Have Electronic Health Records Led to Fraudulent Upcoding by Physicians?

Over the past several decades medical costs in the United States have escalated rapidly, exceeding the pace of inflation and threatening bankrupt to Medicare.   As we heard in last week’s presidential debate, different solutions have been proposed on how to slow Medicare’s growth and reduce cost.  President Obama highlighted his administration’s success in tackling fraud and waste within the system. This strategy appears to be supported across party lines.  On face value it seems like a good idea, but what is not entirely clear to those of us within the medical community is how waste and fraud will be defined.  I have discussed this in a previous blog: "When is Unneeded Care Criminal?".

As reported by the New York Times last week,  recently attention has been focused on going after doctors and hospitals who some believe may be “upcoding” the complexity of their patient encounters to CMS and other insurers for the purpose of receiving better reiumbursement.  Apparently since the advent of electronic health records there has been a trend toward physicians' reporting higher complexity office visits.

The AMA (American Medical Association) Wire reports:

"The Centers for Medicare & Medicaid Services (CMS) notified the AMA that Connolly, a recovery auditor for what is commonly known as the Medicare RAC program, will begin auditing how physicians report CPT® code 99215, used to report evaluation and management (E/M) services. CMS appears to have also granted Connolly authority to extrapolate its review of sample claims to potentially recoup funds on 99215 claims it did not evaluate individually."

The AMA strongly objects to these audits and has written a letter to CMS pointing out that: 

"Audits of such complex services would result in erroneous payment recoupment and undue expense for physicians and CMS. According to the agency's own report to Congress, 46 percent of appealed Medicare RAC determinations are decided in favor of the physician or other health care professional."

What does upcoding mean? Medicare and other payers require that doctors use a convoluted coding system for billing medical visits based on their documented complexity. The system is so complex that for years it has outsmarted doctors who have been tasked with remembering the numerous elements required to justify the level of the visit (1 through 5), and then document the details required to support the billing level.

The selection of an appropriate billing code, as outlined in an 89-page guide prepared by CMS, if done correctly would without a doubt take the same amount of time (or perhaps more) as seeing the patient.  The end result:  most physicians, with limited time and partial recall of the complicated rules, pick the code that they feel best encompasses the visit level based on perceived complexity.

In the past when doctors dictated or hand wrote patient notes it was more difficult to include all of the historical factors required to support a higher level billing code. The use of electronic health records, however, has made the process easier by automating the incorporation of past medical history, medications, allergies, social history and family history into clinic notes, thereby allowing physicians to justify a higher level code. Until recently, based on personal experience, the tendency may have been to “under-code” complex visits, with fear that documentation would be inadequate to justify a more complicated billing code.  In reality, it is very time consuming to fully document the complex information that is exchanged in the context of a 15-30 minute office visit.
The purpose of medical documentation is to convey information.   Ideally doctors would be able to document the salient portions of each patient encounter that would help other providers care for the patient in the future.  In many ways electronic health records have helped facilitate medical documentation.  However, at the same time they have also led to the inclusions of extraneous information (for the purpose of supporting billing codes) that one is required to sift through while getting to the meat of the visit.
What is particularly enraging about these allegations of “upcoding” and fraud is that finally physicians have a tool to help ease the burden of Medicare’s inane billing code system—electronic health records; but now, after going through all the work and tremendous expense of transforming our practices and adopting these systems, we are threatened by the specter of accusations of fraud for “upcoding” the same visits that we’ve been “down-coding” for years.  If politicians would like to eliminate waste from Medicare why not simplify its billing system so that medical practices would not have to employ full time coding experts to ensure that their practices remain fiscally solvent? Of course, this would also eliminate a bunch of jobs.

 

Two Conversations About Health Care

Last weekend I was struck by two conversations that I had with acquaintances about recent experiences that they had had with their primary care physicians.  The first occurred at my local pool. A fellow swimmer asked me if I took new Medicare patients.  She bemoaned that she was abandoned--her beloved physician of over 20 years had sent out a letter announcing that she would no longer accept Medicare patients. My friend had recently gone on Medicare.  She speculated about her physician’s  motives, but felt personally rejected, or “fired.”   After she explained her situation, I affirmed, “I do take new Medicare patients,” but qualified my response with a description of my concierge model primary care practice, which requires an annual retainer fee from members in exchange for improved access to me and other amenities, including my guaranteed smaller patient panel size. 

I started a retainer fee primary care practice after having been in a traditional fee for service practice for 12 years and then after taking a year’s leave of absence from clinical medicine. Many of my old patients sought me out, though currently most patients enrolling in my practice are new patients looking for a better primary care experience.  My swimming friend nodded that she understood and that her mother had a concierge physician--she was familiar with the concept and could see its value, though was going to have to decided whether she could afford it. 

My second conversation was at a friend’s 59^th birthday party the following evening. The party was held at the upscale home of a middle-aged, gay male couple—friends of my friend. As I chatted with one of the hosts, a self-employed professional, he asked what kind of medicine I practiced. I explained that I was an internist, or a primary care physician for adults, and that I was in solo practice in Atlanta after practicing at the Emory Clinic for 12 years.  As I spoke he announced that he was in need of a new primary care physician. He went on to explain that his physician, who he was very fond of, had converted his practice last year to a concierge model practice—requiring patients to pay a membership fee in order to remain in his care.  He had made the decision not to enroll in the new practice model, in part because he was already paying a high deductible for care under his insurance and he was unsure how the annual fee would impact his out of pocket cost.  Before the host of the party said more (not wanting him to feel awkward with me), I explained that my practice was a similar model. He and I spoke for about twenty minutes about the problems in primary care and the reasons that primary care doctors were seeking out new practice models.  The man with whom I chatted pulled over his partner, who had been cared for by the same physician.  His partner reacted to our discussion—“but this is not a solution for our country’s health care problems.” I agreed, and we talked about cost and discussed new models of health care, including the Medical Home and Accountable Care Organizations, both of which have yet to materialize as answers for doctors like me.  He went on to assert that he felt that one solution to the problems in medicine would be to produce more doctors, while at the same time to lower the cost of educating them.  Personally, I doubt that producing more doctors in general, will improve primary care, nor will it reduce cost; though, better incentivizing primary care career choices would be helpful.

These conversations illustrate that for the American populous the main problems in health care today are access and affordability.   For primary care physicians the problem is not so simple.  The "system" has failed to support our work in a manner that is conducive to providing the care that we feel patients deserve. Patients may or may not be aware of the impact of this failure on our practice of medicine.

Most Americans equate spending money on health insurance with spending money on their physicians. Primary care physicians see relatively little of the money that consumers put toward their health insurance premiums. Our fees and reimbursement rates are relatively low in comparison to the exorbitant fees for tests, procedures, E.R. visits, and hospitals stays. As our overhead expense has increased, in part because of the administrative hassle involved in getting money from health insurance companies, we have responded by increasing the number of patients seen per day and our panel sizes to the point where many (including myself) feel that quality of care and the patient-physician relationship is compromised.

“Concierge medicine” and the abandonment of Medicaid, and now Medicare, by primary care practices are a reaction to these pressures, which have changed the nature of general practice and offer solutions to protect the personal aspects of the physician-patient relationship.  However, clearly these motives remain poorly understood by the average American consumer, who is faced with rising out of pocket medical costs to pay for health insurance, and increasingly feels burdened with excessive health care expense.

The disconnect leaves doctors like me in a conundrum. Do we continue to work within the confines of a system that has failed to protect primary care as an honored specialty? Do we compromise the care that we deliver in order to preserve access?  Or, do we jump ship and force change by creating new models of care—models of care that patients are increasingly seeking out as they recognize their value? It can be a difficult position to be in.

Recommended Care, Says Who?

Guidelines for care increasingly help guide medical decision-making. If you’ve followed top health news over the past several years you’ve read conflicting statements about the utility of various medical procedures and tests. As a general internist I’ve devoured these reports with particular interest trying to wade through bias to formulate views that I believe will be of most benefit to my patients.

Recently I put together a talk about recommendations for prevention in women. As I prepared the talk I sorted through the data and opinions of various medical special interest groups.  Guidelines for care are usually developed by professional organizations or “expert panels,”  such as the Center for Disease Control (CDC), or the American Cancer Society (ACS).  One might like to think of these panels as unbiased in their advice, but clearly each expert panel is tainted, at least to a degree, by its own special interests.  Conflicting guidelines make it hard for health care consumers to figure out who to believe.

For example, several days ago the United States Preventive Services Task Force (USPSTF) came out with its final guideline on using PSA for the purpose of screening for prostate cancer. The task force recommended against using the test for screening healthy men, giving the screening test a D level rating (not recommended).

What is the USPSTF?

The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.

As a general internist I was indoctrinated to trust the USPSTF with a degree of allegiance that rivals my commitment to the University of Michigan Wolverines (my alma mater).  Nonetheless, there are other expert opinions that I also pay attention to.  In the case of PSA screening the American Urological Association (AUA) continues to make a strong argument supporting its use in screening. I discuss the debate more in my previous post:  Should Doctors Stop Using PSA to Screen for Prostate Cancer? 

Another example of conflicting opinions in medical guidelines:  Who should be screened for diabetes?  The American Diabetes Association (ADA) recommends that all adults with a body mass index >25 kg/m2 (overweight or obese adults) and one additional risk factor for diabetes be screened at least every three years, and that all adults with a BMI>25kg/m2 who are over 45 years of age be screened. In contrast, the USPSTF recommends for screening only adults with blood pressure greater than 135/80, a grade B (recommended) rating. For other healthy adults, overweight or not, it advises that the evidence is insufficient to recommend for or against screening.

These are but two examples of the numerous medical guidelines and recommendations that conflict:  who should be screened for HIV, whether women ages 40 to 50 should be screened routinely for breast cancer with mammograms, how often women over 50 should be screened with mammograms, how often women under 30 should have a pap smear, whether women need an annual pelvic exam, whether women need an annual breast exam, and at what age screening for colon cancer with colonoscopy should be discontinued.  The ADA,  the USPSTF, the CDC, the American College of Obstetrics and Gynecology (ACOG), the ACS, the AUA, the American Heart Association and American College of Cardiology—along with numerous other professional societies and expert groups have not reached consensus on various matters. 

Primary care doctors, as a group, have largely been supportive of proposed measures to reduce medical “waste”—including “unnecessary” tests and procedures that promise to bankrupt Medicare if they continue to go unchecked. In turn we stand to benefit from proposals to re-organize health care delivery and to strengthen primary care--the Medical Home Model, which may channel additional funds toward primary care. In comparison to specialists, primary care physicians have suffered in recent decades, with reimbursement policies that favor physicians who do procedures, as opposed to those who primarily talk to patients for a living.  We have been historically under-represented in the American Medical Association, the largest physician’s professional group in our country. I am part of the American College of Physicians (ACP), a national organization of internists — physicians who specialize in the prevention, detection and treatment of illnesses in adults--but recognize that we also have bias—currently, in my view, a growing skepticism of tests and procedures,  which in many ways is overdue. Yet I would wager that it’s a sentiment that primary care physicians find easier to rally behind than do many specialists, whose interests are more likely to be threatened by changes to reimbursement policy.

Who does one believe? Professional guidelines are likely to shape what is covered by Medicare and private health insurance. If you’re a gynecologist you might trust ACOG, if you’re a primary care doctor, the USPSTF or the ACP, a urologist, the American Urological Association--the politics of medicine are as real as the patients that we treat. Moreover, advocacy groups, such as the Susan G. Komen Foundation and Planned Parenthood, play a role in shaping public opinion, which no doubt can also influence the opinion of even “expert panels,”  afraid to anger these factions.

If you are a medical professional it’s important to be aware of where guidelines conflict and to avoid reflexively supporting one own expert panels.  Even better (though more difficult), read through the original data. If you’re a patient, sometimes it’s good to get the opinion of both a specialist and a generalist in these matters—each can be equally valid and it can help one see both the trees and the forest.  

 

ACP Leadership Day 2011

Last month I attended the American College of Physician’s Leadership Day at the Capitol. The American College of Physicians is a national organization of internists--physicians who specialize in the prevention, detection and treatment of illnesses in adults. ACP is the largest medical-specialty organization and second-largest physician group in the United States after the AMA.

ACP Leadership Day brings together primary care physician advocates from all over the country to discuss national health policy and to lobby for key health regulation. I went as a representative of the Georgia Chapter along with six other physicians from our state, including our Chapter Governor, Jacqueline Fincher, MD, MACP, a medical resident and a medical student from Emory University School of Medicine and Executive Director of the Georgia Chapter, Mary Daniel.  The event included a learning session in which we reviewed the ACP’s priorities.  We heard from ACP president Virginia Hood and Bob Doherty, SVP, Governmental Affairs & Public Policy for ACP. Dr. Doherty also summarizes the day in his blog ACP Advocate.

Nancy Nielsen, MACP, Senior Advisor, Center for Medicare & Medicaid Innovation spoke, appealing to physicians to provide feedback to the Center on the recently proposed rule for Accountable Care Organizations, which has been criticized for its complexity and for being out of reach for smaller medical practices.  We also heard from a bipartisan congressional panel that discussed the ACP priority issues in the context of current legislative considerations. As one might imagine, much of this year’s discussion focused on the national budget crisis and lack of available funds for key Accountable Care Act programs.  Later in the evening, after a keynote address by Alex Castellanos, Political Strategist and Analyst at CNN, Max Baucus was awarded the Joseph F. Boyle Award for Distinguished Public Service. 

The ACP supports the following legislative action:

•  Fix the Sustainable Growth Rate:  The "SGR" is the formula used to determine physician payment by Medicare. The formula is linked to the GDP. However, with advances in technology and the aging population, health expense has outpaced inflation leading to a series of short term fixes to avoid drastic cuts in physician payment.  The "fixes" continuously threaten to expire. The next expiration date is January 1^st, 2012 when physician payment will be cut by 29.5% unless action is taken.  As reported recently in Modern Medicine: 

"Wiping out Medicare’s accumulated debt would cost almost $300 billion, according to the Congressional Budget Office, and maintaining it with 0% updates until the end of the decade would cost more than $275 billion. With the current focus on reducing the deficit, neither of those options looks appealing."

• Fund programs that support expansion of the primary care workforce:   the National Health Service Corps, Section 747 Training in Primary Care Medicine and the National Health Care Workforce Commission.   

• Strengthen access to primary care, improve quality and lower cost by funding: 
• The Medicare Primary Care Incentive Program, which preserves primary care incentive payment through 2015, while enacting further reforms to strengthen primary care (Medical Homes and Accountable Care Organizations).
• The Medicaid Comparability Program (ties Medicaid payment rates to Medicare rates--currently they are significantly lower).
• The Center for Medicare and Medicaid Innovation.  The new Center needs adequate resources to accelerate broad pilot testing of new health care delivery models to improve access, quality and value)
• The Patient Centered Outcomes Research Institute, which researches the clinical effectiveness of different treatments to better inform patients and physicians in decision-making.

• Improve Health Reform by supporting:
• Empowering States to Innovate (allows states to opt out of ACA requirements three years early if they enact a program with equivalent coverage, i.e. Vermont).
• Patient’s Freedom to Choose Act, which repeals a provision of the ACA that requires that physicians provide written authorization for over the counter drugs reimbursed by a flexible spending account or a health savings account.
• State pilots to test health courts (would have medical liability cases heard by expert judges rather than lay juries).

On Thursday the Georgia Chapter broke out into small groups to speak with our legislators about these priorities.  Among others, our chapter met personally with Senator Saxby Chambliss and Representative Tom Price.  I was struck by various things I learned while at Leadership Day.  As I spoke with a local physician who is employed by the Piedmont Physician’s Group in Atlanta I learned that this large multispecialty group is no longer accepting new Medicare patients who are enrolled in Medicare Advantage programs, and that many Piedmont physicians are also closed to new traditional Medicare patients. This speaks to the significant access issue that patients of the future will have unless Medicare is able to successfully reform, while still guaranteeing stable reimbursement for physicians. 

In Washington there was significant discussion about Medicare innovation and the proposed new models of care delivery—Medical Homes and Accountable Care Organizations.  Whether or not participation in such models will be feasible for small independent physician practices remains to be seen—and many are fearful.  At present most physicians cannot get health insurance funding for being “Medical Home” certified.  Locally, in Atlanta, several hospital-based groups are experimenting with Medical Home Pilots:   Wellstar participates in a Medical Home pilot with Humana, Piedmont Physicians Group participates in a Medical Home pilot with Cigna, and Emory will soon launch a Medical Home pilot with Aetna. However, none of these pilots involve more than a single payer.

While I sensed bipartisan support for fixing the SGR, there was significantly less agreement about how to best reduce Medicare cost while improving quality of care and access.  

CMS’ Administrator Don Berwick recently stated in the Health Affairs blog that health care transformation

"won’t yield to a massive top-down national project...Successful redesign of health care is a community by community task. That’s technically correct and it’s also morally correct, because in the end each local community – and only each local community – actually has the knowledge and the skills to define what is locally right"

This being said, Dr. Berwick will need to work to succeed in convincing many that implementing these ACA programs can make a positive difference on a community level in improving health care. To help reach consensus from both sides of the aisle, ACP Leadership Day was a good opportunity for practicing internists from around the country to tell their local stories, illustrating how federal policy impacts day to day practice on a micro-level. I hope that some of our messages were heard.