August 17, 2009

As Congress finally left Washington, D.C. for the August recess, it was clear that the cost of universal coverage was becoming the dominant challenge in healthcare reform. We may not be able to afford healthcare for all – according to one recent estimate, spending on health services will grow to 20 percent of GDP as early as 2017, and to 100 percent before the end of the century – but we also may not be able to afford a continuation of current levels of spending.

Attempts to define and eliminate wasteful spending, including fraud and abuse, are not by themselves going to cover much of the cost of healthcare reform. All the healthcare proposals include provisions on strengthening fraud and abuse prevention programs, however. Fraud and abuse make a good target for several reasons, chief among them (1) the policy decision to reduce the incidence of fraud was made long ago and the tools for recovering overpayments are well known, (2) there is no noisy pro-fraud lobby, and (3) the size of the Medicare budget -- $461 billion in total spending in 2008 -- is so large that scrutiny is inevitable when the health care dollar has to go farther than ever.

The $461 billion figure comes from the Data Book on Healthcare Spending and the Medicare Program published by the Medicare Payment Advisory Commission (MedPAC) last June. The Data Book provides interesting information on, among other things, the proportion of total spending that goes to each of eight major program categories: 
 

The sheer volume of claims submitted to Medicare – according to CMS, more than 1.2 billion claims per year which equates to 4.5 million claims per work day, 574,000 claims per hour and 9,579 claims per minute, submitted by more than 1 million providers and suppliers, prevents the contractors from ascertaining the validity of most claims before paying them. Hence the RAC program, which seeks to recover improper payments, and also the “program safeguard contractors” established nationwide in 2006 to perform data analyses that would identify problem areas, investigate potential fraud, develop fraud cases and coordinate Medicare fraud and abuse efforts with CMS.

This is, therefore, a good time for all Medicare providers -- including physician practices -- to check up on their compliance programs. We have identified many of the potential points of vulnerability in anesthesia and pain practices in various publications over the years. We would like to put a current comprehensive list in your hands. For example, some compliance areas to focus on include:

• Each provider should only report allowable anesthesia time, supported by solid documentation showing start and end times.
• Groups should ensure that compliance with the medical direction requirements is satisfied, including improving documentation practices to demonstrate medical direction compliance.
• Groups should evaluate their documentation protocols in the area of medical direction. Take a careful look at the ease in which the medical direction elements can be identified on the record in the event of an audit. Different methods of recording medical direction (e.g., attestations, handwritten notations, combination of these approaches) are acceptable but it is essential that all relevant information be legible and can be identified on the record.
• Good documentation practices for separately payable services such as invasive monitoring lines and post-operative pain management procedures are also highly important. Anesthesiologists must keep in mind that each and every service reported on a claim form must be supported by complete and legible documentation.
• Documentation of medical necessity can be particularly burdensome but it is indispensable, particularly in connection with the provision of monitored anesthesia care and chronic pain management services and with evaluation and management services

There are a number of action steps that an anesthesia group can undertake to increase its sophistication and to reduce compliance exposure related to medical necessity issues including:

1. Carefully evaluate those cases in which surgeons have traditionally handled the anesthesia but are now requesting your group’s presence;
2. Carefully evaluate services provided in physician office locations;
3. Obtain, review, and follow your Medicare Administrative Contractor’s policies on monitored anesthesia care and on pain medicine procedures;
4. Obtain, review, and follow other policies and medical guidelines issued by third party payors including Medicare that address anesthesia services;
5. Establish internal documentation criteria for all members of the group to follow with regard to services that may raise medical necessity issues;
6. Educate all members of the group as to the importance of documentation;
7. Establish a protocol to determine when a service denied based on medical necessity should be appealed; and
8. When the hospital requests that your group provide a new service, prior to submitting claims for that service, make sure that it is in fact a billable service for the anesthesia group. In some cases, while the anesthesia group may be fully providing and documenting a particular service, there could be bundling or other rules that would not permit billing.

Groups should also coordinate with their internal billing personnel or billing company, as applicable. For example, compliance coordination is beneficial with regard to compliance education and training as well as other compliance feedback protocols.

As always, we hope that the information provided here will be helpful to all our readers. We continue to encourage our clients to work with their account managers to clear up any areas of confusion or concern. Finally and also as always, we invite your comments, questions and suggested topics for future Alerts.

With best regards,

Tony Mira
President and CEO