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Archive for September, 2011

The RAConteur: And This Is Helpful Why Exactly?

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

When it comes to government publications, I have come to believe that the main purpose of any given release is to communicate absolutely nothing using as many words as is humanly possible.

As one example, I present you with this link to a “pamphlet” put out by the Texas Department of Public Safety as a guide for trucking firms. The first question that pops up in my mind is what pamphlet any of us have seen (prior to today) that clocked in at 171 pages. I can sum up the entire pamphlet in 28 words: get a trucker’s license, don’t use drugs or alcohol, careful how you move toxic substances, don’t fall asleep and the state will check on all of the above. 

Late yesterday, I received an e-mail from CMS about another such publication that falls under my area of interest. Found at this particular link is the Fiscal Year 2010 report to Congress regarding the implementation of the RAC program. 

Let’s talk for a moment about the timing of the release of this 39-page report. Today is the last day of Fiscal Year 2011, meaning that this report is being released a year after the fact. The way I see it, the data from the report that I am about to relate to the reader has already been superseded by information that the government has yet to compile. Any seemingly positive news in this report, when placed in this context, is akin to a waiter in the dining room of a sinking Titanic bragging about the quality of the silverware. We were hoping to hear more about the lifeboats, and we all kind of lost our urge for a sit-down dinner when the ship hit the iceberg.

The fact that this report is late is another in a continuing and disturbing pattern of CMS not releasing vital data on a timely basis. The Fiscal Year 2010 CERT report, as of this moment, has not been released, with the 2009 report having been released almost 20 months ago. In addition, tomorrow is the first day of Fiscal Year 2012, and the OIG has not yet released their Work Plan for the next 12 months. Picture the movie Planet of the Apes being reshot with none of the actors wearing ape makeup and you begin to understand the effects of the absence of this particular report on the provider community.

Now that we’ve tackled the preliminaries, let’s take a look at the outdated nonsense entombed in this report. Pages 3 and 4 provide us with an overview of the need for the RAC program, which can be best distilled into the phrase “the MACs don’t know what they’re doing”. Page 5 relates the financial results of the first year of the program as a window into ancient history. This information was made available on April 26th of this year, but there’s nothing a government publication loves so much as repetition. For the record, again, the RACs identified $92.3 million in improper payments in FY 2010, with 82% of that total reflecting overpayments.

Pages 6 thru 18 repeat everything we’ve been taught about the RAC program to date, from the need for the program, their methodologies, the appeals process and steps taken to ensure accuracy, transparency and minimal provider burden. Pardon me as I take the time to clean up the unsweetened iced tea that just came out of my nose as I typed the final three words of the previous sentence.

Page 19 gives us the first “fresh” information in the report, that being the first numbers regarding appeals of overpayment determinations. As is indicated in a footnote on this page, because the full appeals process for providers can take up to two years, the following numbers aren’t final, but they are revealing nonetheless. In all, 8,449 claims (5 percent of all overpayments identified by the RACs) have been appealed. Out of that number, 3,902 claims were ruled in the provider’s favor. This represents a preliminary provider success rate on appeal of 46.2%.

To date, we have only had hints about the RAC learning curve with regard to review determinations, and when compared to the latest AHA RACTrac report, the success rate seems low, but it is still inflated. Imagine for a moment that 20% of all RAC overpayment determinations were appealed by providers. The RAC program would evolve from a major time-wasting exhibition of paper-shuffling to an epic time wasting exhibition of paper-shuffling.

Page 20 shows the top issues being identified for improper payment by the RACs, which have been detailed in previous quarterly reports, and continue to evolve. Pages 22 and 23 are dedicated to examples of corrective actions and continuous improvements being undertaken by the program. I would have hoped that these sections were somewhat larger, but one can dream.

Pages 24 thru 39 feature a series of appendices that show the hard numbers for all of the word salad in the previous portions of the report. For my purposes, I skipped right to page 38, which showed the appeal rates by contractor. If you are a provider in Region B under CGI, which happens to be my little corner of the world, it would benefit you greatly to cast doubt on any and all RAC determinations, as 60% of all appealed overpayment determinations are overturned in the provider’s favor. Sadly, only 18.2% of all of CGI’s overpayment determinations were appealed through last September 30th, meaning that CGI’s statistically demonstrated incompetence is being allowed to let slide by the provider community.

Page 39 is what I summise to be CMS’ version of absurdist comedy. For some time I’ve spoken about the fact that the RACs are assigned an accuracy score, on a scale of 1 thru 100, by the RAC Validation Contractor (RVC) based on a random audit of sampled claims from each contractor. CMS, thru its program managers, is not shy about communicating that a low score jeopardizes a RAC contractor’s continued participation in the program.

Now, review again my paragraph about CGI’s abysmal rate of overturned claims on appeal. Having done that, now try to convince me how that contractor earned a cumulative accuracy score of 99.2 by the RVC. I invite you all to review the remainder of Appendix F of this report – using the previous sentence as a beachhead – if the Marx Brothers classic Duck Soup isn’t showing on cable this week, as both the appendix table and the film are overtly silly and have similar affects on your mood.

We have all waited months for some glimmer of measurement of the RACs and their performance. If this report is being released as an exercise in chest beating by CMS regarding the “success” of the recovery program, I would invite those who drafted the report to refer to the Webster’s definition of that word for clarification. This report illustrates a number of oft-repeated ideas and beliefs, but success is hard to find among its pages.

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September 30th, 2011 | 7 Comments »

The RAConteur: MACs Take Over Demand Letters

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

Sometime last week, while I wasn’t paying attention (more than likely because someone was offering me a meal), the Medicare RAC website underwent something of a makeover. There is now a subcategory entitled “Recovery Audit Program Providers”, which appears will be used for program releases that have gone beyond their freshness date.

The previously established “Recent Updates” category, for the first time, is aptly named. At the top of this page is the announcement of MLN Matters article number MM7436, which announces a significant change to provider reporting. Beginning on January 3, 2012, the Medicare Administrative Contractors (MACs) will assume the responsibility of issuing demand letters for overpayments.

This change can be seen as positive for two reasons. First, I have heard anecdotal evidence of at least two RACs who have issued demand letters for one amount, only to have the MACs issue a recoupment for a different amount. The lot in life of the provider community is made difficult enough by the RACs without the process of bookkeeping taking a hit.

Second, one ax that I continue to grind revolves around the fact that the MACs, while reimbursing claims incorrectly, are escaping punishment for their sins. If it turns out that the MACs end up messing up the balancing of accounts they have adjudicated incorrectly, it puts another rather prominent demerit on their growing lists of sins. I’m not optimistic that this will lead to drastic changes in MAC assignments, but I do like being proven right at least once per decade.

Sometime in the next three weeks, the RAC results for the 4th Quarter of Fiscal Year 2011 should be released. We are still missing quite a bit of vital information related to appeal success rates, but now that one rather large task is about to be removed from being under the purview of the RAC contractors, providers should prepare for a spike in RAC activity as we head to the new year.

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September 28th, 2011 | No Comments »

The Nervous Animals of ICD-10

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

It was roughly 9 years ago this week that my wife Leslie and I moved to Milwaukee from suburban Philadelphia. We had experienced some tough times back on the East Coast, and our final night there was no exception. We ended up loading our moving truck, with the help of two friends, as the leading edge of Hurricane Isidore passed through the area. Nothing says “Let’s leave here and never come back!” better than having to pack a moving truck while it’s raining horizontally.

Severe meteorological events, in the absence of a TV or a radio, are most often prefaced by animals acting strangely, whether it be either zoo animals in a cage pacing back and forth at a quickened pace or birds suddenly taking flight en masse away from the coming cataclysm. We have one such storm being tracked in the world of health care, that being the implementation of ICD-10 on October 1st, 2013.

I can honestly state that over these past two weeks, I for the first time noticed the animals of our industry beginning to shuffle nervously for the impending arrival of ICD-10. When I first became a certified coder in 1998, I was told that ICD-10 was right around the corner, with the first implementation date being the year 2000. When ICD-10 finally sees the light of day as our disease reporting system, 15 years will have passed from those first pronouncements.

The biggest lesson I learned between those early, naive days and the release of the ICD-10 final rule on January 16, 2009 was that the chances of any major health care change coming to fruition can be measured directly against the amount of lobbying dollars the insurance industry spends in order to insure that the change never comes to pass. It was well known that the bigger payers, after over a decade of mergers and acquisitions, were in no mood to spend the money necessary to condense all of the claims payment systems they inherited into one better system utilizing the updated coding standard. When ICD-9 became severely outdated for our providers, the American Hospital Association stepped in and took up the cause, which led all of us to where we are.

Most people outside of the industry are unaware of how ICD-10 will affect health care when it hits. At the symposium hosted by the Wisconsin Medical Society that I attended earlier this week, a number of attendees were talking about this article from the Wall Street Journal. While this could have worked to warn the general public about expected claims delays and drops in productivity that have been experienced in other countries that have undergone implementation, it instead decided to point out funny examples contained in the code set. When I think of improved disease and symtomology reporting, I think about stamping out major epidemics before they happen, rather than being flippant about the fact that we’ll be able to accurately report when someone injures themselves walking into a lamppost. What would we do without the press?

The countdown clock for ICD-10 now stands at 738 days. As that number continues to deflate, expect the lower order animals in our industry to continue their wringing of hands, pacing back and forth and stocking their figurative basements with cans of bargain soup and bottles of water. For the rest of us, we have known for years now that “duck-and-cover” is not a useful strategy when it comes to ICD-10. This new code set isn’t going away, it isn’t going to be delayed any longer and it will not make anyone’s life easier in the short term.

Having stated that, there’s no reason to retire in fear, and the conversion need not be as painful as envisioned. Begin planning now to avoid the looting and car crashes later. Start with a pre-emptive strike on your EHR vendor by putting them through your own form of the Spanish Inquistion. Ask them if they are preparing for ICD-10 and about any planned upgrades. Scour all of your contracts for any mention of ICD-10. If it isn’t there, negotiate favorable terms to add it, and if it is there, find out what it means to your organization.

Like most everything else in this country, it is difficult to drag a large swath of our population into the modern age. This one can’t be accomplished by fear-mongering and snarky jokes. Anyone weathering the oncoming storm will succeed with the only thing that ever truly does, which is work.

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September 23rd, 2011 | 1 Comment »

The RAConteur: A Question From The People

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

This past Monday, I was presenting a session on government audits at the annual Coding & Practice Management Symposium put on by the Wisconsin Medical Society. In the midst of that, I received a very good question that I believe requires further elaboration.

The question (roughly stated because it was the end of a very long first day of the conference) was “What are your thoughts on the costs to taxpayers of these government audit programs?”.

I illustrated, by wild hand gesticulations against a wall, the current system of Medicare payments. First we have the Medicare Administrative Carriers (MACs), independent contractors who are issuing payments for claims that have no reason for being paid. In order to control these incorrect payments, we have the Recovery Audit Contractors (RACs), who are tasked with identifying the mistakes of the MACs. In order to determine the quality of the RACs, we have the RAC Validation Contractor, who has become a contractor who watches a contractor who watches a contractor. It was a fairly good answer, but any reputable response would have included numbers to back it up, hence this blog posting.

Currently, Medicare has the lowest administrative costs of any insurance carrier, the percentage of which has been estimated by trusted, impartial sources as being somewhere between 2-6% of funds. There is plenty of fraud and waste, and that is being addressed successfully on the OIG, HEAT and ZPIC level. Yet as I think about this a little further, it strikes me that if you are a politician who clearly wants Medicare in its current form destroyed, to be followed by private industry taking its place, you might first state that the administrative costs of Medicare are too high, then you would follow that with legislation that forces the program to fit your narrative.

The latest RACTrac survey from the American Hospital Association shows that 84% of claims determinations by RACs that have been appealed by member hospitals nationwide have been overturned in the provider’s favor. In addition, 68% of all medical records requested by the RACs in the survey did not lead to the discovery of an improper payment.

So here’s where we stand. None of the three independent contracting entities tasked with protecting the financial viability of the country’s most important insurance program are successful at their jobs. The MACs are paying billions of dollars in claims incorrectly, the RACs (despite all of the tools available to them) keep driving full speed into dead ends with their audits and driving up administrative costs of the program needlessly, and Provider Resources, Inc., the contractor tasked with judging the work product of the RACs, remains silent, with their ratings information on the RACs hidden behind some kind of administrative firewall.

If independent contractors are causing massive administrative waste, you would think that someone would want to put a stop to it. The only reasons you wouldn’t would be either that you naively believe that the RAC program is working to reduce costs, or you are metaphysically thrilled that the RAC program has been introduced as a budget-busting poison pill for the Medicare program. In either event, the RACs’ very existence continues to add needless administrative costs to the Medicare program.

It’s not a pleasant clarification of my original answer, but better late than never.

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September 21st, 2011 | 2 Comments »

Medicaid RAC Final Rule Released

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

This coming Monday, I shall be presenting a session on government audit entities at a symposium hosted by the Wisconsin Medical Society. My presentation has been finalized and is already being made available to attendees at the conference. With these facts in tow, it is not at all surprising that this would be a week for major announcements regarding recovery audit programs.

In addition to the release of the modified statement of work for the Medicare Recovery Audit program, we now have the release of the final rule for the Medicaid RAC program. At 140 pages, believe it or not, this is one of the more compact final rules I’ve come across in recent years, so let’s dive right in and take a look.

The first bit of information that I can relate is the new implementation date, which is January 1, 2012, just in time for an election year and another meaningless BCS bowl game. To refresh everyone’s memory, the original implementation was scheduled for April 1, 2011, but was delayed due to the ill-preparedness of several states to move their programs forward at that time.

Many of the features that have been folded into the Medicare RAC program have been included into its Medicaid counterpart. Let’s start with something simple. The Medicaid RAC contractors must hire at least one Medical Director who is “a Doctor of Medicine or Doctor of Osteopathy”. It should be noted that based on the anecdotal appeal rates of the Medicare RAC program, this fact alone should not give anyone a false sense of the accuracy of RAC audits.

Medicaid RACs are required to hire certified coders to conduct reviews, but with a catch. If the state determines that certified coders are not required for the effective review of Medicaid claims, the state can escape this mandate. Since the RACs are independent contractors, and the most reputable firms employ certified coders to conduct audits, I find this language intriguing. With the knowledge that less than 20 states have actually chosen a Medicaid RAC, coupled with the fact that less-enlightened states like to use the state contracting process to pay back political favors, the remaining contracts and who gets them should be extremely interesting given that the use of certified coders can be waived at state discretion.

Some other familiar parallels from the Medicare RAC program now codified into Medicaid RAC include a 3-year maximum look-back period for claims, notifying providers within 60 days of receipt of documentation of any overpayment, acceptance of medical records in electronic format, a toll-free customer service number and state-established limits on the number and frequency of medical records requested from a RAC contractor. Provider education and outreach programs also need to be developed. If this has been a required element of the Medicare RAC program, I’m at a loss to show any relevant examples of it being implemented effectively up to this point.

 The final rule also duplicated what may have been the most amorphous portion of the proposed rule. States are required to coordinate Medicaid RAC recovery efforts with other audit entities, most prevalently the Medicaid Integrity Contractors and the OIG. Because there is no centralized database of Medicaid claims, how such coordination occurs remains a mystery even to the state Medicaid agencies themselves. The only saving grace is that if a state contracts with more than one RAC contractor, those contractors are required to coordinate their activities with one another under the final rule.

Because Medicaid parameters are set by the individual states, the balance of outstanding issues will fall to the veracity of the states in setting up their RAC activities. One rather salient example of this is the fact that unlike the Medicare RACs, there will not be one overarching “New Issue Review Board” to approve new issues by the RACs. States are encouraged to form review teams to approve new issues prior to review, but this is not a mandatory guideline. As this process plays out, it will be interesting to see which states create approved issues lists similar to the regional Medicare RACs.

In addition, the Final Rule is very clear in stating that there will not be one national Statement of Work as is part of the Medicare RAC program. Because not all state Medicaid programs are identical, it is being left up to the states to construct the parameters of their Medicaid RAC program. Medicare is encouraging states to use elements found in the Medicare RAC program, but again this is not required past the point of educating providers about audit policies and protocols.

With regard to contingency fees paid to RACs, CMS has placed in the final rule that the amount of the contingency fee should be tied to the current Medicare maximum or 12.5%. Any state with a contingency fee higher than the Medicare maximum will be required to pay that portion on their own, without help from federal funding. One related battle that should be interesting to watch is CMS’ reluctance to require states to make the contingency fees being paid to contractors by individual states public, in the way that Medicare contingency fees are currently. States are encouraged to make it public, but it isn’t mandatory.

Finally, the appeals process is exactly as I originally envisioned it. We will indeed be facing 50 different appeals processes based on what the states already have in place. If you are not familiar with your state’s Medicaid appeals process, I highly recommend that you do so now in advance of January’s implementation. As a disturbing and threatening footnote, states are not being required to make the success rates of provider appeals public.

On the surface, the Medicaid RAC Final Rule creates 50 separate messes adding up to one monumental garbage dump of a program. If you happen to be a medical provider that routinely submits claims to more than one Medicaid entity, your administrative functions are about to be severely challenged. With the new-found zeal to cut government waste after a multi-decade drunken spending spree, I can only promise that this isn’t going to be pretty.

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September 16th, 2011 | 4 Comments »

The RAConteur: The Revised Statement of Work

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

Early Monday morning, CMS sent out an e-mail notification stating that information on their RAC page had been updated. It took about three seconds for me to realize that the RAC Statement of Work (SOW), which was originally released in November of 2007, has been revised as of the September 1st.

I’ve had a few conversations about this between Monday morning and today with other industry observers. The best compendium of specific changes that I have read thus far can be found on the RACShadow.org site (here), but knowing me, the readers should realize that they don’t get off that easily.

The biggest codified change in the SOW is the addition, in writing, of the semi-automated method of review. Also known as a hybrid review, this type of review normally begins as an automated review, but transitions, at the contractor’s discretion, to a complex review. In addition to adding a process that tilts in favor of the contractor, the provider pays a penalty with this type of review. In a complex review, the provider can request reimbursement for provision of medical records. Under a semi-automated review, because the review begins as an automated review, the provider isn’t compensated for records. Given this advantage, I would fully expect this type of review to see a utilization spike sooner rather than later.

Under complex review, the RAC has 60 days to review documentation before issuing a claim determination. Under the new Statement of Work, if the contractor goes over the 60-day review time from the receipt of documentation, they cannot be paid a contingency fee in the event of a determination of overpayment.

There was one update to the SOW that has induced more than a bit of laughter, especially in Region C. By June 1, 2011 (commonly known by calendar watchers as “almost four months ago”), each contractor’s online approved issues list must be sortable by provider type. While three of the contractors currently have this feature as part of their issues listings, Connolly Consulting, the Region C RAC, isn’t even close. Not only is the listing completely non-sortable by any available metric, but it has no reference for the date of approval for any issue. Attempting to find any provider-specific information for sorting on Connolly’s site takes at least an hour without some kind of technical tool. I know this because I recently tried this without such a tool.

In addition to the article linked above, I shall be covering these and other changes to the RAC Statement of Work in an upcoming article next week for RACMonitor.com. You’ll forgive me if it isn’t as entertaining.

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September 14th, 2011 | 1 Comment »

The Hidden Disadvantages of Buying on Faith

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

My house is not usually stocked with junk food, despite the fact that it tends to find me. In those many moments when snack food isn’t available, I tend to reach for the nearest box of cereal.

There has always been one thing that annoys me about breakfast cereals in this country. I have never possessed a box of cereal that contained all perfect specimens. The best example I can give is your basic box of Rice Krispies. Among all of the perfectly toasted grains of dried rice making noise in my bowl, I inevitably find that one black piece of rice that disguised itself among hundreds of other grains poured into my bowl. This outlier grain of rice is always found after I pour the milk in the bowl, which then leads to me spending five minutes trying to fish it out of my bowl before I accidentally eat it. To this day, I have no idea of the consequences are of consuming the black Rice Krispy, and I don’t want to know.

Each one of us, no matter what the product, is susceptible to attractive packaging. The picture of the cereal on the box, strawberries happily floating on top like little red clouds, always looks good, and let’s face it; if the house is out of cereal, you’re going to buy the box. It’s only later that your frustration rears its ugly head when the myth of the packaging is exposed.

It is on this final point that I begin today’s discussion topic; physician alignment with hospitals.

In the lead-up to ACO formation, hospitals are currently on a physician buying spree that would make a sailor on shore leave blush. In a recent research paper by Thomson Reuters, 44 hospital CEOs indicated that physician alignment was an issue of increased focus. If we pair that with another report from Merritt Hawkins stating that 76% of all physician openings offer a signing bonus, and the conclusion can be made that now is a very good time to be a physician looking for employment by a hospital.

Yet as I examine the issue further, there is one critical component missing, that being the due diligence required to determine whether the physician in question is a compliance nightmare waiting to happen.

In the current audit environment, most hospital systems are just beginning to get their arms around the RAC process for facility services. Because the audit entities have yet to expand into physician services, hospitals with large physician populations haven’t focused on the risks presented by the billing practices of doctors. Into this environment comes recently-acquired physicians and their accessory baggage. They look great, what with their shimmering CVs and smart ties, but it’s what you can’t see (or what is not volunteered) that poses the greatest risk.

If a newly-acquired physician comes to your organization either as an outlier based on billing, a poor documenter or someone lacking familiarity with your chosen electronic medical record, he or she can pose an immediate risk to the entire system.

Thankfully, one area where I spend a great deal of my time is in the area of practice analytics. The operative principals are available to determine the risk a physician poses to a facility, and it can be done in a manner that is time-sensitive prior to acquisition. It is a clear choice between paying a little bit now, and paying a lot later. To rephrase, are you buying the Rice Krispies because of the package and trusting that the alluring box contains cereal without flaws? If so, get your spoon ready, as black Rice Krispy fishing isn’t as easy as it appears.

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September 9th, 2011 | 1 Comment »

The RAConteur: The Long Autumn Begins Early

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

Since I’ve moved to the Midwest from my homeland of the East Coast, I have become much more accommodating. This morning, on my way to the office, I was in the right-hand lane of traffic next to an exit ramp. A driver was coming off the exit ramp into the slight congestion that lay beyond. She stopped in the middle of the exit ramp, and I allowed space for her to pull in front of me.

Ten seconds went by, then twenty, then thirty and the driver sat there, seemingly unable to comprehend that a space had been made available to her. Perhaps she believed it was her moment of rapture that would sweep her into the sky on a flaming, Pegasus-drawn chariot to a magical spot 10 feet from her destination, but she wasn’t moving. I briefly revisited the colorful language I tend to use when behind the wheel and left her in the dust.

With some people, it doesn’t matter how many times you wave your hand, fire warning shots or shout “LISTEN TO ME!”;  no warnings are heeded and those who put forth alerts are left to view the consequences from afar. As a person who documents the progress of government audits in this space on a weekly basis, I know this feeling all too well.

While I tend to focus on recovery auditor issues on Wednesdays, a press release hit my inbox this afternoon that reminded me that this is far from the only effort to stamp out fraud and abuse in the Medicare program.

The Departments of Justice and Health & Human Services jointly announced the latest charges from the HEAT team initiative. Ninety-one individuals in 8 cities were charged for their participation in fraud schemes that resulted in roughly $295 million in false billings.

While these numbers are gaudy based on their scope, the HEAT initiative has been busy since its inception, having charged individuals with nearly $1 billion in false claims billing.

In the meantime, the recovery auditors have been ramping up operations almost exponentially. CMS set an aggressive goal of identifying nearly $1 billion in improper payments in the calendar year of 2011. Through nearly three quarters, the contractors have identified just short of $700 million, which means that over $300 million will need to be collected between now and the end of the year.

Today’s news from the HEAT team, as well as the aggressive goals yet to be achieved by the RAC program, are CMS’ attempt at firing warning shots. I am seeing that larger organizations are getting the message, but much like the car I left behind this morning, smaller providers may find themselves having a hard time dealing with the traffic of investigation if they don’t start paying attention as the warmth of Summer gives way to the Autumnal Death Cycle.

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September 7th, 2011 | 3 Comments »

One Service, One Payment: NOW They Tell Us…..

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

In the human experience, there is an overarching idea that controls all of our thought processes known as “the common good”. As I tumble blindly down the hill of degeneration known as Growing Older, I’ve learned that “the common good” means vastly different things to different people, but one thing all of the divergent ideas have in common is the idea of personal sacrifice for improvement of the whole. Whether it is a farming commune, a church community or a governmental taxation system, personal sacrifice is is seen as the key ingredient on a promise of future gains, either in healthy crops, saved souls or roads without potholes.

It is with this idea in mind that I reviewed the latest CMS payment initiative, which was released on August 23rd. Entitled the Bundled Payments for Care Improvement Initiative, it offers four ways for caregivers to accept one bundled payment for an episode of care as a dangling carrot aimed at better care coordination and reduction of expenses. 

While there are four different payment models under the plan, I offer an illustrative example. A patient is in need of a hip replacement. The medical providers who treat the patient voluntarily negotiate one bundled payment with Medicare, covering all providers and services for the hip replacement. Under all four of the models (three offering retrospective negotiation of bundled payment, and one prospective), it would be up to the providers to determine how the one bundled payment is distributed among all of the entities involved with the patient’s care.

At first glance, I see this as another attempt to clarify and strengthen the ACO model. Farther down in fine print lies an enormous caveat, as noted in a brief article by FierceHealthcare this week. CMS states that preference for entering into a bundled payment arrangement will be given to providers who have at least 50% of their caregivers meaningfully using an electronic medical record (EMR). GIven where most hospitals are in the constructing of their particular ACO, this initiative comes a bit late.

Across the country, we have hospitals who are purchasing physician practices in the lead-up to ACO creation. As I communicate with people in this field, I am struck by the lack of due diligence exhibited by hospitals in selecting providers to hire. Most hospitals have no concept of how versed these physicians are in the use of an EMR, the quality of the provider’s documentation in its current form, the provider’s established billing patterns or the compliance risk to the facility of bringing on a particular doctor under the umbrella of the hospital. With respect to the EMR, as I have covered in previous posts here and here, use of an EMR may not signal the end of all compliance troubles, but a rather complicated beginning.

With the Bundled Payment Initiative giving preference to treating entities with high Meaningful Use percentages, hospitals may be regretting purchasing practices in the absence of this information, but it need not be a deal breaker. ACOs, by their very design, encourage a collaborative effort in the delivery of health care services. This idea needs to be applied not just to the care itself, but intangibles at the root of that care, such as the compliant use of an EMR.

The general idea behind the ACO model is that of the best ideas for low-cost care rising to the top. There are many paths to achieving ”the common good”, with human interaction and shared sacrifice being of paramount importance to the process. While this latest initiative might have assisted hospitals at the beginning of ACO formation by exponential factors had it been released earlier, better late than never.

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September 2nd, 2011 | No Comments »

The RAConteur: The Hidden Dangers of EMR

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

This article also appears on RACMonitor.com

We find ourselves at the dawn of the era of the mandatory electronic medical record (EMR). While the technology holds the promise of simplicity of integration and coordination of care, I am beginning to see that creating a medical record that makes sense to an auditor may become a longer road than physicians are anticipating.

In my role as a physician documentation auditor, I am learning that the term “meaningful use” is applicable more to an oblique government standard, and not so much to documentation of a patient’s illness. This year I have conducted documentation reviews for physicians in clinical and hospital settings that have proven this thesis in bold and uncomfortable terms.

In one case, I had a physician who, as part of their examination template, utilized the term “average stature” on every sample submitted for review. The range of patients reviewed in this case went from a 140-pound female to a 397-pound male, which by any measurement would be a rather inclusive definition of the classification of “average”. In another case, we had a hospital-based physician group who was utilizing an EMR for their particular patient base. In more than one case, specific laboratory test results were indicated as pending several days after the desired result was noted in the medical record.

Both of these examples point to the biggest problem with EMR implementation, which is best described as “build what makes you comfortable”. Too often, when training physicians to utilize a new EMR, adequate time to prepare the doctor for its best use simply isn’t available. To combat the time crunch, the trainer, in concert with the physician, assists in building a patient encounter template that represents the most-likely patient to be encountered, rather than one that has the ability for adjustment based on the presenting symptoms of the patient.

This problem is exacerbated by coding consultants who are quick to offer “phrases that pay”, and far too slow in counseling the physician on documentation and code selection focused around medical necessity. This leads to language in typical examination documentation that is in opposition to itself from paragraph to paragraph and, more importantly, doesn’t provide a clear picture of the patient’s actual health status. What at first appears to be a well-organized EMR template built for physician simplicity quickly morphs into the appearance of “cloned” documentation across many patients, which in turns increases audit risk.

With regard to physician documentation, the recovery auditors have thus far focused their attention on plans of care by admitting physicians in the hospital setting. As a result, hospitals in turn have turned to clinical documentation improvement (CDI) to remedy shortcomings identified by the auditors. One wonders whether the timing of CDI programs is accidentally premature, given that newly-implemented EMRs have the potential to reopen Pandora’s Box as hospitals acquire physician practices in advance of the Accountable Care Organization model.

Physicians in private practice have yet to feel the full force of recovery audit efforts to find improper documentation, and CMS has stated in the past that they will alert physicians nationwide when Evaluation & Management services are about to be audited. There is a significant difference with this population of doctors however, as they tend to exist without a training infrastructure to assist them in fine-tuning their electronic documentation. A great many physicians not affiliated with large institutions find themselves at the mercy of either their office staff or of outside consultants of varying quality who do not carry minimal emotional investment in the physician’s best interests.

The proliferation of EMR systems can be seen as a chance to either seize or be seized by opportunity. Choosing a specific electronic medical record for your practice should not simply be seen as a way to make a quick buck. In selecting an EMR for implementation, physicians should do their level best to block out the voice of the salesman promising thousands of dollars in Meaningful Use dollars, and select an EMR that will allow for flexibility based on the range of patients seen by the practice. Any and all vendors should be quizzed carefully as to training expectations and end benefit to your practice. In addition, physicians should enter a mindset that learning how to use your EMR never ends. This would be very similar to recovery auditors being on their never-ending quest to seek out improper payments based on deficient documentation.

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September 1st, 2011 | 1 Comment »