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Archive for November, 2011

The RAConteur: Fiscal Year 2011 RAC Results

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

We live in interesting times as it pertains to numbers.

As human beings have scoured writings left behind throughout recorded history, one can usually find more than a single opinion on any given tome based on the insight or prejudices of the reader. Numbers aren’t supposed to be that way. Based on centuries of evidence, it should be impossible to find anyone who states that 5 plus 5 equals 10. It is with some surprise that we find ourselves in a global economic meltdown with this information, until we find out that banks were taking the manure pile consisting of mortgages in jeopardy and selling them to brokers under the guise of a pile of platinum securities. 

Internalizing all of this as the new reality assists me greatly in reviewing the latest RAC numbers from CMS.

As has become their custom, CMS released the data on Medicare RAC collections for the last quarter this past Monday, along with a supplemental report for the entirety of Fiscal Year 2011.

For the final quarter, the recovery auditors reported identifying $353.7 million in claims corrections, with $277.1 million in overpayments collected and $76.6 million in underpayments returned to providers. This represents a cumulative increase of 22% over all reported corrections identified in the third quarter.

HDI, the Region D RAC, continues its significant lead among the RACs in identifying overpayments, with $108.2 returned to the Medicare program. This represents slightly over 39% of all monies returned in the final quarter of the Fiscal Year.

The storyline behind underpayments returned to providers has shifted dramatically. Connolly, the Region C RAC, returned $60.7 million to providers in the final quarter. This number represents more than an eightfold increase from the $7.4 million returned by Connolly in the third quarter. Significantly, this number represents nearly 50% of all claims corrections identified by Connolly in the final quarter of FY 2011. In contrast, HDI, which identified $33.7 in underpayments in the third quarter, saw their total plummet to $6.9 million in the final quarter.

There were only moderate changes in the top claims issues identified by the recovery auditors. DCS in Region A and HDI in Region D have seen no change from their top issues identified. Region A continues with medical necessity of renal and urinary tract disorders in the inpatient setting. HDI maintained minor surgery and other treatment billed as inpatient as their top issue.

CGI in Region B has seen cardiovascular surgical procedures move to the top of its issue list, while Connolly has seen acute inpatient admission for neurological disorders make a similar jump.

The numbers from the final quarter bring the total identified claim corrections for Fiscal Year 2011 to $939.4 million, with $797.4 million in overpayments collected and $141.9 million in provider underpayments returned. Based on the numbers from FY 2010 in the Report to Congress on RAC activity that was released in September, the auditors have seen more than a tenfold increase in claim corrections in FY 2011.

While this panoply of numbers would appear to be encouraging to CMS, it is worth noting that CMS’ quarterly reports routinely make no mention of appeal success rates. CMS has now established that it will make official appeal rates available in its annual Report to Congress, which provides ample time for multiple levels of claims appeals to work their way through the system. It is worth noting that the latest AHA RACTrac report, which was released on November 21st, indicated a provider success rate of 77% for appealed claims among their member hospitals that reported data. If this percentage is remotely close to the nationwide average, we should expect to see a significant reduction in the FY 2011 number of $797.4 million in overpayments in next year’s congressional report.

If we don’t see a reduction, we can state categorically that we have found yet another modern case where the certainty of numbers crumbles in the wrong hands.

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November 30th, 2011 | 6 Comments »

The RAConteur: The Hidden Danger of Semi-Automated Review

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

I’d like to warn the reader that, for the second day in a row, I’m about to relate a real life issue to my extensive experiences in watching classic television. Yes, I have a fascination with old television, but rest assured, I’m not a complete vegetable.

There is an episode of Rod Serling’s classic television show The Twilight Zone entitled “The Man in the Bottle”. It is a variation on the tried and true rub-the-lamp-for-the-genie story. A nice, elderly couple who own a pawn shop (NOT likely, but suspend disbelief, it’s television) buy a bottle for $1 from someone in the neighborhood and in it is a genie who offer them four wishes. As one can imagine, every wish has consequences and despite the possibilities, the couple ends up right back where they started, which is down on their luck, but wiser and seemingly happier.

The most innocuous of objects all around us pose dangers. On my desk, I could sever a finger in the desk fan, give myself a shock in one of the many outlets here in the Man-Cave or I could give myself a nasty dose of reflux from the bottles of Tabasco on my left. Our job as sentient beings is to view everything around us with skepticism, realizing that there is inherent danger if something is misused.

Which brings my meandering mind to (obviously) semi-automated review of paid claims by recovery auditors.

In the updated RAC Statement of Work, we see the semi-automated review method codified for the first time as a legitimate audit tool, but the dangers of this method to the provider community, in my opinion, have been painted over in an attempt to make the dogs playing poker somehow appear to be the Mona Lisa.

First, there’s the administrative burden and its cost. There is a cost to the provider with regard to automated review results, as this type of audit turns up over-payments. With complex review, there are costs to disputing a negative result. Yet there are boundaries to the administrative burden to providers in the form of limits on the number of requests and the ability to be reimbursed for copies of medical records.

Because a semi-automated review begins with a fully automated review and evolves to a complex review at the RAC’s discretion, there are no limits to the number of records that can be requested in a given time frame. Additionally, when the review goes from automated to complex, there is no reimbursement to the provider for copies of records. Anyone with 100 IQ points who can read a map can see where this is going. This has the potential to be devastating to providers, in particular small physician groups.

If the story ended there it would be your run-of-the-mill tragedy, but leave it to me to point out the potentially catastrophic. Remember that according to the RAC FAQs, recovery auditors can look at any issue at any time to probe whether it is cost-effective to add that issue to their approved issues lists. So if a RAC does an automated review, and suddenly feels that they can collect more money than any currently approved issue, they can request as many records as they want to for any reason under the cover of a “probe review”, and based on how the RAC rules are currently written, there’s nothing that a provider can do about it. The diplomatic among us would refer to this as a “loophole”. Decency precludes me from telling you how I refer to this away from the bright lights of this blog.

Whenever there is a law written, somewhere there is someone trying to find a way to avoid the consequences of legislative wishes. CMS has for unknown reasons built a wormhole into the universe of recovery audits based on the open-ended nature of semi-automated reviews. It is left up to the provider community to monitor the monetary effects of this on their organizations. That is, if there’s any organization left to protect after the RACs have a field day abusing this quirk for all it’s worth.

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November 23rd, 2011 | 4 Comments »

Did the AMA Just Jump The Shark?

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

Due to the upcoming Thanksgiving holiday, my usual Friday post on pertinent health care issues appears today.

Last night, in my nightly bout with insomnia, and under orders from my wife to clear our DVR, I watched an under-appreciated gangster movie from 1980 called “The Long Good Friday”, starring Bob Hoskins and Helen Mirren. The movie revolves around a British mobster who, on the brink of an important partnership with the American Mafia, suddenly finds himself under attack from someone he can’t identify. Bluntly, the only reason it was on my DVR at all is that it was produced by Hand-Made Films, which was the production company of an old musician named George Harrison. I’m told that he was in a rather groundbreaking band at one time.

It is indeed a horrible feeling to have a tormentor whose name and motivations you cannot see. On the other side of the coin is to know long in advance what your biggest challenges are and to ignore them in the hopes that they go away. We had a blunt example of this in the last week from a new policy release emanating from the Semi-Annual Meeting of the AMA in New Orleans. While three of the new policies made sense, based on the setting of the meeting, I’m basing the adoption of the following fourth policy on too many hurricane drinks and an overdose of zydeco music.

The AMA has decided that they will “work vigorously to stop” implementation of ICD-10 on October 1, 2013. The argument the AMA makes is that ICD-10 has no benefit to direct patient care and needlessly inflates administrative cost and disrupts work flow.

I get asked a question on ICD-10 often from physicians in the field. It goes something like this:

“Are they REALLY going to go through with this ICD-10 thing?”

I am going to say this one more time, to a mass audience, which can feel free to continue to spread it far and wide to all of their acquaintances in the industry. There will be no delays of the implementation date, there will be no sudden cancellations, and this is not a test, drill, rehearsal, exercise or interpretive dance presentation by Cirque du Soleil called “Illusion”. The FINAL (“FINAL” meaning the last and not the penultimate) implementation date is October 1, 2013. If you use an ICD-9 code on an insurance claim after that date, you will NOT (“NOT” meaning none, nada, zip, zero or the null set) receive an insurance payment. There is no punch line and no one is going to shout “APRIL FOOL”. It’s happening in 679 days, without fail.

Let’s review recent history. CMS’ ICD-10 proposed rule stated an implementation date of October 1, 2012. Mercifully, the final rule bumped it back one year to 2013. The final date represents the end of movement of the date. CMS has no inclination to change it again, and says so every time they provide education on the topic, usually within the first 5 minutes of the presentation.

I would imagine that by saying the phrase ”work vigorously to stop” implementation, the AMA is talking about throwing a bomb in the form of lobbying money towards the nearest corrupt politician (unfortunately, no shortage of targets) in order to introduce legislation to extend the deadline. I bet they figure that if they pinpoint their strike, perhaps they can get a pay fix for 2012 at the same time. If this is the calculus, may I be the first to provide each member of the AMA with advanced booking for a suite at the Fat Chance Hilton?

Might I suggest a more noble use for that money, such as setting up a fund to assist small-group physicians with implementation, or providing regional education opportunities on the substantial impact ICD-10 will have on physician documentation? Since the AMA was more than happy to state in the new policy that small practices would have to spend over $83,000 to fully implement ICD-10, wouldn’t it be more useful to build some much-needed goodwill in the provider community by offering such assistance, rather than yelling at clouds as their membership continues to plummet due to lack of a relevant or coherent argument in the modern medical delivery landscape?

When I first became a certified coder in 1998, I was told that ICD-10 was on the horizon. The original go-live date I heard at that time was October 1, 2000. When final implementation hits, 15+ years of speculation ends. Anyone without their head in the sand knew this was coming eventually. This isn’t some sudden bomb deviously planted in your decanter of tongue depressors by an anonymous assassin. The time to build a flood wall is before the 100-year rains, not after. My advice on ICD-10, to the AMA and anyone else listening, is to hit the ground running, rather than jumping a shark on water skis in the form of issuing a foot-stomping policy of denial.

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November 22nd, 2011 | 4 Comments »

Even A Decrease Is Still Too High

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

I do my level best to live my life as an optimist, but there are two very important caveats to that statement. First, I wasn’t always this way, and I can attribute that to growing up as a fan of the Philadelphia Phillies, a baseball team that has lost a record 10,282 games in their 128-year history.

Second, and more importantly, I have an acute sense of the proper time to ditch the optimism in situations where all hope is clearly lost. If one uses their imagination, one can imagine that in October of 1781, there was more than likely an optimist on General Cornwallis’ British Army staff telling him with great fervor that they could withstand the Siege of Yorktown. One can also imagine this person getting his head smacked prior to being pushed down a flight of stairs by a less-optimistic staff member for not recognizing the reality of the situation.

With these beliefs in tow, I reviewed the latest chest-thumping report regarding the CMS Payment Error Rate that was released this week.

It is with great fanfare that Medicare is proud to announce that the current payment error rate for the Medicare program is 8.6%, which resulted in improper payments estimated to be $28.8 billion. To put this number in context, I myself could earn the amount of money overpaid by just the Medicare program if I were employed at my current salary for well over 500,000 years. Sadly, current averages indicate that I have 33 years of life left, with only a fraction of that time invested in working (kidding….I think).

Yet, golly gee whiz, that’s an improvement, for you see, the error rate in 2010 was 9.1%, resulting in $29.7 billion in overpayments. So instead of one out of every 11 claims being paid incorrectly, now it’s one out of every 12. You know, Jesus found out that Judas was one of his 12 apostles in error, but hey, he figured how much damage could this one guy do since he was outnumbered by the good guys?

The super wonderful skippity-do crazy fun time doesn’t end there, folks. The Medicare Advantage error rate now stands at only 11% for $12.4 billion in improper payments, which is an improvement over the 14.1% rate from 2010. The Medicaid payment rate, said Pollyanna, decreased 1.3 percentage points to 8.1%, or $21.9 billion in improper payments. Medicare Part D, keeping the elderly medicated since 2006, hasn’t had the same amount of time to invest in screwing up payments, so that error rate stands at 3.2%, or $1.7 billion dollars.

Missing from the data is a payment error rate for the Children’s Health Insurance Plan (CHIP), due to currently incomplete data. This error rate will be published in 2012.

As with any report, CMS gives you the highlights and skirts around the real issue. For the part they left out, and for a bit of Friday fun, let’s go to the calculator.

I’m not an accountant, I don’t play one on TV and I look silly with a green visor on my head, but my rough calculations tell me that about $771 billion dollars was paid out of all of these programs in Fiscal Year 2011, with $64.8 billion being paid out improperly. This leaves us with a cumulative error rate somewhere in the neighborhood of 8.4%. This means that the Medicare Administrative Carriers pay one out of every 12 claims incorrectly, and, as a not-so-subtle reminder, without fear of reprisal or punishment.

The bad news is that the financial ship continues to sink. The good news, to hear CMS tell it, is that instead of four people bailing water to keep the ship afloat, we now have five. Meanwhile, the hole where the water is flowing in is in plain sight, the tools are there to fix it, but everybody’s bailing water and ignoring it, saying things are getting better.

I end today not with rosy optimism, but with a plea to the reader to tell me which one of the bailers I need to push down the stairs.

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November 18th, 2011 | 1 Comment »

The RAConteur: The Bad Gets Worse

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

When a thing or a process is found to be non-functional, I am faced with only two choices. I can either accept the fact that the time and money I’ve invested have not yielded results and scrap it, or I can double down on my investment, stomp my feet, insist it’s going to work, berate everyone but myself, yell at clouds, throw Jell-O around the kitchen, kick the dog, tell the neighborhood kids to get off my lawn and lock myself in the closet for three days so I can sit alone, feeling superior about my principles.

CMS proved this in spades with a news release yesterday. To preface today’s post, all of the readers know my feelings about the RAC program. The automated review process is working, but that process is something that could be done with ten trained chimpanzees hitting a button and is only necessary because the MACs don’t have proper edits in place to avoid the improper payments in the first place.

Complex review, to put it mildly, reminds me of this, based on the chaos it creates for the provider community. At the root of the problem is the appearance of a lack of qualified documentation review specialists to conduct complex reviews in a proper fashion. This leads to a higher-than-necessary success rate for provider appeals. 

CMS announced yesterday that a demonstration project will begin on January 1, 2012 that will include the RACs performing pre-payment reviews of claims “that historically result in high rates of improper payments”. The project will focus on the states with the highest percentage of incorrect claims or error prone providers, which are California, Florida, Illinois, Louisiana, Michigan, New York and Texas. Four states with high percentages of short hospital stays (Missouri, North Carolina, Ohio and Pennsylvania) will also be included in the demonstration.

CMS is investing heavily in pre-payment review, especially when it comes to the predictive modeling technology that was rolled out this past Summer. The problem I see here is that we have a uniquely imperfect model in the RACs as a vessel to recoup improper payments after the fact, and now we’re going to expand that model into the realm of pre-payment audits. While as a taxpayer, I appreciate CMS’ zeal to protect the financial integrity of the Medicare program, I have definite reservations about the RACs taking on another task when it is painfully obvious to me, as a provider advocate, that they don’t have a solid hold on their original work order.

I don’t think it is accidental that this initiative is being announced only two months after the whitewash that is the RAC Report to Congress was issued. If you’re telling the political establishment (a group known for its acute case of issue ADHD) that the RAC accuracy scores are fabulous, it makes it easier to introduce further initiatives under their administrative umbrella. I think we can predict where this project will end up.

There was some other news from the Office of Inspector General this week in the world of audits. The OIG was conducting a review of the Zone Program Integrity Contractors (ZPICs) in Zones 4 and 7 (Health Integrity and SGS, respectively) and found that the CMS’ workload reporting data was neither accurate nor uniform, which rendered a conclusive review of their activities impossible. Similar findings were found with the ZPIC predecessor, the Program Safeguard Contractors, more than 10 years ago when the OIG was similarly attempting to conduct a review of their activities.

Remember that the total collections by the PSCs were never more than 2% annually from 2003 to 2007. If there are problems with the workload data that are similar to those from the good old days, can we then surmise that the total collections by the ZPICs that are up and running are less than stellar, or (worse yet) can’t even be reasonably determined to be lousy?

For the provider community, it’s been an ugly learning curve getting used to increased government audits. It is even uglier when an inefficient process is doubled in size and scope. Today’s post took a long time to construct because I was busy ducking out of the way of CMS’ Jell-O. Hopefully it didn’t land on you.

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November 16th, 2011 | 2 Comments »

Defining The Modern American Doctor

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

I am only 45 years old, which is a pittance with regard to measured time past and upcoming, but thanks to the ever-increasing speed of evolution, there have been some rather remarkable changes in my lifetime. To be clear, I’m not doing the typical old-man-in-checked-pants cliche of complaining about how everything was cheaper when I was growing up. I’m talking about the rapid evolution of things that surround us in daily life. As my 5-year-old son grows older, I am envisioning attempting to explain Pong, vinyl records and Johnny Carson to him as societal touchstones in a world that features Nintendo Wiis, digital music and an increasingly unfunny Jay Leno.

Nowhere is this more apparent than the world of medicine. I was only 20 months old when the first human heart transplant was performed. I have a cousin who was a pioneer in bariatric surgery for the morbidly obese. Yet his surgical method, which was detailed in an article in Time magazine in October of 1965, when compared to today’s techniques of gastric banding and sleeve gastrectomies, could well be viewed as the medical equivalent of bleeding with leeches today.

It isn’t simply in terms of surgery. I am here to ask the reader today to bear some consideration for the evolution of medicine not simply in terms of practice and techniques, but also as it relates to the human element of being a physician in modern times.

I came across a few stories this week that showed in stark terms that the role of the doctor, as we have come to know it, has changed dramatically.

First came this synopsis of an article about physicians using social media to deliver better health care and information to patient populations. Modern patients rely on the internet as an information source in ways that challenge the delivery of health care from the modern practitioner. This article provided a window into the innovative ways that physicians can turn something viewed as a negative into a positive for their patients, as well as their practices’ bottom lines.

Now, in the interest of bringing balance to a universe existing in a constant state of chaos, the mixed-to-bad news. A study in the November issue of Health Affairs indicates that the technical knowledge of new physicians in clinical practice is lacking. The study seems to point the finger at reduced hours in residency as a big contributor, but it also pointed to changes in technology leading to a diminished skill level with regard to performing “open” procedures.

Over the last 40 years, we have seen how a society’s slavish devotion to getting everything cheaper has destroyed job after job in the American marketplace. If you thought that the medical community is immune from such an attack of thrift, think again. It was reported this week that deep in the fetid bowels of an office in Bentonville, Arkansas, Wal-Mart is planning an expansion of their well-documented retail activities into the realm of health care as a reaction to the not-quite-invalidated Affordable Care Act. As a solution to the country’s societal ills, this news ranks only slightly above ”Soylent Green is people”.

Finally, we have the curious case of Conrad Murray, the physician who was convicted of involuntary manslaughter for administering operating-room grade anesthetics to Michael Jackson in the months leading to his death. There are two problems here, the first being why this guy had a medical license to be able to implement a pain treatment plan like this, but there is a second problem here that is not being mentioned.

In this scenario, Conrad Murray is acting as an extremely well-paid concierge physician to someone with the resources to be able to afford this kind of questionable medical care. While there are a number of physicians leaving the insurance payment model to reduce administrative burden and to provide a better standard of care to their existing patient population, the high-dollar end of the concierge model is populated by physicians who are in the practice of  medicine strictly for the money. This is not to say that every physician who chooses this particular population to service is as ethically challenged as Dr. Murray, but Murray’s conviction has the appearance of a case where the number of zeroes in the pay check were directly proportional to the patient acting as his own practitioner, with the doctor acting as a spectator. Did Michael Jackson pay for a doctor, or a pusher with the imprimatur of ”M.D.” after his name in order to keep up appearances? More importantly, how many other doctors serving the well-heeled are following the same model currently, seemingly in opposition to the Hippocratic Oath? 

We have before us an interesting window of time to exist as a gatekeeper in the scientific discipline of medicine in the United States. There is progress, opportunity and danger both to the practitioners and to the patients they treat. While technology and delivery systems will continue to evolve, it is important to remember where medicine has come from since the time of Hippocrates. There will always be a part of medicine that will require a good bedside manner, manual dexterity and something more than a retail exchange. There are many mysteries about the human body yet to be discovered, but the presentation of care, at its core, has been and should remain the same.

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November 11th, 2011 | 4 Comments »

The RAConteur: Of Explosions and Acquisitions

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

The first and most obvious thing that my readers know about me is that my gender is male. I’m a guy, and while I’m not completely immersed in “guy things” in my off hours, there are a few exceptions. I like watching sports on TV, I drink beer (we’ll leave out the part about how much) and, as partly relates to today’s post, I like blowing things up with high grade fireworks. Give me a few M-80’s and anything inanimate (particularly stuffed animals) and we’re bound to have some fun. It is for this reason that this music video is one of my all-time favorites. 

I haven’t been to any of the local fireworks stands of late, but that doesn’t exclude me from lighting a fuse. Last Wednesday, I wrote a post on the lack of provider outreach by the RAC contractors. I also wrote an abbreviated version of the same post for RACMonitor.com here. The response and residual fallout from these articles has been enlightening, to say the least.  

First I’d like to give everyone an interim update. On the heels of the article appearing on RACMonitor.com, that publication’s Monday RAC webcast, Monitor Monday, put up a survey question regarding RAC provider outreach. The listeners had three choices: satified with my RAC’s outreach, not satisfied or “what outreach?”. Only 10% were satisfied, 34% were not satisfied and a whopping 56% have had no outreach at all. That represents 90% of people who express dissatisfaction with RAC provider outreach efforts, which, as a reminder, is part of their Statement of Work.

With these numbers for encouragement, I picked up where last week’s investigation left off.

To briefly encapsulate, when last I left you, I had sent e-mails to DCS, the Region A RAC and Connolly, the Region C RAC requesting schedules for upcoming provider outreach education sessions. I received a response from DCS asking for my provider NPI number so my request could be sent to the “correct area”. When I responded that I worked for a provider financial management company representing clients in New York and Connecticut, I received a response from the same person (she must have been the “correct area” all along) stating that DCS would be presenting a joint outreach webinar with NGS for providers in those states in February. I was also told that I should check the NGS website “later in 2011 or early 2012 for updates”.

That covered two of the eleven states under the DCS umbrella, so over the past week, I decided to go deeper. I went to the website of NHIC, the Jurisdiction 14 MAC covering the balance of the states of New England. Their education schedule ran only to the end of 2011, and included no upcoming sessions on RAC activities. A review of the website for Highmark Medicare Services, which represents the rest of the states in DCS’ universe, yielded identical results to NHIC.

To date, I have not received a response to my inquiry from Connolly, but I followed the lead I received from DCS and reviewed the websites of MACs within Region C. I began with Palmetto GBA for West Virginia, Virginia and the Carolinas, and found no upcoming education events. Next I reviewed Cahaba for Tennessee, Alabama, Georgia and (currently) Mississippi with similar results for the remainder of 2011. Pinnacle for Arkansas and Louisiana and First Coast Service Options for Florida had nothing related to RAC for the remainder of 2011. Trailblazers (representing the states in the Western portion of Region C) showed nothing thru January of 2012.

A quick review of MAC websites for carriers in RAC Regions B and D turned up one positive glimmer of hope. Noridian conducted a RAC workship this past Monday, but a review of the PowerPoint from the presentation indicated that the information was out-of-date, as there was no mention at all in the presentation of semi-automated review as a RAC method. Fortunately, there is an Ask-The-Contractor teleconference tomorrow that stars the Region D RAC and Noridian. Be sure to call 1-800-230-1951 before 1 PM CST, tell them I sent you and congratulate them for being an outlier.  

Returning to a previous subject, the saga of Connolly doesn’t end there. On the heels of my article, I received a rather enlightening e-mail from a reader in a Trailblazers state. This person has a problematic issue that has been identified by Connolly as part of a RAC audit for which this person cannot get a resolution from either Connolly or Trailblazers. In a pyrrhic attempt at a solution, this person contacted Connolly and was told by a phone representative at Connolly that they don’t have to educate. I invite this week’s reading population to reread that last sentence and internalize it, then go have a Long Island Iced Tea and try to put it out of your mind.

Now let’s go back to the Fiscal Year 2010 Report to Congress on RAC Implementation that was released in late-September. On Page 9 of the report, a summary of the outreach efforts that CMS has undertaken appears, but mentions nothing about what the individual RACs have done to satisfy the education requirements as detailed in the RAC Statement of Work. It’s also worth nothing that the wording in the Report to Congress gives the distinct impression that CMS has completed their outreach efforts, save for occasional updates to their Frequently Asked Questions on the RAC program. In this context, a Connolly phone representative stating that they don’t have to educate the provider community should set off alarm bells.

 To review, CMS has completed their outreach efforts, the RACs have either nothing scheduled or have yet to update the education calendars on their websites and a majority of the MACs will get to it next year, if at all (after all, what’s the rush?). Meanwhile, all the provider community requests is feedback and guidance, and instead are mostly left needlessly in the dark.

Now that we’ve squeezed the life out of the topic of outreach, I’ll end with an important update. I was sent this link by reader Sue Ann Jantz of Cottonwood Pediatrics in Newton, Kansas. HMS Holdings Corp., the parent company of HMS, announced this past Monday that it had acquired Health Data Insights, the Region D RAC, for $400 million. HMS will now take over all of HDI’s RAC activity, which if you remember also includes the Medicaid RAC contract for Kansas. I did get one good laugh when HMS stated in the announcement that HDI had the best “accuracy score”, as well as the highest collections. If the ridiculously inflated scores for all four RACs meant anything at all, this would be a statement worth making. Provider experience to date shows them to be meaningless.

As we welcome HMS into Region D, let me begin by stating that we hope that you will concentrate as hard on provider outreach as you will on Region D’s affect on the corporate bottom line.

I shall be appearing on Monitor Monday on November 14th at 9 AM CST. A link to sign up to this webcast can be found here.

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November 9th, 2011 | 2 Comments »

The 2012 Physician Fee Schedule: Here We Go Again

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

As an overfed American with a penchant for sandwiches, it grieves me to report that my current weight stands at 217 pounds. To measure it against random things in my immediate universe, this equates to roughly 79 unsweetened iced teas from Speedway or the contents of just over 694 bottles of Tabasco.

If I reduced my current girth footprint by 27.4%, my weight would be roughly 158 pounds. I’d also be 15 years old, pummeled with acne and at the mercy of the world of 1981, and I promised myself that I’d do my best to avoid the music of Juice Newton for the rest of my life (and no, I’m not providing a hyperlink; it was that bad).

It is with these thoughts in mind that I begin the annual November discussion of physician fee schedule cuts to the Medicare program.

The 2012 Physician Fee Schedule Final Rule was released this week. The size of the cut, representative of the can that has been kicked down the road for over ten years, now stands at 27.4%. Medicare tells us that this is good news, because due to unexpected savings this year, the original scheduled cut of 29.5% has fallen to only the stated percentage.  

If this were any other year, I would shrug this off. We think we all know the drill by now. Every November, just in time for the coming holiday season, we get the fire-and-brimstone treatment with a threatened cut to the fee schedule, and at the last minute (sometimes a few moments after), everything  goes back to normal. Maybe, if we’re lucky, we actually get a few percentage points of a payment increase.

One look at any believable information source will tell you that this is not your typical year. 

We exist in a world where politicians around the globe have developed an unhealthy fetish for economic austerity. Great Britain was the first country up to the plate, slashing government programs like Freddy Krueger, only to find out too late what any reputable economist could have told you from the beginning, which is that slashing spending also slashes growth to near-zero. At this moment, Greece straddles the precipice between being a flat-broke member of the European Union, or a flat-broke country descending into anarchy that threatens to take the entire EU banking structure down with it. Other European nations are slowly lurching towards the same fate.

We’ve seen unprecedented allegiance towards austerity in this country this year in a fashion that can only be described as sociopathic. Rock bottom was reached when Eric Cantor, the 2nd-in-command in the House of Representatives, refused to provide emergency aid to his own Virginia congressional district when it was hit with an earthquake without equal cuts coming from other parts of the federal budget.

With this type of attitude at the fore, I have little hope of a last-minute fix to the fee schedule this year. The very idea of across-the-aisle compromise has come to an end in this country. Physicians, a group that used to have a seat at the lobbying table, will be left out in the cold in favor of industries who write bigger checks for a seat at the table.

I have definitive reasons for not wanting to weigh 158 pounds. I could stand to lose a little weight, but losing 27.4% of me would be counter-intuitive to existing in the modern world. Those of us faced with the realities of physician reimbursement know full well that these types of cuts from the Medicare portion of the physician bottom line could be lethal. Reductions of this magnitude almost certainly insures that care will be deferred for the portion of the population that, with regard to their health, possesses the narrowest margin for error.

However, the current political landscape doesn’t bode well for avoiding this fate. At the same time that the cuts are scheduled to take place, Presidential primaries begin, accompanied by chest-beating about who can cut the national debt by a wider margin. Add to the mix the European Union tanking and police in riot gear responding to people in the streets of our country demanding balance and fairness to our economic system and you have a recipe not just for a health care meltdown, but a societal one. The principals in this debate are digging in their heels and showing no signs of compromise. With all of the hand-wringing, no one is talking about eliminating the Sustainable Growth Rate, which is the root cause of this problem.  

I’d tell the physician reading this to buy popcorn and watch the self-defeating circus from the sidelines, but perhaps packets of ramen noodles would be a better, cheaper alternative. If needed, I’ll provide the Tabasco.

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November 4th, 2011 | No Comments »

The RAConteur: Does Provider Outreach Exist?

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

In the United States, we have a serious problem with customer service assistance. Currently, I’m fighting a fee that was recently charged to a Dollar rental car and getting limited help. If you watch TV, you are familiar with the series of commercials for a major credit card company where a male, bearded East bloc customer service representative named “Peggy” pulls out every excuse possible in order to hang up on the customer in record time. The eternal question still reigns supreme: “Where’s good help when you need it?”.

I offer for my reading populace another example.

Since the beginning of the permanent Recovery Audit program, the four RA contractors have been mandated to perform provider outreach to “notify provider communities of the recovery auditor’s purpose and direction”, according to the RAC Statement of Work (SOW), which was updated in September.

The SOW details how the RACs submit a baseline provider outreach plan to CMS. CMS uses the plan as a starting point for discussion, which would lead to a more detailed plan, which should include “potential outreach efforts to associations, providers, Medicare contractors and any other applicable Medicare stakeholders”.

On a hunch (that hunch being that provider outreach has come to a grinding halt), I decided to look into the efforts of the contractors in this area. I started my informal Columbo-like investigation at the RAC website level. The first roadblock I encountered was that DCS and Connolly, the Region A & C RACs, respectively, do not have an education schedule on their websites. I snapped into action immediately and sent out e-mails to each RAC for clarification. I’ll provide more on the results of those communications later in this posting.

CGI, the Region B RAC, does have their schedule of all conducted outreach sessions on their dedicated RAC website. The last provider outreach session from CGI occurred on March 24th of this year in Illinois. Being from Wisconsin, I was particularly interested in the fact that in my state, only three sessions have ever taken place. To add insult to the injury of ignorance, none of these three sessions were aimed directly at facilities or physicians.

HDI, the Region D RAC, doesn’t make their list of outreach meetings easy to find, but after some fancy clicking of links, I came across this page on their website, which lists all of the outreach conducted thus far by HDI. As it indicates, the last outreach session for Region D providers occurred in September of 2009.

To get a mental picture of what this outreach vacuum means for the provider community, it helps to compare the outreach schedules of these two contractors with the number of approved issues added by each RAC over the same period where outreach education didn’t occur. In Region D, 336 of their 386 approved issues have been added since their last provider outreach session. In Region B, 53 new issues have been added since March 24th, with 43 of these issues being complex.

While I was exploring these assorted bits of ancient history, I received an e-mail from a customer service representative at DCS stating that an outreach webinar will be conducted jointly with NGS for providers in New York and Connecticut in February 2012. Using this as a lead, I checked the education schedules for MACs in each region, and to date, I see no webinars or other outreach events related to RACs on their calendars. I invite the reader to do a more thorough investigation. As a footnote, I had yet to receive a reply from Connolly at the time I published this post.

While many larger organizations have taken to discussing RAC issues as a group in search of enlightenment, it would appear that the RACs are in violation of  their work order. In the SOW, the Recovery Auditors are tasked with submitting monthly progress reports to CMS that outline all work accomplished during the previous month. The report is supposed to include upcoming provider outreach efforts, but perhaps CMS is so busy dissecting the appalling appeal statistics that they have been skimming over this section.

When the RAC in charge of the most densely populated state in the country has produced 87% of its approved issues list without presenting outreach to providers in its region, I would argue that it is indicative of a problem. Hospitals at this point know the ins and outs of the program, but I continue to encounter physician groups across the country that have only passing knowledge of the RAC program. Many that I encounter have no knowledge of RACs at all. CMS asks a lot from the provider community with regard to compliance. Perhaps the time has arrived for physicians to request that CMS and their contractors return the favor with a little shared knowledge.

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November 2nd, 2011 | 6 Comments »