One of the nearly forgotten geniuses of early cinema was Buster Keaton. While Charlie Chaplin was satisfied with one or two Keystone Kops chasing after him, followed by humanizing close-up shots, Keaton’s films thrived on a constant state of anarchy breaking out around him. Since he was a master of silent movies, I offer this as a short example.
Ninety years ago, when the above film clip was made, it was understood that constant chaos was restricted to the movies. Because the layers of bureaucracy that exist today were nowhere to be found, outbreaks of people with conflicting information and goals were rare. Twenty minutes of cable news is really all you need to see that those carefree, Charleston-filled days have disappeared for good.
As if I needed more reminders of the chaotic times we live in, yesterday’s e-mail gave me another one, and as is expected if I’m writing about it in this space, this particular example is from the world of health care, under the section marked “Medicare Administrative Contractors”, subsection “Comprehensive Error Rate Testing”, under the paragraph labeled “OW! THE STUPID! IT BURNS!”.
As we should all be aware, the CERT program has been around since 2003. Its main purpose is to determine an error rate for claims payment. A constant area of focus under the CERT program has been Evaluation & Management (E/M) services. This is due to the consistently high error rates for these services, particularly CPT codes 99214 for established office patients, as well as 99223 and 99233 for high-level new and subsequent hospital visits, respectively.
There are two sets of E/M documentation guidelines. In 1995, CMS released the first set of guidelines that were tailored more towards primary care. The specialists soon revolted, stating that under the 1995 guidelines, system-focused examinations were under-represented. Responding to the drumbeat of dissatisfaction, CMS created a new set of guidelines in 1997 designed for specialists.
In addition to the vast differences in examination guidelines, there was one other unique difference between the two sets of guidelines. In documenting the history of present illness (HPI) for a patient, the 1995 Guidelines stated that four elements of HPI (of eight to choose from) were needed to justify either a detailed or comprehensive level of service. For the 1997 Guidelines, providers have the choice of either four elements of HPI or the status of three chronic conditions.
WPS, the Medicare Part B Legacy Carrier for four states in the Midwest, sent an e-mail blast out yesterday stating that “based on a communication received from CMS several years ago”, WPS was incorrectly applying the standard of the status of three chronic conditions to providers who used the 1995 guidelines. Unfortunately for providers, the CERT contractor was not privy to the same communication, and was correctly applying the guidelines as written. WPS went on in the e-mail to state that beginning with all dates of service on or after April 19th, the status of three chronic conditions for HPI will be applied only to documentation utilizing the 1997 guidelines.
The upshot of this is that providers who have for years believed, based on guidance from CMS parroted by WPS, that their documentation was correct, may have been receiving CERT errors and been responsible for overpayments because two independent contractors were being given conflicting information and guidance from CMS. It took roughly nine years to figure this out.
The last four months have been horrible for my perception of government audit efforts to strengthen federal health care programs. In November, the OIG released a report stating that based on poor data, there was no way to measure the effectiveness of the work product of the ZPIC contractors. Next came the latest AHA RACtrac study released in February, stating that 66% of all complex review requests for documentation from the RAC contractors do not lead to the discovery of an improper payment. Then came an article stating that CMS’ use of their highly-vaunted and quite expensive predictive modeling system has led to the savings of exactly $7,591 through the end of 2011. This week, the OIG released a report on the Medicaid Integrity Program which stated that 81% of MIC audits either did not or are unlikely to identify an overpayment. Finally, we have yesterday’s e-mail missive from WPS.
I want to state firmly that I am in favor of expunging fraudulent activity from the Medicare and Medicaid program. As an advocate for physicians who want to do the right thing, in addition to being an aging taxpayer who still has an outside chance of utilizing the Medicare program someday, I have clearly defined reasons for wanting audits to work effectively. As we stand right now, audits alone will never save the program if they continue to operate in today’s substandard fashion. It is hoped that nine years from now, the Buster Keaton-like chaos of the present day has evolved into something resembling organized and rational behavior.

