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The RAConteur: The Status of Medicaid RACs

Posted by J. Paul Spencer, CPC, CPC-H in The RAConteur™

There are times in my life when excessive quiet is unwelcome. Living two blocks away from a major metropolitan hospital is a challenge to the sleeping habits of others, but as a person who went to sleep this morning just after 3 AM who subsequently awoke around 7 for work, ambulance sirens have no effect on my sleep patterns.

There is one area of the government audit universe that has maintained an eerie quiet in 2012, despite the fanfare that accompanied its creation. The Medicaid RAC program, already harboring a secondary implementation date of January 1, 2012, continues to be plagued by delays in certain states. Yet through the silence, anecdotal evidence is beginning to filter out that the Medicaid RAC program has begun in earnest.

To date, information has reached me from two human sources that Medicaid RAC audits have begun in three states: Connecticut, Kansas and New Jersey. I am attempting as best as I can to determine what audit issues are being reviewed in these states, but I can relate that all three of these states have one thing in common.

HMS, who has emerged as a major player in the Medicaid RAC universe, is the Medicaid RAC for New Jersey and Connecticut. Kansas, which was the first state nationally to enlist a Medicaid RAC, has HDI, the Region D Medicare RAC contractor and a subsidiary of HMS as of late in 2011.

To date, HMS is the finalized or intended Medicaid RAC contractor or subcontractor in 18 states, with HDI handling Kansas under HMS’ corporate umbrella. For providers of all types, I would fully expect that Medicaid RAC activity will soon begin in the following states under HMS’ purview: Alabama, Delaware, Indiana, Maine, Michigan, New Mexico, New York, Oregon, Pennsylvania, South Carolina and Tennessee. These states all have finalized contracts with HMS, and based on its activity in Connecticut and New Jersey, it is reasonable to expect that the remainder of the dominoes will soon begin to tumble.

There are two states worth mentioning that are so far behind the Medicaid RAC curve that the futures of their respective programs is in doubt. In Arkansas, a Request for Proposals (RFP) for a RAC contractor was originally released in April of 2011. The responses to the RFP were of such a poor caliber that the state has declined to enter into a RAC contract. A similar situation exists in Texas, where CGI, the Region B Medicare RAC contractor was originally awarded the Lone Star State’s contract, but the contract was later withdrawn. Texas later issued a new RFP, but this was also withdrawn on May 8th.

Out West, Wyoming, Idaho, Montana and Utah continue to pursue a four-state solution for their RAC activities. Meanwhile, Minnesota and Wisconsin are considering the same type of group arrangement for Medicaid RAC issues here in the Upper Midwest.

Clearly, with so many states not mentioned above, it is safe to say that the balance of the states are operating in an eerie silence as the provider community awaits first contact with the Medicaid RAC process. At that future point in time, the sound of an ambulance siren will be somewhat redundant.

Click here for a recent interview with Fi-Med’s Jared Krawczyk regarding our data analytics capabilities.

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June 13th, 2012 | No Comments »

A One-Day Diversion To Music

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

The general state of the American health care system isn’t on my mind today.

Perhaps I am in the throws of an extended “information cool-down” from the Fi-Med RAC Summit that concluded on Tuesday. Maybe I am burned out on the hot topics of the day, which are the ICD-10 proposed rule and the Supreme Court deciding the fate of PPACA. It could be that I really didn’t want to get out of bed this morning on a cloudy, rainy day, as a day of sleep with my dog and cat nearby sounds better than writing about another study, opinion or semi-breakthrough in the world of medicine.

More than likely, it’s because I lost one of my musical heroes yesterday.

Those who have read my pieces in this space know that one of my bigger areas of interest is music, both listening and performing. Any musician with any value will look you right in the eye and tell you that they are only the sum total of musical heroes that have gone before. As a singer, I would be nothing without the previous vocal contributions of the likes of Tim Buckley, Van Morrison and Paul McCartney. As a songwriter, I wouldn’t have much to offer lyrically without the craft displayed by Richard Thompson, David Ackles, Graham Parker or Bob Dylan.

And then there was The Band.

When I was in high school, I was in an enviable position, as my high school had a functioning, licensed radio station. For two years in the early ’80s, I had the coveted Friday night on-air slot. While I have some regrets about not being on the air with my current music collection, it was a great laboratory for pointing me in the right direction in the realm of both listening and composing. I discovered the bulk of The Band’s catalog during those years, and as time has passed, I have come to consider them to be the greatest band that North America ever produced. They are also the centerpiece of The Last Waltz, the greatest musical documentary ever filmed.

In the middle of The Band’s music was drummer and singer Levon Helm, an Arkansas native tasked with keeping the beat behind four Canadians. On Tuesday, a notice was released to the world that Levon was in the final stages of his 14-year battle with cancer. Yesterday, that battle concluded. He was 71.  

I never had the chance to see him in concert. My friend Curtis did, as he states here. Yet having occupied a unique musical space for nearly 50 years, everyone who came across him had a story about his calming and welcoming presence that went along with his first rate musicianship.

My favorite story about Levon Helm has nothing to do with music at all. There used to be a morning DJ in Philadelphia by the name of John DeBella, who had previously been employed in New York. One morning, he told a story about having interviewed Levon Helm on-air during his days in New York. When the interview concluded and the microphones were turned off, Levon turned to him and in his gentlemanly Southern drawl said, “John, if you ever find yourself in Woodstock on a Sunday, just drop on by. We’ll have the game on”. Some time later, DeBella found himself around Woodstock, New York on a Sunday afternoon and thought to himself, “He probably doesn’t remember me, but what the hell? Let me try it”. He found Levon’s house in Woodstock, parked the car, walked up and knocked on the door. Levon answered the door, amazed and said “JOHN! HOW ARE YOU? COME ON IN! WE’VE GOT THE GAME ON!”.

There is a local band in Milwaukee called the Flood Brothers that do a mix of originals and covers. Sometimes, when I’m in the audience, they invite me up onstage to do a song, and invariably, the song we choose is “The Weight” by The Band. There are only a few songs in existence in this day and age that when played, the bulk of the audience feels compelled to sing along with the chorus. Mostly thanks to Levon’s vocal tone, mixing a storyteller’s care for narrative with a weariness of a traveler wanting only “some place where I could lay my head”, “The Weight” is a song that never gets old. The Flood Brothers play in town tomorrow night, and the urge is striking me to sing one more chorus.

Yet isn’t that the magic of all art, especially music? A song has a way of transporting you back in time to a moment when for a brief few minutes, it was the center of your existence. The listener never realizes that the song has just become a part of that person’s oral history until time passes. For me and my fan’s relationship with The Band, it is the vision of a 10-year-old kid, up late on a Saturday in 1976, watching the Band’s last television appearance on “Saturday Night Live” and listening as “The Night They Drove Old Dixie Down” spilled out of the television and into my mind for the first time, never to vacate since. At the center of the music was Levon Helm as drummer and one of three rotating lead and harmony vocals, presenting a story so seemingly real that I could picture him as a Confederate soldier. I remember buying The Band’s greatest hits on vinyl when my teenage years hit and being similarly ignited.

My childhood and high school days have disappeared with a combination of time, weight, acne medications and a pressing need to live in the moment. If the truth is told, all time prior to my introduction to my wife Leslie (half-Canadian; coincidence?) can be accurately described as my Dark Ages. Yet the music from as far back as AM radio in 1971 to the present day always resonates with a memory in tow in ways that my first encounter with a CPT book never can. Levon Helm has danced on the edges of my memory – consistently as a positive one – for over 35 years, and will continue to for many years to come thanks to his significant musical contributions. I am left with being able to only say “Thank you” to him from a distance.  

This space is supposed to be dedicated to medicine, so in order to satisfy that requirement, here’s a song by The Band about the early days of frontier medicine called “W. S. Walcott Medicine Show“. I bid Levon Helm a fond farewell with a special life-long thank you from my ears, and we’ll talk about things more closely related to health care next week. I thank the readers for their one-day exhibition of patience.

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April 20th, 2012 | 1 Comment »

Healthcare & The Value Of Memory

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

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

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

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

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

Oklahoma it ain’t……

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

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

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

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

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

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

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

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January 20th, 2012 | 1 Comment »