Documentation errors and omissions for tele-mental health services accounted for $348 million.
More than half of the $1 billion in temporary pandemic-related psychotherapy services paid by Medicare in the first year of the public health emergency were incorrectly billed, federal auditors say.
The Department of Health and Human Services Office of the Inspector General examined the Centers for Medicare & Medicaid Services' mental health services records for both in-person and telehealth visits from March 2020 through February 2021 at the start of the public health emergency.
The audit covered approximately $1 billion in Part B payments for more than 13.5 million psychotherapy services during the period. The audit picked two random samples of psychotherapy services: one of 111 enrollee days for telehealth services, and the other of 105 enrollee days for in-person services.
For 128 of the sampled 216 enrollee days, providers did not properly document psychotherapy time or omitted other needed information. In 54 sampled enrollee days, providers' failed to sign their claims.
"Based on our sample results, we estimated that of the $1 billion that Medicare paid for psychotherapy services, providers received $580 million in improper payments for services that did not comply with Medicare requirements, consisting of $348 million for telehealth services and $232 million for non-telehealth services," OIG says.
"The deficiencies we identified in our audit occurred because CMS's oversight was not adequate to prevent or detect payments for psychotherapy services, including telehealth services, that did not meet Medicare requirements and guidance," OIG says. "CMS's oversight was partially affected by the unprecedented challenges of the PHE because CMS's focus was to ensure that Medicare enrollees had access to health care."
"However, as CMS continues to reinstitute its program integrity measures and considers making other permanent changes to telehealth services, CMS should focus on implementing adequate oversight of providers to minimize the risk of paying for psychotherapy services, including those provided via telehealth, that do not meet Medicare requirements."
The health system denies intentionally filing false billings, and has worked with regualtors to resolve the case.
Northwest Arkansas Hospitals, LLC will pay $1.1 million to settle allegations that the not-for-profit health system improperly billed the state's Medicaid program on 246 occasions, Arkansas' U.S. Attorney Tim Griffin says.
Griffin says in a media release that the violations of the Arkansas False Claims Act were found during an audit by the Arkansas Foundation for Medical Care, which showed that records submitted by Northwest Hospitals for its claims "did not justify or support the medically necessary requirement for hospitalizations."
In a statement to the media, Northwest spokeswoman Christina Bull says the submissions to Medicaid "were based on medical evaluations, diagnoses and other supporting documentation created by the unit's former independent medical director Dr. Brian Hyatt and non-physician providers working under his supervision and direction in the unit."
"While there is no evidence that the hospital intended to submit improper claims, we also believe settlement is in the best interest of the organization at this time," Bull says.
Griffin notes that "Northwest has cooperated at all points during this investigation."
"While state and federal law give great deference to the diagnosis made by a medical doctor, all Medicaid providers must maintain complete and accurate records that justify claims filed and fully document the medical necessity of all services," Griffin says.
The bureau warns that a burgeoning medical credit card market could exacerbate medical debt woes for millions of people.
Americans put about $23 billion in healthcare expenses from 2018 to 2020 on high-interest medical credit cards and medical installment loans and paid about $1 billion in interest and other fees, a federal watchdog says.
And the Consumer Financial Protection Bureau in a new report, warns that the proliferation of these payment schemes "can create a significant financial burden for patients and deter them from seeking needed healthcare in the future."
The cards were used more than 17 million times in the three-year span to pay for everything from medications and lab work to emergency department visits for bills ranging from $35 to $40,000, the report says, warning that the proliferation in the marketing and use of medical credit cards, medical installment loans and other "high-cost specialty products" can easily and quickly saddle consumers with mountains of debt.
Medical financing companies market their credit cards and payment schemes directly to hospitals and other care venues, and patients are often offered these credit cards in physicians’ offices, the report notes, "even when their insurance may cover the procedure, or they qualify for a hospital’s reduced or no-cost financial assistance program."
"Fintechs and other lending outfits are designing costly loan products to peddle to patients looking to make ends meet on their medical bills," CFPB Director Rohit Chopra says. "These new forms of medical debt can create financial ruin for individuals who get sick."
The report warns that financial terms and interest rates of many of the medical credit cards and medical installment loans are also "significantly higher than traditional consumer credit cards, 26.99% to 16%, respectively," and that the payment plans "often have deferred interest plans, with all accrued interest potentially becoming due at the end of a defined period, which can prove especially expensive and unaffordable for patients."
To bolster the use of medical credit cards, the CFPB says financial firms woo providers with a promise of quick payments, minimal financial risk and administrative ease. The report warns that after accepting these incentives, providers may be "disincentivized to explain legally mandated financial assistance programs or zero-interest repayment options before offering these products to patients."
The report also found that credit cards, installment loans and other deferred-interest payment plans are often sold to patients with little disclosure or explanation of the terms of the debt. Clinicians pushing the products on their patients often rely "solely on marketing materials and training that financing companies provide to them at no cost," the report says.
Worse still for consumers, financing medical debt on a credit card could increase patients’ risk of legal exposure if they’re in arears because creditors could use aggressive collecting tactics such as lawsuits that providers typically wouldn’t pursue.
The award dates to 2017 and 2018, when Envision and UnitedHealthcare had an in-network agreement.
An independent arbitration panel has ruled that for-profit physician services provider Envision Healthcare is owed $91.2 million in its long-running fight with UnitedHealthcare over disputed payments.
UnitedHealthcare could pay even more, because the three-member panel from the American Arbitration Association may also consider additional payments to cover prejudgment interest and Nashville-based Envision's attorney's fees, court costs, and other expenses related to the dispute, which dates back to 2017.
Jim Rechtin, CEO of private equity owned Envision, says the physician services provider is "very pleased with the outcome," but complained that "it should not take five years to get paid for the lifesaving care our clinicians provide."
"We currently have three other lawsuits against UnitedHealthcare, which will likely take several more years to resolve. It is challenging to create a stable environment for our teams when health plans choose not to pay their bills," Rechtin says.
The award dates to 2017 and 2018, when Envision and UnitedHealthcare had an in-network agreement. Envision complained that UnitedHealthcare breached the terms of that contract when it unilaterally cut payments for services Envision rendered as an in-network provider.
In a statement emailed to HealthLeaders, UnitedHealthcare noted that the settlement is unrelated to its other lawsuits with Envision.
A spokesman with the Minnesota-based payer says they "disagree with the panel's decision."
"However, it did reject many of Envision's claims, including damages it was seeking," the spokesman says. "We remain committed to helping contain rapidly rising healthcare costs for the people and employer customers we're privileged to serve. We'll continue efforts to protect our members and customers from the small number of bad actors—often private equity-backed physician staffing companies like Envision—who demand unreasonable and anticompetitive rates for their services and drive up the cost of care for everyone."
Rechtin says the decision "sets a critical precedent for insurers like UnitedHealthcare to pay in full for the high-quality care its members receive in their most acute time of need."
"While we are disappointed that we had to take the step of entering into arbitration to compel UnitedHealthcare to pay its bills, we are satisfied with the panel's decision against UnitedHealthcare and its systematic underpayment to clinicians for the care they provide," he says.
Peach State clinicians who violate it risk censure from their respective professional credentialing boards.
Effective July 1, any clinician in Georgia who claims to be a medical specialist better have the credentials to back it up, under a new law signed this week by Gov. Brian P. Kemp.
Under Georgia Senate Bill 197, also known as the "Health Care Practitioners Truth and Transparency Act," a clinician's advertisements must include the clinician's names, and the specific license that the clinician holds for specific services.
The law also bans the use of the title "doctor" by nonphysicians in clinical venues. Advanced practice nurses and physician assistants with doctorates who identify themselves as "doctors" must make it clear in their advertising that they are not a medical doctor or a physician.
Georgia clinicians who violate the new law risk disciplinary action from their respective professional credentialing boards.
Michael W. Champeau, MD, FAAP, FASA, president of the American Society of Anesthesiologists, strongly supports the new law, which he says "makes it clearer for patients to make informed decisions because they know the qualifications of the professional providing their care."
"Every patient deserves to be certain of exactly who is performing and responsible for their care during a procedure or surgery," Champeau says.
Joon Sup Lee, MD, replaces interim CEO Dane C. Peterson, who has served in that role since September 2022.
Cardiologist Joon Sup Lee, MD, president of physician services at UPMC, has been named CEO of Emory Healthcare, effective July 1, the Atlanta-based academic health system announced this week.
"I am honored to have the opportunity to join such a strong leadership team and to be a part of a truly world-class academic medical center," Lee says in a media release. "The outstanding faculty and staff at Emory Healthcare are second to none, and will fulfill our mission to deliver the highest quality care with the utmost compassion while training the health care workforce of tomorrow and creating innovations in health sciences that will set the new paradigm for health care."
Lee replaces interim CEO Dane C. Peterson, the president and COO of Emory Healthcare, who has served in that role since September 2022. The 11-hospital system includes 250 care venues and more than 24,000 employees in the Atlanta area.
As president of UPMC Physician Services, Lee oversees 5,000 employed physicians and all clinically active faculty, with a focus on quality of care, patient experience, patient access and financial oversight of physician services. During Lee's 25-year tenure, he has played a role in UPMC's growth from a five-campus hospital system to a more than 40-hospital mega-system.
"I am thrilled that Dr. Lee will take on this important leadership role at Emory Healthcare," says Emory University President Gregory L. Fenves. "He is a problem-solver who cares deeply about the patients and families he serves and the doctors, nurses and health care staff he works with."
An interventional cardiologist, Lee's research has focused on the use of stem cells for treating coronary artery disease, rapid treatment of cardiac emergencies and catheter-based therapy for valvular heart disease.
Lee received his bachelor's degree from Dartmouth College and his medical degree from Duke University's School of Medicine. He completed a medical internship and residency, as well as two cardiology fellowships in cardiology and interventional cardiology, at Massachusetts General Hospital in Boston.
He joined the University of Pittsburgh faculty in 1996 where he has served in leadership roles, including chief of cardiology at the University of Pittsburgh School of Medicine and CMO for the UPMC Health Plan. Lee is certified in cardiovascular disease by the American Board of Internal Medicine. He is a fellow in the American College of Cardiology and Society for Coronary Angiography and Interventions.
Auditors blame CMS for failing to establish a data-sharing agreement with the VA.
Medicare overpaid providers about $128 million over five years for medical care that the Veterans Administration had already paid for, federal watchdogs report.
The Department of Health and Human Services Office of the Inspector General determined that the "duplicate payments occurred because the Centers for Medicare & Medicaid Services did not implement controls to address duplicate payments for services provided to individuals with Medicare and VHA benefits."
"Specifically, CMS did not establish a data-sharing agreement with VHA for the ongoing sharing of data between the two agencies and did not develop an interagency process to include VHA enrollment, claims, and payment data in CMS's data repository," OIG says. "Inclusion of these data, which is required by federal law, would have allowed CMS to compare VHA claims data with existing Medicare claims data to identify duplicate claims paid for by both Medicare and VHA."
The audit covered $19.2 billion in Medicare Parts A and B payments for 36.3 million claims for Medicare and VHA benefits that received services from VA's community providers between January 2017 and December 2021. The auditors compared claims data from the VA and Medicare to match payments that had been claimed in both datasets.
"Because CMS did not develop an interagency process, CMS did not establish an internal process (such as claims processing system edits) to address duplicate payments for medical services authorized and paid for by VHA. Furthermore, CMS guidance to providers on VA’s responsibility to pay for medical services did not clarify that a provider should not bill Medicare for a medical service that was authorized by VHA," OIG says.
CMS Agrees
The OIG recommends that CMS: Create a data-sharing agreement with VHA; Build an interagency process to integrate VHA enrollment, claims, and payment data into the CMS Integrated Data Repository to identify pMedicare otential fraud, waste, and abuse under the Medicare; and establish an internal process to address duplicate payments made by Medicare for medical services authorized and paid for by VHA; and issue guidance to providers on not billing Medicare for a medical service that was authorized by VHA.
CMS agreed with the recommendations and said it was taking up the recommendations.
The findings highlight a critical need to improve medical treatment provided to women and make the workplace more supportive for women experiencing menopause.
Menopause-related symptoms such as hot flashes, night sweats, mood changes, sleep disturbances, joint aches and cognitive difficulties cost about $1.8 billion a year in lost work time, and another $26.6 billion for related medical expenses, a Mayo Clinic study reports.
Menopause occurs at a mean age of about 52 years, and because midlife women are a sizable proportion of the workforce, the effect of menopause symptoms on absenteeism, productivity, increased medical costs, and career setbacks is notable.
Mayo Clinic researchers invited 32,469 women aged 45 to 60 who are primary care patients Mayo to participate in the survey. Just over 5,200 women responded (16.1%) and of those, 4,440 were employed and included in the study.
The findings, published in Mayo Clinic Proceedings, linked menopause symptoms and adverse work outcomes, including lost work productivity, with the severity of the symptoms strongly predicting the odds of an adverse work outcome.
The study authors say the findings highlight the need to improve medical treatment for women and make the workplace more supportive for women in menopause.
"A full 13% of the women we surveyed experienced an adverse work outcome related to menopause symptoms, and about 11% were missing days of work because of these symptoms," Faubion says. "We also found some racial and ethnic differences on a sub-analysis of the results, though more research is needed in this area, in larger and more diverse groups of women."
The survey was conducted between March and June, 2021. The symptoms were assessed by the Menopause Rating Scale (MRS). The mean total MRS score was 12.1, a moderate menopause symptom burden. The mean age of the 4,440 participants was 54 years, with the majority being white (93%), married (76.5%) and educated (59.3% with college degree or more).
A total of 597 women (13.4%) reported at least one adverse work outcome due to menopause symptoms, and 485 women reported missing one or more days of work in the preceding year due to symptoms.
"Adding to the complexity of women's experience of menopause is that the topic has been taboo, particularly in the workplace, which potentially adds to the psychological burden of symptoms," says senior author Ekta Kapoor, M.B.B.S., assistant director of Mayo Clinic Women's Health.
"Women often fear bias, discrimination and stigmatization, and therefore may be reluctant to disclose their menopause symptoms to their workplace managers and others. Recognizing these concerns and creating a safe workplace environment for women to discuss their health care needs may help address this."
TBI and hip fracture were the two most common injuries among senior dog-walkers.
Walking the family dog is good exercise, but it also puts adult pet owners — particularly women and seniors — at risk of serious injuries such as bone fractures and traumatic brain injuries, according to a new study from Johns Hopkins University.
Using the National Electronic Injury Surveillance System database, the researchers examined 20 years of emergency department records and found that finger fractures, TBIs, and shoulder sprains were the most common injury among the approximately 422,659 adults who sought treatment related to walking a leashed dog between 2001 and 2020.
The researchers also found that women, and all adults age 65 and older, were more likely to sustain serious injuries, such as fractures and TBIs, than people in other demographic groups.
TBI and hip fracture were the two most common injuries among adults age 65 and older, and women were 50% more likely than men to sustain a fracture. Older dog walkers were more than three times as likely to experience a fall, more than twice as likely to have a fracture and 60% more likely to sustain a TBI than younger dog walkers.
Across the 20-year study period, the estimated annual incidence of injuries due to leash-dependent dog walking more than quadrupled. The researchers say this may be due to concurrent rising dog ownership rates and promotion of dog walking to improve fitness.
The team hopes its findings will promote awareness among dog owners and encourage clinicians to discuss the injury potential of leash-dependent dog walking with their patients.
The study was published in Medicine & Science in Sports & Exercise.
"Dog ownership also increased significantly in recent years during the COVID-19 pandemic," says Ridge Maxson, the study's first author and a third-year medical student at The Johns Hopkins University.
"Although dog walking is a common daily activity for many adults, few studies have characterized its injury burden. We saw a need for more comprehensive information about these kinds of incidents." Edward McFarland, MD, the study's senior author and director of the Division of Shoulder and Elbow Surgery at Johns Hopkins Medicine, says "clinicians should be aware of these risks and convey them to patients, especially women and older adults."
"We encourage clinicians to screen for pet ownership, assess fracture and fall risk, and discuss safe dog walking practices at regular health maintenance visits for these vulnerable groups," McFarland says. "Despite our findings, we also strongly encourage people to leash their dogs wherever it is legally required."
Danville, PA-based Geisinger will be the first hospital to join Risant Health.
Megasystem Kaiser Permanente and Pennyslvania's Geisinger Health announced Wednesday that they plan to merge, with Geisinger to become the first hospital under KP's newly created but separate, value-based care affiliate, Risant Health.
Financial terms were not disclosed for the deal, which will have to clear daunting state and federal regulatory hurdles.
In a media release, the two systems describe Risant as a "nonprofit organization, created by Kaiser Foundation Hospitals, to expand and accelerate the adoption of value-based care in diverse, multi-payer, multi-provider, community-based health system environments."
"Risant Health's vision is to improve the health of millions of people by increasing access to value-based care and coverage and raising the bar for value-based approaches that prioritize patient quality outcomes," the health systems say. "In addition to Geisinger, Risant Health will grow its impact by acquiring and connecting a portfolio of like-minded, nonprofit, value-oriented community-based health systems anchored in their respective communities."
Geisinger will keep its name and mission, and will continue to work with other health plans, employed physicians, and independent providers. At the same time, Geisinger will tap Risant's value-based platform to maximize practices in care model design, pharmacy, consumer digital engagement, health plan product development, and purchasing.
As the first health system in Risant, Geisinger will help develop the system's strategy and operational model.
Geisinger President and CEO Jaewon Ryu, MD, JD, will be Risant's first CEO, transitioning from Geisinger when the deal closes.
"Geisinger will be able to accelerate our vision and continue to invest in new and existing capabilities and facilities, while charting a path for the future of American health care, through Risant Health," Ryu says. "Kaiser Permanente and Geisinger share a vision for the future of healthcare, and as the Risant Health name indicates, we believe by working together we will reach new heights in health care and raise the bar for better health for all communities."
Health systems that join Risant Health "will continue to operate as regional or community-based health systems serving and meeting the needs of their communities, providers and health plans while gaining expertise, resources, and support through Risant Health's value-based platform," KP says.
In addition, Risant Health will operate separately from KP's integrated care and coverage model while building on the mega-system's 80 years of expertise in value-based care.
"Our mission calls on us to find new ways to promote high-quality, affordable, and evidence-based care with equitable and improved health outcomes," says Greg A. Adams, KP chair and CEO.
"We know fully replicating KP's closed integrated care and coverage model is not viable in all communities. By helping other health systems achieve our value-based quality outcomes and savings in multi-payer, multi-provider environments, we believe Risant Health can deliver a transformative new solution to America's systemic health care problems."
