The Friday Funny: Medicare Reimbursement
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When Fraud Isn’t Fraudulent: RAC And The Spanish Inquisition
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?
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For more excellent analysis of the subject, I strongly recommend Dr. Rich Fogoros’ recent book: Fixing American Healthcare.
I Can’t Believe They Said That: Overheard On Amtrak
I was traveling on an Amtrak train to a dinner meeting in Philadelphia. Two portly business men wedged in next to me and had an animated conversation about which companies do well despite a down economy. Here’s how the conversation went:
Businessman #1: You know, I’ve taken such a beating on the stock market, I just don’t know where to put my money to protect it and grow it. But I was thinking – one thing’s for sure – lots of people are going to continue dying despite the recession.
Businessman #2: So what kind of business insight is that?
Businessman #1: Funeral Homes, dummy. That’s where the action is. People still have to cremate or bury their loved ones, even in tough economic times.
Businessman #2: Nah, that’s not really scalable. I mean, you can’t save on costs with more volume. It’s fixed – a coffin costs what it costs. What you should really get into is Assisted Living facilities. Now THAT’s a growth market.
Businessman #1: No way, people can’t afford to pay for assisted living after the market crash. Their savings won’t last long enough to make it worth my while to take them in. Then when it runs out, what can I do? You can’t put them out on the street so you’re stuck with them till they die.
Businessman #2: You don’t have to be stuck with them, when their cash runs out you can transfer them to a lower quality facility. Then Medicare will pay for it.
The Ultimate Criterion For A Hospital “Never Event”
As many of you know, I’ve been pretty upset about the “never events” policy put forward by CMS. That’s because they took a theoretically reasonable punitive rule (Medicare will not pay hospitals for patient care related to gross medical errors, aka “never events,” like wrong-side surgery) and made it far too general (never events include delirium, falls, and any infection – even a cold). It is absolutely impossible to prevent these sorts of things 100% of the time. So how should “never events” be defined?
The Happy Hospitalist nails it:
Can the never event happen at home? If the answer is yes, it cannot be a never event. It is a natural event. Even the criminal events that nobody can foresee are considered never events. Tell me how a hospital can prevent a random crazy family member or hospital guest from going berserk and assaulting an employee or patient. It’s impossible to predict or prevent.
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