Blue Cross Blue Shield of Michigan will increase payments to physicians involved in patient-centered medical homes by 10% beginning July 1. Blue Cross has paid $100 million over the past five years to create a system for 1,000 Michigan doctors in 300 primary care practices to practice in the medical home.
As part of an ongoing investigation, the U.S. Defense Department is currently searching the Siemens Medical Solutions office near Philadelphia. The nature of the investigation has not been made public. It is known, however, that in recent weeks, Siemens received a $267 million contract with the Defense Department to sell medical imaging equipment to the military.
Office of Inspector General Chief Counsel Lewis Morris stressed to the Senate Finance Committee this week the ongoing urgent need to fight healthcare fraud, waste, and abuse in order to foster the healthcare reform the SFC is working toward.
Morris made the statement on behalf of the OIG April 21 during the first of three SFC roundtable discussions on healthcare reform.
"Regardless of the structure of healthcare reform, detecting and preventing waste, fraud, and abuse in the healthcare system is critical," he said.
The U.S. spends more than $2 trillion on healthcare annually, Morris pointed out. The National Health Care Anti-Fraud Association estimates conservatively that 3%—or more than $60 billion—is lost to fraud, he said. More specifically, Morris said in fiscal year 2008:
The government won or negotiated approximately $2.35 billion in investigative receivables, including criminal, civil, and administrative settlements or civil judgments. The government's enforcement efforts resulted in 455 criminal actions and 337 civil actions against individuals or entities that engaged in healthcare-related offenses.
The OIG opened 1,750 new healthcare fraud investigations and had more than 2,500 healthcare investigations open at the end of fiscal year 2008.
The OIG excluded 3,129 individuals and entities from participating in Medicare, Medicaid, and other federal healthcare programs. Most of these exclusions stemmed from convictions for crimes regarding Medicare/Medicaid, patient abuse or neglect, or as a result of license revocation.
Morris also emphasized the progress the OIG has made in the past couple of years investigating cases of fraud and abuse. Since fiscal year 2006, the OIG's investigative receivables averaged $2.04 billion and its audit disallowances resulting from Medicare and Medicaid oversight averaged $1.22 billion per year. This gave Medicare and Medicaid a return on investment for OIG oversight of $17:$1. The OIG also implemented recommendations with providers that resulted in $16.72 billion in savings and funds put to better use, Morris said.
While the OIG is successful, looming budget cuts could jeopardize the fight against fraud and abuse. The SFC needs to continue to fund enforcement efforts as a part of healthcare reform, says James Kopf, former director of program investigation for the OIG, and president of Healthcare Oversight in New Canaan, CT.
"It's been an ongoing battle," he says. "We have to stay vigilant. We have to set up new ways of detecting (fraud and abuse). We have to go after actual criminals because they've changed their tactics."
Increasing the efficiency of the enforcement process could help government agencies in their efforts, he said. For example, setting up a national data bank similar to the FBI's National Criminal Information Center could speed up the investigation process and also help prevent further crimes, Kopf said.
With so many Medicare reimbursement dollars at stake, it is no surprise that everyone is putting in their two cents. Make no mistake—the wealth of information becoming available is a good thing. The more you know about the Recovery Audit Contractor program, the better you will be able to manage the process.
Most recently, the American Hospital Association is sharing what it knows via a Member Advisory released April 20. The publication, "Medicare Recovery Audit Contractors (RACs): Permanent Program Basics," (available to AHA members on the organization's Web site) contains a wealth of RAC-related information for healthcare providers.
"With the RAC program in the process of rolling out nationally, it is crucial for hospital executives to use tools like this to help educate themselves on the permanent program," says Robert Corrato, MD, MBA, founder, president, and CEO of Executive Health Resources. "There have been some changes since the RAC demonstration, which we have seen result in confusion for many hospitals across the country."
While the Advisory discusses a wide variety of RAC-related topics, healthcare providers may find useful the information on medical record request limits—a topic many organizations find confusing. And CMS has left its options open to alter the current medical record request limits in the future.
Interestingly, the AHA notes that while hospital campuses with more than one NPI are currently capped at 200 medical records per 45 days, this could change. "[CMS] will be looking at organizations with multiple NPIs closely to ensure that the organizational structure does indeed warrant a cap of 200 medical records. It is not CMS' intent to have multi-hospital systems subject to a cap of 200 medical record requests per 45 days," according to the Advisory.
CMS has not yet updated, or clarified, this information on the RAC Web site, notes Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc. She suggests that hospital systems, which this may affect, should keep an eye on the CMS Web site for more information.
In addition, RACs will communicate the medical record request limit for each healthcare organization in its initial medical record request letter, according to the Advisory. Make sure your RACs number matches up with the one you've calculated for yourself.
RACs may not "supersede" medical record request limits by "bunching" requests, according to the Advisory. In other words, think of cell phone plans featuring rollover minutes. Unlike such a plan, RACs can't store unused requests and roll them over for later use. The AHA uses the following example:
If the medical record request limit for a particular provider is 50 per 45 days and the RAC does not request medical records in January and February, the RAC cannot request 150 records in March.
Finally, RACs may request a limited number of records related to issues they will target for claim reviews not yet approved by the New Issue Review Board, and thus not listed on the RAC Web sites as areas RACs will review. The AHA Advisory explains:
CMS requires a RAC to present data analysis or other evidence of improper payments before it proceeds in wide-scale review of claims. In order for the RAC to compile that information, CMS will allow each RAC to request a limited number of medical records from hospitals before the new issue has been approved. CMS has indicated that no more than 10 medical records per provider can be requested for any particular issue before it has been approved by the New Issue Review Board.
Remember that RACs must make the status (e.g., outstanding, received, underway, completed) of requested records available upon request. Each RAC will have a toll-free number for this purpose. CMS is requiring each RAC to have a Web-based application for this purpose developed by January 2010.
A Dean Health System physician made an incision during a recent routine surgery, but it's a manager's cut during the procedure that is making waves.
Healthcare professionals are now questioning why the manager laid off a nurse during the surgical procedure.
Paul Pitas, director of corporate communications at the Madison, WI-based facility, confirmed the incident followed an announcement on April 8 that the health system would lay off 90 employees "immediately."
The facility released a statement in which Pitas declared "the absence of an RN goes against established patient care procedure" and that the act was "clearly . . . an error in judgment on the part of the manager conducting the layoff." Pitas declined to release the manager's name, who he stated has more than 30 years of nursing experience in the Wisconsin State Journal.
The timing of the layoff—during a surgery—is what has upset many nursing advocates.
"Layoffs may occur in these economic times, but there are correct methods for doing them," says Polly Gerber Zimmermann, RN, MS, MBA, CEN, FAEN, assistant professor at Harry S. Truman College in Chicago, and former ED nurse director. "The employee should be told at the end of the day, after care responsibilities have concluded. Healthcare workers are traditionally known for their caring approach; it is important that the same consideration is given to them in this type of situation."
Neither the name of the dismissed nurse nor the type of procedure he or she was assisting in were released. According to Pitas, the layoff didn't endanger the patient because other clinical staff, including a physician, were present during the remainder of the surgery.
But regardless of the surgery's severity, the nurse is there to advocate and care for the patient, while the operating physician focuses on the procedural aspect, says Zimmerman. "One nurse does not leave a procedure without being replaced," she says. "If the same nurse left on his or her own initiative, they could have been charged with patient abandonment."
Pitas stated in the Wisconsin State Journal that the nurse manager is "very upset" and "extremely remorseful" over the incident. He added that the layoffs created "extraordinary circumstances."
No one can deny that the pressures are mounting for healthcare leaders in today's economic climate, but Beth Kessler RN, BC, director of patient care services at Lehigh Valley Muhlenberg Hospital in Bethlehem, PA, questions whether the manager could have delayed the layoff until the procedure was completed or if it was just a bad decision on his or her part.
"I cannot judge the actions of the manager without knowing the circumstances that he or she faced," Kessler says. "We in the healthcare industry are not escaping the effects of the economy. But we, as a profession, must unite and recognize the need to be efficient while still providing safe patient care."
Strong outpatient volume and expense control helped the Sarasota County (FL) Public Hospital District improve its financial operating performance in the first six months of the district's fiscal year. The hospital system posted a $2.8 million operating loss for the six months ended March 31, compared to a $5.8 million operating loss in the same period one year earlier.