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

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

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

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

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

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

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

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

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

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

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

Despite all of my efforts, I have a large ongoing problem, that being my futile attempts to get physicians to pay attention to government audit issues. Perhaps it is the landscape in which large numbers of physicians are seeking employment under the assumed safety of hospitals, but my general feeling is that physicians are largely ignoring the message.

Just this morning, I received yet another reminder of this battle in my e-mail box. I subscribe to updates from multiple sources, most notably Medicare Administrative Carriers for assorted issues of interest to the provider community. Today’s electronic missive comes from WPS, the legacy Part B MAC for Illinois, Michigan, Minnesota and Wisconsin. For a few years, WPS has been a few steps ahead of other MACs with regard to conducting service specific probes on the heels of CERT testing discoveries under their jurisdiction. Of note, CPT code 99233 (Level III Subsequent Hospital Visits) has been on WPS’ radar for nearly two years across multiple specialties. Yet if today’s e-mail is any indication, the message of the importance to attention to review issues continues to fall on deaf ears with regard to the physician community.

WPS looked at this CPT code for the specialties of Neurology and Family Practice. Over the past 15 months, initial probes for these specialties revealed an error rate of 96.24% for Neurology and 89.54% for Family Practice, which quite obviously necessitated a follow-up review for both specialties. While there has been some improvement since the initial probes, a simple glance at the latest numbers show that physicians aren’t giving these reviews proper attention.

For Neurology, 128 line items across 98 claims were selected to review prior to payment. Of these, 102 line items were denied, for a cumulative error rate of nearly 80%. For Family Practice, 157 line items across 100 claims were selected, with 113 line items being denied, for an error rate of just under 72%. These numbers are bad enough, but a closer look reveals that roughly 60% of the denied claims for both specialties were due to physicians not providing the requested documentation for review. This means that 6 out of every 10 complex inpatient follow-up visits were denied because no one opened the envelope and/or read the correspondence inside of it.

I have limited amounts of free time in the coming year. I have people to educate face-to-face, networking opportunities with others in my profession, personal trips to various parts of North America between now and the end of Summer and a 5-year-old to keep on the straight and narrow. Nowhere in my small, handwritten pocket calendar do the words “BEAT HEAD AGAINST WALL” appear. From the moment The RAConteur began in September of 2010, I have been warning providers that the auditing landscape is changing, and not in a way that will be beneficial to either the delivery of care to their patients or their financial bottom line. Perhaps, someday, the physicians of America will begin to take a small step towards increased awareness. Might I suggest that the first part of that process to be the purchase of a letter opener?

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

The 9/11 attacks had the effect of changing that perception for the balance of my life. I remember having a conversation a few days after the attacks with someone I knew at the time, talking about how best to prepare for similar incidents in the future. I felt that every community should have a disaster plan similar to the air raid wardens of World War II or the nuclear attack drills of the 1950’s, which would integrate public employees and buildings, along with the local health infrastructure, to provide an organized and coordinated response to such incidents.

Instead, we received the “War on Terror”, color-coded paranoia and the Big Brother-esque overreach of the Patriot Act. I stopped being optimistic shortly after that. Perhaps it’s my tendency to watch old post-nuclear science fiction films during my late-night fits of insomnia that informs my decision making, but when I heard the head of the Department of Homeland Security tell me that my best defense against future attacks was plastic and duct tape, I was immediately skeptical about our country’s ability to handle future disasters.

It was with all of this in mind that I read a 44-page report released this week from the OIG entitled Local Public Health Preparedness for Radiological and Nuclear Incidents. The report was commissioned based on the belief of our current national security apparatus that the greatest danger to America is a terrorist attack utilizing a nuclear weapon. To assess planning and coordination in the event of such an incident, the OIG requested information from 40 localities from around the country, representing the largest metropolitan areas in and around cities in 23 states, totalling just over 50% of the total population of the United States. The findings of this report clearly show that preparedness for radiological and nuclear incidents is far behind where it needs to be.

Thirty-six of the 40 surveyed localities have conducted some type of risk assessment for a disaster. Because the OIG report did not specifically name the four localities that did not, I am unable to tell anyone specifically to begin digging holes for your survivalist bunker. Of the 36 that did conduct a risk assessment, 30 specifically identified non-power plant related radiological/nuclear incidents as a threat, with 24 of those determining the specific threat level. Taken as a whole, this means that there are 16 major population centers in the country that have not fully determined the risk of a nuclear attack in their area. Only four of the 40 localities have identified radiological incidents as a high-priority threat, but only one had a specific plan in place to respond to such an incident.

The OIG assessed the preparedness of each locality in five areas of responsibility in public health: Monitoring of the population for exposure, decontamination, planning for laboratory analysis, fatality management and communications. Only 21 of the forty had any sort of public health plan in place in case of a nuclear incident that encompassed any one of these areas, but only two localities had plans that included all five. Perhaps the scariest thing to me was that only 8 major population centers in the United States have fatality management plans to limit the amount of exposure to the surviving population emanating from those that will have already perished in such an attack. Knowing this bit of information suddenly reminds me that thoughts of a zombie apocalypse are not as rib-tickling as they were prior to the release of this report.  

When the issue of greater coordination with federal, state and local partners was assessed, only 16 localities have plans that coordinate with any one federal department, with 10 coordinating with their state agencies and 14 coordinating with local entities such as hospitals, county health departments or other emergency medical personnel.

Taking all of this information into account, I have determined that the community health plan for most population centers in the event of a nuclear event consists of three steps: hoping for survival, fitting your vehicle with a plow attachment to move the bodies out of the street, and concluding with more hope for survival. I know it’s hard to see my face in that this is written material, but it is important for you to know that I didn’t crack a smile when I wrote that last sentence.

Chances are fairly good that when you drive home tonight, you’ll pass an older public building with a faded sign that says “Fallout Shelter” on it. There was a time in America, corresponding to the existence of a country known as West Germany, when that sign was brand new, painted a bright yellow, with everyone in the community having acute awareness of what it meant. Perhaps you’re even old enough to remember a “duck-and-cover” drill, the CONELRAD system, the letters ”CD” standing for “Civil Defense” rather than “Compact Disc” or some other quaint custom that kept the idea of the dangers of radiation exposure in the forefront of your mind.

Since this is a health care forum, I ask the reader to save a thought for how they believe their local health infrastructure would respond to such an attack. We find ourselves in an era of consolidation of health care resources under the ACO model that is designed mainly to reduce cost. While IT initiatives have mentioned such things as better coordination of care and improved public health reporting, all of these good intentions will crumble during a cataclysmic event without a disaster plan in place in the communities surrounding the hospitals. The OIG report shows that many areas don’t  have one that is adequate. Additionally, if the recent breakup of the band REM didn’t already drive the point home for some of you, know that the relatively tranquil and naive days of the 1990’s are an increasingly distant memory on the roadways of our lives.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

Before I do my level best to attempt to erase all memories from last week’s posting, let me start by saying that I grew up in an urban environment. I say this because I want everyone to know that I’m not a fan of camping. Having never started a literal or figurative fire before in my life, I’m not particularly well-versed in controlling a conflagration before it takes out the surrounding trees. I have come to believe that the biggest part of the survival instinct is knowing where you don’t belong and seeing that you never arrive there.

In the realm of accuracy, last week’s post might as well have been a wicker man soaked in gasoline dancing in dry brush. 

As many readers almost immediately pointed out, the data supplied in last week’s posting, which was taken directly from a CGI PowerPoint presentation, was about as accurate as Kim Jong Il’s state-sanctioned official biography. While I have already posted the corrected information on a Google group board dedicated to RAC issues, I shall repeat them here for everyone’s benefit.

The original information posted stated that there had been only 7,919 audits conducted through December of 2011, with only 5 yielding no findings. The correct number of audits completed is actually 23, 594, with 17,984 of these lacking findings. For the math challenged, that represents an increase in lack of findings from the original number of nearly 3600%, or as Bob Uecker put it in the movie Major League, “Juuuuust a bit outside”. Of note is the fact that over 22,000 of the claims reviewed thus far have been for inpatient services, but this too was patently obvious to those who have had the most interaction with CGI in Wisconsin.

With regard to discussion periods, CGI’s original number of 502 discussions requested was actually revised downward to 216. According to my source in attendance, when CGI presented this number at last Thursday’s session, they followed it up by saying that 200 discussions were “affirmed” while 8 were “dismissed”. Unfortunately, they did not offer clear definitions regarding the true meaning of these terms. I reviewed the modified Statement of Work from this past September, and this also shed no light on any possible definitions.

There is one additional slice of information that CGI shared regarding discussion periods. My source states that the CGI educator conducting the outreach session last Thursday made a point of encouraging providers in Wisconsin to enter discussion periods based on the low number requested statewide thus far. I have come to learn that based on the compressed time frames of both discussion periods and recoupment, providers are finding it to be a nearly impossible task to track dollars that were first determined to be overpaid, then either slated for recoupment or recouped, only to be subsequently reversed by a discussion period and repaid to the providers. As it is currently configured, providers are finding the discussion period to be a useless level of bureaucracy in an already laborious process. Until this paradox is meaningfully addressed, CGI should not be looking for an increase in requested discussions.

The above numbers were not the only piece of information provided by CGI in their presentation that was found to be incorrect. As part of their printed materials, CGI offered addresses for providers to enter Extended Repayment Plans with their Medicare Administrative Carriers (MACs)that were incorrect. The person conducting the outreach session did not have the correct information on hand.

One of my pet peeves about the RAC program is that the contractors are not telegraphing when outreach sessions are taking place. Based on my fire-fighting experiences of the last week, I can add an addendum to this frustration, that being that when the contractors do conduct outreach sessions, the information brought forth is self-serving and inaccurate. This whole episode serves as a lesson to the provider community to cast a skeptical eye on future outreach efforts. That is, if anyone even lets you know when they are occurring in the first place.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

Tomorrow night in Milwaukee, I am going to see Glen Campbell perform in concert, but the occasion will more than likely be bittersweet. The man who has given his music to the world for a majority of my lifetime is on his final tour, having recently been diagnosed as being in the early stages of Alzheimer’s Disease. It is not lost on me that all of the facts in the above paragraph, which my lifetime of music as a hobby has allowed me to commit to memory, will someday be foreign to the very person who made them possible.

As someone who has been involved with the health care industry for over 20 years, I have learned that based on the sheer volume of facts that inundate me on a daily basis, it has become nearly impossible for me to forget key elements of my job. As the cost of health care has become a central focus for cuts in a post-war economy, a number of  memories of failed policies of the past are skipping to the front of my mental line. Nowhere is this memory more acute that in the realm of physician reimbursement from the Medicare program.

Forty-one days from now, a song-and-dance act that has been running longer than Cats will repeat itself, as the increasingly polarized sides of our government once again raise the curtain on this year’s performance of Doc Fix. There are slight casting changes with every performance, but the script is the same. In the torch-lit Temple of SGR, an automated computer program threatens to take money away from the white-coated sailors on the HMS Doctor. As the sailors fight off armies of infirmed elderly waving checkbooks from behind the wheels of their Buicks, an unlikely set of heroes, wearing bad suits and American Flag lapel pins, short circuit the program with a stack of paper. As they stand in the setting sun, they promise to one day rid the world of the computer, but vow to be ready for anything else it plans to offer.

Oklahoma it ain’t……

Medicare reimbursement has gone from “pay everything” at the beginning of the program in 1966, to RBRVS and Gramm-Rudman-Hollings reductions in the ’80’s, subsequently to SGR in the late ’90’s, and finally to a yearly hostage crisis, with the only missing element seemingly being the security camera shot of Patty Hearst with a machine gun. We know this because it has affected us all in one form or another over the years and we have internalized the memories of the negative results of every one of these “solutions”.

Might I suggest that the solution doesn’t lie with finding a new payment methodology, but in finding savings from outside contractors for the Medicare program that (because I have it committed to memory) continuously take money needlessly from the program.

You can start by eliminating Medicare Part C. Virtually all of the “preventive benefits” offered to patients under these plans are now codified into traditional Medicare, which leaves Medicare Part C as nothing more than a government subsidy designed to prop up the insurance industry with billions of dollars that it doesn’t require for its survival.

Next we can go to Average Wholesale Price for reimbursement under Medicare Part D, rather than Average Sale Price. Additionally, pick one formulary and take the program out of many of the same hands that currently pollute Medicare Part C.

As for fraud investigations, leave in place predictive modeling and the HEAT teams, because these methods are actually getting to the root of the problem and are returning ill-gotten dollars to the Medicare program. When it comes to outside entities, we need not develop memories of the Recovery Audit  Contractors, because their abhorrent work product is currently on display for all the world to see. Roughly 2/3rds of everything they do is dedicated to purposeless paper shuffling, rather than the detection of actual improper payments. One marvels at the thought of the massive celebrations that would result if the RACs suddenly disappeared. Farther up the chain, the ZPICs on average collect about 2% of everything they extrapolate as an overpayment, but we don’t really know the actual number because the OIG has stated that the baseline data to measure their performance is fatally flawed. This reminds me that until that data is purified, the ZPICs will continue to mainly operate as a middle man for government-sponsored subsidies to the legal industry. Ask your typical taxpayer if that is something they wish to continue.

The development of the human memory keeps one from being fascinated by the latest shiny pocket watch issue being pendulated in our faces by the self-absorbed politician of the moment. Much like Glen Campbell, there may come a day that the many facts parading in our minds will begin to slip away. Until that day comes, in the realm of health care, memories are not just a rudimentary tool of assistance, but a blunt weapon against the many forces attempting to shove unwelcome schemes into an arena currently collapsing from the bad ideas of the past.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

In past postings in this space, I have touched on the lack of useful provider outreach on the RAC program. This week, thanks to one of my contacts roaming the landscape in the land above my sealed concrete and steel bunker somewhere outside Milwaukee, Wisconsin, I received a PowerPoint presentation from CGI, the Region B RAC, that will be presented tomorrow to a meeting of health care finance professionals in my state. The slides represent further proof not only of the sporadic nature of current provider outreach, but through the use of statistics, also show that the RAC program still has a long way to go to prove the quality of its work product.

The presentation begins with RAC statistics just for the state of Wisconsin in Region B, which are quite revealing. Through the month of December just passed, CGI has completed 7,919 audits. Amazingly, only 5 of these audits have been without a finding of some type of improper payment, which on the surface appears to be a testament to the accuracy of the approved issues listing in Region B.

Of the completed audits, 502, or just over 6%, have had a discussion period requested by the provider in question. Of these claims, 258, or over 51%, have resulted in determinations of either a full reversal or findings  ”partially favorable” to the provider. These particular statistics appear to indicate that the discussion period is being under-utilized by the provider community in Wisconsin. It is worth remembering that providers can initiate a discussion up to 40 days from the date on the demand letter. Because the RACs do not directly handle claims appeals, it shouldn’t be surprising that this presentation does not contain appeal statistics.

There is one additional important bullet point in CGI’s presentation related to discussion periods. There may be some cases where due to the length of the discussion period, an adjustment request will be processed by the Medicare Administrative Carrier (MAC) prior to the issuance of a Discussion Results Letter. In these cases, if the discussion period yields a reversal, the provider will see the overpayment on a subsequent remittance advice and will receive a Demand Letter from the MAC, but the reversal will be processed and seen on a future remittance.   

There are slides in the CGI presentation that remind providers of time lines like the one in the previous paragraph above. There are 5 slides concentrating on how to best use the CGI RAC website. In checking the site, there is an update regarding the demand letter process on their front page. Other updates will have to be discovered under the Provider tab by individuals handling the RAC process for physicians and facilities.

The slides contain overviews of semi-automated review, current approved issues in Region B and the new process by which MACs issue Demand Letters. One interesting point found near the end of the presentation is related to Extended Repayment Plans. The MACs are now the point of contact for initiating such plans rather than the RACs, which is consistent with the Demand Letter change. Remember that the RACs are responsible for claims issues, and MACs cover the financial implications of those claims.

I have been critical of RAC outreach efforts in the past, but I can honestly say that there is some useful information in the slides. After reviewing the presentation in full, I do have two complaints about this process. First, it is long since past the time that the contractors update the outreach sections of their websites to reflect current and future sessions. In CGI’s case, there have been no updates to this particular schedule in 10 months. Second, while the time lines in the presentation have long been part of the RAC Statement of Work, there is increasing anecdotal evidence that there are common breakdowns in the process. Based on the volume of requests being received by some facilities, these “improvised” timelines are creating havoc even for those providers who have put a technological tracking tool in place. Many questions remain unanswered, and a few occasional PowerPoint bullets are proving insufficient to explain why.

I have sent some questions to ask of the presenter at tomorrow’s session through my contact. It is hoped that I can address my questions in a future edition of The RAConteur. Until then, from deep in the dimly-lit hallways of the compound, I bid you a temporary farewell.

Paul Spencer will be a presenter at the Fi-Med RAC Summit in Milwaukee, WI on April 16th and 17th, 2012. Go to the Summit website for further information on this unique educational opportunity. Use promo code “SPENCER” to receive $50 off the registration price for a limited time.

In the last 50 years, technology has changed the way we live. Other than what surrounds us in our homes, institutions such as aviation, public libraries and finance have seen paradigm shifts thanks to the core technologies at the heart of their operations. Perhaps no other sector has been altered quite like the world of health care.

Over the past few days, with CES’ shadow looming over the landscape, a few indicators of the changes that have either come to or are on the horizon for health care came to light.

The first was a study appearing in the American Journal of Tropical Medicine and Hygiene (now THAT’S specialized) that looked at the role of social media in the reporting of the post-earthquake cholera outbreak in Haiti in 2010. Given the ubiquitous nature of Twitter, the study looked at “tweets” emanating from the quake zone in the time leading up to when the outbreak was widely reported by the news media. What was discovered was that Twitter users were reporting the cholera outbreak and bringing forth case data to the world a full two weeks before then outbreak was widely reported.

This story teaches us that in bold terms that the news cycle is evolving to “up-to-the-minute” faster than any of us anticipated. In the case of a disease outbreak, time between identification and treatment can prevent further loss of life. With the threat of pandemics such as SARS and avian flu over the past decade, we now have scientifically-vetted proof that social media can play a very important part in shrinking that time frame.

Part of CES is what is called a “Digital Health Summit”, where a particular innovation or initiative takes center stage during the keynote address. This year was no different, with Ford Motor Company stating that they are partnering with Microsoft and two other tech companies to design a car that will monitor the driver’s health while traveling.

In reading this item, I was immediately reminded of my car trip this past summer that saw me drive from Milwaukee, WI to St. John’s, Newfoundland, Canada and back. In particular, the drive back became what I can only describe as driving between memory gaps. After setting off at 7 AM in St. John’s, I had planned to stop for the night on a Thursday in Moncton, New Brunswick after 12 hours of driving across Newfoundland, 7 hours on a ferry and roughly 5 more hours on the road from Northern Nova Scotia. What I didn’t count on was that apparently Thursday night is “Take Your Mistress Out To Dinner Night” in Moncton, as every hotel room in the town was booked. What followed was 22 more consecutive hours of driving from Moncton to Milwaukee, with stops only for gas, fast food & caffeinated beverages on the New York Thruway and moose hallucinations along the darkened roads of Maritime Canada. Somehow, I arrived safely in Milwaukee at 2 in the morning on a Saturday.

It would have been nice to have had a car that knew I was seeing antlered mirages, so it could shut off and pull over to the side of the road until it detected REM sleep. I hope that Ford follows through on their concept, not just for the exhausted, but for the drivers with health risks that could pose a hidden danger to themselves and other nearby motorists.

The last bit of technology news borrows something from the dark arts of psychic phenomena. On the heels of a study at the University of California-San Francisco which covered development of useful prognostic indicators for older adults, a new website has been created to help create a mostly accurate estimate of an elderly patient’s remaining life expectancy. While planning end-of-life care is a neglected part of the health care debate in this country, there is something about this technology that sends a shiver up my back. One of my all-time favorite short stories is “Imagine A Day At The End Of Your Life” by Ann Beattie. Someday, when my time comes and with the help of this website, I’ll not only be able to imagine such a day, but I may very well be able to mark it on a calendar. Having always believed that life doesn’t include a two-minute warning, I shall look deep within myself in the intervening years to decide how I feel about such a website.

The lightning pace of technological innovation has brought dramatic change to the science of medicine. It would be naive to think that the emerging technologies indicated above are simply novelties, as for every failed invention comes the spark of furthern imagination. Upon my retirement 25 years from now, it is very possible that one or all of these current technological leaps will be considered a quaint stepping stone to what exists at that future moment in time.

Paul Spencer will be presenting at the Fi-Med RAC Summit in Milwaukee, April 16-17, 2012. Go to the summit website for further information. Use promo code “SPENCER” to receive $50 off the registration price for a limited time only.

Those of us affected by the gravitational pull of government audits are entering the new year with two challenges right out of the starting blocks.

One important change that occurred was widely known prior to implementation, but fell apart in execution. Beginning on January 1, Medicare Administrative Carriers (MACs) took over the process of issuing demand letters for Medicare RAC overpayments. Given the fact that the RACs exist because the MACs make claims adjudication mistakes, it was perhaps inevitable that this seemingly simple task would become a problem.

The demand letters, as issued by the RACs, would include multiple claims issues for one provider on one demand letter. The MACs, demonstrating the administrative acumen that launched 1,000 fraud investigations, have been issuing a demand letter for every identified RAC overpayment. This was followed by urgent e-mails from each MAC stating that they were “working with the system maintainer to ensure transactions are aggregated at the provider level on a daily basis”. This is legalese meaning that for the short term, demand letters will pile up in provider mail rooms like vacation junk mail.

The second challenge facing providers has yet to truly reveal itself to the provider community. The Medicaid RAC program has officially reached its implementation date as of January 1, 2012. Because there was very little guidance on the provider level leading up to this date, most providers find themselves in the dark with regard to the Medicaid RAC program, save for what appeared in the Final Rule released back in September.

To fill in the blanks, CMS released an 18-page Frequently Asked Questions (FAQ) document addressing the Medicaid RAC program and what can be expected. In all, there are 53 questions and answers within the pages. As is my custom, I did some reading so you can go do something else. I’ll go in semi-numerical order covering the high points, as some of the questions have information that is duplicative as compared to the Final Rule.

FAQ 5 asks what a state can do to prepare providers for Medicaid RAC audits, and whether physicians will need to implement new compliance procedures due to the program. The answer was that states should be “as informative as possible” about implementation, with the minimum information being the name of the RAC contractor with contact information, when the RAC will begin to identify improper payments and “a general description of the scope of its RAC program”. From what I’ve seen, while more than 50% of the states have an identified Medicaid RAC contractor, information on the contractors emanating from the Medicaid programs themselves is virtually absent.

The second part of FAQ 5 was answered with what I found to be curious wording; “We do not expect that providers will have to undertake any major activities to prepare for Medicaid RACs”. We have all seen the glaring weaknesses of the Medicare RAC program, and if current appeal trends continue apace, we are in for about 5 solid years of endless paper shuffling. For CMS to once again soft-peddle the effect of expanding the process on providers to Medicaid borders on irresponsible.

FAQ 10 was the next to catch my eye. Already, there are auditing entities that have gained more than one state RAC contract. This particular FAQ focused on the need for a unique Contractor Medical Director that is licensed in the state covered by the contractual agreement. To illustrate, let’s say Company A has contracted with states B and C to do the Medicaid RAC work. Because these are two separate contracts, Company A would have to hire two full-time Medical Directors, with one being licensed to practice medicine in State B and the other being licensed in State C. However, the FAQ does make one distinction. If States E, F, and G wish to be bundled into one contractual arrangement with a contractor, more than one Medical Director may not be necessary. CMS indicates that the volume of claims in this particular arrangement could be a determining factor in deciding how many medical directors are needed.

FAQ 13 is the “Who’s The Watcher?” Question, asking how CMS will monitor and evaluate Medicaid RAC programs. Apparently, CMS will conduct program integrity reviews, collect a State Program Integrity Assessment and review overpayments collected, with states being required to “comply with reporting requirements as specified by CMS”. Note the big divergence from Medicare in this case. There is no single Validation Contractor to judge the work product of the Medicaid RACs, as is employed for the Medicare side. I’ve spoken about the comic nature of the RAC Accuracy scores in the last Report to Congress on RAC activities in the past, so I am on the fence as to whether this is either a good or bad thing at the present time.

This issue dovetails nicely into FAQ 17, which asks whether states are required to perform quality assurance of the RAC work product. States ”should” determine how it will validate the accuracy of overpayment determinations and include it in the Statement of Work in their RAC contract. Given that there are 50 states and 5 territories, all with different ways of measuring effectiveness, we should not expect one overarching accuracy score for the Medicaid RAC program as a whole, but rather dozens of bits of individualized data. 

FAQ 19 is the Duplication Question, asking how CMS will enforce multiple integrity efforts in addition to the Medicaid RAC, and how duplication of efforts can be avoided. With whitewash brush in hand, CMS states that they “intend to make every effort to incorporate and consolidate questions related to program integrity into scheduled reviews so as not to overburden states”. To be clear, there is nothing in that statement that gives any indication at all as to how CMS will avoid duplicate integrity reviews, thereby reducing provider burden. It is a new standard by which to measure a non-answer.

There were several FAQs about potential conflicts of interest, notably in cases when the RAC contractor already performs an integrity function in that state. CMS warns states to be cognizant of conflicts that may reveal themselves, but does not specifically ban one entity from performing multiple integrity functions for a single state.

I’ll wrap up the review with FAQ 28, which is of particular interest. What happens if a State does not receive any responses to its RAC Request for Proposal? CMS presents the options of either requesting an exception to the program, or “consider partnering with other states in order to attract a RAC” (I call this “The Wingman Option”). There are a few states who have requested exceptions to the RAC program, according to the Medicaid RACs At-A-Glance website created by CMS, but it is unclear whether these states have done so based on their inability to find a RAC contractor.

I recommend downloading the FAQ document, reviewing what I have omitted and keeping it safely on file, until such time as certain states catch up to the implementation date, now 10 days in the past. We need not hit the ice cream just yet, for all is not (quite) lost.

Paul Spencer will be appearing at the Fi-Med RAC Summit on April 16 and 17th in Milwaukee, WI. Information on this unique learning opportunity can be found here.

My experience with Facebook is hit and miss. I am now careful to limit incoming friend requests to “friends of friends”. The reader might find this next bit of information surprising, but I can actually be quite aggressive on certain topics that I come across in my personal life (that was a demonstration of my sarcasm, of course). When I need to pop off about something with the colorful language I learned in my youth as a Philadelphia sports fan, it is best that these are kept sequestered from the majority of my professional contacts. We have LinkedIn for actual professional networking. As a footnote, in order to satisfy any of your lingering curiosity, I have only ever “unfriended” 3 people, and it has been because I discovered retroactively that some of the friends of my actual friends are political troglodytes.

With the generations coming up behind my own (quick note: please do not refer to mine as Generation X; you young punks would be cynical and disconnected too if you grew up around AMC Javelins and Disco music) feeling free to share anything and everything online, intersections with reality are sure to follow. We’ve learned that it’s not a good idea for the local elementary school teacher to post pictures of herself on vacation doing body shots off the locals in Cancun. Additionally, a few frustrated employees have learned that criticizing your employer with language not normally shared in your typical convent earns you an express ticket to the Island of Free Time.

One such intersection with reality was this recent story from Mission Hills, California. An employee at Providence Holy Cross Medical Center, who was recently hired through a staffing agency, came across a patient’s medical record with featured conditions that he found amusing. He then took it upon himself to post the page from the medical record, complete with patient name and date of admission, as a photo on his Facebook page, accompanied by comments that mocked the reasons for the patient’s encounter. When told by his more level-headed, law-abiding friends in the Comments section of the post that he was violating  HIPAA laws, he said (and I must quote this verbatim so the reader can fully internalize it), “People, it’s just Facebook…Not reality. Hello? Again…It’s just a name out of millions and millions of names. If some people can’t appreciate my humor than tough. And if you don’t like it too bad because it’s my wall and I’ll post what I want to. Cheers!”.

It has never been my professional goal, but how I wish I had law enforcement power for just 10 minutes when I read things like this.   

I was born in the semi-mythical Time Before Pong, but there were two lessons I learned before the age of 6. There are five distinct human senses, and everything on television is fake. With new technology, my 22 years in health care and with the story above in mind, allow me to add an extremely important caveat; while your computer can stream television shows, what you type on Facebook is not, in fact, a mythical television show, but reality. Yes, it is two-dimensional, but no, it is not fake. If you create it, it exists. Additionally, thanks to online archiving, if you create it on a popular networking website, it exists beyond your lifespan, allowing succeeding generations to see not only that you had a bad sense of humor, but that your version of belly laughs came at the expense of someone’s legally codified right to privacy.

Social networking, and the prevalence of internet usage in general, offers challenges that did not exist at the time the HIPAA laws came into being. Health care providers of all types now find themselves playing catch-up to a public social structure that is quickly migrating away from meaningful, face-to-face discourse and toward two to three sentences of unexpurgated online communication (complete with photos) to hundreds – or perhaps thousands – at a time. Many employee policies on technology usage remain woefully inadequate for this environment.  

People employed at all levels of the health care field must be made aware of what is and isn’t allowed when discussing their work in a permanent public forum. Since I have your attention, I’ll start, using myself as an example. I’m a compliance officer for a company that does high-end data analytics that allows health care entities to quickly identify their highest areas of compliance and audit risk. We also provide some medical billing services, but I’m not going to tell you for whom. I see protected health information for medical conditions as part of my daily duties, but that also is none of your business, and I keep it at work.

On a personal note, I am currently employed by bosses whom I actually like and respect and who have done wonders for my professional development. If that happened not to be the case, I would save it for happy hour, which I never document or photograph for public consumption anymore, as my multiple glasses of dark beer kept spilling on my camera phone. To round out, I live with my wife, son, dog and obnoxiously loud nocturnal cat, my main hobbies are music and being a fan of ice hockey, and my bar trivia team can usually be found on Wednesday nights trouncing the local competition at O’Lydia’s Pub in Milwaukee.

Now you have all you need to know to begin to update your employee policies for social networking, as well as my general background, demonstrating once again that there are indeed acceptable paths to spreading wisdom on the internet.

Back in November, CMS announced that on January 1, they would begin a demonstration project wherein the Recovery Audit Contractors would review claims before they are paid in 11 states with high established error rates. Yesterday, almost as quickly as it was announced, CMS decided that this project has been delayed until further notice. CMS instead stated that it will provide 30 days notice in the future before implementing the project.

I stated at the time that based on the quality of the RAC work product to date, it hardly seemed like a good idea to expand their audit mission when the contractors clearly have not shown the baseline acumen necessary for post-payment review, despite the vaunted “accuracy scores” that were reported in the RAC Report to Congress back in September.

It’s a short piece of good news to start off the year, but given the administrative burden the RACs have already placed on hospitals due to complex review, even the smallest flicker of light in a storm is welcome.