Medicare audits and why they drive us crazy
Medical Rants March 9th. 2008, 2:47pmAudits Sting Hospitals, Physicians
In coming weeks, private audit companies will begin scouring mountains of medical records. Their mission: Determine if health care providers erred when billing Medicare and require them to return any overpayments to the federal government. The auditors will keep a tidy percentage for their services.
I hope that the bold statement bothers you as much as it does me. Clearly the auditors have a financial incentive to err for their own profit.
Health care providers are nearly unanimous in their dislike of the program’s continuation, much less its expansion. Many lawmakers have similar sentiments, though it was Congress in 2006 that made the program permanent. A bill sponsored by Rep. Lois Capps, D-Calif., calls for a one-year moratorium.
The program’s critics say that contractors have too much incentive to question as many claims as possible. That’s because they get to keep about 20 percent of the overpayments.
“What we have here is bureaucrats and government contractors coming in and trying to second guess what doctors and nurses have done in a hospital setting,” said Don May, vice president for policy at the American Hospital Association. “They’re playing Monday morning quarterback.”
We have a great formula here. Give hospitals and physicians an obtuse set of rules for billing. Make certain that no one, and I do mean no one, understands the rules. These rules often resemble a Rorshach test.
But what gets health care providers most upset is when auditors determined a procedure or hospital admission was not medically necessary.
May said that there’s a “lot of gray area” when it comes to whether a patients needs to be admitted to a hospital or rehab facility. Often the patients have diabetes or other complicating factors that prompt a physician to want closer monitoring.
“You need a physician looking at these daily if not more so to make sure the patients are being managed effectively,” May said.
March 10th, 2008 at 7:55 am
A prosecutorial coding climate will add to the burden of generalism and make it even less attractive. The irony is that a visit with a generalist is the biggest bargain CMS will ever get, no matter what level it is coded. The more generalists per region, the lower the costs, and the higher the quality.
A dermatologist gets 90% of his income from discrete procedures, as does an orthopedic surgeon. They can downcode their E/M services, writing them off as loss leaders, and thus minimizie their vulnerability to an attack-dog type audit recrimination. A general internist gets 90% of her income from small piecemeal E/M services, can’t survive by undercoding, and will be weighted down by the fear of misinterpretation for every service of every day. Not a good climate for professional satisfaction. Not ideal working conditions to foster patient-centered care.
March 10th, 2008 at 3:10 pm
The whole private Medicare audit business is a criminal operation.
All the way up to characters like Sen. Dianne Feinstein of California, who personally profits big time from her ownership of one of the shady audit companies.
The insider political class of Ms Feinstein and her crooked cronies makes vast wealth for themselves. Patients and doctors suffer.
Reference: Medicare audits spark protest that nudges Feinstein
By David Whitney - Sacramento Bee Washington Bureau Saturday, May 19, 2007
http://www.sacbee.com/111/story/185989.html
March 12th, 2008 at 1:06 pm
Criminal? Really? I think HealthSouth and Tenet’s constant fraud problems would be a better example?
Speaking of criminal or “selective ignorance” what about this tidbit - from a Congressional Quarterly 2-29-08 article - Examples of improper payments CMS cited include a health care provider who bills Medicare for conducting three colonoscopies on the same patient on the same day; payments that are coded for one Medicare service when in fact another was performed; or a health care provider who is paid twice because they submitted duplicate claims.
Also, would like to point out Capps’ ignorance to her own issue/bill -on Feb. 28 - Congresswoman Capps was quoted as saying, “inpatient rehabilitation facilities make up 88 percent of the claims denied in the Medicare Recovery Audit Program.” To paraphrase - this is the whole basis for my continued fight against this program.
WRONG!
Per the CMS FY 2007 report (page 18, Table 2-6), inpatient rehab facilities represent $20.8 million of the $357 million recovered or 5.8%, not 88% as Capps claims.
What it did say is that 88 percent of the overpayments recovered in ‘07 came from inpatient rehab facilities. Leading one only to believe they are better bilkers than other healthcare providers. Smooth move, Capps.
Also, the Feinstein story is dead. It’s time to move past Whitney’s hospital lobbyist sound bites and join all of us in 2008.
Furthermore, since you brought up on my favorite stories of ‘07 - I love this quote - “These rules have been on the books since 1985,” Combs said. “Maybe it’s possible some have been overlooking them. Maybe there have been CONSULTANTS out there helping hospitals to, quote, MAXIMIZE REIMBURSEMENTS. And maybe perhaps some of that has entailed looking the other way.” YA THINK?