By James E. Lewis, PhD
Although it is has been a generation (and many generations of medical school leadership in institutions that may or may not have good institutional memories) since several major U.S. medical schools incurred multi-million dollar paybacks to Medicare and paid multi-hundred-thousand dollar fees to accounting and legal firms either from or on behalf of their faculty practice plans, the specter of paybacks, fines and adverse publicity continues to hover over medical schools — allopathic and osteopathic, elite and aspiring, well-established and new babes in the wood. The recent letter (September 24, 2012) from DHHS Secretary Kathleen Sibelius and Attorney General Eric H. Holder, Jr. should have reminded everyone that unintentional as well as intentional fraudulent billing can have major consequences that could include jail time as well as paybacks and fines. Unfortunately, the letter conflates hospital and physician billing and may be misinterpreted by some to be focused solely on hospitals. Not so, my friends.
Upcoding, “cloning” (a new sin related to the Electronic Health Record when it is improperly designed or used), and inadequate documentation of services rendered, are among the more common billing issues. Changes in laws, regulations, and enforcement priorities and intensity, along with the discovery of some egregious violations (e.g., billing for non-existent services to non-existent patients, which is truly rare in academic medical centers) have transformed what used to be considered billing and documentation “errors” into “attempts to defraud the government” that may carry penalties far more serious than payback.
But, particularly in academic medical settings, it is erroneous to assume, for example, that because Medicare payments for Evaluation and Management (E/M) in aggregate are increasing rapidly, there must be some skullduggery afoot. There are several more than plausible explanations that have nothing to do with skullduggery and everything to do with the ever-changing nature of academic clinical practice:
Historically, most billing systems in academic medicine were riddled with weak spots, starting with the physician’s relatively independent decision as to whether to even create notes on the patient interaction and following through every step and handoff in a long series of processes and transactions leading to a claim being sent to a payor, among which Medicare is the largest. In these institutions, huge investments in training, effective and auditable systems increasingly linked to the Electronic Health Record (EHR), compliance plans, and experienced and qualified billing personnel have worked toward elimination of potential billing problems.
When payments per unit of service are reduced, responsible institutions start identifying and correcting any billing system weak spots while staying well within the extant laws and regulations. Result 1: Aggregate payments by Medicare likely will increase. Result 2: The index of suspicion may be raised for the Medicare contractors responsible for proper reimbursement for services. Other results may follow, for example, publicity like the Sibelius/Holder letter or “probe audits” to determine whether and where there may be conditions that would result in substantial overpayments if billing practices are not improved. Highly suspect situations might be subjected to full-blown audits or, if the evidence warrants, to extreme sanctions like partial or complete pre-payment audit. The most extreme sanction, of course, is being designated as ineligible to provide services to Medicare beneficiaries.
Older patients with one or more chronic diseases require more services, cognitive and otherwise, on each visit and they frequently require more visits per year than analysts of E/M code billing patterns and trends might expect. “High-intensity primary care,” as recently described by the Center for Studying Health System Change, only begins to suggest the need for regular review and updating of E/M codes.
Technological advances that may change E/M concepts and content can be expected to have effects on E/M coding and billing, too. For example, is there additional medical decision-making value in referring a patient to an imaging center for ultrasound when a primary care physician/nurse/technician can administer a handheld General Electric V-scan ultrasound and interpret it immediately as part of an E/M visit? Furthermore, from a technical standpoint, we are not far from the day when, for the consented patient at hand, any physician will be able to call up on an iPad or tablet computer-generated, multi-dimensional, manipulable visualizations made from CT and other images. Then, physician and patient can have a truly informed interaction that gets to the nub of the purpose of their being together in the first instance: the reduction of uncertainty for each party.
Academic medicine has not ignored the problems and issues regarding billing and collecting for faculty clinician services to patients that started to come to light soon after Medicare went into effect in the late 1960s. AAMC established the Group on Faculty Practice in the 1980s, the Compliance Officer’s Forum in 1996, and in 2000 joined with the University Healthcare Consortium to establish the Faculty Practice Solutions Center. The founding dates suggest the peaks of concern in this area and how they have fluctuated over time. Faculty practice, the central focus of these groups and their members, is essential to the programmatic life and the financial well-being of academic medical centers. High-level attention and constant focus are required to assure that billing systems are comprehensive, compliant, and effective. Well-managed institutions place great emphasis on faculty, trainee, and staff training, even including pre-billing audits for teaching purposes, and maintenance and enforcement of their compliance plans so as to avoid any hint of errors.
Nonetheless, in the grand scheme of payment for physician services, the volumes of patient care activity in academic practices loom large and by their very size attract attention or suspicion that, while they may be unwarranted, require cogent, factual institutional responses to put the matter to rest.
—James E. Lewis, Ph.D., is an independent consultant to departments and schools of medicine, teaching hospitals, cardiovascular and cancer research and clinical programs, medical professional associations, disease oriented foundations, consulting firms, pharmaceutical companies, components of the National Institutes of Health, the Centers for Communicable Diseases, and the predecessors of the Center for Medicare and Medicaid Services. Previously he served as Deputy Dean for Operations and Vice President for Academic Administration, The Mount Sinai School of Medicine and Medical Center, New York City, where his academic title was Professor of Medicine and Health Policy; and Senior Executive Officer, Department of Medicine, University of Alabama at Birmingham, where his academic titles were Professor of Medicine and Adjunct Professor of Sociology. He can be reached at firstname.lastname@example.org.