Is Informatics the The Curse of Healthcare Reform?

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Medical Coding Complications and Greed

[By Darrell K. Pruitt DDS]

Coding complications in government healthcare ALWAYS favor the house — CMS guarantees it with lawsuits and whistleblower rewards that could attract dishonest employees. Are you careful who you hire?

Complications 

Complications in healthcare informatics – including 5-digit CPT® code mistakes as well as foul-ups that involve physicians’ “voluntary” 10-digit National Provider Identifier numbers – ALWAYS grant insurers more time to pay past-due bills owed to their clients and their clients’ doctors.

Call me Cynical 

Call me cynical, but if interest rates climb ever higher as predicted, watch for unexplained, proportional increases in coding errors to help fund insurance CFOs’ bonuses while raising the cost of healthcare even more without improving value. Is it any wonder why Americans don’t get the quality of healthcare we purchase compared to citizens in other countries? Tax-payers in my neighborhood are begging for in-network providers who put their patients’ interests ahead of insurers’ as much as allowed by insurers’ self-serving rules – without committing fraud. As a general rule, healthcare stakeholders accommodate parasites more than principals.

CPT® Codes and Patient Care 

Accurate CPT® coding may have nothing to do with patient care, but CMS makes it nevertheless important to physicians. Whereas the most innocent NPI foul-ups reliably delay payment and never turn out well for providers, the new fraud and abuse provisions of the Patient Protection and Affordable Care Act [ACA] can cause an innocent coding mistake on a Medicare claim to land the doc in court with charges of fraud depending on the quality of employees one hires – but only if the error favors the provider and not the payer. In June, David Burda posted “Attorney tells audience to brace for a storm of whistle-blower lawsuits” on ModernHealthcare.com.

http://www.modernhealthcare.com/article/20100623/NEWS/306209989/-1

Of Whistle-Blower Lawsuits

Burda reports that healthcare attorney Joanne Judge, a partner with Stevens & Lee in Reading, Pa., predicts a significant increase in whistle-blower lawsuits simply because the new law makes it far too easy for a dishonest employee to file an unwarranted lawsuit. No longer is there a requirement for the whistleblower, who stands to win money from his or her patriotic effort, to directly witness the crime. That kind of idea could catch on in this economy.

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“The new law also converts accidental Medicare overpayments to providers into potential false claims, Judge said. She said the law considers an overpayment as fraud if the overpayment isn’t identified by the provider and returned to the government within 60 days. Judge said that will require providers to beef up their internal billing systems to detect an overpayment as soon as possible and then send Medicare back its money.”

Assessment 

What can possibly go wrong with that plan? Thorough background checks on all new employees is increasingly important, doc. For my employment security issues, I’ve learned to depend on Richard at Investigation Resource Service out of Dallas. He’s never let me down (This is not a paid ad).

Conclusion

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Understanding CPT® Code Payment Components

Determinations More Complex than Most Believe

By Staff Reporters

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Currently, there are more than 10,000 physician services designated by the current procedural terminology (CPT®) or healthcare common procedure coding system (HCPCS) codes.  Each reflects the three major cost drivers of a particular procedure:

  • Physician work effort or the relative value unit (RVUw) of medical providers’ work efforts, pre-service, intra-service and post-service time.

Patients may exhibit anxiety when examined orduring procedures resulting in the need for additional timeand effort by the physician to respond to and prepare for the examination or procedure. This uniformly adds moretime and stress to the pre-service and intra-service period as doctors respond to constantly changing behavior, questionsand level of cooperation in varying specialties.  Follow-up communicationwith employers, family, friends and concerned others requires increased post-service times.

  • Practice expenses (RVUpe), including non-physician costs but excluding medical malpractice coverage premiums.

The practice expense component of the resource-based relative value scale (RBRVS) includes clinicalstaff time, medical supplies, and medical equipment.  Often, the costsof supplies and equipment are not proportional to practicesize.  Major factorsaffecting practice expense are the volume of telephone, cell, or Internet management services, and the case management and administrative work required. For example, high patient turnover requires more examination rooms to maintain physician efficiency. High volume requires moreclerical staff to deal with larger patient-flow volume and resulting phone calls, difficultiesdressing and undressing patients, and is marked by increasedcomplexity and time in collecting laboratory specimens.  Thesefactors must be accounted for in any resource-based practiceexpense study and in the resulting practice expense calculationsfor medical services; and

  • Malpractice (RVUm) representing the cost of liability insurance.

The RBRVS system assigns RVUs to cover the malpractice expensesincurred by physicians. These malpractice RVUs, originally calculatedfor office-based physicians, may systematically undervaluethe practice liability costs for some specialties. The prolonged statutes of limitation on some legalactions may result in increased malpracticerisk exposure for physicians providing such services [i.e., pediatricians]. The differences in exposure may not be calculated in theRBRVS system, and were not included in initial studies.  Specialty specific survey data for malpractice expenseshould be used for this component when assigning final RVU valuations.  Without specialty-specific CPT® codes, however, there was no wayto do this objectively.

Conclusion

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