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An Easy Budget Fix For Medicare

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

I was, perhaps unfortunately, born into a political family. Because my early childhood memories revolve around assorted family members watching the evening news and commenting loudly, sometimes using the off-color language of prejudice that was the hallmark of bygone generations, I continue to be sucked into political discussions as an adult.

There are only a few differences between the political junkie and the heroin junkie, not the least of which is that I lived beyond 30. While the actual junkie can usually be found in a dank room without furniture, huddled around a candle with a needle, a spoon and their latest bag of potential death to get them through the next six hours, the political junkie can be found in a different kind of shooting gallery (probably a Starbucks), huddled around a laptop, reading an opinion blog, with the latest cup of cream-softened caffeine to keep them going for the next four hours. The only physical similarity is the sunken eyes, one from walking death, the other from absorbing too much information, with both self-constructed prisons ensuring that they’ll never live carefree and happy again.

With this in mind, and with more than a little information about America’s health care situation in my mind, I wade into the morass that is our country’s current slouch towards debt default. Ironically, I’m due to be in Canada when the default is scheduled. Judging from the idiocy I see scattered among the people placed in charge of preventing the default, I might have to stay there. Why wouldn’t I? They have wonderful people, cold weather, intelligent public discourse, hockey, beer and doughnuts, all in abundance, which those who know me can tell you is a pretty sexy package in Spencerland. My wife is one-half Canadian, so I’m practically there already.

As the latest posturing about the federal budget drags on, I was struck by Senate Minority Leader Mitch McConnell recently stating that unless something is cut from Medicare, Republicans will not compromise on raising the country’s debt ceiling. Being the paragon of common sense that I am (at least during work hours), I’m here to accept Mr. McConnell’s challenge, and I can do it in three words.

End Medicare Advantage.

Federal contracting, in every Cabinet department, is a vast, apocalyptic land of waste, fraud, overpayment for everyday products and services, political back-scratching, and unfulfilled promises. Within the Department of Health and Human Services, there is no more salient example of a program that exists to no benefit for the country’s citizens than Medicare Advantage, or Medicare Part C.

The idea behind Medicare Part C is that private insurance companies offer Medicare beneficiaries an alternative to traditional Medicare coverage which, in theory, would also offer other benefits not available under the original plan. The beneficiary pays the competitive premiums to the insurance company, and voila!, everything is rainbows, good fairies, dancing elves, candy buttons and fountains of strawberry milk and gumdrop trees.

Since this is a joint initiative of the federal government and the insurance industry, one cannot be surprised that the program is one big con job and money pit all rolled into one.

Let’s start with the accuracy of claims payment. The claims error rate for traditional Medicare is 10.5%. That’s a lousy number, but the error rate for Medicare Part C is 14.1%, meaning that if your claim is sent to a Medicare Advantage plan, and it waits in a virtual line for claims adjudication on a given day, and its number in that line is divisible by seven, it will be paid incorrectly. It doesn’t end there. The American Medical Association issues an insurance report card, showing the accuracy of claims payment of the largest insurance companies in the country. The results of these measurements is the finding that one out of every five claims sent to the big insurers is deliberately underpaid based on contracted rates with physicians. In addition, the amount of the underpayment is usually far less than the administrative costs on the provider end to collect the remaining money owed. If we combine the Medicare error rate with this set of facts, the picture painted is less Rembrandt and more Picasso.

Next, we look at the incentive payments we pay to Medicare Advantage as taxpayers. Each Part C plan receives extra dollars if the data received from claims indicates that the population they are servicing is sicker and consuming more resources. These payments are in addition to the financial benefits to the insurance company of syphoning off patients from the traditional Medicare program. If you’re on Medicare, you’re either 65 or older, or have a chronic disease. If an insurance company makes a business decision to offer a Medicare replacement plan for a population that common sense dictates is worse off in terms of health than the rest of the general population, why is this incentivized? Opening a store offering glass figurines is fraught with inherent risks, but the government doesn’t pay to keep it open simply because of what’s being sold inside. Old people and those with chronic diseases get sick more often. The Medicare program offers them coverage because the insurance industry looked at their actuarial tables and said “no dice”. Medicare Advantage is being paid a tribute just to provide coverage to the sickest beneficiaries under the plan to make up for the actuarial loss. Voiding Medicare Part C would end this circular logic once and for all.

As the infomercial says, “But wait! THERE’S MORE!”. When Medicare Part D, which offers coverage for prescription drugs, came into being in the last decade, the vultures circled. Insurance brokers used the selling opportunities for Medicare Part D to sign up traditional Medicare patients to corresponding Medicare Advantage plans, many without their knowledge. The best comparison for this practice was the long-distance “slamming” that went on in the late-’80’s and early-’90’s, where virtuous corporate paragons like MCI/Worldcom would sign up someone for their long distance service without their knowledge, with the first indication that it actually happened being an eye-popping bill to the slammed. Medicare recipients have been lured into Medicare Advantage plans, hypnotized by drug formularies, to the great financial benefit of the insurance companies behind the Advantage plans. The OIG is aware of these behaviors and has issued a few slap-on-the-wrist fines, but the practice continues.

Finally, the so-called “advantage” of Part C plans was that they offered benefits above and beyond what traditional Medicare offered. The most common of these was coverage for yearly preventive exams with the beneficiary’s primary care physician. As of 2011, traditional Medicare offers an annual wellness exam to all beneficiaries as part of the plan, which significantly diminishes the value of Medicare Advantage plans right out of the starting gate.

Medicare Part C has become a worthless boondoggle. It has value only to the insurance companies collecting premiums. It is the worst kind of corporate welfare, redirecting benefit dollars from the sickest of our citizens into the pockets of corporate America. It is a drain on the budget at a time when we can’t afford it. If you want to be serious about deficit reduction ahead of raising the debt ceiling, tackle the waste. Other than the continuing misadventures in Iraq and Afghanistan, I can think of no better example than Medicare Part C.

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June 3rd, 2011 | 3 Comments »

Another Week, Another CMS Initiative

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

Quite obviously, health care is always on my mind, but it has been an interesting week for me to say the least.

Last week, I had my annual physical. I can report that as of today, 14 days prior to my 45th birthday, the Earth’s natural process of shedding itself of my presence appears to have begun in earnest. If the examination bullets and lab reports are accurate, I am iron deficient, vitamin D deficient, my cholesterol has spiked, I’m heavier than I’ve ever been and my resting blood pressure was measured at 150 over 110. Naturally, given my personality, I sprang into action immediately; I went home and I had a beer.

Given all of these newly-discovered health risk factors, I’ll try to get to this week’s point as quickly as possible.

This past Tuesday, my e-mail box lit up like the skies around Devil’s Tower in Close Encounters of the Third Kind. CMS announced their latest initiative, called Partnerships for Patients, with great fanfare and a bonus conference call. The call was targeted at “stakeholders, and not the media” as I was told twice prior to the guts of the call. Nevertheless, since my vital signs are screaming at me to relax, I listened in for a few moments

CMS administrator Donald Berwick was the first to speak, introducing the initiative. Dr. Berwick called it a “turning point for patient care” and then came forward with the goals of the program. Simply put, Medicare is partnering with hospital systems to find ways to reduce hospital-based adverse events and readmissions. The program has set aggressive goals of reducing hospital-acquired conditions (HACs) by 40 % and readmissions by 20% by 2013. The initiative will be funded by the Department of Health & Human Services to the tune of $1 billion in federal funding that has been made available by the Patient Protection and Affordable Care Act.

Dr. Berwick touted the work of pioneering hospitals across the country that have successfully lowered their instances of HACs and readmissions. He stated a larger goal of “making best practice the normal practice” to reduce preventable medical errors nationwide.

On the heels of CMS’ April 7th release of proposed rules for Accountable Care Organizations (ACOs), as well the April 5th release of the House Republicans’ Medicare privatization model, it has been an eventful few weeks for the Medicare program. The unspoken undercurrent regarding all of this sudden activity is that the Medicare program is the largest drain on the federal budget, and everyone is realizing (somewhat belatedly) that something desperately needs to be done to reign in the growing costs of the program.

About the only fact that all parties can agree on is that medical care is too expensive, and that the upward trend is unsustainable. The two choices we have been offered this month are “fix it from within” and “sell it off to the highest bidder”, both of which fail to offer anything close to a solution if we strictly use history as a guide. Add to that the announcement in early March that Dr. Berwick, who is the CMS Administrator by recess appointment until December 31st, is not going to be re-nominated for Senate confirmation prior to the end of his term due to objections from Republicans in that chamber, and Medicare’s immediate future suddenly becomes murky. It will be left to Dr. Berwick’s eventual successor to see the ACO and Partnership for Patients initiatives to their conclusion.

As this month’s initiatives get up and running, the puffy-cloud dreams that are yesterday’s initiatives continue unabated, the biggest of which are focused on improper payments. I continue to eagerly await HHS’ annual report to Congress detailing the financial impact of these initiatives, especially with regard to the Recovery Audit Contractor program. Given that healthcare costs currently consume 16% of the country’s gross domestic product, any initiative that shows tangible evidence of savings can’t be anything but positive. It is hoped that the political will can be found to insure that Medicare will still be around when people of my generation reach a certain age. My odds of seeing it suddenly became longer in the last week, but I wish my contemporaries luck nonetheless.

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April 15th, 2011 | 2 Comments »

The RAConteur: As The Shutdown Approaches

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

Political theatre is a way of life in this country. It takes a mix of acting skills and a thesaurus of important-sounding words to be a politician in the United States. Knowing that this template has existed this long, it takes a special kind of insanity on the part of the citizens of this country to expect that things will ever change for the better.

The current act in this never-ending stage production finds the Speaker of the House of Representatives and the President lobbing the usual verbal bombs at one another as a partial government shutdown approaches on Friday at 12 Midnight.

If a federal spending measure is not passed by that time, certain “non-essential” government services begin to experience delays and stoppages. This is defined as museums close, passport applications stop and tourism comes to a standstill. 

With respect to the RAC program, this feels like a good time to remind everyone that the RACs are independent contractors. While they do work for CMS, they are paid by contingency fees based on identification of improper payments. RAC letters will not stop and discussion periods will not pause. All time periods as defined in the RAC statement of work will continue unabated.

Using history as a guide, I feel confident in saying that all Medicare operations will continue during any government shutdown. Because Medicare claims are paid out of a trust fund, and are not subject to Congressional appropriation, claims will still be paid. By extension, this means that any pending recoups that reach the 41st day during a government shutdown will still be taken. All RAC appeal time line clocks will continue to tick with CMS.

The one wrinkle, if a shutdown occurs for an extended period, would be the payments Medicare makes to the administrative contractors (MACs) for the processing of those claims. During the last government shutdown, the MACs extended credit to CMS for claims paid, and were reimbursed upon passage of a new spending measure. There is an unanswered question in the industry as to the limits of the MACs’ charity in any repeat performance of such an eventuality (competency at their jobs notwithstanding). This is in spite of the fact that a few MACs have come forward and stated that they will pay claims until instructed otherwise. In an extended shutdown, we very well could see Medicare claims payments cease if this issue remains unresolved.

For now, American politicians will enjoy their posturing, their tears and their litany of bad toupees as they dance in front of the camera in the climax of their latest magnum opus. The rest of us, as has been standard operating procedure for many years, will be forced to shovel away the muck and mire they spew forth as the puppet show continues.

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April 6th, 2011 | No Comments »

Politicizing Healthcare

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

I grew up in a very political household.

Now when you first read that last sentence, there are a few ways that you can break it down. The first thought may be “so was someone in your family a politician?”, to which the answer is a resounding no. Next, you may think that ol’ mom and dad packed up the kids and took them to hear political stump speeches, and the answer to that is, again, no.

When I state that I grew up in a political household, what I mean was that at 6:30 PM (I grew up on the East Coast), the family watched the evening news, my ultra-right wing father pontificated on what was just stated by the talking head, and everyone who asked the question “why?” got an earful of orthodoxy and, since he was of a certain generation, a heavy dose of Anglo-Saxon exceptionalism.

Thanks in part to this rigidity in my upbringing, I have a natural tendency to hear an opposing opinion that comes from a place of analysis that lies beyond the intellectual laziness of conspiracy theories and Wikipedia. I can literally count on one hand the number of people in my private life whose opinions matter to me.

With this fact as a backdrop, the national debate on issues important to our society and the world at large, as it is currently configured, is horrifying. A case in point was displayed in full regalia when I stumbled upon this article regarding the newly-configured and empowered Republican Party wanting to “re-open” the debate about privatizing Medicare and replacing it with a menu of coverage options offered by the insurance industry.

In order to determine what such a system would do to the Medicare plan as we currently know it, let’s look at the effect of private industry on the Medicare program up to the present time. We can start with Medicare Part C, which is really the closest thing to what is proposed in the privatization model, and the facts don’t paint a pretty picture.

Medicare Advantage plans have a claims payment error rate of 15.4%, or $12 billion in improper payments, which clocks in at just short of being twice as high as the error rate for traditional Medicare. When you look at the claims payment error rate, you have to approach it with the knowledge that Medicare benefits are stated clearly in policies that can be referenced on the CMS website at any time. Computer edits by some carriers make it that much easier to find an incorrect claim and reject it for payment. Despite this, 3 out of every 20 claims processed by a Medicare Advantage plan is done so in error.

Undaunted, we stumble on to the next conclusion, which is that Medicare claims for Part A and Part B are currently processed by private contractors. For Fiscal Year 2009, the latest year for which we have statistics, $24 billion was paid in error by the Medicare Administrative Carriers (MACs), creating an error rate of 7.8%. While this is not as vaunted as the Part C rate, 24 billion of anything is still a significant number, let alone dollars. The MACs are dealing with the same coverage guidelines as Medicare Advantage, and some of the MACs have been working with the Medicare program since 1966.

I too was born in 1966, and while human fallibility states that I can’t do everything right, I can state with confidence that if I was only given one task to complete in life, after 45 years I would hope that I could do it right every time. I didn’t start out knowing how to feed myself, but one look at me in my current form shows that I’ve aced that one.  The only task that the entities who process Medicare claims is given is to process a claim correctly the first time. After up to 45 years of trying, even with all coverage facts at their fingertips, their level of failure at this one assigned task is causing incredible damage to the Medicare program, and by extension our country’s finances.

Privatization of key portions of the Medicare program has been a fact of life since the program’s inception, and it’s not doing the program, or the taxpayers who support it, any favors. Medicare, as it is currently configured, is the biggest threat to any hope of  financial stability on a national level, but you have a hard time convincing me that private industry, given their track record with the Medicare program up to this point, offers the be-all and end-all of solutions to the problem.

The universe is not a one-size-fits-all proposition. Rather it is filled with contradictions, consequences, subtlety and unrealized synergy. It offers challenges on many fronts, with several different ideas and solutions to keep it in balance. It only tolerates orthodoxy until such time as one human mind steps up to challenge it with increased understanding. I justifiably laugh at those who, in the 21st Century, believe that the Sun revolves around the Earth. Given the fund of knowledge currently at my and indeed everyone else’s disposal, I believe I have the right to extend that same mocking laughter towards anyone who believes that every problem we face in this country is solved by tax cuts, tort reform, privatization and killing those who disagree with you.

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January 28th, 2011 | 1 Comment »

Billing For Consults After “The Apocalypse”

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

“Orchestral music rises as the first glimmers of an ominous sunrise brings light to a dusty and desolate landscape, where once-plentiful streams of revenue have been vaporized by statute. Small bits of paper with numbers such as “99254″ and “99241″ blow across the feet of our stethoscope-clad hero, as he faces a future full of financial uncertainty and unwanted adventure…”.

We are now two weeks into a world where Medicare has eliminated reimbursement for inpatient and outpatient consultation codes. To many specialists for whom consultations have become a way of life, it is tempting to see themselves as a manufactured post-apocalyptic film character similar to the one above. It is my duty, as a compliance officer, certified coder and budding writer of screenplays to inform you that it doesn’t have to be that way.

In a previous post on this blog, I demonstrated one way to navigate the imperfect crosswalk that exists between inpatient consultations and the CPT codes for initial inpatient encounters (99221 through 99223) that are now to be used in its place. In the past weeks, the Medicare administrative carriers have released their own guidance about what should be billed in place of a consultation code if the documentation does not meet the requirements of CPT code 99221.

For Palmetto GBA, First Coast and WPS, the suggestion is that CPT code 99499 (Unlisted evaluation and management service) be utilized for services formerly billed as 99251 or 99252. When using this code, be aware that it lacks a set payment. The reimbursement of this code is driven on a case-by-case basis and is determined by carrier review of documentation for the service. When billing 99499 to a carrier that accepts it, always be certain to include the documentation for the service.

National Government Services, as well as other carriers, is suggesting that the appropriate inpatient follow-up code (99231 through 99233) be billed in place of a low-level consultation. The choice of code would depend on the depth of the documentation for the service.

The second challenge that has been brought forth is the question of consultations when Medicare is the secondary payer (MSP). In the final revision of the new consultation policy in MedLearn Matters article MM6740,  there are two solutions that can be used. You can either choose not to bill consultations at all to a commercial payer and be reimbursed for E/M services by both commercial and MSP, or you can bill the consultation to the commercial payer, then report the amount paid and bill an equivalent E/M code to Medicare to determine whether additional reimbursement is due.

The first solution is the path of least resistance, as this eliminates consultation billing from your practice immediately and entirely. Financially, this may not be the most advantageous approach. While commercial payers are expected to eventually follow CMS’ lead and eliminate reimbursement for consultations, these codes are still active with commercial payers at reimbursement rates that are typically larger than equivalent E/M codes based on documentation.  Contractually, if you are still receiving healthy reimbursements from commercial payers for consultations, the second approach may be more to your advantage.

The reimbursement landscape has changed, but it has not been irrevocably altered for the worse. The road to reimbursement commensurate with services performed now has a few more detours than it did a month ago, but water recedes and bridges can be rebuilt. With increased attention to documentation detail and increased awareness of the new rules of the road, providers can successfully navigate a world without consultation reimbursement.

Paul Spencer CPC, CPC-H

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January 15th, 2010 | 1 Comment »

Reports Are Falling From The Sky

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

Here in Milwaukee, we had our first snowfall of the season overnight. While it wasn’t enough to keep me at home today, it was just enough to make the process of getting from here to there just slightly more time-consuming. For someone like me, who operates in this world of ours thinking that a great deal of the world functions specifically to be in my way, it was a typical morning.

As the calendar turned to December earlier this week, I am also reminded that snowflakes are not the only thing  falling from the sky. With the approach of a new calendar year, a number of news releases, reports, pending legislation, industry updates and warning shots are coming from the federal government. Some of these began implementation at the beginning of the fiscal year on October 1, but it helps to review the regulatory landscape on a regular basis. With that in mind, here’s a portion of what we know:

  • The OIG Work Plan - While some of the usual suspects appeared once again on the OIG work plan for fiscal year 2010. there were a few new and not-so-new things that jumped out at me. OIG is again looking at the unbundling of laboratory tests. One of the most surprising bits of news this year was the large fine levied against Quest Diagnostics for violating bundling rules, mainly because this company, under its previous incarnation as Smithkline Beecham Clinical Labs, faced a 9-figure fine for similar violations back in 1996. The OIG has now officially decided to revisit this topic. Other targets of the OIG in the coming year will be E/M services performed in the global period of a surgery, a review of the current payment system for ambulatory surgery centers, practice expense for radiologists, the effects of payments for services referred by excluded providers, and a multi-layered review of claims related to durable medical equipment.
  • The OIG Semiannual Report – In addition to this year’s Work Plan, the OIG just released their semiannual report, which reports a total of almost $21 billion in program savings and recoveries. For fiscal year 2009, the OIG recovered just short of $4.5 billion through investigations and audits. The savings portion of $16.5 billion came through recommendations for putting agency funds to better use which were finally implemented long after they were suggested during the last administration.
  • The 2010 Conversion Factor - Quietly over the Thanksgiving holiday, the projected conversion factor for 2010 was lowered from 28.4061, which represents a 21.2% cut from 2009, to 28.3895, bringing the total cut from 2009 to 2010 to just short of 21.3%. In past years, there has been last-minute legislation passed that eliminated projected cuts to the conversion factor. This year, the urgency to address this issue has disappeared in a wave of uncivil, unproductive and distracting arguments about the future of health care in the United States. With the New Year 4 weeks away as of today, it may be in the best interests of all Medicare Part B providers  to make financial preparations for the coming year that assume a 21.3% reduction in Medicare reimbursement. If this cut is rescinded on the cusp of January, those that have planned ahead will be that much better off.
  • Medicare Fee-For-Service (FFS) Error Rate – CMS reported that the error rate for claims payments under Medicare FFS plans more than doubled from 3.6% in 2008 to 7.8% in 2009. This was a result of increased scrutiny of claims for these plans. This FFS error rate works out to $24.1 billion dollars in improper payments.

 

With the rancor currently displayed in the Legislative Branch of the government, coupled with the attention-deprived caterwauling that defines the 24-hour cable news environment, it will not be the occasional regional snowfall making December a treacherous time for our industry. Much like the Buick-driving senior citizen in a hat, these and other reports will make the best attempt at getting in the way of a pleasant holiday season. As always, look for an opening, give it some gas and do your best to leave it in the dust, but be aware that you’ll more than likely see them again.

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December 4th, 2009 | 2 Comments »

Denial Management Made Easier With Version 5010 Billing Standard

Posted by J. Paul Spencer, CPC, CPC-H in Fi-Med Services, Hot Topics, In the Press, Industry Updates, J. Paul Spencer, CPC CPC-H

We are often told that life has no instruction book. Personally, I have seen this blatantly come true in the form of my daily dealings with my 3-year-old son. I also longed for a better set of rules back in 1990, when I found myself briefly dating a woman who thought she was telekinetic, but was actually a hypochondriac. No worries, though. I came out unscathed and not once was she able to throw me across the room using only the power of her mind.

In the realm of Medicare denials, currently, under Version 4010 of the X12 electronic billing standards, Medicare offers very little in the way of pointing the EOMB recipient to a solution for a denial. With time, an experienced follow-up specialist can train themselves to understand in what direction each claim adjustment reason code (CARC) and remittance advice remark code (RARC) is pointing, leading to faster resolution.

Version 5010, set to be implemented by CMS beginning on January 1st, 2012, is slated to make this process much easier. As part of Version 5010, if a claim is denied due to a conflict with a Local Coverage Determination (LCD) or a National Coverage Determination (NCD), the Explanation of Medicare Benefits will indicate what LCD or NCD is being applied in the denial of this claim.

Given that local carriers now have their LCD’s categorized on the CMS website, first by carrier, then in alphabetical order (which is helpful roughly 30 % of the time),  referring the follow-up specialist to the exact coverage determination will cut down on the amount of time needed to research these denial issues.  As someone with daily involvement in Fi-Med’s denial management process, I cannot begin to tell you how I welcome this change.

While there are many other benefits to Version 5010, such as compatibility with ICD-10 and the removal of some redundancies found in the current version, finding a clearer path to a denial solution may turn out to be its most substantive change.

I look forward to the day when my lack of psychic powers ceases to be an impediment to the timely correction of Medicare denials. This whittles down my list of  ”50-10″ challenges in my life down to what happens in 7 years when I’m 50 and my son is 10. I really need to get in shape….

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November 24th, 2009 | 2 Comments »

Calling Health Care Fraud What It Really Is

Posted by J. Paul Spencer, CPC, CPC-H in Coding and Compliance, Hot Topics, Industry Updates, J. Paul Spencer, CPC CPC-H

I’ve got theft on my mind this week.

Last Saturday night, while I was spending some spare time acting as the opening musical act for a handful of stand-up comedians, someone took a football-sized rock and threw it through my passenger-side front window. Aside from the costs of repairing the damage, I was relieved of my satellite radio player and a pair of $3 sunglasses.

This episode taught me a little something about crime, and that is that criminals aren’t know for their skills of selection. The satellite radio player is virtually worthless, as it is only good as long you have an antenna, power supply and a subscription. Perhaps they thought it was in actuality a GPS device, but a cursory check of my back seat would have shown them all they needed to know, as there was a rather large road atlas in plain view. My thesis has now morphed into the idea that it takes a special combination of hubris and stupidity to be a criminal on any level.

Which brings me to the world of Medicare compliance. I read a variety of trade publications from week to week that catalog the numerous billing violations – and subsequent fines paid – by health care providers around the country. To highlight just a few from the past few weeks:

  • An Atlanta radiologist found himself under federal indictment for falsely claiming that he had personally reviewed thousands of x-rays and radiological studies over a period of 8 months, when in fact the work was done by non-physician radiology techs;
  • A New York podiatrist was charged with multiples counts of fraud for billing out complicated surgical procedures of the feet, when in actuality, he was performing the less-complicated act of clipping his patients’ toenails;
  • A Boston man pleaded guilty to a 54-count indictment that accused him of enlisting people to stage auto accidents in the greater metropolitan area, then turning around and billing insurance companies for therapy services at his clinics stemming from “injuries” sustained in the fake accidents.

 

These are only three of the more egregious examples among dozens of other cases nationwide, and remember that these are all within the last month.

When I present Fi-Med’s compliance plan to new employees, I define “health care fraud” as “theft”. In a world where “stewardesses” have transformed into “flight attendants”, and “shell shock” is now “post-traumatic stress disorder”, it is tempting to use less pointed language to describe all-too-common objects and occurrences. Yet whether it is Medicare, Medicaid or a commercial insurance plan, the thieves such as the ones highlighted above exact a heavy toll not only on the resources of the insurer, but on the entire health care infrastructure with the increased costs of premiums and enforcement.

Having grown up in a family with 5 physicians of different specialties, one of the happier aspects of my job as a compliance officer is working together with health care providers to find simple solutions, whether it be for front desk processes or documentation, that keep them from inadvertently slipping onto the wrong end of the regulatory process. There is usually a “light bulb moment” in each of these conversations when a satisfactory conclusion is reached and where peace of mind is achieved.

While health care fraud has more subtlety than the mentally prehistoric toss of a rock through a window, it is no less an act of theft. Going forward, with a major national health care overhaul on the horizon, it particularly falls on those of us in the medical reimbursement field to give the best guidance possible to the providers we service to assist them in avoiding the sinkholes along the regulatory highway.

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November 20th, 2009 | 1 Comment »

Time Documentation in the Post-Consult Era

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

I don’t wear a wristwatch. 

I have three basic reasons why you’ll never find a time piece in my possession. The first being my dislike of all things related to jewelry. I’ve been married for nearly 5 years and I still play with my wedding ring, which is my only piece of jewelry. The second is I am surrounded by clocks at all times.  As I type this, I have a clock on the phone, computer and fax machine in my work area. Why complicate it by putting something on my wrist? The third is more cultural. Having a bloodline that is 1/2 Mediterranean in descent, the odds of my arm hair covering the face of any watch I own increases with each passing day, and not even I want to see that.

Having said all this, as we approach January 1st, 2010, a date which marks the end of Medicare’s acceptance of consultation codes for reimbursement, a wrist watch could very well end up being the best friend of specialists nationwide who suddenly find themselves without a longstanding reporting tool for patient encounters.

Evaluation and management documentation guidelines state that if more than 50% of your face-to-face time with the patient is spent in counseling and/or coordination of care, the E/M service can be selected based on time. For a specialist who invests time determining a proper course of treatment in either the office or hospital setting, this rule deserves a second look.

As an illustrative example, one problem that has presented itself is in regard to what used to be considered consultations in the hospital setting. Physicians will now bill an initial hospital care code (CPT codes 99221-99223) upon their first encounter with the patient in the hospital. On the surface, one can immediately see a problem, as there are 5 inpatient consultation codes, but only 3 initial hospital care codes. Because of differing documentation standards, there is no clear crosswalk between the two code sets. 

Now let’s look at two of these codes for comparison. CPT code 99252 (level 2 inpatient consultation), strictly from a documentation standpoint, requires an expanded problem focused history, an expanded problem focused examination and straightforward medical decision making. Using Southern California in 2009 as a reimbursement benchmark, CPT code 99252 is listed in the $81 range. Compare that to CPT code 99221 (level 1 initial hospital care). This code requires either a detailed or comprehensive history, a detailed or comprehensive examination and straightforward to low medical decision making. Using the same reimbursement benchmark, 99221 is listed at around $96.

Now on the surface, it appears that the documentation standards work against the specialists if given the choice between the two codes, but let’s add the documentation of time spent in counseling and/or coordination of care into the mix. The average total time for a 99252 is 40 minutes, but the average total time for a 99221 is 30 minutes. The lesson taken away from this is that an awareness of the time you are spending with the patient could lead to less of an investment of total time, but for a higher reimbursement.

Before jumping headlong into time-based billing, it is in the physician’s best interests to remember the two most important things with regard to documenting for this type of code selection. First, the medical decision making portion of your E/M documentation must detail the counseling and/or coordination of care. It is not enough to use generic statements such as “Spoke w/ Dr. X” or “Orders written”. The documentation must include the results of that conversation and detail about the physician’s care orders for the patient. Second, and most importantly, your time caveat statement must show that more than 50% of the total encounter time was spent in counseling and coordination activities. This can be stated either by using the exact minutes or as a clear statement of percentages. Good examples of this are:

  • I spent 50 total minutes with the patient, 30 minutes of which were spent in counseling and coordination of care.
  • I spent 50 total minutes with the patient, more than 50% of which were spent in counseling and coordination of care.

Documentation that simply states “I spent 30 minutes with the patient” is insufficient for choosing your CPT code based on time.

And while I’m on the subject of time, from previous entries on this blog, you know that I was recently in Georgia doing some musical recording. That particular investment of time on my part has yielded an unexpected dividend, as one of my songs that I recorded during my stay was selected as the Track of the Day in the Folk Rock category on Garageband.com yesterday. In an ironic twist, my friend in Georgia who recorded this track is employed by day as a high-end watchsmith. I may not wear a watch, but I guess it helps to befriend people who do. Have a great weekend!

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November 13th, 2009 | 3 Comments »

Is Your Referring Physician Enrolled in PECOS?

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

Beginning on October 5th, if the name of an ordering/referring provider appears on a Medicare claim, this provider will be compared against the Provider Enrollment Chain and Ownership System (PECOS). Between this date and January 3, 2010, if the referring provider is not found in the PECOS system, informational claim adjustment reason codes and remittance advice remark codes will appear on the explanation of Medicare benefits stating that the ordering/preferring provider identifier is invalid.

Beginning on January 4th, 2010, any claims that include invalid referring physician information will be denied. In addition, any provider who does not appear in the PECOS system with up-to-date information runs the risk of being excluded from the Medicare program for a period of one year.

It is imperative that Medicare remittance advice be watched very closely during this Phase 1 period. For providers who rely on patient referrals for the bulk of their business, such as specialists and laboratories, any warnings received should be shared with the referring providers in question to bring this situation to their immediate attention, as continued non-compliance with this enrollment rule by referring or ordering providers could lead to your claims being denied.

Fortunately, the PECOS system has simplified what can be a laborious enrollment process. Simply go here to begin the process and follow the step-by-step on-screen instructions. After completing this process,  remember to sign and return the two-page certification form within seven days of you PECOS submission. Your information in the PECOS system will not be completed without this step. If you have previously registered with the PECOS system, go here to login to the system and update your information. If you experience technical difficulties during the process, CMS offers help desk support from 7 AM to 7 PM Eastern Time Monday thru Friday either by calling 1-866-484-8049 or by e-mailing .

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October 30th, 2009 | 2 Comments »

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