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Posts Tagged ‘physicians’

Defining The Modern American Doctor

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

I am only 45 years old, which is a pittance with regard to measured time past and upcoming, but thanks to the ever-increasing speed of evolution, there have been some rather remarkable changes in my lifetime. To be clear, I’m not doing the typical old-man-in-checked-pants cliche of complaining about how everything was cheaper when I was growing up. I’m talking about the rapid evolution of things that surround us in daily life. As my 5-year-old son grows older, I am envisioning attempting to explain Pong, vinyl records and Johnny Carson to him as societal touchstones in a world that features Nintendo Wiis, digital music and an increasingly unfunny Jay Leno.

Nowhere is this more apparent than the world of medicine. I was only 20 months old when the first human heart transplant was performed. I have a cousin who was a pioneer in bariatric surgery for the morbidly obese. Yet his surgical method, which was detailed in an article in Time magazine in October of 1965, when compared to today’s techniques of gastric banding and sleeve gastrectomies, could well be viewed as the medical equivalent of bleeding with leeches today.

It isn’t simply in terms of surgery. I am here to ask the reader today to bear some consideration for the evolution of medicine not simply in terms of practice and techniques, but also as it relates to the human element of being a physician in modern times.

I came across a few stories this week that showed in stark terms that the role of the doctor, as we have come to know it, has changed dramatically.

First came this synopsis of an article about physicians using social media to deliver better health care and information to patient populations. Modern patients rely on the internet as an information source in ways that challenge the delivery of health care from the modern practitioner. This article provided a window into the innovative ways that physicians can turn something viewed as a negative into a positive for their patients, as well as their practices’ bottom lines.

Now, in the interest of bringing balance to a universe existing in a constant state of chaos, the mixed-to-bad news. A study in the November issue of Health Affairs indicates that the technical knowledge of new physicians in clinical practice is lacking. The study seems to point the finger at reduced hours in residency as a big contributor, but it also pointed to changes in technology leading to a diminished skill level with regard to performing “open” procedures.

Over the last 40 years, we have seen how a society’s slavish devotion to getting everything cheaper has destroyed job after job in the American marketplace. If you thought that the medical community is immune from such an attack of thrift, think again. It was reported this week that deep in the fetid bowels of an office in Bentonville, Arkansas, Wal-Mart is planning an expansion of their well-documented retail activities into the realm of health care as a reaction to the not-quite-invalidated Affordable Care Act. As a solution to the country’s societal ills, this news ranks only slightly above ”Soylent Green is people”.

Finally, we have the curious case of Conrad Murray, the physician who was convicted of involuntary manslaughter for administering operating-room grade anesthetics to Michael Jackson in the months leading to his death. There are two problems here, the first being why this guy had a medical license to be able to implement a pain treatment plan like this, but there is a second problem here that is not being mentioned.

In this scenario, Conrad Murray is acting as an extremely well-paid concierge physician to someone with the resources to be able to afford this kind of questionable medical care. While there are a number of physicians leaving the insurance payment model to reduce administrative burden and to provide a better standard of care to their existing patient population, the high-dollar end of the concierge model is populated by physicians who are in the practice of  medicine strictly for the money. This is not to say that every physician who chooses this particular population to service is as ethically challenged as Dr. Murray, but Murray’s conviction has the appearance of a case where the number of zeroes in the pay check were directly proportional to the patient acting as his own practitioner, with the doctor acting as a spectator. Did Michael Jackson pay for a doctor, or a pusher with the imprimatur of ”M.D.” after his name in order to keep up appearances? More importantly, how many other doctors serving the well-heeled are following the same model currently, seemingly in opposition to the Hippocratic Oath? 

We have before us an interesting window of time to exist as a gatekeeper in the scientific discipline of medicine in the United States. There is progress, opportunity and danger both to the practitioners and to the patients they treat. While technology and delivery systems will continue to evolve, it is important to remember where medicine has come from since the time of Hippocrates. There will always be a part of medicine that will require a good bedside manner, manual dexterity and something more than a retail exchange. There are many mysteries about the human body yet to be discovered, but the presentation of care, at its core, has been and should remain the same.

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November 11th, 2011 | 4 Comments »

The Hidden Disadvantages of Buying on Faith

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

My house is not usually stocked with junk food, despite the fact that it tends to find me. In those many moments when snack food isn’t available, I tend to reach for the nearest box of cereal.

There has always been one thing that annoys me about breakfast cereals in this country. I have never possessed a box of cereal that contained all perfect specimens. The best example I can give is your basic box of Rice Krispies. Among all of the perfectly toasted grains of dried rice making noise in my bowl, I inevitably find that one black piece of rice that disguised itself among hundreds of other grains poured into my bowl. This outlier grain of rice is always found after I pour the milk in the bowl, which then leads to me spending five minutes trying to fish it out of my bowl before I accidentally eat it. To this day, I have no idea of the consequences are of consuming the black Rice Krispy, and I don’t want to know.

Each one of us, no matter what the product, is susceptible to attractive packaging. The picture of the cereal on the box, strawberries happily floating on top like little red clouds, always looks good, and let’s face it; if the house is out of cereal, you’re going to buy the box. It’s only later that your frustration rears its ugly head when the myth of the packaging is exposed.

It is on this final point that I begin today’s discussion topic; physician alignment with hospitals.

In the lead-up to ACO formation, hospitals are currently on a physician buying spree that would make a sailor on shore leave blush. In a recent research paper by Thomson Reuters, 44 hospital CEOs indicated that physician alignment was an issue of increased focus. If we pair that with another report from Merritt Hawkins stating that 76% of all physician openings offer a signing bonus, and the conclusion can be made that now is a very good time to be a physician looking for employment by a hospital.

Yet as I examine the issue further, there is one critical component missing, that being the due diligence required to determine whether the physician in question is a compliance nightmare waiting to happen.

In the current audit environment, most hospital systems are just beginning to get their arms around the RAC process for facility services. Because the audit entities have yet to expand into physician services, hospitals with large physician populations haven’t focused on the risks presented by the billing practices of doctors. Into this environment comes recently-acquired physicians and their accessory baggage. They look great, what with their shimmering CVs and smart ties, but it’s what you can’t see (or what is not volunteered) that poses the greatest risk.

If a newly-acquired physician comes to your organization either as an outlier based on billing, a poor documenter or someone lacking familiarity with your chosen electronic medical record, he or she can pose an immediate risk to the entire system.

Thankfully, one area where I spend a great deal of my time is in the area of practice analytics. The operative principals are available to determine the risk a physician poses to a facility, and it can be done in a manner that is time-sensitive prior to acquisition. It is a clear choice between paying a little bit now, and paying a lot later. To rephrase, are you buying the Rice Krispies because of the package and trusting that the alluring box contains cereal without flaws? If so, get your spoon ready, as black Rice Krispy fishing isn’t as easy as it appears.

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September 9th, 2011 | 1 Comment »

When Is A Business Model Not A Business Model?

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

My wife is not a big fan of gambling. In the few instances during our nearly ten years together where we’ve found ourselves in a casino, we tend not to hang around long. We were in Vegas once and I dropped $60 on a particularly surly slot machine. What I wouldn’t give to have avoided that ten minutes of spousal rage.

When we think of gambling, we tend to think of smoke-filled dens of thick carpeting, thicker cigarette smoke and the thickest dreams of hitting it big. Yet gambling comes in many forms, such as driving a car at rush hour, eating a sandwich from 7-11 or sitting on a toilet seat in a truck stop.

Thanks to data from two recent independent reports, we can add running a medical provider organization to the list.

The first of these reports was released on Tuesday, when the American Medical Group Association (AMGA) detailed the ongoing struggle of physicians nationwide to develop a workable business model. The survey of medical group compensation and finances found that most provider organizations are operating at a loss. 

The section of the country where the group operated in 2010 went a long way in determining the average extent of losses. This ranges from organizations in the Western region of the country averaging a loss of -$27 per physician, to the Northern region of the country, where physicians are operating at a staggering yearly loss of $10,669 each. This was in spite of the fact that compensation increased roughly 2.4% across all specialties in 2010.

If the AMGA survey set the table, another survey from the Medicus Firm offered information that seemed to find at least some sources of the revenue problems faced by physicians. Medicus’ survey, found here, found that the average compensation of those surveyed was down .14% from 2009 to 2010. Sixty-six percent of physicians surveyed stated that they expect their income to either stay the same or decrease in 2011.

When physicians were asked what issue most limits their income, 30.2% selected reimbursement decreases, which far outpaced other factors such as payor mix, increases in overhead and patient volume.

We are in the beginning stages of what is expected to be a critical shortage of primary care physicians. When such a large swath of the established physician community objectively states that they don’t see their financial lot in life improving, that certainly works as a flare fired above the heads of potential medical students faced with a decision to take on ten years of college loans for an occupation where reimbursement has plateaued.

These and other surveys are also taking note of the fact that hospital affiliation doesn’t equate to a better financial outcome. My inbox has been littered lately with stories of hospital systems trimming payroll by removing employees at the bottom of the ladder. This may very well be a side effect of the pre-ACO physician hiring binge. Odds are strong that physicians that have already affiliated with hospital systems will see their salaries flatline as the realization hits home that someone needs to absorb practice expense.

The bottom line is that between declining reimbursement and the looming threat of more of the same under PPACA, the incentives to remain part of the medical profession are disappearing. Physicians are told by a new era of hard line legislators and an entrenched insurance industry that they must accept someone else’s business model and deal with it. In order to build a working model, you have to have a reasonable expectation of revenue, which, given the insurance industry’s penchant for non-compliance with their own fee schedules, is impossible.

Interestingly, in the Medicus survey, less than 5% of physicians overall stated that the concierge practice appeals to them most, with the majority of physicians continuing to prefer the familiarity of a single specialty practice. Sometimes, the worst kind of gambling happens not in a casino, but in the place that is most familiar to you, when you simply decide to do nothing in the hope that things improve. In the immortal words of Kevin Bacon in that cinematic classic Animal House, as he absorbs hits from a wooden paddle to his gluteus maximus, “Thank you sir, may I have another!”.

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August 19th, 2011 | No Comments »

The RAConteur: Evidence of Physician Unpreparedness Mounts

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

I have an ongoing conversation going on with my friends and acquaintances about modern applications of the survival instinct.

The topic tends to come up when I see a news item about hikers getting lost and either dying or being rescued by park rangers after eating snow for 17 days in order to survive. I am an urbanized / sub-urbanized American. In addition to being allergic to virtually every natural thing on the planet after the outdoor temperature reaches 70 degrees Fahrenheit, I can look a person in the eye and tell them unabashedly that I do not like the woods, I’m not equipped to go hiking, and I’m not interested in the nutritional qualities of tree bark and wild berries. The more enlightened of my discussion partners tell me that knowing my own limitations, and the skills at which I do (and do not) excel, indicate that I have in large part passed the self-preservation test.

The topic of survival leads me to turn attention to the modern state of medicine. Physicians, especially primary care providers, are getting slammed in the modern age. A combination of rising caseloads, colleague shortages and changing insurance demographics have many front line providers operating at margins that are not sustainable. While it’s true that the Patient Protection and Affordable Care Act included incentives for current primary physicians, as well as plans to encourage more medical school graduates to enter primary medicine, the results of these proposals, if achieved at all, won’t be seen for roughly a decade.

All of these factors make it all the more important to monitor the financial health of the physician practice. The one constant with physicians is that they are lulled into a false sense of security with regard to revenue. The thought process that I have noticed is that as long as large insurance checks keep coming through the door, then all is well. I’d like to once again burst that bubble. Money isn’t a threat, but many things threaten your money.

This brings me to the subject of audits, RAC and otherwise. I was reminded again about the short attention spans of physicians with the release of the latest results from a service specific probe conducted by WPS Medicare. CPT code 99213 was probed for all specialties in the state of Wisconsin. This particular probe had an unusually low error rate of 30%, as compared to past probes of evaluation and management services. What was revealing to me was the fact that 80% of the claims found to be in error were due to lack of a physician response to the request for documentation from the probe. This demonstrates a continuing ignorance in the provider sector towards government audit processes.

The RAC contractors are fast approaching the day of reckoning for complex review of physician documentation. Unlike the popular board game Life, this will not consist of selling your blue and pink peg children and retiring to Millionaire Acres. With operating expenses nearly to the point of overwhelming practice profit, the beginning of expanded RAC review of physicians, if ignored, ensures the rapid demise of your bottom line, and eventually your practice.

A basic tenet of long-term survival is the ability to pay attention to and be prepared for threats. An example in the urban setting is looking both ways before crossing the street. In the woods, one would be best served by not waving and shouting ”HELLO!” to the bears. In the physician office setting, an easy stop on the road to long-term survival of the practice is to read all of the mail thoroughly. If processes aren’t in place to perform proper triage on the practice correspondence, it’s time to build them, and fast. If you’re a physician, your continued survival depends on it. You’ll be surprised how much easier it is than drinking melted snow.

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June 1st, 2011 | 1 Comment »

Tales of The Toxic Doctor

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

As I travel about the decaying world of civilized conversation, I have come to realize that people have varying opinions of physicians. As the gatekeepers of medical care, perceptions of doctors, based on cause-and-effect, eventually determine a person’s level of personal investment in their own health.

Having had five doctors in my family, I have absolutely no fear, and admittedly few ill feelings, towards those on the delivery end of the medical profession. When my pediatrician was “Uncle Ed”, how could I? With that said, knowing the dedication of the physicians in my family has given me a tremendous sense of what I like to refer to as “quack radar”. There have been providers who in the past have only seen me once, and then briefly, as the internal blips in my head have indicated that there is something about the encounter that isn’t in my best interests long term.

Which brings me to a white paper that was released this week regarding disruptive physician behavior. The report is a joint effort between a physician learning and communication collaborative called QuantiaMD and the American College of Physician Executives. The report is the result of a survey of 840 physicians and physician executives.

The report shows that roughly 71% of physicians state that they have noticed at least one instance of disruptive behavior by a fellow physician per month. Among the aberrant behaviors most often encountered are degrading comments or insults, refusal to cooperate with other providers, refusal to follow established protocols and yelling. The use of profanity came in a strong fifth among a list of 13 disruptive behaviors.

It is revealing that the behavior most concerning to the parties surveyed was the refusal to cooperate with other providers. Step back a moment and think not only of our current health care model, but the Accountable Care Organization model currently on the table as the proposed future of patient care. Increased integration and collaboration is envisioned as being the key to the elimination of redundancy and, by extension, the reduction of  healthcare costs, leading to institutional savings.

If the physician community is encountering barriers to care in the form of lack of cooperation from other health care providers, all models for integration, savings and, ultimately, better patient outcomes, grind to a halt. Consider that 90% of respondents to the survey believe that disruptive behavior either always or sometimes affects patient care. In the pre-ACO world, patients face the choice that I myself have been faced with in the past; stick around for care that would not be in my best interests, or find someone else to be the gatekeeper of my care. The ripple effects are something of a one-to-one measurement of one doctor’s loss to one doctor’s gain.  

Now consider the proposed integrated model. With a healthcare facility as the hub of care, everybody’s reputation stands to take a hit for the actions of a few abrasive personalities. Unless the hub facility has firm policies of reporting such incidents, with appropriate progressive discipline up to and including discharge for the most egregious violations, potentially every provider of services presents a threat to the organization.

Having passed the halfway mark in my life, I’ve made a commitment not to surround myself with miserable people or those whose attitude I find aggressive or prickly. Personalities like this drain the air out of the room and eventually lead to a toxic environment. When such a personality is your medical professional, it could be a direct threat to a healthy existence. From the results of this report, enough physicians see this as an ongoing problem. The question now becomes how important such an issue is to health care organizations, and whether the potential risk to reputation will finally be enough to force them to act.

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May 27th, 2011 | 1 Comment »

The RAConteur: And Still, Physicians Wait….

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

Being a lifelong insomniac, I am a seasoned watcher of late night black-and-white horror and suspense films. From a film maker’s perspective, there are a number of ways that a camera can use the unique light and shadow of black and white film to raise the level of tension needed for such a film. For my money, the best of these is the time-honored shot of the pendulum of a clock, swaying back and forth, an ominous tick marking the limits of its swing on either side of its well-worn path.

From the moment the Recovery Audit Contractor program became permanent, the world of silence broken only by the movement of the pendulum is where physicians linger. Every health care professional with any kind of awareness of the RAC program has blared warnings from the rooftops stating that doctors are next. Yet to the moment, the effect of the RAC program on physicians has been minimal.

Since we’re now more than one-quarter of the way through 2011, I’ll ask the question on my mind, and possibly yours; if I keep speaking of the RAC program as soon coming after physicians, am I reading from the book of Revelation or a play by Samuel Beckett?

The RAC contractor websites are beginning to offer clues as to what happens next for physicians. DCS, the Region A RAC, has added several issues affecting physicians since the beginning of 2011. Most of these relate to E/M services billed without the -25 modifier on the same date as other procedures. Incorrect usage of the -50 modifier for bilateral procedures has also been added to their list of approved issues. HDI, the Region D RAC, added issues in February and March of this year related to the billing of Mohs micrographic surgery and physician visits billed as inpatient for patients who are staying in a swing bed that is classified for nursing facility care on the date of service. These issues have been approved for automated review.

CGI, the Region B RAC, has neglected to add any issues relating to physician services in 2011. Similarly, all recent issues added to the approved issues listing for Connolly Consulting in Region C have related only to inpatient hospital services.

Three weeks ago, I conducted a seminar under the auspices of the Wisconsin Medical Society on RAC audits and how physicians might be affected. One question / comment that I received at the end of the presentation (paraphrased) was that is appeared that physicians as a whole are not prepared for the RAC audit process, which I agreed with wholeheartedly. Keeping that in mind, we are now almost two years into the permanent RAC program, and not a single physician-related issue has been approved for complex review. Only the “low-hanging fruit” that are blatantly obvious billing errors are being captured.

I am learning through anecdotal evidence that RACs are conducting complex probe audits of some larger physician practices for issues not yet appearing on the approved issues list. This is a legitimate practice according to CMS. For the rest of the physician population, this lull in the action provides an opportunity to assess your practice’s risk for audit, not just from governmental entities and RACs, but from special investigation units. Have someone with a non-jaundiced eye take a look at your practice’s utilization and determine whether your billing patterns display you to all the world as an outlier from your colleagues.

The pendulum continues to swing, but it need not be suspenseful. Conduct all the necessary legwork for your practice now to drown it out. After all, staring at it is liable to put you to sleep, which is exactly what the RACs are hoping happens to you.

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April 13th, 2011 | No Comments »

The RAConteur: Shifting into Success

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

I love driving in a car. I have a personal dream of driving from Anchorage, Alaska to Tierra del Fuego, which is one of the southernmost points in Argentina. As it is, I am deferring to this year’s warm-up, which is a drive to St. John’s, Newfoundland in Canada in August, a mere 2,500 miles and change from where I’m sitting. If nothing else, Jim, my mechanic, is never bored.

Over the past week, I drove over 1,900 miles throughout the Midwest and South visiting sites and friends in Nashville, Knoxville and suburban Atlanta. I happily admit that I also feel the need for speed. On Wednesday, at the conclusion of this past week’s journey, I drove 801 miles from Marietta, GA to my garage in Milwaukee in 12 hours and 5 minutes. This time included two stops for gas, one for the omnipresent call of nature, and a one-hour traffic jam coming back through Nashville. Since I own an economy car, there is an air of unbelievability when I pass a slow moving V8 at 80 miles per hour.

Speeding has its place on the highways of the Americas in controlled circumstances, and for physicians and their paper correspondence, speed, coupled with a little knowledge, can be a friend as it pertains to RAC requests.

As the RACs prepare for their expansion into complex review of Part B services, one concern that I have is that physician offices to date have a terrible record of responding to requests for documentation for other types of audits. Here in Wisconsin, WPS, the MAC in this part of the country, is in the process of conducting Service Specific Probes for selected E/M codes, based mainly on CERT results. As these individual probes are completed, the biggest reason for negative results for physicians under the probes is providers not responding to requests for documentation. This is an enormous red flag as we find ourselves on the brink of expanded RAC activity.

The time has come to educate front desk staff to recognize RAC correspondence, and how best to respond. Since the car finally stopped, I’ll volunteer to do it.

If an envelope has “CMS” in any form in the upper left-hand corner, the correspondence should move to the top of the pile immediately. One needs to remember that the deadline clock doesn’t begin to tick when you open the letter. In fact, the clock began to tick as soon as that letter was postmarked, which makes rapid response to the request that much more important.

After compiling all requested data, copy it for your records and forward the information to the RAC. After the information is forwarded, follow up with the RAC in 10 days to verify receipt of the information and to establish a verbal contact with the contractor. Throughout the process, be aware of the RAC’s 60-day timeline to respond once information is requested. This can become a quality issue for the RACs as they seek to keep themselves contracted under CMS as a RAC if they are late with their response.

At this point, it is up to the front desk to keep an eye out for the review results letter from the RAC. A different set of timelines now come into effect with regard to a possible discussion period with the RAC. The practice has 40 days from the date on the results letter (or demand letter, in the case of automated review) to make a decision regarding discussion or appeal.

If you are a physician, dealing with practice expenses that leave you with little margin for sudden loss of revenue, it is imperative that you educate your staff to inform you of any demand letters of an amount that would be financially ruinous to your practice. A review results letter or a demand letter should not come as a surprise, but if your staff doesn’t treat it with the immediacy it deserves, or worse cannot recognize it at all, a high-dollar recoup could end up being your most unwelcome (and possibly last) surprise as a physician in private practice.

Much like being behind the wheel of a car, hyper-awareness and speed make all the difference on your journey. The RACs are mercenaries tasked with finding mistakes, and are incentivized by a cut of any dollars recovered. It is not enough to bring a big car to the fight for protection. It requires the ability to fire back. Do the right thing now and educate office staff. It will be the equivalent of the A-Team turning your car into a tank.

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April 1st, 2011 | No Comments »

The RAConteur: Still Catching You Unprepared

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

People are never prepared for a surprise.

As I look at that last sentence, I realize that all of the great surprises foisted upon humankind, both positive and negative, have been done. Someone walks into a room full of friends and balloons on their 50th birthday, a baseball is fouled off and somehow ends up in a fan’s hands, Pearl Harbor, auto accidents and (of late) natural disasters are just some of things that continue to surprise people.

Surprises bring with them equal parts discomfort and risk, and so it is with the RAC program as it applies to the physician community. I have spent the better part of the last seven months educating providers about the risks of a RAC audit to their practices. I have taken the extra step of letting doctors know what codes will more than likely be in the cross hairs. At the end of the day, I’ll still find physicians who fall into one of three categories who will completely ignore everything I continue to say:

The “But-I’m-So-Small-They’ll-Never-Come-After-Me” Group – Whenever you are dealing with an entity that works for the federal government, size doesn’t matter. The only things that matter to a RAC are 1) utilization patterns and 2) finding easy contingency fees. You can be the country doctor in a rural town of 200, but if your billing patterns are outside the norm, let me pre-empt an upcoming surprise for you: you are going to be the subject of a RAC audit.

The “I-Just-Bill-Every-Patient-At-Level-3″ Group – Ah yes, the magical, mythical road of perceived safety known as “the middle”. You know the ones in the middle. They’re the ones at the party observing everyone else having a good time, never approaching anyone for conversation, hovering around the peanut bowl like a vulture targeting carrion, going home satisfied just to have survived. Meanwhile, the host is stunned at how few peanuts are left at the end of the party. The providers who take the middle approach damage everyone by skewing utilization, but do the greatest damage to themselves by telling the world that true medical necessity doesn’t exist in their world. Patients with multiple chronic illnesses exist on the same plane as rashes in this universe. Your surprise is coming, too.

The “What’s-A-RAC?” Group - Isn’t it amazing how this random collection of letters I compile every week in this space add up to no clear message for physicians in this group at all? The time to learn about recovery audit contractors is most definitely not when you receive a request for either records or money as a result of an audit. I’ll remind doctors in this group of a common theme that runs through all of my RAC education. Recovery dollars are not just sitting around in a big pile in a safe somewhere. Those dollars have already been reinvested back into your practices, and paying it back could be devastating to your bottom line. Your coming surprise will be twofold, and both will be unpleasant in nature.

The way we mitigate unwelcome surprises in our lives is to prepare for the worst. From auto insurance to long-range radar to skipping town for your 50th birthday, we have tools at our disposal to deal with life’s curve balls before they are batted into our laps. The permanent RAC program has been up and running long enough for everyone in the provider community to now internalize that this is real, it’s a threat and it’s not going to stop anytime soon. Change is difficult, but change in the midst of an entity taking away monetary resources is impossible.

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March 23rd, 2011 | No Comments »

The RAConteur: Physician RAC Experiences

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

It has been an interesting week in the news, with a revolution in Egypt, a Super Bowl winner being crowned (being in Wisconsin, I think I heard something about that) and the news that a diet of junk food lowers your IQ. I take exception  to that last item. I myself had a donut for breakfast and it tasted very much goodly.

There was another news item that caught my eye. A few industry news sources reported that the American Medical Association spent $22 million in 2010 for lobbying activities on Capitol Hill. Most of this money was focused on heading off the adjustments to the Medicare Physician Fee Schedule.

The AMA, as an organization, has been putting most of their organizational might towards insuring future reimbursement. In addition to their efforts on the Medicare Fee Schedule, the AMA has been active with an initiative that grades the major health insurance carriers on their claims activities. While this is a noble goal given the extraordinary level of proven malfeasance in the insurance industry, we now face a two-tiered reality with regard to physician reimbursement. Physicians are not only having to go to extremes to insure current reimbursement, but now find that dollars already received and reinvested in their practices are in jeopardy thanks to an expanded audit environment that includes RACs, MICs, Medicare Risk Adjustment and special investigation units from commercial insurance companies.

By comparison, as it pertains to the RAC program, the American Hospital Association has had their pulse on the RAC program with the AHA RACTrac Initiative. This program is an ongoing survey of its member hospitals that tracks their RAC activity on several levels, from the number of records requests to the rate and success of appeals of negative RAC determinations.

Up to this point, there has yet to be an entity that collects this same data sets for physicians. It would seem to make sense that the AMA collect this data, but this has yet to occur.

In the absence of information, I received an e-mail this week from an independent entity who surveyed their client base on the level of RAC activity. Approximately 80% of the respondents to this survey identified themselves as medical practices. While the survey was rather small, the most revealing result is that 32.3% of overpayment determinations were later overturned on appeal. This number shows that the RACs are still on a learning curve for their reviewing skills.

Like many others, I eagerly await the overall results of the RAC program from 2010, along with those of other governmental audit initiatives. The detailed results should be released sometime in the next two months. In the meantime, my ongoing advice to physician practices stands. If you believe that the RAC contractor has made an incorrect determination, fight it. Even the most die hard junk food junkie has a few IQ points remaining to figure that one out.

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February 9th, 2011 | 1 Comment »

The RAConteur: The 2011 Physicians RAC Summit

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

I returned to Milwaukee yesterday after attending the first 2011 Physicians RAC Summit in Orlando, FL. As a presenter at the conference, I found it to be a fantastic venue for interaction between professionals from multiple arenas in health care. I had a chance to have break-out discussions with physicians, consultants, hospital billing staff and representatives of the AMA within a span of 4 days.

We now have one year of the RAC permanent program already in the books. Yet one theme that continually reoccurred during the summit was that many health care providers and institutions still do not have recovery audit contractors on their radar. Based on the needs demonstrated at this conference, a commitment was made by Fi-Med Management, Inc. (the sponsor of the summit and – for purposes of transparency – my employer) that the Summit will be repeated throughout the country in 2011 in the other three RAC regions.

Much time was spent at the Orlando Summit focusing on data that practices generate, and the best way to collect that data in an objective fashion to determine audit risk. This is a different approach from the current standard of simply waiting for bad news and reacting to it. The balance of the other sessions focused on RAC targets in physician practices, audit tendencies of RAC’s and other entities and current trends in health care affecting providers.

Physicians find themselves at a disadvantage in the current educational climate when it comes to the RAC program. While there is a national RAC summit in Washington, DC in the second week of March, a look at the conference schedule yields not one session dedicated to RAC preparedness, either administratively or economically, for physician practices. It is almost as if the co-sponsors of the event and the actual event itself are in direct opposition to one another. Given that one piece of news shared at the Physicians RAC Summit is that a few practices are now receiving additional documentation requests (ADRs) for E/M services, an information vacuum has developed on the physician side.

While the subject matter will be different based on future presenters, the Physicians RAC Summits will continue to focus on physician issues, primarily in the realm of economic health and future viability. There is a perception that physicians have no choice, based on RAC audits and other negative stimuli, but to cede their practices to hospital systems with a belief in there being a perceived strength in numbers. The Physicians RAC Summits are an attempt to show that there is another set of numbers that are being ignored, that being physician revenue, and that the time of believing  that the physician has no power in the face of deleterious insurance audits and contracts has finally come to an end.

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January 14th, 2011 | No Comments »

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