Posts Tagged emergency physician

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  www.ficklefinger.net/blog/

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Your Opinion is Important to Us

Sandra Schneider, MD, FACEP, ACEP Past President

I would like to personally invite you to become a member of the Emergency Medicine Practice Research Network – EM-PRN. Becoming a member is simple; just click on this link and answer a brief survey. It will take less than five minutes. We want to know if you are seeing patients with chronic pain, we want to know if you are experiencing medication shortages and how you are coping. We want to know how you practice. YOUR ANSWERS will provide ACEP with essential information for our advocacy in Washington and improving emergency care. To stay a member, all you need TO DO is to agree that you will complete 3-4 surveys, five minutes or less, each year.

Membership at this time is only open to ACEP members, residents, attendings and life members. Sorry, we cannot as yet accommodate non-members or medical students. Many other specialities have built practice research networks. Pediatrics has had one for more than a decade. They started small, like us. They have found that getting data from physicians on the front lines is often very different than getting it from inner city, teaching hospitals. Once you join EM-PRN, you will be able to do much more than just give opinions to survey questions. We want to submit ideas for research projects and survey questions that YOU would be interested in. Our group will pick the more interesting and the most popular IDEAS for the next survey. So you not only will be providing answers, you’ll be designing the questions.

Right now and for the next few years, EM-PRN will be largely surveys. Eventually, we will likely want to grow to collect some data. For example, IN THE FUTURE we might want to monitor the number of patients seen with chronic pain in emergency departments. You would simply count the actual number of patients you see during a single shift (no names, no identifiers) and submit it to ACEP.

We could then monitor this number over time to see if it is increasing, decreasing or staying the same. The members of EM-PRN will help direct what research projects we consider and will be acknowledged on any publication. Members will also receive the results of any project ahead of publication. So in the time it has taken you to read this Blog, YOU could contribute to advancing our knowledge of the real practice of emergency medicine. Join now.

www.acep.org/em-prn

 

 

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What is the Fair Market Value of an Emergency Physician’s Services?

What is the Fair Market Value of an Emergency Physician's Service?

Trying to define the market value of someone’s professional services is difficult when those services are typically paid at vastly different rates, depending on the payer, especially when the party paying is usually not the direct recipient of the service.  So when an emergency physician provides clinical services to a patient, how are those services valued by different payers, and what does that say about the reasonable market value of those services?

For example, let’s say that you come to the emergency department with an acute asthma attack:  you can’t breath well, and your inhaler hasn’t helped to break the attack.  A pretty straight-forward case, really:  your ER doc does a history and physical exam, orders up some oxygen and a few respiratory therapy treatments, some steroids, perhaps an IV to rehydrate you and get access in case your condition worsens and you need IV meds, and returns to re-evaluate you every 15 minuets to make sure the treatments are working.  Two hours later, you are able to go home with a script for three days of Prednisone and a refill for your Ventolin inhaler as the one you have is running low.  You get instructions on how to care for yourself at home, when to see your primary care doctor, and what you should do if the wheezing comes on again despite the treatment.  Chances are, you will likely get a charge for this service from the physician for 99284 level care for around $320, give or take, if you live, let’s say, in central California.

If you didn’t have insurance, you would be expected to pay the full charge.  Unfortunately, many patients can’t afford to pay; or could afford to pay but are just irresponsible, and don’t pay anything.  If the patient pays nothing, the emergency physician may be able to recover about $45 from California’s EMS Fund, a tobacco settlement funded program that pays on average about 15% of the emergency physician’s fee.

However, if you were uninsured with a family income at or below 350% of the federal poverty level; or you are insured and have incurred high medical costs (greater than 10% of family income over the prior 12 months) with a family income at or below 350% of federal poverty, and you submitted a request for a discount; you would (by virtue of California law) only have to pay 50% of median billed charges of a nationally recognized database of physician charges, probably around $150.

If you were covered by your County’s new Low Income Health Program (a family of 4 making less than $41,000/year), the county may pay the emergency physician about 30% of the Medicaid rate, or a whopping $21.

If you were covered by California’s Medi-Cal program, one of the lowest paying Medicaid programs in the country:  $68.

If you were covered by Medicare: the federal program would pay about $125.

If you had HMO coverage, but had to go to a closer out-of-network ER, your HMO would pay the ER doc between $140 and $250.

If you had PPO coverage, the plan would pay between $175 and $240, minus any co-insurance payment, and you would have to pay the rest up to the $320 charge.

So, for a $320 emergency physician service, the emergency physician might receive anywhere from the full $320 down to $21, and about 10% of the time – nothing.  The average emergency physician in California provides about $140,000 a year in unreimbursed care.

Of course, in order to provide these services, the emergency physician has to spend $10 to pay for malpractice insurance, $30 for billing services, and additional costs for other overhead amounting to a total of about $55 for every ED patient treated (even if the payment is $0)

So, what’s the real market value for an emergency physician’s services?  I would argue that it is the full amount that the emergency physician charges, as long as these charges aren’t significantly higher than what other emergency physicians in the same area charge, but then I just paid a heating technician $175 for 10 minutes of maintenance on our furnace.  Others would argue differently, but their estimate would be based on their particular agenda:  protecting those living in poverty, reducing costs for the employer, dealing with government budget deficits, or making higher profits for the insurer.  Unfortunately, none of these advocates actually provides emergency care to anyone.

By the way, if you were suffering from a heart attack or serious injury, and the emergency physician (and his team) actually saved your life (it happens hundreds of times every day), the emergency physician’s charge would be around $800 to (rarely) $2000.  So, what’s the real market value of YOUR life?

This post also appears on the blog The Fickle Finger www.ficklefinger.net/blog/

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An Emergency Physician’s Updates From Japan

Editor’s Note: An international ACEP member has been giving real-time updates to the ACEP Disaster Section about the developing situation in Japan. He agreed to share the information with the emergency medicine community and will try to continue to provide updates when he can.

Friday, March 11, 2011 1:13 AM CST

Hello. I am Dr. Takashi Nagata, international ACEP member and a Japanese emergency physician working in the southern part of Japan.

Currently we are suffered from a sudden catastrophic earthquake and tsunami in the northern part of Japan.

The damage is still under investigation; however, it seems serious to see TV news. 

Because I do not have enough information, I am not sure we need international disaster relief work; however, I would like to ask all the members in this mailing list to follow the situation.

Friday, March 11, 2011 3:18 AM CST

Dear all,

We are fine currently.

This earthquake and tsunami in Japan is the most serious in the past.

It mainly hit Tohoku area, the northern part of Japan main land.

In Miyagi prefecture and Iwate prefecture, they had quite serious damage.

There was a catastrophic damage caused by tsunami along Natori river in Miyagi prefecture and Port Kamaishi in Iwate.

In my impression, the damage of tsunami is more devastating than earthquake itself.

Tokyo was also attached; however, the damage seems relatively limited.

In Tokyo, the railway is stopped, and most businessperson (more than 1 million people) will have to stay in Tokyo.

People try to be calm. So far there is no major fire or building collapse.

According to national disaster plan, the medical response teams have started working.

However, the airports (Naneda international airport in Tokyo and Miyagi airport) are closed now.

So, the teams in the neighboring prefectures try to move by motor vehicles.

The teams in the remote areas are being stand-by.

I try to keep sending information.

Thank you for your kindness.

Friday, March 11, 2011 5:11 AM CST

Dear all,

It is night time now.

It is difficult for us to rescue and search for the victims, and we have to wait for the sunrise at least 10 hours.

As far as the media reports, the situation seems stable. Many hospitals are intact in the affected area.

And most people stay in the designated shelters. Food and electric power can be provided.

However, we do not know the whole impact of the earthquake and tsunami.

Military, police, fire, EMS and disaster medical teams have already been deployed to the scene.

There are 11 atomic power plants in the affected area, and so far, all of them are stopped automatically. So far there is no risk of radiation leakage.

Friday, March 11, 2011 7:50 AM CST

We estimate about at least 1,000 fatalities and 2,000 severe injuries in the affected area.

The access from the neighboring prefectures to the affected area is limited. And rescue/search activity does not work well.

Now the media reported that 200-300 drowning were found dead now.

The affected area, Tohoku, is next to Tokyo, and we would like to send teams from Tokyo to the front line; however, the hospitals are busy to work for the overcrowding mild patients in the urban area. So, we cannot afford.

We guess that the situation is like Tsunami in Asia, 2005 or Hurricane Katrina in 2006.

In addition to emergency disaster relief in the acute phase, I think we will need public health approach for the affected area in the long time.

Friday, March 11, 2011 8:52 AM CST

Dear all,

We still have tsunami repeatedly at night, and the most coast lines of Japan become alarm zone now.

The government issued the emergency of nuclear plant in Fukushima prefecture.

The system has already shut down the reactor and then caused problems with its cooling system. So far there are currently no reports of radiation leakage. Military and fire are working hard for it now. These power plants are located about 200 km away from Tokyo.

Now we have several major fires in several places. Rescue activity is quite difficult because of darkness.

In Kobe earthquake in 1995, about 6000 people died, but this occurred in the single prefecture.

This earthquake and tsunami attached multiple areas and regions in Japan.

It is sad to say, but this is the largest disaster we have ever had.

After 6 hours, we will have sunrise.

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