Dr. Isaac Kojo Anakwah Thompson, a Florida primary care physician, was sentenced in July 2016 to 4 years in prison and a subsequent two years of supervised release. Dr. Thompson pled guilty to health care fraud. He was further ordered to pay restitution in the amount of $2,114,332.33. Ouch!! What did he do?
According to the Department of Justice, Dr. Thompson falsely reported that 387 of his clients suffered from ankylosing spondylitis when they did not.
Question: How does faking a patient’s disease make a physician money???
Answer: Hierarchal condition category (HCC) coding. Wait, what?
Basically, Medicare Advantage assigns HCC coding to each patient depending on the severity of their illnesses. Higher HCC scores equals substantially higher monthly capitation payments from Medicare to the managed care organization (MCO). In turn, the MCO will pay physicians more who have more extremely sick patients (higher HCC codes).
Ankylosing spondylitis is a form of arthritis that causes inflammation and damage at the joints; eventually, the inflamed spinal joints can become fused, or joined together so they can’t move independently. It’s a rare disease, affecting 1 in 1000 people. And, importantly, it sports a high HCC code.
In this case, the Office of Inspector General (OIG) found it odd that, between 2006-2010, Dr. Thompson diagnosed 387 Medicare Advantage beneficiaries with ankylosing spondylitis and treated them with such rare disease. To which, I say, if you’re going to defraud the Medicare system, choose common, fabricated diseases (kidding – it’s called sarcasm – I always have to add a disclaimer for people with no humor).
According to the Department of Justice, none or very few of Dr. Thompson’s 387 consumers actually had ankylosing spondylitis.
My issue is as follows: Doesn’t the managed care organization (MCO) share in some of the punishment? Shouldn’t the MCO have to repay the financial benefit it reaped from Dr. Thompson?? Shouldn’t the MCO have a duty to report such oddities?
Let me explain:
In Florida, Humana acted as the MCO. Every dollar that Dr. Thompson received was funneled through Humana. Humana would pay Dr. Thompson a monthly capitation fee from Medicare Advantage based on his patient’s hierarchal condition category (HCC) coding. Increasing even just one patient’s HCC code means more bucks for Dr. Thompson. Remember, according to the DOJ, he increased 387 patients’ HCC codes.
Dr. Thompson reported these diagnoses to Humana, which in turn reported them to Medicare. Consequently, Medicare paid approximately $2.1 million in excess capitation fees to Humana, approximately 80% of which went to Dr. Thompson.
In this case, it is reasonable to expect that Humana had knowledge that Dr. Thompson reported abnormally high HCCs for his patients. For comparison, ankylosing spondylitis has an HCC score of 0.364, which is more than an aortic aneurysm and three times as high as diabetes. Plus, look at the amount of money that the MCO paid Dr. Thompson. Surely, it appeared irregular.
What, if anything, is the MCO’s duty to report physicians with an abnormally high number of high HCC codes? If you have knowledge of someone committing a crime and you do nothing, isn’t that called aiding and abetting?
With the publication of the Yates memo, I expect to see CMS holding MCOs and other state agencies accountable for the actions of its providers. Not to say that the MCOs should actively, independently investigate Medicare/caid fraud, but to notify the Human Services Department (HSD) if abnormalities exist, especially if as blatant as one doctor with 387 patients suffering from ankylosing spondylitis.
Recently, Montana became the 31st state, including D.C., to expand Medicaid. Discussion regarding Medicaid expansion is ongoing in one state: Utah. Nineteen (19) states have rejected Medicaid expansion, including NC.
When Medicaid expansion was first introduced, it was a highly polarized, political topic, with Republican governors, generally, rejecting expansion and Democrat governors, generally, accepting expansion.
Now, however, many Republican governors have opted to expand Medicaid. There are currently 31 Republicans, 18 Democrats, and one independent that hold the office of governor in the states. Yet, 31 states have expanded Medicaid. Here is an extremely, difficult-to-read chart outlining the states that have opted to expand, those that have opted to reject expansion, and the one state (Utah) still discussing:
I know, it’s hard to read. Feel free to go to the actual Kaiser website to see the chart readable by humans. (Microsoft’s “Snipping Tool” leaves much to be desired; Apple’s “Screen Shot” is much better, in my opinion).
An interesting fact is that, in its first week with Medicaid expansion, Montana had over 5,500 people sign up for Medicaid.
Another interesting fact is that, approximately 18,078 physicians graduate from medical school in America per year. But in Montana?
N/A…as in, none. Not applicable. You see, Montana does not have a medical school. It does participate in the Washington, Wyoming, Alaska, Montana, and Idaho collaborative program. However, the collaborative program does not do a stellar job at recruiting physicians to Montana. It tries. But the statistics are stacked against Montana.
“Sixty-eight percent of doctors who complete all their training in one state end up practicing there,” according to the Association of American Medical Colleges.
Yet Montana has no medical school. And expanded Medicaid. If any of you ever took economics, there is this accepted theory called, “supply and demand.”
Supply and demand dictates that, when supply is low and demand is high, the product, whatever it is, can be sold at the highest price. Medicaid expansion, however, is creating an anomaly. Medicaid expansion expects a higher demand to meet the lower supply without increasing the reimbursement rates. This is a fundamental flaw in Medicaid expansion. If, on the other hand, Medicaid expansion was premised on an increase in reimbursement rates, we may see an uptick in supply. When demand is high and supply is low, many people “demanding” get nothing.
Let’s think about how many patients each primary care physician can handle.
“According to a 2013 survey by the American Academy of Family Physicians, the average member of that group has 93.2 “patient encounters” each week — in an office, hospital or nursing home, on a house call or via an e-visit. That’s about 19 patients per day. The family physicians said they spend 34.1 hours in direct patient care each week, or about 22 minutes per encounter, with 2,367 people under each physician’s care.” See article.
“The baseline projections from BHPr’s physician supply and requirements models suggest that overall requirements are growing faster than the FTE supply of physicians (Exhibits 51 and 52). Between 2005 and 2020, requirements are projected to grow to approximately 976,000 (22 percent), while FTE supply is projected to grow to approximately 926,600 (14 percent). These projections suggest a modest, but growing, shortfall of approximately 49,000 physicians by 2020 if today’s level of health care services is extrapolated to the future population. ” See article.
This is not the first time I have noted the increasing physician shortage with Medicaid expansion. There is a huge difference in giving someone a Medicaid card and providing a person with quality health care. A card is a piece of paper. If you cannot find a physician..or psychiatrist…or pulmonologist….or neurosurgeon who will accept Medicaid, then your Medicaid card is simply a piece of paper, not even worth the paper upon which it is printed. See blog. And blog. And blog.
The same can be said with the shortage of dentists. See blog.
With a shortage of approximately 49,000 physicians in 2o20, I pray that I am not holding a Medicaid card.
If I am, I will be another victim of high demand with low supply.
This is a story from NC Health News by Rose Hoban…a follow up blog to come…
In the 2014 state budget passed last August, state lawmakers inserted what could be considered a poison pill for Medicaid providers: a 3 percent pay cut that for specialists could be effective retroactively to January 2014.
Primary care providers such as pediatricians, internists and family doctors will see the same pay cut, effective back to Jan. 1, 2015.
But the cut is only now being implemented.
“All of us were optimistic that the cut wouldn’t happen,” said Karen Smith, a family doctor in Raeford who runs her own practice.
Smith said she and other physicians have been writing, calling and talking to legislators, working to convince them not to implement the cut.
But she and thousands of other primary care providers received notification late last week that on March 1 they would begin seeing the 3 percent cut.
And for specialists, the reduction will go back 14 months.
“It’s quite a hit,” said Elaine Ellis, spokeswoman for the North Carolina Medical Society.
Failed shared-savings plan behind the problem
The origin of the 3 percent cut goes back to the 2013 budget for Medicaid, the program that covers health care for low-income children, some of their parents, pregnant women and low-income seniors. In 2013, the federal government paid North Carolina 65.5 percent of every dollar billed for Medicaid-eligible care, while the state covered the other 34.5 percent (The rate, which changes annually, is 65.9 percent for 2015).
In 2013, the Medicaid budget had grown to close to $4 billion in state dollars, and lawmakers at the General Assembly were looking for ways to trim costs. So they devised a “shared-savings” program, in which Medicaid providers would take a 3 percent rate cut that would be collected by the state Department of Health and Human Services. If doctors and hospitals saved money by operating more efficiently, DHHS would share those savings back with the providers, effectively reducing the amount of the 3 percent cut.
But DHHS needed federal approval to initiate the program, which would have been complicated. The agency never submitted a plan to the federal government, so neither part of the program was initiated.
That created a problem for lawmakers, who had calculated the savings from the rate cut into their state budget. When lawmakers returned to Raleigh in 2014 to adjust the state’s biennial budget, they implemented the rate cut retroactively to Jan 1, 2014 for specialists. Primary care providers, such as Karen Smith, had their rate cut put off until the beginning of 2015.
Officials from the Medical Society have been gathering numbers from around the state and are finding that some specialty practices could owe tens of thousands of dollars that would need to be repaid to state coffers.
The need for retroactive payment is in part a logistical problem: The computerized Medicaid management information system, known as NCTracks, has not been able to process the cuts. NCTracks has had technical issues since it was rolled out in mid-2013; at that time, glitches in the system created months of delays and tens of thousands of dollars in unpaid services for providers.
“Requiring these [specialist] medical practices to pay back 3 percent of what the state has already paid them for the last 14 months would wreak havoc with the finances of these businesses – really, any business would struggle to recover from such a financial blow,” Robert Schaaf, a Raleigh radiologist and president of the Medical Society, wrote Monday in a press release.
And primary care doctors like Smith are also fretting over paying back 3 percent of what she earned from Medicaid for the past two months.
“Practices such as my own are functioning on an operating budget that’s month by month,” said Smith, who said that a great many of her patients are Medicaid recipients.
“We simply do not have that type of operating reserve to allow for that,” she said.
The cuts will be especially tough for rural providers, who have high numbers of Medicaid patients, said Greg Griggs from the N.C. Academy of Family Practitioners (The Academy of Family Practitioners is a North Carolina Health News sponsor).
“It’s one thing to make the cuts going forward, but to take money back, especially for that period of time, is pretty significant for people who’ve been willing to take care of our most needy citizens,” Griggs said.
“It’s pretty bad,” he said, “and its not like Medicaid pays extraordinarily well to begin with.”
In addition to the state cut is a federal cut of 1 percent to Medicaid reimbursements for primary care providers that went into effect on Jan. 1.
As part of the Affordable Care Act, primary care providers like Smith got a bump in reimbursement last year, but that ran out with the new year. Smith said that legislators in other states found ways to keep paying that enhanced rate for primary care doctors.
“We were hoping our legislators would do the same,” she said.
Instead, Smith finds herself talking to her staff about possible reductions, and she’s hearing from providers in her area that they’re throwing in the towel.
“I already have colleagues who’ve left practice of medicine in this area,” she said. “My personal physician is no longer in this area. Another colleague who was a resident three years in front of me told me he cannot deal with the economics of practicing like this anymore.”
Smith acknowledged that North Carolina’s Medicaid program has a slightly higher reimbursement to physicians than surrounding states. But she said many of her patients are quite ill.
“We are in the stroke belt,” she said, referring to the high rate of strokes in eastern North Carolina. “When we look at how sick our patients are compared to other states, is it equivalent? Are we measuring apples to apples?
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.
According to a report in the “Mason Conservative,” Virginia Democrat delegate candidate, Kathleen Murphy, stated, during a debate, that the government should force physicians to accept Medicaid.
After reading that, how many of you shuddered from horror?
I think we can all agree that we need more physicians to accept Medicaid. We simply do not have enough physicians to meet the needs of all our Medicaid recipients. Not enough physicians equals not enough quality health care to our most needy. In particular, rural areas suffer most from the lack of physicians who accept Medicaid.
According to Forbes magazine, “Right now, the United States is short some 20,000 doctors, according to the Association of American Medical Colleges. The shortage could quintuple over the next decade, thanks to the aging of the American population — and the aging and consequent retirement of many physicians. Nearly half of the 800,000-plus doctors in the United States are over the age of 50.” I’m sure Forbes would have found even more shortage had it researched the rural areas.
But is the answer to force doctors to accept Medicaid?
A week or so ago I saw my primary care physician. I’ve seen my primary care doctor for years. (We will call him Dr. Bob). He’s a native North Carolinian, just like I. So he knew me in college, law school, and for the past 13 years of my legal career, both pre-baby and post-baby. Until a week or so ago, I always knew Dr. Bob accepts Medicaid as a form of insurance. I liked that he did.
Per our normal routine, Dr. Bob asks about my husband, my daughter, and my job. But, usually he is extremely interested in “all-things-Medicaid.” He normally asks the status of reimbursement rates, my opinion on the current administration, my perception of the trend at my job (who was getting audits, who may be getting audits soon, etc.), and other various Medicaid-related issues.
But, at my visit, Dr. Bob fails to ask about the current events of Medicaid. And I, being I, just started talking about Medicaid. He interrupts me and says, “Knicole, I made a difficult decision since I have seen you last.”
Retirement….change in profession???
Retirement…closing his practice???
Instead, Dr. Bob says, “I’ve decided to no longer accept Medicaid.” (My jaw is agape).
My first instinct is, “What? But you CARE! How could you?”
My second instinct is, “I get it. Medicaid is a hassle.”
My third instinct is to actually ask HIM why HE made this decision. (My first couple instincts are usually the wrong route).
When I ask him why he decided to no longer take Medicaid, his response is “I’m sick of people who are not physicians telling me what to do in my practice.”
I get it.
As a primary care physician, the bulk of his Medicaid work is conducting physicals (or what Medicaid calls, “preventative care”).
He says that he is ‘ok’ with the low reimbursement rates of Medicaid because he is able to offset the low reimbursement rates by accepting more privately insured patients (like me). He says he loves serving the Medicaid population. His issue lies in the administrative burden of accepting Medicaid versus accepting private insurance, including the regulatory audits, the way in which the regulatory audits are conducted, NCTracks debacles, and possible unannounced payment suspensions…to name a few. Dr. Bob explains that when he decides a procedure is “gender-and-age-appropriate,” inevitably, someone, from some, state-contracted company, will come back to him a couple of years later to recoup the Medicaid money because that (non-physician) auditor disagrees that the procedure he chose, as a physician, was “gender-and-age-appropriate.”
DMA Clinical Policy 1A-2 defines preventative care as, “An adult preventive medicine health assessment consists of a comprehensive unclothed physical examination, comprehensive health history, anticipatory guidance/risk factor reduction interventions, and the ordering of gender and age-appropriate laboratory and diagnostic procedures.” (emphasis added).
He describes an audit during which an auditor, who was not a physician, attempted to recoup a date of service (DOS), citing the reason as the procedure was not “gender-and-age-appropriate.” How can a non-physician decide what treatment is or is not “gender-and-age-appropriate?”
I’ve seen this before. In behavioral health care audits, an auditor with no substance abuse clinical background determines no medical necessity exists for a service for a Medicaid recipient suffering from substance abuse. In dental audits, an auditor without ever attending dental school, will determine that a partial implant is not medically necessary.
N.C. Gen. Stat. 108C-5 requires that, “[a]udits that result in the extrapolation of results must be performed and reviewed by individuals who shall be credentialed by the Department, as applicable, in the matters to be audited, including, but not limited to, coding or specific clinical issues.” (emphasis added).
Credentialed in the matters to be audited.
Is DHHS seriously credentialing non-physicians to audit physician? Non-dentists to audit dentists? Non-substance abuse clinical providers to audit substance abuse clinical providers?
I do not know whether DHHS is credentialing the auditors, but, in my experience, non-qualified auditors (in the field in which they are auditing) are conducting audits.
Going back to my original premise, are we going to force/require that physicians, in order to be physicians, to accept Medicaid, thus subjecting themselves to limitless and unannounced Medicaid audits? To force physicians to undergo the administrative burden that comes with Medicaid audits, not to mention the administrative burden to just follow Medicaid regulations? To force physicians to accept the quite possible possibility that the physician will need to defend him or herself against audits and incur steep attorneys’ fees?
In Dr. Bob’s case, he did accept Medicaid for years. Then, he consciously made the decision that he no longer wanted to be subject to the regulatory scrutiny that comes with accepting Medicaid. So, now, would we force Dr. Bob to undergo the very scrutiny he so loathes?
It would be similar to the State forcing all attorneys to accept clients at a discounted rate and accept the threat of audits. Or forcing accountants to accept clients at a discounted rate and accept the threat of audits. Or forcing a plumber to accept clients at a discounted rate and accept the threat of audits.
Don’t we, in the United States, have the economic freedom to own private property, thus, logically, allowing us the right to pursue private property?
“We hold these truths to be sacred & undeniable; that all men are created equal & independent, that from that equal creation they derive rights inherent & inalienable, among which are the preservation of life, & liberty, & the pursuit of happiness;…”
See the Declaration of Independence.
I understand that Ms. Murphy’s comment was just that…a comment at a debate. But her comment demonstrates that, while politicians understand there is a shortage of physicians who are willing to accept Medicaid, some politicians may believe that physicians should be forced to accept Medicaid.
But aren’t we all entitled to the economic freedom to pursue private property, happiness, and liberty?
Or is that all a ruse?