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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.

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.

THE RAConteur: Medicare Part C RAC Update

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

This past Friday, the comment period regarding RAC activity for Medicare Parts C and D ended. As stated in a previous post here, CMS approached this comment period seemingly looking for suggestions as to how to contain costs in Medicare Advantage (MA) programs.

The timing of this comment period couldn’t possibly be worse for MA plans. Just prior to the end of the comment period, CMS released preliminary CERT data for 2010 showing that the Medicare Advantage payment error rate currently stands at 14.1%, which stands head and shoulders above both traditional Medicare and Medicaid. Sadly, this number actually shows improvement from the 15.4% error rate from 2009, yet the total dollars paid in error actually went up by $1.6 billion in 2010.

While the last-second comments have yet to be posted for public viewing as of today, the American Hospital Association, as it usually does, happily trumpeted the comments they submitted. As usual, the comments were well-organized, expressed exasperation with the current audit environment and contained a list of the organization’s desires, only some of which have any chance of ever being implemented.

The AHA argued that MA plans are already auditing providers for payment accuracy, so RACs aren’t needed. If the MA plans had an error rate in the single digits, I would agree with this assessment. Yet if the MA plans can’t adjudicate the claims for their beneficiary population correctly, what are the odds they can find payment errors they themselves have caused? If ever there was a section of the Medicare payment universe that needed comprehensive review, MA plans trail only durable medical equipment in need. Since the payment error rate is so stark, it would be of enormous benefit to have an independent set of eyes combing through the claim lines generated by MA plans.  

In their usually resigned fashion, the AHA had a wish list of requirements if RACs are implemented. Some of these are parts of the permanent RAC program for Medicare Parts A & B, such as requiring trained medical professionals to conduct RAC audits, medical records request limits and RAC websites with approved audit issues. Others, such as a 1-year look back period and excluding medical necessity from the Part C RAC program, are the equivalent of a wingless flight into Fantasyland, as CMS has to this point shown no interest in either approach.

It will more than likely be several months before we see anything resembling a proposed rule for Part C RACs. Meanwhile, in the backdrop, is the fact that MA beneficiary premium prices are now equitable with traditional Medicare for the first time beginning this year. With the incentives for private industry to sponsor MA plans decreasing with each passing day, I wonder if setting up a RAC program for a dwindling number of MA plans requires such a focus. The next 10 months will go a long way in defining that necessity.

The RAConteur: Medicare Parts C And D RACs Now On Drawing Board

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

Fresh off a day of digging out of a major Midwestern snow storm (the reason for a 1-day delay in posting), I bring you a quick update on the Medicare RAC program.

Back on December 27th, in what could be considered an end-of-year news dump, CMS released a request for comments for the expansion of RAC activities to include Medicare Parts C & D.

Comments will be accepted until February 25th, but as is my lot in life, I’m happy to offer a little bit of a window into Medicare’s thought processes at the moment.

In the world of Part C, also known as Medicare Advantage, there currently exists no useful cost control model. As I pointed out in an earlier post, the current error rate for Medicare Part C stands at 15.4%. If ever there was a portion of the Medicare program in need of stronger controls, this would be it. With these statistics in mind, it was with a high level of surprise that CMS is asking for comments regarding the potential for Part C & D plans to include RAC activities within their plans to identify overpayments.

This statement wouldn’t have caught my attention were it not for the fact that later in the notice, CMS requests information on successful overpayment recoupment models in managed care that “may already exist” in the commercial sector and whether these models could be applied to Part C. Looking at the wording in an impartial manner, this appears to be CMS telling all the world that they have no idea what commercial insurers utilize to control costs. Further, how is current Part C claims data being stored that CMS seems to have no clue as to how to mine it for improper payments?

With Part D (The Medicare Prescription Drug Plan), comments are being requested mostly on topics such as the level of reinsurance sudsidies received by Part D contractors from CMS. Part D contractors receive payments based on utilization of benefits by certain beneficiaries. How these payments are verified within the RAC framework appears to be a challenge for which CMS is requesting assistance.  

It is no secret that I view RACs in two ways. As a taxpayer, I see them as a necessary evil, yet as a physician advocate, I view RACs as something of a suddenly untethered parade float. I know it’s big, overinflated and is going to crash somewhere, but waiting for it to land leaves a sickening feeling in my stomach. We are a long way from seeing a final rule related to Parts C & D in the Medicare program, but the taxpayer side of me sees it as long overdue.