so in order to satisfy that requirement, here’s a song by The Band about the early days of frontier medicine called “W. S. Walcott Medicine Show“. I bid Levon Helm a fond farewell with a special life-long thank you from my ears, and we’ll talk about things more closely related to health care next week. I thank the readers for their one-day exhibition of patience.

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12:18 pm, April 20th, 2012 | 1 Comment »

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The RAConteur: And STILL More Administrative Costs To Providers

Posted by J. Paul Spencer, CPC, CPC-H

Categories:
The RAConteur™

There was once a time in this country where reasonable people within our government would come together and craft legislation with an intended purpose. When that purpose wasn’t achieved, they would convene again and do their best to attempt to fix it.

Obviously, in this world where reasonable people are missing, there has been a fundamental shift. Because of Congressional gridlock and the new political reality of the never-ending campaign, we now encounter situations where extra-Congressional changes are put forward in order to insure that the original intent of the law achieves its goal. From my perspective, the RAC program under CMS is a perfect example of this phenomenon.

Since I’m here and feeling surly and tired, let’s take a little Cynical History Tour of the permanent RAC program.

In the beginning (a few years ago), the RAC contractor would send an additional documentation request for complex review to a provider. The provider would return the requested records to the RAC, and the RAC would reimburse $.12 per page for the record. Next, the RAC would make their determination. If the determination was that an improper payment existed, the RAC would send a review results letter to the provider. The provider would have the opportunity to enter into a discussion with the RAC regarding the legitimacy of the determination. In the meantime, the RAC would send the detail of the improper payment determination to the MAC, and would then issue a demand letter to the provider. The provider would have to appeal within 30 days to avoid recoupment by the MAC, which would occur automatically on the 41st day after the date on the demand letter. Once the appeal was submitted, any outstanding discussion period would be immediately cancelled in favor of the appeal.

The problem with this process was that it worked too far into the provider’s favor. Providers have enjoyed lofty appeal success rates since the beginning of the permanent program. While the administrative burden was significant, the provider was compensated per page, which lessened the blow somewhat. The providers were able to direct all correspondence simply by informing the RAC of one preferred address. Despite CMS’ quarterly newsletters stating several hundred millions in returns to the Medicare program, the American Hospital Association’s RACTrac survey shows that these numbers are far from finalized. While the process was onerous, at the very least there were documentation limits to minimize the burden.

My, how times have changed…..

It started on September 1, 2011, with a change in the statement of work that allowed for semi-automated review, which came with no request limits and no reimbursement for records. Fast forward to January 1st, when the MACs took over the process of issuing demand letters from the RACs. The MACs are now sending RAC correspondence strictly to the payment address, which is causing RAC coordinators headaches. Because correspondence is not stemming from one source, and because demand letters are not arriving to the needed destinations, the number of discussion periods is beginning to wane. On March 15th, Medicare upped the record request limits for complex review per 45 days for all providers. Next came April 1st, where CMS has now decreed that the maximum that a provider can be compensated for providing records is $25 per requested record, which includes postage. 

While the Patient Protection & Affordable Care Act currently stands in a state of flux, the plan was predicated on funding from rooting out fraud and overpayments paying for the program. Since the permanent RAC program came to pass, the reality is that the money the RACs are returning to the program is far lower than stated in the quarterly reports. Thus, as fits my thesis at the beginning of this posting, CMS continues to tinker with the rules for providers in an attempt to gain a better financial result for the program.

There are reasons to want to root out fraud and abuse in the Medicare program, but to continue to punish hospitals with paperwork for what amount to discrepancies in the interpretation of Medicare rules is not the way to achieve the goal. Hospitals will begin to fail under the weight of investigation long before the worst offenders in the Medicare arena are escorted from the program in handcuffs and orange jumpsuits. Gaming the system to punish the wrong people is clearly the incorrect approach to the problem.

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3:34 pm, April 18th, 2012 | 1 Comment »

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