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Archive for July, 2012

Vultures Team With Blind Skeet-Shooters To Fight “Medicare Fraud”

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

At this point, it’s safe to say that you all have an inkling of how I think and the direction from which I approach topics related to health care. I have presented facts regarding issues that affect those with a financial stake in our health care system, which let us not forget includes doctors and patients (remember them?).

I have been critical of government “anti-fraud” efforts, mainly because a payment error isn’t always indicative of fraud. Sometimes, as we would expect with a confusing behemoth of a system such as ours, typical human error rules the day. I have been a certified medical coder for 14 years and I can tell you that every once in a while, two digits get transposed, not because I have a diabolical plan to buy a classic, mint-condition Ferrari Daytona by padding my wallet one office visit at a time, but because I’m human, imperfect and make mistakes. For further evidence of this, I direct your attention to the file marked “Marriage, First”.

It was with these thoughts in mind that I read a press release from CMS that hit my e-mail box yesterday. CMS proudly announced that they will now be teaming with assorted insurance carriers, insurance commissioners, the OIG, the FBI and an alphabet soup of insurance industry anti-fraud front groups to fight health care fraud with something of a united front. The partnership has the stated short- and long-term goals of information sharing, the ability to stop payments for the same patient on the same date from payers in different cities and using technology to predict and detect fraud schemes long before the damage is done.

There is one problem with this approach, as I see it. The two main players in this partnership, CMS and the insurance industry, are approaching the partnership with opposing sets of guiding principles.

The government, in the form of CMS and the Obama Administration, wants to eliminate waste, fraud and abuse in government healthcare. The Administration is desperately in search of good news news with regard to bringing improper payments under control, so much so that contracted entities such as the Recovery Audit Contractors (RACs) and the Zone Program Integrity Contractors (ZPICs) are now the beneficiaries of rules of combating overpayments deliberately tilted in the favor of the auditor. This is being done for no other purpose but to achieve the desired monetary results for CMS. After that, claiming success becomes a fait accompli.

On the other hand, the insurance industry wants to provide premium value to its stockholders. It is naive to think that the insurance industry has a goal that revolves around anything other than maximizing profits and retaining the maximum amount of  money in premiums by consistently lowering the amount paid in benefits to health care providers and patients. When approaching the partnership from their particularly odious side of the fence, working with the government to lower “fraudulent” payments makes perfect sense.

To justify the partnership, CMS goes on to state that the partnership builds on efforts that, “have resulted in a record-breaking $10.7 billion in recoveries of health care fraud over the last three years”. Disputing that stated collection total, line-by-line, would provide fodder for my writings through the end of the calendar year. In other news, I turned approximately 25,000 years old on my last, record-breaking birthday, but bear in mind that I am human and prone to error.

Somewhere in CMS’ press release, facts go unstated. There are a lot of improper Medicare payments going out the door, the problem needs to be brought under control, and we need a fresh approach. Yet, if the goal of CMS is to build the trust of the provider community regarding payment integrity, teaming with the carrion-chewing vultures of the insurance industry may not be the best approach. Trust will come only when all participants in the process are devoid of a profit motive for conducting activities.

That sound you just heard was me not holding my breath awaiting that circumstance.

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July 27th, 2012 | 2 Comments »

The Age of the Phantom Menace

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

The best films classified as “psychological thrillers” usually feature a main character who walks among the civilian population in an unassuming fashion. Hannibal Lechter, as portrayed by Anthony Hopkins in Silence of the Lambs, wasn’t insane to the blind eye, but rather revealed his insanity slowly to an unsuspecting population susceptible to good manners.

We spend a lot of our time – thanks to force of habit, the nightly news and actuarial tables – attempting to protect ourselves from unseen threats. From reckless drivers, to the food and drink we consume, to pucks and balls that often leave the field of play, we like to think of ourselves as prepared for the threats that surround us. Yet the truth is, as was so eloquently stated in the famous episode of The Mary Tyler Moore Show in which a beloved clown, dressed as a peanut, is killed by a rogue parade elephant, “Somewhere, there is an elephant with your name on it”.  

There are two bits of news out today that remind me in stark terms that threats to our health and safety walk among us, invisible, until we realize it is too late. We all woke to the news out of Aurora, Colorado this morning regarding the mass shooting at a midnight showing of The Dark Knight Rises!, leaving at least a dozen dead. This story is developing, so I’d like to set this aside for a story closer to my realm of health care.

Yesterday in Massachusetts, a former cardiac catheterization tech at Exeter Hospital in New Hampshire was arrested on federal drug charges. This stems from his habit of stealing syringes full of the anesthetic fentanyl, injecting himself with same and refilling the syringes with saline. These syringes were later used on patients during procedures. The 33-year-old technician was charged while in a Massachusetts hospital being treated for hepatitis C. Since the person in question was a “floater”, doing similar work for hospitals in six additional states, authorities are just beginning to determine the extent of the damage to the health of the affected patients and those around them. It more than likely offers no solace to those who have and those who have yet to be diagnosed that the technician in question passed drug tests before working at Exeter Hospital.

When assessing threats to our well-being, we don’t tend to think of movie theatres and hospitals as hot spots that become tests to our survival, which makes these news stories all the more shocking. There is no preventive cure for a lone gunman in a movie theatre, and as we learned a few weeks ago, this country’s hospitals have a long way to go with basic infection control, far beyond the sudden threat of a drug-abusing cath tech.

Yet we know that basic peaceful interaction is integral to our ongoing planetary presence. Humankind was not designed to live in the outside world contained within a Kevlar bubble. The insane and the irresponsible rarely wear flashing name tags to warn us that our safety is threatened. The news from the last 24 hours is indeed bleak. It is sometimes painful to realize that The Phantom Menace is more than just a poorly written summer blockbuster, but if you’re reading this, you still have now. It might not hurt, as we approach the weekend, to take a moment, stand back, take a larger deep breath than normal and make sure that the minuscule moments without life-changing events are the ones worth remembering.

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July 20th, 2012 | No Comments »

The RAConteur: ZPIC Contracting Conflicts

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services

I ask the pardon of my readers for the brief absence from this space. Due to work-related volumes, the Fi-Med blog has been delayed, but we now return to bring you the latest in audit news and healthcare trends.

As I have opined in this space previously, a virulent orthodoxy has embedded itself into the halls of Washington, D.C., and slowly to the rest of the country, that private enterprise can always perform basic tasks better than the government can on its own. A deep look into every Cabinet-level agency can find some example of bureaucracy run amok, yet with the blood-lust for private contracting in all areas of government, a new paradigm has emerged. What was once a government that worked slowly, and within a set of defined rules, is now in the hands of a private sector that fights to justify its existence as a contract holder by any means necessary. As a codicil to this shift, it appears that once a company receives a government contract, there is no behavior so egregious that the contractor doesn’t stick around in one form or another doing something at the expense of taxpayers.  

The Centers for Medicare and Medicaid Services, based on their independent contractors, has under its umbrella some of the worst examples of this behavior. It is a seldom-spoken truth that CMS contractors never really go away, but rather metamorphose into something else that takes its money from the government in the form of a contract for services.

The Office of Inspector General overseeing the Medicare program released a report on July 9th that shines a light on the shell games that go on with Medicare contractors, in this case with Zone Program Integrity Contractors (ZPIC). The OIG decided to take a look at the relationships between the ZPIC contractors and their subcontractors to assess conflicts of interest that could hinder their work product.

In reviewing the contractors, the OIG identified 10 actual conflicts and 1,451 possible conflicts with the companies who are now either contractors or subcontractors under the ZPIC program. These conflicts were related to contractual relationships either with CMS or with other contractors of CMS that provide various other services. In most cases, the companies analyzed did not consider these internecine relationships to be actual conflicts, more than likely because CMS does not have a written policy for reviewing conflict of interest information.

Now, let’s combine this information with another OIG report that was released this past November, which showed that data issues between CMS and the ZPIC contractors has severely hindered the work product of the ZPIC program. This same report stated that over the history of the Program Safeguard Contractor (PSC) and ZPIC programs, less than 2% of all dollars identified as fraudulent have been collected by the contractors.

The picture that is beginning to emerge on the ZPIC program is beginning to look less like Ansel Adams and more like Ralph Steadman. What we have are contractors, aggressively going after identified “fraud” targets, that may very well have a monetary interest in pursuing one target over another, at the expense of the entire Medicare program. With actual results rating so low on the completion scale, I may very well have stumbled upon the best example of private enterprise siphoning contract funds out of CMS for no other reason than to prop up private industry to satisfy orthodoxy. Unfortunately, it is taxpayers and medical providers attempting to do the right thing that pay the penalty under this belief system.

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July 18th, 2012 | 2 Comments »

Hospital Stay or Sky Diving?

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

When it comes to personal safety, there are behaviors that we have learned require a second thought. Most of us know to wait until the soup cools down, to fasten the seat belt prior to driving a car or to use a Q-Tip for ear cleaning rather than a kabob skewer. Yet for all of these examples, there are people, places and things that surround us that we believe to be safe based on their role. Sometimes, we learn too late, and in rather painful terms, that our inherent trust was misplaced.

The August issue of Consumer Reports shines the spotlight on one such group of trusted institutions, that being our nation’s hospitals. Using a 100-point measurement system that evaulated the categories of infections, re-admissions, communication, CT scanning, complications and mortality, the magazine rated 1,159 hospitals in 44 states for safety, culled from data from independent sources and the government. The data analyzed did not include success rates of treatment, so the data is somewhat incomplete, but the findings make for an interesting read.

If one only took into account the scores on this report, it would be enough to begin exercising and eating vegetables immediately. The highest score of any hospital in the study was only 72 out of 100, which would be roughly the equivalent of a D student being the valedictorian. The physician-in-chief of the “winning” hospital, the Billings Clinic in Montana, humbly stated that their facility was far from perfect. The bottom hospital on the list, Sacred Heart Hospital in Chicago with a whopping 16 out of 100, declined comment for the article. Perhaps it was too hard to hear the quotes from the administrator through his HAZMAT suit?

In the CT scanning category, it was found that only 28 percent of the hospitals measured had rates of double-CT scans (that is, a CT with contrast following a scan without) at 5% or less. This points to an alarming trend of repeated doses of radiation for patients who in most cases may not need it.  

The findings of the study only includes data for 18% of this country’s hospitals. This is because there is great rancor in the hospital community of late regarding who will be the ultimate gatekeeper of data on patient harm suffered in the hospital setting. The Leapfrog Group, whose data was analyzed for the study, has seen a rash of defections of late, as larger, well-known health systems begin to questions the methodologies and motivations behind the group’s information. A look at the members of Leapfrog reveals mostly purchasers of health care in the form of large and small employers. A similar peek at the partners of Leapfrog reveals insurers, for-profit hospital chains and pharmaceutical corporations. You are invited to draw your own conclusions about Leapfrog based on their membership and partners.

About the only group in this scenario who never seems to have a voice in the discussion on hospital safety is the patients. The study challenges patients and their families to carefully question decisions about their health care and where they choose to have it delivered. With scores seemingly so low universally, one wonders whether increased patient understanding will really make a difference in the long run.

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July 6th, 2012 | 3 Comments »