Inspector General Daniel Levinson of the Department of Health and Human Services has stated in his Spring 2012 Semiannual Report to Congress that his office expects to recover $1.2 billion from audits ($483 million) and investigations ($748 million) concluded during the first half of 2012.  Between October 2011 and March of this year, the OIG also brought 346 new criminal cases and 138 civil actions. Information technology is playing as important a role in the OIG as it is in every other health care arena.  In his Executive Summary, Mr. Levinson said: Over the past 6 months, OIG has stepped up our focus on data analytics as a critical tool for enhancing our fraud, waste, and abuse activities. We are using advanced data analytics to help us conduct risk assessments; more effectively pinpoint our oversight efforts; and significantly reduce the time and resources required for audits, investigations, evaluations, and other program...

The EHR Incentive Program, often dubbed “Meaningful Use” (MU), has been surrounded by questions and confusion among anesthesiologists and practice administrators since its inception.  Currently, the majority of anesthesiologists and pain physicians are classified as an Eligible Professional (EP) under the Medicare portion of Meaningful Use and most of the public conversation is centered on that program.  However, the Medicaid option offers more flexibility and financial incentive which raises the question, “How does the Medicaid EHR Incentive Program differ from the Medicare portion?”  The major differences between the Medicare and Medicaid programs of Meaningful Use center on:Provider EligibilityProvider EnrollmentFinancial IncentiveAttestation ScheduleProvider Enrollment and Eligibility To be considered a Medicaid EP, an anesthesiologist or pain physician must perform less than 90% of their services in an inpatient setting (POS 21), but also must provide at least 30% of services to Medicaid patients.  According to CMS: Medicaid patients might be fee-for-service encounters where...

Wow, what a day! You've just left a meeting with the hospital's CEO. Of the fifteen anesthesiologists in your openstaffed department, the CEO wants you to be the new, first medical director of anesthesia services. You've been the department's chair for the past two years, but now you've been offered an administrative stipend of $2,500 a month. It doesn't appear to be any more work than what you've been doing, and the $2,500 is more than you need for the payments on a new Porsche!Just as you feel your grip on the steering wheel, the alarm clock jars you awake. Should you savor the memory . . . or be thankful that it was only a nightmare?DREAM ANALYSIS 101Relax. Put your feet up. In order to analyze the dream, we need to back up a bit and consider the operation of an anesthesia department, as an element of the medical staff,...

Patient AB underwent a rotator cuff reconstruction in January, more than four months ago.  You billed the health plan that Mr. AB’s hospital record indicated.  The health plan denied the claim on the ground that Mr. AB was not enrolled.  You then billed Mr. AB directly for $1072.50 your usual and customary charges for anesthesia for a 120-minute open procedure on the shoulder joint (CPT™ code 01630, 15 units x $75 conversion factor) and an epidural for post-operative pain (CPT™ code 64415, $97.50).  You re-billed the patient in March, in April and again on May 15th.  Your billing office reached Mr. AB on the telephone on May 16th and was told that (1) his insurance was supposed to cover everything, (2) no one had told him to expect a bill for anesthesia separate from the hospital and surgeon statements and (3) he was now unemployed and did not have the money. ...

Abby Pendleton, Esq., The Health Law Partners, P.C., Southfield, MIStephanie P. Ottenwess, Esq., The Health Law Partners, P.C., Los Angeles, CAOn March 7, 2012, the Centers for Medicare and Medicaid Services (CMS) published its Notice of Proposed Rule Making (NPRM, or proposed rule) for Stage 2 user requirements for the Medicare/Medicaid Electronic Health Record (EHR) Incentive Program (“meaningful use,” or MU) in the Federal Register. 77 FR 13698.1 There is a three pronged focus to the Stage 2 criteria: standardizing data formats to dramatically simplify how information is both captured and shared across disparate IT systems in order to be better able to coordinate care with other physicians; ensuring that patients be able to access and easily download their healthcare records and images for their own use; and expanding the scope of tracked quality metrics to include specialists and to reflect and improve specific patient outcomes as well as care coordination.Although subsequent to...

“Coordinated care” is one of the key concepts in health system reform.  It is central to the cost savings and quality improvements expected from Accountable Care Organizations, value-based purchasing and the medical home.  It is also the basis of the American Society of Anesthesiologists’ model, the perioperative surgical home.A just-published study demonstrates the potential of coordinated management of patients, inter alia, to reduce complications in knee replacement surgery.  A research team from the High Value Healthcare Collaborative used administrative data to examine differences in their delivery of primary total knee replacement (TKR) care.  They reported their findings in A Collaborative Of Leading Health Systems Finds Wide Variations In Total Knee Replacement Delivery And Takes Steps To Improve Value (Ivan M. Tomek, Allison L. Sabel, Mark I. Froimson, George Muschler, David S. Jevsevar, Karl M. Koenig, David G. Lewallen, James M. Naessens, Lucy A. Savitz, James L. Westrich, William B. Weeks, and James N....

Anesthesia Business Consultants, LLC (ABC) embraced a new role and filed formal comments on a “Notice of Proposed Rulemaking” with the Centers for Medicare and Medicaid Services (CMS) on May 7, 2012.  The Proposed Rule would modify the requirements for physicians and hospitals to demonstrate “meaningful use” of certified Electronic Health Record (EHR) technology.  Meaningful users of certified EHRs are able to earn Medicare bonuses of up to $44,000 or Medicaid bonuses of up to $63,750 per physician.  Just as important, eligible professionals who fail to become meaningful users  will be subject to payment penalties beginning in 2015. Even with the best of intentions and a reasonable amount of funds to invest, very few, if any, anesthesiologists can qualify for the bonus incentives—but they may nevertheless be subject to the penalties.  To earn the former and avoid the latter, a physician must comply with a set of 15 (17 in Stage...

The Affordable Care Act (ACA) requires providers including physicians to report and refund known overpayments within 60 days, or, for providers that submit cost reports, by the date the corresponding cost report is due.  The parameters of this mandate are unclear, but the duty to refund overpayments exists regardless.  After summarizing some of the problems with the ACA provision and with CMS’ proposed regulations implementing the statute, we will offer some practical suggestions on compliance.The refund requirement, which has been in effect since March 23, 2010 (the date the ACA became law), is vague in several important particulars.  The lack of certainty, far from discouraging compliance, has left many providers, suppliers and affected health plans scrambling to find and refund overpayments within the 60-day window to avoid hefty penalties.  On February 16, 2012, CMS issued a proposed rule that limited its application to Medicare payments and cleared up some, but not...

This issue of the Communiqué is a keeper. On pages 6 through 10 you will find tables that lay out clearly the Electronic Health Records (EHR) incentive program’s Stage 1 Meaningful Use objectives, the recently proposed changes to Stage 1, and the potential Stage 2 objectives, measures and exclusions as proposed by CMS in March. The objectives, translated into measures, are capabilities that your EHR must have in order for you to qualify for the incentive, which is non-negligible at a maximum of $44,000 per physician, or to avoid the penalty for non-compliance. Even though the proposed changes discussed in the Meaningful Use article by Abby Pendleton, Esq. and Stephanie Ottenweis, Esq. are likely to be different in some respects when CMS issues the final regulation later in the year, it is worth familiarizing yourself with the proposals because understanding the final versions will be that much easier.The Meaningful Use article,...

The Anesthesia Quality Institute was chartered in 2009, and it began collecting case data in the National Anesthesia Clinical Outcome Registry (NACOR) on January 1, 2010. NACOR was designed to harness the power of the Information Age by aggregating and analyzing large quantities of data. Unlike traditional registries that depend on a trained abstractor to examine medical records and pull out the facts of interest, NACOR accumulates data by direct reporting from the electronic health records (EHR) that are in use every day, including administrative systems such as the ABC billing software and clinical support systems such as ePreop. As anesthesia practices become increasingly digital — driven by the “meaningful use” requirements of the federal government discussed elsewhere in this issue of the Communiqué — even larger quantities and types of data will be available. The barrier is no longer the creation of digital records; it is now the enormous challenge...

Do you check your professional association’s web site regularly?  There is more practice-related information there than you may realize.  One recent addition to the resources on the American Society of Anesthesiologists web site (www.asahq.org) is worth your special attention.  The ASA Committee on Quality Management and Departmental Administration (QMDA) has produced a comprehensive set of questions for anesthesiologists and others involved in perioperative patient care that can guide the development of a quality program tailored to your own department.The QMDA Anesthesiology Department Quality Checklist is a “compendium of anesthesia safety and quality measures suitable as a reference for anesthesiology departments of any size as they develop a comprehensive set of quality standards.”  It consists of separate sets of questions for these individuals and offices:Chair of AnesthesiaStaff AnesthesiologistSurgeonCRNA and/or AA Perioperative Nursing ManagerOperating Room NursePACU Nursing ManagerObstetric Nursing ManagerQuality ManagementAdministrationAnesthesia Technicianas well as for Office Based Anesthesia Facilities.  The questions, and the answers received, can...

Every year, the time comes to begin looking at one or a set of payor contracts. A multitude of questions abound regarding appropriate rates, term length, and whether or not to participate or stay on panel. These are all good questions to raise. But are these the only questions to ask? This article seeks to explore the value of planning for payor negotiations.As a backdrop to the planning, it is important to remember the value of strategic planning as described by Sun Tzu:The general who wins a battle makes many calculations in his temple where the battle is fought. The general who loses a battle makes but few calculations beforehand. Thus do many calculations lead to victory, and few calculations to defeat: how much more no calculation at all! It is by attention to this point that I can foresee who is likely to win or lose.1The point is primarily to...

The acronym “HIPAA” has become a household name since the enactment of the Health Information Portability and Accountability Act of 1996, which, among other things, established rules for protecting and securing patients’ health information. In fact, it is not uncommon to hear about breaches of patient information costing healthcare providers and suppliers six and seven figure civil monetary penalties or settlements. Typically, such settlements and penalties have arisen out of patient complaints that the privacy of their protected health information (PHI) has been compromised. However, beginning November 2011, patient complaints will not be the only way in which the Department of Health and Human Services (HHS) Office of Civil Rights (OCR) will learn about non-compliant entities.Section 13411 of the American Recovery and Reinvestment Act of 2009, which established the Health Information Technology for Economic and Clinical Health (HITECH) Act, requires the Secretary of HHS to “provide for periodic audits to ensure...

  A moderated discussion of compensation strategies at last week’s MGMA-ACMPE AAA meeting showed a good deal of flexibility in allowing anesthesiologists to job-share or otherwise to reduce their hours. The groups represented at the discussion were also creative in compensating members for business development and administrative activities. If case loads decline substantially, layoffs may occur, although they are the least favorite option.Along with more than 300 other MGMA-ACMPE Anesthesia Administration Assembly (AAA) members and exhibitors, we participated in the annual AAA meeting in Scottsdale last week.  One breakout session discussion group in particular was so informative that we obtained permission to bring a summary to our readers.About 60 individuals attended the discussion of compensation strategies moderated by Stephen E. Comess, Executive Director, United Anesthesia Services, P.C.  Mr. Comess got the ball rolling on responses to twelve prepared compensation management scenario questions by giving each member of the audience a playing...

Anesthesia Business Consultants (ABC) keeps a keen eye on the continued proliferation of electronic medical record (EMR) technology.  It is not enough to adopt the latest technology, ABC investigates the latest technological advancements in EMR, carefully testing new systems to ensure their compatibility with our renowned OneSourceAnesthesia platform, and working with leading-edge software providers.  Our goal:  to facilitate a smooth transition from paper to electronic billing of anesthesia services.  ABC strategically considers each upgrade from both a technological and functional update—in an effort to provide clients an unparalleled level of service. OneSourceAnesthesia Successfully Integrates EMR with Epic Anesthesia ABC is pleased to announce that we have successfully interfaced with Epic Anesthesia.  ABC worked with Orange Regional Medical Center and its Epic project team on a repeatable approach for electronic professional billing at Orange Regional Medical Center, located in Orange, New York.  The records and billing information, when combined with the automated...

While the eventual fate of the Patient Protection Affordable Care Act (PPACA) will be decided in the near future, by either the Supreme Court or the next Congress and Administration, what is not open for debate is that healthcare has changed. As the business of medicine evolves to accommodate the changes called for in the healthcare reform laws, so should anesthesiologists anticipate their place in the new environment. The physician group that is able to make informed decisions will be best positioned to evolve and thrive in this era of change. Just like the old Saturday morning cartoon said, “Knowledge Is Power”; by gathering, understanding and responding to information, anesthesiologists can be certain to meet the needs of their clients and proactively position themselves as a catalyst for change.One way of taking that proactive step is to use data to help shine a light on the inner workings of your anesthesia...

CMS has announced the selection of the first 27 Accountable Care Organizations (ACOs) to participate in the Medicare Shared Saving Program.  The 27 organizations have agreed to be responsible for improving care for nearly 375,000 beneficiaries in 18 states through better coordination of services among hospitals, physicians and other providers. ACOs organize to achieve quality improvement and greater efficiency, with a goal of ensuring “that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. … When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.” (from the CMS ACO web page). The ACOs selected will involve more than 10,000 physicians, 10 hospitals and 13 smaller physician-led organizations.  More than half of the ACOs are being led by physicians,...

Virtually all large anesthesiology practices have a corporate website. Some are quite detailed and complex. Fewer medium and small practices maintain a web presence. Should every practice consider creating a practice website or upgrading its current site?After examining a number of anesthesia practice websites, one can see that most have common elements and purposes. Before considering website design, the practice should seriously consider the purpose of the website and its intended effects.The reasons given by anesthesia practices for expending the time and money needed to produce an effective website are to implement one or more of the following:Establish a “web presence”Recruit anesthesia personnel via the websiteProvide patient informationAssist in the patient billing processSchedule anesthesiologists via surgeon preferenceInternal uses such as maintaining call schedules, document retrieval and communications.Marketing to patients, surgeons and facilities seeking anesthesia coverage.WEB PRESENCECurrently, almost every business has a website, so anesthesiology practices may believe that they too should...

Consolidation in the hospital sector has proceeded at a rapid pace in the last few years.  Hospitals, like anesthesiologists and other health care professionals and organizations, are seeking the advantages of combined size to secure their future in a marketplace undergoing a revolution with an unknown outcome.  Oral argument before the Supreme Court on the constitutionality of the Affordable Care Act, discussed in our Alert of April 2nd, did nothing to mitigate the uncertainty. The Federal Trade Commission (FTC) scored a significant victory last week when a federal District Court judge in Rockford, Illinois halted the acquisition of Rockford Health System by a competitor, OSF Healthcare System, until the FTC can conclude an administrative review of the deal (including all appeals, which means a delay of at least a year even if the hospitals ultimately prevail). According to the FTC, the acquisition would violate antitrust law by reducing competition in...

The variety of commonly used modalities for the management of post-operative surgical pain makes it imperative that practitioners understand the specific documentation and billing requirements of each option. Listed below are the five most common approaches and their corresponding claims submission guidelines. As is always the case, reimbursement will vary by payer.Intravenous Patient-Controlled Analgesia Management (IV PCA) – Surgeons are reimbursed for routine post-operative pain management as part of their global fee. Due to this fact, Medicare does not allow anesthesiologists to bill for this service. However, many non-Medicare payers do. The physician must see the patient on a post-operative day and document a progress note to include a problem focused history and exam with straightforward medical decision making. The typical code billed for this service is “subsequent inpatient visit” code 99231 (2 units).Patient-Controlled Epidural Analgesia (PCEA) – If an epidural is placed for post-op pain and is not the...