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For every silver lining, a cloud: The reality of Medicare incentive payments, audits

February 18, 2013

Edited by Jason Miller, O.D., Walt Whitley, O.D., and Chuck Brownlow, O.D., Medical Records consultants, AOAExcel

The silver lining—CMS EHR incentive program

The press has reported information related to a silver lining for Medicare providers, including many optometrists. Through November 2012, optometrists received nearly $57 million from the federal government as a result of their participation in the Electronic Health Records (EHR) Incentive program. This represents the successful registration and attestation of more than 3,600 individual optometrists. Most striking is the realization that almost $5 million in EHR incentives were paid to optometrists in the month of November 2012.

It’s easy to imagine the positive financial impact on an optometrist receiving an average of $18,000 in incentives payments in one year, and it’s just as easy to imagine the sacrifices made by each optometrist to “take the plunge” into the full use of EHRs in her/his office. The transition from paper to EHR takes commitment on the part of doctors and staff, including the commitment of finances for new hardware and software, staff and doctor training, lighter appointment schedules during start up, as well as commitment to the benefits of better medical records and better patient care, and commitment to compliance with the meaningful use requirements integral to the EHR incentive program.

The cloud—CMS audits for compliance 

Through the EHR Incentive Program, 2012 was unique in the incentive payments paid to optometrists and other providers in the Medicare and Medicaid programs. It is just as important, however, that 2012 was unique in the amount of money the Centers for Medicare & Medicaid Services (CMS) recovered from physicians through post-payment audits of claims. It is likely that final figures for calendar year 2013 will show an excess of $10 billion repaid to the CMS by Medicare providers alone. That contrasts dramatically with the total payments made by the CMS for the Medicare EHR Incentive Program to all physicians in its first two years: $1.7 billion!

For decades, the CMS has concentrated its audits in two directions. First, Medicare carriers were urged to watch for unusual patterns in claims from specific providers, with audits then triggered by certain patterns. Second, carriers would watch for patterns of billing across all providers, as changes in techniques for managing patient care would result in increased frequency of billing certain procedures, certain levels of office visits, etc., which would in turn result in audits of claims, including those specific procedure or visit codes.

Recent audits have been more general in nature, focused on the medical necessity and reasonableness of care provided to the patient, and not necessarily triggered by patterns in billing. For example, if an audit were to reveal the recorded reason for a specific patient visit was quite minor, such as an itching or burning around the eyes, and the case history, physical examination, and medical decision-making were all very extensive, resulting in the billing of a high-level office visit code, the auditor would probably dig a little deeper to determine whether the patient actually needed to be asked all those questions and have all those tests performed.

Living with both the silver lining and the cloud

The key to compliance with the rules of medical record-keeping remains unchanged. Each health care provider must maintain an unwavering commitment to the needs of the patient. This is paramount, but needs to be balanced with the requirements of outside entities, such as HMOs, insurers, and the courts. There is no simple way to guarantee that balance, but it begins with a very careful interview of each patient to identify the needs of this patient on this day, as well as the needs of the doctor in diagnosing and managing the patient’s needs.

The second significant commitment every provider must make is to keeping an excellent record of each patient encounter: focused, thorough, and legible. The record will clearly show the reason for each visit while providing clear evidence that each element of the encounter was relevant to the needs of the patient and, in the words of the insurers, “reasonable and necessary.” Each patient is unique, and each patient encounter is unique, so the doctor may need to help the auditor understand why a specific question was asked or test performed. That will require some careful thought on the part of the doctor, but it often will be effective in convincing the auditor that the doctor did what was appropriate and therefore “reasonable and necessary.”

Ideally, the potential reward of the “silver lining” and the potential threat of the “cloud” will lead providers, including ODs, to take a closer look at in-office protocols relative to the delivery of care, the quality and thoroughness of their medical record-keeping, compliance with payers’ rules relative to provision of care and reporting that care, the codes for the patients’ conditions relevant to the day’s visit and the codes used for the care provided.

Life, especially health care practice, is full of rewards and rules. Patient care today requires a definite plan, or a set of protocols, to be sure one is meeting the needs of every patient while following insurers’ rules. Make 2013 the year you create your master plan to balance the silver linings and the clouds. When you’re audited, you’ll be glad you did.

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