Slashdot Mirror
Medicare Bills Rise As Records Turn Electronic
theodp writes "As part of the economic stimulus program, the Obama administration put into effect a Bush-era incentive program that provides tens of billions of dollars for physicians and hospitals that make the switch to electronic records, using systems like Athenahealth [note: video advertisement] (which made U.S. CTO Todd Park a wealthy man). The goal was not only to improve efficiency and patient safety, but also to reduce health care costs. But, in reality, the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care. Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms, according to a NY Times analysis. There are also fears that features which can be used to automatically generate detailed patient histories and clone examination findings for multiple patients make it too easy to give the appearance that more thorough exams were conducted than perhaps were. Critics say the abuses are widespread. 'It's like doping and bicycling,' said Dr. Donald W. Simborg. 'Everybody knows it's going on.'"
The issue is changing from an E&M to an intensive care E&M. Same procedure, higher payout. Same goes for taking a common tests that are bundled and breaking them into smaller component tests. A few wears ago I met with an Ausie founder of a startup that was talking about how revolutionary their software was that would optimize billing codes to ensure maximum revenue per procedure by basically scanning a billing batch and re-coding it using more lucrative codes for the same procedures. I waked on doing any development for them.
-- $G
Physician here. Medicare/Medicaid is tied to really arcane and often inane rules. You must document X of this and Y of that and word it in a specific way to get paid. What you actually do for the patient does not always matter but the way you document it makes a big difference. EMR has made it easier to conform to the rules and makes sure you write notes that can be easily billed for. It has simplified documenting for things that are tedious to do on paper (like review of systems, and counseling).
The type of fraud described in the article is not restricted by medicare but is pretty much standard practice in most medical offices that use electronic billing.It is a simple play on the "power of the default" that makes it difficult for doctors to behave honestly even if they don't intend to carry out fraud. The way it works is that when a doctor or a nurse pulls a page for a particular task, all possible tests and procedures are checked by default. In many cases there are a dozen or so check boxes that the doctor will have to actively uncheck if he/she needs to just take the pulse of the patient. Naturally, doctors don't have neither the time nor the patience to click around the screen. They also don't have the incentive to reduce their income while wasting their time. An obvious and simple solution would be to set the default to all procedures unchecked and require manual input for to check the boxes. If I remember correctly this is how electronic records are handled in the Keiser hospitals. Another thing that should be required is to retain and provide unique tracking information for every sample and test being done. This is also not difficult because the sample tracking is already part of the software. Finally it should be legislated that the medical records belong to the patient, not the medical office. I don't see why I have to repeat the same panel of tests and fill same questionnaires every time I choose to ask for a second opinion or if due to various reasons I seek help from a different practitioner.
Because the whole system is idiotic. It's not like doctors and hospitals have prices for (non-emergency) procedures, tell you what those prices are in advance, tell you what the procedures they will be performing on before in advance, and get agreement on price before doing anything. They don't even do so much as give you an estimate.
No, instead, assuming an insured patient, they do an exam and get a flat fee from you. Then depending on what they did during the exam, they bill for everything they did (according to the standard set of codes) at some totally fictitious rate that maybe one sucker in a million pays. The insurance company or Medicare then looks at what they did (according to the codes), ignores completely the amount they charged, and pays them whatever they, the insurance company or Medicare, feels like paying. So basically, a doctor who doesn't code the most expensive codes he can based on what he did is leaving money on the table for no reason.
Then depending on what they did during the exam, they bill for everything they did (according to the standard set of codes) at some totally fictitious rate that maybe one sucker in a million pays.
Furthermore, insurers typically calculate their reimbursement for procedure #123 based on a percentage of the average "retail" price of procedure #123 across all physicians in the local area. For instance, say the average price for a strep throat exam in your suburb is $100. An insurance company might say that they'll reimburse at 40% of the local rate for a billing code, so any given doctor will get paid $40.00 for that exam whether their invoice price is $20 or $200. Is your doctor a med school near-dropout or the guy who invented the exam procedure used worldwide? Doesn't matter. $40.
Because of that, doctors almost universally raise their rates regularly, not to increase the amount they'll get paid for each invoice but to bring the local average rate up. In case you're wondering, that 40% in the example is particularly generous. Most insurance companies reimburse at significantly lower multiples. Medicaid has notoriously horrible reimbursement rates, to the point that my wife (a podiatrist) would literally get paid less for many common procedures than she spent for consumable supplies. Every patient she treated like that took money out of her pocket - it's hard to make money when you get paid $15 to do a procedure that costs you $20 to perform (assuming your time is free) - but she saw them anyway because she feels morally compelled to help sick people regardless of their circumstances.
Dewey, what part of this looks like authorities should be involved?
Somebody at Medicare should be looking at the billing records and saying, "It can't be right for every procedure to be billed at the highest possible code when they're a regular full-service hospital. These people are cheating us and I have a red phone on my desk to the Department of Justice Prosecutor's office."
If there are two legal, legitimate ways to code for a given procedure, why would a clinic not bill for the more expensive of the two? Medicare - not the hospitals - sets the reimbursement rates and defines the codes. If they didn't intend for the higher code to be billable, they should have written the definition so that it wasn't.
There are also lots of coding seminars that teach doctors things like "if you ask question X during the history and physical part of their exam, you can bill code #123-2 instead of your normal #123-1. You're already doing 95% of the work to qualify for #123-2, which pays double of #123-1, so why not do the extra 5% and double your income?". Again, Medicare and the insurance companies are settings those standards. Sucks to be them if health care providers decide to play by the rules that have been dictated to them.
Let's put it in tax terms. Suppose that if you give $10,000 to charity, you get a $5,000 tax break. Your accountant notices that you've already given $9,500 to charity and advises you to donate $500 more before the end of the year. You do so, and that $500 turns into a $5,000 benefit for you. Are you cheating? You didn't make the rules. You're playing entirely within the codes that Congress has set. It would ring a little hollow for Congress to complain that you're defrauding the IRS of $5,000 by going along with the procedures that they put in place.
Dewey, what part of this looks like authorities should be involved?