The 'F' word: Fraud
Remember: fraud exists and it is amazingly/sadly common in healthcare. Tighten up your processes and procedures for paying bills, credit card usage and permissions. Differentiation of duties, cross checks and transparent reporting are great ways, all be it not ironclad ways, to stop or discourage fraud. It is ALWAYS the last person you would expect! “Why didn’t I see that” and “I was such a fool” seem to be the response after the F word shows up. Look for it, before it looks for you!nnStay tuned for more Todd’s Tips!nn
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About R. Todd Welter • MS, CPCnFounder and President of Welter Healthcare Partners
nMr. Welter has over 25 years of healthcare industry experience assisting physicians and other providers, hospitals and other facilities with the business side of medicine. Through strategic planning and analysis, Mr. Welter’s main focus is to strategically increase revenues and profitability in this radically changing health care environment. Mr. Welter has a Masters Degree in Organizational Leadership from Regis University in Denver where he has had an appointment as affiliate faculty in the School for Professional Studies for over ten years. In addition, Mr. Welter holds a faculty appointment at the University of Denver’s University College. In the Health Care Leadership program he teaches Macro Economics in Health Care and Innovative Strategies and Change in Health Care to graduate students.
CMS announced earlier this month that it will provide greater flexibility during the transition to ICD-10 billing codes, easing physicians’ trepidation about the move by incorporating several changes that the AAFP urged the agency to adopt.nnWhen CMS introduced plans for ICD-10, family physicians raised concerns that moving to a new set of codes required additional time for staff training and the possibility of mistakes was too great to implement the codes so quickly. After all, the new system includes more than 68,000 codes — a far cry from the 13,000 ICD-9 uses. So primary care physicians and others sought an extension to prepare for the transition.nnCMS got that message loud and clear, and the agency has taken steps to ensure physicians don’t summarily fall victim to claims denials or audits for making innocent mistakes in coding.nn”The AAFP applauds CMS for taking actions to ease the transition to ICD-10,” said AAFP President Robert Wergin, M.D., of Milford, Neb., in a prepared statement. “Taken together, these provisions will enable family physicians to bill accurately, be paid appropriately and provide continued access to care for patients.”nnAlso during the grace period, Medicare claims will not be audited based on the specificity of the diagnosis codes used as long as they are from an appropriate family of codes.nnCMS is releasing additional guidance on flexibility in the auditing and quality reporting process as the medical community gains experience using the new set of codes.nn
In addition, physicians and allied health professionals who participate in CMS quality programs such as the Physician Quality Reporting System, the value-based payment modifier initiative and/or meaningful use of electronic health records will not be penalized during the 2015 reporting year for failure to select a specific code, as long as they have selected one from an appropriate family of codes. Moreover, practices will not be penalized if CMS encounters trouble in accurately calculating quality scores.nn”We have called for additional appeals and agency monitoring for reporting systems that determine appropriate payment for medical services based on quality measures and meaningful use of electronic health records,” Wergin said.nnPhysician practices can receive an upfront payment from Medicare administrative contractors as an option to protect against mistakes that could occur in coding.nn”The AAFP urged CMS to expand advance payment options for physicians, which will ensure that physician practices have an adequate revenue flow to maintain financial stability during the transition,” Wergin said.nnPhysicians should be aware that after Sept. 30, Medicare will no longer accept ICD-9 codes for service. Neither will it accept claims using both ICD-9 and ICD-10 codes.nnCMS will appoint an ombudsman in each regional office to handle ICD-10 questions, and the agency said it will announce ways to contact the ombudsmen as the October implementation date approaches.nnThe International Classification of Diseases, or ICD, was developed to standardize codes for medical conditions and procedures. The codes used in the United States have not been updated in more than 35 years and contain outdated terms.nn
ICD-10 was introduced with the intent of improving public health research and emergency response times by facilitating early detection of disease outbreaks and tracking adverse drug events. The new codes are also meant to support innovative payment models that improve overall quality of care.nThe grace period to adjust to the exclusive use of the ICD-10 codes is a welcome relief, and our academy deserves credit for representing our interests and concerns. I think that also goes for those of us who have had a hands-on course with the new codes, not because the use of these codes is in itself such a great challenge, but because the central problem is how to find the additional time needed to sort through 5 times as many codes. I think this is particularly so, when confirmation of a definitive diagnosis is pending further tests.nnNow, while we may be the last major country in the world to adopt usage of the ICD-10, I understand from speaking with primary care physicians in Canada, that they do not do the coding themselves because it decreases necessary time spent with the patient. So, all coding is deferred to trained support staff.nnAs practice demands on our time have already seriously decreased necessary visit time with our patients, I suggest that during the 12-month grace period, our academy develop and implement a plan together with CMS, to take this burden off of our shoulders and replace it with supportive training for competent coding by our office staff.nnThis 
The U.S. Supreme Court upheld a core component of President Barack Obama’s health-care law, backing tax credits used by millions of Americans to buy insurance and preserving the landmark measure that will define his legacy.nnThe 6-3 ruling eliminates the most potent legal challenge to a law designed to cover at least 30 million uninsured people and averts a collapse in state insurance markets. Chief Justice John Roberts and Justice Anthony Kennedy joined the court’s four Democratic appointees in the majority. They said the 2010 Affordable Care Act allows tax credits in all 50 states, not just the 16 that have authorized their own online insurance exchanges.nn“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Roberts wrote. “If at all possible, we must interpret the act in a way that is consistent with the former, and avoids the latter.”nnThe ruling is the high court’s second in three years to preserve Obamacare in the face of Republican-backed legal attacks. Republican opponents now must look to winning the White House in the 2016 election if they hope to roll back the law.nn
The Affordable Care Act “is here to stay,” Obama said at the White House. “What we’re not going to do is unravel what has now been woven into the fabric of America,” the president said. “I can work with Republicans and Democrats to move forward. Let’s join together. Make health care in America even better.”nnHospitals led a rally among health-care companies after the ruling. HCA Holdings Inc., the largest for-profit hospital chain, gained 8.8 percent to $90.72 at 4 p.m. in New York. Tenet Healthcare Corp. jumped 12.2 percent and Community Health Systems Inc. added 13.0 percent.nnStock gains at insurers were smaller, in part because subsidized customers make up a small proportion of the total at the biggest firms. UnitedHealth Group Inc., the largest U.S. health insurer, rose 2.7 percent to $122.33.nnThe decision also helps ease the path to dealmaking among health insurers. Bloomberg News reported today that Aetna Inc. could reach a deal to acquire Humana Inc. as early as this weekend. Anthem Inc. went public with a bid for Cigna Corp. on June 20 that Cigna rejected. Groups representing hospitals and doctors praised the ruling. Steven Stack, the president of the American Medical Association, said his group is “relieved.” The American Hospital Association said the decision was a “significant victory for protecting access to care for many of those who need it.”n
Last week, we reviewed a new bill that would allow for a new two-year “grace period” for accepting the new set of ICD-10CM/PCS code that was presented to the US House of Representatives.
These bills, the Coalition for ICD-10 says, could:n
American Airlines, back in 2008, started charging for checked baggage (really, I looked it up!). Up to that point, and even today, most of us have thought that the cost of the ticket should include the cost of checking a bag! As it turns out, the ticket price is only for getting us safely (not even necessarily comfortably) from point A to point B. The rest (food, bags, drinks, in-flight entertainment, etc.) is an up charge.nnIs ambulatory medical care really that much different? The contracted reimbursement rate is for safe, quality and effective medical care. Could everything else (some things) be an up charge? Think about all those administrative services your practice provides to make the health care system work: filling out paperwork, making referral authorizations.nnStay tuned for more Todd’s Tips!nn
T75.1XXA — Swimmer’s crampnnH60.331 — Swimmer’s ear, right earnnB65.3 — Swimmer’s itchnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to