As time passes and I crawl ever closer to my eventual expiration date as a life form, it becomes almost second-nature to think about people that exist only in memory. One person that we lost in the last few years was comedian and social critic George Carlin, who during his career catalogued his observations to thousands of audiences, sometimes in pointed and indelicate language that will not be shared in this forum.

One of his famous routines dealt with needing “a place for your stuff” and the way humans create artificial supply lines of similar items, based mostly on time, place and need. When your stuff outgrows your space, you get a bigger space, which allows you to get more stuff, and so on. Eventually, it becomes hard to keep track of where you stuff is and what stuff is needed at present.

CMS works a lot like this. With every new initiative (for the purposes of making a point, I’ll call this “new stuff”), CMS has been losing command control of their goals. There are many examples of this, but the provider community is feeling the largest burden in the realm of the multiple audit entities chasing waste, fraud and abuse.

Up to this point, the alphabet soup of contractors have been successful mostly in creating a nearly-unmanageable administrative burden for providers. Rather than acknowledge what providers are going through, CMS is instead doubling down, expanding audit activities in order to meet a pre-determined dollar projection, then declaring success.

This week, CMS announced the opening of the new Program Integrity Command Center, which can be viewed as CMS’ first logical attempt to bring monitoring of the Medicare Trust Fund into the modern age. For the first time, claims info will be monitored in real time to detect payment errors before they happen, rather than the current “pay-and-chase” model.

I see this as a positive development, but one question is lingering in my mind. Once the Command Center shows success, will the need for the outside contractors (ZPIC, RAC, MIC, QIO) someday disappear? If CMS is just at the beginning stages of real-time fraudulent claim detection, it stands to reason that there will one day no longer be a need for retrospective auditing.

Yet this is not the view from the ground. Hospitals negatively affected by the RAC process continue their upstream efforts, while further expansion of the number of records that can be requested from a facility during a 45-day period lay on the horizon. ZPIC auditors continue their particular brand of beyond-the-pale investigative techniques on providers who may have made mistakes without intent. The Medicaid RAC program is just coming out of the box in a handful of states.

As if that were not enough, long-standing government contractors who, as I explained in a recent post, never really go away, now find themselves in the sights of outside investors, who see the fees that the contractors collect  for their services and smell an easy way to get a continuous cash flow, courtesy of taxpayers. It amounts to an investment bet that CMS will never be able to get their house in order with regard to program integrity. As we have learned from contemporary American History, nothing keeps things from changing faster than a well-healed entity with a monetary stake in the status quo. 

If you ask any reputable provider of service, you invariably come to agreement that the bad players must be removed from the field, but you also get unanimous feedback that states that the current audit climate isn’t working. Now that CMS has found a place for their stuff, I look upon the news with a lot of resignation given the current climate, but also with a little bit of hope that this will someday be looked upon as the beginning of the end of a dark era for providers of medical care in the United States.

Tags: CMS / George Carlin / Medicaid RAC / Medicare Trust Fund / MIC / Program Integrity Command Center / QIO / RAC / Recovery Audit Contractors / ZPIC
12:28 pm, August 3rd, 2012 |