Once again we have “big” headlines here again about how hospitals and doctors bill Medicare.  Sure there are absolute fraud cases and better use of analytics can certainly help identify patterns and bring those to light for investigation but overall that’s a small portion of the process.  Again with HHS using their new software to identify patterns this should help with those cases.  Now we get to the battle of the algorithms again with codes and what is actually being done at hospitals and doctor’s offices.  imageYou can read the entire article in it’s entirety and see some good points made.  You do have to also remember there are the “consultants” that work with hospitals to show them areas to where they can increase revenue and save money.  Many times too the consultants will quote some type of percentage figure with their sales pitch on how much additional revenue they are missing out on.  This article misses the input there completely and whether or not they are right or wrong they exist and an entire industry exists because of this factor.  I don’t know where the author got their information but he/she quoted that a medical records company is also touting higher reimbursement with using their system which is kind of unusual unless there’s a big focus on revenue cycling and that may be a separate module for purchase. I wrote about it back in October of 2011.

Bad Algorithms in Healthcare Payment Systems and Risk Assessments–Did the Hospital Bill Fraudulently or Were They Sold Formulas That Did Not Conform

You just have to be careful of when you read these OMG stories anymore about billing because most of the times there’s no good guy/bad guy here, just interpretations.  One doctor says due to his medical records system he spends more time evaluating patient care and thus so does that deserve more money?  You would have to be living under a rock not to realize the additional data that doctors review today compared to the past and they do spend more time and do a better job, but again the antiquate compensation systems sometimes look at these situations as upcoding, when in fact it may not be.  In the news last year we had Prime for one example with one billing code and with automated coding how did this happen?  Oh we go back to the queries and coders again, it is what it is when automated.  Actually the companies that are set up to “just bill” that are fraudulent end up being better codes than doctors and hospitals as that’s their only focus as they don’t see patients and just work numbers. 

Prime Healthcare Billing Processes Under Question as 25% of Medicare Patients are Showing Malnutrition- Profit Algorithms?

Healthcare Billing Fraud–Office of the Inspector General HHS-OIG Is Finding “Organized Crime” With Some Criminals Armed With Guns and More….

Sometimes again how much money are you chasing and what would be the return, zero of there’s no fraud or mistakes so unless one is at least chasing a million or so in suspected fraud, does it make sense to chase everything out there?  Somewhere along the line someone needs to make some kind of a business decision and it might be to check the 3rd party consultants to see what they are selling too.  When you go back through a little history here we had the United/Ingenix cases too where for 15 years doctors we short paid with the use of data base that low balled the customary fees, so this certainly brought an awareness around as well with looking around by doctors and hospitals to make sure they are not short paid or missing money.  The algorithms and the lawsuits that followed set the stage here. As time moves forward, many forget about this and how algorithmic formulas were used to short payments and make profits for the corporate insurer.  We don’t want that again.  It is also worth nothing that United has ton of analytics subsidiaries that work out there today and they are hiring folks to analytics at a rocket speed.  So again who set the stage for all of this?  United also owns a bank and the other day a question popped into my head in wondering how manyquants” might work there. 

New FAIR Data Base Slated to Be Available Later this Year To Replace the Corrupted Data Base Used by Ingenix to Calculate Out of Network Insurance Charges

Outpatient Surgery Centers File Class Action Lawsuit Against UnitedHealth and Ingenix for Underpayments

If you read the news then you know that doctors and hospitals are being cut right and left too with contracts from insurers so when the money goes down in some areas it’s a matter of survival to replace income and if there are “legal and “document” billing codes with Medicare, well you get the picture, and again I’m not talking about the absolute “fraud” cases as those with insurers or Medicare should be investigated and brought to justice.

Then we also have this, the re-admissions algorithms which is not more than just swapping money back and forth, although there are some great strides made here with improvements as we study data, but the cut and dry algorithmic formulas are just a showing of the lack of using analytics properly in my opinion as when this plays out in the news today, we have these “bad guy” OMG headlines stating doctors and hospitals are doing nothing about this which is not true.  The analytics used by insurers are not without fault or do the job 100% either.  On these fines for re-admissions you find some of the best healthcare facilities in the US, so what’s that tell you?  An algorithms is not complete answer.  Like I keep saying, folks are algo duped. 

How Good Are The Insurer Algorithms That Determine Normal and Customary Fees–In Some Cases They Didn’t Work Too Well Where Their Analytics Systems Missed the Call and Now We Have More Lawsuits

Basically it’s crap journalism for ratings on some of this and the naïve public thinking that some algorithms are going to be 100% of this solution…you have to give that a chuckle as we have so much “Algo Duping” going on today.
  It’s the intelligence you get from studying the data and not a black and white algo that makes the difference.  You can see this in the $3 million dollar carrot program that Heritage has going, they think an algorithms is going to be the answer…information will help but look at the site too on how they go about it, looks a gaming website.  Again the information is valuable but no black and white algorithm for a solution and again naïve beliefs here at work and former HHS secretary Leavitt is all in it so again has he been duped too?  Just talk to folks who write code about the logic and sense behind a lot of this and you will see much different side than what you are sold via media. 

Medicare Re-Admissions Penalties–Algorithms Keep Money Shifting and Make It Difficult for Realistic Budgets to be Met Along With Good Patient Care–Algos Keep the Money Moving In One Direction or Another

Again we have to determine how time and effort it is worth to chase some of this as again it makes for confusion and algorithms just shift money back and forth and back and forth.  It will never be perfect for sure and again common sense should enter here on what should be chased.  On that note too when a for profit hospital chain shows huge profits like HCA, certainly it would call for a look at their coding to ensure everything is done correctly.  If everything is systematic and legal then it open doors for others, but it depends on how they are going to interpret the algorithms and formulas an someone has to make a decision on the “value of time” with added Health IT complexities in care if the hospitals and doctors are worth the money if you want to get down a real simple question. 

How is HCA a For Profit Hospital Chain, Making All That Money–Billing in the ER a Contributing Factor for Reimbursements–The Algorithms Move Money and Created Some Very Large Profits And Others Generated ER Care Parameters for the Facilities

Don Berwick was right with his assessment of the system, you pay more when folks do more and charge the piece and that’s you get and now stories are in the news about “stents” that may not have been needed and that area for sure should be looked at as now we have gone beyond just billing here and have safety and patient care involved.

So before you get all enraged about this article and thinking doctors and hospitals are thieves, take another look as you may have been Algo Duped here.  More time spent, the higher the code and it’s always been this way with a HPI and several other components that enter into a patients chart as they document the work.  I think now Medicare has to take a look at their side of this and somewhere along the line see what they are chasing too and go after those where it makes sense with fraud and where upcoding beyond the normal office visit code 99213 and other codes still appear to be legal to bill as when the additional time is spent and also I hear doctors say too it does take more time today as I can cure the young patients but with the older population they get more treatments with chronic disease care than cures so does this earn them a 99214?  Sound like it’s a big question to ask as all the consultants will tell you the documentation needed to use it so the bill goes through, its what they do.  BD 


Medical groups say the shift to higher codes reflects the fact that seniors have gotten older and sicker, requiring more complex care. “I rarely have a person who comes to me for a cold,” said Brantley B. Pace, who has practiced family medicine for more than a half-century in Monticello, Miss., and whose bills were among the highest in the sample of claims.

Although patients at individual practices such as Pace’s may be older and sicker, many health-care experts say the age and health of Medicare beneficiaries as a group has not changed, and research supports that contention.

Doctors, hospital emergency rooms and many other providers are paid by Medicare based on a series of billing codes that are designed to reflect the complexity of the treatments delivered and the time required. For doctor visits, the lowest code, which pays about $20, is for minimal problems requiring a few minutes’ time. The highest code, which pays about $140, is for more serious cases that typically require
40 minutes of face-to-face contact.

Many doctors and hospitals say that computerized medical records encourage the move to higher codes because the software makes it easier for providers to quickly create documentation for charges. One electronic medical records company predicts on its Web site that its product will result in an increase of one coding level for each patient visit, potentially adding $225,000 in new revenue in a year.

Thomas Weida, a family physician in Hershey, Pa., said that as a result of his switch to electronic records, he typically spends an additional five minutes with patients reviewing their medical information and prescribing treatments. That alone could justify higher billing codes in many instances, said Weida, a medical coding expert for the American Academy of Family Physicians.



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