17 October 2008

Work Plan

One thing I don't like about having the government as our biggest single payer is that if they think we've broken the rules, they can send me to jail. Granted, that's pretty uncommon They usually settle for incredible punishing fines and driving you out of business. So it's pretty important to stay on the right side of the law, and one thing I like about working with the federal government is their boy-scout earnestness in their approach to enforcing the law.

For example, every year the HHS OIG (Office of the Investigator General) releases its work plan for the upcoming year. Basically, they tell the industry, in advance, what practices and violations they are going to be looking for in the upcoming year. It's remarkable! It's as if the state police announced that this week, they're going to be cracking down on lane changes, next week they'll be running speed traps, and the week after that will be enforcing DUI laws. I know when I'll be avoiding the bar on my way home from the ED.

I'm happy to furnish the full work plan to anybody who is interested (it's kinda dull), but here are the key points with some commentary:

Payments for Diagnostic X Rays in Hospital Emergency Departments
We will review a sample of Medicare Part B paid claims and medical records for diagnostic x-rays performed in hospital emergency departments to determine the appropriateness of payments. [...] concerns regarding the increasing cost of imaging services for Medicare beneficiaries and potential overuse of diagnostic imaging services.

My take: This sounds more like a "medical necessity" review more than anything else. So a sampling review will be conducted to see if the studies ER docs are ordering were actually justified. Sampling reviews are a little worrisome because they can open the door to more intrusive audits. Another possibility is that CMS may be looking to see who got paid, and did they actually provide the service. This is of concern to ER goups who bill for interpretive services. If you document CXR (-), and bill for it, you may be in trouble. Another common point of interest is whether radiologists who do not provide a contemporaneous read should be permitted to bill, but I do not see that practice as the biggest target of this measure.

Oversight of Hospitals’ Compliance With the Emergency Medical Treatment and Labor Act
We will review CMS’s oversight of hospitals’ compliance with the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). A previous OIG review raised concerns about CMS’s EMTALA oversight, specifically regarding long delays to investigate complaints and inadequate feedback provided to hospitals on alleged violations. We will identify any variation among regions in the number of EMTALA complaints and cases referred to States, examine CMS’s methods for tracking complaints and cases, and determine whether required peer reviews have been conducted prior to CMS’s making a determination about whether to terminate noncompliant providers from the Medicare program.

My take: Note that this is an audit of CMS itself! I suppose it's nice to see that there is accountability within government. Clearly, the OIG wants to kick-start CMS back into actually enforcing EMTALA, and to improve the process and safeguards for practitioners. One might expect that we will see stepped-up investigations of EMTALA violations, though that is far from sure. As an ER doc, I'm kind of conflicted about this. I'm on record as being opposed to the unfunded mandate EMTALA levies on ER docs. There are, however, many private hospitals and private practitioners out there (in CA, especially, I understand) who flout the law with the tacit approval of their adminstrators. Make no mistake: patient dumping still goes on. So it is not entirely bad that EMTALA enforcement may come under scrutiny.

Patterns Related to High Utilization of Ultrasound Services
We will review services and billing patterns in geographic areas with high utilization of ultrasound services. In areas of high utilization of ultrasound services, we will examine service profiles, provider profiles, and beneficiary profiles.

My take: Pretty clearly a straight-up medical necessity review. I'm kind of surprised, since ultrasound doesn't seem to be the big problem. The costs of imaging have shot up, but I would say that for medicare patients I order ten or more CT scans for each ultrasound that I order.

Physician Reassignment of Benefits
We will review the extent to which Medicare physicians reassign their benefits to other entities. The Social Security Act, § 1842(b)(6), prohibits physicians who provide services to Medicare beneficiaries from reassigning their right to Medicare payments to other entities, unless a specific exception applies. For example, physicians are permitted to reassign benefits to other entities enrolled in Medicare when contractual arrangements that meet certain program integrity safeguards exist between the physicians and the entities or when payments are being made to the physicians’ employers. Investigations in South Florida have revealed schemes in which fraudulent providers obtain identifying information about legitimate physicians and request reassignments on their behalf. We will examine a national sample of Medicare physicians to determine the extent to which they reassign their benefits to other entities and the extent to which the physicians are aware of their reassignments.

My take: Wow. That sounds bad. I think it's good that they should investigate that sort of thing.

2 comments:

WhiteCoat said...

Thanks for this.
You don't happen to have a link to this information, do you?

Nurse K said...

With the ultrasound stuff, maybe they've seen a pattern of certain hospitals having a culture of ultrasounding everyone for questionable reasons, especially given that, like you said, it's way outside the norm to be ultrasounding a bunch of old people for things.

For instance, at my hospital, there's a culture of high use of MRIs from the ER for relatively minor problems (like knee pain or low back pain with minimal or no neurologic deficit) and scanning everyone's chest for aortic dissection which I find odd. I hope someone audits us for that kind of stuff.