Here's that same old battle again over billing and the lump sum costs are a step in the right direction for treatments where it can be done and this way all know up front what the bottom line is and it’s like one step at a time for a lot of the changes.  I looked at this latest idea with the ER room changes and right away the big hospitals are going to be right there as they do a lot of facility charges for clinics associated with the hospital.  When the fee is passed back to the patient it becomes more costly.  This was a recent discussion on those types of fees. 

Hospital Facility Fees Up for Discussion Again as Out of Pocket Costs Rise for Patients When Hospitals Buy Physician Practices And Appear to be Growing

Back in 2009 the Cleveland Clinic had patients upset over the billing.

Cleveland Clinic “facility fee” or “hospital services fee” has Patients up in Arms

There are a couple of facts here that are just that I saw this myself for overall increases in billing as whole and that was  for a few years that doctor’s offices would bill for a office visit as a 99213 just to keep their cash flow going as when you bill for a longer extended visit, then you have things that need to go along with the bill, review of systems, history of present illness, family history to name a few and to justify their time these had to be covered and documented and due to the hassle it was to send the paper to match up with the claim, it delayed payments so doctors for years instead of messing with it just billed the standard 99213 where the payments rolled in on schedule and they ate the rest of it. Cash flow is more important especially in a small practice. 

With electronic medical records, that barrier is gone and doctors can document and I guess some of this has not really set in back at CMS or maybe nobody has told them but this accounts for a good portion of the increases and not only just that one code, many of them but that one would be most common where doctors for years under billed because of the hassle and delayed payments.  When CMS sent out their nasty letter telling all they were cheating and not bringing one example to the table, I assumed and so did many others that the very medical records they campaign and encourage doctors to use were at crux of their big issue and they couldn’t see the full picture.  Otherwise I don’t think that letter would have gone out, just voice of frustration and it was nasty.

HHS and DOJ Send Letters to Hospital Trade Associations Warning of Gaming Billing System Via Use of Electronic Medical Records–Hospitals Just Learned How to Bill Better & Hired Consultants–Case of Being Algo Duped With Numbers?

Now I am not overlooking at all the fact that some will game it and their new auditing software will help establish patterns, that’s what you look for with anti fraud queries that will lead in the right directions to start looking and that is the best tool they have.  Folks at the top though don’t quite understand queries I don’t think and the mechanics of it all. You will have false positives with it as well as every pattern will not be fraud.  Right after they sent out the nasty letter a month later we have this headline, (link below) so tell me folks are not confused about data:)  They are all over the place.  The recovery is good news catching fraud and it was the software patterns that put them in the right direction.

Government Recovers $4.2 Billion in Medicare and Medicaid Fraud–With Numbers This Good Using Anti Fraud Analytics To Help Identify Patterns, Maybe Some Cheating Obsessions Might Lighten Up A Little

Things get equally as complicated trying to explain some of it to Congress too and one should note that 84 Senators still rely on and use all paper resources for their work and numbers are tiny bit better in the House so what does that tell you…non digital literate lawmakers and their questions..

Senators Letter to HHS Regarding Fraud Reform Tools–Oddest Thing I Have Read in a Long Time and Really Makes A Huge Case for Reinstating the Office of Technology Assessment!

I do HHS a favor with my blog and keep the link and widget to their most wanted list for readers to see and I don’t see any other bloggers out there doing that.  That’s a great program to keep out there and visible.  I also blog when they catch one.

CMS is right in saying they look for a mix of the levels of billing and this is exactly what the software will point out if there is not a mix and you have 90% of the visits at the top level and yes then you have something to question for sure.  It’s also worth noting that the records they are looking at are from 2001 to 2008, well that was right about the time and years that many were converting to electronic medical records too and the ER rooms are usually the firs to go electronic. Why not look at records starting at 2010 to present and get some recent numbers to work with.  Also remember the big stock market crash occurred in 2008 and that impacted hospital too as many lost their shirts on investments.  It’s not a direct hit to this but did play a roll. 

No More Unsubstantiated Blame Shifting on EHRS, Doctors, Hospitals, Developers, Patients Or Whatever Your Role Happens To Be–Government Executives Wake Up On How Corporate USA Eats Your Lunch With Models, Math, and Formulas for Profit (Algorithms)

I don’t know how much modeling they do there at CMS but it would really be helpful for them to have a computer model of a couple of different types of hospitals, a big one, a rural one and so forth so they could model this stuff.  When I say model I mean something along the lines of not only numbers but a visual that would replicate and maybe even in a video ER visits for an example, get an idea on how it would play out.  I think may have something to do with some of this and why not look at what HCA is doing since they seem to be somewhat bragging about their ER billing?

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

Perhaps along with the data and just plugging in numbers a little augmented reality would be help when it comes to understanding hospitals and how they operate.  Some companies do this and of course there’s other ways to model but something that gives the business intelligence angle of this as well as a virtual model as to how the model will play out across a number of scenarios. It would put them miles ahead and then too there’s the money to invest in this but it seems like this is a never ending situation to be monitored and other areas could use the expertise as well.  This is some of what Big Data Machines IBM Watson or other could provide.  It  is doing it for banks…hint..hint..and those folks as I have said many times over on the Hill could use a blast of help with data mining to help create laws and model more before we get things with loop holes that could have been avoided. 

IBM Watson Going to Work At Citigroup on Wall Street–Congress Didn’t See Big Data As A Tool (Hadoop Framework) When They Had Their Chance…For Consumers The Attack of the Killer Algorithms–Chapter 22

The hospitals and the medical associations would really appreciate it if some of the homework was researched ahead of time as well to model outcomes and get the obvious out of the way.  This is the way big business does it and I think it would be a much smarter working environment than having to “guess” if you will on how to make adjustments when needed.  On the overall picture, face it costs are going to go up and the fact that saving in one area will increase potential cost in another.  We’ve seen that.  I’d much rather see efforts in this direction rather than money spent to get more data on HHS employees with buying more software there…what’s the purpose of that.  Many patients, doctors and hospitals are either going broke or having some severe financial issues so can we go look elsewhere for some savings?   We all have to deal and work with two of the biggest software conglomerates around today, banks and insurance companies to survive.  BD

Banks Are Actually Just Software Companies and the Same Can Pretty Much Be Said for Health Insurance Companies As Well-5 Unspoken Reasons Tech Projects Fail

Federal officials for more than a decade have let hospitals decide on their own how much to charge Medicare for certain emergency room overhead and staffing costs called “facility” fees — a controversial policy some critics believe invites overcharges.

Now in a major turnabout, the Centers for Medicare and Medicaid Services are seeking tighter controls over the fees as part of a plan to redirect billions of dollars Medicare spends annually on outpatient health care. But this new proposal, though still preliminary, is already drawing fire on its own.

CMS officials want to replace five escalating price codes hospitals can choose from in billing facility fees with one flat rate, starting next year. Whether charged at one rate or five, the mere existence of facility fees is contentious because they come on top of physician bills and hospital charges for tests, medicines and other supplies, and have risen sharply in recent years. Hospitals counter that the fees are needed to help defray the costs of big-ticket medical technology and resources, such as operating rooms.

The 2013 rates for ER facility fees start at $51.82 for a “level 1” patient visit and move up to $344.71 at the top range. CMS is proposing a new flat rate at $212.90 for emergency room visits regardless of how much medical muscle went into the treatment. Doctor fees aren’t affected. Several of the nation’s major hospital groups declined comment on the proposed rule, saying they are still studying its impact and preparing written responses. The rule was published July 19 in the Federal Register and comments are due by Sept. 16. It is set to take effect Jan. 1, 2014. As of Sept 12, 1,470 comments had been received.

Between 2001 and the end of 2008, use of the two most expensive codes nearly doubled, from 25 percent to 45 percent of all claims. Many of these patients were treated for seemingly minor injuries and complaints and sent home without being admitted to the hospital.


Post a Comment

Google Analytics Alternative