CMS anticipates Recovery Audit Contractor (RAC) automated reviews will begin in late June and July, according to Marie Casey, deputy director of the Division of Recovery Audit Operations at CMS. However, this is not set in stone, she says, noting, "there is some leeway."
But complex reviews won't begin until later, says Casey. CMS is aiming to begin certain types of complex reviews (e.g., coding and DRG validation) this fall. However, medical necessity complex reviews won't begin until early 2010.
The nature of automated reviews is simpler on the whole, she says, making them an easier choice to roll out first. "The automated reviews are less burdensome on the provider, because there's no request for medical records," says Casey, adding that automated reviews are also easier on the RACs themselves to manage.
The further delay of medical necessity auditing is due to the sheer complexity of the reviews. "We're delaying because it's more difficult. We are really trying to ensure that when there is a difference of opinion [on the medical necessity determination of the case], the RAC clearly documents their rationale," says Casey.
Casey says the delay will also help CMS with the rollout of its "issue review team," a group comprised of members of various agency divisions that will look at questions that come in about policy (e.g., whether the RACs are correct in interpretation of coding guidelines).
The issue review teams will be looking comprehensively at the questions, with staff with varying expertise on the review team, before approving new issues for RAC review, according to CMS representative Kathleen Wallace, who spoke during a May 28 Region D RAC training session held in Helena, MT.
What it all means
This is good news for providers and RACs. "Not only can providers avoid medical record requests for a few months, but this will allow providers and RACs to get used to the process before moving on to complex reviews that are more complicated and concerning," says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.
Because complex reviews are on hold until the fall, so too are medical record requests. When they do begin to arrive, they will likely be sporadic at first--at least in Region D.
HealthDataInsights, Inc., President and CEO Andrea Denko confirmed during the Helena training session that requests will initially be sporadic but should eventually fall into a pattern. "This cycle of receiving record requests will be helpful to providers," says Hoy. "People will be able to anticipate when they'll be getting record requests and be able to plan accordingly."
The American Hospital Association elaborated on CMS' decision to wait until 2010 to begin the medical necessity reviews in the May 28 issue of AHA News Now. Thirty-two percent of all demonstration program claims denials were for medical necessity, but a CMS study found a 40% error rate for medical necessity denials of inpatient rehabilitation facility claims performed by one of the RACs in the demonstration program, according to the article.
"This study validated concerns about the ability of RAC auditors to accurately judge the clinical decisions made by a patient's treating physician--sometimes three or more years after the care was provided," according to Rochelle Archuleta, the AHA's senior associate director for policy.
There is some truth to this, says Casey. "The medical necessity reviews are typically more difficult and include use of clinical judgment that's not defined in policy."
Benko indicated that HealthDataInsights has a system to direct cases to staff members familiar with particular types of care or facilities to help mitigate the potential for errors. HealthDataInsights Corporate Medical Director Ellen Evans, MD, highlighted their clinical review staff's wide variety of experience. For example, the RAC would direct a cardiac case to a nurse with cardiac experience for review or a rehab case to someone with rehab experience for review.
Other RAC news
In discussions with AHA this week, CMS clarified the time providers have to use the RAC discussion period, according to a May 28 AHA RAC Program Update. Providers will "have the option to use the RAC discussion period from the date of the RAC Review Results Letter through the date of recoupment of an overpayment--41 days following the date of the demand letter--rather than only through the issuance of the demand letter," according to the AHA.
In addition, CMS issued a sample demand letter to the RACs, which the AHA shared with the hospital community. This will be only the first sample letter in a series from CMS, says Hoy. Wallace and Denko indicated during the Region D training session that CMS will be developing multiple uniform letters addressing various situations for providers. "This should help providers understand exactly what is going on when they receive RAC-generated demand letters," says Hoy.
Finally, AHA confirmed in the RAC Program Update that the Government Accountability Office hopes to complete an analysis in November 2009 of the RAC demonstration program and the permanent program implementation.
The latest statistics released by The Joint Commission show the top cited standard in accredited hospitals involves fire protection problems. And it is likely that many of these deficiencies stem from low-hanging fruit that surveyors can easily grab, including items improperly stored in exit corridors.
The 2000 edition of the National Fire Protection Association's Life Safety Code—which The Joint Commission and CMS both enforce—forms the foundation of hospital corridor requirements through minimum widths, says Frederick Bradley, PE, a fire protection engineer and owner of FCB Engineering in Alpharetta, GA.
Exit corridors offer a fundamental fire protection feature in medical centers, allowing staff members the room to move patients to safe areas if a fire alarm goes off on a unit.
Stopwatch is set for 30 minutes
Items left in exit corridors—such as housekeeping carts—technically impede minimum width requirements and are code deficiencies. Not all aisles in hospitals count as exit corridors, so consult with your facilities director or safety officer for further information.
As with all Life Safety Code concerns, it's up to authorities to interpret and apply the requirements.
In an August 2004 regional memorandum to state survey agencies and fire authorities, CMS states that wheeled items "in use" can't be left unattended in egress corridors for more than 30 minutes, and the agency specifically mentions linen carts, medication carts, and janitor equipment.
Attended carts are those that are being used actively by an individual; an unattended cart is one that is not in use. Other similar items that would be affected by the 30-minute limit include food service carts and computers-on-wheels.
The CMS memo further states that:
Infection control isolation carts can remain in corridors indefinitely as long as they are outside an active isolation patient's room
Crash carts can always remain in corridors so that staff members can quickly get to them in an emergency
An online FAQ from The Joint Commission, which carries the same weight as an accreditation standard, reiterates the points of the CMS memo.
CEOs may need to step in
A hospital's success in dealing with corridor clutter could rest upon administrators' shoulders, says Brad Keyes, CHSP, a safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
"If your staff feels there's no way to solve corridor clutter, then a change in culture is in order," says Keyes, who is a former life safety surveyor for The Joint Commission.
When Keyes was a safety officer at Rockford (IL) Memorial Hospital, workers didn't always listen to him about keeping corridor widths clear until he started showing them a letter signed by the hospital executives supporting the life safety provisions.
In Bradley's opinion, a best practice is to limit in-use carts in a typical unit corridor to a crash cart and perhaps one or two other carts. "The food service cart should only be in the corridor during meal times," Bradley says.
In late 2007, staff members at Abington (PA) Memorial Hospital (AMH) knew their handoff process could use some work.
Their process, like that of many other hospitals, used a paper form to communicate important patient information from one provider to the next. However, the form would often be filled out improperly, labels would be missing, and ultimately, the receiver might not be aware of everything he or she needed to know about a patient, putting the patient at risk for an error in care.
The hospital also needed to stay in compliance with the National Patient Safety Goal concerning handoff communication, currently NPSG.02.05.01. Additionally, nurses often had to double-document information on the handoffs that had already been captured in the electronic medical record.
AMH had implemented computer physician order entry and clinical documentation by September 2007 and decided to utilize the EMR to enhance its handoff process. At the time, the hospital also used another system that pulled information from the EMR to provide patients with a daily care report.
"We thought maybe we could use that type of technology—that report writing—to get better, more accurate information in a simple way to ancillary staff," says Diane Humbrecht, MSN, RN, C, nurse director of informatics at AMH.
Humbrecht and her colleague Linda Mimm, RN, BC, DL, CPHQ, safety and quality specialist at AMH's Center for Patient Safety & Quality, worked with a team to decide how the process would function and what information should appear on the new "electronic hall pass."
The team decided that the information contained on the handoff should be pulled directly from the EMR, using the documentation notes that the nurse wrote up each morning. However, only data deemed pertinent would be included, as the team wanted to limit the printout to one page. This included items such as whether the patient was a fall risk, whether the patient was on oxygen, and the patient's isolation and code statuses. Since the effort launched, a team of support staff members reviews this list of items regularly to ensure that they are the most important ones to include.
Nurses were trained to use the EMR so that if a patient was to be transported to another department, they could merely go into that patient's record and click "print hall pass" for all of the necessary information to be printed.
Transfer staff members were trained to make sure that any patient ready to be escorted had a printed hall pass and to reconcile that information. If any patient information was missing, the transfer staff member would stop the process until he or she could locate the information.
The departments receiving patients from a transfer played a large role in redefining this process. Mimm says she originally was collecting data regarding whether the information on the hall pass was present, but she has since shifted to understanding who is receiving and using that information.
"What's nice is we can give monthly feedback to the receiving departments on how they are doing with reviewing the hall pass, and we're able to hit compliance because they were getting timely feedback," says Mimm.
This process has worked well since implementation and has increased the awareness of the support staff, without whom this process redesign would not have been possible, says Mimm.
"The whole process made me really appreciate the people outside of the nursing department who really need to know more about our patients and are concerned about their safety," she says.
Plans for future alterations
The simple set of directions for preparing the electronic hall pass is something that AMH staff members hope can be easily taught to transfer staff members. Instead of having nurses print the hall pass after updating the patient's record during rounds, AMH is planning to engage the escort staff members in the process more to minimize risks.
"If the hall pass is printed at 9 o'clock in the morning, it's only as good as the information updated until 9 o'clock," says Humbrecht. To that end, transfer staff members will be trained on how to enter the patient's record and print the most up-to-date hall pass upon arriving to pick up the patient.
Although Humbrecht and Mimm stress that the idea is to keep the printout as simple as possible, they are considering adding patient allergies to the form.
In the bulls-eye for cuts to find billions of dollars for health reform sit a wide array of physician radiology services whose annual price tag to Medicare has more than doubled to $14 billion between 2000 and 2006.
Services related to advanced imaging–specifically CT, MRI, and PET scans–could take much of the hit, with costs that have risen from about $3 billion to $7.6 billion in that time. Payments for MRI alone account for nearly half.
"Spending on advanced imaging, such as CT scans, MRIs, and nuclear medicine, rose substantially faster than other imaging services, such as ultrasound, X-ray, and other standard imaging," said the General Accounting Office report to Congress last summer. And that was just for Part B, Medicare's physician fee schedule.
A March report from the Medicare Payment Advisory Commission (MEDPAC) added: "The rapid volume growth of costly imaging services may be driven, at least in part, by prices that are too high."
The GAO report said the increase was seen across multiple specialties, especially cardiologists and vascular surgeons, but also vascular and orthopedic surgeons, primary care physicians, and urologists.
They are considering a hotly contested move to require prior authorization, especially for advanced imaging technologies, similar to practices by many health plans. A Congressional Budget Office report last December suggests a savings of $220 million between 2010 and 2014 and about $1 billion between 2010 and 2019 with radiology benefit managers who would block unnecessary scans.
They are evaluating the controversial proposal to restructure the payment formula in such a way that lowers the value of equipment factored in the equation, resulting in a much lower reimbursement to the provider.
Radiology groups are opposed to both strategies, but acknowledge that the high increases in federal payments have made them a target. "To do the things they're suggesting without adequate data and research, without examination of alternatives, is problematic because it only addresses the costs without addressing why they have gone up so much," says Jonathan Berlin, MD, associate professor of radiology at Northwestern University Feinberg School of Medicine.
The Access to Medical Imaging Coalition is vehemently against using authorization managers to approve physician scan requests. Such managers "are for-profit management companies established by the health insurance industry to deny coverage for imaging services. Physicians who deal with RBMs (radiology benefit managers) say they undermine patient care, force patients to wait to receive needed tests, and cause delays in diagnosis and care," the coalition says.
The Medical Imaging and Technology Alliance has a similar view. "Based on insufficient data and analysis, the MedPAC report makes recommendations that will lead to dramatic Medicare cuts for imaging and have dire consequences for the diagnosis, treatment, and care of patients," said Ilyse Schuman, MITA's managing director.
The federal reports acknowledge that much of the growth in both expense and number of images is rooted in the growth of more sophisticated and costly technology that appropriately diagnoses and treats more complex patient conditions.
And while the legitimate need for such services has clearly increased as has the resolution capabilities of these devices, some of the greater demand is pushed by forces without necessary medical justification, according to the reports. The GAO report mentions a trend toward physicians ordering scans to defend themselves "against malpractice suits." Other reasons for more utilization include the influence of direct-to-consumer advertising, and a shift of the use from Medicare Part A (hospitals) to Part B (physicians' offices), the GAO said.
The ability of physicians to refer patients to their own practices for imaging "was a major spending driver," the GAO said. Also, the report added health plan representatives believe "primary care physicians often lacked knowledge about the most appropriate test to order for a patient, and therefore tended to order a significant portion of imaging tests that would be considered unnecessary based on clinical guidelines."
Berlin acknowledges that imaging has "become a target" and realizes the "distinct possibility that a certain amount of imaging in some parts of the country may be inappropriate."
But he echoes the views of many in the American College of Radiology who question the government's assumptions that there is overuse. The Deficit Reduction Act has already imposed significant cuts in fees on imaging providers, and further cuts could drive some providers away, he says.
"If you continue to cut the reimbursement for imaging arbitrarily, you will continue to put imaging facilities out of business. That may not be a problem in overserved markets, but it could be in rural areas, where there may not be another imaging facility for another 150 miles," Berlin says.
Changes to radiology payments
The most controversial cost-cutting measure under consideration is how federal officials propose to change the radiology payment equation. The formula now assumes that imaging devices operate 25 hours a week, or half the time the office is open for business. But MEDPAC's and Senate Finance Committee's May 20 reports suggest that a more accurate number is 45 hours a week, or 90% of the time the practice operates.
"Once providers purchase machines, they have an incentive to use them as frequently as possible. Indeed, there is evidence that MRI and computed tomography (CT) machines are used much more frequently than Medicare assumes," the March MEDPAC report concludes.
Using the higher percentage would spread the equipment's cost over many more patient images, a change that "would result in a reduction in [practice expense] for costly imaging services and an increase in [payment] for other physician services," the Senate Finance Committee report suggests. The section is entitled "Adjusting Reimbursement for High-Growth, Over-Valued Physician Services."
Such a change is advised for imaging equipment that costs "at least $1 million," which recommends exploring the application of the 90% time standard "to less expensive imaging equipment" as well.
Berlin says these assumptions may be flawed because they were based on "informal reviews" of a few facilities. The ACR has initiated talks with CMS about the need for a more comprehensive survey, he says.
Berlin adds that Medicare program should investigate whether there are other ways to induce efficiency within imaging "short of draconian cuts," such as encouraging standardization of technology so many institutions can view and interpret the same images.
"Eventually, after addressing privacy concerns, storing images in a national computerized repository," might eliminate duplication, he suggests.
Lastly, he says, CMS should really explore the variety of other reasons why the imaging costs have gone up. "Defensive medicine, self-referral, advertising, all play a role. The bottom line is that people are demanding imaging more now than they were in the past."
But the GAO points to wide variation in in-office spending per beneficiary across geographic regions, a trend that suggests not all utilization was necessary or appropriate.
In 2006, "in-office imaging spending per beneficiary varied almost eight-fold across the states–from $62 in Vermont to $472 in Florida," the report said, adding that such variation "is more likely due to differences in physician practice patterns rather than patient health status."
The report adds, "in general, more health care services do not necessarily lead to improved outcomes."
The number of uninsured Americans will balloon another 6.9 million next year, stretching the number of uninsured to 52 million, according to a report released this week in the journal Health Affairs. The results are further evidence that when the price of health insurance goes up, the number who can afford it goes down.
"We're seeing faster increases in the number of uninsured, and because of the poor economy, that means more hospitals and physicians will have more demand from people for uncompensated care," says Richard Kronick, who co-authored the paper with University of Calfiornia San Diego colleague Todd Gilmer.
Among workers not covered as a dependent or by a public program, the number of uninsured rose from 23% in 2002 to 25.1% in 2006 and is expected to be 26.4% in 2010.
Their study cautions that estimates do "not directly take into account the additional effects of job losses, which are likely to add millions more to the number of uninsured Americans."
The recent stimulus package that provides 65% subsidies toward continuation of healthcare coverage for some laid-off workers "will help. But our research demonstrates once again the importance of more comprehensive action to extend adequate and affordable health coverage to all Americans," the researchers said in a statement.
"Because of the number of Americans who have lost their jobs or will lose them in the coming months, the increase in the number of uninsured people is, if anything, likely to exceed the projections in this paper."
Kronick was a former senior healthcare policy advisor in the Clinton administration. Gilmer is a specialist in health policy and the economics of tobacco use.
The "hidden health tax"–a surcharge on family health coverage paid each year by employees and businesses to subsidize uncompensated care–grew to $1,017 in 2008, while the cost for insured individuals grew to $368, according to a report released by Families USA today.
"As more people join the ranks of the uninsured, the hidden health tax is growing," says Ron Pollack, executive director of Families USA. "That tax hits America's businesses and insured families hard in the pocketbook, and they therefore have a clear financial stake in expanding health coverage as part of health reform."
The report says uninsured people are more likely to delay care as long as possible, which generally aggravates their illnesses. When they eventually receive care: 37% of that care is paid for by the uninsured out of their own pockets; third-party sources, such as government programs and charities, paid for another 26%; and the remaining amount, approximately $42.7 billion in 2008, is considered uncompensated care that is shifted to the insured in the form of higher premiums.
America's Health Insurance Plans endorsed the findings and says it underscores the need for universal healthcare coverage. "This is a very important study showing the hidden tax that uncompensated care puts on consumers and employers and it highlights why it's so important that we address healthcare reform this year," says AHIP spokesman Robert Zirkelbach. "The most expensive thing we could do is nothing at all because our healthcare costs are rising at unsustainable rates. This report shows that we are spending a significant amount of money to provide care for people who don't have health insurance and we are doing it in the most expensive way possible–which is through the doors of the emergency room."
Families USA contracted with the actuarial firm Milliman, Inc. to analyze the data for the report.
A previous Families USA report for 2005 put the hidden tax on family health coverage at $922 annually, and $341 for individuals.
Pollack says it could get worse this year because of the recession. "More and more people are losing their jobs and their health coverage. As a result, it is highly likely that the hidden health tax for 2009, which is not yet known, will be considerably higher than the $1,017 amount experienced in 2008," he says.
In its first audit of funds provided under the federal stimulus package, the Department of Health and Human Services' Office of Inspector General found that HHS had correctly calculated temporary increases in Medicaid's medical assistance percentages (FMAPs).
The Recovery Act provides fiscal relief to states to protect and maintain state Medicaid programs through temporary increases of the FMAPs. The federal government pays its share of the states' Medicaid costs based on the FMAP calculations. Sometimes, the FMAP can vary--depending on each state's relative per capita income.
The Recovery Act is providing about $87 billion in temporary additional Medicaid funding for the states through 2010. The Centers for Medicare and Medicaid Services made available to the states for the past two fiscal quarters approximately $15.2 billion in additional Medicaid funding based on the increased FMAPs.
Because the OIG audit found no discrepancies, OIG said in its report released yesterday that it was not making any recommendations to HHS at the current time in regard to the FMAPs. "We will continue to monitor HHS Recovery Act funds closely so that taxpayers can be assured that their monies are being expended appropriately," HHS Inspector General Daniel R. Levinson said in a statement.
In a separate OIG report also released yesterday, 40 states with capitated Medicaid managed care were found to be collecting encounter data from managed care organizations; however, usefulness of the Medicaid Statistical Information System was limited because CMS did not enforce encounter data requirements, the report said.
The MSIS must include encounter data to be representative of Medicaid beneficiaries because more than 65% of Medicaid beneficiaries receive all or part of their healthcare services through Medicaid managed care, the OIG report said.
Based on our findings, the OIG called for CMS to clarify and enforce existing federal requirements that states include encounter data in their MSIS submissions. In its comments to the draft report, CMS concurred with those recommendations. The OIG also recommended that CMS seek legislative authority to impose sanctions against states that fail to meet the MSIS reporting requirements for encounter data.
Almost half of the hospitals in Florida never reported having a problem with any doctor over a 17-year period, according to a report released Thursday. Public Citizen, a Washington watchdog group, said 105 of 227 Florida hospitals had never filed a complaint from 1990 through 2007 with the National Practitioner Data Bank, the federal group that keeps track of problem doctors nationwide. The report's authors said the reason for the low number was the clubby atmosphere in which the healthcare industry protects its own.
Texas lawmakers killed the bill that would have expanded the Children's Health Insurance Program in the state. The bill would have made available subsidized health insurance for an additional 80,000 Texas children by raising eligibility for CHIP to 300% of poverty, or a maximum income of $66,540 a year for a family of four.
The Orleans Parish Hospital Service District has entered into an agreement to buy the former Methodist Hospital and other healthcare centers in eastern New Orleans from Universal Health Services, according to the Methodist Health System Foundation. If the purchase goes through, it would mark the first real progress toward the restoration of a full-service in eastern New Orleans, whose residents now have to drive as far as 30 minutes to get emergency care.
