Posts Tagged CMS

Why is the Government Targeting the Most Charitable Physician Specialty?

Why is the Government Targeting the Most Charitable Physician Specialty?

I don’t get it.  I do not understand why the US government has decided to paint a target on the backs of physicians who, according to the AMA, provide more charity care than any other specialty, in a program that uses so-called hired gun auditors to recoup over-payments in Medicare’s fraud and abuse prevention strategy.  These are physicians who give away, on average, more than $140,000 a year in unreimbursed services to the poor and uninsured (4-10 times more than any other specialty), and serve a larger proportion of Medicaid and under-insured patients than the vast majority of other physicians.  These charitable physicians are willing to treat everyone, regardless of their insurance status or ability to pay, day or night, Sundays and holidays, whether the patients are upstanding citizens or the disheveled homeless.  These docs provide care to everyone who asks to be treated or comes to their door, even if they are intoxicated to near stupor, or ranting obscenities, or smell like a garbage dump, or shed deadly viruses in an epidemic, or are soaked in toxic chemicals released in an accidental spill or a terrorist attack.

None of these physicians are engaged in a criminal enterprise to cheat Medicare and the tax payers out of millions of dollars for care they never provided, or using stolen or purchased patient IDs to submit fake claims, or billing for tests not performed, or charging for equipment they never ordered.  In fact, these specialists work almost exclusively in hospitals that carefully screen their credentials, and in medical groups that have some of the most extensive claims coding and billing compliance programs in the health care industry.  Nonetheless, the government has selected these physicians for auditing under the Medicare Recovery Audit Contract (RAC) program by focusing on the evaluation and management (E&M) CPT codes that are used almost exclusively in claims submitted to Medicare by these specialists.  Other E&M and procedure codes are also being targeted for audits by these RACs, but these other codes are widely  used by many other physician specialties.

There is no question that fraud and false claims are a serious problem for Medicare, and cost taxpayers hundreds of millions of dollars every year.  For every $1 the government spends on these RACs, it gets back $40.  I am all in favor of dealing a heavy blow to those who try to cheat the system, provided the adjudication process is fair and the focus is on activities that are clearly in violation of the rules.  There are those who believe that hiring these private audit contractors on a contingency basis (based on the amount of overpayments they find) is like paying a bounty hunter to bring in a possible suspect dead or alive, especially since many claims that the RACs deem overpaid are frequently found to be ‘not guilty’ on appeal.   The rules that are applied to these claims are, unfortunately, not always clear and concise:  E&M coding in particular is about how sick the patient is, and how complicated or difficult the medical decisions are to make.  In other words, medical coding is an art, not a science, and using an auditor that is financially incentivized to interpret these rules in the most aggressive way, with the threat of big penalties and forfeitures, is like writing a law that stiffs you with a big fine for ‘parking too close to a fire hydrant’ without specifying how close is too close, or paining the curb red.

I don’t doubt that a few of these ‘charitable physicians’ stretch the coding rules a bit, or even overcharge for their services.  It happens, but it’s not the rule, by any means.   I have talked to quite a few of these particular specialists who have experienced RAC audits.  They usually consider themselves to be good at documenting their care, who employ careful and conscientious claims coders for their billing service.  They come away from the RAC audit experience angry, frustrated, baffled, fearful, indignant, and depressed.  These physicians don’t go out of their way to intentionally up-code their claims, or un-bundle them (charge separately for items that should be covered under a single charge), and they take pride in their willingness to treat patients few other physicians are willing to see, regardless of the patient’s ability to pay.   They are all overworked, sometimes underpaid, subject to stress burnout, and challenged by a seemingly impossible mission; and they do this for over 130 million patients in the US every year.  These docs just don’t understand why their government would go out of its way to paint a target on the backs of emergency physicians.

This post also appears in The Fickle Finger

, , , , , , ,

No Comments

Headlines and Updates

CMS Scam Alert

Officials at the Centers for Medicare & Medicaid Services (CMS) said recently that scam artists have been contacting physicians’ offices by fax, claiming to be a Medicare carrier or Medicare Administrative Contractor. The fax instructs office personnel to respond to a questionnaire and provide an account information update within 48 hours to prevent an interruption in Medicare payments. The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.

The CMS advises physicians who have received such a request to contact their Medicare contractor immediately. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the website 

Follow the ACEP Board Meeting on Twitter

The ACEP Board of Directors will met in Dallas on June 23 and 24. And for the first time, updates will be sent live from the meeting by Twitter. Follow the ACEP Board meeting at

, , , ,

No Comments

Encouraging Signs for Emergency Medicine

ACEP's Washington, DC Staff

ACEP's Washington, DC Staff

It is 2009 and we have a new administration, new impetus for health care reform and new hope for meaningful change. It seems everyone agrees that the current system is not sustainable, but that seems to be all anyone agrees on. Everything else is anybody’s guess.

ACEP has worked hard to include emergency medicine in the current debate. It has been a struggle, but fortunately, the ACEP-supported “Access to Emergency Medical Services Act of 2009” enjoys bipartisan support in the House and Senate. More than 120 legislators are now co-sponsors and ACEP continues to working closely with key legislators and their staffs to promote the legislation.

One very positive note was passed on by ACEP’s Washington, DC office yesterday. Legislative staff in the House and Senate have said that various provisions of the bill have been submitted to the committees writing the health care reform bills. That is very good news and it looks like the work of the thousands of ACEP members who have called, written and visited their members of Congress is starting to pay off.

Their efforts are part of a comprehensive three-pronged approach. First, there is a strong direct lobbying campaign on Capitol Hill by ACEP staff members, including Brad Gruehn, Jeanne Slade and Gordon Wheeler. This dovetails with a grass roots lobbying campaign supported by the 1350 members of the 911 Legislative Network. These ACEP and EMRA members have developed relationships with their Senators and House members and contact them regularly to relate ACEP’s positions on legislation and regulatory initiatives. In addition, hundreds of other ACEP and EMRA members have participated in ACEP’s “Contact Congress Campaign” and are demanding that emergency medicine’s issues be addressed in upcoming reform legislation.

The third part of this approach, and a key piece of ACEP’s ability to influence the debate, is the National Emergency Medical Political Action Committee, better known as NEMPAC. This ACEP-supported organization is now one of the top-five medical specialty PACs in the country, and contributes more than $2 million per election cycle to federal legislators who support emergency physicians.

Change comes slowly in Washington, DC. But ACEP will continue its decades long work to make sure that when a bill is put on the President’s desk for his signature, the concerns of emergency physicians will be included.

CMS establishes new Toolkit, PQRI helpline

On the regulatory front, CMS recently posted 2009 implementation advice for the 2009 Physician Quality Reporting Initiative (PQRI).

Tools include a downloadable numerical listing of all codes included in the 2009 PQRI for incorporation into billing software, and a link to measure-specific worksheets for reporting each measure. CMS has also established a new help line for PQRI participants with questions regarding participation procedures, feedback reports, and bonus payments. The telephone number is 866-288-8912, and will be in operation between 7:00am and 7:00pm Central time.

CMS plans to create a new email address for inquiries as well. Additional information about these tools and the PQRI program may be found at the CMS PQRI Web site.

, , , , , ,

No Comments