OK, so one of those things is atypical. I’ll give you a hint: I usually eat breakfast.

For more information on my 14th minute and 58th second of fame in my lifetime, click here (I’m the guy with the orange guitar). The story accompanying my grainy image is self-explanatory. So as not to worry readers who may not click through about the reasons for appearing in the newspaper, it doesn’t involve an indictment, a drunken man running onto a baseball field or (surprisingly, to those who know me) a vicious automobile accident. In these troubled and trying times, it’s nice to be part of a good story for a change, and I’m looking forward to tomorrow’s events as described in the article.

So now that we all know what a happy story looks like, let’s explore the flip side as it applies to health care compliance. I came across a story out of Florida that is a good case in point. A couple from a town called Land O’ Lakes (like you, I immediately thought of butter) were making their Sunday run to their local recycling center. When they got there, they found that there was no room for their paper items in the designated dumpster at the center. This was because someone had filled the paper bin to capacity with discarded medical records. In some cases, the records included Social Security, credit card and driver’s license numbers in addition to medical information.  

The first thing I thought of with this story was regarding EHR, and how stories like this may become obsolete within five years. Then I begin to think the opposite, with the personal theory that as practices transition from a paper record to an electronic record, we may see instances like this more often thanks to record destruction companies attempting to cut corners.

Then I begin to daydream, first about dancing in rain made of Newcastle Brown Ale to the music of the Who, then shaking my head and quickly transitioning to the government’s recent re-dedication to recovering money lost from Medicare and Medicaid due to fraud.

Having been involved with coding and compliance for several years, I’ve learned that there really is no end to to the devious machinations of the ethically-challenged in our business. From podiatrists who bill foot care on patients who have had previous foot amputations to DME suppliers forcing unneeded power mobility devices on the local population of elderly residents, extending to the virus of identity theft currently infecting  some medical practices, you need a chain saw to cut through the levels of immoral behavior in this industry.

The damage that these assorted criminals inflict is not restricted to the CMS trust funds. Medical providers who spend their waking hours operating by the rules inadvertently find themselves in the outer remnants of the spotlight that shines on the crooks. The doctors acting above board and rendering legitimate services ultimately pay a high price for the actions of the bad seeds in increased regulation, investigation and bad public relations for the health care industry as a whole.

The current administration has doubled down on recovery of overpayments through fraud and abuse investigations. For the future of Medicare and Medicaid, I see this as overdue. There are many ways to make the news, but perhaps the best approach for the honest medical provider is to implement and follow policies that insure that you end up in the non-”perp walk” portions of the local news.

To start out with a bracing dose of truth, I tend to live by very few rules, mainly because I fall back on survival instincts for most of my decision making process. This includes not dancing barefoot in poison ivy, realizing that I’m not cut out for living in the forest and stopping at the occasional red light. However, when it comes to what is referred to in more puritanical quarters as a moral code, my list of rules is rather short: don’t kill, don’t steal and don’t profit from other people’s bad luck (there’s one more multitiered rule that’s rather graphic and won’t be shared in this forum).

A good example of the application of these ideas is the fact that on the side, I’m a singer. My mother once suggested to me that there could be money to be made singing hymns at funerals and I found this idea incredibly revolting and insulting. It’s not enough that someone has just lost a loved one, but you’re going to stick a hand in the family’s pocket for the act of ushering the deceased into the next life with song? I find the very thought disgraceful.

As an extension of this rule, I have a deeply wired disdain for anyone who makes a living profiting from human misfortune. My hit list of occupational vultures includes funeral homes, pawn shops, payday and title loan stores and drug dealers. For purposes of this posting, let’s add an obvious one to the list: health insurance companies.

It is a well-documented reality that since the introduction of “managed care”, insurance companies are making out pretty well on the profit side. Hand in hand with this is the fact one study indicates that in 2007, 62% of all bankruptcies filed were due to outstanding medical expenses. Of that number, 80% had health insurance coverage. Given this statistic, why are we calling the purchased product “insurance”, as the very definition of this term suggests a contract that provides a guarantee against loss?

The effects of this same industry upon the provider community are no less damaging. Due to over 20+ years of deleterious contract terms, providers across the country are struggling with the costs of practice operation. With the proliferation of PPO plans that expand abhorrent fee schedules and payment rates to insurers across the country through the use of silent PPO’s and wraparound plans, the reimbursement playing field is evolving into a mine field.

It is my duty to inform the provider community that after six paragraphs, 400+ words and a brief discussion of funeral music, I’ve reached the point in this narrative where I can relay some good news; these mine fields have maps, and these would be your insurance carrier contracts.

Provider contracts make for interesting reading. What at first presentation will sound like an opportunity to expand your patient base to another insurance population can quickly shift in shape to something more resembling indentured servitude with the simple act of a signature. Knowing this, there is no longer any valid reason for not reviewing your insurance contracts on a regular basis, at the very least yearly.

In addition to the base contract, it is equally important to be wary of any and all amendments to that contract that are offered after initial contracting. I recently came upon a case where a physician had been under contract with an insurer for 4 years (with no legitimate review of the base contract language in that time span) and was sent an amendment that he dutifully signed which gave the insurer permission to share their pricing structure with other insurers. This had the effect of extending already negative contract terms far afield to insurers to which the provider had never been formally introduced.

Health care delivery finds itself on the brink of entering a world of increased physician cost and time investment. If a provider looks at his or her bottom line today and can see beyond all doubt that the current path is unsustainable, the best way to plug the income leak engulfing the practice is to go right to the source, which would be your insurance contracts. There are many directions that can be taken with regard to building a successful and sustainable medical practice. Given what we know about the singularly predatory nature of the modern insurance industry, the time has come to ask the most important question; where are your contracts taking you?

The first positive thing is just knowing that the World Cup of soccer won’t be occurring for another 4 years. My mind marvels at the fact that the rest of the world loves this sport with a passion. On television, a great majority of this sport looks like ping pong expanded to fit onto a field. In addition, apparently if you breathe on someone the wrong way in soccer, it’s common practice that the offended party throws themselves on the field as if they have just been assassinated. I haven’t seen acting this bad since the explosion scenes in the second and final season of The Rat Patrol. Thankfully, ice hockey training camps open in 7 weeks to assist me in getting memories of this “sport” out of my head.  

The second positive thing that occurred holds the promise of transforming a great deal of the health care system in the United States. The final rule was released by CMS this week involving the meaningful use of electronic health records (EHR).

The rule clarifying meaningful use differed slightly from the proposed rule. Originally, there were 25 standards that had to be satisfied in order to meet the definition of meaningful use. In the final rule, only 20 markers will need to be met in the beginnings of the program, with the 25 standards having been divided into two groups.

The first group consists of 15 “core” standards which must be met. These include such things as electronic prescribing, implementing and maintaining lists of drug interactions and drug allergies, the recording of patient smoking status and the reporting of quality measures to CMS. The remaining 10 standards are now placed in what is called a “menu set”. In order for a provider to demonstrate meaningful use, one can meet any five of the remaining ten criteria from the menu in addition to the core standards. This would be in effect for the first part of the incentive program, with the expectation that the remaining 5 standards on the menu will eventually be satisfied. 

Based on the number of comments received on the proposed rule about the burdensome nature of meeting some of the core standards, CMS has sharply reduced the percentage of patients that must fall under 8 of the standards.

With the release of this final rule, providers can now begin a one-year journey toward demonstrating meaningful use and maximizing incentive payments from CMS. The process of selection of a certified EHR system can now begin in earnest, if it has not already. As stated in a previous post here, the Office of the National Coordinator for Health Information Technology (ONC) is currently in the process of certifying health systems with the ability to meet the meaningful use standards. After selection of a certified EMR system, a registration link through the CMS website will become available sometime in January of 2011 that will allow providers to register to participate in the incentive program.

It is a time of paradigm shift in American health care. The release of this final rule brings all of us one step closer to fundamentally altering the doctor/patient end of the delivery system. A period of high drama, either from dread anticipation of this final rule or from attempting to guess which soccer player pretends he’s just been killed, has come to an end, with many new beginnings to follow.

I like making fun of old people.

There are a number of reasons for this, but when I try to get to the root of my mocking attitude towards the elderly, it comes down to two influences on my psyche that are the most extreme examples of poor behavior in one’s twilight years: Abe Simpson from the now-iconic TV show The Simpsons and my own father.

In Abe Simpson, we have an extreme study of a stereotypical senile old man who spends his time watching Matlock, falling asleep mid-sentence while trying to verbalize a flight of ideas and yelling at clouds. In my father, I see a man so internally and ideologically consumed by resistance to change that when he begins to verbalize his belief system in horrifying detail, I begin to look around me to make certain that no one who may have any small control over my human fate isn’t around to hear the man with whom I share DNA spouting such abominable and atavistic nonsense. It is in the general – if not exact – example of my father where today’s journey begins. 

“Set in their ways” is one of the most common terms I hear from others in describing older people. We’re often told that the 18-54 age group is “the money demographic” in advertising terms, as the belief goes that this age range hasn’t found one particular product, lifestyle or set-in-stone place in society to the point where they can’t be convinced to change their mind about something. By extension, people beyond this age range are seen as having made up their minds about everything and are less able to be convinced to try something new or make a switch to a different product.

For better or worse, we all reach different definitions of “comfort zone”, from the cars we select to drive to the music we choose to hear. If you’re a provider of medical services, the way in which you practice medicine is developed after years of study and one-to-one patient interactions. While you’ve weathered the dozens of adverse changes in the reimbursement for your services, the fundamentals of your practice may not have seen such a drastic overhaul to the point where the root of your profession is adversely affected.

Over the next roughly 42 months, a paradigm shift is going to occur within the walls of the comfort zone that is your medical practice. From the moment a patient enters your sphere of treatment, your well-honed approach must be modified. I wish I could tell you that this is mere opinion, but the volume of changes about to sweep over the landscape moves this into the realm of impending fact.

The mandatory conversion to an electronic health record (if you haven’t already) will change the way your information is stored and shared. What is documented in that record will need to change to accommodate the long-delayed conversion to ICD-10 for diagnostic reporting. With quality reporting and patient outcome indicators moving from its current voluntary model to one of compulsory permanence, the patient record will need to include a level of detail that will require you to go through a period of adjustment.

Many providers should begin a short period of assessment immediately to decide how these changes will be handled on the practice level. The first uncomfortable idea I’d like to bring forward is this one; nothing is off the table. Many providers have no doubt begun to enter a self-examination phase, questioning the changes and the effect these will have on them as doctors. My advice is to expand that analysis to every aspect of your practice as it currently stands. Perhaps you have a front desk staff that has been with you for many years, but are these trusted people savvy enough to handle the coming environment? Do your billing agents have the expertise to seize every reimbursement opportunity for your practice? Are the documentation habits of any ancillary staff such that they could pose a risk in the days to come?

3 1/2 years seems like a long time, but one by one, the changes in our industry will transform from ideas and initiatives to possibly uncomfortable new realities. Channel the mental anguish you may be feeling about the future into a vision for a pliable yet compliant medical practice.

As a postscript, I know that some of you who may be older are saying, “just wait, sonny. Your time to be mocked is coming”. In answer to that, I approach age in this way. As long as there’s one person on the Earth who’s older than I am, I’m still a young man. Recently, a 130-year-old woman was discovered in Russia. I figure I’ve got a lot of young living to do, so go get in your Buick and get ready for bed.

While the spending going on currently in my house is mostly in the realm of personal happiness and general frivolity, medical providers are currently contemplating an investment of a more serious nature. With incentives of up to $44,000 from the government for the adoption of electronic health records on the horizon, and with the mandatory use of EHR following close behind, practices are on the brink of making what could become the most important decision of their careers.

On June 18th, buried amidst the Sturm und Drang of the latest Medicare Physician Fee Schedule fix, HHS’ Office of the National Coordinator (ONC) for Health Information Technology released a final rule concerning standards for gaining certification of an EHR system. This sets the stage for the final rule defining “meaningful use” of an EHR system, which is set to be released within the next few weeks. This rule release can be considered the humble beginning of the providers’ decision process. 

The final rule for certification did not differ dramatically from the proposed rule, but there were some interesting tidbits. First. the final rule opens the door for more than one certification agency being involved in the process. Currently, the Certification Commission for Health Information Technology (CCHIT) is the only certifying agency, but as of yesterday HHS began to accept applications from companies wishing to become certifying agencies. I’m interested to see how this particular corner of the process develops, particularly as it relates to business relationships between certification agencies and software developers. While the certification standards come from ONC, how will compliance to the standards be measured to guarantee transparency in the certification process?

Once the testing agency applications are approved and certifications are granted, ONC will keep a list of certified software products on its website. Even though the approved certification agencies will more than likely publish the same listing, I recommend going right to the source once this list begins to be compiled.

As October 1, 2012 looms in the distance as the deadline by which practices can begin to demonstrate meaningful use of EHR in order to qualify for the maximum incentive payment, there is a healthy allotment of time to choose the EHR system offering the best fit for practices. When considering such a life-changing investment of financial resources,  this time element presents itself as a positive in the process. With the impending release of the meaningful use rule, it is hoped that the map of the road about to be traveled is revealed to be the shortest distance between the two points of selection and implementation.

The legislation that originally contained the pay fix was returned to the Senate for consideration by House Speaker Nancy Pelosi on Friday June 18th. In addition to the pay increase, the larger bill contained extensions of unemployment benefits and supplemental payments to the states to augment Medicaid programs. Senate Majority Leader Harry Reid spent the second half of yesterday afternoon attempting to garner the 60 votes needed to advance the legislation to a full vote on the floor. Ultimately, his efforts failed when the cloture vote tally of 57-40 doomed the bill. Minutes after the Senate vote, the House, by an overwhelming majority, passed the breakaway bill containing the pay fix that was sent to them late last week. The legislation was signed this morning by President Obama.

CMS has been processing claims with a 21.3% cut for the last 5 working days.  It is expected that CMS will soon announce that claims are now going to be processed at the pay fix rate. Any claims that have been processed over the last week will need to be reprocessed at the new, higher rates absent the previous cut.

While this legislation brings the latest chapter in this drama to a close, the story will begin anew as December 1st approaches. If either another temporary remedy affecting the fee schedule or a permanent fix to the Sustainable Growth Rate (SGR) formula is not passed prior to this date, physicians will face a 23% across-the-board cut in reimbursement.

I invite you to look very carefully at the mathematics involved with this. The conversion factor for 2010 was frozen at the beginning of January at 36.0846. Due to the larger health care reform legislation passed earlier in the year, the conversion factor was decreased for all 2010 claims to 36.0791. This did not affect claims already processed, but if you have recently submitted claims to your contractor for dates of service from early 2010, you may have noticed that the payments are decreased by a few pennies from how similar services were processed in the beginning of the year. The 2.2% increase now in effect applies to the lower, updated conversion factor.

While the latest conversion factor for the six-month period has not been released as of yet, a 2.2% increase to 36.0791 gives you a number in the neighborhood of 36.8728. Now, let’s suppose for purposes of envisioning the worst-case scenario that a 23% cut goes into effect on December 1st. This cut would be applied not to the temporary conversion factor, but the legislated conversion factor of 36.0791, which would give you a conversion factor closely resembling (again, not exact due to a lack of CMS announcement at the time of this writing) 27.7809.

The conversion factor is slated to take a further hit at the beginning on 2011, which would result in reductions that would bring the total net cut very close to the 30% range. Words have yet to be devised that would fully describe the negative impact on the healthcare delivery system in the United States that occurs if such a cut ever takes place.

For now, enjoy the summer sun and bask in the beauty of Autumn’s color when it arrives, as it could very well be a winter longer than any other we’ve ever experienced.

This past Saturday, House Speaker Nancy Pelosi (D-CA) made it very clear that she was not inclined to pass the Senate bill unless it is part of a larger measure similar to what the House passed in late May. It appears from a cursory look at the House calendar for yesterday and today that Pelosi was not bluffing. Yesterday’s legislative session in the House was dedicated to such weighty issues as a recognition of National Caribbean-American Heritage Month and a discussion of a resolution supporting National Men’s Health Week. Today’s calendar continues the focus on just the sort of topics that should shoot straight up to the top of the legislative calendar when there is near-10% unemployment, two wars and the looming threat of Medicare patients not receiving medical treatment: a discussion of the Formaldehyde Standards for Composite Wood Products Act and the Congressional Award Program Reauthorization Act (who would want an award from these people?). Sixteen other bills and resolutions are on the House calendar for today, and the Senate pay fix bill is not one of them.

Here’s a tip for the House of Representatives: the best way to insure that National Men’s Health Week comes off as a success is to make sure that men, and indeed all people, of Medicare age do not have their relationship with their physician threatened by a 21.3% percent cut in the doctor’s reimbursement.

I’ll continue to monitor the ongoing and oh-so-important work of Congress as the payment apocalypse continues. For now, as the headline says, there is indeed no news on this front.

The bill under consideration last evening, which also included an extension of long-term unemployment benefits, was defeated on primarily on a straight party line vote. Following the vote, Senate Majority Leader Harry Reid (D-NV) attempted to bring a bill to the floor for a vote that addressed only the physician pay cut. This bill would delay the pay cut until the end of 2010. Minority leader Mitch McConnell (R-KY) raised an immediate objection to the bill being brought up for debate, and the Senate adjourned until this morning.

A look at the executive schedule of business for the Senate today shows that no legislation is scheduled to be brought up for debate.

Fi-Med will be following this story as it develops throughout the day. This post will be updated immediately upon release of new information regarding a possible fix to this situation.

UPDATE: [2:18 PM EDT, 6/18/2010]: The Senate has passed legislation that delays the 21.3% pay cut for a six-month period. Because this bill is now a new piece of legislation, it must be returned to the House of Representatives for approval. Apparently, the House is unable to take up the legislation until next week. Moments after the bill passed the Senate, CMS issued a statement saying that claims processing will begin today at the lower pay rate. By law, CMS has run out of options with regard to delaying claims processing any further.

One good piece of news comes out of this. When the bill is passed by the House, all claims with dates of service between June1st and November 30th, 2010 will be subject to a 2.2% increase in the fee schedule that has been followed in the first 5 months of this year.

So to recap, this is a 21.3% cut, followed by reprocessing that repays the cut, plus 2.2%.

A curiosity in all of this is that the AMA is stating that after the cut is eliminated, CMS will only automatically reprocess claims when the submitted charges are higher than the reinstated allowed amount. Those claims with charge amounts that are lower than the new rate will require contact with the contractor.  When the cut is reversed, this needs to be watched carefully.

This current hold affects services from June 1st, 2010 and after. If for some reason legislation is not passed by Thursday, the claims hold will be lifted on Friday and claims will be processed with the cut.

The pay reduction was originally scheduled to be implemented on June 1st. CMS is currently holding claims for the first 10 working days of June, which is delaying the cut until this coming Monday, June 14th. Senator Reid’s office has stated that no votes are scheduled on the pending legislation either tomorrow or Monday, as senators will be visiting their home states during this time.

The earliest a vote could be cast on the legislation would be Tuesday, June 15th. In the recent past, when faced with a similar deadline, Congress requested that CMS not release claims for payment until the legislation could be considered and sent to the president for his signature. Given this history, I am of the opinion that this legislation will be reviewed and passed upon the Senate reconvening on Tuesday the 15th. The only way to be certain of this outcome is to stay tuned.

The legislation currently on the table provides for a 2.2% payment increase for the remainder of 2010, followed by a 1% increase in 2011. The current oft-delayed pay cut would be restored in 2012, more than likely at a deeper percentage rate, unless a permanent fix to the Sustainable Growth Rate is implemented prior to 2012.