The trouble with consultations
In a rather surprising move, the Centers for Medicare and Medicaid Services (CMS) included in the proposed rule on the 2010 Medicare physician fee schedule a proposal to remove codes for consultations from the Medicare fee schedule. Physicians instead would report the office/outpatient, hospital, or nursing facility evaluation and management (E/M) visit codes as appropriate, and these codes would be awarded higher relative value units (RVUs) in the fee schedule, resulting in potentially higher payment. Whether these increased payments would make up for the elimination of the higher-paying consultation codes likely depends on each individual physician’s mix of consults and office/hospital visits and the percentage of established patients versus new patients.
Some physicians won't like this, as it redistributes payment for E/M services among all physicians. These physicians state that their work is always worth more money because of the additional education and training they have related to specific medical problems. What they may be missing is that Medicare is offering a carrot, an increase in RVUs for non-consult E/M codes and fewer of the coding and documentation burdens that were associated with consultation codes.
At the same time, the Medicare auditors are bringing out the sticks in the form of pre-payment and post-payment audits. Medicare's Comprehensive Error Rate Testing (CERT) Report for May 2008 specified a high "paid claims error rate" of 16.6 percent for consultation services, with a projected improper payment of $516,912,824. Incorrect coding accounted for 86.4 percent of the consultation coding errors. WPS, Medicare contractor for Iowa, Kansas, Nebraska and western Missouri is performing a widespread probe of all consultation claims submitted and requiring pre-payment submission of medical records to substantiate charges. Other Medicare contractors have also chosen consultations for review. Given the state of Medicare funding, can the administrators ignore these results and not attempt to collect (with interest) the money paid out for these consultation services? Will Medicare's Recovery Audit Contractors, who receive a percentage of all money returned to Medicare, ignore these findings? If it were me, I'd accept the carrot and hope the stick is eventually aimed elsewhere.
The proposed removal of consultation codes from the Medicare fee schedule is mostly positive for family physicians, since you seldom get the benefit of the higher payment associated with consultation codes despite doing extensive work-ups before referring patients to subspecialists for specific procedures. However, there could be a drawback in that the higher payment was an incentive for the subspecialists you refer to to promptly report back to you, as the consultation codes require. There is some danger that removal of the incentive will cause greater delays or failure of communication, making it more important than ever that your staff keep logs (automated or manual) to be sure that you are aware of all physicians caring for your patients and follow-up as needed to receive records or reports. If you don't have systems in place to help track referrals, lab tests, etc., consider downloading the AAFP's Road to Recognition guide. Though created to help physicians document the elements necessary for recognition under the National Committee for Quality Assurance's Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH), the simple tracking tools it includes may be useful in many practices. If you feel certain that you always receive timely written follow-up from consultants, using these tools will provide you with evidence of whether your feelings are matched by your results.
Posted at 04:52PM Aug 20, 2009 by Cindy Hughes | Comments[0]
Pay for performance: It's not just for doctors anymore
It's a different interpretation of pay for performance, but the concept does apply to Medicare's Recovery Audit Contractors (RAC) program. Physicians in California and other states involved in the demonstration program may already understand the ramifications of this effort to recover improper Medicare payments. Now that the permanent program for RACs is gearing up across the country, it's important for all physicians to understand how it works.
The RAC program is different from Medicare safeguard audits like Comprehensive Error Rate Testing (CERT) that focus on identifying error rates for the Medicare payment contractors or postpayment review audits performed by individual carriers. RACs contract with the Centers for Medicare & Medicaid Services to perform post-payment reviews of Medicare claims to find overpayments and underpayments in return for a percentage (from 9 percent to 12.5 percent) of the amounts recovered. Put simply, they eat only what they kill. According to an evaluation of the three-year demonstration program, RACs returned $693.6 million to the Medicare trust funds, after subtracting the dollars in refunded underpayments, overpayments overturned on appeal, and operating costs for the program.
The RAC has two methods of uncovering improper payments - using computer software to analyze claims and auditing medical records. Hospital claims will likely continue to be a focus of their efforts, as was the case in the RAC demonstration program. However, hospitals have mobilized to defend themselves against RAC recoveries. At this time, physicians should not be overly concerned about being targeted but must not expect to be exempt from the program.
You should be aware of your rights in relation to records requests and refunds and how you might avoid some problems. If your practice does not have policies and processes in place to be sure that records sent in response to a payer/auditor request are appropriately screened for accurate dates of service and completeness and returned within the required time frame, I hope you'll schedule a few minutes to discuss the importance of this and establish a standard for your practice. It could save you money and headaches.
The AAFP has joined others in asking CMS to make changes to the program to lessen the burden and the risk to physicians. The AAFP has also put together an online guide to answer questions about the RACs and provide some tips that may help lessen the burden if an RAC does contact you.
It's a shame that honest physicians need to concern themselves with programs like this one, but here's hoping that the contractors do a good job of finding and stopping those few who create most of the concerns about fraud and abuse. They are out there, and now there are bounty hunters looking for them.
Have you had any experience with an RAC? Has the RAC contractor for your area provided any education to physicians? If you have tips that may help your fellow physicians, I hope you will share them.
Posted at 04:17PM Apr 03, 2009 by Cindy Hughes | Comments[0]
