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Archive for August, 2010

The Hidden Costs of Mandatory EMR

Posted by J. Paul Spencer, CPC, CPC-H in Electronic Health Records, J. Paul Spencer, CPC CPC-H

From a purely spiritual perspective, one of my favorite musicians of all time was John Coltrane. There have been many musicians who have attempted to become one with their instrument in an attempt to achieve something beyond mere virtuosity who, while technically perfect, ended up being vacant in matters of the soul. Coltrane achieved the lofty goal of connecting the known and unknown world with the power of music to an extent not seen before or since.

Coltrane was known for taxing the patience and constitution of his many band mates. One incident involved a drummer who became so tired of trying to keep up with one of Coltrane’s saxophone marathons that in order to end the solo and earn a break, he felt he had no other option but to throw a cymbal at Coltrane. There is a legendary story about John Coltrane and Miles Davis having a conversation about the physical limits of music. John Coltrane was asking Miles Davis how he could control his innate need to continue to play until the musical resolution was discovered, if at all. Davis, in his legendary, gravelly whisper of a voice, looked at Coltrane and said “Take the horn outcha mouth!”.

I love this story for two reasons, one being that it continues to make me laugh after repeated telling, but more so because here we have a perfect illustration of finding a simple solution to a complex problem.

If only the solution to physician documentation and medical records were so easy. Sadly, as we get closer to the beginning of the incentive period for meaningful use of an electronic health record, it appears that the “solution” offered in the form of mandatory EMR is looking a lot like the beginnings of a Rube Goldberg device.

The Office of National Coordinator for Health Information Technology (ONC) projected this week that 50,000 additional IT workers will be needed by providers across the country in order to meet the meaningful use criteria. Without the gift of a calculator on my desk, I quickly compute in my head that with a maximum incentive of $44,000 over a five-year period (remembering that not every provider will qualify for this dollar amount), you would have to find one IT person at a salary of $8,800 a year to break even. If you’d like to place a wager on your odds of finding this unicorn of the IT world in today’s economy, give me a call.

Let’s look at a timeline for a moment to put this in perspective. In order to qualify for maximum incentives, registration of meaningful use of an EHR begins this coming January. At the time of this writing, that’s 126 days away! The Certification Commission for Health Information Technology (CCHIT) is still reviewing applications for companies that will test and certify EHR systems to determine whether they have the ability to meet the meaningful use criteria. Also in the equation is the plan for regional extension centers to assist providers during the transition. Currently, 5 states lack an extension center and 28 states, including California,  have only one center currently open to offer assistance.

Seventy community colleges across the nation are also part of the plan, offering non-degree training courses for IT professionals to bring them up to speed. While the ONC’s website gives a time frame of “six months or less” for this training, the issue of whether 4 months of instruction prior to registration is sufficient will go unanswered up until the moment when the training is most needed.

We all crave simple solutions. The Great Migration currently underway towards the goal of electronic health records, given the rampant shortcomings of paper records, is a noble goal. Yet I may not be alone in rethinking whether the established timeline to qualify for maximum incentive payments is too short to be of value in the long run. Unfortunately, unlike the removal of a saxophone from one’s mouth, an easy fix does not appear to be readily available.

August 27th, 2010 | No Comments »

Employee Trust In The Modern Environment

Posted by J. Paul Spencer, CPC, CPC-H in Industry Updates, RAC / Recovery Audit Contractors

In this age of increased technology and business consolidation, I’m finding trust hard to come by lately. Standards that I used to take for granted when I was growing up appear to have been forever cast aside.

I’ll offer this illustrative example, since it involves a subject that’s close to my heart. The homogenization of American business has led to every town in this country having at least two fast food restaurants. Off the top of your head, can you think of an instance when you purchased the same meal from a fast food restaurant in consecutive visits and received food of the same quality (I leave out the word “good” because, let’s face it – IT’S FAST FOOD!)? In most cases, either the fries were warmer the last time you visited, or the sandwich hadn’t been sitting under the heat lamp longer than it should have after the lunch rush. Perhaps the person filling up your drink behind the counter stiffed you this time around, either by not filling your beverage cup to the top or by giving you enough ice to cryonically freeze all of your vital organs for the next millennium to accompany the few teaspoons of raspberry ice tea dancing upon the ice cubes.

My inherent lack of trust isn’t exclusive to products I buy. As a compliance officer,  part of my makeup is to trust no one. On the surface, this may seem like a cynical way to view the universe, but I feel confident that no one is going to slip anything by me. I naturally think the worst of people, which allows for few surprises when I end up being right.

Given the focus and pace of a typical medical practice, physicians have little time to consider such matters when it comes to their staff. Most doctors are in a position of being at the mercy of their non-medical employees to keep the practice moving efficiently and cost-effectively. In an economic situation of near-depression such as the one currently in effect in this country, people who find themselves in dire monetary straits seek opportunities based less on moral imperatives and more on survival and maintaining a status quo for their lifestyle. Many targets present themselves for theft, and none is more tempting than the readily available health care dollars of a medical provider.

It appears a good time for providers to take a moment and ask themselves how much they trust the ancillary staff. With the instances of identity theft stemming from access to patient medical records on the rise,  there is a risk that potentially lies within every person in the reimbursement chain. When someone does something in your name, whether you want to or not, you now have ownership of that person’s actions. While the financial impact of a nefarious employee can be minimized, the effect on your reputation, depending on the scope of the infraction, can lead to long-lasting damage to your practice.

Depending on the length of service of current staff, due diligence in the form of background and credit checks are a simple and cost-effective way of mitigating this risk. In order to feel secure, the psychological hurdle of the feeling of “prying” has to be weighed against the risks posed by the possibility of misdeeds.

We now find ourselves on the brink of a period of increased scrutiny from governmental payers. With the coming expansion of the Recovery Audit Contractor program, coupled with increased investigations from a larger and more aggressive OIG, being able to trust the work product of ancillary staff will be of paramount importance in positioning your practice for the gathering storm of hyper-analysis. Allowing yourself a few moments of skepticism before entering this new era can give you the peace of mind necessary to prepare for the coming environment.

August 20th, 2010 | No Comments »

Surviving The Times

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services

Being an obsessed fan of music as I am, I’ve realized over a period of time that it’s difficult not to develop something of a fascination with self-inflicted casualties and the personalities behind them.

I’ll give you an extreme close-up of a salient example relating to my own life. In 2004, due to a number of life circumstances that I won’t get into here, I made the decision to change my birth name. I began thinking of musicians that I admire, and I revisited the story of Alexander “Skip” Spence.

Skip Spence was the first drummer for the Jefferson Airplane back in 1966 (the year of my birth). He was something of an itinerant and kept his own mental schedule, which was incompatible with the rest of the band, and he was fired prior to their greatest success as a band. He later took his guitar-playing and songwriting skills to the band Moby Grape, another San Francisco band of the era. Through a series of record label miscalculations and ludicrous promotional planning, Moby Grape became the gold standard for how not to succeed in the music business, but Skip Spence wrote, and the band performed, the song Omaha, which is a musical touchstone of the era.

Skip was also a victim of the attitudes and excesses of his time. During the sessions for Moby Grape’s second album, Skip descended into madness fueled by excessive intake of LSD, to the point where he showed up at the studio one day in 1968 looking for the band’s drummer while carrying a fire axe. He spent the remainder of his life battling advanced mental illness until his death in 1999 at the age of 52. To mercifully abbreviate this long story, inspired by the unique music he left behind, I am now known to the world as John Paul Spencer. I added the final “r” so as to not appear as too pretentious to the world around me.

While the history of recorded music has its share of self-abuse stories similar in outcome to what you’ve just read, not all self-inflicted casualties of their times occur consciously. The many companies and corporations who have come and gone since the Industrial Revolution disappeared because they could not adapt to changes in products, demand or business conditions.

Today our medical delivery system finds itself at just such a crossroads. Over the next four years, business principles such as comparison shopping, outcome measurements and diversification are going to be applied to medical practices and hospitals in ways not previously seen.

Take a moment to internalize just how much of a philosophical shift this represents to a physician in private practice. At its core, we are now instructing a person who spent 10 years of his or her life (at great monetary expense) in rigid study and training towards their life’s occupational goal, to learn flexibility. Medical delivery by its very nature is tightly controlled, not typically lending itself to improvisation or random chance. Most established medical problems have been researched, measured and treated to such a degree that treatment protocols zero in on the problem faster now than at any time in human evolution. As the gatekeepers of this collective knowledge, physicians are trained to eliminate all questions, diagnose and treat.

Many smaller medical practices now find themselves in a time of soul-searching. Due to the technical demands brought about by healthcare legislation over the past two years, a perception is beginning to take hold that the independent physician cannot survive and will either have to merge with another larger practice or seek a health system affiliation. Add to this the increased anxiety over the expansion of fraud and abuse investigations by Medicare and other large payers, and the medical marketplace suddenly becomes threatened with shrinkage not from consolidation, but rather attrition similar to the long-lost corporate brand names of the past.

Beings and entities survive based on the ability to adapt and successfully navigate the harsh nature of their surroundings. The human advantage in this equation is the gift of critical thinking and analysis, leading to judgment. Each provider of medical services has within them a unique area of expertise, focus and patient approach that differs from their colleagues in the marketplace. Rather than being a self-inflicted casualty of the changing times, it now becomes the responsibility of each physician to let the world know what it is about them that makes them stand out among their medical brethren. I believe that the identification and greater application of this proficiency holds the key to surviving the changing landscape of healthcare delivery over the next decade.

August 13th, 2010 | No Comments »

Court Ruling Obliterates “Good Cause” for RAC Audits

Posted by J. Paul Spencer, CPC, CPC-H in CMS, Hot Topics, RAC / Recovery Audit Contractors

Life is nothing without meaning.

As a demonstration of this statement, imagine for a moment that everything in your life that has some kind of fixed value or representation suddenly shifts. Here are a few illustrations to help you: the nickels in your pocket are now worth nine cents, the dishwasher in your kitchen is now used for the cleaning of clothing and your family dog is now an animal known as a boopwiffle.

To the best of our abilities, we have attempted to assign shape and definition to everything that exists. The moment of debate occurs when someone else applies a different set of definitions to things in our world with a long-established value. Depending on the new person’s definition, the result is either a clearer understanding of the things that surround us (such as someone like Copernicus or Galileo) or a complete and total breakdown of established order, leading to chaos. Last week, a judicial decision was handed down from a U. S. District Court in a case involving a hospital and a Recovery Audit Contractor that, if left to stand, could hold dire consequences for all providers of medical services paid by the Medicare program.

In February of 2009, CMS issued Change Request 6157, that stated that a contractor could go back as far as 4 years to reopen an initial determination on a claim, provided that the contractor has ”good cause” for the reopening. Specifically, this update clarified what constituted new and material evidence needed to substantiate good cause. The Change Request stated that the information has to be something that was not readily available at the time of initial determination. There was a key passage in this document that was at issue in last week’s case:

“A contractor’s decision to reopen based on the existence of good cause, or refusal to reopen after determining good cause does not exist, is not subject to appeal.”

The plaintiff in this case sued the Department of Health & Human Services, stating that a RAC auditor reopened a claim 20 months after the initial determination without sufficiently providing just cause for the reopening. The final decision of the judge was that a decision by a contractor to reopen a claim is not subject to appeal, regardless of whether “good cause” exists.

In summation, this decision means that RAC’s and ZPIC’s no longer have to follow any rules for the reopening of claims. No appeal rights are available to any provider to force the disclosure of a reason for claim reopening and no court can provide relief. Any contractor can reopen any claim at any time for any reason, and CMS isn’t interested in monitoring contractor reopenings to determine whether good cause exists.

While the RAC program as designed on paper was to find both overpayments and underpayments, there is no financial incentive for the RAC’s to identify both with the same veracity. If one factors in that RAC’s keep anywhere from 9% to 12.5% of all overpayment dollars collected depending on geographic area, the judge’s decision has devastating potential.

If I were to identify one silver lining with regard to the RAC’s, it would be the success rate of appeals of RAC determinations. Currently, 8.2% of all RAC decisions have been appealed by providers with a success rate of 64.4%. This indicates a high error rate on initial determination, and provides a great argument for internalizing an inherent mistrust of any RAC determination. Thanks to a short-sighted court decision, appeals against a RAC as it relates to the administration of statute are limited. Yet if the decision of the RAC as it relates to the payment determination for services seems incorrect, anecdotal evidence strongly suggests that it is, and that’s worth an appeal.

I can’t promise that the process is as easy as taking your boopwiffle for a walk around the park, but half of survival is the art of making yourself an unappealing target for predators. An aggressive response is a provider’s best defense against continued RAC audits.

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August 6th, 2010 | 2 Comments »