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.'"

Comments

Medicare fraud is not new

[bit trollent]

Medicare fraud is not new. It existed way before electronic records.

Florida's governor, Rick Scott's company committed medicare fraud way before electronic records were introduced.

Electronic records should make it easier to detect medicare fraud, as statistical analysis is much easier with computerized systems.

Re:Medicare fraud is not new

[russotto]

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.

Re:Medicare fraud is not new

[Just Some Guy]

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.

This is silly

[rsilvergun]

it's already been established that moving to electronic records helps track Medicare fraud. Yes, the system has a lot of gaps, but electronic tracking reduces them. If that wasn't true companies wouldn't use electronic purchasing systems to track expenditures, and the spreadsheet would just be an interesting foot note in computer history...

I gotta ask (since I'm far too lazy to read the article): Is this a lame attack on the existing administration?

Proper coding != fraud

[Anonymous Coward]

It's not clear to me that medicare providers changing their coding is the same as fraud. If a doctor was coding for a 10 minute E&M (evaluation and management) but was actually spending 20 minutes with the patient, then it's totally reasonable for them to change their coding. If EMRs are making it more obvious that the practice users are mis-coding, then this is at worst an unintended side-effect of the EMRs.

(Full disclosure, I work for a company that builds EMR systems.)

Re:Proper coding != fraud

[Just Some Guy]

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.

There's a problem on both ends

[rickyb]

Yes, some physicians will abuse the system. Some will do so willingly, while others will do so out of ignorance. However, many physicians at large academic medical centers (also known as "residents"), are not taught how to code and bill at all until they reach independent practice. This leads to very bad habits and often to underbilling quite significantly for their services. They all do the work, but don't appreciate the importance of recording and documenting the work for billing purposes, leaving money on the table. This impacts primary care most of all, where margins are very slim, and many physicians are struggling to remain solvent. EMRs actually take care of the coding and billing far more efficiently and accurately than the physicians themselves. But as the saying goes, "garbage-in, garbage-out." The coding is only as accurate as the physician documentation. The vast majority of physicians do not intentionally document erroneously to inflate billing - once the error is pointed out to them, they are more than willing to fix it. And for those physicians who are maliciously abusing the system, there's no better solution than EMRs to record and track this behavior.

Not necessarily fraud

[Cipster]

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).

Re:Just socialise the damn thing already

[girlintraining]

You Yanks fear the word "socialist" so much you spend far more to get rid of it!

You're parroting a commonly held misconception about how politics in the United States works. Firstly, your elected representatives come from more than two parties; Your voters have a wider diversity of candidates to choose from, and are less apt to vote along party lines. This also spreads out the concentration of money paid to your elected representatives by private interests. Put more simply, it's harder to buy legislation in your country. As well, the disparity between the rich and poor is far less pronounced. This results in your legislators being more likely to represent the actual will of the people, rather than the apparent or manufacturered will.

It's also no small matter that the UK has the BBC. It's more important than you guys give it credit for: The licensing fees you pay are amply repaid not just in terms of quality programming, but also unbiased programming. The BBC can't be co-opted with a corporate buyout. In our country, the media is largely controlled by a few dozen men like Murdock. An informed voter is a voter that can't easily be duped; And the BBC provides a mechanism to prevent your media from becoming too biased towards any one political view. Compare the US section of the BBC with any major news network here -- stories that make front page there, or are internationally relevant, simply don't make it. They aren't reported. It's not just that there's bias in what is reported, there's also things that the public simply isn't told about. You can probably deduce what this means for the political landscape.

Lastly, the UK was bombed into near-nothingness. The US never has been. The closest we've come to having to reassess economically was the Great Depression. Because we never had to rebuild from scratch, we never learned the social lessons that an experience like that offers -- specifically, we never really developed a cultural center of "We're all in this together". American culture has long been based on individualism -- which during times of material prosperity is great, but during economic trouble, it creates a "blame the victim" mentality. You are poor because you want to be poor, not because some bad shit just happened to drop on your head. The American Dream has become a political crucible -- maintaining our collective ego has forced us into social policies that are ultimately harmful and destructive to our way of life. It's a societal-scale version of the Just World phenomenon.

It's not socialism per-se that we're afraid of -- it's the idea that we aren't in control of our own fate. That we aren't individuals, but actually part of something more than ourselves, and that our success is determined only in part on our own choices, rather than entirely by it. It's ego protection, individually and collectively. And when you read anti-socialist opinions in our media, they may use the same words you know and understand, but they don't mean the same things. It all goes back to the cold war, the super power stuff, and that collective ego I mentioned earlier.

For us, socialism is a sign of weakness; It's a sign that we've become like the russians, the iranians, and all the other boogie men we've bomed the hell out of. So even when it would be good and proper for us to adopt socialist social policies, we don't... we'd rather go on maintaining the notion that We're Number One. America is on a path of self-destruction because it simply can't acknowledge, individually or collectively, that we need help and we need to work together. Our problems are world problems too -- but until that fact ingrains itself into our culture, it's pointless to expect change. America, as an idea and as a culture, would rather die than admit defeat.

Just like the British did at the height of their empire. It's a phase we'll outgrow eventually, just like you guys did. But it won't happen quickly, or easily, or gracefully.

Re:The real fraud...

[Deathlizard]

The Real Fraud is how much health care costs in the first place.

The main reason for that is simple. Insurance and Litigation

1) You Need Insurance to get healthcare, because healthcare costs too much.
2) Your Doctor Needs Insurance because you might sue him for malpractice, the state he's in requires it, or both, Raising the cost of healthcare.
3) The pharmaceuticals your Doctor prescribes you needs Insurance because you might sue them for complications. Raising the cost of healthcare.
4) Your Hospital needs insurance because you might sue them for hiring the doctor that you sued for malpractice, or because he prescribed you something that didn't work, or the state they are located in requires it or a combination of all of the above. raising the cost of healthcare.
5) The ambulance chasing lawyer on TV needs more money to buy TV commercials to help you, so he sues the insurance companies of your doctor, the pharmaceutical company, and your hospital for malpractice, so you get the 5-25% of the total compensation that you deserve and he pockets the 75%-95% to pay for his paper costs and time, which of course, Raises the cost of Insurance, which in turn raises the cost of healthcare.
1) Repeat step 1

Until we get a president and congress that will pass healthcare reform that will truly end this cycle for good, expect your health costs to skyrocket.

you're ignorant beyond belief

[circletimessquare]

a free market in real life translates to "give as many expensive tests as we can get away with"

healthcare isn't a MARKETPLACE. it is not driven by best price, because the buyer has no control to seek the cheapest service. no knowledge of medicine. no time when he is having a heart attack to shop around

face reality: there are some issues in life, where, believe it or fucking not, market forces do not help, and make things worse

i say this as a committed capitalist. capitalism works. but i'm not a looney tune frothing at the mouth ignorant free market fundamentalist who believes the magic unicorn and rainbows marketplace is a magic elixir that solves all problems. it doesn't