Being a natural skeptic, I live by a central belief that based on the innate failings of humankind as a species, to attempt to live by a belief system written in any form by the hands of a human being is a waste of time. Additionally, anything new in written form should be regarded as highly suspect. This is not to say that I am a nihilist, as we (hopefully) all read Fathers and Sons by Ivan Turgenev, and we all know how adherence to that belief system turned out for Bazarov (I never said I didn’t read and digest fiction).
December is a special month when it comes to government healthcare reporting, and the past ten days brought forth a holiday season cornucopia full of chest-beatings, distortions and half-completed projects as it relates to Medicare “Integrity” efforts.
I’d like to rewind to the OIG’s Semiannual Report to Congress. The OIG reported $6.9 billion in “recoveries”, as well as $8.5 billion in estimated savings. Those are rather lofty numbers, so let’s take another look at what the OIG actually uncovered.
With regard to the recoveries, more than half of that total involved the illegal marketing and promotion of prescription drugs by two pharmaceutical companies. This is important to point out for two reasons. The pharmaceutical industry is making a killing on Medicare Part D thanks to the Billy Tauzin kickback that states that the government must purchase pharmaceuticals using average sale price. rather than the much lower average wholesale price. It’s once again simply wonderful to know that my tax dollars are being spent to subsidize aberrant corporate behavior. The second reason comes down to a simple conclusion. If more than half of your investigative recoveries come from those not involved in the direct delivery of health care, could it be that the constant “fraud” spotlight on doctors and hospitals needs to be redirected?
As for the “estimated savings”, if you look at all of the issues, from finding 1,700 physicians billing at a higher than expected E/M level to the 51% overpayment rate on vacuum erection systems for male impotence (you knew I would cover this in this blog) point back to what I have been telling anyone who will listen for years; the Medicare Administrative Carriers (MACs) are paying claims improperly and there are no consequences to their actions. Finding the savings are obvious with the slightest bit of deductive reasoning, but sometimes the solution doesn’t rely on redesign, but rather the threat of a hammer.
Since it’s RAC day here, let’s talk about the latest quarterly whitewash reports regarding RAC results. If we were to believe the latest quarterly RAC newsletter, the RACs collected $648 million in overpayments, with HDI-brought-to-you-by-HMS in Region D responsible for 37% of that total. That brings the total to $2.4 billion for Fiscal Year 2012 and nearly $3.5 billion over the 3-year life of the program, according to a second newsletter.
Once again, CMS has no reliable numbers regarding either the number of claims currently under appeal, appeals finalized, those appeals found in favor of the provider or the dollar amount returned to providers after successful appeal. These quarterly missives make for a great self-aggrandizing press release for CMS in the same fashion as a press conference featuring a single survivor of an Andean plane crash who was found four months after the crash and hearing this individual state that he only ate the women in order to survive.
Yesterday, the Justice Department sent out news stating that $4.9 billion was collected involving government fraud for FY 2012. When we scroll down to the Health Care Fraud section, we find that most of the money identified is from the two drug companies identified in the OIG Semiannual Report from a few paragraphs ago. Of note is the fact that 647 qui tam whistleblower suits were filed during the fiscal year, with $3.3 billion collected from such suits in the same period. As a compliance officer, the biggest responsibility I have is explaining why processes occur the way they do in order to avoid these types of filings. If your business model is shady, you deserve this kind of employee activity, but on-the-job teaching goes a long way.
Finally, we come to something from the OIG called the Compendium of Unimplemented Recommendations. This used to be known as the Red Book once upon a time, but post-traumatic stress disorder used to be called shell shock, so are you really surprised that something else in this world is now more complicated?
Here’s how unimpressive this particular report is as anything but as a doorstop. Of the 28 recommendations detailed under the headings “Avoid Wasteful Spending” and “Identify and Reduce Improper Payments”, 18 have a conclusion stating ”Savings probable but not estimated”. In short, the OIG did one very narrow review of a questionable payment issue, came up with findings pointing to significant savings, but are unable to quantify it beyond the realm of probability. I’ll give you an equal example, just to show my brilliance as compared to the OIG. Sometime in the future, on any given roulette wheel, someone will land on the Green zero, and the amount of the payout will vary based on the bet. For this display of brilliance, I’ll expect my first government pension check next Friday.
As Ben Franklin once stated, and Gladys Knight & The Pips later paraphrased in song (I prefer this version, as it’s got soul!), “Believe half of what you see, and none of what you hear”. In matters related to government reports, the percentage of belief in what you see is directly proportional to the level of information presented. In the cases of these reports, the percentage plummets from half to near-zero. From my comfortable spot in the skeptic’s world, I could have told you so.