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Archive for April, 2012

Surprise! It’s A Sternly-Worded Letter!

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

Another birthday weekend is upon me.

This coming Sunday will mark yet another anniversary of my birth. Coming up on 46, for me birthdays are no longer a celebration of my birth, but rather another mile marker on the (hopefully long) highway leading to my cremation. This is a somewhat dark way of looking at it, but as one of my living musical heroes, Robyn Hitchcock, so eloquently put it, “God finds you naked and he leaves you dying / What happens in between is up to you”.

As I get older, I find that I am making less and less time for politics in my life. There are many reasons for this, but the biggest reason is simply that every politician that I come across on the state and national stage lacks imagination. Just once, I would like to turn on C-SPAN during a Special Orders session in the House of Representatives and see a member of Congress painting a seascape, singing a new song that they’ve written or doing an interpretive dance in honor of the planet Jupiter. It would assure me that at least someone with their hands on the levers of power had the ability to think outside of the box.

In the absence of my grand vision, we are left with the oft-repeated habits of the Beltway Set; grandstanding for the cameras, filling their pockets with lobbying dollars and (my personal favorite in terms of absurdity) taking advantage of Congressional free mail to fill people’s mail boxes with letters that combine the worst of the two previous activities just listed. So much for elected leaders representing “public servants” or the “best of the best”.

If it’s another week in Washington, then someone must have sent a sternly-worded letter, and this week’s is a doozy.

Anyone who reads my missives in this space knows that I have a dim view of government audits, mainly because they are shifting the blame for abuse in the system to the wrong people, namely well-meaning hospitals and physicians who have a hard time understanding federal rules of documentation and reimbursement. We all know who the thieves are when it comes to healthcare delivery, and pelting hospitals with thousands of requests for documentation per year rarely smokes these rats out of their lairs. Claims are paid badly by MACs and subsequently reviewed poorly by RACs based on complexity built into the system by CMS. Shifting the administrative burden of such a system on providers is short-sighted and does nothing to improve the care being administered.

With all of that being said, you would think that I would be in favor of this week’s sternly-worded letter from a subcommittee of the House Ways and Means Committee to Marilyn Tavenner, the Acting Administrator of CMS. After a short preamble, the letter asks for every statement of work, performance report, case referral and contractor fee paid relating to Medicare and Medicaid program integrity efforts for every contractor involved in such activities.

You should all know by now that I’ll sprint to the front of the opinion line to talk about government audits, and I have always been a fan of full disclosure. As it applies to the Recovery Auditor Program, every quarterly report that has been issued by CMS on RAC performance is either a collection of half-truths or (in the case of the first provider accuracy scores issues by the RAC Validation Contractor) bald-faced lies. I am encouraged that CMS will be called onto the carpet regarding RAC appeal rates, as any provider that has been affected by RAC audits can tell you that a look at that aspect of the program is well overdue.

With all of that being said, it helps to consider the source of the letter to CMS. Charles Boustany, the Louisiana Congressman who chairs the oversight committee has quite the revealing report when it comes to an analysis of his biggest campaign donors. The list includes Blue Cross and Blue Shield and an organization known as the LHC Group, a nationwide provider of home health, hospice and long-term acute care services. That list of LHC’s services looks a lot like the list of the types of providers often caught in the HEAT team net. In all, Congressman Boustany has taken in over $350,000 in campaign contributions from entities involved in health care, including nearly $170,000 from various factions of the insurance industry.

Whenever a legislative opponent mugs for the camera, they do so hoping for a knowledge vacuum by the viewer. This latest in a string of sternly-worded letters that bounce back and forth within the Beltway is part of the never-ending gamesmanship that has led to the system we currently have in place. If I believed that anyone in Washington, DC cared for my opinion, I would issue my own correspondence to those in power. I can guarantee that there would be just enough in every letter to anger everyone on both sides. I can also promise you that unlike this blog, it would be unexpurgated.

I am happy with the long-overdue demands made in this letter, but I simply know better than to trust this particular messenger. It takes no imagination whatsoever to take action simply because someone pays you to do so. Sometimes, you have to do it because no one else will and it is the right thing to do. By this standard, the letter is a failure.

So if you want an uncensored and uncompensated opinion, and you’re not doing anything tomorrow night, come out and celebrate my birthday at 7:30 and I’ll be happy to impart some wisdom, but take this latest sternly-worded letter with a grain of salt until we see a response from CMS.

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April 27th, 2012 | 4 Comments »

The RAConteur: Medicaid Integrity Update and A Notable Sale

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

Covering the world of government audits in a continuing series of ruminations has the feel of yelling at the ocean. It is an exhilarating feeling until you realize that the ocean is always going to be louder than you are and you’re always going to end up smelling vaguely of dead marine life and salt. Until last week, I had a mostly walled-in desk, so pity my poor co-workers going forward.

Today I have some updates with regard to government audits that, while not related to the RACs, give us small windows into where government audits are going, and, more importantly, who’s pulling the strings.

I covered two recent OIG reports on the Medicaid Integrity Program on a recent episode of Monitor Monday podcast, but I’ll give you a quick synopsis for purposes of brevity. There was an OIG report released back in February with regard to how well the Review Medicaid Integrity Contractors (MICs) were performing their tasks. The report found that the review MICs completed 81% of their assignments, but had limited input into what specific leads were forwarded to the audit MICs. The review MICs created 114 reports identifying 113,378 unique providers. CMS then filtered that information and targeted 244 providers for audit. The report recommended that the quality of data given to the review MICs improve, as well as allowing the review MICs more input in the selection of audit leads.

This first report led into another, released roughly one month later, regarding audit MIC performance. The report showed that 81% of review audits conducted between January 1 and June 30, 2010 did not lead to the identification of an overpayment. Additionally, 11% of assigned audits were completed and $6.9 million in overpayments were identified, with $6.2 of that coming from collaborative audits between the review MICs, audit MICs, state fraud control units and CMS. The report recommended that further collaborative audits be initiated.

This past Monday, the OIG issued a 5-page addendum to the February report on the Review MICs to further clarify the status of the 244 providers targeted for audit by CMS. It turns out that in the second half of 2011, CMS assigned 161 of the 244 providers targeted to the audit MICs. As of February 1, 2012, 127 of these proposed audits have been completed. From this universe of targets, only 25 audits uncovered overpayments, totalling $285,629. This number represents less than 1% of the estimated $33.5 million in potential overpayments identified by the review MICs at the time of referral of these cases from CMS to the audit MICs.

Once again, we see clear and compelling evidence that a CMS audit initiative is plagued by poor data and substandard execution. It is also worth remembering that some portion of the minuscule amount identified as overpaid will be appealed by providers successfully, which further decreases the total amount of overpayment collections under the Medicaid Integrity Program.

Switching gears, I took note of an interesting financial transaction that affects government health care audits in a small fashion. It was announced on Monday that Thompson Reuters reached agreement on a sale of their health care division to Veritas Capital for $1.25 billion in cash. Thompson Reuters had been previously identified as the Medicaid RAC contractor for the state of Indiana. This is an interesting purchase for Veritas, a company that has made a rather salutary living in the world of government contracting (mostly in areas of defense) since 1992. Some of Veritas’ owned entities have had a less-than-sparkling record with contracted tasks in war zones over the last decade. If some of these patterns repeat, the health care providers in Indiana are owed our collective sympathies.

As the waves continue to crash, and as the salt sea air continues to invade my nostrils as my voice grows weak against the tide, I leave the reader to ponder the intricacies of the world of government audits. I recommend having some tequila handy, as it’s not a gentle subject.

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April 25th, 2012 | 2 Comments »

A One-Day Diversion To Music

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

The general state of the American health care system isn’t on my mind today.

Perhaps I am in the throws of an extended “information cool-down” from the Fi-Med RAC Summit that concluded on Tuesday. Maybe I am burned out on the hot topics of the day, which are the ICD-10 proposed rule and the Supreme Court deciding the fate of PPACA. It could be that I really didn’t want to get out of bed this morning on a cloudy, rainy day, as a day of sleep with my dog and cat nearby sounds better than writing about another study, opinion or semi-breakthrough in the world of medicine.

More than likely, it’s because I lost one of my musical heroes yesterday.

Those who have read my pieces in this space know that one of my bigger areas of interest is music, both listening and performing. Any musician with any value will look you right in the eye and tell you that they are only the sum total of musical heroes that have gone before. As a singer, I would be nothing without the previous vocal contributions of the likes of Tim Buckley, Van Morrison and Paul McCartney. As a songwriter, I wouldn’t have much to offer lyrically without the craft displayed by Richard Thompson, David Ackles, Graham Parker or Bob Dylan.

And then there was The Band.

When I was in high school, I was in an enviable position, as my high school had a functioning, licensed radio station. For two years in the early ’80s, I had the coveted Friday night on-air slot. While I have some regrets about not being on the air with my current music collection, it was a great laboratory for pointing me in the right direction in the realm of both listening and composing. I discovered the bulk of The Band’s catalog during those years, and as time has passed, I have come to consider them to be the greatest band that North America ever produced. They are also the centerpiece of The Last Waltz, the greatest musical documentary ever filmed.

In the middle of The Band’s music was drummer and singer Levon Helm, an Arkansas native tasked with keeping the beat behind four Canadians. On Tuesday, a notice was released to the world that Levon was in the final stages of his 14-year battle with cancer. Yesterday, that battle concluded. He was 71.  

I never had the chance to see him in concert. My friend Curtis did, as he states here. Yet having occupied a unique musical space for nearly 50 years, everyone who came across him had a story about his calming and welcoming presence that went along with his first rate musicianship.

My favorite story about Levon Helm has nothing to do with music at all. There used to be a morning DJ in Philadelphia by the name of John DeBella, who had previously been employed in New York. One morning, he told a story about having interviewed Levon Helm on-air during his days in New York. When the interview concluded and the microphones were turned off, Levon turned to him and in his gentlemanly Southern drawl said, “John, if you ever find yourself in Woodstock on a Sunday, just drop on by. We’ll have the game on”. Some time later, DeBella found himself around Woodstock, New York on a Sunday afternoon and thought to himself, “He probably doesn’t remember me, but what the hell? Let me try it”. He found Levon’s house in Woodstock, parked the car, walked up and knocked on the door. Levon answered the door, amazed and said “JOHN! HOW ARE YOU? COME ON IN! WE’VE GOT THE GAME ON!”.

There is a local band in Milwaukee called the Flood Brothers that do a mix of originals and covers. Sometimes, when I’m in the audience, they invite me up onstage to do a song, and invariably, the song we choose is “The Weight” by The Band. There are only a few songs in existence in this day and age that when played, the bulk of the audience feels compelled to sing along with the chorus. Mostly thanks to Levon’s vocal tone, mixing a storyteller’s care for narrative with a weariness of a traveler wanting only “some place where I could lay my head”, “The Weight” is a song that never gets old. The Flood Brothers play in town tomorrow night, and the urge is striking me to sing one more chorus.

Yet isn’t that the magic of all art, especially music? A song has a way of transporting you back in time to a moment when for a brief few minutes, it was the center of your existence. The listener never realizes that the song has just become a part of that person’s oral history until time passes. For me and my fan’s relationship with The Band, it is the vision of a 10-year-old kid, up late on a Saturday in 1976, watching the Band’s last television appearance on “Saturday Night Live” and listening as “The Night They Drove Old Dixie Down” spilled out of the television and into my mind for the first time, never to vacate since. At the center of the music was Levon Helm as drummer and one of three rotating lead and harmony vocals, presenting a story so seemingly real that I could picture him as a Confederate soldier. I remember buying The Band’s greatest hits on vinyl when my teenage years hit and being similarly ignited.

My childhood and high school days have disappeared with a combination of time, weight, acne medications and a pressing need to live in the moment. If the truth is told, all time prior to my introduction to my wife Leslie (half-Canadian; coincidence?) can be accurately described as my Dark Ages. Yet the music from as far back as AM radio in 1971 to the present day always resonates with a memory in tow in ways that my first encounter with a CPT book never can. Levon Helm has danced on the edges of my memory – consistently as a positive one – for over 35 years, and will continue to for many years to come thanks to his significant musical contributions. I am left with being able to only say “Thank you” to him from a distance.  

This space is supposed to be dedicated to medicine, so in order to satisfy that requirement, here’s a song by The Band about the early days of frontier medicine called “W. S. Walcott Medicine Show“. I bid Levon Helm a fond farewell with a special life-long thank you from my ears, and we’ll talk about things more closely related to health care next week. I thank the readers for their one-day exhibition of patience.

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April 20th, 2012 | 1 Comment »

The RAConteur: And STILL More Administrative Costs To Providers

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

There was once a time in this country where reasonable people within our government would come together and craft legislation with an intended purpose. When that purpose wasn’t achieved, they would convene again and do their best to attempt to fix it.

Obviously, in this world where reasonable people are missing, there has been a fundamental shift. Because of Congressional gridlock and the new political reality of the never-ending campaign, we now encounter situations where extra-Congressional changes are put forward in order to insure that the original intent of the law achieves its goal. From my perspective, the RAC program under CMS is a perfect example of this phenomenon.

Since I’m here and feeling surly and tired, let’s take a little Cynical History Tour of the permanent RAC program.

In the beginning (a few years ago), the RAC contractor would send an additional documentation request for complex review to a provider. The provider would return the requested records to the RAC, and the RAC would reimburse $.12 per page for the record. Next, the RAC would make their determination. If the determination was that an improper payment existed, the RAC would send a review results letter to the provider. The provider would have the opportunity to enter into a discussion with the RAC regarding the legitimacy of the determination. In the meantime, the RAC would send the detail of the improper payment determination to the MAC, and would then issue a demand letter to the provider. The provider would have to appeal within 30 days to avoid recoupment by the MAC, which would occur automatically on the 41st day after the date on the demand letter. Once the appeal was submitted, any outstanding discussion period would be immediately cancelled in favor of the appeal.

The problem with this process was that it worked too far into the provider’s favor. Providers have enjoyed lofty appeal success rates since the beginning of the permanent program. While the administrative burden was significant, the provider was compensated per page, which lessened the blow somewhat. The providers were able to direct all correspondence simply by informing the RAC of one preferred address. Despite CMS’ quarterly newsletters stating several hundred millions in returns to the Medicare program, the American Hospital Association’s RACTrac survey shows that these numbers are far from finalized. While the process was onerous, at the very least there were documentation limits to minimize the burden.

My, how times have changed…..

It started on September 1, 2011, with a change in the statement of work that allowed for semi-automated review, which came with no request limits and no reimbursement for records. Fast forward to January 1st, when the MACs took over the process of issuing demand letters from the RACs. The MACs are now sending RAC correspondence strictly to the payment address, which is causing RAC coordinators headaches. Because correspondence is not stemming from one source, and because demand letters are not arriving to the needed destinations, the number of discussion periods is beginning to wane. On March 15th, Medicare upped the record request limits for complex review per 45 days for all providers. Next came April 1st, where CMS has now decreed that the maximum that a provider can be compensated for providing records is $25 per requested record, which includes postage. 

While the Patient Protection & Affordable Care Act currently stands in a state of flux, the plan was predicated on funding from rooting out fraud and overpayments paying for the program. Since the permanent RAC program came to pass, the reality is that the money the RACs are returning to the program is far lower than stated in the quarterly reports. Thus, as fits my thesis at the beginning of this posting, CMS continues to tinker with the rules for providers in an attempt to gain a better financial result for the program.

There are reasons to want to root out fraud and abuse in the Medicare program, but to continue to punish hospitals with paperwork for what amount to discrepancies in the interpretation of Medicare rules is not the way to achieve the goal. Hospitals will begin to fail under the weight of investigation long before the worst offenders in the Medicare arena are escorted from the program in handcuffs and orange jumpsuits. Gaming the system to punish the wrong people is clearly the incorrect approach to the problem.

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April 18th, 2012 | 1 Comment »

FLASH: ICD-10 Delay Lays Bare Spencer’s Genius

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

Today, I exist in a world where the last 12 hours of my time has been filled with a lot of information. As is my usual custom, about 1/3 of it is actually job-related.

It started last night at about 12 Midnight as I was watching an early ’70’s B-movie off of my DVR (I’m not even going to share the title with you, as this is one field of interest of mine that I can’t even begin to explain to people based on it being rooted in insomnia). As the movie’s plot and soundtrack continued in my head prior to leaving my house this morning, I was packing to leave for a weekend wedding in central Illinois. This morning, I listened intently at an off-site meeting on RAC issues that gave me weeks of fodder for my Wednesday posts in this space. Next comes preparations for the Fi-Med RAC Summit this coming Monday and Tuesday, a business invitation that was just extended to me upon my arrival in the office, the work awaiting my hands currently occupying my desk (the true 99%, if ever it could be measured) and we finally work down to the fact that I’m hungry and that my chosen lunchtime remedy for this condition today is woefully inadequate.

And then there’s the ICD-10 delay…….

For those of you in health care that have been living on a beach without cell service for the last week, CMS has issued a proposed rule indicating a new compliance date for ICD-10 of October 1, 2014.  

I had a plan for today’s post, B-movies, meetings, packing and summits not withstanding. My plan was to share with you the comments I am going to share with CMS regarding the proposed rule that I shall upload onto Regulations.gov. The comment period for this proposed rule is only 30 days, which is CMS’ way of stating that they’re sick of the crosstalk on this topic. Unfortunately, the proposed rule has yet to be uploaded onto the comment site and I am not about to use regular mail for submission. Until such time as the proposed rule is entered into the Federal Register, allow me to give you all a preview of coming attractions.

You all know my feelings with regard to ICD-10 as it pertains to ICD-11. If you do not, please review this recent post. We now have a compliance date for ICD-10 that, thanks to delays (caused mostly by entities such as commercial insurance carriers who threw lobbying dollars), will fall 22 years after its release by the World Health Organization. I ask the reader to also remember that work on the design of ICD-10 began in 1982, the year that America was riveted by the happenings of the Ewing family on Dallas between spins around town in their AMC Eagles.

Here’s one last number for everyone to chew on, and this one will take up quite a bit of my comments to CMS. The proposed final compliance date for ICD-10 falls only seven months prior to the scheduled release of ICD-11 (including a clinical modification) in May of 2015. Because I’ve been banging the ICD-11 gong to CMS since 2008, newcomers that are late to my party are now telling me that an American clinical modification can’t be ready until 2024 or 2030, so I feel I need to respond to the conjecture emanating from certain quarters of our industry in the only way I know how, given my formative years spent as a sports fan in the City of Philadelphia.

BOOOOOOOOOOOOOOOOOOO!!!!

The only reason we have an American clinical modification to ICD at all is because we kowtow to the insurance industry so they can use the US version to more easily deny claims. ICD-11 is a system that brings SNOMED CT into the code set for better clinical representation of a patient’s condition. If we are truly concerned about paying for performance rather than quantity, and if we want to redefine the fundamental goal of medicine in the United States to be one of better patient outcomes, then who in their right mind would argue to putt along with a clunker of a reporting system for up to 16 more years?

If you were reading this post thoroughly, you know that the answer to that question is the companies of yesterday who threw money towards adopting ICD-10 as the reporting standard.

There was a time when people in other parts of the world were isolated from one another, which made one global disease and morphology reporting standard something of a moot point. We now live in a world of international interaction brought on by technological advances in travel and communication. For the rest of the world to utilize one reporting standard while the United States uses another is no longer a viable option. I feel happy to add that throwing out monetary reasons to justify being behind shows a distinct lack of citizenship. In America, if you want to get something done, you plan and act. Crying about all of the money you spent (or are about to spend) on ICD-10 is the same as telling me “but we’ve always done it this way” and you never says those words to a compliance officer.

My pending drive deep into Illinois, my workload, today’s meeting, next’s week’s Summit, my growling stomach and B-movie soundtracks and plot lines will continue on in my head unabated until I decide to bring new stimuli into it in order to continue evolving. I would recommend to those who wish to belittle the idea of a faster ICD-11 implementation to perhaps open their minds to the same process.

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April 13th, 2012 | 1 Comment »

The RAConteur: Whither Medicaid RACs?

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

Today, I return to this space after a one-week absence due to my attendance at the AAPC’s National Conference in Las Vegas. Given the venue, I wouldn’t have thought that it would have provided an opportunity to clear my head, but it did provide me a chance to recharge, if not refill my wallet with winnings. In addition, since I attended two breakout sessions that contained incorrect information on the Medicare RAC program, it reinforced the importance of putting good information regarding government audit activities into the public sphere.

Today’s thesis begins with the idea that unintended bad consequences often stem from good intentions. As an example, a few years ago, my family adopted a shelter cat. The unintended consequence of this act of altruism is that he waits until 2 AM to begin his incredibly loud vocal practice, which necessitates that I sleep in close proximity to books, shoes and other projectiles.

Yet there are examples where unintended consequences stem from acts of fury and aggression. As I normally do in this space, I’ll give you a relevant example from the world of American Health Care.

It has now been two weeks since the conclusion of oral arguments at the Supreme Court regarding the Patient Protection and Affordable Care Act. Given the constant drone of virulent opinion towards PPACA coming from the neo-conservative side of the political spectrum, and given that my take on the Supreme Court arguments was that these leaned strongly towards throwing out the entire statute, people in many areas of health care are left wondering about the consequences of a world without the law in place.

As it applies to government audits, suddenly the Medicaid RAC program finds itself  with an uncertain future. The program was scheduled to begin on January 1 ,2012, but by my count has yet to produce a single documentation request for any provider in any state. As if that was not enough, only 22 of 50 states have finalized a Medicaid RAC contract, with 4 other states pending an announcement of such a selection. This leaves 24 states without a Medicaid RAC. It should c0me as no surprise that there is a conspicuous overlap between the list of states without a contractor and the list of states suing the federal government to overturn PPACA.

As anyone who has read my blatherings in this space knows by now, I am not a fan of the RAC process as it is currently constituted, as the Medicare RACs have yet to demonstrate a wide-ranging competence with regard to their assigned tasks. I think I can speak for the provider community when I state categorically that no one is looking forward to the expansion of the blind skeet-shooting that has come to symbolize the work of the four Medicare recovery auditors into Medicaid reimbursement.

However, if the Supreme Court acts as I think they will by invalidating PPACA in its entirety, the 5 conservative justices on the Court and the political forces who support them will actually be arguing for improper Medicaid payments to continue unabated. Given the caterwauling about stretched state budgets emanating due to Medicaid from those same governors of states lending their names to the lawsuits that brought PPACA to the steps of the Supreme Court, my logical brain finds itself perplexed by this consequence.

The premature end of the Medicaid RAC program is but one unintended consequence of PPACA’s possible / probable disposal. Given that the final law clocked in at 906 pages in PDF format, many initiatives and programs suddenly find themselves needlessly threatened based on the whims of 5 people in a columned building in Washington, D.C. The setting is somewhat fitting, given the antiquated form of Olympus-like justice that is about t0 befall the act. Given the sheer volume of consequences, I may not need a bellowing cat to keep me up at night for much longer.

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April 11th, 2012 | No Comments »