Secure Transfer System »     Client Portal Access »

Archive for March, 2011

PPACA: One Year Later

Posted by J. Paul Spencer, CPC, CPC-H in Health Care Reform

On the 13th of March, my wife and I celebrated our 6th wedding anniversary. We found out that the 6th year is the iron anniversary. We commemorated this by going out to dinner and seeing the film Black Swan. I’m still trying to figure out what a chicken sandwich and the latest celluloid self-abuse fest from Darren Aronofsky have to do with iron, but nothing made of this particular element struck our fancy.

The first anniversary is celebrated with paper, and do I ever have a chunk of paper with which to celebrate the latest one.

This past Wednesday marked the first anniversary of the passage of the Patient Protection and Affordable Care Act. The 2,409-page document, despite a few current legal decisions to the contrary, remains the blueprint for expanding health care coverage to as many citizens of the United States as possible by 2014.

The last year has been an odd journey for this law. In the past year, we’ve seen the House of Representatives switch parties, with the new party putting forth as their first piece of legislation a full repeal of the Act. We’ve seen two judicial votes against and three votes for implementing the act as it is currently written. We’ve seen Aetna and Cigna, two of the richest corporations in America, look the government in the face and tell them that they couldn’t afford to provide their employees with the minimum coverage mandated in the act, and the government believed them and granted a waiver.

With all of this in it’s first year, the biggest threat to the implementation of the act as written is currently one that rumbles under the surface. The creation of state-run exchanges and the expansion of Medicaid coverage mandated in the Act is encountering the roadblock of America’s lingering economic quagmire. An almost genetic unwillingness to raise revenue from the upper end of  the existing tax base is leading many state legislatures, including my own, to cut every service for everyone unfortunate enough not to be able to afford a seat at the lobbying table. One of the prime targets across the country has been Medicaid spending. State budgets are a mess, and excitement about expanding Medicaid, especially for bigger states such as Texas and California, is non-existent.

A few weeks ago, President Obama attempted to bridge this divide by proposing to change the time frames for state innovation waivers from the current 2017 to 2014. It’s a calculated gamble from an administration seemingly saying “if you can do it cheaper and provide the same level of coverage, while not increasing the federal deficit, be my guest”. Unfortunately, the audience for this message consists of the same states who are suing to negate the Act prior to that date. The states of Vermont and Massachusetts, who were uniquely positioned from standpoints of politics and existing policy prior to PPACA, would appear to already qualify for the waiver.

One part of PPACA that is going well is anti-fraud activity. $4 billion was collected in fiscal year 2010. We have yet to hear the final numbers for the Medicare RAC program for 2010, but all indications are that the number will provide enough encouragement to expand the program to Medicare Parts C & D some time in 2012. The Medicaid RAC program final rule is due later this year.

For its paper anniversary,  PPACA is creating and giving more than it’s receiving. A majority of the goals of the legislation are still three years away, but the journey of health care reform continues.

Tags: , , , , ,
March 25th, 2011 | No Comments »

The RAConteur: Still Catching You Unprepared

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

People are never prepared for a surprise.

As I look at that last sentence, I realize that all of the great surprises foisted upon humankind, both positive and negative, have been done. Someone walks into a room full of friends and balloons on their 50th birthday, a baseball is fouled off and somehow ends up in a fan’s hands, Pearl Harbor, auto accidents and (of late) natural disasters are just some of things that continue to surprise people.

Surprises bring with them equal parts discomfort and risk, and so it is with the RAC program as it applies to the physician community. I have spent the better part of the last seven months educating providers about the risks of a RAC audit to their practices. I have taken the extra step of letting doctors know what codes will more than likely be in the cross hairs. At the end of the day, I’ll still find physicians who fall into one of three categories who will completely ignore everything I continue to say:

The “But-I’m-So-Small-They’ll-Never-Come-After-Me” Group – Whenever you are dealing with an entity that works for the federal government, size doesn’t matter. The only things that matter to a RAC are 1) utilization patterns and 2) finding easy contingency fees. You can be the country doctor in a rural town of 200, but if your billing patterns are outside the norm, let me pre-empt an upcoming surprise for you: you are going to be the subject of a RAC audit.

The “I-Just-Bill-Every-Patient-At-Level-3″ Group – Ah yes, the magical, mythical road of perceived safety known as “the middle”. You know the ones in the middle. They’re the ones at the party observing everyone else having a good time, never approaching anyone for conversation, hovering around the peanut bowl like a vulture targeting carrion, going home satisfied just to have survived. Meanwhile, the host is stunned at how few peanuts are left at the end of the party. The providers who take the middle approach damage everyone by skewing utilization, but do the greatest damage to themselves by telling the world that true medical necessity doesn’t exist in their world. Patients with multiple chronic illnesses exist on the same plane as rashes in this universe. Your surprise is coming, too.

The “What’s-A-RAC?” Group - Isn’t it amazing how this random collection of letters I compile every week in this space add up to no clear message for physicians in this group at all? The time to learn about recovery audit contractors is most definitely not when you receive a request for either records or money as a result of an audit. I’ll remind doctors in this group of a common theme that runs through all of my RAC education. Recovery dollars are not just sitting around in a big pile in a safe somewhere. Those dollars have already been reinvested back into your practices, and paying it back could be devastating to your bottom line. Your coming surprise will be twofold, and both will be unpleasant in nature.

The way we mitigate unwelcome surprises in our lives is to prepare for the worst. From auto insurance to long-range radar to skipping town for your 50th birthday, we have tools at our disposal to deal with life’s curve balls before they are batted into our laps. The permanent RAC program has been up and running long enough for everyone in the provider community to now internalize that this is real, it’s a threat and it’s not going to stop anytime soon. Change is difficult, but change in the midst of an entity taking away monetary resources is impossible.

Tags: , ,
March 23rd, 2011 | No Comments »

No Saints In The Healthcare Industry

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

With more than 20 years in the health care industry, one thing that I have become used to is the constant finger-pointing regarding who’s to blame for our current health care troubles. If you listen to the physicians, declining reimbursement is the largest threat to their practices. If you listen to insurers, it’s the fault of doctors for ordering unneeded services and driving up costs. If you listen to Medicare, the biggest problem is fraud.

In some sense, all of these groups are right, but after seeing three stories this week, I’ve come to the conclusion that the ills of the Health Care Industrial Complex are everyone’s fault, including some entities not previously mentioned above.

The first story hit my inbox this Monday, and it came from the OIG. A review of Medicare Part D claims from 2007 and 2008 revealed $3.1 million dollars in improper payments for erectile dysfunction drugs, which are excluded from coverage. As the reader giggles, I can tell you that this was due to Part D listings that were incomplete. It would be all Medicare’s fault in this case, except for the fact that additional claims for these drugs continued to be paid after the exclusion lists were updated. For this story, Medicare and their contractors get a thumbs down.

The next update came on Tuesday in the form of a report released by the advocacy group Public Citizen. According to the report, 55 percent of the nation’s doctors who had either lost clinical privileges or had their privileges restricted by hospitals were never disciplined by their state medical boards. Among the 5,887 physicians who never received licensing actions were 220 who were identified by their hospitals as being an immediate threat to patient health and safety. The state medical board with the worst record of licensing actions is Hawaii, where 77 percent escaped sanction. The best record belongs to the Colorado State Medical Board, where only 31.6 percent had no licensing action. Sixty-one percent of the physicians who were never sanctioned lost their admitting privileges for either a year or permanently. While a few bad apples do not spoil the whole bunch, the lack of uniform willingness of physicians to discipline their brethren leads to a lack of trust in the medical delivery system. For this story, doctors and those who oversee them also get a thumbs-down.

Finally, we have a story from today. The Government Accountability Office released a study showing that nearly half of all commercial insurance claims are reversed on appeal. The largest reason for this was due to missing information or billing errors on the original claims. On the one hand are insurance reimbursement rules that make it diificult to submit a clean claim upon first submission. On the other hand, you have people making coding errors, leading to unnecessary delays in payment. Since this is my article, I give both insurance carriers and coders thumbs-down.

As a certified coder, I have been concerned that medical coding has moved up the ladder to being the new “hot” industry. Afternoon television offers commercials from technical schools offering courses in medical coding sandwiched between ads for ambulance chasing attorneys and power mobility devices. More and more coders are becoming certified after entering health care from other industries. At a certain point, someone has to put forward the comparison of quality vs. quantity and make a determination as to the strength of individual certifications.

If you dig deep enough into every group involved in health care in the United States, you find something objectionable. Our government has come up with ways for more people to have insurance, but it is stories such as the ones above that demonstrate pressing oversight needs on many fronts. To reach a higher standard for our system will require multiple parties insisting on accountability for those in the industry with poor results.

Tags: , , ,
March 18th, 2011 | No Comments »

The RAConteur: Medicaid RAC Update & Shameless Plugs

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

March is a good month to read maps and learn geography. Tomorrow, the NCAA basketball tournament begins, and as sure as there are a number of colleges who are familiar to those with only a passing interest in college sports, there are always a few schools that require further study, and sometimes a map. I had never heard of Belmont University until this past Sunday, when this year’s tournament bracket was announced and this small school in Nashville, Tennessee came up as Wisconsin’s opponent in the opening round.

In the RAC world, a useful map was released a few weeks ago for the Medicaid RAC program. While the program itself currently exists in a state of suspended animation between a proposed and final rule, states have been submitting state plan amendments (SPAs) to CMS for approval in advance of the program.

The map, entitled “State Medicaid RACs At-A-Glance”, shows the status of approvals for SPAs throughout U. S. states and territories. As of this writing, the map shows that every state and territory has submitted an SPA for approval, with 23 states and 4 territories having had their SPAs approved. The map also shows whether a selected state has filed for an exclusion from the Medicaid RAC program, and also reveals that virtually every state has adopted contingency fees as a RAC fee structure.

With all of this information in one place, one thing that is lacking is a listing of RAC contractors by state. As I referenced in an earlier post, CMS is working on a transparency initiative to bring this information forward.

This brief piece of news today leaves me with room for a plug. Next Thursday, I’ll be presenting, in conjunction with the Wisconsin Medical Society, a webinar entitled RAC Audits: Guidance for the Physician Practice. This 75-minute webinar will provide an overview of the Recovery Audit Contractor program and highlight best practices for physician practice response. There is still time for registration for this webinar by visiting this page.

I now retire in preparation for my annual one-day St. Patrick’s Day ”retreat”. F0r those who know me personally, feel free to sign onto FourSquare as I document the atrocities.

Tags: , ,
March 16th, 2011 | No Comments »

Does Health Reform Stand A Chance?

Posted by J. Paul Spencer, CPC, CPC-H in Health Care Reform

As anyone who knows me can tell you, laughing is my favorite activity. For the most part, I’m an easy audience, but my favorite kind of comedy usually involves one central character with demonstrated acumen at the center of a world that is crumbling around him, despite his best efforts. Groucho Marx was an absolute master of verbal comedy, but the magic of the Marx Brothers lies with his Harpo and Chico foiling his most well thought out plans with slow-burning lunacy.

Another favorite of mine was Benny Hill. Thanks to my long-term viewing of his show in reruns on American TV when I was younger, whenever I hear “Yakety Sax” by Boots Randolph, I immediately associate it with chaos. It is with this musical gem playing in the never-ending jukebox of my mind that I look upon the current landscape of health care reform in America.

It’s been yet another confusing week. The first news was of action taken was by Judge Roger Vinson in Florida. This was the jurist who ruled the entirety of the Patient Protection and Affordable Care Act unconstitutional back in January, based on the narrow belief that the effects of the individual mandate on the other 450 or so provisions in the Act couldn’t be ascertained, thereby voiding the entire law. On March 3rd, over the length of 20 pages, in a self-serving  judicial equivalent of a temper tantrum, Vinson demanded that the Department of Justice expedite their appeal of his ruling, while at the same time granting a stay of his declaratory judgment against PPACA.

The wording of the 20 pages is widely seen as response to criticism that his original ruling in the case was a case of activism and overreach, seeing as three federal judges have ruled the Act constitutional. When the Justice Department submitted a motion to clarify the judgment, Vinson responded in imperial tones of annoyance that the Obama Administration dared wait 2 1/2 weeks to file the motion. “It is possible that the defendants may have perhaps been confused or misunderstood its import”, said Vinson of his original ruling, a quote that would carry great weight had Vinson been elected Czar, rather than appointed as a district judge. Judicial experts state that it is rare for a District Court judge to insert themselves so bluntly into Appeals Court scheduling.

All of this posturing currently changes nothing with regard to the implementation of the Affordable Care Act, but a press release from HHS yesterday gives me pause about the Act’s viability and the emotional state of the Executive Branch. One provision of the ACA involved “state innovation waivers”. These waivers were to be granted to the states beginning in 2017 to states that have created insurance infrastructures that provide at least as much coverage at the same or less cost as what is mandated in the Affordable Care Act for state insurance exchanges, without increasing the federal deficit. The press release stated that the Obama Administration now supports legislation that would grant waivers beginning in 2014.

While this press release sounds innocuous enough, consider the backdrop for a moment. We have 26 governors suing to keep PPACA from being implemented who have thus far shown no interest in beginning the process of putting the law into place in their states. We have a judge in Florida who is stomping his feet to fast track this legal challenge, and we have a House of Representatives that has already voted (mostly symbolically) to cancel the entire law. Taken as one, this appears to be a political move aimed more at the 2012 election cycle. By moving up the waiver date, Obama is attempting to show that states in the hands of the opposite party are penalizing their own citizens by challenging the constitutionality of the law, rather than attempting to provide affordable coverage to their residents.

I’m seeing more than a little fear from the administration in this approach. The administration realizes that a change in the executive branch in 22 months spells the end of PPACA. It remains to be seen whether the President’s calculus of redirecting the spotlight will be successful, but between the lines of the press release is a realization of the consequences if he fails.

And so concludes the week in health care reform news. It’s not Harpo Marx stomping barefoot in a tank of lemonade, or Benny Hill running away from an angry mob, but it brings forth its own brand of chaos nonetheless. Cue the saxophones!

Tags: , , ,
March 11th, 2011 | No Comments »

The RAConteur: Expanded E/M Service Reviews Arrive

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

I’m not the kind of person cut out to deliver bad news. I’m better at spotting trends, firing verbal flares and watching as people ignore my advice in the same way that Gene Hackman’s character was ignored at the beginning of The Poseidon Adventure. The water rushes in, too many people try to climb up the Christmas tree and I’m stuck standing on the ceiling, watching them drown.

Since the beginnings of the RAConteur entries, I have been trying to warn physicians that E/M services is the greatest undiscovered country with regard to RAC audits. As E/M services represent the majority of reimbursement for physicians, it’s something of an obvious conclusion. The follow-up question I’m usually asked is “when will RACs begin audits of E/M audit services?”. Limited automated reviews have been occurring on issues such as E/M services in the global period, but the RACs have been forging their own pace to add other approved E/M issues.  

DCS Healthcare, the Region A RAC, over the past six weeks, has added 4 approved issues involving E/M services. Like those that have preceded them, the new approved issues are automated, and involve E/M services billed with other services. Three of the issues involve E/M services that were billed without the -25 modifier when first submitted for reimbursement. The remaining issue relates t0 E/M services billed by radiologists on the same day as mammography services.

Some of these issues have been posted to other RAC websites in the past. While complex reviews of E/M services have yet to be explored, the RACs are showing signs of ramping up their E/M activities. It is far beyond the appropriate time to conduct either an internal or third-party review of your evaluation and management services to prepare for the RACs’ inevitable onslaught.

I’d like to end today’s RAConteur entry with a shameless plug. On Thursday, March 24th, 2011, I shall be conducting an educational webinar for the Wisconsin Medical Society entitled RAC Audits: Guidance for the Physician Practice. This 75-minute webinar has been prepared for physicians under the Region B RAC for whom WPS is the current Medicare Administrative Carrier. The webinar is filled with information that will help your practice prepare for the coming RAC expansion into physician services. Registration information for this seminar can be found here.

Thus ends the plug, and thus ends our Wednesday time together.

Tags: , ,
March 9th, 2011 | No Comments »

The Wacky Week in Review

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

I entered the modern world of the smart phone a few months ago. Upon showing the phone to friends of mine, one associate introduced me to an application that can be added to the phone that has the ability to play every free radio station in the world through my phone. I have been making great use of this app on a daily basis, from BBC radio broadcasts, to music stations in New Zealand to sports radio out of Canada. I now wonder what I ever did without it.

In listening to foreign news services, I have gotten a sense of how poorly regarded the American health care system is outside of our borders. There’s nothing like a fresh perspective to clean the slate and begin anew. Yet there is news that hits my desktop on a weekly basis that shows me that maybe the foreign news services have a point. This week, I have two examples, and these are keepers.

First, we travel to Washington, DC for a Senate Finance Committee hearing on combating health care fraud. Daniel Levinson, the Inspector General for Health and Human Services, presented testimonyat the hearing on the OIG’s efforts to combat healthcare fraud. A majority of the nine pages of testimony focuses on successes with the many anti-fraud initiatives currently taking place, but all of their efforts are focused on the provider community. Thanks to the miracle of the search-enabled PDF document, I typed in the word “contractors” to see how many times the word appears in the document. The answer is one, and that was in relation to recommending that edits be put into place to identify claims on the front end.

I would submit that there is a very big difference between a recommendation and an obligation. If we are all in agreement that the “pay-and-chase” model doesn’t work with respect to combating fraud, then it is at this point that the Medicare Administrative Contractors (MACs) be forced to implement front-end edits to avoid the patterns of aberrant payments the Medicare program has experienced for decades. If the MACs refuse or do not follow a set timetable for implementation, it’s time to either find new MACs or bring claims adjudication in house. Simply “recommending” front end edits is the equivalent of “suggesting” that someone shut off the main water supply in a house that has flooding up to the second floor.

For our second and final example, we travel to Oceanside, California and the monthly board meeting of Tri-City Hospital. At their latest meeting on February 24th, a member of their own board, who in the past has been censured six times in the last six months for verbal outbursts and disruptive behavior, injured two security guards while attempting to crash the meeting. Based on her past patterns of abusive behavior, including referring to everyone on the board as “Nazis”, the board member in question has been barred from actually being in the meeting room during board meetings, as part of her past reprimands state that she must be in another room and can only communicate with the other board members via speakerphone. This same board member is also under indictment for felony bribery charges related to her board position. The members of the board are now considering obtaining restraining orders against her for future meetings.

In a country with 15.9% true unemployment and a plentiful supply of qualified candidates for just about any position, what does it take to get fired in today’s society? We like to think that board members of our local non-profit hospital are working on quality of care and related cost issues. At the point where they are injuring security guards, can’t anybody dig up a box of pink slips and fill one out? More to the point, how did someone so apparently unhinged end up on a hospital board in the first place? Whoever wrote that recommendation needs to have all of his/her writing implements repossessed.

Since the passage of PPACA almost a year ago, several sources, either informed or uninformed, have offered their opinions about what works best for the healthcare system in the United States. I’d like to submit that perhaps a good starting point would be removing the incompetent and loony from decision-making positions throughout the healthcare delivery and payment system. If CBS can cancel Charlie Sheen’s show, then anything is possible. Then one day, we could all be….WINNING!

Tags: , ,
March 4th, 2011 | No Comments »

THE RAConteur: Medicare Part C RAC Update

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

This past Friday, the comment period regarding RAC activity for Medicare Parts C and D ended. As stated in a previous post here, CMS approached this comment period seemingly looking for suggestions as to how to contain costs in Medicare Advantage (MA) programs.

The timing of this comment period couldn’t possibly be worse for MA plans. Just prior to the end of the comment period, CMS released preliminary CERT data for 2010 showing that the Medicare Advantage payment error rate currently stands at 14.1%, which stands head and shoulders above both traditional Medicare and Medicaid. Sadly, this number actually shows improvement from the 15.4% error rate from 2009, yet the total dollars paid in error actually went up by $1.6 billion in 2010.

While the last-second comments have yet to be posted for public viewing as of today, the American Hospital Association, as it usually does, happily trumpeted the comments they submitted. As usual, the comments were well-organized, expressed exasperation with the current audit environment and contained a list of the organization’s desires, only some of which have any chance of ever being implemented.

The AHA argued that MA plans are already auditing providers for payment accuracy, so RACs aren’t needed. If the MA plans had an error rate in the single digits, I would agree with this assessment. Yet if the MA plans can’t adjudicate the claims for their beneficiary population correctly, what are the odds they can find payment errors they themselves have caused? If ever there was a section of the Medicare payment universe that needed comprehensive review, MA plans trail only durable medical equipment in need. Since the payment error rate is so stark, it would be of enormous benefit to have an independent set of eyes combing through the claim lines generated by MA plans.  

In their usually resigned fashion, the AHA had a wish list of requirements if RACs are implemented. Some of these are parts of the permanent RAC program for Medicare Parts A & B, such as requiring trained medical professionals to conduct RAC audits, medical records request limits and RAC websites with approved audit issues. Others, such as a 1-year look back period and excluding medical necessity from the Part C RAC program, are the equivalent of a wingless flight into Fantasyland, as CMS has to this point shown no interest in either approach.

It will more than likely be several months before we see anything resembling a proposed rule for Part C RACs. Meanwhile, in the backdrop, is the fact that MA beneficiary premium prices are now equitable with traditional Medicare for the first time beginning this year. With the incentives for private industry to sponsor MA plans decreasing with each passing day, I wonder if setting up a RAC program for a dwindling number of MA plans requires such a focus. The next 10 months will go a long way in defining that necessity.

Tags: , ,
March 2nd, 2011 | No Comments »