A Report from the Trenches

The annual conference of the American Association of Medical Society Executives (AAMSE) was held this year in Seattle, Washington July 21-24th.   The nearly 300 attending executives represented medical societies with memberships of a few hundred to several thousand physicians each.   Needless to say, these were some very sharp professional people with their fingers on the pulse of physician concerns.

Their Concerns

While there were many interests represented, as my colleagues and I interacted with them during breaks, exhibits and over lunch, several topics seemed to grab the most attention.  When asked “what do you do”, we would mention various services we offer, and more often than not the most interest seemed to center on document management, our web-based EMR, and the RAC Review (baseline audits).

Closely connected with RAC audits of course is the ZPIC threat.  I found that the executives want to educate their physicians regarding the need for strict compliance with Medicare guidelines, thus conserving income and preventing “pattern of abuse” investigations by ZPIC.

Their Sense of Urgency

Regarding RAC Audits, the consensus seemed to be that the time is rapidly approaching when RACs will target physicians, and it may get ugly.   This has been our prediction all along, as regular readers will recognize.   Really in-the-know physicians are taking the necessary steps – RAC baseline independent audits, remote coding services, office staff and physician coding training, etc.

The government’s July 2010 announcement of arrests and prosecution of physicians in Florida and elsewhere – with more to follow – has everyone’s attention.   Several executives I spoke with mentioned that they were not concerned with protecting those involved in deliberate criminal activity.   Their concern is that some physicians, whether through carelessness or otherwise, may be setting themselves up for charges of fraud through a “pattern of abuse”.

No Idle Threat

Their concern was that the “highly sophisticated data mining technology” mentioned by President Obama earlier this year was no idle threat.   The belief was that probably most physicians either don’t know about it or underestimate just how effective it is.   Hospitals are finding out.   Physicians are about to.

We had a number of executives express the desire to have someone come and speak to their membership.   Medical societies are beginning to take the RAC threat seriously, and are concerned that their physician members do likewise.

We do these audits nationwide.  The average practice scores run about 60% compliant.  The lowest score nationwide has been 32%, and the highest so far has been 78%.

If you are reading this article and either know or are a physician who has not had an independent third-party RAC compliance analysis, drop me an e-mail at winston@nbsoga.com and let’s talk.

Winston Creath is an independent healthcare consultant working in the compliance and revenue cycle management arenas on behalf of physicians and clinics.  He serves as President of National Business Solutions of GA, LLC.  He can be reached at winston@nbsoga.com for questions or comments.

Get It Right the First Time

Recently a friend mentioned some advice he often heard as a boy.  His dad would say if you have time to do it wrong and then do it over, you could have done it right the first time.   When it comes to coding and claims filing, perhaps we could learn from this father’s advice to his son.

Did you know that for just a few bucks per claim, you could be practicing medicine in Florida and have an AAPC coder certified in your specialty do your coding remotely from an office in Ohio?  Or Colorado, or Arizona?   It’s so easy and convenient in this technological age!

Remote Coding Protects You

Why do I mention this?   More and more physicians are looking for ways to maximize their earnings and protect themselves from future recoupments.  In this world of RAC Audits, MIC Audits, ZPIC, the OIG, and continual tightening of compliance requirements, wouldn’t it be great to know that at least your claims are being coded correctly and won’t trigger an audit?

Having your coding done by a certified coder reduces your exposure to the highly sophisticated data-mining software that is being used to audit hospitals now and will be used to examine your claims in the future.

Remote Coding Makes You Money

Did you say makes me money?   Yes, absolutely it does!   If you have thought of outsourcing your coding as just another expense, think again.   It’s a proven fact that certified coders pay for themselves several times over by maximizing claim reimbursements while minimizing claim rejections.  A certified coder will also help you as a physician improve your documentation and compliance, again resulting in more income for you.

Remote Coding Cuts Expenses

Outsourcing your coding eliminates the vulnerability that comes from depending on employees. Never again get “surprised” when your in-house coder is out sick, gets pregnant, or leaves for another job offer.   You can reduce staff or better yet, free her up to work with patients as your practice grows.

I am fortunate to have access to around 250 AAPC certified coders.  If you send me an e-mail, I can put you in touch with one in your specialty.

Winston Creath is an independent healthcare consultant working in the compliance and revenue cycle management arenas on behalf of physicians and clinics.  He serves as President of National Business Solutions of GA, LLC.  He can be reached at winston@nbsoga.com for questions or comments

Do the Math

Just last week I spoke with a hospital Utilization Chairman from Indiana who is concerned about ZPIC and its relationship to RAC denials.

In the course of our conversation he mentioned the challenge he is facing in trying to get other physicians to get serious about RAC.    He wants to alert his colleagues to the danger of assuming the RACs won’t affect them.  A lackadaisical attitude toward RAC issues could expose them to ZPIC investigations, which in turn could result in serious consequences up to and including imprisonment.

Our Prediction

It has long been our belief that it’s only a matter of time until the RACs will be coming after physicians.   Mainly it’s an issue of manpower and priorities.   At present, they’re auditing hospitals because they represent big-ticket claims with the highest commissions.   But it won’t always be that way.  Here’s why.

Do the Math

Everybody knows that hospitals receive the lion’s share of Medicare payments.   The figure we hear most often is that 17% of Medicare claims are paid to doctors.   That sounds like such a small, insignificant amount doesn’t it?   Only 17% – surely the RACs won’t bother to audit physicians, right?

Wrong!   Think about it.  Medicare’s budget is about $500 Billion dollars a year.   RACs can look back 3 years.   Three times $500 Billion comes to about $1.5 Trillion, and if about 17% of this is paid to physicians, that figures out to $255,000,000,000.00.   Two Hundred and Fifty-Five Billion dollars is a lot of money!

Now … Just a Little More Math

Did you ever play “What If”?   What if the RACs were able to recoup only say one dollar out of every 25 that was paid out to physicians?   That would be four percent.   Four percent of $255 Billion would come to $10,200,000,000.00.   And while RAC commissions vary from 9% to over 12%, just using a conservative average of 10% would result in $1.2 Billion of commissions paid to RACs.

When the dust settles, will you as a physician be left with 24 out of every 25 dollars you were paid by Medicare?   I can’t answer that – nobody knows.  If you’re honest – like most doctors – I hope you do better than that.

Once you understand the magnitude of the commissions involved, how could any thinking person still believe that RACs won’t audit physicians?    And if they’re going to audit you, wouldn’t it be wise to seek professional help and see what your exposure is?   If you’re concerned, e-mail me and let’s discuss it.

Winston Creath is an independent healthcare consultant working in the compliance and revenue cycle management arenas on behalf of physicians and clinics.  He serves as President of National Business Solutions of GA, LLC.  He can be reached at winston@nbsoga.com for questions or comments.