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Archive for May, 2012

CMS: What Anarchy Looks Like

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

Among my many musical areas of interest is punk rock, as performed by the original creators between 1976 and roughly 1984. If music was ever in need of someone stepping to the fore with an airing of grievances, it needed to happen in the middle of the self-indulgent, fashion elitism of the disco era.

One of the founding principles of the punk rock movement was the idea of skipping revolution and going straight to anarchy. In the post-Watergate era in America, and as the post-World War II excesses of the upper economic echelons continued in Great Britain, the idea of being completely leaderless held a certain appeal for many, including me. That personal fascination ended abruptly in 1994, when the events in Rwanda showed the world in stark terms what anarchy actually looks like. Nations, organizations and institutions need stable leaders and a cultural direction, mainly because to leave the human race to their own devices invites the worst of all possible scenarios.

It was with this philosophy in mind that I came across a story this week regarding Marilyn Tavenner, the current Acting Director of CMS. Due to archaic procedural rules in the U. S. Senate (seemingly designed to insure gridlock), it was announced that there would be no confirmation hearings to remove the “Acting” portion from her title. As a reminder, based mostly on political pie fights, CMS has had only acting directors since 2006. Ms. Tavenner is the 5th such temporary director in that time period.

CMS is now deeply submerged in multiple initiatives designed to transform the government health benefit payment model from one of consumption to one based on the quality of the outcomes. Most of these initiatives have come into being with the agency lacking long-term leadership. It has indeed been a difficult task to bring forth such things as ACOs, increased audit initiatives, mandatory medical records and ICD-10 when the average tenure length of leadership at CMS over the past 12 years is one year and 73 days. Looking at that number, it reminds one more of the random length of a prison sentence rather than a legitimate term of leadership.

As the story linked above clearly demonstrates, Ms. Tavenner does not appear to be as polarizing a figure as her predecessor. She has admirers on both sides of the aisle, which is admirable given the rhetorical gulf between the two sides in Congress. On the surface, there is no logical reason why her installation as a “permanent” agency head should be postponed. Given that based on averages, Ms. Tavenner is more than likely just about half way through her term as acting director, the nonsensical nature of the delay is compounded.

By their inaction towards the needs of CMS and the people who rely on the Medicare and Medicaid programs running smoothly, the Senate is giving us another window into the world of anarchy, albeit a less violent example than the streets of Rwanda in 1994. As announcement e-mails from CMS regarding new initiatives slowly fill my inbox, I head into the long holiday weekend wondering who or what will run CMS the next time the Anarchy Train comes to town. As a pointedly-named punk band of yesteryear once put it, “It’s coming some time, maybe”.

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May 25th, 2012 | 1 Comment »

The RAConteur: Rethinking The Statement of Work

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

Because I have lived and worked up and down the Eastern seaboard throughout my life, I have had a chance to interface with some interesting characters in my life. One of the most colorful is my friend Scott, who lives in suburban Atlanta. Scott is a veteran of the Iraq War and much like me, admires things that are rooted in the logical.

Scott was telling me a story one day about buying a prefabricated piece of furniture that he then had to assemble for his home. Because the parts and instruction book were created overseas, the assembly guide was written in a fashion in which the first instruction under a given step followed the second instruction, which stretched a 20-minute assembly into three hours. Deciding to act on his frustrations, Scott called the furniture company’s customer service number and was placed on hold for 15 minutes. When the hold music stopped and the representative asks how he could be helped, Scott yelled an oft-repeated, two-word expletive and hung up. It was related to me that this was very therapeutic.

I often ruminate on the intellectual decline of the United States, but it is another matter altogether to request clear and concise guidance, only to receive advice and instruction that leads to dead ends. This thesis leads perfectly into a discussion about the Recovery Auditor Statement of Work.

To review, the RAC Statement of Work currently stands with its latest revision date of September 1, 2011. I know of several hospitals that are dealing with thousands of RAC claims and their aftereffects, yet I do know that there are indeed some facilities that have yet to receive an additional documentation review request for complex review. I direct this post to those handful of facilities.

If you are looking for insight into the RAC process that has just arrived at your doors, consult colleagues for the first half of the process dealing with documentation requests and interactions with the RAC contractor. For the second half of the process, which involves appeals, the statement of work can be of some assistance, but know that it contains some outdated information that CMS apparently does not feel the need to update for accuracy.

The RAC Statement of Work available on the CMS website continues to indicate that the recovery auditors issue demand letters after the determination of an improper payment. This information has been incorrect since January 3, 2012, when the MACs took over this portion of the process. Know that the MACs are now handling this process, that the demand letters will go to the payment address of the facility in question and beyond that, the MACs really don’t care. Knowing this information up front will help keep your blood pressure in check when you get deeper into the process.

For an additional point of clarification, I would like to point you to page 22 of the Statement of Work, under bullet point 8, which is titled “Semi-Automated Review”. For regular readers in this space, I wrote a piece recently that mentioned the AAPC National conference that I attended in Las Vegas this past April. At one of the sessions that I attended at that conference, a person with a compliance credential indicated that based on the wording of the language in this particular section of the Statement of Work, provider response to an additional documentation request under semi-automated review was “optional”. As is my wont when I hear something that is grossly incorrect, I pointed out to the presenter that this was not the case. As a clarification for this audience, if a provider decides not to respond to a request for additional documentation from any government audit entity, the lack of response will lead to an overpayment determination. Simply, the “decision” not to respond to a government audit entity can be directly connected to a “decision” by CMS and their many auditing tentacles to audit you further.

These are but some of the highlights of the dicier portions of the RAC Statement of Work. Even for those RAC coordinators who are neck-deep in the process, the 57-page document, though riddled with either errors or unclear language, remains the resource of the moment with regard to the RAC process. For the RAC program as a whole, trust nothing, but be smart enough to arm yourself with information. As you sink deeply into the appeals process, knowledge, even knowledge that reads like an overseas-published assembly guide for home furnishings, can be of value.

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May 23rd, 2012 | No Comments »

A Requiem for ICD-11 & Perspective on Physician Compensation

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

It has been my habit in the past to begin my weekly dissertations in this space with amusing anecdotes and random thoughts blurted out from a brain long since “modified” by a habit of sleeping roughly 4 hours per night for many years. Instead, in order to jolt you into the content about to follow, I shall precede the guts of today’s post with this brief but powerful musical interlude, which features Donald “Duck ” Dunn, bass player extraordinaire (easily in my top 5), who passed away this week.

Now that we have that out of the way, let’s talk about the latest in a long line of proposed rules for an ICD-10 compliance date, the comment period for which expired last night at 11:59 PM.  As promised, I submitted my comments yesterday afternoon, which I have decided to post in this space as well as on regulations.gov. It is a healthy mix of seasoned opinion and “poking the bear” that states my views on the proposed, revised compliance date of October 1, 2014:

RE: CMS Proposed Rule, File Code CMS-0040-P, Docket ID: CMS-2012-0043

I wish to submit the following comment on the above proposed rule. Specifically, I would like to address the portion of the Proposed Rule regarding the revision of the compliance date of ICD-10 from October 1, 2013 to October 1, 2014.

It is with particular disappointment that upon reviewing the Proposed Rule, one again CMS is committed to a path that will lead to the United States being on a lower tier internationally with regard to symptom, disease and morphology reporting.

As was stated in the Proposed Rule, CMS rejected the idea of moving directly from ICD-9 to ICD-11, scheduled for release by the World Health Organization in May of 2015, which is notable for being only 8 months after the new proposed date for ICD-10 compliance. This two-paragraph rejection of such a move was footnoted by two recent industry articles, which indicated that a clinical and procedural modification would “take anywhere from 5 to 7 years for the United states to develop its own ICD-11-CM and ICD-11-PCS versions”.

During the original Proposed Rule comment period in late-2008, leading up to the Final Rule in January, 2009, I submitted a comment regarding the oncoming implementation of ICD-10 (then slated for October 1, 2011 in the Proposed Rule). Commenting on the original proposed date of October 1, 2011, I stated that the United States “will have finally caught up to the rest of the world in its reporting structure, only to see that disappear within three years as the world begins to use ICD-11”. With the proposed release date for ICD-11 now appearing a mere 8 months after the proposed date, I again state that I am in favor of moving directly to ICD-11 from the current outdated standard.

The industry articles cited in the new Proposed Rule under footnote 48 had arguments that fell into two lines of thought, the first being the expense and time already spent planning for ICD-10 implementation, and the processes that would need to happen to move our current system to ICD-11. I would like to address the first of these two articles, which involved the costs and time already dedicated to ICD-10. The article states that work first began in 1993, and concludes with the statement “We could have skipped ICD-10 in 1993-it’s a bit late now”. This appears to me to be a facetious argument, as the planning for the succeeding code set, ICD-11, did not begin until roughly a decade later. If the overarching argument of the article is that the amount of time and dollar investment now necessitates the country staying behind the global health care curve, I am having a hard time fathoming why CMS finds the article worth quoting, if CMS’ current mission to modernize our health care system is in earnest.   

The other main argument against ICD-11 implementation appears to be the idea of being unable to bring forth a “clinical modification” acceptable to stakeholders in the American health care system. The original final rule for ICD-10 released in January of 2009 offered an implementation date of 2020. There are now estimates being put forward of ICD-11, after American clinical modification, not being released until as late as 2030. The previously quoted article in the new proposed rule offers an implementation date of 2024.

CMS has stated very clearly, both with words and with a host of payment reform initiatives that the Centers wish to connect reimbursement for services with patient outcomes. Given that ICD-11 interfaces with SNOMED-CT as part of its design, and given that a global clinical modification will be part of the ICD-11 code set upon release, I see little reason to attempt to modify ICD-11 after release in order to make it fit into the current payment models in the United States if CMS’ goal remains as stated. ICD-10 has been modified for our current payment model, and based on its design dating back to the late-1980’s, allows for better reporting for reimbursement, rather than better reporting for clinical outcome. I posit that it is time to abandon the idea of a uniquely American clinical modification so that we as a country can begin to report diseases, symptoms and morphology in a way that is conducive to bringing forward better outcomes.

I am more in agreement with another recent article on this subject, which was penned by five physicians, one of whom happens to be a member of the ICD-11 Revision Steering Group for the World Health Organization. The opinion of this article is that if ICD-10 is to be the standard for the immediate future, that a delay of one to three years in the implementation date be enacted, but with the understanding that planning for ICD-11 implementation begin immediately. I would like to go a step further and state categorically that in order to stay true to CMS’ goal of aligning payment with outcomes, the ICD-11 code set, as scheduled for release by the World Health Organization, should be accepted without further modification as the reporting standard for the United States.

I then signed off, with name, rank, serial number, shoe measurements and other pertinent information.

Originally, ICD-10/ICD-11 was going to be my only topic today, but I came across a study yesterday in my daily search for new information that is instructive with regard to one of many sore subjects in the healthcare debate. According to a joint survey by the Overseas Employment Development Board (who?) and a private company called Jackson Healthcare, physician compensation in the United States is equal to 8.6% of total healthcare spending in this country. Compared to the healthcare systems of seven other industrialized nations, only Sweden and New Zealand, at 8.5% and 7.35% respectively, had a lower percentage of healthcare spending going to physicians.

On the surface, one might be tempted to cry for the poor American physicians, until we take a closer look at the numbers, as well as the populations of the countries listed in the survey. There were eight countries measured in the survey, with data from Australia, Canada, France, Germany, New Zealand, Sweden and the United Kingdom joining that of the U. S. When we look at total healthcare spending, we see that the combined healthcare expenditures of these countries equals only 38% of the total healthcare spending of the United States. For more perspective on the numbers, I also notice that the $216 billion dollars paid to American physicians is higher than the combined healthcare expenditures of Australia, Canada and New Zealand.

Yet population differences tend to cleanse these figures somewhat. The United States is the third largest country in the world in terms of population, trailing China and India by a good distance. The closest country in terms of population in the survey was Germany, but the total population of Germany only represents roughly 26% of that of the United States. In fact, the United States is roughly ten to fifteen percent higher in population than all seven countries combined. By virtue of our size and dollars spent, the 8.6% number could almost be admirable, but the amount of waste in our system, coupled with the knowledge that 13.9% of America’s gross domestic product is spent on healthcare, makes any admiration fleeting.

As I try to gain control of these and other random thoughts, I leave you with the above points to ponder as the weekend approaches.

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May 18th, 2012 | 1 Comment »

The RAConteur: Another Opinion on Government Audits

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

Given the increasing incompetence in our society, I feel that with each passing day there are more jobs that I myself could perform. Yet there is one exception, and that would be the job of sports referee. It takes either a special level of off-the-chart arrogance regarding your own skills or a deep-seeded self-hatred to be a referee. Every decision that a referee makes guarantees that one-half of the participants in the sporting contest will come away hating you.

In the world of government audits in the last week, we heard from one such policy referee, that being the General Accounting Office (GAO).

The GAO is officially the investigative arm of Congress. It operates as the actuarial governor on Congressional legislation, reviewing the receipt and payment of public funds to gage the financial impact of legislation. Much like a referee, the reports released by the GAO tend to briefly alienate political factions based on whether the reports fit a particular party narrative. A report released last Wednesday was no exception.

The GAO chastised the Department of Health & Human Services for not implementing past recommendations to reduce improper payments from the Medicare program. The most prominent of the GAO’s recommendations was CMS demanding automated prepayment edits of the Medicare Administrative Contractors (MACs) in order to identify improper claims. This recommendation was first brought forward in 2007 and remains an elusive goal.

In addition, the GAO wants to see payments to Medicare Advantage plans to reflect the correct health status of the beneficiary in question. Risk Adjustment Data Validation (RADV) audits have revealed that the Medicare Part C plans have been claiming more dollars than they are entitled to based on patient condition, so this GAO recommendation should gain some traction. In addition, the GAO wants to see the current Medicare Advantage Quality Bonus Payment Demonstration halted, as it claims the design of the program precludes it from yielding meaningful results.  

It is one thing for the Senate Finance Committee to request input from stakeholders on how to avoid waste, fraud and abuse in the Medicare program. It is quite another for the GAO to state that there is more that CMS could do to fight improper payments, in addition to RACs, ZPICs and predictive modeling technology, all of which have been shown to be failing in their own unique ways. The injection of the GAO as an impartial observer into the debate should be welcomed by a provider community left shell-shocked from audit activity. For this one time, everyone should rejoice in the arrival of the referee.

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May 16th, 2012 | 3 Comments »

Who Will Best Prepare You For ICD-10?

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

I stopped reading the local newspaper’s Op-Ed page, as well as viewing Sunday opinion shows, a long time ago. It wasn’t the constant back and forth between factions of opinion that turned me off. What irked me was the very idea of the people offering their opinions being regarded as “experts” simply by their presence in a certain forum, when in fact what they actually had were good industry connections in order to be able to spout off any kind of nonsense imaginable. As time passes, a resigned acceptance takes hold within the reader / viewer that a particular person stands as an expert in their field, when in actuality they are nothing more than a human embodiment of a long-existing restaurant in a good location.

I have been thinking about this as it relates to my chosen profession lately. At the root of my experience is my 14-year-old coding certification. Medical billing and coding has become the “hot” job in America over the last two years. Twenty years ago, if you had a day off or a sick day and you were watching afternoon TV, the three main commercials you would see were “Have you been hurt in an accident?”, “I’ve fallen and I CAN’T GET UP!” and “Are you looking for an exciting career in trucking/hair styling/graphic design?”. Today, between scenes of “The Rockford Files”, you still get the ambulance-chasing attorneys, but the latter two choices have been replaced by commercials for Medicare Part C plans and technical schools offering courses in medical billing and coding.

As a result, there has been a significant influx of people in my profession who are just entering my occupational universe. This comes at a time when a paradigm shift is about to occur in the basic tasks of a coder, that being the looming implementation of ICD-10. When I sat in a hospital meeting room in Pennsylvania in 1998 to take my 5-hour certification examination, I had been involved in the administrative side of health care for over 8 years. I passed that examination, as well as a subsequent one a few months later, which gave me a couple of spiffy acronyms after my name conveying the imprimatur of expertise in my field. In the succeeding decade and a half, I have worked hard to continually improve the work product of myself and others in my chosen field.

If only I could say the same for my certification body.

About 5 weeks ago, I traveled to Las Vegas and attended the annual national conference of the American Academy of Professional Coders (AAPC), the organization that oversees my two coding certifications. The AAPC has been in existence since 1988, but went through a change in stewardship in the middle of the last decade in the wake of separate controversies regarding the founder and his estranged spouse, who was the president at the time of the takeover. As a result of this purchase, the AAPC is now a for-profit certifying entity. While the new owners did have some positive immediate impact upon acquisition, their actions since, as embodied by the national conference I recently attended, couldn’t come at a worse time.

I have a few beefs with the AAPC that I was unable to move up the chain of command in Las Vegas, thanks to the coding game shows, simplistic, beginner-level presentations and the ongoing abomination that is modern popular music being blasted over the speakers during every general session. Lucky for my readers, they get a dose of my attitude here, and it comes with better music.

A cursory look at the AAPC website shows that in addition to their most important core credential of Certified Professional Coder (CPC), they list twenty-five additional certifications. Twenty of these deal with individual areas of coding expertise, with the remaining five being certifications in hospital outpatient facility, auditing, “payer perspective coding”, interventional radiology and compliance. A majority of these certifications have come into being in the last five years. In creating this alphabet soup of credentials, the AAPC has created the unintended consequence of weakening their core CPC credential for physician practice coding.

Which leads me to everyone’s favorite topic, ICD-10. With the exception of the first presentation I attended by Michael Arrigo of No World Borders, who expertly connected the dots between ICD-10, payment reform and the revenue cycle, the balance of the information presented on ICD-10 at the Las Vegas conference consisted of “prepare now”, “it’s coming” and “it will affect things here and here”. This approach came complete with a guy dressed up like some mutated form of Elvis and an ICD-10-CM book (I wish I was kidding). Instructing the 2,200 coders and other professionals who attended just how to prepare and how things will be affected was conspicuously absent.

It helps to contrast the approach of the AAPC towards ICD-10 with that of the American Health Information Management Association (AHIMA). Because AHIMA certifications have more to do with hospital billing and coding, AHIMA has been engaged in the ICD-10 implementation process for over a decade. This included the 36 days of field testing that was done back in 2003 that is now seen as sufficient for implementation of the code set. As this recent article points out, AHIMA vigorously defends the need for the code set, has no tolerance for outside opinion to the contrary and is leading the charge toward a smooth transition.

Meanwhile, last week, the AAPC created yet another new certification and has taken the position that training in the code set should be undertaken no more than one year before the implementation date, which is set to move again soon after the CMS comment period on the latest proposed rule closes next week.

With the number of coders suddenly multiplying thanks to afternoon TV advertising, we now have an army of new AAPC-certified coders who not only are brand new to the administrative side of the industry, but who were proficiency-tested on ICD-9, which won’t be around 2 1/2 years from now. Meanwhile, the AAPC page on LinkedIn.com consists mostly of postings from newly certified coders who are still looking for work months (or even years) after attaining certification. The AAPC’s answer to this is to have a membership count proudly displayed on the home page of their website.

While I do plan to submit some rather pointed and mocking comments to CMS regarding the lost opportunity about to be undertaken so close to worldwide release of ICD-11, I am resigned to the fact that ICD-10 is a reality that is best planned for sooner rather than later. To those who took a break from afternoon TV and happened upon this article, might I suggest that rather than entering the overpopulated world of medical billing and coding at a high tuition cost to you, maybe instead try to draw Tippy the Turtle for an art school scholarship. A brand new CPC certification from the AAPC, in its current form, will mark you as an expert two years from now about as much as anyone on a Sunday afternoon talk show. Trust me when I say that’s not saying much. Do yourself a favor and try a new restaurant.

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May 11th, 2012 | 3 Comments »

The RAConteur: An OIG Preview Of Coming Attractions

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

I’m going to start out today’s post with a confession of a personal shortcoming. I am much more dynamic on paper than I am in person. When I discuss a subject face-to-face with people, I have a tendency to obsess on one topic, much to the detriment of a random listener. I tend to blurt out thoughts without thinking, and based on my fund of bar knowledge, some of those random thoughts are downright frightening and have led to bans in several social circles across the United States.

There are some issues from which I squeeze the life in print, as many of my regular readers will certainly attest. If I had to select one topic which I have revisited more than others in my professional life (restricting our universe to the world of health care), it would be the billing and documentation of evaluation and management (E/M) services. Thanks to the majesty and splendor of the OIG Work Plan, I get another opportunity to write about it again today.

When the latest Work Plan was released last October, the OIG indicated that they would be reviewing trends in E/M coding for claims submitted between 2000 and 2009. In particular, the work plan stated that the OIG would “also identify providers that exhibited questionable billing for E/M services in 2009″. This morning, as I was searching the macabre depths of my mind for today’s topic, I received an e-mail stating that this review has been conducted and finalized.

There were two slight changes from the Work Plan and the released report, that being that the years of E/M data being reviewed was 2001-2010, and the identification of physicians with aberrant patterns being based on 2010 data. The findings of the report should come as no surprise to anyone who has been involved in medical billing consistently over the last decade. In the years surveyed, physicians “increased their billing of higher level E/M codes in all types of E/M services”. The analysis of the billing data identified approximately 1,700 physicians “who consistently billed higher level E/M codes in 2010″. Based on the report, the OIG recommended continued education, encouraging contractors to review physicians’ billing for E/M services and to commence review of physicians “who bill higher level E/M codes for appropriate action”. For those not studied in Apparatchik language, that means audits. Dr. X, meet Mr. ZPIC.

For the last 30 years, physicians in private practice have been feeling the reimbursement squeeze from government and commercial payers. In this environment, the physicians who care most about their reimbursement have been searching for ways to stop the bleeding. One of the easiest ways to do this is to increase reimbursement for the most common service of the practice, which is the face-to-face encounter with the patient. As a result of this philosophy coming to the fore, a cottage industry of consultants promising to increase reimbursement for E/M services by “strengthening” documentation has popped up, often focusing too much on “bullets” and not enough on medical necessity. In the world of the electronic medical record, this type of approach by practices is fraught with risk, especially if the physician is more receptive to a financial message rather than a message centered around compliant documentation. With ICD-10 poised to be shoved down our throats like a Turkish scimitar, documenting for reimbursement is a habit that is best broken sooner rather than later.

In the eyes of CMS and the OIG, the roughly 1,700 providers identified as outliers by this OIG analysis are about to have a rude awakening. Having reviewed tens of thousands of pieces of E/M documentation in my career, and having seen nine years of CERT results that have consistently identified high level E/M services as being coded improperly, there is absolutely no excuse for not knowing the documentation rules for E/M services. I have heard every physician canard (“…but I spend a lot of time with my patients…”, “…but my patients are sicker than others…”, “…these rules are so arbitrary…”, “…how am I supposed to keep my doors open…”, etc.) multiple times from multiple sources, and none of them make sense if your documentation of services is not a true reflection of the scope of the patient encounter. From personal experience, I can tell you that the instances where assumptions made by physicians about the care they are rendering being accurately reflected in their documentation upon initial review are few and far between.

Those of us who exist on the side of physicians have been waiting for the RAC contractors to announce their entry into the E/M universe. The RACs are surrounded on all sides with evidence from other audit entities that E/M services should be targeted. Based on the poor quality of the RAC work product up to this point, it is something of a blessing that the RACs have stayed on the sidelines. There should be no illusions that the RACs will continue with this indifference indefinitely.

I have written and spoken about E/M services in one way, shape or form on just about every day of my health care career. Those who know me are sick of hearing me talk about it, and future acquaintances will respond the same way given time. The OIG report is but another warning shot across the bow of providers who have been taught to game the system through creative coding and documentation techniques. My wife can tell you that I often repeat myself, but this is one topic that must be consistently reiterated based on rampant errors that exist.

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May 9th, 2012 | 1 Comment »

A Heavy Week For The Police Blotter

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

When I was growing up, there used to be a phrase for a person or a business enterprise that could be trusted to do the right thing. That phrase was “on the level”. In the grand scheme of things, my life experience to date is fairly short, so it is distressing to me that the idea of someone being “on the level” seems to be some kind of quaint notion from yesteryear. Once upon a time, it was fairly easy to distinguish what was legitimate and what was too good to be true.

Unfortunately, in modern times, we are surrounded on a daily basis with scams. From the spam in our e-mail inbox to the “price rollbacks” offered by virtually every retailer, there is very little that I see across the landscape as “on the level”. Even adding something to your meal from the fast food menu for “another dollar” seems like an honest bargain, until you realize two years later that you can’t fit through the doorway without coating your hips and shoulders with margarine.

After a while, what tends to happen is people become numb to the ugliness around them and get consumed by it, rather than feeling like they are spending their lives swimming upstream under the delusion of something wonderful greeting you at the river’s source, even though it never comes into view. Maybe it’s all the psychedelic music I’ve cheerfully listened to in my life, or maybe it’s my love of oceans, lakes and rivers, but I’m here to tell you that I’ll keep swimming for the rest of us.

I read two stories this week that make me believe that the idea of “on the level” is poised for a comeback. The first news came to me this past Wednesday, when the latest wide-ranging HEAT teams busts were announced in a joint statement by the Department of Justice and the Department of Health and Human Services. In all, 107 people at various levels of decision making in the health care chain were charged with false billing to the Medicare program totalling $452 million. Fifty-nine of those charged were from (say it with me!) South Florida, with the majority of the remainder coming from the high fraud areas of Baton Rouge, Los Angeles, Houston, Chicago and Detroit. We even had one defendant from Alabama, so let me take this opportunity to welcome those in the Yellowhammer State (yes, I had to look that up) to the world of Medicare Fraud arrests.

In addition to the “perp walks” in many cities, Medicare suspended payments to 52 providers based on aberrant billing patterns and what they called “credible allegations of fraud”. I find this to be the most interesting announcement by the team, as this indicates to me that the predictive modeling technology implemented by CMS last July is beginning to prove it’s worth, albeit on a small scale thus far. There is still a long way to go to expunge the Medicare program of fraud (as indicated by this insightful comment from my blog posting this past Wednesday that begs for a larger audience), but anytime providers of ill repute are led away in handcuffs, my soul does a Daffy Duck “Woo Hoo” Dance.

The other bit of news from the true crime files came in this morning, and has a connection to one of the many places I’ve lived in my life. In 2010, a pharmaceutical distribution center for drug giant Eli Lilly located in Enfield, Connecticut (past home base number 2 of 12) was robbed of over $70 million of Prozac and Zyprexa in a sophisticated heist. Thanks to a long investigation by local and federal authorities, 12 arrests were made in Florida this week against individuals who ran a cargo heist ring up and down the East Coast. In addition to the Eli Lilly robbery, the same ring was involved in cargo thefts at truck stops in Pennsylvania, Ohio and Tennessee, as well as a similar heist at a GlaxoSmithKline warehouse in Virginia. A statement from Eli Lilly indicated that the remaining drugs recovered as part of the arrests will eventually be destroyed. 

While two news releases will not completely restore the idea of entities being “on the level”, it is to the benefit of those in the medical field who are working hard to do the right thing that those players acting in bad faith are removed from the field. It continues to be a swim upstream, but for a small window of time, the rocks we encountered on this part of our journey were made of Styrofoam.

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May 4th, 2012 | No Comments »

The RAConteur: Other (Wide) Shoes Begin To Drop

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

I thought I’d begin today’s rumination by dispensing a bit of just-uncovered wisdom; having wide feet in and of itself does not guarantee that one is standing on steady ground. Allow me to offer one literal and one figurative example.

This morning, I was making my usual run to purchase a 44-ounce unsweetened iced tea at my local Speedway store (a Midwestern gas station-mini-mart chain) against the backdrop of rainfall in the Greater Milwaukee region. I took about four steps into the store and promptly slipped on a wet spot on the floor, quickly losing footing under my size 12 wides. I was able to catch myself before I made any more of a rush hour spectacle of myself. To Speedway’s credit, this morning’s iced tea was complimentary due to the apologetic clerk’s self-flagellation for not putting down a mat across the floor, thereby keeping my lifetime record of never hiring an ambulance-chasing attorney intact. Little did she know I’m a singer and not a dancer…

Upon my arrival at the office this morning, I was greeted by an article that should be of great interest to all providers adversely affected by government audits. A representative of the Senate Finance Committee told an audience at the just-concluded Health Care Compliance Association conference in Las Vegas that the Committee will soon be issuing an open letter to healthcare providers. The purpose of the communique is to solicit advice on the best ways to prevent waste, fraud and abuse in Medicare, Medicaid and their many offshoots.

On April 24th, this same committee held a hearing entitled “Anatomy of a Fraud Bust: From Investigation to Conviction”. It was at this hearing that Senator Orrin Hatch (R-Utah), the ranking minority member of the Finance Committee, announced his intention to solicit provider input. In the absence of the letter, the Committee has apparently been inundated with complaints from providers regarding auditing tactics. The bulk of the ire has been focused on the Zone Program Integrity Contractors (ZPIC) and that less-than-popular ongoing scourge of the hospital community, the RACs.

As the reader knows, I’m more than happy to share clearly defined opinions of both of these outside contractors. Bluntly, gathering the organized input of the provider community is overdue. Yet I would caution the reader, as I did with another such open letter issued last week, to consider the source of the request and the backdrop under which it occurs. The committee hearing from the 24th was commenced with two agendas. On one side was Senator Max Baucus (D-Montana), attempting to point to successes of government audits in the hope of propping up the thesis that states that fraud & abuse collections will pay for health care reform. On the other side is Senator Hatch, whose party’s ultimate mission is to vastly redesign the Medicare program into some kind of an amorphous voucher program.

Given this, there are reasons not to trust the motives of the minority portion of the Committee on this particular subject, but we are all fully aware that the RAC and ZPIC processes appear to be deliberately designed so that providers are at a disadvantage. The RAC program in particular has been problematic in that CMS continues to tweak the program to make it harder for providers to respond to incorrect audit findings in a cost-effective manner. As the majority of the contentious issues revolve around short hospital stays and observation status, it would appear that the RAC program could be formally concluded if CMS would only clarify these standards. It would be much more cost-effective for all concerned than the current model. To complicate matters, the boastful and glowing quarterly reports on RAC results that have been released by CMS thus far crumble under the realities of provider appeal results.

Yet something is missing. One set of entities that is more responsible than any other for Medicare’s haphazard payment practices appears once again to be avoiding the spotlight. I speak of the Medicare Administrative Contractors, who have been allowing Medicare benefits on claims that had no business being paid for decades, all without consequence. If the effect of a set of policies is studied in the absence of studying the cause, only half of the story has been written. Providers would be wise to consider this in any testimony or remarks submitted to the committee.

While this announcement was being made, I came across interesting news on a live broadcast by the RACMonitor team from the same conference. They had a guest on their broadcast yesterday afternoon stating that she has now seen Medicaid RAC activity in the states on New Jersey and Kansas. While the fate of the Medicaid RAC program now hangs on the looming Supreme Court decision regarding PPACA, it is no less distressing to learn that activity that has done very little for the Medicare Trust Fund is now reaching into Medicaid with their error-prone tentacles.

I saw more than just my own wide feet drop in the last day and a half, and only my own dealt directly with rain and iced tea. With regard to the other two, I am less than thrilled at the beginnings of the Medicaid RAC program given recent history, but I couldn’t be happier that the RAC and ZPIC contractors and their processes are finally being put under a credible and critical microscope.

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May 2nd, 2012 | 3 Comments »