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2011: Push It Down The Well Already!

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

When I open any reputable history book, the first thing that strikes me is the names of people who have existed and made an impact in history. There is an old quotation of unknown origin that says “May you live in interesting times”. Certainly, there have been those that have fulfilled that saying to its utmost.

While I occupy what is a very small space in the world of mass communication, and despite the fact that my science-based belief system automatically precludes me from thinking that my words have very little long-term impact in the grand universal chaotic scheme, I am ready to make the following pronouncement based on facts in evidence.

I do not live in interesting times, for fascinating eras cannot possibly contain this many stupid people.

Unlike all of the promising black-and-white documentaries of yesteryear, where the future promised technological convenience, helicopter commuting to work and (in general) faster ways to become as least as smart as the briefcase-carrying regional sales manager of 1954, the modern times that have appeared in front of me features a cornucopia consisting mostly of dullards, the willfully ignorant and neo-neanderthals of every size, shape and creed.

I am far from my idealized world of Buckminster Fuller, populated by efficient 3-wheeled cars and modest housing that allows everyone to live in a confined space comfortably and equitably. I am in the opening scenes of 2001: A Space Odyssey, where the lead Cro-Magnon finds a bone and instead of using it as a rudimentary tool to grind corn into flour, can only think to use it as a truncheon to beat the life out of his enemies on the other side of the creek.

In the past, I could ignore this empty-headed herd for two reasons. First, in days gone by, these people usually congregated in places where I never appeared, such as drunken bar fights, floating crap games and (such as those that occurred around the corner from my house in a public park in Wilmington, North Carolina  in 1974) cross burnings. Second, I slept fairly well at night, believing that there existed reasonable people to show us that there was indeed a common good worth fighting for, despite the randomly spewed venom of the wrong-headed minority.

In 2011, we showed no promise of cultural evolution to a higher standard. Instead, as a society, we stood and watched as the rightfully maligned slack-jawed yokel of yesteryear grabbed the keys to the car, passed out drunk from moonshine and drove the Car of Country off a cliff.

The end of December is usually a time when the news reflects on the twelve previous months of the year, marking seminal milestones, important events and offering a final toast to those who have gone. It is enough to make the modern network news anchor, complete with high, wavy hair and a teleprompter full of words he or she can read but cannot comprehend, a little misty-eyed. Does anyone else remember when Ted Baxter was the parody of an anchorman and not the shining example?

There is absolutely no reason to miss 2011 if you live in the United States. To begin with, no one in power, or for that matter anyone currently seeking either to keep it or obtain it for the first time, is representative of the term “reasonable”. A large swath of the voting public began the year by inviting roughly 200 barefoot ignoramuses into the halls of power in Congress fresh from some far-flung philosophical manure field. That same voting public is now stunned to discover that the carpets are indelibly ruined. This is the Spalding Guide demonstration of the idea that people get the government they deserve.

I usually cover health care issues in this space, so I cannot possibly complete my thesis on mass inanity without giving a mention to Medicare Administrative Contractors and the blind stumblers in a roomful of rearranged furniture that are the Recovery Audit Contractors who attempt to fix their numerous mistakes. Then there’s the American Medical Association, who decided that nearly three years after the issuance of a Final Rule on ICD-10 from CMS was the perfect time to fight for a different implementation date. Finally, let me raise a glass to all the Medicare crooks that have been nabbed by the HEAT teams this year, for these people suffer from an acute infection from a special mutated strand of the Idiot Virus known as the Thieving Moron Flu (scientific designation: URTM-1).

Tomorrow night, I am not going to tearfully say goodbye to 2011 as if I was attending a wake. I am going to be home with my wife, eating the last bad food of my life before attempting once again to lose my extra 35 pounds of body weight beginning on Sunday, drinking well-chilled beers from my refrigerator and spitting on the grave of 2011. This past year was neither interesting nor memorable. It should be held up as the shining example of everything you can do wrong to a society and its people. It should be mocked, stripped naked and kicked out the door for these last hours to perish of frostbite as it wails and gnashes its teeth. 

To paraphrase Bette Davis’ comments upon hearing of the death of Joan Crawford, you should never say bad things about the dead. You should only say good. 2011 is dead. Good!

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December 30th, 2011 | No Comments »

2010: The Year of Continued Loss

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

Roughly a year ago, I wrote in this space about a future I envisioned as a child growing up in the 1970’s, since destroyed in a hail of greed and misplaced priorities. The end of another calendar year gives each of us an opportunity to take another objective look at how it all keeps going wrong. I hope you’ll pardon me as I take a break from my usual subject matter for some dime-store philosophising. 

The quick summation is that 2010 became just another year of bloviating  and rhetoric, with continuing stasis and the usual figurative fist-pumping shouts of “GET OFF MY LAWN” emanating from elderly citizens so resistant to change that they took the tack of doing nothing while they were young so they could kvetch loudly about it to anyone who bothers to listen as the end draws near. In the end, who could really blame them? It’s a choice between that, driving half the speed limit in the left lane or staring at the wall. Admittedly, from the standpoint of evolutionary sociology, the staring-at-the-wall option does less overall damage, but once the excess gastric acid from the 5 AM breakfast kicks in, there’s no stopping them.

I look at 2010, as you could probably tell from the title, as a year of loss, both in terms of the expanded degradation of human aspiration and in ideas we used to all hold as core values, now battered by a political discourse that elevates people more suited for heavy doses of electroconvulsive therapy to a spot right in front of the television camera.

Loss occurs in small doses over time, but if not measured or monitored, suddenly makes people nostalgic when it’s far too late. I try to approach every conversation and action in life as a visionary, which requires shining the brightest flashlight on incomplete information and filling in the many blanks. With that in mind, I’d like to highlight five losses from 2010 that beg for such increased focus. These losses could be ideas, products, trends or people, but their demise, both individually or collectively, give me all the information I need to predict future shifts.

“E Pluribus, Unum” – One problem with being a country of immigrants is that the destination homeland ends up with no cultural cohesion or unification. As a result, in our national discourse, we have spokespeople usually stepping up to the plate for their own select focus group, which further insures that we not identify ourselves as simply “Americans” but rather hyphenated Americans all fighting for their little piece of territory. E Pluribus, Unum is Latin for “From many, one”. The chance of achieving this ideal in the future, given the current rigidity of opinion in this country, is roughly as fat as most of our waistlines.

Pontiac – For the first time in my 44 years of life, new Pontiacs will not be rolling off the assembly line in 2011. Pontiac is a victim of the $3 gallon of gas. When we think of Pontiac, we tend to think of the halcyon days of the 1960’s. My brother once owned a gold 1966 Catalina that was easily one of the biggest cars I ever saw. In an era when the gallons-per-mile standard of yesteryear is an impossible proposition, Pontiac didn’t have a chance. They had small victories, but they never stayed with them long enough. The 1988 Pontiac Fiero was once of the best cars Pontiac ever made. It was also the last year that the Fiero was in production. After five years, they finally got it right, and then they abandoned it. Oh well, at least we’ll always have memories of the GTO.

Captain Beefheart – Thanks to MTV, modern popular music is no longer a proposition where people of a certain niche can flourish with a cult following. In 1982, one year into MTV’s existence, Don Van Vliet, better known to fans of his music as Captain Beefheart, retired from the music business to concentrate solely on his impressive gifts as a visual artist. The music of Captain Beefheart and the Magic Band was best described as a meeting of blues, avant garde jazz and free form poetry. As a result, his music was not widely accepted by the listening public, but the band cast a long shadow of influence over countless musicians since their recorded debut in 1967. When Don Van Vliet passed away a few weeks ago due to complications of multiple sclerosis, I was reminded once again why every democracy desperately needs a contrarian. The music world was poorer when he retired, and humankind takes a hit just knowing that he won’t be around anymore.

Civil Discourse – Reading through the news today, I was reading about some lunatic fringe political group who decided to announce to the world that they consider the ACLU and the Department of Homeland Security to be “hate groups”. What sickens me about their reasoning is not what they say, because I’ll defend anyone’s right to say anything. What is truly disturbing about this is that someone gave them a wide-ranging  journalistic platform with which to spout such intellectually challenged rhetoric. Common human decency, as I have viewed it throughout my lifetime, states that people who lack gravitas and any manor of learning can yell and scream all they want, but are best ignored for the good of society. If I walked through life with as low a level of basic academic curiosity, this blog posting would actually be written in mud and smeared onto the side of my house. Is it too much to ask that we give a platform to sentient beings for a change? It would be a great first step towards solving the overwhelming problems this country now faces.

Leslie Nielsen – The one thing I want to do every day of my life is laugh. I can go without food, love, music and my car for any amount of time, but my continued physical and mental health requires that I have a cheap laugh at least 5 times a day, with at least 2 of them being of a childish and guttural variety. Over the past 30 years of my life, Leslie Nielsen provided me with this requisite need in bunches in movies and TV shows (Airplane, Police Squad) so patently ridiculous that I couldn’t help but howl. I’m grateful that he left behind a compendium of media which will unfailingly amuse me. You may have a more evolved sense of humor than I do, but as Leslie so eloquently put it in The Naked Gun, “I’m sure we can discuss this like adults, can’t we, Mr. Poopypants?”.

No calendar ever turns without a high degree of challenge. As Lou Reed once wrote, “There’s a bit of magic in everything/and then some loss to even things out”. The turning of the calendar into 2011 is presented upon a backdrop of impending social cataclysm. The last 10 years in America have brought forth a grim Butcher’s Bill of  losses across many planes of existence, and yet, tomorrow morning brings a new sunrise. In new light lies new opportunity. Tomorrow night, give one final toast to the lost and come Saturday morning, embrace the light.

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December 30th, 2010 | 1 Comment »

The RAConteur: A Year-End Point To Ponder

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

Dwight Eisenhower, an accomplished general and our 34th President, gave a famous speech three days prior to the end of his presidency warning of the “military industrial complex”. Eisenhower felt that the topic was of such importance that he worked on the speech off and on for a period of two years prior to delivery.

Many of the things that we were warned about almost 50 years ago have unfortunately come to pass, but what I am struck by is the fact that Eisenhower was focusing solely on military matters, upon which, as a retired general with the then-recent historical gravitas of being credited with directing the Allied victory in World War II, he was eminently qualified to opine. When I see the changes inflicted upon the United States in the last 50 years, I have come to the conclusion that the warnings could have been expanded to the entire landscape of American business.

Slowly, an unchallenged orthodoxy has developed in our national discourse that states in unwavering fashion that private industry can accomplish all tasks, while at the same time self-regulating, better and cheaper than a government entity. What I’m always struck by when I hear someone state this is that no one asks the person in follow-up to offer a single example that proves this theory to be true. In fact, when specific instances of private industry waste of governmental program funds are illustrated for the many congregants of the Church of Industry, it only appears to strengthen their belief system.  

Being on the administrative side of health care, and facing the current audit climate, I am more than happy to offer a glaring example of how this idea can be proved patently false, and I do so knowing the response it will elicit from the high priests of the orthodoxy. I put forth as evidence the entire system of claims payment for the Medicare Program.

The Obama Administration is focusing on fraud in the Medicare program as a focal point to reducing costs, and I am completely in support of this. Having said that, with the current model of “pay-and-chase” embraced by the program, fraud can only be detected if the criminally desired financial transaction is completed. At that point, mere discovery becomes a “maybe-maybe not” proposition.

At the root of all problems in the Medicare program is the fact that bad claims are paid. It doesn’t seem to matter what guidance is provided by CMS. Claims that shouldn’t have any hope of passing the most rudimentary tests of probability are paid often and repeatedly.

It is at this point that I point out the obvious to everyone inside and outside the medical reimbursement field; the Medicare Administrative Contractors are private companies, they are doing an abysmal front line job of upholding the economic integrity of the Medicare program and in doing so are making a killing at the public trough. For your reading and analytical enjoyment, I now bring forth a wrinkle that you’ve been programmed not to expect. I can actually provide you with a credible example.

In the last week, I came across a story regarding an OIG report that confirmed what everyone in our industry with two eyes and triple-digit IQ’s already knew. When it comes to fraud perpetrated against the Medicare program, no other area of the country does it like Miami-Dade County in Florida. The OIG report was specific to outpatient therapy services being more than three times the national average, but as someone who is dialed into the industry, not a week goes by where someone in Florida is busted for either Medicare or Medicaid fraud. Durable medical equipment, particularly power mobility devices, are a large source of fraud in this part of the country of late, but that is just one of many examples.

With the numerous societal references about just how many elderly citizens live and drive (slowly) in the State of Florida, one would expect that controlling Medicare spending and claims adjudication in this particular environment would be at the top of the list. Sadly, not so much.

Let’s take a look at the Medicare Administrative Contractor in Florida, which is First Coast Service Options (FCSO). This subsidiary of Blue Cross and Blue Shield of Florida (a “non-profit” entity with $2 billion in revenue in 2009) has been in charge of Medicare claims processing for Florida since 1966, despite the enormous amount of fraud that surrounds them. In the Keystone Kops production that continues to be the Medicare Contracting Reform Project, FCSO was re-awarded the MAC contract for Florida (along with Puerto Rico and the U.S. Virgin Islands). This was done without so much as either a redrawing of the borders of Jurisdiction 9 or a serious competing bid. This area is expected to be placed up for competitive bidding again in September of 2012. 

Internalize that thought for a moment. The entity cutting the checks for fraudulent claims in the area of the country easily identified as the highest target-rich environment for criminal activity against the Medicare program was handed another four years as the keeper of the regional Medicare checkbook with virtually no questions asked.

Now let’s take the example one step further. In order to reign in spending caused by the rank incompetence of an entrenched regional contractor, the solution brought forth 5 years ago is to hire yet more private industry contractors to chase the over-payments retroactively, and thus the RACs were born.

The jury is still out regarding the effectiveness of the RACs as improper payment control entities, with the final numbers from the Demonstration Project leaning heavily to “ineffective”, but the focus of containing Medicare fraud to this point is avoiding the elephants in the room that are the MACs. I find it very hard to digest the idea that when improper payments from Medicare alone are estimated at $36 billion for 2009 ($12 billion of which was caused by Medicare Advantage plans, but that’s another topic) that the Medicare Administrative Contractors are getting a free pass for issuing the checks.

Privatization for privatization’s sake has consequences. A few months from now, a shouting match will erupt about raising the national debt ceiling, and the first salvos of that heated argument are being lobbed by all sides at Social Security as the root of all deficit evils. In actuality, Medicare is exponentially more damaging to the nation’s financial health than Social Security. Medicare spending can be controlled, but up to this point, the front line gatekeepers of Medicare funds, the MACs, have escaped accountability for the damage they cause to the Medicare program, and by extension the country as a whole. It is neither unorthodox nor heretical to suggest that the time has come to determine whether the privatization of Medicare claims payment needs to end.

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December 29th, 2010 | 3 Comments »

The RAConteur: Special Musical Edition

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

This past Monday, I was asked by RACMonitor.com to present a special musical performance of an original song I composed on the RAC topic for their weekly Monitor Monday podcast. The recorded version of the song can be found on the RACMonitor website here.

A few months back, Fi-Med’s CEO, Adrian Velasquez, requested that, if I could find time in my off hours, I compose a song about the Recovery Audit Contractors. I must admit that from a musical standpoint, this particular topic exists outside of my usual lyrical stomping ground. On the Milwaukee music scene, I am more well known for songs about obsessive cannibal love, fast food drive-thru experiences and clowns on fire, but I decided to meet Adrian’s challenge head-on. I am hopeful that the results can be seen at the very least as a positive use of my free time.  

This song will be performed live at the 2011 Physicians RAC Summit, taking place in Orlando, FL from January 9-12, 2011.

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December 23rd, 2010 | 2 Comments »

The RAConteur: The 3-Year Timeline

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

I live my life as a firm believer in expiration dates. If the pills in the cabinet are beyond the “Use By:” date, out it goes. If there’s an open gallon of milk in the refrigerator, it better be before the “Sell By:” date stamped on the side, or I’m opening up the new gallon of milk. When there is something on the shopping list that will eventually have an expiration date, I go spelunking among the cartons of eggs or begin looking at the bottom of every yogurt container for the latest date I can find.

If a deadline has passed, it has passed. You can’t cheat the clock or the calendar. I learned this week that yes, this rule also applies to Recovery Audit Contractors.   

If you are a regular visitor to the web sites of the four regional RACs, you have probably noted that the contractors have very different ways of displaying information. To offer a few examples, Connolly Consulting, the Region C RAC, is the only entity who doesn’t provide the date when selected issues became approved for widespread review. CGI, the Region B RAC, has organized their issues page in such a way that the details of the issue must be brought up in a separate window.

There is one item which all RACs share on their issues page that, based on the most current information available, is incorrect. Next to every issue on every one of the sites, the dates of service affected are listed as all dates of services from 10/1/2007 forward. 

Recently, a hospital in the Southeastern United States received an additional documentation request from Connolly Consulting, the Region C RAC, requesting records for services rendered on 10/16/2007. The ADR was dated 10/24/2010. Based on what is clearly stated as a three-year look back period for all services, the hospital contacted Connolly to dispute Connolly’s right to request records for this date of service. Connolly disagreed, stating that the date of service fell under the window of 10/1/2007 and beyond as listed on their website.

Disliking that answer, the hospital contacted CMS regarding this issue, and CMS agreed with the hospital’s interpretation of the RAC guidelines. The hospital was told that CMS would contact Connolly to issue a clarification regarding this issue.

The permanent RAC program states that all services after 10/1/2007 can be looked at for review, but now that the three-year look back period no longer encompassed this earliest of dates, it should now be regarded as a general reference date for approved issues under the RAC program and nothing more. The above story also acts as a timely reminder to pay attention to the date of all correspondence emanating from the RAC contractors, not only for errors such as this, but to accurately track the amount of time still available to you to submit documentation to the contractor.

Everything, and for that matter everyone, has an expiration date. For the RACs, the expiration date is always three years ago yesterday. Now, before you try to slip me some eggnog this weekend, let me get a look at that carton…

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December 22nd, 2010 | 1 Comment »

When The Elephant In The Room Is You

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

I had a second cousin on my father’s side who was a surgeon specializing in gastrointestinal procedures. In 1965, he adapted one of the first rudimentary bypass operations for weight loss for the chronically obese. His ingenuity won him a brief writeup in Time Magazine.

Being based just outside Philadelphia, his procedure also won him an appearance on The Mike Douglas Show, which was a nationally syndicated talk show that was based out of Philadelphia in the late ’60’s and most of the ’70’s. Mike Douglas was an early television innovator in that he absolutely lived to put guests on his show that were diametrically opposed to one another in some fashion. One of the most famous clips of the show is from 1976 and features Richard Dreyfuss yelling at the top of his lungs at Donald Rumsfeld about America’s handling of the end of the Vietnam War. Another episode featuring Tom Waits in full neo-beatnik, chain-smoking regalia and the very proper Marvin Hamlisch stands out in my mind as well.

So who did Mike Douglas book on the same program in opposition to my cousin? None other that Mama Cass Elliott, one of my favorite singers of all time, and as was and still is pointed out ad nauseum, one of the biggest physically as well. My cousin, being a dedicated physician, gave Cass his business card off-camera. She skulked away insulted, and died of a massive heart attack less than a decade later at the far-too-young age of 32.

Two weeks from now, roughly every adult in the United States will go through the laughable exercise of making a New Year’s Resolution to lose weight. Somewhere around January 4th, roughly 98.4% of those people will find themselves eating something rich in fat and/or high fructose corn syrup (probably out of some kind of bag) wondering where among their last 96 hours it all went wrong. I can say this without hesitation because I have been and continue to be one of these people.

The first fact that you must internalize is that when we make the personal compact with ourselves to lose weight, we are all starting out as long shots. Here are a couple of experiments to demonstrate this. First, when you’re at home, watching TV, eating something out of a bag, drinking Yoohoo, piling up crumbs on the shelf that is your abdomen, count the number of television commercials for some kind of food product that run during the show. Yes, soft drinks count. Second, on your way home today, count the number of facilities from the beginning to the end of your travels in which you can purchase some kind of food for consumption. Yes, gas station mini-marts, drug store chains (!) and bars that serve food count towards your total, to say nothing of supermarkets, big box retailers and restaurants of every type. My personal experience indicates that both numbers will be surprisingly high.

In the United States, food of every size, shape, color and texture is inescapable. Anyone in this country, no matter where they are, can get something to eat – and a LOT of it – within 2 to 30 minutes. If you don’t feel like getting it yourself, why bother getting up? Just keep the crumbs on your shirt and call someone else to bring it to you. Someone younger and closer to the front door can pay the driver.

This week saw a few developments on the national health care front. The long-awaited correction to Medicare’s formula for paying physicians was punted for the 14th consecutive year. Next, a  judge in Virginia ruled that the individual mandate in the Patient Protection and Affordable Care Act was unconstitutional, which sets in motion years of litigation on the topic.

Nowhere in the ”serious” conversations of health care in the United States is a discussion of the competing interests throwing checks at Congress to maintain the status quo. For those of you who haven’t noticed, that status quo is best measured as an index of how much WD-40 we all have to collectively spray on ourselves in order to fit through the nearest doorway. The food and beverage lobbies pay good money to insure that dozens of food outlets greet you in the course of a day, either live or televised. It has never been the purpose of large businesses to care about consequences. It’s the problem of the undertaker to figure out which forest needs to be cleared in order to build a coffin big enough for Mr. Creosote.

The numbers on the general condition of our population tell a bleak tale. The diabetes rate in this country is going through the roof, there is an obesity epidemic in younger populations and the preponderance of evidence indicates that if you’re heavy when you’re younger, it’s far more damaging to your lifetime of health than if you enter adulthood thin and slowly inflate thanks to overindulgence.

If you want to see in which direction health care costs are going to go, look around you. Delaying taking better care of ourselves is incredibly damaging in a country where 17.3% of our gross domestic product is spent on health care, with this number showing no signs of halting its yearly increase.

It takes more than a New Year’s Resolution to make the floor stop creaking beneath our feet. We must first open our eyes to the tilted reality of our surroundings, and the sheer long-term expense of finding ourselves in that situation. A flippant thought about losing weight as we nurse New Year’s Eve hangovers is insufficient.

Second, refer to the long-time advice of one of the first - and still the greatest –  gurus of personal health and fitness, Jack Lalanne; get yourself moving, and if man made it, don’t eat it! In the meantime, please do your best not to look at me in profile.

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December 17th, 2010 | 1 Comment »

The RAConteur: The Role of RAC Validation Contractors

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

Nothing stokes the darker recesses of the human imagination like a conspiracy theory.

Usually, a conspiracy theory begins with a confluence of facts leading to an unanswered question. From the Kennedy Assassination to the Bilderburg Group, lack of knowledge leaves the majority of people at the mercy of anyone who comes in to fill the void, no matter what the level of their actual knowledge or credibility on the subject.

With regard to RACs, we have one such knowledge gap that is becoming more glaring by the day based on the paucity of information currently in existence. I am writing of the RAC Validation Contractor (RVC).

Who are they? What shadowy deeds are they responsible for in this country? What darkened room with circular tables, 25 long-backed, padded chairs and a large video screen showing the world divided up into fief-like parcels holds this covert group of movers and shakers?

If only this entity was half as interesting.

Our investigation begins in Erie, PA (such a fittingly spooky name!), the “Flagship City” located in Northwestern Pennsylvania on the banks of the Great Lake that bears its name. It is in this city of roughly of 100,000 people where Provider Resources, Inc. (PRI) works as the only RVC.

PRI was named publicly by CMS as the RVC on October 9, 2008. It is on the CMS website where the search for further information begins.

According to the original announcement of PRI as the validation contractor, CMS works with PRI and the regional RACs to approve new issues RACs want to pursue in search of improper payments. In addition, PRI should be conducting accuracy reviews of RAC claims that have already resulted in overpayments being collected and returned to CMS. In a slide show available on CMS’s RAC Recent Updates page, it is stated that the RVC provides annual accuracy scores for each RAC.

Seeing this as a healthy head start in determining the work of the RVC, I decided to take a brief look at PRI. 

The following description of the services PRI renders as the RVC is taken directly from the company’s website:

….CMS looked to PRI to perform the critical quality control function of this program as the RAC Validation Contractor (RCV). In performing this work, PRI applies its considerable depth of Medicare knowledge and expertise on behalf of CMS to validate those efforts of the Medicare RACs. Our medical review teams—paired with our Medicare policy and procedures experts—audit the RACs’ determinations for Medicare claims which were paid under Part A or Part B of title XVIII of the Social Security Act. Through its reports to CMS, PRI ensures that the RACs are not unnecessarily denying Medicare claims which were properly paid. Similarly, our findings can also assure CMS that the RACs are properly recovering improperly-paid claims.

The above paragraph appears to be the usual self-aggrandizement often seen on the websites of small businesses and does very little to illuminate the full scope of the work PRI conducts as the RVC.

To set my mind in motion further, I contacted Scott Wakefield, the CMS Project Officer for Recovery Audit Operations for RAC Regions A & B with a few questions. I first asked about the idea of accuracy scores for the RACs, and was told that these scores would be released “along with the Annual Report to Congress in early 2011″. The release of this report will be announced on CMS’ RAC web page.

The second question I had was a blast from the recent past. I’ve decided to make it a mission of mine to nail down someone on defining “good cause”, since the term has been rendered meaningless by the current status of Palomar Medical Center vs. Sebelius, which states that good cause cannot be reviewed in an appeal by a provider based on the RAC statute. According to Mr. Wakefield, “…the RAC must establish good cause.  RACs and the RVC are required to comply with Reopening Regulations located at 42 CFR 405.980″. That’s an interesting comment, as the regulations in this portion of the Federal Register do not directly define good cause. The only references to good cause made in this section refer to appeal timelines from the original or subsequent determination of good cause. This just about proves that “good cause” remains largely undefined by both CMS and the RVC, and is better interpreted to mean “We look at whatever we want to because we said so. Nyah Nyah!”

CMS’ Annual Report to Congress will provide some picture about the work product of PRI in their capacity as the validation contractor. We know that the RAC rate of successful appeals in the Demonstration Project was conspicuously high. The RVC, which has so far been relatively invisible publicly to the quality control process, will be the internal line of defense to RAC improvement. Yet if the first rate of successful provider appeals is anywhere in the neighborhood of the numbers seen in the Demonstration Project, a few blinds over windows in an office in Erie, PA will more than likely open a little wider.

December 15th, 2010 | 3 Comments »

What Red Flags Rules?…And Other Observations

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

There is nothing quite as satisfying as the delivery of a gift to a willing recipient.

The previous statement seems like it should be a given at this time of the year, but when the prelude to every December is an elephant stampede through the doors of Wal-Mart at 4 AM, it’s becomes increasingly difficult to remember the goodwill that is supposed to exist at this time of the year.

If one looks back at all of the gifts received in a lifetime, it is usually something very odd that rises to the top of the list. For me, the best gift I ever received was from my Aunt Jeanne. It was a book called Incredible But True by Kevin McFarland. It was a 400-page book chock full of oddities in every realm, from the story of the man who never slept during his 86-year life, to a bird called the plover, which derives part of its diet by eating leftover food from the teeth of crocodiles. At a young age, it acted as an exceptional primer to the volumes of bar knowledge now contained in my head. Its well-worn spine is still on display in my living room.

The physicians of America received a few gifts this week, the largest being yesterday’s enacted delay of the cut in the Medicare Physician Fee Schedule. The second and less trumpeted gift was a law which permanently exempts doctors and other professionals from the Red Flags Rules of the Federal Trade Commission.

The end of the Red Flags Rules brings to an end a long-running, over-litigated saga which at its heart was an attempt to mitigate identity theft, but slowly morphed into yet another burden on physician practices. Despite the unceremonious end to the rules as they apply to our medical delivery system, the ideal behind the rules – making sure people are actually who they claim to be – should be something that every medical practice puts in place.

In our current depressed economy, patient financial responsibility is growing at unsustainable rates. This past Tuesday, the Cleveland Clinic, one of the largest of its kind in the country, announced that it would no longer provide uncompensated care to patients who are uninsured, ineligible for government assistance, reside more than 150 miles from Cleveland and earn between 250 and 400 percent of the federal poverty level. Those making less would be eligible for aid and those making more are expected to pay. These measures have become necessary based on 50% of insured patients not paying their balances to the clinic and a total of $120 million in uncompensated care in the past year.

With rising patient debt as a backdrop, in the foreground should be due diligence to determine to the best of a practice’s ability the patient’s true identity and their most likely future payment arrangements. Dismissing the overarching financial message from the Red Flags Rules to “creditors” makes little sense with a patient population either unable or unwilling to pay the balance of their bill for services. The spirit of giving, while noble, has its limits.

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December 10th, 2010 | No Comments »

UPDATE: Physician Pay Cut Postponed For One Year

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

This afternoon, the House of Representatives passed a bill previously ratified by the Senate that delays a scheduled 25% pay cut in the Medicare Physician Fee Schedule. The bill now goes to President Obama for his signature.

The cost of the pay fix is estimated to be $19 billion. As a possible harbinger of things to come, the offset of the cost of the program comes from a provision in the Patient Protection and Affordable Care Act (PPACA).  The line item affected allowed for tax credits for wage earners at or near the poverty line who pay their own insurance premiums.

The passage of the bill freezes the current fee schedule until December 31, 2011. This gives Congress yet another year to devise a replacement to the Sustainable Growth Rate (SGR) formula. The SGR was brought forward in 1997 as a solution to Medicare spending. In every year since, Congress has passed a delay in scheduled cuts, leading to the 25% cut level now removed from the table for 2011.

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December 9th, 2010 | 1 Comment »

The RAConteur: We’re Paying For This?

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

If each one of us thinks about it for just a moment, we can probably think of a product, service or perhaps a person who doesn’t match up to their perceived value.

Since it’s Christmas time, I think back to the sales pitches of my childhood. Seemingly every December in the 1970’s brought forward an onslaught of commercials for Ronco products. From the Pocket Fisherman to Mr. Dentist (“Buy a separate Mr. Dentist for your DOG!”), each one of these ridiculous, fell-off-the-back-of-a-truck curios sold for $9.98, then usually worked once and broke. 

As a sports fan, I can think of countless examples of players who have signed long-term contracts for obscene amounts of money who didn’t come close to their value. The Washington Redskins discovered this belatedly with Albert Haynesworth two days ago. My fellow hockey fan friends know that I can sum up underachievement based on contract terms in two words: Alexei Yashin (I realize that the NHL ranks roughly 6th among sports in the United States, so I invite you to look it up).

On the subject of RACs, this topic comes up when I again review the results of the RAC Demonstration Project. When we look at the successful appeal rate of 64.4%, most people in health care see a great chance for victory for the provider community simply by drowning the RACs in appeals, and I can’t say that I disagree with that assessment.

I, however, remembering the abject lesson of the Veg-O-Matic, have internalized the idea that the demonstrated usefulness of a product or service and its actual value exist on different planets. At a bare minimum, RAC determinations were incorrect 8.4% of the time based on the percentage of RAC results reviewed. I suspect that based on the high percentage of Part B claims reviewed in the demonstration project, coupled with well-documented abysmal response rates from physicians to requests for documentation, the RAC error rate is much higher.

In baseball, it’s acceptable to be good with a bat 30% of the time, and when it is less than that, who other than the owners of the 30 teams and degenerate gamblers have a financial stake in a better outcome? The RACs are independent contractors, but at the very root of their payment structure for uncovering incorrect payments by the Medicare program is a tax payer. We invest in the Recovery Audit Contractor program with the promise that what they uncover strengthens the Medicare program financially. Yet their is an outstanding question that hangs over the heads of the RACs like a sword, and that is a question of competence.

One of the more frustrating aspects of a country that currently carries a 17% true unemployment rate is the knowledge that there are gifted, productive people who for a variety of reasons are viewing working life from the sidelines. We are handed conflicting rationales for this phenomenon on a daily basis from our leaders and the national media, none of which directly address the abandonment of the fundamental belief in shared experience and sacrifice being a cornerstone of building a strong society.

However, it takes a special blend of arrogance and blatant exploitation to ask a country’s people to fund incompetence. If our order in the fast food drive-thru line is screwed up, we’re getting what we pay for. When an independent contractor of the federal government produces shoddy work product, it affects all of us in a fashion much more profound than a few hours of bad digestion.

It is hoped that future reports of results of the RAC program reveal better results than their poor showing out of starting gate. Given my direct experience with the law of diminishing returns, I suggest we not hold our collective breaths.

December 8th, 2010 | 3 Comments »

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