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FLASH: ICD-10 Delay Lays Bare Spencer’s Genius

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

Categories:
Industry Updates

Today, I exist in a world where the last 12 hours of my time has been filled with a lot of information. As is my usual custom, about 1/3 of it is actually job-related.

It started last night at about 12 Midnight as I was watching an early ’70’s B-movie off of my DVR (I’m not even going to share the title with you, as this is one field of interest of mine that I can’t even begin to explain to people based on it being rooted in insomnia). As the movie’s plot and soundtrack continued in my head prior to leaving my house this morning, I was packing to leave for a weekend wedding in central Illinois. This morning, I listened intently at an off-site meeting on RAC issues that gave me weeks of fodder for my Wednesday posts in this space. Next comes preparations for the Fi-Med RAC Summit this coming Monday and Tuesday, a business invitation that was just extended to me upon my arrival in the office, the work awaiting my hands currently occupying my desk (the true 99%, if ever it could be measured) and we finally work down to the fact that I’m hungry and that my chosen lunchtime remedy for this condition today is woefully inadequate.

And then there’s the ICD-10 delay…….

For those of you in health care that have been living on a beach without cell service for the last week, CMS has issued a proposed rule indicating a new compliance date for ICD-10 of October 1, 2014.  

I had a plan for today’s post, B-movies, meetings, packing and summits not withstanding. My plan was to share with you the comments I am going to share with CMS regarding the proposed rule that I shall upload onto Regulations.gov. The comment period for this proposed rule is only 30 days, which is CMS’ way of stating that they’re sick of the crosstalk on this topic. Unfortunately, the proposed rule has yet to be uploaded onto the comment site and I am not about to use regular mail for submission. Until such time as the proposed rule is entered into the Federal Register, allow me to give you all a preview of coming attractions.

You all know my feelings with regard to ICD-10 as it pertains to ICD-11. If you do not, please review this recent post. We now have a compliance date for ICD-10 that, thanks to delays (caused mostly by entities such as commercial insurance carriers who threw lobbying dollars), will fall 22 years after its release by the World Health Organization. I ask the reader to also remember that work on the design of ICD-10 began in 1982, the year that America was riveted by the happenings of the Ewing family on Dallas between spins around town in their AMC Eagles.

Here’s one last number for everyone to chew on, and this one will take up quite a bit of my comments to CMS. The proposed final compliance date for ICD-10 falls only seven months prior to the scheduled release of ICD-11 (including a clinical modification) in May of 2015. Because I’ve been banging the ICD-11 gong to CMS since 2008, newcomers that are late to my party are now telling me that an American clinical modification can’t be ready until 2024 or 2030, so I feel I need to respond to the conjecture emanating from certain quarters of our industry in the only way I know how, given my formative years spent as a sports fan in the City of Philadelphia.

BOOOOOOOOOOOOOOOOOOO!!!!

The only reason we have an American clinical modification to ICD at all is because we kowtow to the insurance industry so they can use the US version to more easily deny claims. ICD-11 is a system that brings SNOMED CT into the code set for better clinical representation of a patient’s condition. If we are truly concerned about paying for performance rather than quantity, and if we want to redefine the fundamental goal of medicine in the United States to be one of better patient outcomes, then who in their right mind would argue to putt along with a clunker of a reporting system for up to 16 more years?

If you were reading this post thoroughly, you know that the answer to that question is the companies of yesterday who threw money towards adopting ICD-10 as the reporting standard.

There was a time when people in other parts of the world were isolated from one another, which made one global disease and morphology reporting standard something of a moot point. We now live in a world of international interaction brought on by technological advances in travel and communication. For the rest of the world to utilize one reporting standard while the United States uses another is no longer a viable option. I feel happy to add that throwing out monetary reasons to justify being behind shows a distinct lack of citizenship. In America, if you want to get something done, you plan and act. Crying about all of the money you spent (or are about to spend) on ICD-10 is the same as telling me “but we’ve always done it this way” and you never says those words to a compliance officer.

My pending drive deep into Illinois, my workload, today’s meeting, next’s week’s Summit, my growling stomach and B-movie soundtracks and plot lines will continue on in my head unabated until I decide to bring new stimuli into it in order to continue evolving. I would recommend to those who wish to belittle the idea of a faster ICD-11 implementation to perhaps open their minds to the same process.

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1:52 pm, April 13th, 2012 | 1 Comment »

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The RAConteur: Whither Medicaid RACs?

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

Categories:
The RAConteur™

Today, I return to this space after a one-week absence due to my attendance at the AAPC’s National Conference in Las Vegas. Given the venue, I wouldn’t have thought that it would have provided an opportunity to clear my head, but it did provide me a chance to recharge, if not refill my wallet with winnings. In addition, since I attended two breakout sessions that contained incorrect information on the Medicare RAC program, it reinforced the importance of putting good information regarding government audit activities into the public sphere.

Today’s thesis begins with the idea that unintended bad consequences often stem from good intentions. As an example, a few years ago, my family adopted a shelter cat. The unintended consequence of this act of altruism is that he waits until 2 AM to begin his incredibly loud vocal practice, which necessitates that I sleep in close proximity to books, shoes and other projectiles.

Yet there are examples where unintended consequences stem from acts of fury and aggression. As I normally do in this space, I’ll give you a relevant example from the world of American Health Care.

It has now been two weeks since the conclusion of oral arguments at the Supreme Court regarding the Patient Protection and Affordable Care Act. Given the constant drone of virulent opinion towards PPACA coming from the neo-conservative side of the political spectrum, and given that my take on the Supreme Court arguments was that these leaned strongly towards throwing out the entire statute, people in many areas of health care are left wondering about the consequences of a world without the law in place.

As it applies to government audits, suddenly the Medicaid RAC program finds itself  with an uncertain future. The program was scheduled to begin on January 1 ,2012, but by my count has yet to produce a single documentation request for any provider in any state. As if that was not enough, only 22 of 50 states have finalized a Medicaid RAC contract, with 4 other states pending an announcement of such a selection. This leaves 24 states without a Medicaid RAC. It should c0me as no surprise that there is a conspicuous overlap between the list of states without a contractor and the list of states suing the federal government to overturn PPACA.

As anyone who has read my blatherings in this space knows by now, I am not a fan of the RAC process as it is currently constituted, as the Medicare RACs have yet to demonstrate a wide-ranging competence with regard to their assigned tasks. I think I can speak for the provider community when I state categorically that no one is looking forward to the expansion of the blind skeet-shooting that has come to symbolize the work of the four Medicare recovery auditors into Medicaid reimbursement.

However, if the Supreme Court acts as I think they will by invalidating PPACA in its entirety, the 5 conservative justices on the Court and the political forces who support them will actually be arguing for improper Medicaid payments to continue unabated. Given the caterwauling about stretched state budgets emanating due to Medicaid from those same governors of states lending their names to the lawsuits that brought PPACA to the steps of the Supreme Court, my logical brain finds itself perplexed by this consequence.

The premature end of the Medicaid RAC program is but one unintended consequence of PPACA’s possible / probable disposal. Given that the final law clocked in at 906 pages in PDF format, many initiatives and programs suddenly find themselves needlessly threatened based on the whims of 5 people in a columned building in Washington, D.C. The setting is somewhat fitting, given the antiquated form of Olympus-like justice that is about t0 befall the act. Given the sheer volume of consequences, I may not need a bellowing cat to keep me up at night for much longer.

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11:44 am, April 11th, 2012 | No Comments »

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Avoid The Rush: Say Goodbye To PPACA Now

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

Categories:
Health Care Reform

I began writing this post at 1:12 AM in the morning on the 30th of March (or is it May?). At roughly 7:20 PM last night, I commenced reading through this week’s oral arguments from the Supreme Court regarding the constitutionality of the Patient Protection and Affordable Care Act. The three days of testimony spanning four sessions was strewn across over 400 pages.

Given the title that I have chosen for this particular post, it should not be hard for the reader to discern my conclusions about the future of PPACA after my reading the arguments, but in order to give full context as how I came to this inference, I feel I must first share a few personal observations on the Supreme Court.

In a perfect world, the make-up of the Supreme Court would consist of nine swing votes. Attorneys would present their arguments to the Court, and the justices would impartially decide the merits of each case using 223 years of judicial precedent as their guide. Unfortunately, since the administration of Ronald Reagan, nominees for the bench have been selected based solely on their political ideologies, rather than on legal competence. Since the rejection of Robert Bork in 1987, the Supreme Court has ceased to resemble the impartial interpretive Court of Last Resort envisioned by the Framers of the Constitution and has instead evolved into a 9-person monarchy. Sniveling weasels lurk in the shadow of the Court, waiting, much like over-eager princes, for a vacancy caused either by death or retirement, for with that one open seat, the ideological leaning of the entire Court hangs in the balance. In this context, the justices of the Supreme Court cease to be recognizable as respected jurists and instead morph into blathering carrion with vultures circling above their collective heads.

We fought a revolution to rid ourselves once and for all of this type of regal intrigue, with our evolution as a country helping to greatly reduce the additional lingering paternalistic stains of gender and racial discrimination. The three-decades-old politicization of the Supreme Court has been but one of several new and unexpected ideological battlefields that have had a measurable negative impact on the political discourse in our country. One need only peer briefly into the mosquito-infested swamp of the 24-hour cable news cycle or the comments section of the online version of your local newspaper to realize how far we have fallen. It is with great disappointment that I report that based on this week’s oral arguments, the Supreme Court of the United States continued down a path that eventually will lead directly to the end of our once-functional democracy.

Monday’s session began with all justices present and accounted for. On the conservative wing of the court sat budding weird uncle and semi-professional Borscht-Belt comedian Antonin Scalia, the self important tacticians Samuel Alito and John Roberts, the accidentally aloof Anthony Kennedy and, reprising his sterling impression of Harpo Marx for a sixth straight year (minus hat, horn and any sense of actually being funny) Clarence Thomas. On the other side of the Court sat Steven Breyer, whose interjections during oral arguments took on the appearance of following an old man wearing a hat in a Buick LeSabre in the left lane of the freeway. He was joined by the Court’s answer to Wilson Phillips, in the form of Elena Kagen, Ruth Bader Ginsburg and Sonia Sotomayor, shimmering with their sunny liberal harmonies.

The first day of arguments centered on the penalty terms of the individual insurance mandate provisions of PPACA. There was extended discussion over whether this penalty was actually a tax. It was referred to as a tax, a penalty and (you knew this was coming) a “tax penalty” during Monday’s arguments by different parties. This evolved quickly into a discussion as to the proper timing of injunctive relief for parties subject to the penalty, with the government attorneys arguing that it should be after the determination of a penalty. It is worth noting here that this portion of the Act isn’t in effect until 2014 (for now). 

Prior to recounting the second day of arguments, I should pause now for another philosophical rambling along our path. I have never had much of a need for attorneys. This comes mostly from personal interaction with lawyers within my own family. There were segments of my family that went into the medical profession and some that chose the legal route. The doctors were mostly well-meaning and successful people dedicated to their profession. The best of the attorneys in my family only rose to the unimpressive level of Apprentice Dirtbag. Other less-skilled familial esquires rose to the lesser title of Pond Scum. There was even one who ripped off the estate of an older female client to the tune of hundreds of thousands of dollars. Decency precludes me from telling you what notorious level this person occupied, but is it any wonder that I eventually changed my surname?

That being said, if your life’s mission is to be a high-level trial attorney, and you someday accept the position of Solicitor General of the United States, it is hoped that you have the ability to argue a case before the highest court in our country without resembling someone who accidentally swallowed a throat lozenge. Such was the fate of Donald Verrilli as Day 2 of arguments unfolded. Tuesday’s session was dedicated to the constitutionality of the individual mandate. The fundamental question to be answered was whether forcing uninsured citizens to purchase health insurance constitutes a creation of commerce (which Congress is prohibited from doing based on the Constitution), or the regulation of existing commerce. Verrilli found himself on more than one occasion without credible answers to questions that in his role as Solicitor General, he must or at least should have known would be asked. It bespoke of a fatal flaw in legal strategy for Team Obama. Tuesday’s session was further complicated by Justice Scalia attempting to compare the automobile industry to health care as similar types of commerce, which spoke volumes about his disdain for relevant context and his philosophical allegiances.  

Prior to this day’s session, it was thought that Anthony Kennedy may have been a swing vote with regard to this most important question regarding the Act. All illusions of such a stance were shattered shortly into oral arguments when Kennedy asked “Can you create commerce in order to regulate it?” This signaled to me that Kennedy’s mind is made up about Congress having overstepped its authority by creating commerce, making him by my count the fifth vote to eventually strike down the individual mandate to purchase insurance.

This led into the arguments of Day Three. Over two sessions on Wednesday, the issue of severability was on the table. Attorneys for both sides argued either for or against throwing out the entirety of the Act if the Supreme Court declared the individual mandate portion unconstitutional. Of all of the arguments brought forth this week, those of the third day should sufficiently scare the daylights out of everyone involved in any way, shape or form with a government health care program. The conservative wing of the Court appeared to signal their willingness to throw out the entire law based upon the central importance of the individual mandate, even those unrelated portions such as payment reform, the temporary 2010 Doc Fix (which set the table for the next four fixes), funding for the Indian Health Service and a host of other issues addressed across over 1,000 pages in the Act.

A final ruling is expected in June, but this week’s arguments were only the latest in the long and painful journey that has been the decline of the Supreme Court. It is recommended that all health entities begin to conduct impact analyses to determine what throwing out PPACA and starting again will mean to your facility or physicians. I’ve been wrong before, but I’m betting it all that PPACA died this week. E Pluribus, Chaos!

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9:21 am, March 30th, 2012 | 5 Comments »

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The RAConteur: Catching Up On A Big Omission

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

Categories:
The RAConteur™

Needless to say, the past three weeks have been an interesting time in the health care arena. Today, in the third day of arguments before the Supreme Court, the question of whether the entire Patient Protection and Affordable Care Act should be thrown out if one section of the law is found to be unconstitutional will be debated. Two recent reports released by the OIG cast doubt on the effectiveness of the Medicaid Integrity Program. In such an environment, significant news on other fronts is easy to miss.

One such update came to the RAC world about two weeks ago that I now need to address, albeit in a tardy fashion.

Very quietly, CMS announced that as of March 15, the annual limit for documentation requests increased to 2% of all claims submitted in the prior year, divided by eight. This raised the maximum number of eligible requests for providers with less than $100 million in DRG claims to 400 every 45 days, from the previous limit of 300. For providers over that dollar mark, the limit has been increased from 500 to 600.

For the majority of the provider community, the sudden increase in records requests came as an unwelcome surprise. Whatever their sins with regard to the RAC program, CMS had been good up until now about telegraphing changes to the provider community. This particular announcement was released quietly on March 13th with an effective date of 48 hours after its release.

When we combine this change with the shift of demand letters from the RACs to the MACs, it’s time to call out CMS for attempting to game the system for better audit results. Knowing that the success rates of provider appeals remains sky-high, and knowing that 67% of what the RACs request in complex review leads nowhere, CMS had to adjust the house rules to their favor by making it harder for facilities to respond to the program. RAC coordinators nationwide, in addition to dealing with having to track down demand letters, have now seen their number of requests dramatically increase.

We are only 3 months into 2012, and the early returns for government audits are looking bleak, both for the contractors conducting audits and the facilities affected by their actions. This latest salvo by CMS is another in an ongoing attempt to justify the existence of audits by guaranteeing their success. It would be naive to think that this course correction by CMS will be their last attempt at changing the rules.

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1:25 pm, March 28th, 2012 | 1 Comment »

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And That Only Took Nine Years

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

Categories:
Medicare

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.

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10:41 am, March 23rd, 2012 | 2 Comments »

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The RAConteur: Yes, I Do Get Feedback

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

Categories:
The RAConteur™

If there is one fact that I have internalized about the RAC program, it is the importance of communication between affected entities. More and more, as new problems are encountered with the program, it becomes imperative for affected providers and other informed parties to talk to one another.

When I look at the number of subscribers I have to this particular blog, I am acutely aware of my rather small footprints in the online world. Thanks to the generous largesse of several industry benefactors, I get the opportunity to throw random thoughts on the RAC process out of my head in other fora.

Of late, one such arena has been Monitor Monday, the weekly podcast put forward by RACMonitor.com. Over the past two weeks, I have covered the topics of the MACs now issuing demand letters, as well as the living, breathing false start that is the Medicaid RAC program. Much to the credit of their audience, my appearances have been followed by follow-up questions and comments. In addition, writers from assorted publications have been contacting me of late regarding these two topics.

As a blanket response, and in the interest of better communication, I’d like to cover these two issues today.

I’ve been asked by a few sources what services the Medicaid RACs will review when they finally get started. This question requires a multi-tiered answer. First, if we remember from the Medicaid RAC Final Rule, CMS did not make approved issues lists mandatory for the Medicaid RAC program. Knowing this going in makes it somewhat hard to predict what issues will gain the most attention, but it would make the most sense to expect that reviews will fall into two categories. The first front will be reviews for hospital claims for beneficiaries with Medicaid as a primary insurance. Given that RACs work on a contingency fee basis, it stands to reason that the contractors will go after high-dollar claims, which equals hospital claims. In addition, I would fully expect that Medicaid RACs will concentrate at least some of their efforts on services that are covered uniquely by Medicaid, such as select mental health benefits.

Currently, we have only 21 states that have officially contracted with a RAC for Medicaid audits. For those in states that have not yet selected a contractor, a unique opportunity now exists to review your most prevalent services billed to Medicaid for medical necessity and other information.

As providers know all too well, the demand letter process was shifted to the MACs as of January 1, 2012. Since we know that RACs exist because the MACs have an inability to perform their primary function of claims adjudication effectively, it should come as no surprise that problems with demand letters appeared immediately upon the shift in responsibility. Providers were initially receiving one demand letter for every identified improper payment. This was followed by a CMS communique stating that they were “working to fix the problem”.

Two months later, problems persist dating back to mid-January with providers not receiving demand letters. This is causing multiple problems in attempting to find the ones that are missing. When it comes to cooperation with providers, the MACs are offering varying levels of assistance.  More than one person that I have corresponded with this past week wrote that their MAC stated that they were not obligated to provide copies of demand letters not received, which was the opposite experience of someone else with whom I corresponded.

RAC coordinators have also noticed a pattern of an ICN# on a claim found on their respective RAC websites not matching the ICN# on the claim from the MAC. Unfortunately, there are no other elements of information that can be used to compare claims from the two entities, which complicates financial reconciliation of the claims in question.

The RAC program will continue to haunt us for many years to come, but the sharing of important information can offer much-needed assistance as the burden continues. By all means, keep those e-mails and phone calls coming. In a storm, any information that helps navigate the waters is welcome.

The Fi-Med RAC Summit is less than a month away. Here’s your chance to attend for free! Click here to go directly to the Summit Registration page and enter the promo code “SPENCER” (all caps). The first six people to register with this code will receive complimentary entry to the Summit.

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3:37 pm, March 21st, 2012 | 1 Comment »

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American Healthcare: Fighting Through Red Herrings

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

Categories:
Health Care & Society

Through a combination of mass misinformation, complete lack of curiosity and laziness, I am noticing of late a tendency of blind acceptance of the way things are. I see people who pass themselves off as “experts” exposing themselves as nothing more than stenographers of conventional wisdom. Any idea that makes anyone remotely uncomfortable must have dirt thrown on it and summarily dismissed.

Let me start the St. Patrick’s Day Weekend reverie by offering a different approach, that being hard work, logic and openness to ideas. As always, I’ll help us all get started with some clarity about the (cue the fireworks, waving flags and citizen salutes to the clouds) American Healthcare System, brought to you by….AMERICA!

I begin with a news release from this week. The Congressional Budget Office (CBO), which theoretically operates in a strictly actuarial capacity, put out a report this week that stated that based on budget estimates, and taking into account our aging population, spending for Medicare and Medicaid could double by 2022. As a reasonable person who likes to discuss how to improve things, my first instinct is to think of ways to avoid this. Since my first instincts are comedic and cynical, I think of quick fixes such as Senior NASCAR, raising the military volunteer age to 85 and a new game show called Canasta for Surgery, but I quickly see the possibly unpopular nature of these ideas.

However, I could argue that at least I’m offering ideas (however twisted) as to how to solve the problem posed by the CBO numbers. What we get from the people in charge of fixing it are recriminations about how everything would be great if the people on the other side of the aisle would just do it our way, plans to obliterate Medicare and Medicaid entirely or (as has been the case for the last 15 years) punting the problem down the road for someone else to fix. You will notice that none of these options remotely resembles a workable solution. We expect a high end pork loin from our legislation, and instead we get scrapple. I eat scrapple, but only because by the time I was old enough to figure out what was in it, I was already addicted, much like virtually every other thing that has been stuffed down our throats in this country over the past four decades.

At the time of his departure, I ruminated about Donald Berwick, the immediate past CMS administrator. Because one side of the political divide decided very early on that they would use Dr. Berwick for rhetorical target practice, Mr. Berwick remained mostly silent during his tenure as CMS Administrator, which ended back on December 2nd. No longer shackled by his office, Berwick has come out in favor of finding a comprehensive vision for the agency free of constant Congressional meddling, underfunding and chronic under-staffing.

In a widely disseminated article this week, Berwick was joined by a number of past employees of the agency voicing similar concerns, chief among them the fact that the average tenure of a CMS Administrator is 14 months. Given the staffing vacuum, it’s a wonder that any CMS initiative is introduced at all. CMS has 4,900 direct employees, with the balance of work farmed out to contractors (we all know my low opinion of MACs and RACs by now, I hope). Even counting the contractors, CMS’ staffing is dwarfed by the Social Security Administration’s 62,000 employees. To pay Social Security benefits, you wait until someone gets old, disabled or insane and you cut a check. Paying a Medicare claim is significantly more complex, but the government employs fewer people to do it, which gives us the abominable payment error rate of the program. Add on the dozens of health care initiatives going on at the agency right now, and we learn a new respect for the employees of CMS for trying as best they can to keep it all straight. If only the Legislative Branch of our government was as solutions-oriented, but there are TV cameras that require their attention.

Finally, I feel I need to respond to the lazy voices in the health information management community regarding my feelings on ICD-10. Among others in our field, I have raised the issue of our health care system preparing itself to step into a new paradigm of being left behind. After two decades of waiting, ICD-10 will be the standard sometime in the next two years (remembering that CMS has decided that they are delaying the October 1, 2013 compliance date). I suggested in 2008, and reiterated recently that ICD-10 should be skipped for ICD-11, given that the worldwide release date by the World Health Organization is now May of 2015.

The popular response to my suggestion, now being widely parroted by professional acquaintances, is three-tiered, with all levels of argument being  so devoid of logic, curiosity and self-awareness that I feel I must now openly mock them.

The first response I get is that ICD-11 is based on ICD-10, and we can’t introduce the former without the latter. This one is as easy to punch holes in as Glass Joe in the classic arcade game “Punch-Out“. Version 5010 of the X12 billing standard was mainly designed for ICD-10. If ICD-11 is based on ICD-10, what’s the problem with skipping? Second, the American Association of Professional Coders (AAPC) is warning coders not to become too familiar with the ICD-10 code set until we get close to implementation. If virtually no one knows how to code a claim using ICD-10 currently, than we are not faced with a Labor of Hercules to skip ICD-10 in favor of the the newer global standard. You need a better reason than perceived codependence to convince me.  

The second response sounds something like “CMS has so many initiatives going that are built around ICD-10 that adapting it is now inevitable”. As I pointed out earlier in this piece, CMS is understaffed. If the cost of waiting 18 months for the latest and best disease reporting system is that over-burdened CMS employees move on to other timely tasks, the inevitability argument begins to sound a lot like a cult preacher telling you that the end of the world is a week away and that he has something really tasty for you to drink.

Finally, there’s the third argument, which I’ll again puncture like the foil top on a bottle of antifreeze. There’s this belief that an American clinical modification of ICD-11 can’t be available until 2020. Bluntly, this is a lie borne out of acceptance of the current status quo in American Healthcare being the absolute best we can do. ICD-11 will include a clinical modification upon release. What the ICD-10 Final Rule was referencing when they put this idea forth was an industry-approved clinical modification which will enable insurance carriers of all types to more effectively deny claims. Given the long-standing abuses of Big Insurance, what provider advocate in their right mind would argue waiting for that?

Going from ICD-9 to ICD-10 with ICD-11 so close on the horizon has the effect of waiting in a line for 20 years for the expressed purpose of moving to another 20-year line. It displays the quitter’s mentality of someone who has given up asking questions and accepts things the way they are. As St. Patrick’s Day approaches, I know full well how good beer should taste. To those who’ve quit trying, I’ll ask one final question: what do defeat and red herrings taste like?

Paul Spencer will appear at the Fi-Med RAC Summit coming up on April 16th and 17th, 2012. Click here for more information about this unique education opportunity.

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12:02 pm, March 16th, 2012 | No Comments »

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The RAConteur: Lest We Think The MACs Know What They’re Doing…..

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

Categories:
The RAConteur™

A good comedy movie has a way of moving up my all-time favorite film list in a fashion that a drama cannot. Some of the movies on my list are either long-forgotten comedies such as Start The Revolution Without Me, or contemporary slapstick favorites like Dodgeball: A True Underdog Story.

For purposes of today’s posting, I offer another modern favorite of mine: Idiocracy. The plot of this movie centers around a semi-dullard in the Army who takes part in a top-secret project that will leave him in suspended animation for what he believes is a year. The project is forgotten and his hibernation pod opens up 500 years later to a world that has descended into chaos due to widespread rank stupidity. The protagonist is quickly discovered to be the smartest person on Earth by a wide margin.

There are two main reasons why I realize that there are indeed smarter people than myself in this world. The first is that I tend to share a long list of expletives with those in my vicinity whenever I try to build or fix something. The other is that as of yesterday, I’ve been married for seven years.

Yet this does not mean that I am at the bottom of the intellectual food chain. In fact, I can guarantee you that I could identify proof of at least one incredibly stupid action or statement every single day of my life somewhere in the world. We’re still early in 2012 and somebody impregnated Snooki from Jersey Shore, which goes a long way towards insuring continuing diminution of brain aptitude for generations to come.

Looking at the latest updates to the RAC issues lists, I found today’s example that is germane to the health care industry.

2010 was a less-than-entertaining year for the Medicare Physician Fee Schedule. Thanks to the unsustainability of the Sustainable Growth Rate (SGR) formula, political posturing and a series of temporary fixes, providers were faced with four fee schedules during the calendar year. The Medicare Administrative Carriers (MACs) were instructed by CMS to hold claims between all of these fixes due to Congress not fulfilling their legislative duties. Being the gatekeepers of Medicare claim dollars, it was up to the MACs to make sure that claims were paid properly. Over a year later, providers who had been underpaid on claims were still attempting to obtain proper reimbursement for their claims.

On March 5, 2012, more than 2 years after the beginnings of the Incredible Revolving Fee Schedule of 2010, Connolly, the Region C RAC, has now entered the fray with a related approved issue for automated review. Connolly is now reviewing all payments issued in the past three years by the MACs in their region for incorrect fee schedule application for carrier claims.

My biggest problem with the RAC process has always been that the wrong people were being punished for claim payment errors. Hospital providers have been getting bashed over the head with administrative burdens coming from the RAC contractors for very little payoff. The latest AHA RACTrac survey indicates that roughly 66% of all medical records reviewed by the RACs do not result in a determination of an improper payment. Hospitals are being paid pennies per page in copying costs for massive amounts of work that leads to no monetary benefit for the facility. In addition, roughly three-quarters of all appealed claims are still in the appeals process.

Still, after five years of activity through the Demonstration and Permanent RAC Projects, the MACs continue to escape the penalties of improper payments. This is despite the fact that the CERT error rate continues unabated with only slight declines, and the RACs having no shortage of improper MAC payments to explore. With Connolly Issue #: C002332011, the continuing incompetence of the MACs is at the top of the RAC issues list for all to see, and we have yet to hear Word One from CMS about what consequences they have outlined for the MACs for continuously churning out a substandard work product.

CMS wants us to eternally expect that claims will be paid by MACs incorrectly, with the consequences falling solely on the shoulders of the provider community. If these circumstances continue unchecked, no one will have to fall asleep for 500 years to wake up to find ourselves squarely in the middle of a rank idiocracy. In fact, as I look out at our current landscape, roughly 8 hours does it for me.

Paul Spencer will be appearing on “Monitor Monday” on March 19th. Click here for more information and to register for the broadcast.

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9:01 am, March 14th, 2012 | 1 Comment »

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Bad Timing is Sometimes Your Fault

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

Categories:
Industry Updates

In my never-ending quest for new information, I was listening to an interview yesterday on satellite radio with a gentleman named Dan Emmett. Mr. Emmett is a former Secret Service agent, and has written a book about the history of the agency and his time as a member. He shared an interesting tidbit about the beginnings of the Secret Service during the broadcast, namely that Abraham Lincoln signed the executive order creating the Secret Service the day before he was assassinated.

I do feel that I must follow up that factoid by pointing out that it wasn’t until 1901, following the assassination of President McKinley, that the Secret Service shifted their focus from rooting out counterfeit currency to presidential protection, but on the surface, the creation of an agency now dedicated to guarding the president happening within 24 hours of losing our 16th president to an assassin’s bullet points out the eternal problem of timing sometimes not being on our side.

Physicians that I come into contact with in my occupational life increasingly feel as if they are up against a wall. After 25 years of declining insurance reimbursement, physicians are being told that they now must implement electronic medical records (EMR), prepare for ICD-10 and accept a higher Medicaid population, all without an accompanying increase in revenue. In the case of primary care physicians, they are being asked to do this as they look behind them only to find that there are few newly-knighted physicians following in their footsteps, which is leading to higher numbers of patients in their waiting rooms.

Yet all of these changes are in the future. In the present day, governmental and commercial carriers are focusing on audits as a way to further constrict long-established revenue streams. It is easy to look at every dollar that is returned to an insurance company in this fashion as a poorly timed strain on the practice balance sheet, but we must remember the root causes of these audits taking place to realize how wrong that assumption turns out to be.

To begin with, if a commercial carrier is requesting records from you, something has happened that is your fault. Namely, your billing patterns have revealed you to be an outlier from your peers in the same specialty. The insurance company is taking a gamble that if your billing patterns skew higher that your documentation isn’t matching. If you’re either returning money to them or they are denying your claims prior to payment, they have guessed right. In this case, you can no longer blame the Demons of Bad Timing.

There are many new payment models coming down the pike, but every single one of them points back to your medical records. With EMR, the opportunities abound for payers to expand everything they know about you in a mathematical sense into the world of the clerical. As a chart auditor, I am seeing physicians who are falling into uncomfortable patterns of documentation to the point that I can pull two visits for two patients, go line by line and see virtually no difference between them. My readers should know by now that if someone like me can pick up that pattern, a government auditor of even moderate skill level can come into your practice and have a field day.

I do not have the ability to appear at every medical clinic simultaneously, and I can’t protect everybody. However, I would hope that I have accomplished one thing in the lead-up to the many reforms to come. I have tried not to be too much of an alarmist, but if I have encouraged just one provider to take a critical look at their documentation, then perhaps somewhere down the road there’s a doctor who’s timing has improved.

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11:03 am, March 9th, 2012 | 2 Comments »

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The RAConteur: Pummeling Them With Paperwork

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

Categories:
The RAConteur™

I enjoy inundating people with my large memory bank of useless information. I have inserted myself into a line of work that at first was not that interesting, but has now become an enabling force for my long memory. At moments in the public sphere, the presentation of arcane facts can be quite dazzling. When I’m at home with my wife, I usually hear, “I know; you’ve told me that before”. I desperately need new audiences for my material.

In the RAC universe, we are facing a new reality. Because demand letters are now coming from the MACs, the road map for the handling of disputes of RAC determinations has been redrawn. The new route can be best described as an interstate bypass.

Before it becomes a quaint memory of the past, I’ll remind the reader that the Discussion Period is an opportunity to provide additional information to the RAC to indicate why recoupment based on a RAC determination should not take place. This archaic piece of the process could have been useful going forward, were it not for the fact that Demand letters are now being received long after the RAC determinations, due to address issues within the HIGLAS system.

The rebuttal period, which was designed for the provider to show why a recoupment would cause a financial hardship, is similarly compromised by the new demand letter process. A rebuttal would need to be filed within 15 days of the date on the demand letter. Given that the demand letters now need to be hunted down by RAC coordinators nationwide, unless the 15-day window is expanded, the rebuttal period will die of neglect.

So here we are on the newly drawn road, left only with the Medicare appeal process. Because the overpayment redetermination period is our only path, it becomes important that the submission of documentation be correct from the beginning of the process. The commencement of the appeal provides the opportunity to pummel your MAC with paperwork, so long as it has at least been looked at prior to submission of the appeal.

Before the deluge, it is recommended that the documentation be reviewed to verify that the identified issue is legitimate. If after review, the RAC turns out to have been correct regarding the issue in question, it’s time to allow a recoup. If the RAC turns out to be wrong about the issue in question, you are not quite done. The MACs have recently displayed an annoying habit of reviewing the documentation, overturning the issue identified by the RAC, and then subsequently asking for a recoup on a previously unidentified issue for the same charge. This is your reminder to review the documentation thoroughly prior to sending the appeal.

After this review, if you believe you have grounds for appeal, I stand by the advice that I have dispensed to providers since the beginning of the RAC program, which is to open an appeal and defend it forcefully. The numbers remain on the side of providers until such time as the RACs demonstrate that they know what they are doing, which simply hasn’t happen yet. In the latest AHA RACTrac survey, hospitals reported appealing one-third of all RAC denials, with 74% being overturned in the provider’s favor.

All of the claim information, as well as the demonstrated value of persistence, show that the odds are on your side. CMS has virtually cut off the paths to discussion periods and rebuttals, but that doesn’t mean that you can’t make them suffer. If appeal is the only road available to you going forward, as Todd Rundgren once put it, “just draw a bead on that mother, and drive”.

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12:34 pm, March 7th, 2012 | 1 Comment »

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