There are very few non-spam comments that I do not pass on the the blog posts. Most of these are of the crazy political conspiracy variety, the internet being the Speaker’s Corner for the entire world. Yet on my post in this space from two weeks ago regarding Medicaid RAC activity, I received a comment from an interesting source, that being the Vice President of Communications at HMS, the company that acts as a Medicaid RAC contractor, co-contractor or subcontractor for (by my last count) 29 states. The e-mail acts in one part for sake of clarification and one part for sake of being defensive, and some of the information shared in this comment is important for the readers. It starts off innocently enough, with the requisite ego-greasing of:

 “HMS appreciates your continuing to provide information about the Medicaid RAC program”.

What follows this sentence is a reading from Book of Damage Control:

“We would like to take this opportunity to note some corrections related to RAC activity in some of the states you reference…”

Rather than attaching this comment to the previous post and leaving it unaddressed, I wanted to offer my comments on their comments. For the sake of the reader, I shall include all communication from the individual in Italics, and add clarifications. It will be helpful to the reader if you click on the link above to my past blog post being referenced:

“Connecticut, Idaho, and New York – At the direction of our clients, HMS does perform Medicare/Medicaid coordination of benefits under either our Third Party Liability or Medicaid RAC contracts.  We are not aware  of the errors you cited.  HMS has a full-time Provider Relations team to service the provider community and providers are encouraged to contact us with any questions.  Providers also have access to our Provider Portal on a 24/7 basis.”

Fi-Med has clients in all three of these states. In reviewing the letters that came for our clients in these states, errors were found, our providers were notified and, where applicable, were brought to the attention of the Provider Relations team.

In an automated review setting, it is understood that the RAC is at the mercy of the data collected by the state, but it does highlight a question that has yet to be answered; who validates the Medicaid data that is forwarded to the RAC for action? Unlike the Medicare RAC program, I highly doubt that there is a RAC Validation Contractor for Medicaid in every state and territory. Perhaps that is a good thing considering that Medicare’s RAC Validation Contractor has thus far come up with Medicare RAC accuracy scores that are patently unbelievable.

“Indiana – As per our client’s request, the Medicaid RAC correspondence in Indiana contains only the state’s logo.”

For providers in Indiana, this is a very important piece of information. This again highlights the importance of reviewing all correspondence that is received very carefully. It is not enough to simply get the records and mail them back, or worse to set aside correspondence for “another day”. Call the numbers on the correspondence immediately demanding answers. Most importantly, treat everything in an envelope that doesn’t have a check attached to it as if it contained anthrax. Investigate it – and where applicable, fight it – until it is resolved and a final answer derived.

On an emergent basis, I would recommend that the providers in the State of Indiana begin to make noise and ask the state why contractors working towards contingency fees are allowed to send out correspondence as if they are the state. This correspondence method should be changed, as it has the potential to be ruinous to medical practices who don’t know enough about the program. As an added note, in putting together this post, I found that the same holds true for the state of New York. Had the request we received not been accompanied by a CD with HMS’ logo on it, we would have never known it was a Medicaid RAC letter.

“Kansas – The work that both HMS and HDI perform in Kansas under both the Medicaid RAC contract and our Third Party Liability contract is performed in accordance with Federal and state statutes, as well as Medicaid policies and procedures.”

This was in response to providers in this state telling me that straight Medicaid payments are being recouped in full if the RAC contractor finds that at the time of service, the patient was covered by a Medicaid HMO.

It’s fine that HDI and HMS are following guidelines. What I have been saying about this practice for over a year does not change. The better way to approach this subject, rather than penalizing providers long after the fact and giving a RAC contractor a contingency fee, is for the state and the HMOs to subrogate these claims between themselves.

Medicaid recipients are notorious for changing claims payment entities in the manner that the rest of us exchange socks. What Kansas, in its infinite wisdom, is telling providers is that even if a Medicaid recipient comes into your office with a card that by all visual measurements is valid at the time of service, you could be penalized 100% of payments received many years down the line if you are wrong. In many cases, the cost of validating eligibility for these patients takes a large chunk out of any payment you would receive from Medicaid. I have asked this question before, and I continue to ask it: is this the message that you want to send to providers 7 months before PPACA  kicks in, leading to the largest expansion of Medicaid beneficiaries since the beginnings of the program?

“North Carolina – HMS’s scope in North Carolina does not include ambulance or hospice claims, and our inpatient hospital reviews do not target specific DRGs. (Please be aware that there are two Medicaid RAC contractors in the state). Also, we operate under a request limit that allows for a maximum of 300 records every 45 days (exceptions are made for smaller providers).”

Let the record show that Public Consulting Group, the Medicaid RAC co-contractor in North Carolina, is the one looking at ambulance services, 5 DRGs for short stays and are dropping the ball on hospice reviews. Additionally, I had the number at 300 records every 30 days, rather than 45 days. My spreadsheet has been updated. It is notable that HMS does not tell us what they are looking at as part of their “inpatient hospital reviews”. I’ll have more on that later.

“Pennsylvania – HMS is not the auditor for the scope of work mentioned (i.e. medical necessity on the hospital side).”

Duly noted. That would be CGI, who has a website set up for Pennsylvania providers here. I want you to take a long look at this particular CGI website. Not only does it have all relevant information related to the work they are doing in Pennsylvania (including, in a general sense, what they are reviewing), but note that I am not a provider in Pennsylvania (despite being a former Pennsylvanian) and I was able to access the website from my seat along the shores of Lake Michigan. Apparently, as we shall learn later, this is not the standard with all Medicaid RAC contractors.

“Tennessee – HMS does not subcontract this work out to its wholly owned subsidiary HDI.”

This would be news to the providers from Tennessee who have reached out to me, as they are receiving correspondence from HDI. Of note, the fact that providers are having payments recouped prior to receiving denial letters has thus far gone unexplained.

Finally, we’d like to mention that HMS has set up Medicaid RAC websites for providers in many states, which are typically restricted to providers in the state.

Where do I begin…….?

There is a fatal flaw in the Medicaid RAC program, and that is a mandated lack of transparency. As we saw above, CGI has created publicly available websites for the states they were awarded (by the way, here is Ohio and here is Washington). It is important to internalize that an entity operating in 29 states has just told me that Medicaid RAC websites, and the information they contain, are restricted to providers in that state. This is on top of the fact that approved issues lists, with CMS’ blessing, will not be shared (and apparently, given the opportunity presented above, still won’t be shared) and the correspondence you receive could look the same as any other letter from your state’s Medicaid agency.

The Medicaid RACs continue to be the airborne virus of the audit world. Much like tuberculosis, you won’t know you’ve caught their attention until your practice bank account begins to consumptively cough up funds. This isn’t some kind of game we’re playing here. Providers who care for high numbers of Medicaid beneficiaries already operate on a knife-edge based on lackluster fee schedules. If you put these providers out of business based on Kafkaesque audit rules, you put the most vulnerable health population in the country at risk just so someone else can make a buck and satisfy their shareholders.

I thank HMS for their input, but based on the federally mandated lack of transparency, I expect that this isn’t the last time I’ll receive such detailed comments such as these.

The biggest problem I tend to have in this line of work is the volume of knowledge. I say “problem” because any person that I know in my personal circles who doesn’t happen to be connected to the healthcare field usually has absolutely no clue as to what is happening in health care until they themselves need treatment. That treatment moment usually becomes the time when I am called in to remold their medical bills from the origami crane shapes in which they now appear.

This post is specifically about a payment paradox that exists on a few CPT codes. It is something I discovered a few weeks ago, but am only now getting to due to travel schedules and hours on the telephone in a professional capacity.

Let’s talk about soft tissue tumors. These are little deposits that creep up in the subcutaneous skin layer that are removed most often by either dermatologists, plastic and reconstructive surgeons or general surgeons. The codes for the removal can be found under the Musculoskeletal section of CPT based on body area, and they are normally split into two codes based on the size of the tumor.

Having stated that, there is a catch. In most cases, due to CPT code reseqencing, the numerical code for the removal of a larger tumor is lower than that for the smaller tumor. Unfortunately, the problem doesn’t end there.

As an example, let’s use CPT code 24075, which is for the removal of a subcutaneous soft tissue tumor of the upper arm or elbow measuring less than 3 centimeters. The code that follows it in CPT is 24071, which is for a tumor of 3 centimeters or greater from the same body area.

Now, go to this link for the Medicare Physician Fee Schedule Search. Choose the bubble that says “List of HCPCS Codes”, and then the one somewhat below it that states “Specific Carrier/MAC”. Put 24075 in the box that says “HCPCS Box 1″, then place 24071 in the box that says “HCPCS Box 2″. Below that, choose the drop-down stating “All modifiers”, and then select your Carrier/MAC from the last drop-down. After that, click “Submit”.

The next screen shows you two disturbing things. The website has not only re-ordered your codes to show 24071 as the first code, but (and this should make the surgeons and dermatologists out there furious) the allowance for the larger tumor is roughly $100 less than that for the smaller tumor, depending on your MAC locality.

This pattern will repeat itself no matter which area of the body has subcutaneous soft tissue tumors. What I think is happening is that Medicare set the Work RVUs based on numerical order, rather than the actual amount of work involved with the procedure. CMS is not recognizing CPT resequencing, which is leading to providers being underpaid for their large soft tissue tumor removal expertise. 

Appendix N of the CPT code book contains the entire list of resequenced codes. I am a simple blogger with a lot on my plate right now, so I’m not going to go through all 100 codes on that list to find similar payment inconsistencies. I shall leave that up to an enterprising reader out there. The larger point here is that Medicare is the straw that stirs the drink with regard to reimbursement for services. If Medicare makes a mistake in setting reimbursement, that error is compounded by every commercial carrier who uses Medicare allowances as a baseline for setting a fee schedule.

At the very least, I hope dermatologists take to the streets with their scalpels and benzoyl peroxide and demand change. At most, I’d like to point out that just because Medicare happens to be the Irish Wolfhound in a room full of Pomeranians doesn’t necessarily mean that they always have the first and only correct answer.

On April 12th, my house in Milwaukee was burglarized. While on my way to work, two rank teenage amateurs smashed my son’s bedroom window, ransacked the house and took items that were mostly recovered the same day when the police in another district caught them. I have learned lessons about the attention spans of my neighbors, the price of getting a window boarded up on a Saturday and home owner’s insurance coverage. The mothers of these fine juveniles will soon receive a lesson in what we call “subrogation”.

Two days after the robbery, I found myself in Florida (one of the many lands of my nomadic youth) for this year’s AAPC National Conference. Being that it occurred in Orlando, my wife and son joined us for days at Disney World. I have thoughts to share on the slogan “Let the Memories Begin”, but I’ll hold those thoughts until later. The conference itself was one that was strangely productive as compared to those of the past.

More than anything else, as it applies to this recently-neglected space, April of 2013 became the month when the awareness of Medicaid RAC program reached critical mass. I have been a frequent guest on RACMonitor.com’s Monitor Monday RAC webinar/broadcast, and the number of questions regarding Medicaid RAC, as well as comments from affected facilities, has begun to pick up. In the interest of my entire reading population, I am going to share everything I have on Medicaid RACs right here, right now. There are still considerable gaps, so if you have any information to fill them, let me know.

Let’s begin by a little exercise in addition by subtraction. Despite the fact that the Medicaid RAC reviews were scheduled to begin nationwide on January 1, 2012, six states – Florida, Hawaii, Maryland, Oklahoma, South Dakota and Vermont – still lack a contractor. Half of these states have received what are called “time-limited exemptions” from the program, meaning that CMS’ patience for these states not having a contractor is finite.

I have no information, other than the name of the contractor, for 29 of the remaining states. For the 15 states below, information remains sketchy, but at least I have something:

Connecticut, Idaho & New York – HMS has been pursuing what they believe to be incorrect Medicaid Secondary payments for patients with Medicare as their primary insurance as part of automated review. Providers in these states who receive these repayment demands are urged to review each line item carefully, as there have been several errors in the reports that have crossed my desk.

Indiana – HMS has been going after DRGs for septicemia (416, 417, 584), OR procedures unrelated to diagnosis (468, 476, 477) Tracheostomy (482, 483, 700 with ICD-9 procedure codes 31.1 or 31.29) and claims featuring excisional debridement (procedure code 86.22). There also appears to be a focus taking shape on long term care claims, but these investigations have yet to fully emerge. Indiana providers are also urged to review each piece of Medicaid correspondence carefully, as it has been reported to me that it is somewhat problematic determining the difference between a Medicaid RAC request and one from the state’s fraud control unit.

Iowa – OptumInsight is casting a wide net. They are, at the least, currently reviewing hospital claims for stays over 2-3 days, elective c-sections, elective major bowel procedures, elective total joint replacements, spinal fusions, procedures of the uterine adnexa for non-malignancy, heart failure and shock. For the major bowel procedures, the focus appears to be falling on claims for stays of 6-9 days due to complications. Iowa Medicaid has become ruthlessly efficient in recouping funds, as they have developed a habit of doing so within 30 days of the denial letter, even if an appeal has been filed. It is also notable that Iowa offers no interest on appeals if found in the provider’s favor. Cry not, for they’ll always have ethanol as a companion boondoggle.

Kansas – HDI, a subsidiary of HMS, has been penalizing providers via automated review for patients who had an active Medicaid HMO at the time of service when straight Medicaid paid. What I have noted as “a variety of DRGs” are also being reviewed.

Michigan – I have received extensive information on Michigan’s Medicaid RAC program from two different sources in the last month. Due to an unforgiving schedule, I have yet to review the information that has been forwarded in great detail. I can tell you that HMS is looking at Medicare crossover claims for duplicate payment and overlapping inpatient stays with other facilities. Michigan has a unique request limit of a maximum of 150 records per request, not to exceed 500 records in a 3-month period.

North Carolina – HMS is extremely busy in the Tar Heel State (they must employ a larger-than-normal number of smokers). Beginning on March 1st, DRGs 191, 192, 292, 313 and 391 for short stays are under the microscope. Hospitals are warned that InterQual criteria is used for review. Ambulance claims have been on the hit list for over a year. HMS does appear to be dropping the ball on hospice claims for patients whose hospice services were billed to Medicare. HMS does not recognize that only nursing home room and board was billed as pass-through to Medicaid, which is leading to HMS reviewing the claims in question for “hospice eligibility”. North Carolina’s request limit is 300 records every 30 days.

Ohio – CGI is reviewing short stays for medical necessity. Ohio OB/GYNs  are also on the radar, as CGI is reviewing low-level established E/M services billed at the same time as pre-natal care, particularly as it applies to the usage of the -TH modifier.

Oregon – HMS is looking at credit balance reports in the Beaver State.

Pennsylvania – HMS is looking at short stays for medical necessity on the hospital side in the Keystone State.

South Carolina – Following the pattern, HMS is looking at short stays for medical necessity in South Carolina. The request limit in the Palmetto State is 150 records every 30 days.

Tennessee – HMS appears to be subcontracting work out to their subsidiary, HDI. Claims for infusion services, inpatient medical necessity and DRGs 190, 191, 193, 392, 460, 743, 847 and 951 are on the radar. Watch the dates of the Medicaid RAC correspondence carefully, as there have been cases where payments are being recouped prior to providers receiving denial information.

Texas & Virginia – HMS is in both of these states, but issues have yet to be identified to me other than the fact that both states have no limit on records requests.

Again, if anyone can fill gaps in the information vacuum, I encourage you to do so. Additionally, if any of this information appears incorrect, by all means let me know.

Finally, I’d like to conclude with some quick thoughts on Walt Disney World. It did not escape my notice that upon every overpriced contrivance up for sale in the self-styled “Magic Kingdom” lay the phrase “Let the Memories Begin”. Even in a country dripping with commerce like the United States, the idea that someone has placed a price tag on the human memory should give us pause. The simplicity of life as it presents itself to all of us is not something that requires monetary outlay. It only demands that it be shared with someone close to you. It need not include worthless bric-a-brac stamped endlessly with animated mouse ears, but rather interaction on a human level, which is something that in the end money has no power to purchase.

Since this takes effect in 5 days, I am hoping that my readers have had a chance to read CMS’ update to their medical record request limits for complex review. Since I have space to fill, I’ll provide the highlights.

First, the minimum number of requests per 45 days is being reduced from 35 to 20 for providers who have a calculated limit of 19 or less. This will be of minimal help to small rural hospitals who have been burdened by the RAC process, but when considering these types of facilities, we need to take additional facts into account. Small rural hospitals spent 3 1/2 years being abused by the RAC process to such an extent that many are operating on a financial knife-edge. The main reason for this is based on having neither adequate staffing to fight RAC determinations, nor the dollars to hire such staff. If you are in effect telling rural hospitals, “You now only have to pay us back for 20 inpatient stays every 45 days, rather than 35″, this does not fall under my definition of the word “improvement”.

The second change that is effective Monday has to do with the types of claims that can reviewed every 45 days. In a seeming compromise with hospitals facing a deluge of appeal activity for audit determinations on short stays, a Recovery Auditor may now only select a maximum of 75% of any one claim type during a 45-day period. To illustrate, if a hospital, based on its past financials, can have up to 300 claims pulled every 45 days, 225 of those could be pulled for inpatient claims, with the remaining 75 coming from any other claim type(s).

As the Trojans learned all those years ago based on their experiences with a certain wooden horse, gifts aren’t always what they seem.

It would be wonderful if a 75% cap on inpatient claims (primarily short stays) was based on the maximum number of requests per facility. Yet in the lead-up to this change, something odd was beginning to occur with some facilities. I have heard anecdotal evidence from facilities across the country who regularly appeal RAC determinations that the number of requests they have been receiving has been down from the maximum for a few months. As these stories rolled in, I chalked that up to the abrasiveness of the facilities in question with regard to RAC denials. My reasoning was that if the RACs see that they are in for a fight at certain facilities, the requests go down there and are maxed out at a hospital that won’t fight back. Thinking about this further, I may have been off the mark.

So, I am going to ask a favor of the readers. If you are at a facility who has experienced a recent downturn in ADR requests, let me know if you receive the maximum ADR request limit for your facility on any request you get after Monday, April 15th. If you have a long record of appeals, I am curious to see if the RACs were either keeping their powder dry for future battles with you or directing their cannons somewhere else.

One additional note on this CMS memo. While the minimum number of claims has moved downward, the maximum number of records that can be requested in every 45 days has not changed. It remains at 400, unless the facility has more than $100 million in annual revenue, in which case the limit is 600.

I’m always free with my opinions, so I’ll give you another one related to this latest change to the RAC process. Cosmetic surgery rarely succeeds long-term.

Dennis P.H. Mihale, M.D., M.B.A., is a recognized thought leader in the healthcare industry and medical community with over twenty years experience in healthcare, biomedicine, and healthcare business process.  He currently holds the executive position of Medical Director for Fi-Med Management, Inc.

Prior to joining Fi-Med, Dr. Mihale held executive positions at Parses, Chelsea Management Group, and Advanced Respiratory Therapies. Dr. Mihale was Founder of Parses, Founder/CEO/CMO of St. Augustine HealthCare and Founder/SVP/Medical Director of Ultramedix Healthcare Systems both Florida HMOs.  Dr. Mihale received his M.D. from University of Miami – School of Medicine and an MBA from the University of South Florida. He holds a bachelor degree in Aerospace Engineering.  He regularly presents at conferences on applying technology to healthcare.

Perhaps I was Russian in a past life, or maybe I am evolving into some type of ethereal being with little tolerance for what the planet has to offer, but sunshine, flowers and extended sheets of rain batter my environmentally-challenged immune system. Go ahead and jog, camp, cut the lawn or whatever it is you do. I’ll be inside with off-label allergy medications and stiff drinks in an attempt to ignore the pollen plague lurking outside my window.

Since I have no tolerance for the “Great” Outdoors, it is my task to bring some industry updates forward. Due to my work with Monitor Monday, I have been having some interesting conversations with hospitals and doctors across the country regarding Medicaid RAC programs. I am going to step out of my usual comfort zone today and share some information from one set of providers that is being ignored. I am speaking of dentists.

Two dentists have come to me in the last three months with stark concerns about the effect of Medicaid RAC on their practices and those of their colleagues. I am happy to report that there are professionals on the front lines willing to assist dentists in avoiding government audit traps. On the flip side, what is being encountered in the dental arena is the usual resistance to change and what one of my two contacts described as “crying, whining and scoffing”.

My other contact, to his credit, is in the process of putting together an instructional DVD highlighting some of the federal audit activity aimed at dentists. Yet there is one characteristic of the Medicaid RAC program that endangers dentists as it does other providers, and that is the lack of a mandated approved issues list. As with other specialties, an educated guess at what activity is coming can be gleaned from past audits, but providers will only know what is being reviewed, definitively, when the additional documentation requests start flying.

One area of agreement I have found is that dentists nationwide face significant Medicaid audit risk. Against the headwinds of skepticism, and as I bury my nose in yet another Spring tissue, I would encourage dentists, as I have other providers, to familiarize themselves with their state’s Medicaid RAC contractor and begin a dialogue. If the RAC contractor isn’t providing the answers you are seeking, start making your presence known (and loudly) with the state’s Medicaid office. Let them know that you would like to know what is coming.

Most importantly, I am going to share with dentists a word that must be internalized, and that is appeal! Given the shoddy results of the Medicare RAC program, it is clear that federal and state audit contractor work product cannot be trusted. You have two options: either fight or submit and accede to continuing abuse. Unless you take the form of a seasonal pollen parade, I don’t submit to anything or anyone, and no hospital, physician or dentist should accept this as “the price of doing business” anymore.

Yesterday (obviously) was St. Patrick’s Day. In Ireland, this is considered a serious day for the mostly Catholic country. In America, thanks to the descendants of the rabble from Europe having come to our shores, it’s an excuse to drink (a lot).

It is with great sadness, and to the significant financial detriment of the Wisconsin Tavern League, that I must announce that I was at home this St. Patrick’s Day, as my wife is out of town and I am in charge of my 6-year-old for the time being. As a public service, I would like to offer the reader a flimsy excuse to continue overindulging.

I have been spending a lot of my free time considering the expansion of Medicaid, set to arrive on January 1st, 2014 as part of the ongoing implementation of the Patient Protection and Affordable Care Act. Of late, I have written about the counter-intuitive approach of rolling out the Medicaid RAC program at full speed as millions are about to be added to states’ Medicaid rosters. One infrequently discussed portion of the Medicaid universe that I would like to turn my attention toward is Medicaid State Fraud Control Units (SFCUs).

Back on March 4th, the OIG released the results for SFCUs nationwide from Fiscal Year 2012. The final number is impressive on its face, showing over $2.9 billion in recoveries. Most of the states with bigger recoveries also ended up being our most populous states, which didn’t come as a surprise, but I decided on my own to conduct another exercise for purposes of self-enjoyment.

If we overlay the individual state collections by SFCUs over a map of states that have thus far decided against Medicaid expansion under PPACA (by the latest count there are 14 states in the “definitely not” column), we find that over $1.4 billion of the collections (or 48% of the total) comes exclusively from those same 14 states.

To me this points to another weakness in the Medicaid expansion. Thanks to the Supreme Court decision that gave the green light to PPACA, expanding Medicaid is now optional for all states. At first, those states more vocally opposed to the law quickly stated that they would not expand Medicaid programs in their states. Slowly, some of those original states, such as New Jersey and Florida (thought the Sunshine State has yet to finalize participation) have changed their minds, mainly due to hospitals – which have no interest seeing a spike in uncompensated care – lobbying in these states.

Medicaid Integrity programs are several years behind similar efforts in the Medicare system, mainly because in attempting to control the costs of Medicaid, you are forced into dealing with 50 different audit philosophies. Standardization does not exist, so it becomes any one’s guess as to what will be audited and when.

Obviously, the states involved in turning down a Medicaid expansion are doing it for political purposes, but is it a significant leap to say that the Medicaid Fraud in these same states is so pronounced that expanding the program would overwhelm their ability to control fraud? I leave that up to the reader, but it hands these states some ammunition beyond a simple disdain for all things Barack Obama.

My wife comes home today. See you at the bar!

Twice a year, you are laying backwards and the names “Pelton & Crane” appear within your line of vision. Where are you when you see this? I’ll provide the answer at the bottom of the post, and those of you who didn’t cheat or scroll down this page should color themselves surprised.

Paying attention to the task at hand is becoming more difficult in our society. Most of us make the mistake of thinking that paying attention to detail is about a laser-like focus on the task at hand or “the bottom line”, but that line of thinking can lead to critical mistakes.

Today’s case in point is the latest results of the AHA RACTrac survey. If we compare the report from the previous quarter, not much has changed on the surface. The important percentages haven’t moved appreciably. Two-thirds of all complex reviews do not contain an overpayment. Almost all hospitals state that the most costly denials are for medical necessity, with 61% of denials for 1-day stays being for care in the wrong setting, and not for medically unnecessary care. The provider appeal success rate still stands at over 70%, while almost 75% of all appealed claims are still sitting in the appeals process.

We are nearly 3 1/2 years into the RAC process, so those numbers should not surprise anyone involved in the program, but there is another number that grabbed my attention.

At the top of page 4, there is a bullet point that states that only 2,335 hospitals nationwide have participated in the RACTrac program since January 2010, but only 1,233 hospitals participated in the latest quarter. According to the AHA, there are over 5,800 hospitals registered with the AHA, with estimates of the total number of hospitals in the nation set somewhere north of 16,500. Using these rough numbers, we see that less than 10% of all hospitals in the United States are submitting data to the AHA regarding the RAC program. 

We all know that the CMS data on the RAC program is collected and presented solely for the continuing approval of the legislative branch, and therefore provides a distorted and incomplete picture of the true activities of the program. Given that information vacuum, the AHA numbers are always welcome. Yet with so few hospitals submitting data, it provides only a small snapshot of the abominable work product that has been produced to date, which suddenly makes the scope of the RAC problem one of frightening proportions.

Overall, 66 fewer hospitals reported data as compared to the third quarter of 2012. This could be due to the increasing administrative burden being felt by hospitals nationwide. Yet some hospitals that are reporting data are using software-based solutions that include a reporting component. It may very well be that if the RAC process has become too much of an administrative burden, reporting statistics may be the last thing about which hospitals worry.

As for my question above, you would find yourself in a dentist’s office, as Pelton & Crane has been making dental office equipment since 1900, including the examination light that is staring you in the face. Attention to detail encompasses all details, and not simply the most obvious. As the fight against the RAC program continues, it helps to have different sets of eyes looking at different items of interest in order to solve the problem.

On the heels of last week’s post regarding Medicaid RACs, my e-mail box tells me that the hits just keep on coming.

I received an e-mail from a contact in North Carolina, stating that their Medicaid RAC contractor, HMS (who else), will begin complex review of short hospital stays beginning this Friday, March 1st. As a follow-up to the e-mail, I was curious as to the level of outreach that was occurring on the Medicare side with respect to Connolly’s audit focus on short stays. The phrase that came back in return was that there was “no real guidance” coming from Palmetto, the Medicare Administrative Carrier (MAC) in North Carolina. I guess it’s better to have no outreach than to have feedback that is riddled with mistakes, as we have seen in other regions.

A reader from Indiana reached out to me with information stating that HMS has begun to target DRGs for septicemia (416, 417 & 584), OR procedures unrelated to diagnosis (468, 476 & 477), Excisional debridement (ICD-9 procedure code 86.22) and tracheostomy (DRGs 482, 483 and 700, procedure codes 31.1 & 31.29). In addition, as they have in states such as Connecticut, Idaho, New York and Oregon, HMS is identifying credit balances in automated review. It was also related that facilities in Indiana may be having a tough time distinguishing between Medicaid RAC audits and those emanating from Indiana’s state fraud control unit. This certainly raises the long-suspected spectre of more than one audit entity touching the same claim, but according to my contact, this has not happened as yet.

In response to other follow-up questions, I learned that the Medicaid RAC statement of work is not widely available in Indiana. This is consistent with what I have heard from my in-state contacts here in Wisconsin, where ForwardHealth, the state’s Medicaid arm, released a memo regarding the Medicaid RAC program last week. This consisted of a barely-more-than-one-page description of the Medicaid RAC program. The part that spilled onto page 2 included an 800 number and a link to HMS’ general Medicaid RAC site.

I called the 800 number for “questions regarding the RAC program”, as indicated in the ForwardHealth bulletin and was told “If this is in regard to a desk audit, press 1 now. If this is in regard to an on-site audit, press 2 now”. What followed was silence until I mercifully placed the phone back on its receiver. HMS’ Medicaid RAC website offered no information for Wisconsin providers to such an extent that they don’t even identify themselves as the Medicaid RAC contractor for the state.

One of the common complaints I hear from coordinators dealing with the Medicare RAC program is an inadequate level of transparency regarding audit activities, and the billing rules that drive them. If the Medicare RAC program is opaque, then the Medicaid RAC program, in its current form, can only be described as an invisible scourge. With no reimbursement for records, no approved issues lists, little to no useful contact information and a lack of Medicaid RAC information on state Medicaid websites, Medicaid RACs resemble an airborne illness. I have a feeling we won’t know how sick this will make all of us until it’s too late.

We’ve seen an asteroid the size of half of a football field pass a mere 17,000 miles from the Earth. A meteor hit Siberia and injured over 1,000 people, providing yet another reason to scratch a visit there off of your bucket list, beyond the brutal cold and tuberculosis-ridden prison camps. NASA, now without rockets to launch, is currently tracking a sunspot as wide as six Earths to monitor for a future solar flare.

For all of the scientific study that exists solely within one discipline, history teaches us that amazing things can occur when different fields of science intersect. R. Buckminster Fuller adapted the design of the geodesic dome after witnessing plant cell patterns under a microscope. It was later found that the dome was so much like nature that it is one of the few man-made objects ever devised that becomes structurally stronger as it increases in size. For a parallel, go give a sequoia tree a shove and see how far you move it.

This week, a British study came to my attention which strengthens the thesis of two scientific minds being better than one. Cancer researchers in Great Britain found that software used by astronomers to pick out and clarify blurry objects in the night sky can be utilized by physicians to look for biomarkers for breast cancer. The software was able to review 2,000 samples in a single day. As a comparison, a human with a microscope looking at the same samples would take a week.

This story comes out a week after another story about radiologists being so focused on identifying nodules on a CT scan that they completely missed the appearance of a dancing gorilla on the scan. Who knew that the solution to a human’s hyper-focus on their job would lie in the stars?

This provides a distinct lesson not just for scientific endeavor, but with any task. I’m not talking about “thinking outside the box”, because I hate that term, as no one really wants you to do this for fear of the whole business ecosystem collapsing. I’m talking about looking in unexpected places for inspiration.

As an example, as a musician on the side, I thought I had learned all I needed to about writing song lyrics. Then I heard David Ackles, and everything I ever learned changed in about three days. Learning, and eventually discovery, comes from curiosity, and from never ceasing the search to find something better. Even something that you encounter that is new to you, but lousy, guides you to your next move (usually the nearest door).

Anyone in this world who looks into the night sky and doesn’t have their imagination touched in some way is failing as a human being. Thankfully, science continues to look in unique places for unexpected solutions.