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The RAConteur: Medicaid RAC Targets

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

As I type this, I have one foot out the door as I prepare to travel to Oklahoma City, Oklahoma to present at the 12th Annual National Conference of the American Medical Billing Association. Yes, the topic is government audits, and yes, since it’s Wednesday, I have some new information on this front.

Today’s topic is Medicaid Recovery Audit Contractors. In looking at the contracts that have been awarded, it appears that pluralizing the word “contractor” is an exercise in futility, because HMS is far and away the Medicaid RAC of choice. HMS, or their subsidiaries, have been awarded, or are about to be awarded 28 state contracts, either as a primary contractor or subcontractor, at last count. Ergo, it should come as no surprise that they appear to be the first ones out of the block nationally to begin conducting actual Medicaid RAC audits.

Because an approved issues listing can be provided at a state’s discretion based on the Medicaid RAC final rule, there is no definitive way to ascertain what the Medicaid RAC in any state would be reviewing. Knowing this, it becomes extremely important to gain knowledge and insight, by any means possible, as to what the Medicaid RACs are auditing. Thanks to readers sharing information, as well as information that is hitting my desk from other sources, the knowledge I am gaining should give the provider community pause.

It appears that the Medicaid RACs are targeting coverage and payment issues out of the gate. As an example, in one state, if a state Medicaid agency has made a payment at a time when the patient was covered by a Medicaid HMO, they are requesting money back from the providers. Given that the RACs can go back three years to identify such claims, timely filing issues rise to the surface in a rather stark fashion. 

In my opinion, this type of audit is penalizing providers needlessly. What the RACs are saying, in essence, is that the provider was entitled to the amount paid, but because the provider did not have a clear picture of a Medicaid patient’s ever-shifting eligibility and coverage, that money should now be forever forfeited. The better use of resources in these cases would be for the state Medicaid agencies to subrogate these payments with the Medicaid HMOs that should have made payment in the first place. Instead, the provider, who is already meagerly compensated for caring for the Medicaid patient, now gets nothing. Is this really the message CMS wants to send to the provider community as the medical delivery system stands on the brink of a massive Medicaid population expansion thanks to PPACA?

In addition, it appears that incorrect Part B coinsurance payments to providers are being targeted. Providers in some states are receiving CDs with listings of patients for which the incorrect payment is alleged to have been made by Medicaid. Upon first review, some of these determinations are correct, but there are some that appear to be incorrect readings of the original secondary explanation of benefits issued by Medicaid. This continues the long-standing “literacy-optional” policies for most state Medicaid agencies as applied to their claims adjudication staff.

I thank the readers who have provided feedback to me as to what the Medicaid RACs are reviewing. In the spirit of sunshine being the best disinfectant, I invite all of the readers of this space to continue to share with me this information. It was learned rather belatedly that information sharing is of paramount importance as it applies to Medicare RAC issues, and so the same applies to Medicaid RACs. I may be going out of town, but I’m never out of touch, and I thank you all for your continued attentions.

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October 10th, 2012 | No Comments »

The RAConteur: Sleepless In The Sooner State

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

I know that I usually begin my writings in this space with an amusing anecdote, a philosophical musing or a rhetorical dose of gastric acid directed at some unsuspecting party in the universe. Today, I’m going to begin with a few plugs, as I suddenly have quite the personal appearance schedule.  

On September 17th, I shall be speaking at the 13th Annual Midwest Coding & Practice Management Symposium, presented by the Wisconsin Medical Society. I’ll be speaking on current audit trends for physician practices on the afternoon of the 17th as the attendees struggle to stay awake from the fabulous lunches usually served at the Kalahari Resort in the Wisconsin Dells. I’ll also be generally available on the 18th, attending other informative sessions and extolling the virtues of water slides and the sweet bar in the lobby.

On October 12th, I shall be presenting at the 12th Annual National Medical Billing Conference, presented by the American Medical Billing Association, in Oklahoma City, Oklahoma. I’ll be talking about (good guess) government audits in a breakout session, and will also lend my time, expertise and hair to a guest panel, in which I answer questions asked by the audience. For those attending, random knowledge and music trivia are my strong suits.

While I’m on the subject of Oklahoma (which, admittedly, unless I’m discussing Woody Guthrie or Hoyt Axton, rarely occurs, so let’s seize the opportunity), something rather important occurred in the Recovery Audit universe with a connection to the Sooner State in the past week. Dan Boren, the 2nd-generation political scion who represents the 2nd Congressional District in Oklahoma, called for an examination of the methods currently being utilized by Connolly, Inc. and other RAC contractors. Specifically, Rep. Boren is concerned about the financial impact of RAC audits on rural hospitals, referring to Connolly’s practices as “overzealous predatory tactics” and goes on to ask that key policy-makers ”consider placing a moratorium on the amount of funds recouped from rural hospitals”.

With regard to the attentions of the Legislative Branch, I can only say that this is long overdue. The only regret that I have in Rep. Boren’s letters to CMS and two Congressional committees is that he restricts his comments to the effects of the RAC program on rural hospitals. Hospitals of all stripes across the country are overburdened by the RAC process. From the increase in documentation requests, to a Medicare appeals process that has been brought to its knees due to the high volume of RAC activity, it is clear that most hospitals are struggling to keep their head above water with a RAC process that in many cases is not part of a facility’s budget.

It will be interesting to see what effect this first Congressional salvo will have on the conversation. The Boren Letters have already been a discussion point among RAC coordinators nationwide, mostly approached with optimism that comes with the realization that someone at a state hospital association finally had success in moving concerns up the ladder. Yet with the glacial pace of Congressional action, I would predict that I shall have more than one additional personal appearance scheduled long before credible federal action on the RAC problem sees the light of day.

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August 22nd, 2012 | 4 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 »

The RAConteur: Special Bulletin: Color Me Surprised….

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

Let’s just get right to it. We all know why I’m here today, rather than making my normal appearance on Wednesdays, and we all know what news we’re all waiting for, so here it is.

In a stunning 5-4 decision, the Supreme Court has upheld the most controversial segments of the Patient Protection and Affordable Care Act. Voting in favor of the law were Justices Breyer, Sotomayor, Kagan, Ginsburg and (the absolute surprise of the day) conservative Chief Justice John Roberts. Dissenting were Justices Kennedy, Alito, Scalia and Thomas.

As I write this, the opinions from both sides are still being read from the bench, but already, there is one big change to the law as dictated by the court. As the law was originally written, Congress would make funds available for the expansion of Medicaid programs, but could penalize states by withdrawing all Medicaid funds from a state if it refused to participate. The Supreme Court has invalidated this provision. As Justice Roberts clarified in his opinion:

“Nothing in our opinion precludes Congress from offering funds under the ACA to expand the availability of health care, and requiring that states accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding.”

Other than this funding change to the mandate, the entirety of the law stands.

So to review, here’s what we have:

  • People without insurance are required to purchase coverage. This is also known as the “individual mandate”. Those who do not would be subject to a tax. This will be equivalent to roughly 6% of the entire adult population;
  • Because the individual mandate has been ruled constitutional, the question of “severability”, or separating the mandate from the rest of the law, is a moot point;
  • Children up to age 26 can be covered under their parents’ plans;
  • There will be no such thing as a “pre-existing condition” as of 2014;
  • Medicaid will expand its definition of covered individuals to broaden the coverage pool;
  • Medicaid RACs can now operate freely in order to detect improper payments from Medicaid plans across the country;
  • New payment models that apply to hospitals can go forward uninterrupted; and finally,
  • John Paul Spencer has the equivalent of a four-egg omelette on his face

 

Had I placed a high dollar bet on what today’s decision would have been, I would be declaring bankruptcy about 15 minutes from now. This is why my wife Leslie does the books in our house, and I type here for the general entertainment of the masses.

The decision that was released within the past hour is going to change things. There will certainly be attempts by one-half of Congress to overturn the entire law, but that path faces an impossible road in the short term based on the party make-up of the Senate and the White House.

I leave it to others to determine the political “winners and losers” of today’s decision, but the American health care system has been changed permanently with today’s decision. Cue your inbox, grab the popcorn and let the rhetorical games begin.

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June 28th, 2012 | 1 Comment »

Healthcare & The Value Of Memory

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

Back in 1966, Brian Wilson of the Beach Boys decided that he no longer wanted to tour with the band, instead wanting to concentrate on composition. The band needed someone to fill in on bass and the ridiculously high harmonies usually supplied by Brian for an upcoming tour of Japan. They found a man who was born in Arkansas to fulfill the task, but he only lasted on that one tour. This same man went on to record with a studio band named Sagittarius, before littering the pop and country charts for many years afterward with assorted hits under his own name: Glen Campbell.

Tomorrow night in Milwaukee, I am going to see Glen Campbell perform in concert, but the occasion will more than likely be bittersweet. The man who has given his music to the world for a majority of my lifetime is on his final tour, having recently been diagnosed as being in the early stages of Alzheimer’s Disease. It is not lost on me that all of the facts in the above paragraph, which my lifetime of music as a hobby has allowed me to commit to memory, will someday be foreign to the very person who made them possible.

As someone who has been involved with the health care industry for over 20 years, I have learned that based on the sheer volume of facts that inundate me on a daily basis, it has become nearly impossible for me to forget key elements of my job. As the cost of health care has become a central focus for cuts in a post-war economy, a number of  memories of failed policies of the past are skipping to the front of my mental line. Nowhere is this memory more acute that in the realm of physician reimbursement from the Medicare program.

Forty-one days from now, a song-and-dance act that has been running longer than Cats will repeat itself, as the increasingly polarized sides of our government once again raise the curtain on this year’s performance of Doc Fix. There are slight casting changes with every performance, but the script is the same. In the torch-lit Temple of SGR, an automated computer program threatens to take money away from the white-coated sailors on the HMS Doctor. As the sailors fight off armies of infirmed elderly waving checkbooks from behind the wheels of their Buicks, an unlikely set of heroes, wearing bad suits and American Flag lapel pins, short circuit the program with a stack of paper. As they stand in the setting sun, they promise to one day rid the world of the computer, but vow to be ready for anything else it plans to offer.

Oklahoma it ain’t……

Medicare reimbursement has gone from “pay everything” at the beginning of the program in 1966, to RBRVS and Gramm-Rudman-Hollings reductions in the ’80’s, subsequently to SGR in the late ’90’s, and finally to a yearly hostage crisis, with the only missing element seemingly being the security camera shot of Patty Hearst with a machine gun. We know this because it has affected us all in one form or another over the years and we have internalized the memories of the negative results of every one of these “solutions”.

Might I suggest that the solution doesn’t lie with finding a new payment methodology, but in finding savings from outside contractors for the Medicare program that (because I have it committed to memory) continuously take money needlessly from the program.

You can start by eliminating Medicare Part C. Virtually all of the “preventive benefits” offered to patients under these plans are now codified into traditional Medicare, which leaves Medicare Part C as nothing more than a government subsidy designed to prop up the insurance industry with billions of dollars that it doesn’t require for its survival.

Next we can go to Average Wholesale Price for reimbursement under Medicare Part D, rather than Average Sale Price. Additionally, pick one formulary and take the program out of many of the same hands that currently pollute Medicare Part C.

As for fraud investigations, leave in place predictive modeling and the HEAT teams, because these methods are actually getting to the root of the problem and are returning ill-gotten dollars to the Medicare program. When it comes to outside entities, we need not develop memories of the Recovery Audit  Contractors, because their abhorrent work product is currently on display for all the world to see. Roughly 2/3rds of everything they do is dedicated to purposeless paper shuffling, rather than the detection of actual improper payments. One marvels at the thought of the massive celebrations that would result if the RACs suddenly disappeared. Farther up the chain, the ZPICs on average collect about 2% of everything they extrapolate as an overpayment, but we don’t really know the actual number because the OIG has stated that the baseline data to measure their performance is fatally flawed. This reminds me that until that data is purified, the ZPICs will continue to mainly operate as a middle man for government-sponsored subsidies to the legal industry. Ask your typical taxpayer if that is something they wish to continue.

The development of the human memory keeps one from being fascinated by the latest shiny pocket watch issue being pendulated in our faces by the self-absorbed politician of the moment. Much like Glen Campbell, there may come a day that the many facts parading in our minds will begin to slip away. Until that day comes, in the realm of health care, memories are not just a rudimentary tool of assistance, but a blunt weapon against the many forces attempting to shove unwelcome schemes into an arena currently collapsing from the bad ideas of the past.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

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January 20th, 2012 | 1 Comment »

New Brunswick Is Not A Shiny Bowling Ball

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

At this time last Friday, I was driving on the Massachusetts Turnpike, coming home from a whirlwind car trip to St. John’s, Newfoundland. With regard to our country’s financial health, and in particular how that affects our health care system, I picked an interesting week to drive a total of 5,108 miles from Milwaukee to the eastern edge of the continent and back in just under eight days.

I was taking notes in my car as I observed things about Canada that differed dramatically from life in the sunsetting empire to the south. In honor of that, I’d like to alternate some of these observations with updates from the world of the American health care system.

In Ontario, if you are clocked going 50 kilometers (30 miles) over the posted speed limit, you receive a $10,000 fine, your license is immediately suspended and your car is seized on the roadside. It will surprise many who know me that I returned from Canada with the same car in which I entered the country.

The ”deal” that was struck last week to raise the nation’s debt ceiling, while not addressing health care spending directly, still poses a threat to the Affordable Care Act. Currently, the lines are being drawn on each side for a “Super Congress”, consisting of 6 members from each party hand-selected by party leadership. Thus far, the only programs that are seriously being considered for cuts are Medicare and Medicaid. At best, this could be seen as a severe exercise in denial, given our involvement in two wars. At worst, this is a way to defund PPACA by rendering Medicaid unable to accept the 50 million-plus population of uninsured that will suddenly qualify for this coverage in 2014. Given that the Simpson-Bowles Deficit Reduction Commission had similar goals for Medicare and Medicaid earlier this year but couldn’t even agree on a final report, and given the ideologues that have been appointed to the Super Congress, I have no hope of a forthcoming useful solution to the country’s financial morass.

Radar detectors and honey bee importation are illegal in Nova Scotia. If you’re a honey bee that’s considering speeding in Halifax, prepare to have the book thrown at you.

Hoboken University Hospital in New Jersey recently filed for bankruptcy due to $50 million in debts it could not repay. Somewhere among all the unpaid invoices, the hospital happened to find $600,000 in total compensation as a golden parachute for a former CEO. This and other compensation arrangements are beginning to come under the microscope. The average salary for CEOs of non-profit hospitals in the Midwest is $481,000. The old argument of “we MUST offer high compensation to attract the best talent” unravels when this salary mark is juxtaposed against the trend of non-profits converting to for-profit systems for financial reasons. Throw in money to an ex-CEO whose “talent” led to $50 million is non-payable debts, and it quickly becomes outrageous.

Gasoline is over $5 per gallon in Canada, but due to the roads being in such tremendous condition (except for Montreal, that has roads and infrastructure resembling a war zone), my car got incredible gas mileage North of the Border.

The estate of a patient who passed away two years ago after a lengthy battle with progressive demyelinating neuropathy is being sued by Tampa General Hospital for the cost of care. Hopefully, the late patient at the very least lived in a house made of aluminum cans that can be turned in for recycling cash, because the final bill totals $9.2 million. More than any other story that I have ever come across, this one illustrates what kind of health care system we really have. A majority of the care this patient received was palliative in nature and only minimally decreased the progression of the disease. If a disease has no known cure, what is the best way for a patient to be treated? Additionally, who should pay for it? All the ACO models and expanded insurance pools created in the last two years do not offer a solution to these fundamental questions.

And finally…

There are no bumper stickers on the cars in Canada. When I pointed this out to my wife’s cousins at the end of the Canadian half of my journey, one of them stated “we really have nothing to say”. I disagreed. The reason that Canada has no bumper stickers is that they have no need for self-inflating jingoism. To put a bumper sticker on your car is to deliberately and needlessly pick a fight, either politically, by pointing out how wonderful a student your kid is compared to the car behind you or by telling the car following you that they are driving too close. None of these chest-thumping actions do anything to improve understanding or improve the society as a whole. Canadians argue, but they have the intellectual ability to do it with more than a throwaway phrase. In the end, they make decisions based on what is best for the society as a whole. Most importantly, Canadians NEVER stop rooting for each and every citizen to succeed at their chosen endeavor.

It’s not all hockey and doughnuts. We could learn a few things from Canada.

August 12th, 2011 | No Comments »

Updates: Red Flags Rules & the Medicare Physician Fee Schedule

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

In the coming season of giving, where the profound significance of ancient events in Middle Eastern deserts is reduced to commercial exchanges of clothing and electronic equipment between family members, most of our heads are plunged deeply into personal schedules related to parties, dinners and assorted drinking engagements.

Beyond this frivolity lies the cold hand of reality for those of us involved in health care, namely the year-end litany of oncoming regulations and news updates.

With 2010’s relentless focus on the Patient Protection and Affordable Care Act, a few less notable regulations have tended to fall out of focus. One of the biggest of these is the five-times-delayed Red Flags Rules from the Federal Trade Commission.

To refresh everyone’s memory, the Red Flags Rules instruct anyone who is defined as a “creditor”, to establish internal identification processes, or “red flags” (get it?) for preventing identity theft. The FTC has insisted from the time of introduction of the rules that physicians fall under the definition of “creditor”, as they are rarely paid in full at the time of service.  

On May 21, 2010, the AMA, along with the American Osteopathic Association and the Medical Society of the District of Columbia, filed suit in federal court in an attempt to stop the FTC from applying the rules to physicians. Their central argument was that the FTC, in defining physicians as creditors, exceeded its regulatory authority. The filing of this suit followed an earlier case involving the American Bar Association (ABA), which sued the FTC using the same reasoning, and eventually won. This ruling is currently being  appealed by the FTC. On June 25, the FTC and the stated plaintiffs in the May filing agreed to a delay of rules implementation for physicians until 90 days after the decision in the ABA case. A look at the calendar of the D.C. Court of Appeals for the remainder of 2010 shows that oral arguments in the appeal of the ABA case are not currently scheduled.

On August 17, the Council of Medical Specialty Societies filed a motion to intervene as plaintiffs in the AMA suit, stating that only a small portion of the physician community is represented by the originating parties filing suit. A decision on this motion has yet to be released.

The result of the above pending litigation currently adds up, once again for the physician community, to “delay”. With the latest FTC-stated deadline for enforcement of the Red Flags Rules being December 31, 2010, odds are that the question of physicians being covered under these rules is a long way off. However, while not currently mandated, I would find it to be a good idea for physicians’ offices to develop policies to ensure that the patients they are treating are indeed who they portend to be upon presentation for services.

In other, more immediate news, the U. S. Senate passed a one-month extension of the current Medicare physican fee schedule this week. If the House passes this pending legislation prior to December 1st, a scheduled 23% reduction in the fee schedule will be delayed until January 1st, which will then combine with a previously legislated 6.1% reduction to form the Mecha-Godzilla of all physician cuts.

Enjoy time with family (even that weird uncle), the good food and (if you’re a Dallas Cowboys fan) the bad football this Thanksgiving.

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November 24th, 2010 | 1 Comment »

Surviving The Times

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

Being an obsessed fan of music as I am, I’ve realized over a period of time that it’s difficult not to develop something of a fascination with self-inflicted casualties and the personalities behind them.

I’ll give you an extreme close-up of a salient example relating to my own life. In 2004, due to a number of life circumstances that I won’t get into here, I made the decision to change my birth name. I began thinking of musicians that I admire, and I revisited the story of Alexander “Skip” Spence.

Skip Spence was the first drummer for the Jefferson Airplane back in 1966 (the year of my birth). He was something of an itinerant and kept his own mental schedule, which was incompatible with the rest of the band, and he was fired prior to their greatest success as a band. He later took his guitar-playing and songwriting skills to the band Moby Grape, another San Francisco band of the era. Through a series of record label miscalculations and ludicrous promotional planning, Moby Grape became the gold standard for how not to succeed in the music business, but Skip Spence wrote, and the band performed, the song Omaha, which is a musical touchstone of the era.

Skip was also a victim of the attitudes and excesses of his time. During the sessions for Moby Grape’s second album, Skip descended into madness fueled by excessive intake of LSD, to the point where he showed up at the studio one day in 1968 looking for the band’s drummer while carrying a fire axe. He spent the remainder of his life battling advanced mental illness until his death in 1999 at the age of 52. To mercifully abbreviate this long story, inspired by the unique music he left behind, I am now known to the world as John Paul Spencer. I added the final “r” so as to not appear as too pretentious to the world around me.

While the history of recorded music has its share of self-abuse stories similar in outcome to what you’ve just read, not all self-inflicted casualties of their times occur consciously. The many companies and corporations who have come and gone since the Industrial Revolution disappeared because they could not adapt to changes in products, demand or business conditions.

Today our medical delivery system finds itself at just such a crossroads. Over the next four years, business principles such as comparison shopping, outcome measurements and diversification are going to be applied to medical practices and hospitals in ways not previously seen.

Take a moment to internalize just how much of a philosophical shift this represents to a physician in private practice. At its core, we are now instructing a person who spent 10 years of his or her life (at great monetary expense) in rigid study and training towards their life’s occupational goal, to learn flexibility. Medical delivery by its very nature is tightly controlled, not typically lending itself to improvisation or random chance. Most established medical problems have been researched, measured and treated to such a degree that treatment protocols zero in on the problem faster now than at any time in human evolution. As the gatekeepers of this collective knowledge, physicians are trained to eliminate all questions, diagnose and treat.

Many smaller medical practices now find themselves in a time of soul-searching. Due to the technical demands brought about by healthcare legislation over the past two years, a perception is beginning to take hold that the independent physician cannot survive and will either have to merge with another larger practice or seek a health system affiliation. Add to this the increased anxiety over the expansion of fraud and abuse investigations by Medicare and other large payers, and the medical marketplace suddenly becomes threatened with shrinkage not from consolidation, but rather attrition similar to the long-lost corporate brand names of the past.

Beings and entities survive based on the ability to adapt and successfully navigate the harsh nature of their surroundings. The human advantage in this equation is the gift of critical thinking and analysis, leading to judgment. Each provider of medical services has within them a unique area of expertise, focus and patient approach that differs from their colleagues in the marketplace. Rather than being a self-inflicted casualty of the changing times, it now becomes the responsibility of each physician to let the world know what it is about them that makes them stand out among their medical brethren. I believe that the identification and greater application of this proficiency holds the key to surviving the changing landscape of healthcare delivery over the next decade.

August 13th, 2010 | No Comments »

The Dangers of Digital Immortality

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

One of the more interesting stories that came out over the past week involves Affinity Health Plan, a managed care plan in New York. On April 21st, Affinity began to notify over 409,000 people that their personal data may have been released. The list of people contacted included current and former customers, employees, providers and applicants for jobs and coverage through Affinity.

Affinity had leased a digital copier from a company in New Jersey. The copier was equipped with a hard drive that saved every piece of data that went through the copier. When the leased copier was returned to its owner, the hard drive was not erased, leading to a security breach.

In thinking about the world we live in in 2010, there are very few places we can go that offer safe haven from the digital age. What many people fail to realize is that every bit of data ever transmitted in a digital format either already has been or at the very least offers the opportunity to be saved and stored forever.

I must admit that the very idea of this can be frightening. Every text message from my phone, every night spent playing computer games and every profanity-laced tirade in e-mail form that has ever been emitted from my fingertips can be accessed by someone somewhere. I guess we can scratch off a career in politics from my to-do list.

Now let’s bring this ominous fact of life into the realm of medical billing and compliance. It’s safe to say that in every office involved with protected health information, there exists the possibility of the information becoming vulnerable.

The Affinity case is a good starting-off point. The thing that really jumped out at me in this story was the idea that an unsuccessful job applicant of Affinity being contacted perhaps years later and being told “Remember all of that personal information you gave us before we flatly rejected you? It’s freely available in a warehouse in New Jersey”. When it is determined that an employee isn’t a good fit after the interview process, companies are used to sending out the standard “we’ll keep your resume on file for six months” letter and moving forward, with the company holding all of the cards. Now imagine the embarrassment of having to send out a second letter years later telling the person you never planned on seeing again that you exposed them to identity theft via the office copier.

HIPAA regulations make very clear the responsibilities of digital gatekeepers of patient information. It is best to remember that the computer screen in front of you and the servers to which it is connected are only a small part of machinery utilized on a daily basis that stores PHI for a legitimate business purpose. Take a quick look around you. Did anyone leave papers on the copier? Fax Machine? In a common area while getting a beverage? Take a moment to think about what documents you have placed in a medium offering some type of digital storage.

After that, look around your work area. Ask yourself whether in the eventuality of someone breaking into the office whether your desk is vulnerable to letting PHI fall into the wrong hands.

As a pertinent afterthought, I’ll share this. Spaces such as this included, more people are sharing their thoughts with an ever expanding worldwide audience on a variety of subjects. When someone feels passionate about a topic, it is now easier than ever before to stand on a virtual rooftop and shout extemporaneously to the world at large. It is the world unfiltered, and it’s unlike any form of communication that came before it. It brings into focus not only how many bright and talented people have been falling through the cracks for generations, but it is also demonstrating how many unhinged people once took a typing class.

While life has been simplified to a degree in the digital age when it comes to quick access to information, in the immortal words of Peter Parker’s Uncle Ben, great power also brings with it great responsibility. Take a moment to internalize the idea that hitting the delete button does not translate to the end of life in the digital age. Conversely, itis also a good idea to review what you have typed prior to hitting the Send button. Consider everything you do with anything that can be plugged in and has the ability to store data to be permanent and retrievable once it has left you. The biggest thing this story has taught me is that it should be a long time before anyone sits on a copier with their backside exposed again.

April 30th, 2010 | 1 Comment »

10-Day Payment Freeze Coming: The Senate Strikes Again

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

The latest temporary fix to the Medicare Physician Fee Schedule, which expires on March 31st,  was not renewed prior to the U. S. Senate adjourning for its Spring recess this past Friday. The Senate will now be in recess until April 12th.

In response to this, in similar fashion to a month ago, CMS has declared a 10-business-day freeze on the processing of claims with dates of service of April 1st and after. Because this freeze is measured in business days, it will end on Wednesday, April 14th, which gives the Senate two days to pass a fix.

The latest physician fee schedule fix is attached to a bill that would among other things, extend unemployment benefits. This latest hold was initiated by Sen. Tom Coburn of Oklahoma, who objected based on there not being equal cuts in spending. The ironic twist is that Senator Coburn was a practicing OB/GYN for 11 years prior to beginning his political career. His hold on the bill would appear to complete his journey away from the science of medicine.

As the great songwriter Steve Goodman once wrote, “It’s not hard to get along with somebody else’s troubles”.

March 29th, 2010 | No Comments »

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