Here in Milwaukee, we had our first snowfall of the season overnight. While it wasn’t enough to keep me at home today, it was just enough to make the process of getting from here to there just slightly more time-consuming. For someone like me, who operates in this world of ours thinking that a great deal of the world functions specifically to be in my way, it was a typical morning.

As the calendar turned to December earlier this week, I am also reminded that snowflakes are not the only thing  falling from the sky. With the approach of a new calendar year, a number of news releases, reports, pending legislation, industry updates and warning shots are coming from the federal government. Some of these began implementation at the beginning of the fiscal year on October 1, but it helps to review the regulatory landscape on a regular basis. With that in mind, here’s a portion of what we know:

• The OIG Work Plan - While some of the usual suspects appeared once again on the OIG work plan for fiscal year 2010. there were a few new and not-so-new things that jumped out at me. OIG is again looking at the unbundling of laboratory tests. One of the most surprising bits of news this year was the large fine levied against Quest Diagnostics for violating bundling rules, mainly because this company, under its previous incarnation as Smithkline Beecham Clinical Labs, faced a 9-figure fine for similar violations back in 1996. The OIG has now officially decided to revisit this topic. Other targets of the OIG in the coming year will be E/M services performed in the global period of a surgery, a review of the current payment system for ambulatory surgery centers, practice expense for radiologists, the effects of payments for services referred by excluded providers, and a multi-layered review of claims related to durable medical equipment.
• The OIG Semiannual Report – In addition to this year’s Work Plan, the OIG just released their semiannual report, which reports a total of almost $21 billion in program savings and recoveries. For fiscal year 2009, the OIG recovered just short of $4.5 billion through investigations and audits. The savings portion of $16.5 billion came through recommendations for putting agency funds to better use which were finally implemented long after they were suggested during the last administration.
• The 2010 Conversion Factor - Quietly over the Thanksgiving holiday, the projected conversion factor for 2010 was lowered from 28.4061, which represents a 21.2% cut from 2009, to 28.3895, bringing the total cut from 2009 to 2010 to just short of 21.3%. In past years, there has been last-minute legislation passed that eliminated projected cuts to the conversion factor. This year, the urgency to address this issue has disappeared in a wave of uncivil, unproductive and distracting arguments about the future of health care in the United States. With the New Year 4 weeks away as of today, it may be in the best interests of all Medicare Part B providers  to make financial preparations for the coming year that assume a 21.3% reduction in Medicare reimbursement. If this cut is rescinded on the cusp of January, those that have planned ahead will be that much better off.
• Medicare Fee-For-Service (FFS) Error Rate – CMS reported that the error rate for claims payments under Medicare FFS plans more than doubled from 3.6% in 2008 to 7.8% in 2009. This was a result of increased scrutiny of claims for these plans. This FFS error rate works out to $24.1 billion dollars in improper payments.

With the rancor currently displayed in the Legislative Branch of the government, coupled with the attention-deprived caterwauling that defines the 24-hour cable news environment, it will not be the occasional regional snowfall making December a treacherous time for our industry. Much like the Buick-driving senior citizen in a hat, these and other reports will make the best attempt at getting in the way of a pleasant holiday season. As always, look for an opening, give it some gas and do your best to leave it in the dust, but be aware that you’ll more than likely see them again.

Tags: coding / CPT codes / Denials / Medicare / OIG
7:47 am, December 4th, 2009 |