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Of ICD-10 and Disappearing Doctors

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

Now that the calendar has turned to February, let me share a truth or two that I hold about the shortest month of the year.

First, Groundhog Day may very well be the dumbest thing I’ve ever seen. People in stovepipe hats standing around an overgrown rat in the cold and dark in order to get the weather report is a poor use of human resources. The only cool thing about this day on the calendar is that my wife’s uncle appeared in the film Groundhog Day playing upright bass behind Bill Murray. The rest of February 2nd can forever dedicate itself to other, more useful things.

One last thing before we get started. There is no cooler birthday on Earth than February 29th in a Leap Year. Here’s to all of those people!

Now, turning my attention to recent health care headlines, two of my favorite topics popped up again in the past week.

First, we have the AMA clarifying what was referred to as “work vigorously to stop” ICD-10 at their meeting in New Orleans back in November. Apparently, the AMA’s approach in this area consists of that tried-and-true standard: The Sternly-Worded Letter. On January 17, AMA CEO James Madara led off his Dispatch Path to Prosperity with a 3-page bulletin to current Speaker of the House John Boehner. Because this particular letter didn’t deal with tax cuts, tort reform, deficit reduction or further punishing poor people, it was set aside for golf and further tanning.

Never an organization to back down from a challenge, the AMA doubled down and sent a 4-page letter to HHS Secretary Kathleen Sebelius which covered basically the same territory as the Boehner letter. I covered this topic in a post at the time, and what I said then still holds true. Rather than spitting into a headwind in a quixotic attempt to stop the rotation of the Earth, the AMA’s considerable resources would be better spent either educating their member physicians about ICD-10 or assisting struggling practices monetarily to ease the headaches of transition. Look for more correspondence in the near future, which will more than likely be followed by a bunch of doctors descending on Capitol Hill on an assigned date to “bring awareness” to the issue. You can also look forward to me yawning and changing the channel.

The second piece of interesting news in the past week came from the OIG. When I reviewed the OIG Work Plan back in October, one item that jumped out at me was the OIG’s plan to look into the impact of physicians opting out of Medicare, both in terms of physician access in certain geographical areas andto be certain that non-participating providers were not submitting claims for payment to Medicare. There has been a slow trend developing regarding physicians who take the “third way”, that being the membership/concierge model. Previous studies by CMS have vastly underestimated the exact number of such physicians nationwide.

It was announced last Friday that the plan to assess the impact has failed due to a lack of data maintained by the MACs on physicians who leave Medicare. CMS has been forced to admit that they have insufficient oversight over physicians who opt out of the Medicare program due to this lack of data. CMS concluded their statement of finding by saying that they “plan to conduct a full evaluation when a complete data source of opted-out physicians is available”.

I challenge the reader to internalize that for a moment, and place that statement against the backdrop of PPACA and the ticking time bomb of a growing primary care physician shortage. CMS is stating that they don’t know for certain who is not participating in the program as they attempt to build a health care delivery structure where every citizen is covered under some type of health insurance. Items such as Medicaid expansion certainly appear tenuous when you can’t reasonably identify which providers will not be there to provide services. CMS has set no time frame to provide a reasonable picture of the opt-out landscape. Between you, me and your computer monitor, that’s a little scary.

The shortest month of the year has begun with big items. As the “Doc fix” witching hour approaches towards the end of the month, February is threatening to make up for in quality of news what it lacks in quantity of days.

I don’t live in a hole, but I predict about 4 more weeks of hand-wringing.

Be sure to keep abreast of all news updates about the Fi-Med RAC Summit this April by visiting the Summit website.

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February 3rd, 2012 | No Comments »

Revenge of the Dullards

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

There have been millions of members of the human race that have matriculated to higher education. Many of these people have graduated and earned some type of degree, but one thing is for certain; in every graduating class, someone has to finish first and someone has to finish last, with a corresponding reduction in the quality of that degree from top to bottom. Unfortunately, when we hold degree certificates side by side, we have no way to differentiate those that breathed the rarefied air of achievement from the crustacean masses at the bottom of the barrel. Oftentimes, as in the case of General Custer, who graduated last in his class at West Point, we discover this important detail too late.

I often have an opportunity to think about this concept as it applies to the world of medicine. We have hundreds of thousands of medical school graduates who have become physicians, but we have no way of differentiating which degree denotes outstanding achievement and potential from those that represent a large investment of money to a university for use of their printing press.

Lately, I’ve been taking this thought process a step further, and applying it to the growing trend of concierge medicine. I touched upon this topic briefly about a month ago in a posting that spoke about Dr. Conrad Murray, the jail-bound personal anesthetist for Michael Jackson. Written between the lines of his hefty CV and his prominent Las Vegas clinic where he made Jackson’s acquaintance was a trail of unpaid debts, tax liens and malpractice suits dating back years. With a record like this, it’s no wonder he jumped at the chance to be paid $150,000 a month to be Jackson’s personal physician. In hindsight, no one can possibly be surprised by the outcome.

Among physicians, it is a poorly guarded secret that primary care has become something of a repository for physicians without the requisite skills to enter the world of specialty medicine. For physicians that indeed do possess such acumen, the higher reimbursements that accompany being a specialist become an obvious path. This has led to a critical shortage of primary care physicians as a foremost concern. Secondary to that is the growing threat of the primary care physicians that are left making a decision to go to the concierge/retainer medicine model.

I believe very strongly in the advantages of this model, lead among them the idea of taking medical decisions out of the hands of the insurance industry. My concern, in the wake of Dr. Murray’s Magical Mystery Sleep Elixir Tour, is how a patient who has decided to invest in such a practice for their medical care verifies the quality of care they are about to receive.

Concierge physicians now have a trade group (that’s polite language defined as “lobbying arm”) called the American Academy of Professional Physicians. If this group is trying to ease the fears of the general public about concierge medicine being more than simply a money grab for the lower rungs of medical school graduates, their own website doesn’t fill one with confidence. If you go to the section of their website that assists a prospective retainer patient in finding such a physician, you find the following message:

“AAPP is not responsible for the individual actions of its members. Inclusion on the AAPP website is not and should not be interpreted as an endorsement by AAPP  of the experience, reputation or abilities of the member.”

The Philadelphian skeptic in me translates this to the following terms: 

“We get a lot of membership dues from quacks. We can tell you to avoid a retainer medical practice where there is a bubbling cauldron, bones on the walls and voodoo dolls, but hey, what if the treatment works? Anyway, be careful!”

Having seen the insurance reimbursement model for health care up close for over 20 years, I am more than happy to be the first person in line to listen to any alternative that leads to better patient outcomes, both physically and financially. However, I would remind anyone looking for a more beneficial bottom line to remember that your doctor isn’t just some random person in a white coat wearing a stethoscope that has mass and takes up space. That person should be first and foremost a competent and proven gatekeeper of the science of medicine. Such a personal financial investment should have beneficial effects, but that can only happen when the person writing the check does so with their eyes wide open.

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December 9th, 2011 | 2 Comments »

Goodbye, Dr. Berwick (And With Him PPACA?)

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

The final day of any job is a challenge.

I’ve been a bit of an occupational nomad in my life, so in looking back on instances when  I’ve left one job for another, the only feeling I have is an awkward one. I can remember being given cards that everyone in the office signs saying “Good Luck” or “Best Wishes”, followed by a drink or two after work, accompanied by hollow promises of keeping in touch that never come to pass. Given where I have landed in my life, none of these memories fill me with any sense of regret.

Today, someone in Washington, DC is experiencing one such last day of work. Donald Berwick, the head of CMS, leaves his post today. In his brief time as the appointed head of the agency, Dr. Berwick attempted, against nonsensical political headwinds, to reshape the future of health care delivery in the United States. Based on his impressive resume of accomplishments, we shall more than likely here from him again in the future in a capacity outside government.

Dr. Berwick’s brief time period in his post had to do neither with his abilities for the task nor on-the-job failures during his tenure. The reason Dr. Berwick is suddenly seeking other employment is that he committed the sin of voicing publicly that maybe , just maybe, there are other health care delivery systems in the world that do a better job in certain areas than the United States in the realm of promoting the general welfare. For daring to study the American health care problem with an academic’s path of contrasting, comparing and then arriving at a solution, he is being sacrificed at the chest-beating alter of American Exceptionalism.

Attempting to move the conversation forward, attention is now being focused on Dr. Berwick’s replacement. Marilyn Tavenner has  been nominated to the job having followed a much different occupational path. She worked her way forward in her career solely as an employee of HCA, a for-profit hospital chain with a checkered history with CMS, from a hospital nursing position to their national head of outpatient services. She left the company in 2006 to be the head of Health & Human Resources in the state of Virginia. She is known mostly for her pragmatism, which given the enmity in the current configuration of Congress is a virtue that one side of the aisle will promote while the other side will do everything in its power to exploit.

Provider organizations are falling all over themselves praising Tavenner as an able replacement for Berwick and urging her confirmation by the Senate, something Dr. Berwick never attained because he dared to express an educated opinion.

Ms. Tavenner is left with multiple initiatives created during Dr. Berwick’s tenure that have caused equal parts consternation and confusion within the hospital community. Given her background, a number of these initiatives will more than likely see extensive revision as part of a “pragmatic” approach to satisfy that constituency.

Hanging like the Sword of Damocles above this news is the fact that the Supreme Court has promised a ruling on the constitutionality of the Patient Protection and Affordable Care Act by May of 2012. Ms. Tavenner, in a very short time. could find herself going from the inheritor and fine-tuner of the status quo to the person guiding the transition of CMS right back to the place it occupied in 2008. In either case, the task in front of her is not enviable. Perhaps she and Dr. Berwick can talk about it all over drinks later this afternoon before they never see each other again.

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December 2nd, 2011 | 3 Comments »

Did the AMA Just Jump The Shark?

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

Due to the upcoming Thanksgiving holiday, my usual Friday post on pertinent health care issues appears today.

Last night, in my nightly bout with insomnia, and under orders from my wife to clear our DVR, I watched an under-appreciated gangster movie from 1980 called “The Long Good Friday”, starring Bob Hoskins and Helen Mirren. The movie revolves around a British mobster who, on the brink of an important partnership with the American Mafia, suddenly finds himself under attack from someone he can’t identify. Bluntly, the only reason it was on my DVR at all is that it was produced by Hand-Made Films, which was the production company of an old musician named George Harrison. I’m told that he was in a rather groundbreaking band at one time.

It is indeed a horrible feeling to have a tormentor whose name and motivations you cannot see. On the other side of the coin is to know long in advance what your biggest challenges are and to ignore them in the hopes that they go away. We had a blunt example of this in the last week from a new policy release emanating from the Semi-Annual Meeting of the AMA in New Orleans. While three of the new policies made sense, based on the setting of the meeting, I’m basing the adoption of the following fourth policy on too many hurricane drinks and an overdose of zydeco music.

The AMA has decided that they will “work vigorously to stop” implementation of ICD-10 on October 1, 2013. The argument the AMA makes is that ICD-10 has no benefit to direct patient care and needlessly inflates administrative cost and disrupts work flow.

I get asked a question on ICD-10 often from physicians in the field. It goes something like this:

“Are they REALLY going to go through with this ICD-10 thing?”

I am going to say this one more time, to a mass audience, which can feel free to continue to spread it far and wide to all of their acquaintances in the industry. There will be no delays of the implementation date, there will be no sudden cancellations, and this is not a test, drill, rehearsal, exercise or interpretive dance presentation by Cirque du Soleil called “Illusion”. The FINAL (“FINAL” meaning the last and not the penultimate) implementation date is October 1, 2013. If you use an ICD-9 code on an insurance claim after that date, you will NOT (“NOT” meaning none, nada, zip, zero or the null set) receive an insurance payment. There is no punch line and no one is going to shout “APRIL FOOL”. It’s happening in 679 days, without fail.

Let’s review recent history. CMS’ ICD-10 proposed rule stated an implementation date of October 1, 2012. Mercifully, the final rule bumped it back one year to 2013. The final date represents the end of movement of the date. CMS has no inclination to change it again, and says so every time they provide education on the topic, usually within the first 5 minutes of the presentation.

I would imagine that by saying the phrase ”work vigorously to stop” implementation, the AMA is talking about throwing a bomb in the form of lobbying money towards the nearest corrupt politician (unfortunately, no shortage of targets) in order to introduce legislation to extend the deadline. I bet they figure that if they pinpoint their strike, perhaps they can get a pay fix for 2012 at the same time. If this is the calculus, may I be the first to provide each member of the AMA with advanced booking for a suite at the Fat Chance Hilton?

Might I suggest a more noble use for that money, such as setting up a fund to assist small-group physicians with implementation, or providing regional education opportunities on the substantial impact ICD-10 will have on physician documentation? Since the AMA was more than happy to state in the new policy that small practices would have to spend over $83,000 to fully implement ICD-10, wouldn’t it be more useful to build some much-needed goodwill in the provider community by offering such assistance, rather than yelling at clouds as their membership continues to plummet due to lack of a relevant or coherent argument in the modern medical delivery landscape?

When I first became a certified coder in 1998, I was told that ICD-10 was on the horizon. The original go-live date I heard at that time was October 1, 2000. When final implementation hits, 15+ years of speculation ends. Anyone without their head in the sand knew this was coming eventually. This isn’t some sudden bomb deviously planted in your decanter of tongue depressors by an anonymous assassin. The time to build a flood wall is before the 100-year rains, not after. My advice on ICD-10, to the AMA and anyone else listening, is to hit the ground running, rather than jumping a shark on water skis in the form of issuing a foot-stomping policy of denial.

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November 22nd, 2011 | 4 Comments »

The 2012 Physician Fee Schedule: Here We Go Again

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

As an overfed American with a penchant for sandwiches, it grieves me to report that my current weight stands at 217 pounds. To measure it against random things in my immediate universe, this equates to roughly 79 unsweetened iced teas from Speedway or the contents of just over 694 bottles of Tabasco.

If I reduced my current girth footprint by 27.4%, my weight would be roughly 158 pounds. I’d also be 15 years old, pummeled with acne and at the mercy of the world of 1981, and I promised myself that I’d do my best to avoid the music of Juice Newton for the rest of my life (and no, I’m not providing a hyperlink; it was that bad).

It is with these thoughts in mind that I begin the annual November discussion of physician fee schedule cuts to the Medicare program.

The 2012 Physician Fee Schedule Final Rule was released this week. The size of the cut, representative of the can that has been kicked down the road for over ten years, now stands at 27.4%. Medicare tells us that this is good news, because due to unexpected savings this year, the original scheduled cut of 29.5% has fallen to only the stated percentage.  

If this were any other year, I would shrug this off. We think we all know the drill by now. Every November, just in time for the coming holiday season, we get the fire-and-brimstone treatment with a threatened cut to the fee schedule, and at the last minute (sometimes a few moments after), everything  goes back to normal. Maybe, if we’re lucky, we actually get a few percentage points of a payment increase.

One look at any believable information source will tell you that this is not your typical year. 

We exist in a world where politicians around the globe have developed an unhealthy fetish for economic austerity. Great Britain was the first country up to the plate, slashing government programs like Freddy Krueger, only to find out too late what any reputable economist could have told you from the beginning, which is that slashing spending also slashes growth to near-zero. At this moment, Greece straddles the precipice between being a flat-broke member of the European Union, or a flat-broke country descending into anarchy that threatens to take the entire EU banking structure down with it. Other European nations are slowly lurching towards the same fate.

We’ve seen unprecedented allegiance towards austerity in this country this year in a fashion that can only be described as sociopathic. Rock bottom was reached when Eric Cantor, the 2nd-in-command in the House of Representatives, refused to provide emergency aid to his own Virginia congressional district when it was hit with an earthquake without equal cuts coming from other parts of the federal budget.

With this type of attitude at the fore, I have little hope of a last-minute fix to the fee schedule this year. The very idea of across-the-aisle compromise has come to an end in this country. Physicians, a group that used to have a seat at the lobbying table, will be left out in the cold in favor of industries who write bigger checks for a seat at the table.

I have definitive reasons for not wanting to weigh 158 pounds. I could stand to lose a little weight, but losing 27.4% of me would be counter-intuitive to existing in the modern world. Those of us faced with the realities of physician reimbursement know full well that these types of cuts from the Medicare portion of the physician bottom line could be lethal. Reductions of this magnitude almost certainly insures that care will be deferred for the portion of the population that, with regard to their health, possesses the narrowest margin for error.

However, the current political landscape doesn’t bode well for avoiding this fate. At the same time that the cuts are scheduled to take place, Presidential primaries begin, accompanied by chest-beating about who can cut the national debt by a wider margin. Add to the mix the European Union tanking and police in riot gear responding to people in the streets of our country demanding balance and fairness to our economic system and you have a recipe not just for a health care meltdown, but a societal one. The principals in this debate are digging in their heels and showing no signs of compromise. With all of the hand-wringing, no one is talking about eliminating the Sustainable Growth Rate, which is the root cause of this problem.  

I’d tell the physician reading this to buy popcorn and watch the self-defeating circus from the sidelines, but perhaps packets of ramen noodles would be a better, cheaper alternative. If needed, I’ll provide the Tabasco.

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November 4th, 2011 | No Comments »

Health Care Reform: Chaos From Order

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

I had an interesting visit in my cubicle this week. My CEO stopped into my occupational man-cave to tell me that my blog posting content was good lately. He’s a very busy man, so I appreciated the visit and the input.

There was one part that I left out when discussing this and other issues with him. There are some days when I really have a hard time trying to explain the ins and outs of the American health care system. There’s a part of me that believes that with regard to this topic, the ability to write about it is some type of penance for something I did in a past life. What sick and depraved part of my being keeps getting excited about attempting to explain chaos? I’d rather talk about things that make sense to me, such as the purity of the perfect sandwich, economy cars or ice hockey. Instead, I am entrusted with medical delivery in the United States.

This past week, it became clear that this chaos is about to get worse.

On the legal front, The Supreme Court, which at one time in the distant past was concerned much less about the rights of corporations, announced that it will hear legal challenges to the Affordable Care Act in the opening weeks of November. The thrust of the challenge goes to the Act’s mandate to individuals to purchase health insurance coverage. The ruling, which will more than likely occur in the Spring (just in time to become a Presidential campaign issue) should be interesting. The Court, in its current ideological construct, is pro-business and anti-government. So, how do they rule against a government mandate when the biggest financial beneficiary of the Act is the insurance industry, which we can all agree represents a big business? Get ready for some of the most twisted logic ever committed to paper when the Court releases its ruling. I recommend some type of release valve be installed in your skull prior to that time to prevent the sudden explosion of your head.

PPACA’s life span is a good lead-in topic to the next bit of news that’s slowly coming forth. In the current budget crunch, individual states are beginning to restrict the number of total days per year that Medicaid recipients can be hospitalized. The latest state to vote for such a restriction is Hawaii, which beginning in April 2012 will restrict the number of days to 10. This is the lowest number yet enacted on the state level.

Here’s where policies like this lead. The sickest Medicaid patients, who also double as the poorest residents of the states in which there is a cap, are billed for the unpaid portion of their hospital stay. These bills goes unpaid because the problem isn’t solved by the patients cancelling their country club memberships or selling their cars, as they don’t possess these things. At the end of the process, the hospital eats the bill because they are in the business of admitting people to their facilities who are sick. Hospitals will turn around and shift costs to private health plans, which in turn pass off the costs to insured patients in the form of premium increases. Depending on the dent the new premium places on the healthy privately insured patient, the healthy person may decide to let his or her coverage lapse, which increases the premiums that much more for those who keep their coverage. If the hospital can’t shift the costs, especially a hospital in a rural area, the hospital faces closure.

Remember that at the root of PPACA is an expansion of state Medicaid programs to a higher percentage of the population. On the brink of millions more qualifying for this type of coverage, Medicaid will stop paying for your care after a pre-determined utilization threshold is reached. You barely qualified for your new coverage based on economic factors and now, your coverage stops. This Bill’s for You!

I’m what I would consider a fairly sentient being. I can make sense out of virtually anything. If I can’t make sense of something, such as artichokes, speed limits or baseball’s balk rule, I’ll at least make the attempt. With regard to America’s health care system, I’ve come to a decision. If the world is ever invaded by aliens, in the absence of enough advanced weaponry, I’ll fight off the invasion by explaining the American health care system to them in detail. All it really takes to destroy someone is to introduce an idea too complex to be comprehended and then watch their will and spirit collapse from within in an attempt to understand. Our health care system provides that opportunity amply.

Now, where did I put that skull valve……

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October 28th, 2011 | No Comments »

CMS Clarifies Predictive Modeling

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

I’d like to start this post today by stating categorically that it is a frustrating experience when one types out an entire blog post, follows that by clicking the “Save Draft” button, and in an instant watches a few hours of work disappear. Such is my current predicament. When you read everything below, bear in mind that this is my second pass at today’s topic, much like any clone, there will be things that are just not right, or that represent a horrible attempt at finishing something hastily. Setting this aside, I hope that you find the following information useful.

While I was out of the office for a few days, I received an e-mail from CMS about a topic I covered only briefly in the past. With a special article serving as clarification, CMS went into further details about predictive modeling techniques currently being utilized to reduce the payment of fraudulent claims, and what this will mean for providers, their patients and networks.

Let me quickly type in an overview of what this means before Word Press explodes.

All claims from June 30th, 2011 and after are being fed into CMS’ predictive modeling technology. The information from the claims is then diced, sliced and analyzed Jetsons-style with regard to provider and patient utilization. This leads to the building of profiles not only of providers, but patients as well.

After all of these high-speed calculations comes the assigning of risk scores based on the data collected. Those entities coming up with higher risk scores will be subject to payment delays, followed by a site visit, reviews of claim histories and interviews by CMS analysts at its discretion. If, after analyst intervention and inquisition, the billing is found to be “innocuous” (you know, like a quilting bee or the Lions Club), that outcome is recorded into the predictive modeling system and the payment for the claim(s) in question is released as usual. 

Now the rough part.

If an analyst finds indications of the not-so-innocuous (you know, like Tony Soprano or Dr. Jekyll), these cases will be referred to CMS’ Center for Program Integrity, the MAC involved and the ZPIC contractor in that particular geographic zone. The result could be targeted denials, revocation of billing privileges, and that classic cinema verite production entitled “A Raid”, featuring veteran co-stars Records Seizure, Perp Walk & Civil Penalty.

The main thrust of this new method is the fact that false claims investigations are no longer a guess, or reliant on someone blowing the whistle on an illegal practice. The government is now using the same types of pre-screening methods that used to be reserved for banks and credit card companies to catch the cheaters in the Medicare program. As a taxpayer, I would say this is about 45 years overdue. As a physician advocate, what I do for a living with regard to practice analytics and documentation review just became very interesting.

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October 21st, 2011 | 1 Comment »

The Nervous Animals of ICD-10

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

It was roughly 9 years ago this week that my wife Leslie and I moved to Milwaukee from suburban Philadelphia. We had experienced some tough times back on the East Coast, and our final night there was no exception. We ended up loading our moving truck, with the help of two friends, as the leading edge of Hurricane Isidore passed through the area. Nothing says “Let’s leave here and never come back!” better than having to pack a moving truck while it’s raining horizontally.

Severe meteorological events, in the absence of a TV or a radio, are most often prefaced by animals acting strangely, whether it be either zoo animals in a cage pacing back and forth at a quickened pace or birds suddenly taking flight en masse away from the coming cataclysm. We have one such storm being tracked in the world of health care, that being the implementation of ICD-10 on October 1st, 2013.

I can honestly state that over these past two weeks, I for the first time noticed the animals of our industry beginning to shuffle nervously for the impending arrival of ICD-10. When I first became a certified coder in 1998, I was told that ICD-10 was right around the corner, with the first implementation date being the year 2000. When ICD-10 finally sees the light of day as our disease reporting system, 15 years will have passed from those first pronouncements.

The biggest lesson I learned between those early, naive days and the release of the ICD-10 final rule on January 16, 2009 was that the chances of any major health care change coming to fruition can be measured directly against the amount of lobbying dollars the insurance industry spends in order to insure that the change never comes to pass. It was well known that the bigger payers, after over a decade of mergers and acquisitions, were in no mood to spend the money necessary to condense all of the claims payment systems they inherited into one better system utilizing the updated coding standard. When ICD-9 became severely outdated for our providers, the American Hospital Association stepped in and took up the cause, which led all of us to where we are.

Most people outside of the industry are unaware of how ICD-10 will affect health care when it hits. At the symposium hosted by the Wisconsin Medical Society that I attended earlier this week, a number of attendees were talking about this article from the Wall Street Journal. While this could have worked to warn the general public about expected claims delays and drops in productivity that have been experienced in other countries that have undergone implementation, it instead decided to point out funny examples contained in the code set. When I think of improved disease and symtomology reporting, I think about stamping out major epidemics before they happen, rather than being flippant about the fact that we’ll be able to accurately report when someone injures themselves walking into a lamppost. What would we do without the press?

The countdown clock for ICD-10 now stands at 738 days. As that number continues to deflate, expect the lower order animals in our industry to continue their wringing of hands, pacing back and forth and stocking their figurative basements with cans of bargain soup and bottles of water. For the rest of us, we have known for years now that “duck-and-cover” is not a useful strategy when it comes to ICD-10. This new code set isn’t going away, it isn’t going to be delayed any longer and it will not make anyone’s life easier in the short term.

Having stated that, there’s no reason to retire in fear, and the conversion need not be as painful as envisioned. Begin planning now to avoid the looting and car crashes later. Start with a pre-emptive strike on your EHR vendor by putting them through your own form of the Spanish Inquistion. Ask them if they are preparing for ICD-10 and about any planned upgrades. Scour all of your contracts for any mention of ICD-10. If it isn’t there, negotiate favorable terms to add it, and if it is there, find out what it means to your organization.

Like most everything else in this country, it is difficult to drag a large swath of our population into the modern age. This one can’t be accomplished by fear-mongering and snarky jokes. Anyone weathering the oncoming storm will succeed with the only thing that ever truly does, which is work.

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September 23rd, 2011 | 1 Comment »

The Hidden Disadvantages of Buying on Faith

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

My house is not usually stocked with junk food, despite the fact that it tends to find me. In those many moments when snack food isn’t available, I tend to reach for the nearest box of cereal.

There has always been one thing that annoys me about breakfast cereals in this country. I have never possessed a box of cereal that contained all perfect specimens. The best example I can give is your basic box of Rice Krispies. Among all of the perfectly toasted grains of dried rice making noise in my bowl, I inevitably find that one black piece of rice that disguised itself among hundreds of other grains poured into my bowl. This outlier grain of rice is always found after I pour the milk in the bowl, which then leads to me spending five minutes trying to fish it out of my bowl before I accidentally eat it. To this day, I have no idea of the consequences are of consuming the black Rice Krispy, and I don’t want to know.

Each one of us, no matter what the product, is susceptible to attractive packaging. The picture of the cereal on the box, strawberries happily floating on top like little red clouds, always looks good, and let’s face it; if the house is out of cereal, you’re going to buy the box. It’s only later that your frustration rears its ugly head when the myth of the packaging is exposed.

It is on this final point that I begin today’s discussion topic; physician alignment with hospitals.

In the lead-up to ACO formation, hospitals are currently on a physician buying spree that would make a sailor on shore leave blush. In a recent research paper by Thomson Reuters, 44 hospital CEOs indicated that physician alignment was an issue of increased focus. If we pair that with another report from Merritt Hawkins stating that 76% of all physician openings offer a signing bonus, and the conclusion can be made that now is a very good time to be a physician looking for employment by a hospital.

Yet as I examine the issue further, there is one critical component missing, that being the due diligence required to determine whether the physician in question is a compliance nightmare waiting to happen.

In the current audit environment, most hospital systems are just beginning to get their arms around the RAC process for facility services. Because the audit entities have yet to expand into physician services, hospitals with large physician populations haven’t focused on the risks presented by the billing practices of doctors. Into this environment comes recently-acquired physicians and their accessory baggage. They look great, what with their shimmering CVs and smart ties, but it’s what you can’t see (or what is not volunteered) that poses the greatest risk.

If a newly-acquired physician comes to your organization either as an outlier based on billing, a poor documenter or someone lacking familiarity with your chosen electronic medical record, he or she can pose an immediate risk to the entire system.

Thankfully, one area where I spend a great deal of my time is in the area of practice analytics. The operative principals are available to determine the risk a physician poses to a facility, and it can be done in a manner that is time-sensitive prior to acquisition. It is a clear choice between paying a little bit now, and paying a lot later. To rephrase, are you buying the Rice Krispies because of the package and trusting that the alluring box contains cereal without flaws? If so, get your spoon ready, as black Rice Krispy fishing isn’t as easy as it appears.

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September 9th, 2011 | 1 Comment »

One Service, One Payment: NOW They Tell Us…..

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

In the human experience, there is an overarching idea that controls all of our thought processes known as “the common good”. As I tumble blindly down the hill of degeneration known as Growing Older, I’ve learned that “the common good” means vastly different things to different people, but one thing all of the divergent ideas have in common is the idea of personal sacrifice for improvement of the whole. Whether it is a farming commune, a church community or a governmental taxation system, personal sacrifice is is seen as the key ingredient on a promise of future gains, either in healthy crops, saved souls or roads without potholes.

It is with this idea in mind that I reviewed the latest CMS payment initiative, which was released on August 23rd. Entitled the Bundled Payments for Care Improvement Initiative, it offers four ways for caregivers to accept one bundled payment for an episode of care as a dangling carrot aimed at better care coordination and reduction of expenses. 

While there are four different payment models under the plan, I offer an illustrative example. A patient is in need of a hip replacement. The medical providers who treat the patient voluntarily negotiate one bundled payment with Medicare, covering all providers and services for the hip replacement. Under all four of the models (three offering retrospective negotiation of bundled payment, and one prospective), it would be up to the providers to determine how the one bundled payment is distributed among all of the entities involved with the patient’s care.

At first glance, I see this as another attempt to clarify and strengthen the ACO model. Farther down in fine print lies an enormous caveat, as noted in a brief article by FierceHealthcare this week. CMS states that preference for entering into a bundled payment arrangement will be given to providers who have at least 50% of their caregivers meaningfully using an electronic medical record (EMR). GIven where most hospitals are in the constructing of their particular ACO, this initiative comes a bit late.

Across the country, we have hospitals who are purchasing physician practices in the lead-up to ACO creation. As I communicate with people in this field, I am struck by the lack of due diligence exhibited by hospitals in selecting providers to hire. Most hospitals have no concept of how versed these physicians are in the use of an EMR, the quality of the provider’s documentation in its current form, the provider’s established billing patterns or the compliance risk to the facility of bringing on a particular doctor under the umbrella of the hospital. With respect to the EMR, as I have covered in previous posts here and here, use of an EMR may not signal the end of all compliance troubles, but a rather complicated beginning.

With the Bundled Payment Initiative giving preference to treating entities with high Meaningful Use percentages, hospitals may be regretting purchasing practices in the absence of this information, but it need not be a deal breaker. ACOs, by their very design, encourage a collaborative effort in the delivery of health care services. This idea needs to be applied not just to the care itself, but intangibles at the root of that care, such as the compliant use of an EMR.

The general idea behind the ACO model is that of the best ideas for low-cost care rising to the top. There are many paths to achieving ”the common good”, with human interaction and shared sacrifice being of paramount importance to the process. While this latest initiative might have assisted hospitals at the beginning of ACO formation by exponential factors had it been released earlier, better late than never.

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September 2nd, 2011 | No Comments »

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