Reimbursement Rocks

I traveled this weekend from Denver to Louisiana, to teach a compliance and documentation class. On the way there, on the second leg, in a very small and cramped airplane, I sat next to an Army Sergeant who was on his way home from Iraq. He hadn’t been home in a year or more. We visited a little bit about how excited he was to see his kids. He told me this was his fourth tour of duty to Iraq and he felt like he missed his 5 year old daughter’s childhood. All things in order, he should be coming home for good within 90 days of returning from R&R. He was a very nice, soft spoken gentleman, who enjoyed talking basketball with me. (One of my favorite things to talk about.) The subject naturally turned to the war and his involvement. Despite all that this man had been through and was enduring to serve his country, he admitted that we needed to be there, and that it was a good idea to finish what we started. Then, he said what really touched me. He said, “We appreciate all that the public does to try to get us home, but this is our profession, that we chose, and we knew what we were getting into”. In essence, he said, “this is my job, and I’ll do my job.”

Skip ahead to this Sunday’s class of chiropractors learning about documentation. We were in a part of the country where you have a lot of “old timey” DCs who have been in their small little town doing the same thing, the same way since who knows when. They were not so happy about this Denver girl coming in and explaining how Medicare works and that it’s NOT ok for them to just get around Medicare and make all those patients pay cash. Even after I laid out all the rules and regulations, there was defiance in some of their voices when they explained that they really didn’t have any intention of doing anything differently; regardless of what the government or the law says.

So I got to thinking about our government and the dictates of Medicare. Often, I’m asked about why the government would even CARE if a doctor has a patient pay cash because it’s just saving taxpayer money anyway, isn’t it? The short answer is that it’s because the government wants to protect the Medicare beneficiaries (patients) from unscrupulous doctors who will mislead them into believing that they HAVE to pay cash. Because of this, we’ve swung 180 degrees the other direction and are forced to bill EVERY CMT code to Medicare, maintenance or otherwise. The defiance in these doctors’ voices was clear: Don’t tell us what to do! We’ve done this for 40 years.

So, I’m mentally caught between the loyal and obedient soldier who “just does his job” and the doctor who defies Medicare rules and, yet, I can understand both sides. And still I find myself asking why these doctors don’t have a similar attitude as my soldier friend: “this is our profession and we knew what we were getting into”. I’m not a proponent of the status quo, and blindly following, never questioning. In fact, I think we should always speak our minds and fight for the right. But, Medicare has its rules and regulations. We should support and lobby ACA to change what doesn’t work, but compliance is necessary along the way; a necessary evil, but necessary nonetheless.
Who is right? Which way is best? I look forward to ideas and thoughts in both directions.

CMS (The Center for Medicare and Medicaid Services) recently released a report stating that Medicare has recovered more than $1 billion through the Recovery Audit Contractor (RAC) program since 2005, with 85 percent of the money having been taken back from hospitals. When the costs of collecting the money were taken into account–along with the small number of refunds made to providers–CMS was able to return $693.6 million to the Medicare trust fund. Not bad we may say…good for us as tax payers! Recoup from the evil hospitals…they didn’t need it anyway. But what about the rest of us?? How will (or did) this affect us?

In its analysis, CMS said that most of the improper payments made to providers occurred due to billing and coding errors, frequently when one procedure was billed repeatedly. Other problems discovered by RACs included incorrect procedure codes and submission of duplicate claims that both got paid. When the RACs challenged Medicare payments, 14 percent of providers appealed, and 4.6 percent of those decisions were overturned.

The first call I made when I read this was to my good buddy, John Davila, DC, a partner and VP at Compliant Services and Solutions. He’s the master blaster of compliance and who I defer to on such issues. (and I recommend that that my clients do too!) “So, John,” said I, “what was the first thing you thought when you read this?”. Inquiring minds want to know, and that certainly included me! I knew he would be all over this! John replied, “The first thing I thought of was..’Wow this is only from three states’ and then I thought, Whoa, the appeals rate is so small!”. What this means is that 86% of the providers didn’t trust that their information was accurate and thought “why bother” rather than to appeal.

Now, John is a brilliant guy, so I take my cues from him on compliance. We banter on about Medicare, Documentation, and other such topics that we both enjoy. But, when he pointed this out to me, it really jumped off the page. Imagine that this means more than 95 percent of providers who tried to appeal, lost–and those were the ones who felt they had a strong enough case to go through the appeals process! Not surprisingly, CMS acting administrator Kerry Weems called the results a success. Of course it is a success, Weems!!!

I look at this from two directions…one of them is that the providers need more confidence in notes and systems and the other, why don’t we appeal more often!?? Back in my ACA days, it was estimated that more than 60% of claims denied on the first submission, were paid by the second appeal. Dr. John pointed out to me that it was because a different review nurse had to look the 2nd time. Now, that same review nurse can look the second time, and so the 1st appeal may go the same way. With the addition of the QIC for 2nd appeals (Qualified Independent Contractors), that appeal number will come more into line again. A different set of eyes looks at the 2nd level of appeal. But, doctors, why are you not appealing?

I think it’s for some of the following reasons: 1) No confidence in your notes and systems; 2) Don’t know how to appeal; 3) Feel like it’s not worth it or “what’s the point” since only 4.5% of the 14% that appealed were overturned. Here’s the truth! Most DC’s don’t appeal Medicare and other carriers because there is no confidence in your notes and systems. But guess what? If everyone appeals, they have to start paying more claims, don’t they!?

Don’t be a part of the problem…be a part of the solution. Here’s my recommendation: 1) Get help up front! If you need to know your notes are bulletproof, get help up front. That’s what Dr. John’s company does as well as others. 2) Get your systems locked in. That’s what many of us do to help doctors get the systems in order that include doing it right up front, and then appealing. Even Dr. John’s war cry of “Appeal to the End” will fall on some deaf ears, if you haven’t gotten the help and systems in place up front.

This RAC program will not go away. Here’s the good news: If you go through your own appeals process and your claim is paid, there is no “double jeopardy”. This means that due to the context of the program, no more review or overturning can happen on that claim. That is a sturdy reason for me to want to appeal every claim, to the end.

So, when you get that inevitable letter asking for notes, don’t brush it off. Know that it’s a warning sign. Then take your temperature…are you cold and clammy? Fearful? Or confident and defiant? If you don’t feel confident and defiant, get some help! Not only will your office benefit, but the profession as a whole! Thoughts?

I got the call on my cell phone as I was running through O’Hare Airport between flights. I could tell by the sound of the voice on the other end that this doctor was in distress. He believed he had just figured out that his insurance CA was embezzling. He felt guilty that he hadn’t been more on top of things and angry at the same time for this horrible breach of trust. We decided that he wanted to work with me and my team to unravel this and to help him hire and train a new person. I just returned last week from conducting the onsite visit, both for analysis and training. I have to say, my heart aches for this doctor. As I was working with some of the accounts known to have had money stolen from, I worked with the new team member in talking to patients about it as they came in. As I looked into their horrified faces as we explained what happened, nearly every patient said, “How could anyone do this to my sweet, kind, loving doctor?”

The truth is, the doctor didn’t just delegate his insurance department to another; he actually abdicated it to her. When team members or patients would ask about balances or other work to be done, this evil doer would say, “Not to worry, I’m on it”. But there was no follow up and no proof that it was done. Mostly, this was because there was no system in place. But it really bothers me when I find doctors that have so much trust in their CA’s that they simply accept their word as gospel truth. It’s embarrasing I’m sure for a doctor to admit they don’t know enough about that department to manage it. Now remember, I was a finanical CA for most of my career. I wanted my doctors to trust me and they certainly could. I treated their money as if it were my own. But, in truth, it’s their money, in their office and they alone should have systems of checks and balances in place.

It’s important to have competent staff; trustworthy staff. But remember, this is your livelihood and your income. Trusting that to a third party who is not your spouse is a tall order. (And, no I don’t advocate that you fire your staff and hire your spouse…that is a whole different can of worms!) It’s my opinion that all doctors should strive to learn all they can about that department. I taught a group of about 180 at a Medicare seminar in Missouri yesterday, and it was a little annoying to me the number of CA’s in the room who were sent by their doctors, while the doctor took the day off. I know some were holding down the fort at the office, but in this case, Medicare is so important, it should not be delegated without some knowledge of the program yourself as the doctor/owner.

So, what’s a PokeyHontas? Well, as we were talking about the unfortunate situation in this office and the person who was arrested and charged with embezzelment they just cringed every time they said this former team member’s name. We tried to come up with something else we could call them. We found out that this person was held in jail over the weekend. And as sad as that seems, it’s justice for the nightmare that was poured down on this doctor and the team. We went through many names: Evil-doer; Pokey Princess; and finally came up with the perfect name: PokeyHontas…. I hope you never have to have the nightmare of a PokeyHontas in your practice. Take control of your finanical department now before it’s too late!!