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Surprise! It’s A Sternly-Worded Letter!

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

Another birthday weekend is upon me.

This coming Sunday will mark yet another anniversary of my birth. Coming up on 46, for me birthdays are no longer a celebration of my birth, but rather another mile marker on the (hopefully long) highway leading to my cremation. This is a somewhat dark way of looking at it, but as one of my living musical heroes, Robyn Hitchcock, so eloquently put it, “God finds you naked and he leaves you dying / What happens in between is up to you”.

As I get older, I find that I am making less and less time for politics in my life. There are many reasons for this, but the biggest reason is simply that every politician that I come across on the state and national stage lacks imagination. Just once, I would like to turn on C-SPAN during a Special Orders session in the House of Representatives and see a member of Congress painting a seascape, singing a new song that they’ve written or doing an interpretive dance in honor of the planet Jupiter. It would assure me that at least someone with their hands on the levers of power had the ability to think outside of the box.

In the absence of my grand vision, we are left with the oft-repeated habits of the Beltway Set; grandstanding for the cameras, filling their pockets with lobbying dollars and (my personal favorite in terms of absurdity) taking advantage of Congressional free mail to fill people’s mail boxes with letters that combine the worst of the two previous activities just listed. So much for elected leaders representing “public servants” or the “best of the best”.

If it’s another week in Washington, then someone must have sent a sternly-worded letter, and this week’s is a doozy.

Anyone who reads my missives in this space knows that I have a dim view of government audits, mainly because they are shifting the blame for abuse in the system to the wrong people, namely well-meaning hospitals and physicians who have a hard time understanding federal rules of documentation and reimbursement. We all know who the thieves are when it comes to healthcare delivery, and pelting hospitals with thousands of requests for documentation per year rarely smokes these rats out of their lairs. Claims are paid badly by MACs and subsequently reviewed poorly by RACs based on complexity built into the system by CMS. Shifting the administrative burden of such a system on providers is short-sighted and does nothing to improve the care being administered.

With all of that being said, you would think that I would be in favor of this week’s sternly-worded letter from a subcommittee of the House Ways and Means Committee to Marilyn Tavenner, the Acting Administrator of CMS. After a short preamble, the letter asks for every statement of work, performance report, case referral and contractor fee paid relating to Medicare and Medicaid program integrity efforts for every contractor involved in such activities.

You should all know by now that I’ll sprint to the front of the opinion line to talk about government audits, and I have always been a fan of full disclosure. As it applies to the Recovery Auditor Program, every quarterly report that has been issued by CMS on RAC performance is either a collection of half-truths or (in the case of the first provider accuracy scores issues by the RAC Validation Contractor) bald-faced lies. I am encouraged that CMS will be called onto the carpet regarding RAC appeal rates, as any provider that has been affected by RAC audits can tell you that a look at that aspect of the program is well overdue.

With all of that being said, it helps to consider the source of the letter to CMS. Charles Boustany, the Louisiana Congressman who chairs the oversight committee has quite the revealing report when it comes to an analysis of his biggest campaign donors. The list includes Blue Cross and Blue Shield and an organization known as the LHC Group, a nationwide provider of home health, hospice and long-term acute care services. That list of LHC’s services looks a lot like the list of the types of providers often caught in the HEAT team net. In all, Congressman Boustany has taken in over $350,000 in campaign contributions from entities involved in health care, including nearly $170,000 from various factions of the insurance industry.

Whenever a legislative opponent mugs for the camera, they do so hoping for a knowledge vacuum by the viewer. This latest in a string of sternly-worded letters that bounce back and forth within the Beltway is part of the never-ending gamesmanship that has led to the system we currently have in place. If I believed that anyone in Washington, DC cared for my opinion, I would issue my own correspondence to those in power. I can guarantee that there would be just enough in every letter to anger everyone on both sides. I can also promise you that unlike this blog, it would be unexpurgated.

I am happy with the long-overdue demands made in this letter, but I simply know better than to trust this particular messenger. It takes no imagination whatsoever to take action simply because someone pays you to do so. Sometimes, you have to do it because no one else will and it is the right thing to do. By this standard, the letter is a failure.

So if you want an uncensored and uncompensated opinion, and you’re not doing anything tomorrow night, come out and celebrate my birthday at 7:30 and I’ll be happy to impart some wisdom, but take this latest sternly-worded letter with a grain of salt until we see a response from CMS.

The RAConteur: The .0001% Solution

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

Three thousand five-hundred miles and change later, I find myself back at my desk after a productive and enjoyable week off. For an ongoing summation of my time away, feel free to visit this blog. I promise that I spent my time in a mostly virtuous fashion.

I’d like to re-enter the discussion of the audit universe today with another in a stream of salient examples of corporate payola from the Medicare program. Last Summer, CMS launched a new predictive modeling computer system to pre-emptively stop fraudulent Medicare payments. The total cost of the computer system is estimated to be roughly $100 million, with $77 million having been spent thus far. Northrup Grumman and IBM are two of the main corporations behind the system.

As of the end of 2011, this grand investment has halted exactly one payment for $7,591. On a related note, there was a fly in my house the other day, so I called a company with a wrecking ball rather than reaching for a flyswatter.

Like any other human being, I like being proved right from time to time. I observe every governmental investment in something new and flashy through the lens of what’s in it for private enterprise. Being a citizen of a kleptocratic oligarchy, I have become far too used to industry skimming tax dollars out of the till for no apparent payback. We have all seen this with the rather poor RAC results after nearly 2 1/2 years of audits, with successful provider appeal rates still astronomically high. Given the reams of anecdotal evidence, it makes perfect sense to me that private enterprise gets a government check for very little demonstrated benefit.

I like things that work, and one method that has worked well among CMS’ many blind skeet shooting expeditions is human investigations. The Health Care Fraud Prevention and Enforcement Action (HEAT) Team continues to see tremendous success from their efforts. Through the first 8 days of February alone, the HEAT teams either released indictments or gained guilty verdicts against entities involved in roughly $139 million in health care fraud. Yesterday in Texas, an indictment was unsealed on seven defendants involved in over $375 million in either phony or unnecessary home visits. As part of the investigation into the physician at the center of the fraud, 78 home health care agencies found their Medicare payments suspended. I don’t know about you, but this represents success to me. I’m fairly certain that the payroll of the government-employed human investigators is significantly lower than $77 million.

The deputy director of Medicare’s anti-fraud program called the act of judging their efforts solely from payment suspensions as “unsophisticated”. I find this wording to be alarmingly typical of the institutional arrogance I encounter as a citizen whenever I ask questions about why someone is being paid by tax dollars for providing nothing. Predictive modeling, if designed properly, holds great promise. Yet if the brains of Northrup Grumman and IBM can’t get immediate results in the year 2012 right out of the gate, it bears asking, “who can?”.

When all of the checks are cut, Medicare is in need of much better than a 1/10,000 return on investment.

Paul Spencer will be presenting at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Visit the Summit website for further information.  

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.

2011: Push It Down The Well Already!

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

When I open any reputable history book, the first thing that strikes me is the names of people who have existed and made an impact in history. There is an old quotation of unknown origin that says “May you live in interesting times”. Certainly, there have been those that have fulfilled that saying to its utmost.

While I occupy what is a very small space in the world of mass communication, and despite the fact that my science-based belief system automatically precludes me from thinking that my words have very little long-term impact in the grand universal chaotic scheme, I am ready to make the following pronouncement based on facts in evidence.

I do not live in interesting times, for fascinating eras cannot possibly contain this many stupid people.

Unlike all of the promising black-and-white documentaries of yesteryear, where the future promised technological convenience, helicopter commuting to work and (in general) faster ways to become as least as smart as the briefcase-carrying regional sales manager of 1954, the modern times that have appeared in front of me features a cornucopia consisting mostly of dullards, the willfully ignorant and neo-neanderthals of every size, shape and creed.

I am far from my idealized world of Buckminster Fuller, populated by efficient 3-wheeled cars and modest housing that allows everyone to live in a confined space comfortably and equitably. I am in the opening scenes of 2001: A Space Odyssey, where the lead Cro-Magnon finds a bone and instead of using it as a rudimentary tool to grind corn into flour, can only think to use it as a truncheon to beat the life out of his enemies on the other side of the creek.

In the past, I could ignore this empty-headed herd for two reasons. First, in days gone by, these people usually congregated in places where I never appeared, such as drunken bar fights, floating crap games and (such as those that occurred around the corner from my house in a public park in Wilmington, North Carolina  in 1974) cross burnings. Second, I slept fairly well at night, believing that there existed reasonable people to show us that there was indeed a common good worth fighting for, despite the randomly spewed venom of the wrong-headed minority.

In 2011, we showed no promise of cultural evolution to a higher standard. Instead, as a society, we stood and watched as the rightfully maligned slack-jawed yokel of yesteryear grabbed the keys to the car, passed out drunk from moonshine and drove the Car of Country off a cliff.

The end of December is usually a time when the news reflects on the twelve previous months of the year, marking seminal milestones, important events and offering a final toast to those who have gone. It is enough to make the modern network news anchor, complete with high, wavy hair and a teleprompter full of words he or she can read but cannot comprehend, a little misty-eyed. Does anyone else remember when Ted Baxter was the parody of an anchorman and not the shining example?

There is absolutely no reason to miss 2011 if you live in the United States. To begin with, no one in power, or for that matter anyone currently seeking either to keep it or obtain it for the first time, is representative of the term “reasonable”. A large swath of the voting public began the year by inviting roughly 200 barefoot ignoramuses into the halls of power in Congress fresh from some far-flung philosophical manure field. That same voting public is now stunned to discover that the carpets are indelibly ruined. This is the Spalding Guide demonstration of the idea that people get the government they deserve.

I usually cover health care issues in this space, so I cannot possibly complete my thesis on mass inanity without giving a mention to Medicare Administrative Contractors and the blind stumblers in a roomful of rearranged furniture that are the Recovery Audit Contractors who attempt to fix their numerous mistakes. Then there’s the American Medical Association, who decided that nearly three years after the issuance of a Final Rule on ICD-10 from CMS was the perfect time to fight for a different implementation date. Finally, let me raise a glass to all the Medicare crooks that have been nabbed by the HEAT teams this year, for these people suffer from an acute infection from a special mutated strand of the Idiot Virus known as the Thieving Moron Flu (scientific designation: URTM-1).

Tomorrow night, I am not going to tearfully say goodbye to 2011 as if I was attending a wake. I am going to be home with my wife, eating the last bad food of my life before attempting once again to lose my extra 35 pounds of body weight beginning on Sunday, drinking well-chilled beers from my refrigerator and spitting on the grave of 2011. This past year was neither interesting nor memorable. It should be held up as the shining example of everything you can do wrong to a society and its people. It should be mocked, stripped naked and kicked out the door for these last hours to perish of frostbite as it wails and gnashes its teeth. 

To paraphrase Bette Davis’ comments upon hearing of the death of Joan Crawford, you should never say bad things about the dead. You should only say good. 2011 is dead. Good!

The RAConteur: Are We Looking In The Wrong Place?

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

It’s time once again to look at some numbers.

Being so close to reaching the end of yet another calendar, this is the traditional time when all entities take a step back and talk about what they’ve accomplished in the last year. Since it’s one of my favorite topics, let’s take a look at government audit activities. As is my custom, I’ll also be happy to tell you what the numbers actually represent.

I have already covered the reported numbers for RAC activity for Fiscal Year 2011 in a previous post. For today’s missive, I thought I’d focus on three sets of numbers that came out of the Executive branch over the past month.

Let’s start with a big number. On the 15th of November, the Office of Management and Budget (OMB) announced that agencies throughout the government cut improper payments by $17.6 billion. Roughly $1.1 billion of this money came from reductions in the payment error rate under the Supplemental Nutrition Assistance Program (or “SNAP”; I grew up calling this “food stamps”) and Pell Grants for higher education, but the balance overwhelmingly was under the different branches of the Medicare program, with a cumulative savings of $12 billion from Medicare Parts A, B & C. Isn’t it amazing that faulty bombers costing billions are allowed to let slide, but the government’s anti-fraud focus is squarely on activities such as eating, wellness and making yourself smarter?

Next, we go to money collected due to government-wide anti-fraud efforts. On December 13th, another report was released with great fanfare by Vice- President Joe Biden which showed fraud recoveries totalling $5.6 billion across all agencies. To add to this number in the coming year, HHS is asking Medicare Part D plans to crack down on painkiller fraud, notably excessive prescribing of OxyContin. If the way people drive in front of me is any indication, these should be target-rich investigations. 

Which, thanks to the inevitable trickle-down, brings us to anti-fraud efforts for CMS. Over $2.9 billion dollars in fraudulent payments was recovered in Fiscal Year 2011. Over $1 billion of that total has come from the HEAT team activity that was expanded to nine cities during the Fiscal Year. I am critical of audit entities in this space for not showing the proper aptitudes in their tasks, but as a taxpayer, I am 100% in favor of the HEAT team approach. The providers that are being perp-walked by these joint HHS-Department of Justice strike forces are literally scum-of-the-Earth thieves, and there shouldn’t be one person in their right mind bemoaning the fact that they are taken off the field in a HEAT dragnet.

Going further, the government announced that $2.8 billion in fraudulent payments had been collected from qui tam, or “whistleblower” cases, which stands as a new record for such suits. Of that number, $2.4 billion was the result of fraud committed against federal healthcare programs. The number of whistleblower suits reached an all-time high of 638 in FY2011. As people begin to know the rules, they become more likely to realize that what is going on around them is illegal. As a compliance officer, I can tell you that this can be either a good thing or a bad thing, depending on the person doing the finger-pointing. It is yet another salient reminder to make sure that all employees in organizations that receive remuneration from Medicare know why things are happening. If they don’t, they should always be aware of the reporting structure for problems within your organization.

If you haven’t internalized the idea by now, let me reiterate it. It’s a new world out there. Medicare checks suddenly have quite a few more strings attached than they used to at the beginnings of the program. There’s is a lot more to worry about, and loading up on Tums isn’t going to make the issues disappear. The numbers above keep getting larger. Do your best to make sure that future numbers such as these affect someone else.

The RAConteur: The Long Autumn Begins Early

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

Since I’ve moved to the Midwest from my homeland of the East Coast, I have become much more accommodating. This morning, on my way to the office, I was in the right-hand lane of traffic next to an exit ramp. A driver was coming off the exit ramp into the slight congestion that lay beyond. She stopped in the middle of the exit ramp, and I allowed space for her to pull in front of me.

Ten seconds went by, then twenty, then thirty and the driver sat there, seemingly unable to comprehend that a space had been made available to her. Perhaps she believed it was her moment of rapture that would sweep her into the sky on a flaming, Pegasus-drawn chariot to a magical spot 10 feet from her destination, but she wasn’t moving. I briefly revisited the colorful language I tend to use when behind the wheel and left her in the dust.

With some people, it doesn’t matter how many times you wave your hand, fire warning shots or shout “LISTEN TO ME!”;  no warnings are heeded and those who put forth alerts are left to view the consequences from afar. As a person who documents the progress of government audits in this space on a weekly basis, I know this feeling all too well.

While I tend to focus on recovery auditor issues on Wednesdays, a press release hit my inbox this afternoon that reminded me that this is far from the only effort to stamp out fraud and abuse in the Medicare program.

The Departments of Justice and Health & Human Services jointly announced the latest charges from the HEAT team initiative. Ninety-one individuals in 8 cities were charged for their participation in fraud schemes that resulted in roughly $295 million in false billings.

While these numbers are gaudy based on their scope, the HEAT initiative has been busy since its inception, having charged individuals with nearly $1 billion in false claims billing.

In the meantime, the recovery auditors have been ramping up operations almost exponentially. CMS set an aggressive goal of identifying nearly $1 billion in improper payments in the calendar year of 2011. Through nearly three quarters, the contractors have identified just short of $700 million, which means that over $300 million will need to be collected between now and the end of the year.

Today’s news from the HEAT team, as well as the aggressive goals yet to be achieved by the RAC program, are CMS’ attempt at firing warning shots. I am seeing that larger organizations are getting the message, but much like the car I left behind this morning, smaller providers may find themselves having a hard time dealing with the traffic of investigation if they don’t start paying attention as the warmth of Summer gives way to the Autumnal Death Cycle.