January 20th, 2010 by DrPeggyPolaneczky in Better Health Network, Health Policy
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A study published in this week’s Archives of Internal Medicine looked at so-called errors made in consultation code billing by specialists seeing patients at the request of a primary care practice in suburban Chicago. The methodology? Comparing the primary care office referral form with the specialist’s bill.
The author concludes that specialists are greatly overusing consultation codes in situations where a new patient visit would be more appropriate, to the tune of over half a billion dollars a year in Medicare payments, and suggests that it is time to reconsider the use of these codes. (Medicare, of course, has already come to the same conclusion, and beginning January 1 of this year, is no longer paying for consultation codes.)
There may be misuse of consultation codes going on, but this study does not necessarily prove that. The methodology does not include medical record review, the standard by which coding choices are verified or refuted, and relies entirely on the referring physician’s determination of what the specialist should be billing. Read more »
*This blog post was originally published at The Blog that Ate Manhattan*
November 25th, 2009 by Happy Hospitalist in Health Policy, Opinion
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How widespread is Medicare fraud? The government is now reporting Medicare fraud rates almost three times higher than previously accounted for, at 47 billion dollars this year. How could Medicare Fraud triple in a year? The answer is simple.
In an effort to be more honest with data collecting, Obama ordered the new accounting into effect. All part of the hope and change we always hear about.
It’s not clear whether Medicare fraud is actually worsening. Much of the increase in the last year is attributed to a change in the Health and Human Services Department’s methodology that imposes stricter documentation requirements and includes more improper payments — part of a data-collection effort being ordered government-wide by President Barack Obama next week to promote “honest budgeting” and accurate statistics.
Read more »
*This blog post was originally published at The Happy Hospitalist*
September 21st, 2009 by Emergiblog in Better Health Network, Health Policy, Opinion
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Well, I lead a double life but it isn’t out dancing in formal wear!
“There is time for only fleeting thoughts about that dance you’ll attend during off duty hours.”
There isn’t even time for that.
Besides, who attends a dance during on duty hours?
Well, I guess the most important thing is that our hands are “soft, smooth and free from redness” because “your patients like it and your date expects it”.
Oh yeah?
The day they use a hand sanitizer thirty times in a shift and wash their hands another twenty, they can talk to me about soft hands.
********************
My husband won’t watch football with me because I tend to get hyped up and throw things at the TV when I get upset.
That explains why there were Notre Dame pom poms and a Cleveland Browns jersey at the base of the set this weekend.
I also like to talk back at the President when he is speaking on TV. Usually it’s things like “Say WHAT?” or “Give me a break!” “Get. A. Clue!” is usually a good one. This last speech, the one to Congress about health care, was no exception. My first comment came a bit into the speech when I noted a few times that “I haven’t heard a single thing I disagree with yet” and “he’s right on that point”.
I was afraid hubby was going to need smelling salts.
But I’m like, “let’s hear how he is going to pay for this…let’s hear him out”.
And then I heard it.
And then he lost me.
*****
There were two comments that I could not let go. I looked them up in the text of the speech to make sure I had heard them correctly.
“…we’ve estimated that most of this plan can be paid for by finding savings within the existing health care system a system that is currently full of waste and abuse.”
“The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud…”
Hundreds of billions of dollars? Billions? With a capital “B”?
Waste. Abuse. Fraud.
This means that in order to pay to the proposed health care reform, we have to find enough waste, abuse and fraud to cover expenses.
*****
But I have some questions.
What is the definition of “waste”? To the extent that “waste” means inefficient bureaucratic practices that use up monetary resources, I can get on board with that.
Abuse? What kind of abuse? Using the system inefficiently, like calling an ambulance for a stubbed toe? Remember, the President is using the term “abuse” to represent a potential income stream for the new system, so it would have to encompass behaviors that spend money that should not be spent. Money is spent on patient care, so is he talking about patients abusing the system?
And then there’s fraud…
That’s a crime, folks.
Hundreds of billions of dollars in waste and fraud?
The President must think that there are an awful lot of criminals in the health care system.
So what’s my point?
*****
My point is this: funding for the new proposed health care system (see “most of this plan…”, above) is based on finding waste, abuse and fraud.
What happens when all the waste is taken out, all the abusers are stopped, the fraudsters jailed and the system needs more funding? Does that not make it imperative that we keep finding waste and abuse and fraud? Does that not mean that what constitutes waste, abuse and fraud must be constantly expanded to make up for rising costs?
This can’t be good.
I am in total agreement that our system can be streamlined, big time.
And maybe we could find enough money in waste, abuse and fraud to make it pay for itself, but I doubt it.
If we could do that, wouldn’t we have done it already with Medicaid and Medicare? The budgets for both are getting slashed on a regular basis. Drop the waste, abuse and fraud in those programs and then come back and tell me how much better their budgets are.
If we can’t do it in an existing government-provided system, how on earth do you expect us to believe it can be done on a larger scale?
*This blog post was originally published at Emergiblog*
September 17th, 2009 by DrDavidKroll in Better Health Network, Quackery Exposed
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The premier US cancer hospital and research center in Houston released a statement today distancing themselves from a Dallas company claiming an endorsement of their water product by The University of Texas M.D. Anderson Cancer Center:
Recently, you may have heard or read about a company that sells Evolv, a “nutraceutical beverage,” which is being promoted in part based upon testing done at The University of Texas M. D. Anderson Cancer Center, but also is being mistakenly viewed as endorsed by M. D. Anderson. M. D. Anderson conducted limited chemical analysis of the product to evaluate its anti-inflammatory activity for a fee at the request of the manufacturer. No efficacy or toxicity data were generated at M. D. Anderson nor was the product tested on humans. Moreover, M. D. Anderson does not have any involvement with the company, the product is not produced by M. D. Anderson, and M. D. Anderson does not endorse the product or recommend its use.
The current text on Evolv’s website an Evolv fan site is that:
Evolv’s nutraceutical beverage with Archaea Active is tested by M.D. Anderson Cancer Center in Houston, Texas.
The statement as listed is not exactly wrong; it’s just not complete. Nothing there about what the product was tested for, but the implication is that it gained some healing power by passing through the hallowed halls of M.D. Anderson. I also have no clue as to whether it was tested for archaea (formerly archaebacteria) or if it has the capacity to amplify DNA.
Of course, my blogging about this is going to give the company publicity (a very, very small amount). Evolv is not just water but it is sold by a multi-level marketing company. I already knew to put one hand on my wallet when I dialed up their website. The header has the quote from Mary Kay Ash, “Nothing happens until somebody sells something,” which rotates with others from her and Zig Ziglar who, no doubt, did not authorize their association with the company.
But water? The next multi-level marketing craze?
I don’t think this holds water.
Now if we could only get M.D. Anderson to address this other misuse of their name.
Note added 10 September 2009: This comment from EvolvHealth’s Chief Marketing Officer, Mr Jonathan Gilliam, brought to my attention that I had the incorrect website for the company (as corrected above). The actual website should be http://evolvhealth.com. Currently, their product page lists the M.D. Anderson claim as follows:
Our active ingredient has been tested by the MD Anderson Cancer Center of the University of Texas. Evolv will be released in Fall 2009
*This blog post was originally published at Terra Sigillata*
July 22nd, 2009 by Happy Hospitalist in Better Health Network, Health Policy, Primary Care Wednesdays
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What does that mean? Well. It means everything. And it means nothing. It is the enormous universe of numbered codes (CPT) that every physician must grasp in order to get paid for services provided. In order to remain a viable business, physicians must learn how to code. And they must learn how to code well so they aren’t accused of fraud.
The current coding system is ridiculously difficult and vague. So difficult and vague that audits by the Medicare National Bank (MNB) often result in multiple different opinions by the MNB auditors themselves.
Coding is a system of confusion. I am here to say the coding system is insane. Current coding rules are used by all third parties to determine the economic value of your care. To determine how much your encounter with the patient is worth. Ultimately, the coding system has become the most important aspect of a physician’s professional life because coding determines revenue. And revenue determines the viability of the business model. And that ultimately determines how much you take home to feed your family. Dr Kevin blogged about that here.
So let the games begin. The current coding rules are a futile attempt to bring rings of value to medical service. Services which are so vastly different and unique for every patient. I will attempt to walk you through an example of the payment system, and how it relates to relative value units (RVUs) and ultimately how that affects physician payment.
The number of codes is massive. For all imaginable procedures, encounters, surgeries. Any possible health care interaction. Hospitalist medicine is limited in the types of codes we use. So I only have to remember a few.
95% of my billing is based on about twenty CPT codes:
3 Admit codes (99221,99222,99223)
3 follow up codes.(99231,99232,99233)
2 critical care codes (99291, 99292)
5 consult codes (99251-99255)
7 observation codes (99218-99220, 99234-99236, 99217)
2 Discharge codes (99238, 99239)
There are a few others, but these twenty-two codes determine my very financial existence. Medicare says so. Imagine a surgeon, a primary care doc, and a medical subspecialist. Every single interaction has a code. There are codes for codes, modifiers for codes, add on codes, disallowed codes, V codes, M codes. It seems as if the list is endless. And you have to get it right. Every time. Or you don’t get paid. Or you are accused of fraud. It is an impossible feat. The process of taking care of patients has turned into a game of documentation. And that has drastically affected the efficiency of the practice of medicine.
Let me walk you through a 99223, the code for the highest level admit for inpatient care. A level three. There is no actual law, as I understand it, on the Medicare books that definitely defines the requirement for these Evaluation and Management (E&M) codes. There are generally accepted guidelines which carriers are expected to follow. 1995 and 1997 guidelines. Even the guidelines from different years are different. And you are allowed to pick and chose from both. More silliness.
The following is my understanding of what Medicare requires in order to bill a level three admit, CPT code 99223. You must have every one of these components or it’s considered fraud, over-billing or waste. Pick your verbal poison.
1) History of Present Illness (HPI) : This requires four elements (character, onset, location, duration, what makes it better or worse, associated signs and symptoms) or the status of three chronic medical conditions.
2) Past Medical History (PMH): This requires a complete history of medical (medical problems, allergies, medications), family (what does your family suffer from), social (do you smoke or shoot up cocaine?) histories.
3) Review of Systems (ROS): A 12 point review of systems which asks you every possible question in the book. Separated by organ system.
4) Complete Physical Exam (PE): With components of all organ systems, the rules of which are highly complex in and of itself.
5) High Complexity Medical Decision-Making: This one is great. It is broken down into three areas and you must have 2 of 3 components as follows; Pull out your calculator.
5a) Diagnosis. Four points are required to get to high complexity. Each type of problem is defined by a point value (self limiting, established stable, established worsening, new problems with no work up planned and new problems with work up planned). You must know how many points each problem is worth. Count the number of problems. Add up the point value for each problem and you get your point value for Diagnosis (5a). You must have four points to be considered high complexity.
5b) Data. Four points are required for high complexity. Different data components are worth a different number of points. Data includes such things as reviewing or ordering lab, reviewing xrays or EKGs yourself, discussing things with other health care providers (which I have never been able to define), reviewing radiology or nuclear med studies, and obtaining old records etc. Each different data point documented (remember you have to write all this down too) is given a different point value. You must add up the points to determine your level of complexity. Get four points and you get high complexity for Data (5b).
5c) Concepts. I call this the basket. Predefined and sometimes vague medical processes that are defined as high risk. This includes such things as the need to closely monitor drug therapy for signs of toxicity ( I would include sliding scale insulin in this category), de-escalating care, progression or side effect of treatment, severe exacerbation with threat to life or limb, changes in neurological status, acute renal failure and cardiovascular imaging with identified risk factors. There are too many categories that are defined as a high risk concept. I cannot remember all of them. If you have a concept considered high risk, you get credit for high risk in the concepts category (5c)
Now remember, out of 5a, 5b, and 5c, you must meet high high complexity criteria on two out of three to be considered high risk. Did you remember to bring your calculator to work? And once you’ve calculated your high complexity category, don’t forget to write down all the components required from HPI, PMH, ROS, PE to not be accused of fraud.
Folks, this is what I have to document every time I admit a patient to the hospital in order to get paid and not be accused of fraud. This is what the government (and all other subsequent third party systems) have decided is necessary for me to treat you as a patient. This is what I must consider every time I take care of you.
I always find myself wondering if I wrote down that I personally reviewed that EKG. I wonder if I wrote down that your great great grand mother died of “heart problems”. I wonder if I remembered to write down all your pertinent positives on your review of systems and whether I documented the lack of positives in all other systems that were reviewed.
And remember each CPT code is given an RVU value, the value of which is determined by its own three components.
- The work RVU
- The practice expense RVU
- The malpractice expense RVU
Then the MNB multiplies your total RVU (add the three components above) and attached a geographical multiplier (you get more RVUs in NYC than in Montana).
Then, they take that number of RVUs and they multiply it by the Congressional mandated value of the RVU (currently about $35/RVU). That value is currently determined by the political whims of politicians and is controlled by the irrational sustainable growth formula (SGR). That is the formula that is overturned every year because of the irrational economics it employs.
And that’s how a physician is paid. This is what determines whether physicians survive in the business of medicine. And whether they have enough money to pay the electric bill, the accountant’s fees and the matching contribution to their nurse’s 401K.
Oh yeah. I almost forgot, I have to do all this while actually taking care of your medical problems based on sound scientific principles.
This is coding in a nutshell. A 99223. This is what I think about when I’m admitting you through the emergency room. This is E&M medicine. This is Medicare medicine. This is how your government has decided the practice of medicine should be. To get paid, I must document what Medicare says I must in order to care for you, the patient. It doesn’t matter what I think is important to write in the chart. What matters is what is required to get paid and not be accused of fraud.
Like I have said before, the medical chart has become nothing more than a giant invoice for third parties to assert a sense of control on their balance sheet. It doesn’t matter who that third party is. They are all the same.. I’m telling you, it’s nothing more than a really inefficient game of cat and mouse. It is a terribly inefficient and expensive way to practice medicine.
And I might remind you, the exercise above was an example of just one patient on one day. I do this upwards of fifteen times a day. Every day. Day after day. Year after year. Oh yeah, and the rules are different for inpatient followup codes, discharge codes, critical care codes, and observation/admit same day codes. They all have their different requirements. And I have to get it right for every single patient I see. Every day. Over 2500 times a year. With the expectation of 100% accuracy.
Why? You see, in the eyes of Medicare, you are a nothing more than a 99223.
*This blog post was originally published at A Happy Hospitalist*
July 3rd, 2009 by drval in Quackery Exposed
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In one of the most unethical clinical trial debacles of our time, the NIH approved a research study (called the TACT Trial - Trial to Assess Chelation Therapy - a supposed treatment for arteriosclerosis) in which the treatment had no evidence for potential benefit, and clear evidence of potential harm - and even the risk of death. Amazingly, the researchers neglected to mention this risk in their informed consent document. The NIH awarded $30 million of our tax dollars to ~100 researchers to enroll 2000 patients in this risky study (ongoing from 2003-present). Even more astounding is the fact that several of the researchers have been disciplined for substandard practices by state medical boards; several have been involved in insurance fraud; at least 3 are convicted felons.
But wait, there’s more.
The treatment under investigation, IV injection of Na2EDTA, is specifically contraindicated for “generalized arteriosclerosis” by the FDA. There have been over 30 reported cases of accidental death caused by the administration of this drug - and prior to the TACT, 4 RCTs and several substudies of chelation for either CAD or PVD, involving 285 subjects, had been reported. None found chelation superior to placebo.
So, Why Was This Study Approved?
The NIH and the TACT principal investigator (PI) argued that there was a substantial demand for chelation, creating a “public health imperative” to perform a large trial as soon as possible. In reality, the number of people using the therapy was only a small fraction of what the PI reported.
It’s hard to know exactly what happened “behind the scenes” to pressure NIH to go forward with the study - however a few things are clear: 1) the National Heart, Lung, and Blood Institute (NHLBI) initially declined to approve the study based on lack of scientific merit 2) congressman Dan Burton and at least one of his staffers (Beth Clay) and a lobbyist (Bill Chatfield) worked tirelessly to get the study approved through a different institute - NCCAM 3) some of the evidence used to support the trial was falsified (The RFA cited several articles by Edward McDonagh, the chelationist who had previously admitted in a court of law to having falsified his data.) 4) The NIH Special Emphasis Panel that approved the TACT protocol included L. Terry Chappell, whom the protocol had named as a participant in the TACT.
All evidence seems to suggest that political meddling managed to trump science in this case - putting the lives of 2000 study subjects at risk, without any likely benefit to them or medicine.
A formal analysis of the sordid history and ethical violations of the TACT trial was published by the Medscape Journal of Medicine on May 13, 2008. Atwood et al. provide a rigorous, 9-part commentary with 326 references in review of the case. Congressman Burton’s staffer, Beth Clay, published what is essentially a character assassination of Dr. Atwood in response.
The NIH Writes TACT Investigators a Strongly Worded Letter
On May 27, 2009 the Office for Human Research Protections Committee sent a letter to the investigators of TACT, stating that they found, “multiple instances of substandard practices, insurance fraud, and felony activity on the part of the investigators.” The letter describes a list of irregularities and recommends various changes to the research protocol.
It is almost unheard of for a letter from the NIH to state that research study investigators are guilty of fraud and felony activity - but what I don’t understand is why they haven’t shut down the study. Perhaps this is their first step towards that goal? Let’s hope so.
Conclusion
The TACT trial has subjected 2000 unwary subjects and $30 million of public money to an unethical trial of a dubious treatment that, had it been accurately represented and judged by the usual criteria, would certainly have been disqualified. Political meddling in health and medical affairs is dangerous business, and must be opposed as strongly as possible. Congressmen like Tom Harkin and Dan Burton should not be allowed to push their political agendas and requests for publicly funded pseudoscience on the NIH. I can only hope that the new NIH director will have the courage to fend off demands for unethical trials from political appointees.
February 10th, 2009 by drval in Health Policy, Medblogger Shout Outs, Opinion
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Dr. Rob Lamberts does an admirable job explaining why physicians are worried about the Recovery Audit Contractor (RAC) approach to identifying Medicare fraud. Complying with Medicare coding and billing rules is so difficult that physicians regularly resort to undercharging for their services, just to avoid the perception of fraudulent practices. Any medical practice that bills more than average is potentially subject to RAC audit, and the auditors themselves are paid a commission for finding “fraud.” In many cases, the “fraud” amounts to insufficient documentation of appropriate and necessary work performed by the physician.
Dr. Rob writes:
The complexity of E/M coding makes it almost 100% likely that any given physician will have billing not consistent with documentation. Those who chronically undercoded (if they are still in business) are at less risk than those who coded properly. Every patient encounter requires that physicians go through an incredibly complex set of requirements to be paid, and physicians like myself have improved our coding level through the use of an EMR. This doesn’t necessarily imply we are over-documenting, it simply allows us to do the incredibly arduous task of complying with the rules necessary to be paid appropriately.
Have I ever willingly committed fraud? No.
Am I confident that I have complied with the nightmarish paperwork necessary to appropriately bill all of my visits? No way.
Am I scared? You bet. The RAC will find anything wrong with my coding that they can - they are paid more if they do.
Dr. James Hubbard writes:
It would be fine if they were truly looking for fraud and abuse, but they look for some technicality or just a different interpretation. Forget about any recourse. A few years ago, I was asked to pay Medicaid back $5000. I protested they were completely wrong with their interpretation of their findings. The auditors said I had to pay it, but could argue for a refund by sending forms and proof to the “review committee”. I did that and received a reply that the $5000 was too small for the review committee to take up. I stopped taking Medicaid.
Sounds like the Spanish Inquisition, doesn’t it?
***
For more excellent analysis of the subject, I strongly recommend Dr. Rich Fogoros’ recent book: Fixing American Healthcare.
November 1st, 2008 by drval in Announcements, Medblogger Shout Outs
1 Comment »
Regular readers of my blog will know that health fraud, misleading product and treatment claims, and deception of vulnerable populations (snake oil for cancer patients, for example) really get under my skin. For this reason, I’ve teamed up with a group of scientists and physicians to create a blog devoted to medical accuracy, transparency, and integrity in health reporting. It’s called Science Based Medicine, and we offer daily exposés of misleading health claims and practices. It’s a great way to learn about how to think critically - and to apply a scientific approach (rather than subjective and anecdotal) to discerning truth from error.
My contribution to the blogging team is to highlight online health fraud, scams, deception and misguided attempts to help consumers “live healthier lives.” I post once a week, every Thursday morning. Please head on over and check it out. It’s a great team of bloggers - and they’re looking out for you!
Here is a list of my recent posts:
A Shruggie Awakening: One Physician’s Journey Toward Scientific Enlightenment
Disintegrating Integrative Medicine: Lessons From Baking
When Further Research Is Not Warranted: The Wisdom of Crowds Fallacy
Knowledge Vs. Expertise: The View From Consumer Land
February 7th, 2008 by drval in True Stories
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This (hat tip to KevinMD) is one of the worst cases of attempted personal injury fraud that I’ve heard of:
It was a very busy weekend afternoon in the ED when a city bus accident occurred. What a disaster. Rarely is anyone really injured but everyone on board almost always winds up coming into the ED. The city encourages it so things can be documented and people are like “Cha-Ching!”, lawsuit! So, this particular time, about 5 people were brought in on back boards (we were lucky to get so few!) As the 3rd year resident started interviewing them one at a time (since all were stable and ambulatory (walking) at the scene), one of the patients said, “Hey Doc, that guy over there was not even on the bus at the time of the accident! He jumped on board afterwards and started complaining of back and neck pain!” The resident could have gone over and confronted him angrily (who would blame him) but instead chose a different approach. He calmly went through all the other backboarded patients, clearing them all clinically out of their cervical collars. He simply ignored the man suffering from “Allstate-itis”. The funny thing is that 2 hours went by and everyone just ignored him (although I think he was triaged at some point - damn EMTALA). All manner of stuff was going on around him. His stretcher was parked right next to the nursing station yet it was like he did not exist! Finally, the guy called the resident over and said, “Hey Doc, isn’t someone going to check me out and do x-rays?” He replied, “Well, you weren’t even on the bus so in my mind, you are already checked out!” Knowing the jig was up, the man sat up, took his C-collar off, and left the ER. I guess he was thinking, “Oh well, maybe next time I’ll hit the jackpot!”
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 5th, 2008 by drval in Quackery Exposed
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So my last post stimulated some interesting discussion amongst friends and colleagues. Some applauded the late night supplement “smack down,” and others felt it was too harsh. Still others who don’t read my blog regularly complained that it was unfair to pick on the supplement industry without also pointing out the flaws of Big Pharma. Well, here’s to equal opportunity smack downs - where things “applied directly to the forehead” are as fair game as anti-psychotics, IT mishaps, healthcare professional SNAFUs, and misguided policies resulting in unanticipated harm to patients.
But let’s not forget the happy stories, the unlikely triumphs, and the snatching of victory from the jaws of defeat. We can laugh at ourselves, cry with our friends, and mourn the loss of the lonely. Medicine is full of a broad array of emotions and perspectives, captured here for you in this blog.
And now, back to bunnies and puppies…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
