Secure Transfer System »     Client Portal Access »

Archive for October, 2010

A Halloween Tale Of Medical Travail

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

“The barren trees of late Autumn, as if sketched against the sunset sky with a piece of charcoal, tapped in the wind against the windows of an operating room at Rhode Island Hospital. A patient was being wheeled away as a surgical technician wondered why there was one less drill bit in the OR than before…”

Rather than being the beginnings of an Agatha Christie mystery or yet another book by H. P. Lovecraft about reanimating the dead, what you have just read is the beginning of a story that led this week to the imposition of a $300,000 fine against Rhode Island Hospital. The missing drill bit was discovered to have been left in the patient’s head during brain tumor surgery. One wonders if this was discovered because the patient’s head kept pointing to Magnetic North, as the hospital didn’t follow an internal protocol of performing a postoperative x-ray in the OR when it is discovered that a surgical instrument is missing. Shortly after this incident, the same hospital had a similar incident involving a pair of forceps being left inside a patient’s abdomen.

While the above story is newsworthy, we have come to realize that medical mistakes have become problems that require increased attention. In an earlier posting in this space, I talked about steps taken in this year’s OIG Work Plan towards determining whether the quality of care provided is deserving of Medicare reimbursement. This goes hand in hand with fairly recent CMS efforts to eliminate payments to hospitals for “never events” and hospital acquired conditions. The two examples above topped a list of these occurrences first implemented in 2008 and which continues to expand.

As Rhode Island Hospital so unceremoniously discovered, having protocols in place is not the problem-solving panacea to adverse patient care events in a health care setting.  Incidents like the one above shed light on the inherent problems of this approach, not the least of which is that human beings are still the predominant providers of medical care. Given this fact, we tend to look for better, less spooky paths to improved outcomes.

With the current Halloween candy-like incentives being offered for implementing an electronic health record (EHR), the medical community seeks news of a positive return on this particular investment. Yesterday, CompTIA, an information technology trade group, released a study that gives a snapshot of EHR adoption. The study showed that roughly 50% of all physicians are using either a complete or partial EHR in their practices, which is a heartening figure given that the incentive payment period begins in 2011. Due to its source, the report included no news of how EHR adoption is affecting patient care. While some preliminary studies have yielded results showing that an EHR can be of great assistance toward favorable patient outcomes, the medical world awaits a larger volume of hard data to show this beyond a shadow of a doubt.

Another horrific element of the equation are the many different conceptions of “quality care” held by the patients themselves which become the great intangible in this debate. On one end of the scale is a person like me, who sees his doctor either once a year or in cases of abnormal bodily processes that I myself am unable to stop. The opposite end of the patient care spectrum is the malingering patient who looks forward to further testing for nothing in particular. In cases like this, can it be accurately determined whether a poor outcome is a patient’s frightening perception or the cold, skeletal deathly hand of harsh reality? 

Of all the ghastly and gruesome stops along the road to improved outcomes, medical providers are about to find that worst among these is declining reimbursement for care determined to be avoidable or unnecessary. As Rhode Island Hospital discovered this week, the path to providing consistent and quality care requires continuing effort and eternal vigilence against the dark forces who pay for care, but cheer up. In the end, the road is not half as scary as the effect of this on the world of acting. Now that’s terrifying!

Tags: ,
October 29th, 2010 | No Comments »

The RAConteur: Warnings = Trend

Posted by J. Paul Spencer, CPC, CPC-H in J. Paul Spencer, CPC CPC-H, RAC / Recovery Audit Contractors, The RAConteur™

I try as best as I can not to be a social theorist around people I know, reason being is that the conclusions I tend to draw are uncomfortable realities for people who see themselves as above the fray. The two primary theses I reach are that people generally do not really listen, and when confronted with a truth, a random person has a rather naive tendency to believe that the particular fact doesn’t affect them personally.

I include myself in this group. As an illustrative example, until very recently, I never wore a seat belt in my car. When I add the fact that in 1988 I had an automobile accident in which my car spun out, hitting a stone wall and ejecting me out of my car headfirst through the back windshield, my friends do a combination of bugging out their eyes and adding the local mental health complex to the speed dial on their cell phones. The truth of it is that after surveying what was left of my old car, had I been wearing a seat belt, I would have been dead at the age of 22.

What convinced me to wear a seat belt? One would think that setting a good example for my 4-year-old son had something to do with it, but that wasn’t it. The impetus of my change was that I got ticketed for it in downtown Milwaukee as an adjunct to mistakenly making an illegal left turn at rush hour. Welcome to America, the place where nothing exacts change faster than someone you don’t know or like making you pay for your bad habits.

What a perfect stepping-off point in today’s narrative to turn our attention to expanded audits of medical services billed to Medicare and Medicaid.

This week, I received two more examples of warning shots fired from two Medicare Administrative Carriers signaling what’s ahead in the world of hyper-investigation of physician billing. First, I received a CD in the mail from National Government Services, the Part B MAC for New York, Connecticut, Indiana and Kentucky. The CD was a compendium of all education materials from the carrier related to the Comprehensive Error Rate Testing (CERT) program. In reviewing the materials, it was interesting to note what topics received the most attention, namely E/M services, physician orders and CMS’ updated signature requirements.

On this particular CD is a 60-slide PowerPoint presentation about the common pitfalls of E/M coding and documentation. Roughly 25% of this was related to time-based E/M coding, including critical care and prolonged services. I found this to be significant in that most of the physicians I’ve ever spoken to hold an unwavering belief that time documentation is the overarching solution to all the intangibles of E/M documentation.

For critical care, a common error was that the time was not documented at all, which is quite the oversight for one of the few E/M codes where total time is listed as part of the code descriptor. The NGS materials reinforced the notion that when time is used as the main factor in E/M code selection, at least 50% of the time must be spent in counseling and/or coordination of care for the patient. Additionally, the time indicated must be accompanied by documentation of what was specifically addressed during the extended time. 

For prolonged services, a common finding was that the duration and content of the visit was not supported in the submitted documentation. Based on the increased utilization of these codes since the elimination of consultation reimbursement from Medicare at the beginning of 2010, it is extremely helpful for a carrier to spell out the documentation standards for these codes. A perception has crept into physician billing that billing for prolonged services is as simple as time documentation, which couldn’t be further from the truth. As the NGS materials reiterated, the prolonged services must be face-to-face time with the patient, and documentation for the circumstances necessitating prolonged services must be present.

A CERT E/M tip sheet contained on the CD indicated high error rates for CPT codes 99213, 99214 and 99232 and went into the rules for usage, as well as further detail about the documentation standards for each code. This would seem to be consistent with nationwide CERT findings showing high error rates for these particular E/M codes.

Also of note among the materials was a tip sheet related to physician orders. When placed aside the realm of the early returns from the medical necessity reviews of Part A services by the RACs, this information couldn’t be more important. The medical necessity reviews are finding that the orders from the admitting physician are not going far enough to document the subsequent treatment rendered to the patient during an inpatient stay. When Part A services are denied due to medical necessity, Part B services related to the stay end up caught in the crossfire, with denials and recoups being the result. With these findings, conversations are beginning to occur as to whether the perceived value of hospitalist programs nationwide is currently too high. At a minimum, the documentation of the admitting hospitalist is gaining renewed attention, which given the growth of the specialty in the last decade is somewhat overdue.   

The second bit of news I received was from WPS, the current MAC for the state of Wisconsin and seven other states. This past Monday, the results of this carrier’s latest service specific probe were released, this time focusing on CPT code 99233 for the specialty of Family Practice. In the prospective (prepayment) review of 153 services appearing on 100 claims sent to the carrier, 137, or nearly 90 percent, were denied. The reasons were similar to previous probes, with the highest percentage of denials resulting either from lack of adequate documentation of the service or the request for medical records going unheeded by the provider of service. Twenty services were denied, stating that the documentation received did not support a face-to-face encounter with the patient.

The CERT programs and probes such as the ones conducted by WPS serve to set the table for the Recovery Audit Contractors’ expected expansion into Part B services. The many years of findings from the CERT review contractor have served warning after warning about what services are being reviewed. Yet much like the driver without a seat belt, the yet-to-be-reviewed physician has a tendency to ignore all the warnings until the letter arrives in the mail requesting a substantial amount of the doctor’s past income that has long ago been spent. Excuses no longer exist for this particular brand of “it’s too late” moment.

October 27th, 2010 | No Comments »

Changes As The Leaves Fall

Posted by J. Paul Spencer, CPC, CPC-H in CMS, Industry Updates, J. Paul Spencer, CPC CPC-H, Medicare Fee Schedule

The last 39 hours of my life, edited for the reader to not include periods of sleep, have been filled with catharsis and increased awareness that time and change keeps coming.

Wednesday evening, I went to a local concert venue to see Bob Mould, a legend of punk rock and college radio, who informed the audience that he turned 50 a week ago. I have been listening to Bob in his many musical permutations for over 20 years, from the frenetic to the introspective, and despite the fact that it was his usual great show, you begin to feel the metaphorical vultures circling when your musical heroes get the AARP card in the mail. I’m still struggling internally with how I feel about this fact.

Yesterday, I spent the day at a seminar put on by the Wisconsin Medical Society regarding upcoming changes to the Medicare program. With the idea that change can be either good, bad or ugly, depending on how it is approached, I present an assortment of changes for the coming year, complete with hypnosis exercises to temporarily distract you from just how terrible the results of some of these changes could be.

As you lay back and begin to relax, I can at the very least start with some good news for providers with specialty designations of primary care, internal medicine, pediatrics and geriatrics. Beginning in January, and extending through the end of 2015 (dire Mayan calendar warnings not withstanding), physicians and mid-level providers with these specialty designations are eligible for a quarterly bonus of 10% if at least 60% of the allowed charges are from certain E/M codes. In the same time frame, general surgeons are also eligible for a 10% bonus if they perform surgical services with a 10 or 90-day global period in a Health Care Professional Shortage Area (HPSA).

As I swing a pocket watch in front of your eyes and you feel your eyelids getting heavier, I bring you news of an expansion of preventive care in the Medicare program. Beginning January 1, 2011, Medicare beneficiaries will be eligible for an annual wellness visit. While this development is long overdue, there are three problems with this benefit, the first of which is that any Medicare contracted provider can perform this visit. As only one visit is allowed per year, it will be up to aging patients and frustrated office staff to track one visit in a 12-month span. Second, the “Welcome to Medicare” visit and the new annual wellness visit cannot both be paid within the same 12-month period, which becomes yet another tracking headache. Finally, the documentation standards for the annual wellness appear to be just as onerous as the “Welcome to Medicare” visit. For me, this provides a training opportunity. For the physician community, this represents an opportunity to yell and give dirty looks to the person providing the training.

As you feel all the tension disappear from your neck, shoulders and spine with your eyes completely closed, listening to the cool, clear water running in the happy place of your mind’s eye, I remind you again of the major expansion of payment audits. The Obama Administration has vastly expanded the audit programs centered around the Medicare and Medicaid programs, in addition to the expansion of the Recovery Audit Contractor program into Medicaid in 2011, there is also a relatively new and aggressive entity referred to as the HEAT Task Force, a combined effort by the Department of Justice and the Department of Health & Human Services to make the combating of health care fraud a cabinet-level priority. Recent testimony pegged the amount of fraud in the Medicare system at $54 billion for 2009. The stated goal is to reduce this number 50% by 2012. For those of you in the reading audience who aren’t calendar enthusiasts, there are only 435 days left until 2012. Things are about to get nasty in the audit world.

As you watch glitter-throwing sprites flit above marzipan flowers and waterfalls of pure, sweet Merlot wine, the biggest change is one that has yet to be corrected, this being the ongoing threat of drastic percentage reductions to the Medicare Physician Fee Schedule. Without action in the upcoming post-election, lame duck sessions of Congress, a 23% reduction is set to be implemented on December 1st, 2010. Thanks to the ongoing fire drills of Spring with regard to this issue, we know that CMS can place a hold of ten working days on claims, which makes the actual deadline to fix this life-altering decrease December 14th. As if this wasn’t enough, the fee schedule for 2011 currently includes an additional reduction of 6.1% which takes effect January 1st. It remains to be seen whether the last session of the current Congress will be in the mood to alter a landscape that puts the health care, and by extension the lives, of Medicare beneficiaries, at risk. The Senate being the place where useful legislation goes to die, you’ll pardon me for my skepticism this time around.

When you open your eyes, you will remember everything. Welcome back to the new reality. A snifter of brandy and a few Valium can be found on the small table near the exit.

October 22nd, 2010 | 4 Comments »

The RAConteur: What About DMEPOS?

Posted by J. Paul Spencer, CPC, CPC-H in Durable Medical Equipment, J. Paul Spencer, CPC CPC-H, RAC / Recovery Audit Contractors, The RAConteur™

Afternoon television used to be a place where a person like me could go to satisfy a  fix for classic situation comedies. On days when I find myself eating a vacation day in my living room, I now spend much less time in front of the television, mostly because of the incredibly low quality of advertisers on at that time of the day. What I see is commercials for assorted trade schools, many of which in the modern flat job market are for medical coding careers (which encourage me not so gently to get back to work or else be replaced). These are followed by the ever-popular “Have you been hurt in an accident/worked around asbestos/had a medical crisis due to drug X being prescribed for you” ads from the many now-familiar ambulance-chasing law firms across the country. The third set of ads are usually for power scooters for the elderly. In addition to being amazed at how much thinner the scooter drivers in the commercial are to their real world, 2-miles-per-hour counterparts that I see at my local Target, my thoughts turn, as they are wont to do for a compliance officer, to the world of durable medical equipment fraud.

In my weekly review of health care fraud’s many police blotters, rarely is there a week of reading that does not include at lease one durable medical equipment supplier. In the past 2 years, literally hundreds of millions of dollars in Medicare fraud has been unearthed by OIG and Department of Justice investigations, with the states of California and Florida providing a target-rich environment for DMEPOS fraud investigations.  

With the number of issues related to inpatient hospital reimbursement currently outpacing those of other health care providers, it is easy to overlook the fact that a few DME issues have been approved for investigation by the RAC’s. A quick glance at the active issues lists for the 4 recovery audit contractors indicates that there are currently different levels of engagement in DME audits. CGI, the Region B contractor, has only 5 current approved issues related to DME claims. HealthDataInsights, the Region D contractor, currently leads the pack with 17 active issues. With these facts in mind, I’d like to spend some time today looking at what currently exists on the approved issues lists.

There are 2 specific issues for DME that currently find themselves on the lists of all of the contractors, the most prominent of these being identifying claims for durable medical equipment dispensed after the date of death of the beneficiary. This is an easy issue, as most funeral directors agree that cremation rarely requires a wheelchair. This leads me to the second issue that appears on all lists, which is the unbundling of claims for wheelchair bases and additional options and accessories, with DCS, the Region A contractor, paying particularly acute attention to this issue.

Issues related to the bundling of supplies appear on multiple issue lists, but not all, including the billing of additions or substitutions to different types of knee orthoses, which are not billed separately. Currently only Connolly Consulting, the Region C contractor, is not reviewing these claims. All contractors but CGI are looking at the billing patterns of urological supplies for bundling issues. Two contractors are currently looking at claims for parenteral nutrition solutions, with HDI looking at daily over-utilization and DCS focusing on the improper separate billing of additives to the solutions.     

The dispensing of drugs is slowly becoming an audit focus of the contractors. Connolly, along with CGI, is looking at the unit billing for the asthma drug budesonide, with CGI focusing on the maximum units allowed in a three-month period, and Connolly reviewing  the per vial billing. Connolly is also focusing on the unit billing on claims for the inhalation drugs Perforomist and Brovana. Aside from the drugs themselves, DCS and Connolly are also looking at the billing of pharmacy supply and dispensing fees to verify that these fees are only being reimbursed when accompanied by claims for oral anti-cancer drugs, oral anti-emetics, immunosuppressive drugs or inhalation drugs.

An assortment of other issues exist under the carriers, but it is worth noting that all review issues related to DMEPOS are currently of the automated variety, which is an indicator that DME issues are currently below the radar. Given the scope of the fraud found in this portion of Medicare billing, to say nothing of the fact that not one RAC is currently looking at power scooters for billing irregularities, it appears that the RAC’s have a long way to go, with a number of potential issues still to be considered. It looks like the aisles of my local Target will be clogged with scooters for the time being.

October 20th, 2010 | No Comments »

Your Friday Medical Mafia Update

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

Thanks to the legendary work of Mario Puzo, Francis Ford Coppola and yes, Jimmy Hoffa, for many people in this country, say the word “Italian” in a room with more than 5 people, and the first thing that comes to mind for at least one person is “mafia”. Being half-Italian, I have attempted as best as I can in my life to explain that I came from an Italian family that believed without variation that the Italians involved in organized crime were pigs. My family didn’t so much have piano wire as they did rosary beads. After about 35 years of trying, I gave up and developed an Abe Vigoda as Clemenza impersonation in case the subject comes up again in conversation.

As the new and dumber generation of Italian mobsters have all turned against one another and found new homes under new names in far-flung communities thanks to the Witness Protection program, a new generation of organized criminals have risen up in their place, mostly from countries formerly behind the Iron Curtain. This generation of organized criminals specializes in insurance fraud. As an example, when I lived in Philadelphia, there was a Russian enclave in one section of the city that had mastered the art of faking accidents at great cost to the local public transportation authority. After a few too many claims and a few incarcerations, the large-scale practice stopped. Aren’t we happy that Stalinism taught such a marvelous skill set?

This week, the world of health care met the world of the East Bloc mafia with the arrest of 73 people in 5 states for Medicare fraud. Many of the people involved have ties to an Armenian-American organized crime family known as Mirzoyan-Terdjanian. A man by the name of Armen Kazarian of Glendale, California has been charged as the vor (the Russian equivalent of “Godfather”) of the organization. Kazarian entered the United States fraudulently by claiming political asylum from Azerbaijan, Armenia’s geographic neighbor, in 1996. This same group has extensive experience in insurance fraud, particularly by staging car accidents for false claims, which to me sounds all too familiar.

The size and scope of the Medicare fraud involved is somewhat astonishing given the low overhead of the operation. The organization set up 118 fictitious clinics in 25 states, generating a total of $163 million in fraudulent claims to the Medicare program, resulting in nearly $36 million in payments to the people involved.

The stolen identities of thousands of patients and doctors in the affected states provided the billing data, and the majority of the billing was done out of one office over an auto body shop in Brooklyn, mostly by one woman working the equivalent of sweat shop hours filling out claims.

The intellectual part of me had a good laugh not only about this group being rounded up and perp-walked, but by what types of claims they were billing that eventually caught up with them. The services submitted for reimbursement didn’t pay any particular attention to the specialties of the physicians being billed. This resulted in such improbable claims as an ophthalmologist doing bladder testing,  patient visits to forensic pathologists (coroners; the ones that do autopsies) and an obstetrician performing skin tests.

Three things stand out about this case. First, the sheer scope and size of this fraud is massive. To encompass half the states in the country, including the major population centers of New York, Texas and California, and to do it with such ruthless efficiency, should give pause to all of us in the industry. Organized crime has placed two feet firmly in billing fraud because the sentences for these crimes are light compared to traditional mob businesses such as narcotics. Yet when you add the words “organized crime” to any crime, the acronym “RICO” is sure to follow, which hands down just as stiff a sentence no matter what crime is involved.

Second, the false clinics have been generating bills and resulting in Medicare payments since 2006. With some of the claim examples indicated above, it is obvious that Medicare’s internal claim controls, while strong (after all, the bad guys were caught), could probably use some enhancements.

Last, and most importantly, this and other recent Medicare fraud arrests, demonstrate unequivocally that when it comes to fraud and abuse, we have arrived in a new world. The funding of the Patient Protection and Affordable Care Act (PPACA) will come mostly from fraud and abuse crackdowns. RAC’s, MIC’s, ZPIC’s and HEAT teams are out in force, they are focused, incentivized, growing and are demonstrating that they are very good at their jobs. While the typical doctor doesn’t bill from an office over a Brooklyn auto body shop, audit vulnerabilities are not strictly the problem of the Armenian mob. Like any self-respecting fisherman, the investigative entities are casting a wide net. It is time for every medical provider to ask themselves, “Am I a tuna or an unsuspecting porpoise?”.

Now, if you’ll excuse me for the balance of the day, I’m late for my coroner’s appointment.

October 15th, 2010 | 2 Comments »

The RAConteur: Medicaid RAC’s Take Shape

Posted by J. Paul Spencer, CPC, CPC-H in J. Paul Spencer, CPC CPC-H, RAC / Recovery Audit Contractors, The RAConteur™

It doesn’t take a magnifying glass and a slavish devotion to the news to realize that as our domestic economic troubles deepen, the after effects begin to resemble falling dominoes.

The sudden fanaticism about federal spending has been followed by tough decisions by state governors on how to balance theirs states’ budgets. In this environment of ever diminishing returns, you would think that the very last thing the states would need is a mandate to come up with another program by the end of the year.

You would be wrong.

On the heels of the beginnings of the permanent RAC program, the Patient Protection and Affordable Care Act (PPACA) mandated the expansion of RAC’s into Medicaid services. On October 1st, an 8-page letterwas sent to all state Medicaid directors outlining preliminary time lines and guidance for the Medicaid Recovery Audit Contractor programs. A number of important points were raised in the letter for the programs going forward.

First, states have until December 31, 2010 (that’s 79 days from now) to establish programs to contract with RAC’s to audit payments to Medicaid providers. This will require states to submit a state plan amendment, or SPA, to their CMS regional offices which includes either an attestation of the establishment of a plan or a statement of intent to seek an exemption from the provision. The letter is clear in stating that complete exemptions from the plan would be granted “rarely and only under the most compelling circumstances”. I translate this to be the federal way of saying “never”.

Second,  there was an interesting note regarding contingency fees. CMS expects to publish the highest allowable contingency fee payable to a Medicare RAC no later than December 31, 2013, with this published rate coming into effect for all RAC activity after July 1, 2014. In the interim, the states contingency fee rates should be “reasonable and determined by each state”. States have the option to pay the contingency fees either as a percentage of collections or as a flat fee, but should be structured to offer an incentive to identify underpayments. Given that the Medicare ratio of overpayment/underpayment identification is currently 9:1, coupled with the compressed time frame that states are facing, a majority of these contingency fees will be structured for percentage of collections. 

Third, the Medicaid RAC program is not meant to replace existing cost control programs already in place. The federal rules state that these efforts must continue to be fully funded and uninterrupted. This is where the true usefulness of the Medicaid RAC program will s0meday come into play. I can see a day in the near future, based on the results of the Medicaid RAC program, where states either urge the government to make the Medicaid RAC’s the sole fraud control unit for Medicaid, or they request exemptions from the RAC program. The direction the states take would be based on the costs of maintaining both programs via state budget and which program has the best return on investment.

After initial contracting, states are expected to fully implement their RAC programs by April 1, 2011.

The letter is clear in stating that continuing guidance is forthcoming regarding Medicaid RAC programs. This would appear to be the first of many such letters about to appear. For the physician community, this is yet another entity in the alphabet soup listing of regulations requiring adherence in the near future. For the states, it is one more bombarding salvo of regulatory munitions aimed directly at their already strained budgets.

October 13th, 2010 | 1 Comment »

The OIG Plan for 2011: A New Pattern Emerges

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Industry Updates, J. Paul Spencer, CPC CPC-H, OIG Issues

While zipping through traffic this morning, doing my usual bang-up job of treating the drivers around me like the inconvenient road cones that they are (the truth hurts), I was deep in thought about how best to present the salient points of the OIG Work Plan for 2011 to the world at large.

The last song that I heard on my satellite radio player this morning was “Will It Go ‘Round In Circles” by Billy Preston. This isn’t bad, I thought to myself, as there are a lot of repeating issues making an encore in the new work plan. Then I started dreaming about what I would look like in Billy Preston’s hair because let’s face it, that man had serious hair. Before I knew it, my car arrived at the door of the office parking garage, I still didn’t have an Afro, and I had completely lost my train of thought.

Having returned to the land of the coherent, I took another, closer look at this year’s plan, and discovered two new patterns of investigation emerging that, while not yet directly impacting the bottom line of the provider community, point to an expansion of focus in a few areas.

The first thing I noticed in an understated, yet increased spotlight on quality of care to Medicare patients. A few examples of this include:

  • In the portion of the work plan for hospitals, the OIG will undertake a review of restraint and seclusion-related deaths, looking at the volume of such deaths and what actions were taken based on state investigations of these incidents;
  • In the realm of nursing facilities, hospitalizations of nursing home residents will be reviewed, with the OIG believing that these may be an indicator of quality-of-care issues at nursing homes. The CMS oversight of nursing homes with high rates of resident hospitalization will also be assessed;
  • As part of the OIG’s review of Part B payments for prescription drugs, the costs and usage patterns of Avastin and Lucentis for treatment of age-related macular degeneration will be assessed.
  • The work plan includes a review of services provided to hospice beneficiaries residing in nursing homes, as well as looking at facilities with high percentages of utilization of hospice services. After reading this article in the past week, this couldn’t possibly come at a better time.  

 

These types of reviews appear to be consistent with the quality of care initiatives put forward by CMS and other carriers, who have at long last decided that as gatekeepers of the health care dollar, they want the majority of the money to go to providers and institutions who demonstrate the best patient outcomes.

The second thread had to do with the increasing reliance on private contractors to monitor payments made by the Medicare and Medicaid programs.  The OIG is undertaking reviews of the Zone Program Integrity Contractors (ZPIC) for general performance and disclosures of potential conflicts of interest, The Recovery Audit Contractors’ (RAC) performance will also be assessed. In addition to looking at the quality of the contractors themselves, the OIG will review the value of the program oversight that CMS currently maintains over these programs, as well as CMS’ response to issues raised by the contractors in the course of their audit activities.

I found this second thread interesting, especially coming on the heels of the recent court decision regarding the definition of “good cause” for RAC audits, an answer that by all rights should have been answered either by CMS or the RAC Validation Contractor. It would appear that these types of reviews of contractor activity are overdue. I do wonder whether these appraisals will carry enough substance to accurately assess the work product of the contractors, given the planned expansion of their activities currently taking place. In other words, which came first, Pandora or the box?

There are some repeat topics of particular interest, especially with regard to Part B claims. Despite the end of reimbursement for consultation codes in 2010, the coding and payment of evaluation and management services will continue as a focus of the OIG work plan. Closely following a recently released report from the OIG regarding the large number of claim payment errors related to incorrect reporting of place-of service, this issue has been retained in the new work plan.

When reading the OIG Work Plan (for those of us who are gluttons for punishment), it is important to keep in mind that while this is an important component of combating fraud and abuse in the Medicare program, this is no longer the sole battle plan that it once was. A calculated wager has been made by the current administration that anti-fraud efforts can pay for the many changes put forth in the Patient Protection and Affordable Care Act (PPACA). The efforts behind this wager are going to dramatically alter the current regulatory environment. While the OIG Work Plan for 2011 carries as much importance as it always has in highlighting areas of fraud and abuse, the work of the private contractors will have a tremendous effect on the plan going forward. And before you ask, yes, it will be greater even than the hypnotizing effect of the thoughts of Billy Preston’s hair during a morning commute.

October 8th, 2010 | 1 Comment »

The RAConteur: An “Appealing” State of Mind

Posted by J. Paul Spencer, CPC, CPC-H in J. Paul Spencer, CPC CPC-H, RAC / Recovery Audit Contractors, The RAConteur™

I remain to this day a fan of older TV shows. The adults in my life are perplexed at the reasons why I am perfectly happy to waste perfectly good brain cells watching episodes of Quincy from my DVD collection (one mystery is solved; I’m the guy who bought those). I also consider it a victory that I got my 4-year-old son hooked on old episodes of Scooby Doo. In times before sleep, we can often be found watching yet another costumed carnival operator being thwarted by those meddling kids.

While there are dozens of other shows for which I’ll always make time, I chose the two above because there is a thread of aggressive problem solving running through both. When Quincy’s on the case, you know there’s going to be a fight, complete with self-righteous yelling and hand gesticulations, to reach the proper conclusion. If you have a ghost, the Mystery, Inc. kids and their dog, with a healthy balance of skepticism and fear in tow, will solve the problem.

If only the recipients of negative RAC determinations fought this hard.

The American Hospital Association (AHA), in a continuing attempt to monitor RAC activities of hospitals, has established the RACTrac initiative. Part of this program is a quarterly survey of hospital RAC activity. The results of the survey for the 2nd quarter of 2010 have been released and are available in executive summary form here. While most of the findings did not particularly surprise me, one set of statistics jumped out at me, and if placed in the realm of old TV, would make someone like Quincy have a meltdown.

The 1,389 hospitals taking part in the survey reported that only 16% of RAC denials available for appeal are actually being appealed. Of those, only 13% were reported to be overturned on appeal, with the dollar total of those claims adding up to a pittance of slightly over $420,000.

Let’s take a moment to compare this to the appeal numbers released for the RAC demonstration this past June. In that report, 13% of RAC overpayment determinations were appealed, with 64.4% overturned on appeal. While no dollar figures were released in the RAC Demonstration report, it would appear that the volume of successful appeals topped out. Yet the good news for future physician RAC audits is that this may not be the case after taking a closer look at previous data.

Remember that the RACTrac data is only compiled from surveys of hospitals, and not other types of providers. If we look at the final numbers from the RAC Demonstration project, of the 1.1 billion plus claims reviewed by the RAC’s during the project, only 14.5% were from hospital providers. The overwhelming majority of reviews under the demonstration project came from physicians, clocking in at a whopping 68% of total claim reviewed. Despite this large percentage of claims reviewed, these claims made up only 25% of the total dollars audited under the demonstration project, or over $79 million.  

The RAC’s decided to concentrate their audit efforts on facilites based on the return gained during the demonstration project. Nearly 97% of overpayments collected during the project came from facility providers. Despite all of the claims audited from physicians, the effort only returned $19.9 million dollars, or roughly 2% of total dollars in overpayments recovered. With RAC’s being paid a healthy percentage of all recoveries, hospitals have thus far absorbed the brunt of the permanent RAC program.

This stew of numbers illustrate that despite the relatively low appeal success rate in the RACTrac survey, successful appeals under the RAC Demonstration Project had to come from somewhere for there to be such a wide divergence in the two numbers. Is it such a leap to say that physician appeals had at the very least a modest success rate? Having taken that leap, if I happened to be a physician, wouldn’t I then begin to develop an extremely combative attitude towards RAC determinations?

Despite the fact that it appears that non-facility providers have a high appeal success rate, anyone involved with the audit end of the RAC experience can tell you that this is not the time for an overabundance of self-confidence. The RAC’s are being designed to become stronger and more efficient as they increase their focus and learn on the fly. However, in the end, RAC’s are mercenaries, and the only language mercenaries respect is one of aggressive response. The most abrasive approach you can think of can’t help you if your documentation doesn’t give you a leg to stand upon, but when you do have definitive reasons for appeal, fight back with the strength of 1,000 Quincys and the desire of a million meddling kids. The data up to this point says the odds are in your favor.

October 6th, 2010 | No Comments »

How The Economy Threatens Patient Data

Posted by J. Paul Spencer, CPC, CPC-H in In the Press, J. Paul Spencer, CPC CPC-H, Protected Health Information

The other day, I was coming home from work and witnessed a troubling site. A couple roughly my age with their dog in tow, obviously down in the luck department, were walking down my back alley in the city of Milwaukee, going through recycling bins and taking out aluminum cans by the dozen in an obvious cash grab. Because Milwaukee has mandatory recycling, this activity is considered theft of city property and is illegal. As a compliance officer, it may strike some as disturbing that I didn’t report this activity immediately to the police. In my defense, it’s never a pleasant moment when the less desirable realities of an economic downturn arrive so starkly at your door, but it is not my duty as a member of the human race to jeopardize the survival of someone else if I face no imminent or immediate personal threat.

History teaches us that increasing levels of desperation become a threat to everything in their midst. Primary among human instincts is the instinct for survival. If established tools of survival in a civilized society are threatened - the big three being food, clothing and shelter – the instinct for survival becomes its own morality, and begins to look for opportunity.

The official unemployment rate in the United States, also known as the U3 index, stands at 9.5% based on the latest statistics available through August. Being a man ruled by facts, I tend to look not at the trumpeted U3 figure, but the U6 unemployment rate, which measures newly unemployed, under-employed and discouraged workers who have stopped looking for work, but still maintain the ability and the will to work. The U6 number stands at a staggering 16.7% currently, and has been as high as 17.1% during 2010.

Taken hand in hand with the home foreclosure crisis, the overall economic picture is beyond bleak. What the chattering class sees is a recession that officially ended in the middle of 2009. What the general public sees is the same economic system that has shifted from manufacturing to services and concentrated wealth into the hands of the few continuing unabated, with the antique promise of “trickle-down” being exposed as a myth. Thinking that jobs will magically appear with this backdrop has become a proposition that has moved from “difficult” to “unrealistic”.  

It was with this new reality in mind that I read a story out of Los Angeles this week concerning a privacy breach of roughly 33,000 medical records at Martin Luther King, Jr. Multi-Service Ambulatory Care Center (MLK-MACC).

Files stored at the facility were discovered as missing on July 29th, prompting a search and investigation by the facility, which led to two uncomfortable discoveries. First, the files in question may have been mistakenly marked for destruction. Second, and central to today’s post, the records were subsequently stolen by an employee and taken to a recycling center so he could cash in on the value of the paper contained in the files.

With this new piece of information, it’s time to review our threats to HIPAA privacy. We have identity theft, which was a motivation of the very first HIPAA violation and continues to this day. Next, we have potential unfettered access to information, leading to the more gossipy among those with access spewing forth patient medical data to anyone who is interested. Beyond these and other threats, we can now include an unnatural curiosity for the profit motive of renewable resources.

If I am in charge of compliance at any health care organization, after reading this, I expand my privacy and security focus from “How do I protect patient information?” to “What isn’t nailed down?”. The breach detailed above involves equal parts negligence and opportunism, but this leads me to do an informal exercise with the reader. If you are reading this from your job in the health care industry, I invite you to look around you for a moment and find something containing patient data that can be easily transported and either sold or stripped for cash. Chances are this exercise didn’t take long. I know the most obvious answers to this question, but being a compliance officer, it would be irresponsible of me to supply these to you. I mean, who’s reading this in the first place? If you read my writing with any sense of anticipation, there’s something devious about you that’s well-established.  

Anyone who regularly deals with securing protected health information should try to take every threat into account. We’ve long known that your typical identity thief can come into an organization with PHI and wreak absolute havoc. As economic threats to social order continue, I challenge all of those charged with protecting patient data to look outside well-known breach threats and sharpen your focus to include threats posed by the current economy. It is up to each and every organization to determine the best way to assess potential breaches caused by economic circumstances of those with access to data, but as the MLK-MACC breach illustrates, the time to do so has rudely arrived.

October 1st, 2010 | 1 Comment »