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Inconsequential Medicare Audits Could Morph into a Whopper of a Whale
Emergency room physicians or health care providers are a discrete breed – whales in a sea of fish. Emergency room doctors have – for the most part – been overlooked by the RAC auditors or TPE, ZPIC, or MAC auditors. Maybe it’s because, even RAC auditors have children or spouses that need ER services from time to time. Maybe it’s because ER doctors use so many different billers. Normally, an ER doctor doesn’t know which of his or her patients are Medicaid or Medicare. When someone is suffering from a a broken leg or heart attack, the ER doctor is not going to stop care to inquire whether the patient is insured and by whom. But should they? Should ER doctors have to ask patients their insurer? If the answer includes any sort of explanation that care differs depending on whether someone is covered by Medicare or Medicaid or has private insurance, then, sadly, the answer may be yes.
ER doctors travel to separate emergency rooms, which are owned by various and distinct entities, and rely on individual billing companies. They do not normally work at only one hospital. Thus, they do not always have the same billers. We all know that not all billers are created equal. Some are endowed with a higher understanding of billing idiosyncrasies than others.
For example, for CPT codes 99281-99285 – Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician or physician group with the same specialty to the same patient.
We all know that all hospitals do not hire and implement the same billing computer software programs. The old adage – “you get what you pay for” – may be more true than we think. Recent articles purport that “the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.” – Think a comment like that would red-flag ER doctors services by RAC, MAC and ZPIC auditors? The white whale may as well shoot a water spray 30 feet into the air.
Will auditing entities begin to watch ER billing more closely? And what are the consequences? When non-emergency health care providers are terminated by Medicare, Medicaid, or a MAC or MCO’s network, there is no emergency – by definition. Juxtapose, the need for ER health care providers. ER rooms cannot function with a shortage of physicians and health care providers. Even more disturbing is if the termination is unwarranted and seemingly inconsequential – only affecting under 4 surgeries per month – but acts as the catalyst for termination of Medicare, Medicaid, and private payors across the board.
I have a client named Dr. Ishmael. His big fish became the MAC Palmetto – very suddenly. Like many ER docs, he rotates ERs. He provides services for Medicare, Medicaid, private pay, uninsured – it doesn’t matter to him, he is an ER doctor. He gets a letter from one MAC. In this case, it was Palmetto. Interestingly enough, Palmetto is his smallest insurance payor. Maybe 2 surgeries a month are covered by Palmetto. 90% of his services are provided to Medicaid patients. Not by his choice, but by demographics and circumstance. The letter from Palmetto states that he is being excluded from Palmetto’s Medicare network, effective in 10 days. He will also be placed on the CMS preclusion list in 4 months.
We appeal through Palmetto, as required. But, in the meantime, four other MACs, State Medicaid and BCBS terminate Dr. Ishmael’s billing privileges for Medicare and Medicaid based on Palmetto’s decision. Remember, we are appealing Palmetto’s decision as we believe it is erroneous. But because of Palmetto’s possibly incorrect decision to terminate Dr. Ishmael’s Medicare billing privileges, all of a sudden, 100% of Dr. Ishmael’s services are nonbillable and nonreimburseable…without Dr. Ishmael or the hospital ever getting the opportunity to review and defend against the otherwise innocuous termination decision.
Here, the hospital executives, along with legal counsel, schedule meetings with Dr. Ishmael. “They need him,” they say. “He is important,” they say. But he is not on the next month’s rotation. Or the next.
They say: “Come and see if ye can swerve me. Swerve me? ye cannot swerve me, else ye swerve yourselves! man has ye there. Swerve me?”
Billing audits on ER docs for Medicare/caid compliance are distinctive processes, separate from other providers’ audits. Most providers know the insurance of the patient to whom they are rendering services. Most providers use one biller and practice at one site. ER docs have no control over the choice of their billers. Not to mention, the questions arises, who gets to appeal on behalf the ER provider? Doesn’t the hospital reap the benefit of the reimbursements?
But one seemingly paltry, almost, minnow-like, audit by a cameo auditor can disrupt an entire career for an ER doc. It is imperative to act fast to appeal in the case of an ER doc. But balance speed of the appeal with the importance of preparing all legal arguments. Most MACs or other auditing entities inform other payors quickly of your exclusion or termination but require you to put forth all arguments in your appeal or you could waive those defenses. I argue against that, but the allegations can exist nonetheless.
The moral of the story is ER docs need to appeal and appeal fast when billing privileges are restricted, even if the particular payor only constitutes 4 surgeries a month. As Herman Melville said: “I know not all that may be coming, but be it what it will, I’ll go to it laughing.”
Sometimes, however, it is not a laughing matter. It is an appealable matter.
Inconsequential Medicare Audits Could Morph into a Whopper of a Whale
Emergency room physicians or health care providers are a discrete breed – whales in a sea of fish. Emergency room doctors have – for the most part – been overlooked by the RAC auditors or TPE, ZPIC, or MAC auditors. Maybe it’s because, even RAC auditors have children or spouses that need ER services from time to time. Maybe it’s because ER doctors use so many different billers. Normally, an ER doctor doesn’t know which of his or her patients are Medicaid or Medicare. When someone is suffering from a a broken leg or heart attack, the ER doctor is not going to stop care to inquire whether the patient is insured and by whom. But should they? Should ER doctors have to ask patients their insurer? If the answer includes any sort of explanation that care differs depending on whether someone is covered by Medicare or Medicaid or has private insurance, then, sadly, the answer may be yes.
ER doctors travel to separate emergency rooms, which are owned by various and distinct entities, and rely on individual billing companies. They do not normally work at only one hospital. Thus, they do not always have the same billers. We all know that not all billers are created equal. Some are endowed with a higher understanding of billing idiosyncrasies than others.
For example, for CPT codes 99281-99285 – Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician or physician group with the same specialty to the same patient.
We all know that all hospitals do not hire and implement the same billing computer software programs. The old adage – “you get what you pay for” – may be more true than we think. Recent articles purport that “the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.” – Think a comment like that would red-flag ER doctors services by RAC, MAC and ZPIC auditors? The white whale may as well shoot a water spray 30 feet into the air.
Will auditing entities begin to watch ER billing more closely? And what are the consequences? When non-emergency health care providers are terminated by Medicare, Medicaid, or a MAC or MCO’s network, there is no emergency – by definition. Juxtapose, the need for ER health care providers. ER rooms cannot function with a shortage of physicians and health care providers. Even more disturbing is if the termination is unwarranted and seemingly inconsequential – only affecting under 4 surgeries per month – but acts as the catalyst for termination of Medicare, Medicaid, and private payors across the board.
I have a client named Dr. Ishmael. His big fish became the MAC Palmetto – very suddenly. Like many ER docs, he rotates ERs. He provides services for Medicare, Medicaid, private pay, uninsured – it doesn’t matter to him, he is an ER doctor. He gets a letter from one MAC. In this case, it was Palmetto. Interestingly enough, Palmetto is his smallest insurance payor. Maybe 2 surgeries a month are covered by Palmetto. 90% of his services are provided to Medicaid patients. Not by his choice, but by demographics and circumstance. The letter from Palmetto states that he is being excluded from Palmetto’s Medicare network, effective in 10 days. He will also be placed on the CMS preclusion list in 4 months.
We appeal through Palmetto, as required. But, in the meantime, four other MACs, State Medicaid and BCBS terminate Dr. Ishmael’s billing privileges for Medicare and Medicaid based on Palmetto’s decision. Remember, we are appealing Palmetto’s decision as we believe it is erroneous. But because of Palmetto’s possibly incorrect decision to terminate Dr. Ishmael’s Medicare billing privileges, all of a sudden, 100% of Dr. Ishmael’s services are nonbillable and nonreimburseable…without Dr. Ishmael or the hospital ever getting the opportunity to review and defend against the otherwise innocuous termination decision.
Here, the hospital executives, along with legal counsel, schedule meetings with Dr. Ishmael. “They need him,” they say. “He is important,” they say. But he is not on the next month’s rotation. Or the next.
They say: “Come and see if ye can swerve me. Swerve me? ye cannot swerve me, else ye swerve yourselves! man has ye there. Swerve me?”
Billing audits on ER docs for Medicare/caid compliance are distinctive processes, separate from other providers’ audits. Most providers know the insurance of the patient to whom they are rendering services. Most providers use one biller and practice at one site. ER docs have no control over the choice of their billers. Not to mention, the questions arises, who gets to appeal on behalf the ER provider? Doesn’t the hospital reap the benefit of the reimbursements?
But one seemingly paltry, almost, minnow-like, audit by a cameo auditor can disrupt an entire career for an ER doc. It is imperative to act fast to appeal in the case of an ER doc. But balance speed of the appeal with the importance of preparing all legal arguments. Most MACs or other auditing entities inform other payors quickly of your exclusion or termination but require you to put forth all arguments in your appeal or you could waive those defenses. I argue against that, but the allegations can exist nonetheless.
The moral of the story is ER docs need to appeal and appeal fast when billing privileges are restricted, even if the particular payor only constitutes 4 surgeries a month. As Herman Melville said: “I know not all that may be coming, but be it what it will, I’ll go to it laughing.”
Sometimes, however, it is not a laughing matter. It is an appealable matter.
OIG Report: MCOs Cause Limited Access to Primary Care for Medicaid Enrollees!
With flu season well under way, access to care to primary care physicians for Medicaid recipients is (as it is always) extremely important. During flu season, in particular, emergency rooms (ERs) are full of people suffering from flu-like systems. Many of those in the ER are uninsured, but many of those in the ER have a valid Medicaid card in their wallet.
So why would a Medicaid recipient present themself to the ER instead of contacting a primary care physician? In many instances, the Medicaid recipients do not have access to primary care. Many physicians simply refuse to accept Medicaid. Some managed care organizations (MCOs) refuse to contract with a number of physicians sufficient to address the needs of its catchment area.
A December 2014 audit conducted by the Office of Inspector General (OIG) found that access to primary care for Medicaid recipients is in serious question…especially with the onslaught of states moving Medicaid to managed care systems.
32 states contract with 221 MCOs. From each of the 32 states, OIG requested a list of all providers participating in Medicaid managed care plans. Remember that, here in NC, our MCOs only manage behavioral health care. We have not yet moved to managed care for our physical health care. However, this may change in the not so distant future…
Our Senate and House are attempting to pass Medicaid reform. The House is pushing for accountable care organizations (ACOs), which would be run by physicians, hospitals, and other health care organizations. The Senate, on the other hand, is pushing for MCOs. I urge the Senate to review this OIG report before mutating our health care system to managed care.
Federal regulations require MCOs to maintain a network of providers sufficient to provide adequate access to care for Medicaid recipients based on population, need, locations of providers, and expected services to be utilized.
However, as we have seen in NC, the MCOs are not properly supervised and have financial incentives to terminate provider contacts (or refuse to contract with providers). In NC, this has resulted in hundreds, perhaps thousands, of behavioral health care providers going out of business. See MCOs Terminating Providers and Restricting the Freedom of Choice of Providers for Medicaid Recipients: Going Too Far? and NC MCOs: The Judge, Jury, and Executioner.
The consequences of MCOs picking and choosing to contract with a select few are twofold: (1) the non-selected providers go out of business; and (2) Medicaid recipients lose access to care and choice of providers.
Because of #2, OIG conducted this audit, which, sadly, confirms the veracity of #2.
To conduct the audit, OIG contacted 1800 primary care physicians and specialists and attempted to make an appointment. OIG wanted to determine (1) whether they accepted Medicaid; (2) whether they were taking new Medicaid patients; and (3) the wait time for an appointment. OIG only contacted physicians who were listed on the states’ Medicaid plans as a participating provider, because Medicaid recipients rely on the states’ lists of participating providers in locating a physician.
Yet, the results of the OIG audit are disturbing, to say the least.
51% of the providers could not offer appointments to enrollees, which raises serious questions as to the adequacy of the MCO networks.
- 45% did not accept Medicaid
- 35%: could not be found at the location listed by the plan,
- 8% were at the location but said that they were not participating in the plan.
- 8% were not accepting new patients.
The average wait time was 2 weeks for those physicians accepting Medicaid. Over 25% had wait times of more than 1 month, and 10 percent had wait times longer than 2 months.
I guess they can always go to the ER.
Number of Mental Health Patients Rise in ERs as Willing/Able Medicaid Behavioral Health Providers Dwindle
This is EXACTLY the issue that I have been blogging about for months. The State of North Carolina, for whatever reason, has determined (whether intentional or not) to decrease the number of behavioral health care providers who accept Medicaid. With the aggressive tools in the Division of Medical Assistance’s (DMA) work shed, such as outrageous Tentative Notices of Overpayments, capricious prepayment review audits, and arbitrary terminations of Medicaid contracts without affording due process, DMA has, in the last year or so, successfully bankrupt hundreds of Medicaid behavioral health providers. Or the providers simply washes their hands of Medicaid all together.
With the dramatic decrease in Medicaid mental health providers, where are all the Medicaid recipients going? One answer? The ERs.
People in the industry are also noticing.
My best friend is an ER nurse. She told me recently that she noticed more and more patients coming in to the ER with mental illness the primary diagnosis. I asked her whether she knew whether these patients with primary mental health diagnoses were Medicaid patients. She answered (which I love), “I don’t know. I never look to see if a patient is a Medicaid recipient. I treat them all the same.” She is a good nurse.
Anyway, I asked her to start paying attention (without ever providing me with specific information). She returned a week or so later saying that, yes, the patients with mental illness as the primary diagnosis generally seem to be Medicaid recipients. (In fact the night before a man came in the ER sticking his tongue in and out rapidly and screaming, “Get me my lily pad!” This is not a man who should be in the ER. This man should be receiving mental health services).
Others in the industry have noticed this growing issue of Medicaid recipients with mental illness as the primary diagnosis going to the ER as well. Dr. Judy Tintinalli, an ER physician noticed and researched the issue. Here is her article:
NC Emergency Patients Twice as Likely to Have Mental Health Problems
June 17, 2013 by Rose Hoban
Research published by the Centers for Disease Control and Prevention compared rates of people reporting to North Carolina’s emergency departments complaining of mental health issues to EDs in the rest of the country.
By Rose Hoban
Many people think of emergency departments as mostly treating patients with traumas or heart attacks or an out-of-control infection. But in 2010, Judy Tintinalli, an emergency department physician at UNC Hospitals, was getting the sense that she was seeing more and more patients coming into her emergency department with mental health problems. She started asking around and found she wasn’t the only one with this impression. “We’d all noticed that the number of mental health diagnoses in visits are just going up in EDs,” Tintinalli said. “And this has been going on for a while.” Source: Emergency Department Visits by Patients with Mental Health Disorders — North Carolina, 2008–2010, MMWR 62(23);469-472 So she and her colleagues from several states started work on a study to look at rates of people coming in for care with mental health issues as one of their main complaints. Tintinalli’s intuition was on target. In a paper published last week, she writes that while rates of mental health issues in emergency departments are up all over the country, they’re especially high in North Carolina. Patients who came to emergency departments in the state between the beginning of 2008 and the end of 2010 were twice as likely to have a mental health complaint than in the rest of the country.
Good data
According to the Centers for Disease Control and Prevention, in 2009, about 5 percent of people coming into emergency rooms had a mental health disorder. But at that time, North Carolina’s rate was almost double, according to Tintinalli’s study. She used data that comes from almost every emergency department in the state, a system called the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). The system, begun as a way to catch bioterrorism or disease outbreaks before they get out of control, collects data about the diagnoses of every visitor to North Carolina’s emergency departments. NC DETECT captures more than four million emergency department visits per year. No personal data is collected, just geographic data and information about what happened during the visit. The system collects up to 10 possible diagnoses for each patient encounter. “And at the end of the patient encounter, you list the diagnoses the patient had,” Tintinalli said. “You prioritize based on how critical they are. “So, say you have someone come in with cancer, and they have pneumonia, and they’re also depressed; depression is the third diagnosis. If you come in saying you want to kill yourself, then the depression will be the first diagnosis.” By the end of 2010, 9.3 percent of all ED visits had a mental health problem as one of the top complaints.
NC DETECT draws data from many sources and provides surveillance data to NC public health as well as to CDC. Diagram courtesy North Carolina Preparedness and Emergency Response Research Center
And Tintinalli found that not only were people coming in for mental health disorders, but those people with a main complaint of mental health problems were more than twice as likely to be admitted to the hospital. No surprise. Clinical social worker Bebe Smith, who teaches at the UNC School of Social Work, said she wasn’t surprised to hear that North Carolina has had higher rates of emergency department usage among people with mental health issues. “North Carolina’s mental health system has been in constant flux for over a decade,” Smith said. “Sometimes people end up going to the ER when they’re truly suicidal and despairing and overwhelmed by stress. You know, if there are psychosocial stressors like losing a job, you don’t want to go on, you start drinking, get suicidal,” Smith said. She said it’s called being “in crisis,” and it looks slightly different for each patient. Tintinalli’s data showed that close to two-thirds of people coming in with mental health problems were complaining of stress, anxiety or depression.
“We let people go into crisis,” said Vicki Smith, head of Disability Rights North Carolina, who pointed to the lack of community-based services for people with mental health problems. “We are not providing people with mental health needs the services they need to keep them out of crisis,” she said. “We allow them to go into crisis and they end up in the ED, sometimes via police cars.”
“If numbers are going up, we need to look and ask if we have adequate resources to really deal with these problems statewide,” Tintinalli said. Vicki Smith said that’s exactly the problem. “We can keep people out of EDs, and there are a lot of evidence-based practices to do that,” she said. “But we haven’t provided the resources.”
Severe and persistent
A lot of providers of care for people with severe and persistent mental illness, like schizophrenia or bipolar disorder, have gone out of business, Bebe Smith said. And when that happens, patients lose their continuity of care. “That’s something important for them,” she said, “and it’s something we’ve lost.” She also said that the state has shifted away from continuous provision of care for these people – who often are disabled enough to have Medicaid –into episodic care, as a way to save dollars. “So people might have been in treatment for a while, they do better and then we discharge them,” Bebe Smith said. She said many outpatient clinics have pushed providers into seeing more patients for shorter visits as a way of getting productivity – and revenues – up. Then if patients start to do poorly, they get lost. “So if someone misses the appointment, they don’t have time to check in on that person. But the people who are doing more poorly are the ones who need outreach,” Smith said. “The way they’ve pushed productivity levels on therapeutic workers – that’s another place where you lose the continuity that’s key in keeping people from crisis.” So, she said, many end up in the facility of last resort – emergency departments.