Is Informatics the The Curse of Healthcare Reform?

Posted on February 7, 2011 by Dr. David Edward Marcinko MBA MEd CMP™

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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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3 Responses

  1. Mary, on February 7, 2011 at 3:41 PM said:

    Venture Capitalists and HIT

    Darrell – Who will make big money?

    The markets apparently believe that the government’s health IT blitz will bear fruit in the form of investor profits.

    For example, the IPO of Epocrates (EPOC), a vendor of mobile information for physicians, looks like a wild success, with share values jumping 29 percent above the initial offering price in trading on February 2nd, 2011.

    http://www.fiercehealthit.com/story/venture-capitalists-see-potential-bonanza-health-it/2011-02-03?utm_medium=nl&utm_source=internal

    Are these guys venture, or vulture, capitalists?

    Mary

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  2. Darrell DK, on February 8, 2011 at 3:42 PM said:

    Thanks, Mary

    Informatics is leverage, and Wall Street loves it. In the FierceHealthIT article, Ken Terry writes:”But the biggest reason for high expectations is the $27 billion that the government expects to spend on incentives for providers who show meaningful use of EHRs. That, plus the half a billion dollars in federal funding for health information exchanges, provides a lot of fuel for growth in health IT.” It’s easy to see that informatics helps stakeholders more than patients.

    I’ve long suspected that compliance with informatics challenges like the current ICD-9 coding standard, and soon the even trickier ICD-10 standard, provide HIT lobbyists their most appealing unstated selling point in Washington. Coding makes getting paid for providing healthcare so complicated that doctors who actually treat patients cede control of their practices, including doctor-patient treatment decisions to algorithms. CMS explains, “ICD-10 will affect coding for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA), not just those who submit Medicare claims.

    https://www.cms.gov/ICD10/

    It’s not hard to see that 27 billion dollars in stimulus money further transformed well-connected HIT CEOs and politicians into intrusive middlemen – elbowing their way into doctor-patient relationships as if healthcare delivery in the US is a newly-discovered unexploited wealth-creating natural resource rather than half a million or so small businesses – many of them already struggling under the pressure of micro-management by people who know nothing about healthcare and have no concern for patients’ welfare.

    Keep your eye on Glen Tullman, CEO of Allscripts. The next time he comes out on the internet watch him play to politicians and/or Wall Street rather than his customers who have to use his product. The nation’s healthcare problem is not hard to see if you look in the right places.

    Darrell

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  3. Quinton, on July 23, 2014 at 12:03 PM said:

    Undercover probe finds health law failings

    The nonpartisan Government Accountability Office says its undercover investigators were able to get subsidized health care under fake names in 11 out of 18 attempts.

    http://news.msn.com/us/undercover-probe-finds-health-law-failings

    The GAO is still paying premiums for the policies, even as the Obama administration attempts to verify phony documentation.

    Quinton

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