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Yes, Medicare Does Make Mistakes

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance

At the root of my professional skills is that of a certified coder, which I have been since 1998. Anyone worth anything knows that coding, reimbursement and compliance are inextricably linked. I often tell colleagues in the coding realm that if you are not making a gradual transition towards compliance within two years of becoming a certified coder, you more than likely have chosen the wrong career.

The biggest problem I tend to have in this line of work is the volume of knowledge. I say “problem” because any person that I know in my personal circles who doesn’t happen to be connected to the healthcare field usually has absolutely no clue as to what is happening in health care until they themselves need treatment. That treatment moment usually becomes the time when I am called in to remold their medical bills from the origami crane shapes in which they now appear.

This post is specifically about a payment paradox that exists on a few CPT codes. It is something I discovered a few weeks ago, but am only now getting to due to travel schedules and hours on the telephone in a professional capacity.

Let’s talk about soft tissue tumors. These are little deposits that creep up in the subcutaneous skin layer that are removed most often by either dermatologists, plastic and reconstructive surgeons or general surgeons. The codes for the removal can be found under the Musculoskeletal section of CPT based on body area, and they are normally split into two codes based on the size of the tumor.

Having stated that, there is a catch. In most cases, due to CPT code reseqencing, the numerical code for the removal of a larger tumor is lower than that for the smaller tumor. Unfortunately, the problem doesn’t end there.

As an example, let’s use CPT code 24075, which is for the removal of a subcutaneous soft tissue tumor of the upper arm or elbow measuring less than 3 centimeters. The code that follows it in CPT is 24071, which is for a tumor of 3 centimeters or greater from the same body area.

Now, go to this link for the Medicare Physician Fee Schedule Search. Choose the bubble that says “List of HCPCS Codes”, and then the one somewhat below it that states “Specific Carrier/MAC”. Put 24075 in the box that says “HCPCS Box 1″, then place 24071 in the box that says “HCPCS Box 2″. Below that, choose the drop-down stating “All modifiers”, and then select your Carrier/MAC from the last drop-down. After that, click “Submit”.

The next screen shows you two disturbing things. The website has not only re-ordered your codes to show 24071 as the first code, but (and this should make the surgeons and dermatologists out there furious) the allowance for the larger tumor is roughly $100 less than that for the smaller tumor, depending on your MAC locality.

This pattern will repeat itself no matter which area of the body has subcutaneous soft tissue tumors. What I think is happening is that Medicare set the Work RVUs based on numerical order, rather than the actual amount of work involved with the procedure. CMS is not recognizing CPT resequencing, which is leading to providers being underpaid for their large soft tissue tumor removal expertise. 

Appendix N of the CPT code book contains the entire list of resequenced codes. I am a simple blogger with a lot on my plate right now, so I’m not going to go through all 100 codes on that list to find similar payment inconsistencies. I shall leave that up to an enterprising reader out there. The larger point here is that Medicare is the straw that stirs the drink with regard to reimbursement for services. If Medicare makes a mistake in setting reimbursement, that error is compounded by every commercial carrier who uses Medicare allowances as a baseline for setting a fee schedule.

At the very least, I hope dermatologists take to the streets with their scalpels and benzoyl peroxide and demand change. At most, I’d like to point out that just because Medicare happens to be the Irish Wolfhound in a room full of Pomeranians doesn’t necessarily mean that they always have the first and only correct answer.

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May 3rd, 2013 | 1 Comment »

The RAConteur: Beware of Government Geeks Bearing Gifts

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

As this space has been vacant for two weeks, I shall not bore you with the details of my absence, as it would demean us both. Instead, let’s jump right into the latest RAC-related utterance from CMS.

Since this takes effect in 5 days, I am hoping that my readers have had a chance to read CMS’ update to their medical record request limits for complex review. Since I have space to fill, I’ll provide the highlights.

First, the minimum number of requests per 45 days is being reduced from 35 to 20 for providers who have a calculated limit of 19 or less. This will be of minimal help to small rural hospitals who have been burdened by the RAC process, but when considering these types of facilities, we need to take additional facts into account. Small rural hospitals spent 3 1/2 years being abused by the RAC process to such an extent that many are operating on a financial knife-edge. The main reason for this is based on having neither adequate staffing to fight RAC determinations, nor the dollars to hire such staff. If you are in effect telling rural hospitals, “You now only have to pay us back for 20 inpatient stays every 45 days, rather than 35″, this does not fall under my definition of the word “improvement”.

The second change that is effective Monday has to do with the types of claims that can reviewed every 45 days. In a seeming compromise with hospitals facing a deluge of appeal activity for audit determinations on short stays, a Recovery Auditor may now only select a maximum of 75% of any one claim type during a 45-day period. To illustrate, if a hospital, based on its past financials, can have up to 300 claims pulled every 45 days, 225 of those could be pulled for inpatient claims, with the remaining 75 coming from any other claim type(s).

As the Trojans learned all those years ago based on their experiences with a certain wooden horse, gifts aren’t always what they seem.

It would be wonderful if a 75% cap on inpatient claims (primarily short stays) was based on the maximum number of requests per facility. Yet in the lead-up to this change, something odd was beginning to occur with some facilities. I have heard anecdotal evidence from facilities across the country who regularly appeal RAC determinations that the number of requests they have been receiving has been down from the maximum for a few months. As these stories rolled in, I chalked that up to the abrasiveness of the facilities in question with regard to RAC denials. My reasoning was that if the RACs see that they are in for a fight at certain facilities, the requests go down there and are maxed out at a hospital that won’t fight back. Thinking about this further, I may have been off the mark.

So, I am going to ask a favor of the readers. If you are at a facility who has experienced a recent downturn in ADR requests, let me know if you receive the maximum ADR request limit for your facility on any request you get after Monday, April 15th. If you have a long record of appeals, I am curious to see if the RACs were either keeping their powder dry for future battles with you or directing their cannons somewhere else.

One additional note on this CMS memo. While the minimum number of claims has moved downward, the maximum number of records that can be requested in every 45 days has not changed. It remains at 400, unless the facility has more than $100 million in annual revenue, in which case the limit is 600.

I’m always free with my opinions, so I’ll give you another one related to this latest change to the RAC process. Cosmetic surgery rarely succeeds long-term.

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April 10th, 2013 | 2 Comments »

The RAConteur: A Medicaid RAC Warning

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

Most of the industry coverage of government audits has been focused on Medicare RAC determinations, and with good reason. Nearly 40 months into the program, providers are now well aware of the substandard work product of the RAC contractors. However, the administrative costs of multi-level appeals, as well as for the provision of medical records, remain inordinately high.

On March 26th of 2012, CMS instituted a dollar maximum of $25 per medical record for reimbursement to providers forwarding requested additional documentation to a Medicare RAC contractor. This stands as the only direct remuneration to providers for the Medicare RAC process, save for any underpayments identified in audit.

The Medicaid RAC program, to put it mildly, is markedly different.

I received a comment on one of my postings from last week from one of my readers indicating that the Medicaid RAC program will not reimburse providers for medical records. Continuing the conversation offline, the reader provided me with a host of links from Medicaid RAC programs across the country stating that the contractors are not required to pay providers for medical records. This topic is distinctly absent in the Medicaid RAC Final Rule put forth by CMS.

Expanding my 24-hour search into the world of my professional contacts, it turns out the travails of this topic do not stop with the RAC program. Medicaid Integrity Contractors (MIC) are also not mandated to reimburse providers for medical records.

The prevailing argument that has been brought to my attention in multiple states is that the payment for provision of provider records for any Medicaid audit is included in the provider’s reimbursement for the original service billed.

With this information in hand, we need to take a step back and compare the Medicare and Medicaid RAC programs side by side. For the Medicare RACs, CMS sets the documentation request limits for all contractors. On the Medicaid side, it is much different. The Medicaid RAC Final Rule left it up to the states to determine the limits to documentation requests for providers. In addition, unlike the Medicare RAC program, Medicaid RAC contractors are not required to publish an approved issues list.

Just for kicks (because I’m just that kind of guy), I’ll throw out something else to think about. CMS was very clear at the beginning of the Medicare RAC program that if physician E/M services were to be audited, professional societies (such as the AMA) would be notified. I find no such language in the Medicaid RAC Final Rule. I now ask the reader to draw his or her own conclusion to that information.

It may be the most poorly kept secret in the world that Medicaid reimbursement is the worst of all major insurance carriers. The situation we are faced with right at this moment can be summed up in one sentence. Medicaid pays the provider community poorly, the payment includes the cost of sending records to any Medicaid audit entity, on the cusp of these audits, as well as the Medicaid population nationwide, expanding, and short of dropping out of your state’s Medicaid plan, there is nothing you can do about it.

Even if a provider has seen no Medicaid RAC activity as of yet, I must insist that the Medicaid RAC Statement of Work in your state be reviewed thoroughly. Know your RAC contractor, and begin a dialogue. Familiarize yourself with the Medicaid appeals processes in your state, as based on the provider-friendly overturn rates of the Medicare RAC program, mistakes will be many and often.

Most importantly, track the costs of providing records to audit entities and compare them to the reimbursement of the services audited for your Medicaid patients. If the two numbers are very close to each other, I would say that you, as an affected provider, have a very important decision to make regarding continuing participation in your state’s Medicaid program.

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February 20th, 2013 | 2 Comments »

The RAConteur: The Latest RAC Report to Congress

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

If there is one thing I can’t stand in the world of journalism, it is the alarming trend toward a lack of detail. Journalism is not about stenography. In a country with a “free press”, we must rely on people to not simply accept what they are being told. Journalists have a mandate to discover and report. They should look at the world with the eyes of Magellan, continuing to explore, challenge and report.

Recently, CMS released its Fiscal Year 2011 Report to Congress on Recovery Auditor Activity. Most of the press releases I have seen talk about the numbers, as if the only pages of the 41-page report that were reviewed were the two that dealt with collections and appeal numbers. None of these are remotely believable, let alone finalized, so I am going to ignore them. I feel it is important to look and read the entire report for findings that point to the continuing failure of the program.

The first thing that jumped out at me was on page 7. Under the heading of “How Recovery Auditors are Paid”. Like virtually everyone else who has wide exposure to the program, I was aware of the base contingency fee of 9 to 12.5 percent for the permanent contractors, but what I was unaware of was that this applies to all claim types except those for durable medical equipment (DME). The contingency fees for DME claims range from 14 to 17.5 percent.

This fact requires all of us to stop and think for a moment. One of the biggest areas of fraud in the Medicare program, which has been reiterated over several years and hundreds of OIG police blotters, is DME. Similarly, service specific probes undertaken by the MACs of DME claims have consistently reported inordinately high DME error rates. Seeing this, CMS has incentivized the RACs to go after improperly paid DME claims retrospectively with a 5% premium on the contingency fees.

If the current approved issues listings of the four RAC contractors are to be believed, this incentivization is being met with indifference. The approved issues lists are still made up of an overwhelming majority of inpatient hospital issues. HDI, the Region D contractor, currently ranks highest with 29 DME issues, while Connolly in Region C  brings up the rear with a mere 11. This is in contrast with CMS’ statement on page 18 that says “The CMS also continues to encourage Recovery Auditors to review all claim types”. Apparently, the RACs didn’t get the message about follow-through.

Perhaps the biggest outrage can be found on page 36 of the report. This is the page that shows the cumulative accuracy scores for the four recovery auditors. If we remember, the FY2010 Congressional Report had accuracy scores of 97.6 to 99.4 percent. What we knew at the time of the release of that report that these numbers strained all sense of credibility. Knowing that the number of outstanding appeals of RAC determinations number well into the hundreds of thousands now, the information on page 36 provides little solace. It is at least notable that the accuracy scores have gone down for every single Medicare RAC contractor, but the scores remain in an unbelievable range of 90.7 to 98.4 percent. CMS at least added information regarding how many claims were reviewed, with a post-script to the numbers stating “The sample size reviewed for each Recovery Auditor was between 1275 and 1300 claims”. Based on the fact that any one hospital that receives more than $100 million in payments annually from Medicare can receive as many as 4,867 additional documentation requests for complex review in a year, the claim sample size appears to be paltry in comparison.

The types of claims audited, as well as the entity that is conducting the reviews, was left out of the report. I asked CMS if the RAC Validation Contractor (RVC) was the entity performing the audits to determine the accuracy scores, as well as who is if the RVC is not. As of the release of this posting, I had yet to receive an answer to my question from CMS.

At the end of the day, the problem is not with the report, but the fact that only CMS submits a report to Congress. The more accurate reporting of RAC activity is coming from the AHA in their quarterly RACTrac report. Rather than CMS doing all of the talking on Capitol Hill, I suggest that the AHA get into the habit of sending their quarterly report to every member of Congress to counter CMS’ rosy picture of the program. There isn’t a single government entity that has ever existed that regularly admits to its own shortcomings. In a free society, it is left up to those of us who bother to discover, challenge and report. Despite being long separated by time and progress from Magellan, that process should never end.

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February 14th, 2013 | 1 Comment »

The RAConteur: Another Set of Gross Numbers

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

There is something about the American Public that reflexively loves achievement. As a group, we love a winner, especially if there is an inspiring back story. Part of the reason that we all fell for Lance Armstrong was the fact that he had been a cancer survivor.

Yet it takes quite a bit of hubris to cheat death and then follow it up by cheating at life. Now when ol’ Lance tries to play the cancer card to explain his actions, it rings hollow as an excuse for his less-than-savory post-illness behavior.

When the Recovery Audit Program was introduced, it was sold as a way to return improperly paid dollars to the Medicare program. The auditors would be considered as the good guys, because the end result would be the long-term sustainability of the Medicare program based on the millions of dollars returned. It represented the perfect pairing of our love for a good back story that also helps people far into the future. How could this possibly go wrong?

CMS recently released their latest quarterly report of RAC recoveries. We are now 13 quarters into the permanent program, and we have learned that these numbers amount to nothing more than a chest-beating gross, rather than a quantifiable net.

Health care websites are all abuzz with the fact that the RAC identified nearly $780 million dollars in improper payments in the first quarter of Fiscal Year 2013. As has been the standard, CMS did not put forth numbers regarding the number of claims currently being appealed, the number of claims per Medicare appeal level or the appeal success rate for providers. It would appear that the numbers put forth by CMS are gross in more ways than one.

With all of this in mind, I suggest the following course of action when CMS wants to beat their chest with patently false numbers such as what has just been released. Print out the newsletter, get a camera, hold the newsletter up to the camera, talk about what it is and then shred it while being filmed. After shredding the document, look straight into the camera and say “CMS, tell us the truth”. Once you have done this, post it to YouTube with the title “CMS RAC Myths”.

Public perception of a negative being a positive happens only because of an information vacuum. If the public learns about the administrative burdens that hospitals are experiencing simply to protect revenue from medical care provided long ago, perhaps the perception changes.

With the death by committee of the Medicare Audit Improvement Act of 2012, Congressional action on RAC abuses seems to be falling victim to other budgetary “priorities”. It is left to the grassroots to shine a light on the fact that the statements of billions of dollars returned to the program since the inception of the permanent program is a deliberate exercise in deception.

If you want some numbers that are closer to the truth, wait for three to four weeks for the latest AHA RACTrac data to be released. At the very least, it presents reliable appeal numbers, something CMS hasn’t done in any reliable fashion. We all love achievement, but as we have learned lately in the case of Lance Armstrong, it is best to achieve honestly.

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January 30th, 2013 | 1 Comment »

CMS’ Uncorrected Personality Trait

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

I’d like to start today’s Friday rumination with a small mental exercise for the reader. To begin, stand up in your cubicle, open your office door or look out the nearest window. Now look at the people sitting and working, the humans walking by your office door, or all of the people on the street either walking or driving their cars.

Now that you have done that, internalize this fact; every single person you have just laid eyes on has an uncorrected personality trait. It could be as minor as an irresistible need to wash one’s hands, or as major as having a family of immigrants imprisoned in their basement making opium pipes for export, but every single person has at least one. The reasons for this could be many, but I’ll leave it to Robyn Hitchcock to best describe how they got there in perfect three-part harmony.

My uncorrected personality trait is an inability to forgive. If I have made your acquaintance, even for as little as 30 seconds, and I enjoyed the interaction, you are basically my friend for life. However, if you do me wrong just once, I’ll carry it into the afterlife and do my level best to beat your eternal soul into the celestial ether with the nearest harp.

Since this is a place for healthcare musings, let’s focus on the uncorrected personality trait of the Centers for Medicare and Medicaid Services. As we learned from the Supreme Court this week, CMS has a predilection for never having to pay for mistakes to which it owns up.

This past Tuesday, in an unanimous decision (how often does that happen?), the Supreme Court ruled that provider appeal timelines for reimbursement issues cannot be extended beyond those already established. The case in question, Sebelius vs. Auburn Regional Medical Center, involved 18 disproportionate share hospitals who were found to have been underpaid to the tune of millions of dollars from 1987 to 1994. This mass underpayment was discovered as part of another lawsuit filed in 2006 regarding CMS’ process flaws in determining the number of low-income patients treated by hospitals.

The hospitals argued that because CMS failed to disclose the calculation error, the usual appeal timelines of 180 days or 3 years for good cause should be lifted. CMS countered that appeal timelines could not be extended, and the Supreme Court upheld CMS’ decision.

So to summarize, CMS failed to reimburse hospitals properly over a seven-year period, found out about it 12 years later, declined to rectify the error when it was found and the hospitals affected are now legally required to be stuck holding the bag for patients who had no ability to pay at the time of service.

Some of us have facial tics, some of us are slaves to ritual and some, like me, have an inability to forgive. Compared to CMS being one of the few entities in this world legally allowed to be a financial deadbeat based strictly on the calendar, all of our uncorrected personality traits combined pale in comparison.

Someday, in the lands far beyond, perhaps we’ll all discover how the employees of CMS who are responsible for Medicare payment rules feel about the blunt side of a harp.

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January 25th, 2013 | 3 Comments »

The RAConteur: Incorrect Thoughts & Impressions

Posted by J. Paul Spencer, CPC, CPC-H in RAC / Recovery Audit Contractors

As good as we all think we are, as shiny as our shoes appear and as much as we all believe we possess wisdom, we are all human and we make mistakes.

All along, I have been under the impression that the RAC contractors were mandated to conduct provider outreach for claims issues. Believing this to be the case, I even stated this in a public forum yesterday. I thank the people in that forum for stating that the RACs conduct provider outreach only to explain their “purpose and direction”. Outreach on claims and payment issues must be done by the MACs. My thanks to the people in that forum for the correction. In order to avoid confusing people further, my thoughts on the subject were deleted from said forum by my own hand.

Because many of us in the administrative side of health care have now been knee-deep in the RAC process for over three years, the minutiae of the program is certain to be know by someone, as I have learned. For the balance of the country, all they are hearing from CMS is the gross number of dollars identified as improperly paid by Medicare. What is not being accurately reported are appeal rates, appeal success rates, the level at which most of the successful provider appeals are occurring and – most importantly – the net amount that has been identified by the recovery auditors.

The public is being left with the impression that private contractors are identifying government mistakes. What they are actually doing is shining a light on the cockamamie payment methodologies for hospital services put forth by CMS and the circular logic the MACs use to defend the same. I remind the reader that this is being done with the idea that the monies returned to Medicare will fund health care reform. That, perhaps, is the ultimate false impression and the worst form of mistake.

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January 23rd, 2013 | No Comments »

The RAConteur: The Death of Improvement

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

After another week on the road in an undisclosed location, I return to my desk, separate the papers, prioritize the many projects coming up over the next few months, and bring the reader a brief RAC program update.

I appeared on Monitor Monday this past Monday (hence the name). During the final “roundtable” segment, one listener asked about the status of the Medicare Audit Improvement Act of 2012. I commented that there were co-sponsors that had since left the House of Representatives, but it actually goes further.

According to the Govtrack website, the bill was introduced on October 16, 2012. It was subsequently referred to the House Energy and Commerce Committee, as well as the House Ways and Means Committee. Due to the fact that there was no action taken on the bill before the end of the congressional session, the bill has officially died in committee. The bill lived for only 79 days. So long, we hardly knew ye.

The original sponsor of the bill, Sam Graves, who represents the 6th Congressional District in Missouri, remains in Congress. I would have liked to have contacted him and discussed whether the bill would be re-introduced in the current Congressional session, but because I don’t live in the northern 1/3 of Missouri, I can’t guarantee that I would ever get an answer.

With that in mind, I’d like to release a challenge to my readers. If you happen to live and enjoy the nightlife in Saint Joseph, if you know the roads of Green City, or if you happen to know someone who cruises the neighborhoods of Chula, have you or some “Show-Me-Stater” that you know contact Representative Graves and ask whether the bill will be re-introduced. In the spirit of Milwaukee, the first one to get a clear answer gets a free drink from yours truly (as soon as we meet face-to-face).

In the vacuum created by a lack of Congressional action, CMS is attempting to fill the void of information about the RAC program with news releases and memos that can best be described as self-serving distortions. If CMS is controlling the dialogue, the ongoing damage being put forth by the RACs on the provider community will continue unabated. We can either sit here as a group, commiserating and sharing experiences, or we can fight. Many RAC coordinators have reached the end of their rope and are primed to fight. Let’s start the fight with Congressman Graves.

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January 16th, 2013 | No Comments »

Sneaking Things In While I Am Out of the Country

Posted by J. Paul Spencer, CPC, CPC-H in Health Care Reform

I returned to work yesterday after a six-day sojourn in search of hockey. After driving 260 miles deep into Canada and back, I can say that I saw some amazing hockey and met some great people. I also saw Union Station in Toronto on New Year’s Eve, which you will all have to ask me about privately.

While I was unpacking my suitcase, Congress passed something called the American Taxpayer Relief Act of 2012. We already know the obvious result of this, as physicians did not see their reimbursement drop 26.5%, with hospital cuts making up the difference, but two sections that caught my attention appear consecutively on page 45 of the final bill.

In Section 638, a section titled “Removing Obstacles to Collection of Overpayments”, CMS can now go back 5 years, rather than three, to collect overpayments. The estimate is that this change will bring in an additional $500 million dollars or revenue.

This passage certainly raised the ire of RAC coordinators nationwide. CMS has been painting a false picture of the results of the RAC program by cherry-picking numbers and declaring RAC shortcomings as “myths“. In a late-night coup, CMS now gets to go back two more years to attempt to yank reinvested dollars from physicians and hospitals.

What is not getting sufficient attention is Section 639, which is going to increase the risk adjustment percentage paid to Medicare Advantage. I have covered in some detail in the past about how Risk Adjustment Validation audits have revealed that the Medicare Advantage carriers have been stretching the truth about the acuity of illnesses of their population. The reward for their behavior, aside from continuing Medicare Part C to the tune of billions of dollars, is a raise in the risk adjustment, which most times are found to be incorrect.

The idea of a “fiscal cliff” was nothing more than a deflection. For six weeks we heard about “the American taxpayer”, as if we had some kind of choice in the matter as to what would happen next. What actually occurred, based solely on Section 639, was that taxpayers got no relief and insurance companies bellied up to the trough for more money from our pockets.

I met some great people in Canada who were not shy about sharing with me what they thought about our political system. I also found out that I really like small-town hockey, Tim Horton’s donuts and the food dispensed by the Pizza Pizza chain. If while living here, I am going to be continually lied to about how our health care dollars are being spent, perhaps it is time to follow the lead of Congress and place my patriotism up for sale to the highest bidder.

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January 4th, 2013 | 2 Comments »

The RAConteur: Lacking Patience For Sloppy Work

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

This year’s Christmas was somewhat bittersweet for me.

My family made sure that I received gifts spanning both desire and much-needed utility, but one bit of news arrived over the wire services that put a damper on the festivities.

Jack Klugman, one of my favorite character actors, died on Monday at the age of 90. The obituaries that have been written over the last two days talk mostly about his Emmy Award-winning turn on “The Odd Couple” TV series, but for me, Jack Klugman will always be known for Quincy, M. E.

Looking at this show on DVD (I have three seasons at home) through the lens of 2012, this show seems like the height of camp, with a coroner running out righting wrongs and solving crimes at the drop of a hat when most coroners are glued to a stool over corpses. I do believe that it says something about my personality as an adult that when most kids my age (10-17 at the time it actually aired on NBC) were watching a string of stupid TV shows like Happy Days, I was watching Quincy.

However, when I break it down for my family and friends, I tell them that every tool I need for life, I learned from Quincy. Klugman’s protagonist would fight to the death for a cause that he believed in. In one case, fiction spilled into real life, as Klugman helped usher in the Orphan Drug Act in 1983 as an actual piece of legislation. Quincy would also always use science as a means to an end, which I am much more likely to do as an adult who lives free of organized religion.

Yet the most important thing that Quincy taught me was to have a short fuse for sloppy work. The “doctor without a first name” would spend a few episodes a year conducting secondary autopsies to find things that weren’t found by the first coroner, infuriating and shaming his colleagues, but ultimately getting at the truth. I carry this with me, and in this space, I carry anger and a particularly large chip on my shoulder for the RAC program in particular.

We are now a little over three years into the permanent program, and the RAC work product remains sloppy, inadequately substantiated and poorly executed. The provider community continues to be burdened by government contractors who are only familiar with CMS guidelines in passing. With regard to the RACs, they continue to focus on short stays at hospitals, which is nothing more than exploitation of a CMS guideline that is full of holes and poorly explained.

While I am on the subject of sloppy work product, I would be remiss if I didn’t mention the RAC validation contractor, Provider Resources, Inc. of Erie, PA. There is a severe disconnect between what PRI has stated about the accuracy of the four RAC contractors, and the information we are getting from the AHA on a quarterly basis as part of their RACTrac survey. Two federal fiscal years have passed since the last RAC report to Congress, but on the 39th and final page of that report, the RAC validation contractor’s accuracy scores for each individual RAC were listed. The average accuracy score was just under 99%. In CMS’ eyes, thanks to what could only be a shoddy method of determining RAC contractor accuracy, the RACs are doing an incredibly accurate job. In the eyes of hospital RAC coordinators nationwide, these numbers are high comedy and can be summarily dismissed.

If I could live my life exactly like Dr. Quincy, I would be bursting into offices one by one, raising my voice just below a scream, making wild arm motions and hand gestures and telling select employees of CMS and their contractors that what they are offering as “the best” isn’t good enough. It’s sloppy, underhanded, statistically questionable and threatens to create a health care system where the type of care being applied could be scientifically invalid based on some twisted theory about how facilities should be paid for the care of the sick.

As it stands, I’ll continue to use this space to call the RACs out on their methods, and my friends and family will continue to cringe whenever an incoming call comes into my cell phone, setting off the theme song to Quincy, M. E. as my ringtone.

The Fi-Med blog will be silent until Friday, January 4th as its writer goes on a week-long journey into Michigan and Canada in search of ice hockey.

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December 26th, 2012 | No Comments »

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