WASHINGTON – “President Barack Obama offered a grim portrait of America’s plight in an address to a joint session of Congress on Tuesday night, but promised to lead an economic renewal that would lift the country out of its current crisis without bankrupting its future”. – San Antonio Express-News, February 25, 2009.  Immediately following this speech, Louisiana Gov. Bobby Jindal …”derided Pres. Obama’s legislative agenda as big-government ideas that will not succeed in repairing the nation’s economy.”  Also yesterday Federal Reserve Chairman Ben Bernanke gave Wall Street a prediction that the recession could end this year. 

Who knows what will happen?  One thing is certain; change is going to happen.   Just this week, Director of Finance and Accounting for MedaPhase, Mr. Forrest Smith, pulled an HFMA article from the internet that said that the American Recovery and Reinvestment Act (ARRA) 0f 2009 signed by Pres. Obama made some retroactive changes to COBRA benefits requiring employers to provide a 65% subsidy for the cost of nine months of continuation coverage for employees between September 1, 2008 and December 31, 2009.  Employers are supposed to retrieve this cost through some credits toward FICA tax but no one knows right now how this is going to work. This is an example of the types of changes to which we will have to stay alert and responsive.  Probably we will see similar events with regard to payment policy for healthcare services in the Emergency Department and beyond.  Please note Ms. Kottman’s article later in this newsletter of some impending legislation regarding balance billing in Louisiana and Texas.

Last month at ACEP’s Reimbursement conference entitled “Trends and Strategies in Emergency Medicine” several presenters including Elijah Berg, MD, Robert Bitterman, MD, Edward Gaines, JD, Michael Granovsky, MD, David McKenzie, CAE, David Packo, MD and William Rogers, MD (Medical Officer, Centers for Medicare and Medicaid) presented their perspective on current and future trends in Emergency Medicine.   Here’s a few that were noteworthy:

* ACEP’s lobbyists help stave off a huge Medicare cut.  Doubtful that will continue.
* Continued emphasis on pay for performance with attempts to improve the PQRI initiative, especially with regard to reporting.
* EHR’s and EMR’s will become mandated over time.
* Standardization of technology will be key to enhanced efficiency throughout healthcare.
* Increased scrutiny of payments, code utilization and documentation issues will escalate as the government will more closely monitor physicians and attempt to recover payments.
* CERT’s (Comprehensive Error Rate Testing), RAC’s (Recovery Audit Contractors) and PERM’s (Payment Error Rate Measurement) round out the alphabet soup of governmental monitoring and recoupment programs. 
* More uninsured and underinsured patients to be expected making collecting for services more challenging could somewhat be offset by the new recovery programs.  Certainly mentioned in last night’s speech was comprehensive healthcare coverage for all Americans!  We’ll see…
* More bundling of payments will occur
* Demand for emergency department services will likely continue to increase.

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Much of this potential “doom and gloom” may be accompanied with opportunity.  It could be that some actual reform of healthcare delivery will occur for the better.  This could provide more attention to the safety net that emergency medicine provides the nation.  Increased technological innovation (along with incentives and funding) will stimulate more efficiency and require better accountability data.  At MedaPhase our leadership team meetings have been dominated by discussion about how to respond to this economy.  At obvious thing that we have discussed before is an increased effort at making the paying process more convenient through credit cards, bank drafts etc. will be essential.  If we can convince our hospitals to gather e-mail information from patients, then statements could be sent electronically cutting the time from date of service to date billed.  Innovation and creativity must be paramount for all stakeholders in healthcare.  Our goal is to be responsive to these needs and proactively collaborate with physicians and hospitals toward excellent business support services.

An article in the March/April Texas Medicaid Bulletin discussed the Medical Records Requests process for PERM audit reviews. Medicaid states that claims are randomly selected for review by Livanta LLC who has the contract as the CMS Documentation Database Contractor. PERM audits are or will be performed, on a rotating basis, in all states.

The bulletin states that Livanta began contacting providers in late December and early January “by telephone to verify their contact information and determine how the provider would like to receive the medical records request (by fax or mail).” It is possible that the hospital phone number may be the one in the Medicaid files as on the applications Medicaid often requires a number where services are provided.

If you are a current client, it is very important that providers provide the following information so that when letters or faxes arrive they can be promptly responded to. If you are contacted at the hospital or at home for contact information please use the following: Telephone# - 210-614-0180 x 137 and address for the requests: 8401 Datapoint, Suite 500, San Antonio, TX 78229.

Providers will receive letters from Livanta LLC and HHSC and will have only 60 days to return a copy of the medical records to Livanta and a duplicate copy to HHSC. It is essential that requests are responded to within the time frame as “failure to provide upon request medical documentation that supports the claim may result in the provider being sanctioned under Title 1 Texas Administrative Code”

If you have any questions, please feel free to contact Lynne Kottman, 210-692-0424 x 138.

Balance Billing

After the disastrous finding by the courts in California that effectively ban balance billing without currently providing  a mechanism for fair payment, the insurance industry is attempting to use the momentum to move to prohibit balance billing in other states around the nation. There are specific attempts in both the states of Texas and Louisiana to limit Emergency physicians from balance billing managed care patients.

Louisiana Threat

In Louisiana the State Insurance Commissioner has been threatening to bring a balance billing prohibition to the Louisiana legislature as he did last year.

Erroneous information provided to Texas Legislators

According to the TMA, over the past few months, the Texas Association of Health Plans (TAHP) has distributed flyers and held a tutorial for Texas legislative staff on balance billing. After reviewing the TAHP's materials, the TMA found its assertions neither accurate nor addressing the real reasons patients incur additional costs for out-of-network medical services. It is extremely important, in light of the movement of TX Senate bill 351, that would specifically adversely impact “Emergency Room Physician” payment to the State Affairs committee, that information counteracting the misinformation disseminated by the Insurance industry be created and presented to the Texas Senators.

The TMA has created a new brochure that refutes, by item, the erroneous information presented by the TAHP. A copy of this brochure can be accessed by contacting the TMA or by request from lkottman@medaphase.net. In addition, TCEP and EDPMA are creating additional bullet point materials to be presented to legislators that speak specifically to the issues faced by Emergency Department physicians. Any physician can easily contribute to educating the legislators by attending the First Tuesday meetings in Austin held the first Tuesday of each month during the legislative sessions.

TMA Joins Class-action Suit

A positive news item has been the joining of the TMA in a pair of class-action lawsuits against CIGNA Corp. and Aetna Health, Inc. for using a flawed system to underpay physicians for out-of-network medical services and forcing patients to pay an excessive portion of the costs. The lawsuits, filed recently in a New Jersey federal court, contend that CIGNA and Aetna used the system for more than a decade.

According to the suit, Aetna and CIGNA relied on skewed data from the UnitedHealth Group subsidiary Ingenix to set reimbursement rates for out-of-network care, the lawsuits charge. Evidence from a recent investigation launched by New York Attorney General Andrew Cuomo found that the Ingenix data is intentionally manipulated to allow health plans to scam physicians and patients by shortchanging reimbursements on medical bills.

 TMA President Josie R. Williams, MD said, "It's time for Aetna and CIGNA to stop this unethical business practice that shocks our patients with unexpectedly high bills for health care they thought they'd already paid for," "It's time for them to stop cheating physicians and patients just to pad their own profits."

American Medical Association President Nancy Nielsen, MD, said AMA, TMA, and the other partners in the lawsuits "seek to reform the payment systems used by Aetna and CIGNA by ending their dependence on the Ingenix database. The lawsuits also seek relief for physicians who were seriously harmed by Aetna and CIGNA through the insurers' long-term use of the flawed Ingenix database."

United Agrees to Shut Down Ingenix

In January, UnitedHealthcare agreed to shut down the Ingenix system it uses to determine "usual, customary, and reasonable" (UCR) charges as part of a settlement with Mr. Cuomo. The company also agreed to pay to develop a new system to determine fair out-of-network reimbursement rates.

What you can do

Direct interaction with legislators has proved very effective. In addition to meeting with or talking to your local representatives, it would be very effective if you could invite them to visit your local emergency department. Below you will find talking points that might be helpful when discussing the issue of balance billing with your state legislators.

Balance Billing Talking Points

When advocating on behalf of emergency physicians in an attempt to halt prohibitions on balance billing the following talking points proved effective when used in Louisiana last year:

A ban on balance billing would negatively impact patients, communities, physicians and hospitals.

Impact on patients:

Access to care would be vastly decreased; fewer physicians will be willing to participate as on-call physicians for the local emergency departments. This would , in effect, remove the healthcare safety net in many communities

Impact on Communities:

The impact from this type of legislation on the state of California could result in additional physicians leaving the state or not locating to California.    The legislation threatens to eliminate the right and freedom to contract for one’ services.  This would be particularly unfortunate in the State of Texas which has recently seen an influx of physicians due to malpractice reform in the state. 

Impact on Physicians

Physicians are often/limited on decisions regarding managed care participation because insurance companies know that Emergency physicians can not refuse emergency care.
 

Knowledge of this vulnerability by the insurance companies will unfavorably leverage fee negotiations on the side of the insurance companies.  In other words by simply knowing that physicians cannot balance bill their members, then the insurance companies can further manipulate a fee schedule for their own benefit. 

Impact on Hospitals:

Hospitals will have to increase subsidies or begin to subsidize the facility-based physician groups that currently provide care.

Overcrowding problems in the ED could easily worsen, as the ED becomes the in-network option for everyone.
 

Hospitals will not have adequate backup coverage for the emergency department. Fewer doctors will elect to participate in call lists and the lack of back up coverage will threaten access to certain services.

Documentation Dilemma

Ambiguous procedure notes can often result in improper or missed CPT code assignment. This phenomenon usually happens with highly complex surgical services. Often, the result is a significant loss of Relative Value Units.

For Example:

A patient presents with an exertion injury sustained while holding a horse with a rope. The injuries are noted to be in the left hand/finger.

Radiological Findings:

1. Complex IP Fx   
2. Subluxation Left thumb

Clinical Impression:

1. Open Displaced Fracture of Phalanx of Left thumb
2. Fracture/Dislocation IP of Left thumb
3. Laceration of Left thumb

Procedure #1:

Reduction- lidocaine digital block, betadine prep, reduced with manipulation, marginal alignment, NV intact.

What is the dilemma?

The procedure note lacks definition to support a specific CPT Service. Since there are multiple injuries, it is important for the provider to address the service(s) in terms that will direct the coder to the appropriate anatomical reference.

* CPT asks: Which bone/joint space is being “manipulated”?
* The coder is seeking the terms: Phalanx and/or Interphalangeal

We can take a look at how anatomical reference can clearly define the appropriate CPT.

Procedure #1 revision A:

Reduction: lidocaine digital block, betadine prep, IP of thumb is reduced with manipulation, marginal alignment, NV intact.

Assign CPT: 26742- Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation (Non-Fac RVU- 9.31)

Procedure #1 revision B:

Reduction: lidocaine digital block, betadine prep, gentle traction on middle phalanx of L thumb and fracture is reduced, good alignment, NV intact.

Assign CPT: 26725-Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation (Non-Fac RVU- 8.52)

This scenario is not atypical. Remember to always note “landmarks” or anatomical location when these types of complex services are performed. This is a habit that will only enhance your “relative” value.

Help us to combat those horrible Document Dilemma Days!