As you know, I cover RAC and audit issues every Wednesday in this tiny corner of the world wide web. Based on the spike in government audit activity over the last 28 months, I have continued to do this based on my belief that I am addressing a need in the greater provider community. While the Recovery Audit Contractor program has been at the forefront of CMS’ efforts, I have also tried to demonstrate the road map that is followed by the alphabet soup of government audit entities, showing how certain issues rise to the top of the attention chain.
Despite all of my efforts, I have a large ongoing problem, that being my futile attempts to get physicians to pay attention to government audit issues. Perhaps it is the landscape in which large numbers of physicians are seeking employment under the assumed safety of hospitals, but my general feeling is that physicians are largely ignoring the message.
Just this morning, I received yet another reminder of this battle in my e-mail box. I subscribe to updates from multiple sources, most notably Medicare Administrative Carriers for assorted issues of interest to the provider community. Today’s electronic missive comes from WPS, the legacy Part B MAC for Illinois, Michigan, Minnesota and Wisconsin. For a few years, WPS has been a few steps ahead of other MACs with regard to conducting service specific probes on the heels of CERT testing discoveries under their jurisdiction. Of note, CPT code 99233 (Level III Subsequent Hospital Visits) has been on WPS’ radar for nearly two years across multiple specialties. Yet if today’s e-mail is any indication, the message of the importance to attention to review issues continues to fall on deaf ears with regard to the physician community.
WPS looked at this CPT code for the specialties of Neurology and Family Practice. Over the past 15 months, initial probes for these specialties revealed an error rate of 96.24% for Neurology and 89.54% for Family Practice, which quite obviously necessitated a follow-up review for both specialties. While there has been some improvement since the initial probes, a simple glance at the latest numbers show that physicians aren’t giving these reviews proper attention.
For Neurology, 128 line items across 98 claims were selected to review prior to payment. Of these, 102 line items were denied, for a cumulative error rate of nearly 80%. For Family Practice, 157 line items across 100 claims were selected, with 113 line items being denied, for an error rate of just under 72%. These numbers are bad enough, but a closer look reveals that roughly 60% of the denied claims for both specialties were due to physicians not providing the requested documentation for review. This means that 6 out of every 10 complex inpatient follow-up visits were denied because no one opened the envelope and/or read the correspondence inside of it.
I have limited amounts of free time in the coming year. I have people to educate face-to-face, networking opportunities with others in my profession, personal trips to various parts of North America between now and the end of Summer and a 5-year-old to keep on the straight and narrow. Nowhere in my small, handwritten pocket calendar do the words “BEAT HEAD AGAINST WALL” appear. From the moment The RAConteur began in September of 2010, I have been warning providers that the auditing landscape is changing, and not in a way that will be beneficial to either the delivery of care to their patients or their financial bottom line. Perhaps, someday, the physicians of America will begin to take a small step towards increased awareness. Might I suggest that the first part of that process to be the purchase of a letter opener?
Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.