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Archive for May, 2010

Crossing The Bridge of Hyper-Investigation

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

I have to start this post off by being brutally honest. It’s a bit of a down week news-wise. Other than the fact that Palmetto GBA has now been designated as the MAC for Jurisdiction 11 (West Virginia, Virginia & the Carolinas), there isn’t much of grand importance to report in the world of medical billing. I hope the following paragraphs make sense to all of you. Maybe I’m sitting too close to my terminal today, but what’s below looks borderline insane to me. If you leave a comment, be kind and let me know how I did.

Seventy-three years ago today, the Golden Gate Bridge in San Francisco first opened to traffic.

Man-made marvels can be found all around the world, from the Eiffel Tower in Paris, to the Burj Khalifa in Dubai and the Empire State Building in New York City. For most of us, these assorted modern wonders stand as a testament to human achievement. Having said that, we have learned over the years that most structures of this type have a dark history. Grand designs such as these present dangers to the workers involved in construction, some of whom never live to see the grand opening. Once completed, they tend to attract people from the darker and more unrestrained recesses of the human condition. Nearly three-quarters of a century on, the Golden Gate Bridge has the distinction of being the most popular destination for those wishing to commit suicide on the planet.

Having internalized this bit of gallows knowledge, take the paradigm of buildings and structures as magnets for the unhinged and the sociopathic and apply this to anything that is created with the idea of serving the public good. Our system of law has created lawyers of the ambulance-chasing variety as one of its unfortunate side effects. Given the current state of the economy, one could make the argument that our banking system in its current configuration has attracted people that we don’t usually think of as the friendly, fiscally conservative bankers of years gone by.

In medical billing and compliance, specifically the Medicare and Medicaid programs, the existence of money supplied for public health payable to providers has had the unwelcome effect of attracting all manner of grifters, crooks and thieves looking to fatten themselves at the public trough. 

Eliminating fraud and waste has been a CMS and OIG goal for quite some time. The final report for fiscal year 2009  shows a total of $2.51 billion being returned to the Medicare Trust Fund as a result of investigations. While that can be seen as positive news for the program, it should be viewed as small in comparison to the current stated backlog of nearly 2,800 cases of either health care fraud or civil health care fraud that are currently pending with the Justice Department.

Coming soon to this current climate will be the expansion of the Recovery Audit Contractor program to include state Medicaid programs. RAC’s present an interesting problem in that they aren’t particularly looking at one individual provider’s services or tendencies, but rather coding and reporting norms for certain types of services. I tend to think of RAC’s in the same way as I think about chemotherapy in that it holds the potential to eradicate the good with the bad. It is one of the unfortunate side effects to participation in a publicly funded health program that the honest members of the medical profession are very nearly presumed guilty until proven innocent.

Knowing that investigators cast a wide net can add to the anxiety of a practice who is following the rules to the best of their ability. We all have a common interest in eradicating the worst offenders from the medical delivery system, but it has been my experience that the majority of medical providers want to do the right thing. My advice to the above-board practices is to do their level best to surround themselves with people keenly attuned to changes both within the medical billing industry and their medical specialty. Be the physician who crosses over the bridge, rather than the one who leaps from it.

May 28th, 2010 | 1 Comment »

Of Pay Fixes and Whistleblowers

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Hot Topics, J. Paul Spencer, CPC CPC-H

It has now been roughly 37 hours since I returned home from a vacation in Austin, TX.

A vacation is not usually a time of positive personal accomplishment. From this particular respite, I can say that the only net gains in my column were 4 1/2 pounds of buffet weight, the free beer I had bestowed upon me in an Irish bar on 6th Street from a friendly couple who enjoyed my musical interlude (thank you again, kind strangers) and the bodies of dead bugs from seven different states that now decorate my windshield in all of their Jackson Pollock-esque splendor.

When it comes to a permanent fix to the Sustainable Growth Rate formula (SGR) for Medicare payments, the U. S. Congress accomplished little more than I did during the same period of time.

Currently, there is a plan being floated by the Democrats in the House of Representatives that would delay a permanent fix to SGR until 2015. The plan would provide pay increases for a four-year period. This legislation would again need to advance prior to the latest deadline of June 1, 2010 to avoid the oft-delayed 21.3% cut that was set to originally take place at the beginning of this calendar year.

As with all past temporary fixes that have taken place, this legislation has the effect of kicking the larger problem down the road and feeding the vulture that is the pay cut, which by some estimates could be as high as 37% when 2015 rolls around.

Looking at the calendar, we are again faced with five working days to attend to the latest temporary fix before Congress takes a one-week recess for Memorial Day. This recess is expected to be spent knee-deep in the process of campaigning in an election year. If I had to make a prediction, I would begin to get comfortable with the idea of another CMS-induced delay of 10 business days for claims processing beginning on June 1st until either the legislation above or a different package offering a stay of execution of the current planned pay cut is implemented.

Also greeting me upon my return was another bit of news regarding a study published in the New England Journal of Medicine. The study was conducted jointly by scholars at Harvard Medical School and Tufts University School of Medicine among others, and focused on the effects felt by insiders who decide to file qui tam, or “whistleblower” lawsuits in the pharmaceutical industry. Despite the fact that $9 billion had been recovered due to qui tam lawsuits between 1996 and 2005, the study concluded that there is a high personal and professional toll felt by those who file qui tam lawsuits against their employer.

Twenty-six informants were interviewed for the study, which in addition to the above, led to a variety of findings:

  • 82% were subjected to firing, intimidation or blackballing upon filing the lawsuit;
  • The filing of lawsuits in most cases is precipitated by a job change, such as a promotion or other career change that makes the person privy to inside information about company operations;
  • Most of the whistleblowers attempted in vain to find an internal remedy to the unethical behavior, but were either ignored, dismissed or given orders to continue the behavior unabated.

 

What jumped out at me was that last bullet. With 90% of fraud suits starting with the qui tam process, I find it amazing that after years of awareness of the consequences of non-compliance, the primary reaction of companies whose policies are questioned from the inside tends not to be “OK, let’s investigate and if necessary, fix this”, but instead defaults to “Don’t rock the boat”.

The study recommended several steps to improve the qui tam process, including better employee protections against retaliation, increased resources for the U. S. Justice Department for enforcement (over 1,000 qui tam cases are pending currently with the department) and rewards for insiders that are equitable based on the dollar amount of the fraud that is uncovered.

The co-authors also recommended that policymakers try to instill an ethical sense that encourages more people to come forward. While that is a noble endeavor, it is also up to the companies themselves to operate in an environment of ethics and integrity that encourages the solving of problems as they arise, rather than the time-honored tradition of sweeping the problem under the rug in hopes that problems disappear permanently. 

To put it another way based on recent personal experience, if you’re driving the same road without windshield washer fluid and the bugs are continually hitting your windshield, there will come a time when you can’t see where you’re going and you lose direction.

May 21st, 2010 | No Comments »

Avoiding The Hidden Dangers of Compliance

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, J. Paul Spencer, CPC CPC-H

I come to you a day early this week at the beginnings of a vacation.

My one-week break (save for this space) started with an interesting occurrence in my neighborhood. As my family and I were sitting down to dinner last night, we saw flashing lights coming in from our front window. These lights were the beginnings of what turned out to be a gathering of four fire engines, one fire SUV (the chief drives stag), two police cars and –  one interesting addition to the vehicular melee - an animal control van.  It seems that a house across the street from my own in Milwaukee was discovered to contain a bevy of unattended exotic wild animals, including 5 anacondas ranging in length from 20 to 30 feet.

I am very much a man with concrete in my soul. Due to a contented life of urbanization, annoying allergies and a pathological fear of bugs, I’ve always preferred city life. Say the word “camping” to me and I instantly think of a room on the bottom floor of the hotel. Early yesterday, the list of pluses for city living also included the words “….and no tropical snakes!” at the bottom of it. I guess we can scratch that off now. I used to get a good laugh at the local news’ “man-in-the-street” interviews with stories like this. It’s not so rib-tickling when those sudden TV personalities are your neighbors talking about another person in your neighborhood who decided on his own to start an unsupervised Brazilian zoo in the middle of your block.

Yesterday’s improvised neighborhood reptile round-up was yet another reminder that the world is full of hidden dangers. As my mind races at the thought of what happens the next time I stand in the shower with the water running thanks to my neighbor’s keen interest in herpetology, I also spare a thought to the hidden dangers in the world of medical billing, specifically as it relates to compliance and government audits.

I try to explain it to the laymen in the following fashion: every bit of information that goes out on a typical health claim to an insurance carrier has the potential not only for denial, but for larger compliance problems down the road. Try this exercise: find a blank CMS-1500 form some time and start from Box 1 in the upper left hand corner and work your way down all the way to Box 33b in the lower right. In each box, identify a reason for that box as to why a claim would be denied by an insurance company. Depending on the payer, the reason for the claim, the services being claimed, and a host of other factors, an experienced biller or coder should be able to identify errors that could occur with at least 20 fields that could potentially lead to a claim denial. These could be as simple as “Date of birth entered incorrectly” to “CLIA waiver number not included in Box 23 for a governmental payer”

The compliance view doesn’t stop there. The last question that should be asked before a claim is prepared for billing should always be “Do the services reported on this claim best represent what is documented in the patient’s medical record?”. If there is any question whatsoever of the answer being a firm “Yes!”, It’s best to give the claim a second look.

With some regulatory teeth provided by the Patient Protection and Affordable Care Act, the compliance landscape for providers of all specialties is about to morph into something more intense than we ever could have imagined just 10 years ago. Five years from today, more sets of eyes will be looking at medical claims than ever before, thanks to an alphabet soup of regulatory agencies both currently in existence and still on the drawing board. Now is more than past the time to internalize the idea that the contents of every claim, much like the house full of serpents down the block, is something that should be taken very seriously.

May 13th, 2010 | 2 Comments »

PECOS, A Class Action & People Who Sit On Their Hands

Posted by J. Paul Spencer, CPC, CPC-H in Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

A few tidbits of information were released over the past week that affect providers. Below is a summary of these important updates:

PECOS – Originally, the deadline for performing and ordering physicians to have their provider enrollment information updated in the PECOS system was January 3rd, 2011. This past Wednesday, CMS released an interim final rule that moves this date up to July 6, 2010. From the date of this writing, this now gives providers 60 days to complete re-validation in the PECOS system.

One thing to keep in mind is that this affects all providers. If a physician performs services or furnishes items that were either ordered or referred by a provider who is not updated in the PECOS system, the performing physician possibly faces claims denials for services rendered.

UHC Class Action Lawsuit – If you are a provider who has billed a United Healthcare insurance product in the past 8 years, chances are you or your billing entity received a mailing in the past ten days informing you of an impending settlement of a class action lawsuit brought against UHC.

The suit was originally filed by the American Medical Association and was in relation to UHC’s and their subsidiaries’ method of paying benefits for out-of-network claims from a period beginning on January 1, 2002 and ending on May 18, 2010. If you as a provider furnished out-of-network services for a UHC or allied insurance after this date, you may qualify for a portion of the negotiated settlement amount, currently listed as $350 million.

If you fall into the above category, you now have until October 5, 2010 to file a claim for payment from the settlement fund. If you yourself have not received a mailing from UHC, the AMA has set up a resource link on their website.

Pay Fix Update – And what would a weekly industry roundup be without yet another update in the continuing soap opera that is the delayed fix to the physician fee schedule?

The latest deadline for the implementation of the 21.3% cut to physician fees is now May 31st, but given the painful lessons we have learned about the American legislative process throughout the Winter and early Spring, the actual deadline date to look at is June 14, 2010. CMS has shown their willingness to delay claims processing for the full limit allowed by law of ten working days after any deadline in order to give Congress more time to work on the problem. So far, the Congressional solutions brought forward have been akin to fixing a traumatic amputation with packed mud and a loosely fastened oily rag. I can only imagine which suddenly cost-conscious senator will get on his or her soapbox this time out and complain about costs. 

Adding to the debate on a permanent pay fix was a Congressional Budget Office report of costs associated with the fee schedule being kept in its current form through 2020. CBO estimates a cost of $275 billion for that time period if no adjustments are made to the fee schedule. It remains to be seen how this report will be spun by both sides in the upcoming debate.

National media interest in a permanent pay fix was beginning to increase before the cataclysmic events in the Gulf of Mexico changed the Beltway focus from health care policy to energy policy. With the impending Memorial Day holiday, I fully expect this topic to be handled in the needlessly sloppy and emergent way that it has been addressed in the recent past.

May 7th, 2010 | No Comments »