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The RAConteur: A Tale of Two Timelines

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

There are only two issues in which people in every country and culture can universally agree upon. The first of these is “My government is doing something wrong”. I’ll give you the second one later in this posting, but I want to focus on this one primarily.

The reasons for citizens of the world universally thinking that their governments are incompetent vary as you cross international borders. In Greece, economic policy intrudes on their enormous amount of free time. In North Korea, the food supply could be more plentiful, but given the personality cult that exists in their government, no one dares to speak to that issue while still a citizen within its borders.

American citizens have complaints about many government agencies, but all of them stem from an overarching idea of fairness, which, after all, was the reason we picked up guns and consciously decided to extract the imperial arrogance of 18th Century Great Britain from the continent.

When it comes to Medicare, there is one area where fairness has been completely tossed out the window. I speak of the Medicare Appeals Process. While the RAC process has cast a spotlight on the seedier side of appeals, a challenge from another corner of the Medicare universe reared its head recently with the potential of altering the balance of power in the appeals process.

The Supreme Court heard a case back on December 4th in which Auburn Regional Medical Center, a disproportionate share hospital (DSH) in Washington state, sued HHS for additional funds it felt was owed after a 2008 court ruling determined that CMS’ calculations of such payments were flawed and needed to be adjusted in the DSH’s favor. CMS argued that the 180-day filing deadline for appeal had passed and that the hospitals involved could not challenge past incorrect payments beyond the deadline.

The relief being asked of the Court is referred to as “equitable tolling”, which states that the statute of limitations will not bar a claim if a plaintiff, despite due diligence and best efforts, did not discover the inequitability until after the expiration of the limitations period. The Department of Health and Human Services is vociferously fighting this idea from the other side.

In oral arguments, the justices appeared to be confusing the 180-day provider appeal deadline with the 3-year “good cause” rule utilized by CMS for reopening claims for audit (a time frame that CMS has stated they would like to expand, by the way). I’d like to leave the idea of “good cause” on the shelf, as everyone knows how I feel about that. I shall state categorically that if the 9 justices at the end of the legal road, tasked with interpreting the law, can’t get the facts behind Medicare reopenings straight in oral arguments, doesn’t that speak volumes about the statutory morass that is Medicare?

In a friend-of-the-court brief, the American Hospital Association stated that equitable tolling was necessary in order to give providers “the opportunity to obtain relief from the agency’s errors”. I find this to be the most profound of arguments, as CMS has been far too lax in penalizing their own contractors for poor performance. Payment integrity should be a two-way proposition, and to date, that simply isn’t the case. From the MACs, who consistently pay claims incorrectly without consequence, to the QIC contractors who rubber-stamp MAC appeal denials, to the RAC contractors that wouldn’t know what constitutes ”medical necessity” if it walked up and punched them in the nose, it can be rationally argued that CMS’ payment integrity problem exists mainly under its own umbrella.

If the Supreme Court affirms that the current inequity between the rights of providers and the rights of CMS continues, it should give providers pause. After all, the second thing that all cultures and countries can agree on is the horror that is necrophilia, but there are ghastly similarities between this abhorrent practice and your typical retrospective RAC audit. Without equity of reopening rights, nothing short of a revolt will stop the ongoing retroactive economic despoiling of this nation’s hospitals and doctors.

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December 19th, 2012 | 1 Comment »

Short Week, Short Thoughts

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

Tomorrow, we again celebrate Thanksgiving, a yearly commemoration of that moment in 1620 when puritanical Atlantic travelers came to the shores of a new continent and begged the indigenous people to help them survive the winter. I believe that one of my favorite songwriters, Graham Parker, explained best what those helpful natives received in return.

For me, the extended holiday weekend will be followed closely by another journey to the ever-popular Undisclosed Location. I shall do my level best to check in from the road, but in the meantime, as is my custom, I’ll leave everyone with something to chew on that doesn’t resemble either turkey or some harvest vegetable medley.

Yesterday, the Department of Health and Human Services released their proposed rules regarding essential health benefits, insurance market reforms and employer-sponsored wellness programs. These proposed rules are related to the Patient Protection and Affordable Care Act.

The portion of the news release being touted by most analysts has to do with the idea of pre-existing conditions disappearing as of 2014, but the portion of this proposed rule triad that caught my eye had to do with what can affect your insurance coverage and premiums if the proposed rules are accepted. According to the text, the only valid reasons for raising health insurance premiums would be age, tobacco use, family size and geography. If an insurer wants to raise premiums, there are ratios and limits to the envisioned rate hikes

The first three items on that list make sense. Old people, seeing as they are in the waiting room of the afterlife, make more demands on our health care system. Smokers have every right to puff away, but based on the acceleration of chronic illness tied to long-term tobacco use, it’s time to pay up. As a married father with one child in the household, I would expect to pay a lower insurance premium that the hyper-fertile Duggar family or others like them.

We are left with only geography. Page 32 of the proposed rule on health insurance market rules, as I read it, may very well contain a poison pill for states that have tipped their hand and stated flatly that they plan neither to expand Medicaid nor set up a health insurance exchange.

The rule talks about setting up “rating areas” within states that take into account cost of living and utilization. The rule proposes that a state can set up a maximum of seven areas within a state. HHS offers three methods of setting up rating areas in a states;

  • Setting up one rating area for a state (this makes sense for a state such as Wyoming, the population of which is less than the City of Milwaukee, where I live);
  • Setting up by either county or 3-digit zip code; OR
  • Segregating urban areas from the rest of the state.

 

There is a statement that piques my curiosity that concludes the description of these methods. The proposed rule states that it “makes no distinction between insurance coverage offered inside or outside an exchange, so these rating areas would apply equally to all non-grandfathered coverage in the individual or small group market”.

Now that’s a dirty trick! A state can set up rating areas, but if it decides on its own neither to set up a health insurance exchange nor expand Medicaid coverage, it may have the effect of punishing everyone else in the state, regardless of rating area, with higher premiums. Worse yet, if hospitals are asked to absorb the costs of extensive uncompensated care in their state due to a lack of Medicaid expansion within their borders, a hospital will either close its doors, hike its rates or cut back essential services, with none of these options being a benefit to the portion of the population paying insurance premiums for access to health care.

Much like what appears to be a nice Thanksgiving dinner between family, friends and new acquaintances, the rose-colored theory of peaceful coexistence is challenged by details. It may not be as violent as the wholesale slaughter of native populations that came with Western expansion, or as sloppy as your drunk uncle throwing back Canadian Club on the rocks and making politically incorrect comments about football players, but threats to the norm take many forms. If the proposed rules stand, states without health insurance exchanges or expanded Medicaid coverage may face a revolt from people who now believe that they stand unaffected by “Obamacare”.

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November 21st, 2012 | No Comments »

Checking In From The Road

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

As I type this, I am in a semi-famous fast food restaurant in the middle of an extended road trip.

It started last Monday, September 17th, as I was fortunate enough to be a presenter at the 13th Annual Coding, Billing and Practice Management Symposium that was presented by the Wisconsin Medical Society. As those who were not in attendance could probably guess, the subject of my presentation was current government audit trends. There were some surprised looks among the attendees of my session, but I left a presentation of this type feeling that finally, the message was getting through to the physician population that complacency is not an option. As with past visits to this yearly pilgrimage to the Wisconsin Dells (complete with time on the water slides; I have a 6-year-old-son, but I only use that as an excuse as I’m a sucker for amusement parks), the experience was fantastic, and the sidebar conversations during the conference were fascinating.

This was followed by vacation. I traveled for 12 hours by car to my friend Steve’s home in Marietta, Georgia to complete the recording of an album I began work on back in February. I am happy to report that it is complete and awaits packaging and “wide” release. The music contained within won’t be to everyone’s taste, but I can assure those interested in purchasing the finished product that it will contain enough material to kill 37 minutes that you may have available.

After arriving back home on the 24th, I immediately returned to the road for three days of visits to an undisclosed client in a similarly undisclosed location. I have learned two things during these past three days: first, that extended hotel residency is an acquired taste, and that you have to be out of your freaking mind to believe anything that is reported on any cable news outlet, particularly in a presidential campaign season in the United States. Never in my life have I so longed to break out my DVD collection of episodes of Quincy, M. E. Yes, I hear you all snickering, and I don’t care, for Jack Klugman rocks!

While I was away, I was rather unsurprised to see that the Health and Human Services Secretary and the Justice Department issued a joint letter to the heads of five healthcare associations stating that “EHR fraud will not be tolerated”. We are probably all familiar with the scene in Ghostbusters where Dan Ackroyd’s character has a random thought and inadvertently chooses a giant marshmallow man as “the method of destruction”. Thanks to the current healthcare landscape, it appears that physicians have selected their electronic medical record system as their particular method.

Like many in this industry, I have grown tired of CMS, in concert with the remainder of the Executive Branch of our government, continually resorting to strong-arm tactics when it comes to the billing of services, rather than attempting to educate the provider community in a meaningful way as to what constitutes a “tolerable” way of doing things. In the world of CMS, there appears to be no such approach as “the carrot and the stick”, but rather an approach akin to “the stick and the 42-ounce Louisville Slugger utilized by Babe Ruth”.

Here’s a relevant example of what I just mentioned. The Medicaid Integrity Program was designed to be threefold, with different contractors (or “MICs”) handling different portions of the program. The review MICs pick the audit sample, the Audit MICs audit from the selected sample, and the Education MICs are supposed to provide outreach to the provider community based on audit findings. To date, I am hard-pressed to find any evidence that the Education MICs have addressed their task order in any meaningful way. Instead, the provider community gets audited, old revenue is forfeited, and the band on the Titanic plays on.

I can tolerate a lot of things, such as fast food on a Thursday afternoon, or cable news commentary or even a 12-hour drive to Georgia in the middle of the night undertaken for the purpose of singing. What I am having a harder time stomaching is an audit approach that stems from the need to punish, rather than the need to improve. As the need for TUMS sinks in from the roast beef sandwich I just consumed, I can promise the reader that I’ll continue to help physicians fight the good fight against this audit environment, but much like my time away from home, no one road goes on forever.

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September 28th, 2012 | No Comments »

The RAConteur: Another Opinion on Government Audits

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

Given the increasing incompetence in our society, I feel that with each passing day there are more jobs that I myself could perform. Yet there is one exception, and that would be the job of sports referee. It takes either a special level of off-the-chart arrogance regarding your own skills or a deep-seeded self-hatred to be a referee. Every decision that a referee makes guarantees that one-half of the participants in the sporting contest will come away hating you.

In the world of government audits in the last week, we heard from one such policy referee, that being the General Accounting Office (GAO).

The GAO is officially the investigative arm of Congress. It operates as the actuarial governor on Congressional legislation, reviewing the receipt and payment of public funds to gage the financial impact of legislation. Much like a referee, the reports released by the GAO tend to briefly alienate political factions based on whether the reports fit a particular party narrative. A report released last Wednesday was no exception.

The GAO chastised the Department of Health & Human Services for not implementing past recommendations to reduce improper payments from the Medicare program. The most prominent of the GAO’s recommendations was CMS demanding automated prepayment edits of the Medicare Administrative Contractors (MACs) in order to identify improper claims. This recommendation was first brought forward in 2007 and remains an elusive goal.

In addition, the GAO wants to see payments to Medicare Advantage plans to reflect the correct health status of the beneficiary in question. Risk Adjustment Data Validation (RADV) audits have revealed that the Medicare Part C plans have been claiming more dollars than they are entitled to based on patient condition, so this GAO recommendation should gain some traction. In addition, the GAO wants to see the current Medicare Advantage Quality Bonus Payment Demonstration halted, as it claims the design of the program precludes it from yielding meaningful results.  

It is one thing for the Senate Finance Committee to request input from stakeholders on how to avoid waste, fraud and abuse in the Medicare program. It is quite another for the GAO to state that there is more that CMS could do to fight improper payments, in addition to RACs, ZPICs and predictive modeling technology, all of which have been shown to be failing in their own unique ways. The injection of the GAO as an impartial observer into the debate should be welcomed by a provider community left shell-shocked from audit activity. For this one time, everyone should rejoice in the arrival of the referee.

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May 16th, 2012 | 3 Comments »

A Heavy Week For The Police Blotter

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

When I was growing up, there used to be a phrase for a person or a business enterprise that could be trusted to do the right thing. That phrase was “on the level”. In the grand scheme of things, my life experience to date is fairly short, so it is distressing to me that the idea of someone being “on the level” seems to be some kind of quaint notion from yesteryear. Once upon a time, it was fairly easy to distinguish what was legitimate and what was too good to be true.

Unfortunately, in modern times, we are surrounded on a daily basis with scams. From the spam in our e-mail inbox to the “price rollbacks” offered by virtually every retailer, there is very little that I see across the landscape as “on the level”. Even adding something to your meal from the fast food menu for “another dollar” seems like an honest bargain, until you realize two years later that you can’t fit through the doorway without coating your hips and shoulders with margarine.

After a while, what tends to happen is people become numb to the ugliness around them and get consumed by it, rather than feeling like they are spending their lives swimming upstream under the delusion of something wonderful greeting you at the river’s source, even though it never comes into view. Maybe it’s all the psychedelic music I’ve cheerfully listened to in my life, or maybe it’s my love of oceans, lakes and rivers, but I’m here to tell you that I’ll keep swimming for the rest of us.

I read two stories this week that make me believe that the idea of “on the level” is poised for a comeback. The first news came to me this past Wednesday, when the latest wide-ranging HEAT teams busts were announced in a joint statement by the Department of Justice and the Department of Health and Human Services. In all, 107 people at various levels of decision making in the health care chain were charged with false billing to the Medicare program totalling $452 million. Fifty-nine of those charged were from (say it with me!) South Florida, with the majority of the remainder coming from the high fraud areas of Baton Rouge, Los Angeles, Houston, Chicago and Detroit. We even had one defendant from Alabama, so let me take this opportunity to welcome those in the Yellowhammer State (yes, I had to look that up) to the world of Medicare Fraud arrests.

In addition to the “perp walks” in many cities, Medicare suspended payments to 52 providers based on aberrant billing patterns and what they called “credible allegations of fraud”. I find this to be the most interesting announcement by the team, as this indicates to me that the predictive modeling technology implemented by CMS last July is beginning to prove it’s worth, albeit on a small scale thus far. There is still a long way to go to expunge the Medicare program of fraud (as indicated by this insightful comment from my blog posting this past Wednesday that begs for a larger audience), but anytime providers of ill repute are led away in handcuffs, my soul does a Daffy Duck “Woo Hoo” Dance.

The other bit of news from the true crime files came in this morning, and has a connection to one of the many places I’ve lived in my life. In 2010, a pharmaceutical distribution center for drug giant Eli Lilly located in Enfield, Connecticut (past home base number 2 of 12) was robbed of over $70 million of Prozac and Zyprexa in a sophisticated heist. Thanks to a long investigation by local and federal authorities, 12 arrests were made in Florida this week against individuals who ran a cargo heist ring up and down the East Coast. In addition to the Eli Lilly robbery, the same ring was involved in cargo thefts at truck stops in Pennsylvania, Ohio and Tennessee, as well as a similar heist at a GlaxoSmithKline warehouse in Virginia. A statement from Eli Lilly indicated that the remaining drugs recovered as part of the arrests will eventually be destroyed. 

While two news releases will not completely restore the idea of entities being “on the level”, it is to the benefit of those in the medical field who are working hard to do the right thing that those players acting in bad faith are removed from the field. It continues to be a swim upstream, but for a small window of time, the rocks we encountered on this part of our journey were made of Styrofoam.

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May 4th, 2012 | No Comments »

Random Thoughts As I Fasten My Seat Belt

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

This afternoon, I’m embarking on my latest of many long-distance automobile journeys. I’m driving first from suburban Milwaukee, Wisconsin to Reading, Pennsylvania (the town that the first railroad on the Monopoly board is named after), where I’ll be picking up one of my oldest friends, music blogger and master librarian Curtis, along with a portion of his vast musical instrument collection. From there, we head to Marietta, Georgia to interface with another old friend, musician and noted watchmaker-to-the-stars Steve, to record what will be my first full-length album of any quality in Steve’s home studio (just off his dining room; Steve’s a confirmed bachelor).

As I get ready to encounter the wonder and horror of the American roadways in equal parts, news directly and indirectly related to our health care system will not pause to await my return. In fact, if the last week is any indication, I’m beginning to realize why Godot never bothered to show up.

Since I’m in a musical state of mind, allow me to begin with the all-too-familiar case of  the death of Whitney Houston. Until the complete autopsy and toxicology reports are introduced with great fanfare into the 24-hour news cycle, I am left to put pieces together based on assorted widely released reports. The reports thus far seem to point to a death from prescription drugs, rather than the illegal drugs she had admitted using in her past in interviews conducted during her lifetime.

There is perhaps some good that can come out of one more celebrity death in a long line stemming from misuse of prescription drugs. Responding to an epidemic of prescription drugs obtained illegally and sold on the street, as well as the well-publicized deaths of Houston and others, the State of New York is now looking at instituting real-time reporting of prescription data from pharmacies around the state. Anyone who wants to fill a prescription anywhere in the state at any time would be checked through the proposed database. The person’s demographics and history of drug utilization would be reviewed, with suspect prescriptions denied on site.

Realizing that there are 50 states, it should be noted that even if such a system is put in place, it will be a small beginning. It continues to be a sad commentary that people with the financial wherewithal to poorly self-medicate will continue to do so until some type of national database is put into place.

In other news, HHS Secretary Kathleen Sebelius announced yesterday that the provider compliance date  for ICD-10 will be pushed back from its current date of October 1, 2013, it what appears to be a massive cave to the AMA and other shrill elements on the provider side. In her statement, Sebelius made reference to “administrative burdens” and the intent to work with the provider community to “re-examine the pace at which HHS and the nation implement these important improvements to our health care system”.

If all of you can now grab your welding masks, safety goggles or other appropriate eye wear, this is a short warning that I’m going to gloat now, and I want to save all of your corneas from the supernova of my past brilliance.

Begin your journey of enlightenment by clicking here. Next, scroll down to the attached document in the lower right-hand corner. On September 24, 2008, during the comment period of the proposed rule for ICD-10 implementation, I submitted a recommendation to CMS stating (admittedly, in sometimes clumsy language usage) that ICD-10 should be skipped altogether and that the American health care system should instead prepare for the worldwide release of ICD-11 in 2014. As you can see by my comments from 41 months ago, I theorized that if ICD-10 was instead chosen as the standard, the United States would find itself exactly where it finds itself right now, that being the rest of the civilized world using the sleek, up-to-date disease, symptom and morphology coding system, while the United States putts along with the AMC Pacer.

When the Final rule was released in mid-January of 2009, CMS stated that a clinical modification for ICD-11 would not be ready until the year 2020, so my idea was not feasible. I know this is going to be hard to believe, but your government didn’t tell you the entire truth in this case. ICD-11 will include a clinical modification upon release, so the 2020 timeline is talking about an “American” clinical modification that would enable domestic insurance carriers to more easily deny claims.

Admittedly, since my comment, the World Health Organization has moved back the ratification date of ICD-11 to May of 2015. Yet if ICD-10 implementation is going to be delayed to a date extremely close to one year before the global ratification date of ICD-11, can anyone tell me what the point is of forcing ICD-10 on to the American health care delivery system to stay current with the rest of the world for roughly 12 months? The further we push back ICD-10 compliance, the worse of an overall investment it becomes. To put it in a more popular context, if I want a smart phone, I could go out right now and buy a  smartphone and be needlessly frustrated about missing features, or I can wait for the latest version to come out a few months from now and be happy and up-to-date. To me, this is all about getting everyone frustrated for no apparent reason, and I feel very comfortable telling everyone within earshot that I warned CMS about this.

For those of you who want a peek into the future, here is the working alpha version of ICD-11. Bluntly, as a coder, I find it to be a superior system to ICD-10, but given that I am turning 46 in two months and we’ll be over 20 years into global ICD-10 implementation by the time the United States decides to put it to use, I am predicting today that I’ll never use ICD-11 as a coding system in my occupational lifetime. 

America. Feel the exceptionalism!

Paul Spencer’s Friday blog on industry issues will return on March 2nd. Until then, if you want a chance to meet Paul Spencer, as well as a chance of winning an IPad, consider registering for the Fi-Med RAC Summit on April 16th and 17th, 2012. Visit the Summit website for more details.  

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February 17th, 2012 | 4 Comments »

Of ICD-10 and Disappearing Doctors

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

Now that the calendar has turned to February, let me share a truth or two that I hold about the shortest month of the year.

First, Groundhog Day may very well be the dumbest thing I’ve ever seen. People in stovepipe hats standing around an overgrown rat in the cold and dark in order to get the weather report is a poor use of human resources. The only cool thing about this day on the calendar is that my wife’s uncle appeared in the film Groundhog Day playing upright bass behind Bill Murray. The rest of February 2nd can forever dedicate itself to other, more useful things.

One last thing before we get started. There is no cooler birthday on Earth than February 29th in a Leap Year. Here’s to all of those people!

Now, turning my attention to recent health care headlines, two of my favorite topics popped up again in the past week.

First, we have the AMA clarifying what was referred to as “work vigorously to stop” ICD-10 at their meeting in New Orleans back in November. Apparently, the AMA’s approach in this area consists of that tried-and-true standard: The Sternly-Worded Letter. On January 17, AMA CEO James Madara led off his Dispatch Path to Prosperity with a 3-page bulletin to current Speaker of the House John Boehner. Because this particular letter didn’t deal with tax cuts, tort reform, deficit reduction or further punishing poor people, it was set aside for golf and further tanning.

Never an organization to back down from a challenge, the AMA doubled down and sent a 4-page letter to HHS Secretary Kathleen Sebelius which covered basically the same territory as the Boehner letter. I covered this topic in a post at the time, and what I said then still holds true. Rather than spitting into a headwind in a quixotic attempt to stop the rotation of the Earth, the AMA’s considerable resources would be better spent either educating their member physicians about ICD-10 or assisting struggling practices monetarily to ease the headaches of transition. Look for more correspondence in the near future, which will more than likely be followed by a bunch of doctors descending on Capitol Hill on an assigned date to “bring awareness” to the issue. You can also look forward to me yawning and changing the channel.

The second piece of interesting news in the past week came from the OIG. When I reviewed the OIG Work Plan back in October, one item that jumped out at me was the OIG’s plan to look into the impact of physicians opting out of Medicare, both in terms of physician access in certain geographical areas and to be certain that non-participating providers were not submitting claims for payment to Medicare. There has been a slow trend developing regarding physicians who take the “third way”, that being the membership/concierge model. Previous studies by CMS have vastly underestimated the exact number of such physicians nationwide.

It was announced last Friday that the plan to assess the impact has failed due to a lack of data maintained by the MACs on physicians who leave Medicare. CMS has been forced to admit that they have insufficient oversight over physicians who opt out of the Medicare program due to this lack of data. CMS concluded their statement of finding by saying that they “plan to conduct a full evaluation when a complete data source of opted-out physicians is available”.

I challenge the reader to internalize that for a moment, and place that statement against the backdrop of PPACA and the ticking time bomb of a growing primary care physician shortage. CMS is stating that they don’t know for certain who is not participating in the program as they attempt to build a health care delivery structure where every citizen is covered under some type of health insurance. Items such as Medicaid expansion certainly appear tenuous when you can’t reasonably identify which providers will not be there to provide services. CMS has set no time frame to provide a reasonable picture of the opt-out landscape. Between you, me and your computer monitor, that’s a little scary.

The shortest month of the year has begun with big items. As the “Doc fix” witching hour approaches towards the end of the month, February is threatening to make up in quality of news for what it lacks in quantity of days.

I don’t live in a hole, but I predict about 4 more weeks of hand-wringing.

Be sure to keep abreast of all news updates about the Fi-Med RAC Summit this April by visiting the Summit website.

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February 3rd, 2012 | No Comments »

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.

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December 21st, 2011 | 2 Comments »