to the
Secretary
U.S. Department of Health and Human Services
Medicare Integrity Program,
Physicians Regulatory Issues Team (PRIT),
and Other Matters )
Practicing Physicians Advisory Council
(PPAC)
For March 15, 1999
Marie G. Kuffner, MD, Chair
Anesthesiologist
Los Angeles, CA
Jerrold M. Aronson, MD
Pediatrician
Narberth, Pennsylvania
Richard A. Bronfman, DPM
Podiatric Physician
Little Rock, Arkansas
Wayne R. Carlsen, DO*
Geriatrician
Athens, Ohio
Mary T. Herald, MD
Internist
Westfield, New Jersey
Sandral Hullett, MD
Family Practitioner
Eutaw, Alabama
Stephen A. Imbeau, MD
Internal Medicine/Allergist
Florence, South
Carolina
Jerilynn S. Kaibel, DC
Chiropractor
San Bernardino, CA
Derrick L. Latos, MD*
Nephrologist
Wheeling, West Virginia
Dale Lervick, OD
Optometrist
Lakewood, Colorado
Sandra B. Reed, MD
Obstetrician/Gynecologist
Thomasville, Georgia
Susan Schooley, MD
Family Practitioner
Detroit, Michigan
Maisie Tam, MD*
Dermatologist
Burlington, Massachusetts
Victor Vela, MD
Family Practice
San Antonio, Texas
Kenneth M. Viste,
Jr., MD
Neurologist
Oshkosh, Wisconsin
_______________________
* Absent from this meeting
HCFA Staff present at the March 15 Meeting:
Nancy-Ann Min DeParle
Administrator
Aron Primack, MD
Executive Director
Practicing Physicians Advisory
Council
Medical Officer
Center for Health Plans and Providers
David C. Clark, RPH
Acting Director
Office of Professional
Relations
Center for Health Plans and
Providers
Stephen Gleason, DO
Senior Medical Advisor
Office of the Administrator
Tim Hill
Program Integrity Group
Office of Financial Management
Public Witnesses, In Presenting Order:
Herman Abromowitz, MD,
American Medical Association
Kenneth Krell, MD, Society of Critical Care
Medicine
Neil Brooks, MD, American Academy of Family Physicians
Karen
Nichols, DO, American Osteopathic Association
Edward Maurer, DC, American
Chiropractic Association
George Sample, MD, Society of Critical Care
Medicine
Wayne Hollinger, MD, State Medical Society of South
Carolina
Michael Hansen, MD, State Medical Society of Pennsylvania
Brian
Johnston, MD, Physician in Private Practice
John Vookles, MD, Physician
Formerly in Private Practice
Tom Troost, MD, American Academy of
Otolaryngology
Glenn Littenberg, MD, California Medical Association
The March 15 Meeting: Morning Agenda
The 28th meeting of the Practicing Physicians Advisory Council (PPAC) took place on Monday, March 15, 1999, in Room 800 of the Hubert H. Humphrey Building, Washington, D.C.
Three New Members: Dr. Viste called the meeting to order at 8:40 AM. He welcomed new members Stephen A. Imbeau, MD; Dale Lervick, OD; and Victor Vela, MD. Dr. Viste also announced that Richard A. Bronfman, DPM, had been reappointed. He then recognized Dr. Primack.
The Council wondered whether the risk adjustment proposals for Medicare plans would apply to State-based Medicaid plans as well; thus far, they do not.
Ms. Nancy-Ann Min DeParle, HCFA Administrator, arrived. She welcomed the new Council Members, thanked Dr. Viste for his service as Council chair, and noted the appointment of Dr. Marie G. Kuffner as the new Council chair (effective at the afternoon session).
Y2K Update: Regarding Y2K, Ms. DeParle reported that 54 of the 78 Medicare contractor systems are compliant, while the remaining 24 should be compliant by the end of March. The next and biggest problem is ascertaining whether or not most physicians are Y2K-ready. Meanwhile, in response to an AMA request, HCFA is also exploring changes to its computerized CPT codes and other similar work, but Ms. DeParle said it was not clear that such changes could be made in the midst of the crush to prepare for Y2K. Meanwhile, more work needs to be done to help physicians and others in the highly diverse health sector (hospitals, nursing homes, home health agencies, etc.) upgrade equipment by December 31.
Medicaid/Y2K a “Mixed Bag”: Ms. DeParle said that progress at the State level was not as encouraging. While the eligibility systems seem to be generally ready for Y2K, the claims-paying Medicaid Management Information Systems (MMIS) generally are not. HCFA will soon be directly informing governors, if the situations in their States remain serious. Even though the Federal Government will pay up to 75 percent of a State’s costs for Independent Verification & Validation (IV&V) of its computer system, “most of them haven’t done that”; hence, she said the situation re: Medicaid “is a mixed bag.” (Parenthetically, Ms. DeParle noted that some systems will have trouble on February 29, 2000, as well.)
Medicaid +Choice Update: The Administrator then recalled last year’s “upheaval” in the Medicaid+Choice program. Research has revealed no single reason for the flight of many plans but, rather, a possible mix of business reasons. In an effort to stabilize the system, HCFA is proposing a reimbursement rate that “blends” lower local and regional rates with a higher national rate, a proposal that could benefit plans in as much as 60 percent of all counties. Ms. DeParle said this new rate and the agency’s whole risk adjustment effort should be up and running by the fall of 1999.
Good News on the ’98 Audit: On another matter, Ms. DeParle reported that the auditor’s report for 1998 indicates that the previous year’s “inappropriate payment” rate of 11 percent was reduced by almost half; that translates into a reduction in the annual loss from $20 billion to about $11 billion. In this connection, Ms. DeParle reported on the success of pilot provider education projects in Texas and Florida; pre- and post test evaluations indicate a 20 percent drop in E&M documentation errors. She said she hopes to see the education program used nationally.
Concerned About Quality: Secretary Shalala felt that too much attention has been focused on health care finance and not enough on health care quality or how to “make life easier for the people [who] actually deliver quality medicine in this country.” While insisting she is an “optimist” about improving the health care system, she also noted that progress can only be made with the help of groups such as PPAC, whose advice, she said, “is taken seriously.”
Attention to Poor and Minorities: When questioned by the Council on the continuing disparities between the health status of the poor and everyone else, Dr. Shalala said HHS would be trying some new approaches with the help of Surgeon General David Satcher, MD. She noted, however, that simply extending health insurance to everyone is not the solution; targeted public health education campaigns (as done successfully with mammography) have to be mounted to motivate people and show them how to take advantage of health coverage. Dr. Shalala suggested that community-based networks are ideal mechanisms for “closing these gaps.” After the Secretary left, Dr. Viste declared a short recess.
When the Council reconvened, Dr. Viste relinquished the chair to Dr. Marie G. Kuffner, who will be Council Chair for the rest of the year.
Significant Drop in Error Rates: Dr. Kuffner welcomed Mr. Joseph Vengrin, Assistant Inspector General (IG). Mr. Vengrin described the auditing requirements under the Chief Financial Officer (CFO) Act and subsequent public laws. The HHS CFO audit covers HCFA’s annual fee-for-service expenditures of $176 billion and managed care expenditures of $33 billion.
Under- As Well As Over-Coding: Mr. Vengrin reported that, between fiscal 1996 (the year of the first HCFA audit) and fiscal 1998, there was an estimated drop in improper Part B payments from $23.2 billion to $12.6 billion; in addition, “documentation errors dropped significantly during this particular period,” he said. Of the three main reasons for errors, the first is poor or missing documentation, the second is mis-coding, and the third is the request for noncovered or unallowed services. The Council asked if the CFO auditors also looked for “under-coding”: that is, physicians asking for less money than would be allowed. Mr. Vengrin said that such situations were indeed factored into the CFO calculations.
More Publicity Needed: The Council suggested that the government should publicize this kind of progress in order to reassure the public that their tax dollars are being spent wisely and are not ending up in the pockets of providers practicing fraud and abuse. Mr. Vengrin agreed that the public might want to know that in 1998 some 93 percent of Medicare physicians were following the reimbursement guidelines, a significant rise from the 86 percent just two years earlier.
Council members felt that the progress made to eliminate improper Part B payments and documentation errors is impressive and reflective of the efforts of the medical community to assist in reducing such incidents. Educational efforts aimed at addressing the noted problem areas are having a beneficial effect and are indicative of the cooperation of the medical community as it works to reduce improper payments while stressing the need for better documentation, coding, and understanding of billable coverage.
A New 10-Point Plan: Tim Hill, Deputy Director of the Program Integrity Group, next outlined to the Council the month-old, 10-point plan (“a road map, if you will”) intended to guide HCFA’s program integrity activities. The underlying premise, said Mr. Hill, is the intention of the agency to “pay it right,” if the provider has “billed it right.” Thus, the plan encompasses more than just the elimination of fraud and abuse. In response to the Council’s concern about integrity initiatives in the area of managed care, Mr. Hill indicated he could “only speak generally about...some of the things that we’re thinking about...,” offering no specifics.
More Prepayment Reviews: Mr. Hill indicated that the number and frequency of prepayment reviews under the new plan would increase, reflecting the increase in Medicare and Medicaid funding overall. However, the Council wondered why this should be so, since (as reported only minutes before by Mr. Vengrin) the rates for documentation errors and inappropriate payments have significantly declined in just two years. Mr. Hill said that, while the payment error rate is now down to $12 billion, the “error rate is still $12 billion too high.” He also said the drop in the error rate is further evidence that “we need to be much more pro-active in our relationships with physicians and other providers in terms of education and making sure that they’re billing correctly.” Mr. Hill added that the random prepayment reviews not only help identify the norms for documentation behaviors but also suggest how many “standard deviations away from the norm” would be reasonable for triggering corrective action against so-called “outliers.”
Emphasis on Payment Error Prevention: Dr. Kuffner next welcomed Mark Krushat. MPH, ScD, Technical Advisor in the Office of Clinical Studies and Quality, to update the Council on the forthcoming 6th Scope of Work. Dr. Krushat was accompanied by Jeffrey Kang, MD, Director of the Office of Clinical Standards and Quality. In response to the Council’s request, Dr. Krushat focused his remarks primarily on the payment error prevention program (PEPP) for acute-care hospital DRGs, an important new element in the Scope of Work, scheduled to go into effect in August 1999. Dr. Krushat outlined the four parts to PEPP:
More Specific Than the CFO Audits: Drs. Krushat and Kang emphasized that the proposed PEPP is meant to provide HCFA with a more accurate picture of program integrity down to the State, local, and hospital levels, unlike the CFO audits, which only give an approximate national view. When questioned by the Council, Drs. Krushat and Kang explained that the original draft of the 6th Scope of Work was designed to go beyond the in-patient setting; whereas the current proposal is limited to in-patient hospital care. However, Dr. Krushat also indicated that this level of PEPP “could serve as a model...for further efforts” in home health care, skilled nursing facilities, and “the other Part A side of the house.”
The PRO as a “Good Cop”: Dr. Kang also emphasized that, in a “bad cop/good cop” scenario, the Department of Justice was the enforcement “bad cop,” while HHS/HCFA wants the PROs to play the “good cops” in the revised 6th Scope of Work, which primarily targets payment errors rather than fraud and abuse. When the Council responded that even “good cops” have arrest quotas and lay speed traps for the unwary driver, Dr. Kang explained that the PROs would be urged to provide warnings and educational service rather than “immediate tickets.” He added that, thanks to PPAC’s comments and influence, the PEPP now stresses equally the elimination of under- as well as over-payments.
A 10,000-page Task: The Chair next welcomed Stephen Gleason, DO, Senior Medical Advisor in the Office of the Administrator, who reviewed the work of the Physicians Regulatory Issues Team (PRIT) for new members. Dr. Gleason said he believes the Team’s work could be over by year’s end, since only 10 percent of more than 100,000 pages of HCFA regulations apply to MDs. The Members asked no questions.
Guidance for Witnesses: In light of possible misunderstandings among the public as to the intent behind the Council’s next agenda item, Dr. Primack urged public witnesses to focus on the general question of information dissemination and access, rather than to focus on any specific regulations and regulatory issues. Public witnesses appeared in the following order; those with prepared testimony on file are marked with an asterisk.
Herman L. Abromowitz, MD, presenting for the American Medical Association: Dr. Abromowitz asserted that “[m]ost physicians believe that the government is treating them like criminals rather than law-abiding citizens who care for their patients every day.” He said physicians “strongly take issue today with HCFA's over-zealous implementation of policies that address waste, fraud and abuse,” policies that interfere with “the trust relationship between patient and physician.” Dr. Abromowitz also urged HCFA “to institute pilot tests to assess any new E&M guidelines...and to discontinue prepayment review of E&M services. Instead, [HCFA] should conduct a focused review of medical outliers using independent...peer review.”
More Oversight Over Carriers: Dr. Abromowitz then turned to the role of the carriers, indicating that physicians are “extremely disappointed in HCFA's lack of appropriate oversight on its carriers. HCFA and its carriers continually fail to distinguish between ‘genuine’ fraud and legitimate billing issues involving differences in medical judgment. This attitude...has demonized the medical community and has led to numerous problems during prepayment reviews, post payment audits, and prepayment screens as well.” Dr. Abromowitz cited several examples of carrier error, including the case of Dr. Kenneth Krell of Idaho Falls, Idaho, who was the next public witness. The Council had no questions for Dr. Abromowitz.
Kenneth Krell, MD, presenting for himself and the Society of Critical Care Medicine: Dr. Krell recounted his group’s experience with Cigna, its Medicare carrier, which questioned Dr. Krell’s claims for “a high incidence of evaluation management services and laboratory procedures provided to Medicare recipients." Dr. Krell provided the backup documentation and was confident there would be no further problems, “since all I do is evaluation and management services as an internist.” However, the carrier claimed Dr. Krell’s group had over-billed $81,390, although “nobody ever asked whether it was reasonable, whether in fact those patients were critically ill. In point of fact, there was never any attempt at education. Although we thought we were in compliance, we were following the rules, there was never any intervention prior to receiving the claim for $81,000...”
“You’re Going to Get Burned”: Dr. Krell believes that the “message...in Eastern Idaho is that if you expose yourself to taking care of Medicare patients in any kind of quantity, you're going to get burned.... So, at the present time, I can't get a Medicare patient in to see somebody in plastic surgery or in EMT because they have all withdrawn from seeing Medicare patients, except...through the emergency room. We now have no primary care physicians in family practice. We have very limited resources now in internal medicine willing to see Medicare patients. It's made patients frightened, and they want to know how much longer we're going to be able to...continue to care for patients.” Dr. Krell said he had “absolutely no intention of withdrawing [from] taking care of patients who are Medicare recipients, but the regulations haven't made it easy, and the discretion of the carrier hasn't made it easy.”
The Problem Is at “Both Ends”: Responding to Dr. Krell’s presentation, Dr. Primack concluded that “it's really a local carrier issue...[since] you sound extremely knowledgeable, and you've been engaged in the definitions...and evaluation management codes.” But Dr. Krell responded, “[We] think that it comes from both ends. Cigna interprets their mission from HCFA right now as being very aggressive in interpretation of the regulations.” Following Dr. Krell’s presentation, Dr. Kuffner called for the lunch break at 12 noon.
Neil Brooks, MD, presenting for the American Academy of Family Physicians: When the Council reconvened at 1:10 PM, Dr. Kuffner invited Dr. Brooks to the witness table. Dr. Brooks based his testimony on the results of a survey sent to 250 AAFP members. These were some of the surveys results:
Karen Nichols, DO, representing the American Osteopathic Association: Dr. Nichols touched upon many of the same issues raised earlier by others. She also noted that, because of their “frustrations and fears...a lot of osteopathic physicians [are] beginning to opt out of Medicare...” The following are several other points made by Dr. Nichols:
Edward L. Maurer, DC, DACBR, representing the American Chiropractic Association: Dr. Maurer spoke primarily to the issue of current Medicare+Choice regulations (“not final but in effect”) that give managed care plans “the option of permitting non-physician practitioners and other non-qualified individuals to provide the uniquely chiropractic physician service of ‘treatment by means of manual manipulation of the spine to correct a subluxation.’” Dr. Maurer called this option “a shell game in which the Medicare beneficiary always loses.” Dr. Maurer added that “the ACA has filed suit against the government to challenge these proposed regulations...”
Drs. George Sample, Wayne M. Hollinger, and Michael Hansen, representing the Society of Critical Care Medicine: Dr. Sample raised the issue (noted earlier by Dr. Krell) that, despite the existence of the 1995 memorandum by HCFA’s Elizabeth Cusick regarding critical care, “carriers are defining critical care services so narrowly that the majority of the services provided by the critical care physician would be deemed by the carrier as not medically necessary for the Medicare patient.” One reason for this state of affairs, said Dr. Sample, is that carrier medical personnel are unfamiliar with critical care medicine, a point similar to the AOA’s Dr. Nichols’: i.e., physicians with similar training should evaluate each other.
A Clean Record for 15 Years: Dr. Hollinger then told of his own battle with a carrier’s sudden conclusion that his critical care practice had been overpaid $193,000, despite the fact that “[there] had been no previous experience with any significant denials of charges by Medicare in 15 years of practice,” nor had they ever “received any pre-audit educational direction as to our coding practices.” Dr. Hansen next recounted his own experiences with a carrier medical director who had never seen the Cusick memorandum; when it was finally shown to him, he rejected it out of hand anyway.
Special Mailings Proposed: In each of the above cases, the physicians confessed to not knowing about or never having been told of certain relevant rules and regulations. The Council asked what HCFA might do to make sure physicians are informed of all the latest rule changes and interpretations. Surprisingly, the critical care physicians suggested special first-class mailings to every participating physician, instead of the current bulletin formats.
“Into the Garbage Can”: Council Members generally agreed that the bulletins from HCFA and from the carriers are usually passed along, unread, to administrative staff for reading and possible deciphering. (One Council member admitted that, prior to her membership in PPAC, she “used to throw that monthly bulletin in the garbage can.”) The Council also discussed the fact that physician bulletins are often sent to a physician’s billing agency, which keeps it and never passes it on to the practicing physician for his or her information.
More Effort at Education: Instead of the current bulletin approach, Members’ sentiment ran strongly toward HCFA substantially increasing its physician education efforts not only among physicians in practice but also among younger physicians still in training. The suggestion was also made to produce a kind of “Cliff Notes” version of HCFA rules and regulations to make them more accessible to physicians. But even if HCFA took these actions, PRIT’s Dr. Gleason was still skeptical, noting “the differences between carriers, the differences between interpretations of what's critical care and what's emergency care...”
Brian Johnston, MD, an emergency physician in private practice: Dr. Johnston reported on the effect of a carrier’s narrow interpretation of HCFA’s rule on independent physician contractors, ending in a delay of payments worth $4.5 million to Dr. Johnston’s group, which uses the services of 180 emergency physicians who are independent contractors. Again, the “horror story” involved the intransigence and unresponsiveness of the carrier (TransAmerica). Dr. Johnston argued that, “if we're an ethical group and doing good work and providing the services...and billing properly, that we shouldn't be subjected to this.” The Council agreed.
John Vookles, MD, formerly in private practice: Dr. Vookles had an unusual specialty consultation practice (ophthalmology consults in emergency medical care) that attracted the attention of a carrier medical director, who concluded that Dr. Vookles had to repay the carrier $133,000 in alleged overpayments, a sum which would equal “a year’s [net] income for my wife and myself,” said Dr. Vookles. Finally, after much negotiation, many attorney’s bills, some payments, and the abandonment of his specialty, Dr. Vookles declared bankruptcy and closed his practice. Central to his case was the existence, he said, of HCFA rules and regulations that he had never seen before. Dr. Vookles made the following four suggestions:
After a brief mid-afternoon break, Dr. Kuffner re-convened the Council to hear the remaining two public witnesses.
Tom Troost, MD, presenting for the American Academy of Otolaryngology: Dr. Troost made two points:
Glenn D. Littenberg, MD, presenting for the California Medical Association: Dr. Littenberg, the final public witness, reviewed many of the issues raised by previous witnesses, including the difficulty physicians have of getting a Medicare number. Returning to the central question of this quarterly meeting, Dr. Littenberg asked rhetorically, “[H]ow do we become informed? How do we keep up? The answer is there's really no way. There's such a huge volume of these...details, even pertinent to just your own specialty. It just truly isn't feasible. As much as I read [of] these things, I'm still two or three issues of the bulletin behind...” Dr. Littenberg also made the following suggestions:
Final Words and Adjournment: Members observed that this quarterly
meeting was marked by “an unusually silent Council. We've never had a
meeting...where we have sat so silently” to listen to “such eloquence from our
testifiers...” The meeting ran past its customary adjournment hour; hence, the
Council did not recapitulate the main arguments of the day but agreed that the
meeting report would yield much new food for thought.
The only possible agenda item mentioned specifically for the Meeting on June 14,
1999, concerned the (by then) new Notice of Proposed Rulemaking (NPRM) to revise
the Medicare physicians fee schedules.
The 28th meeting
of the Practicing Physicians Advisory Council was adjourned by the Chair at 4:45
PM. The next meeting will be in Baltimore, Md, on Monday, June 14, 1999.
Marie G. Kuffner, MD
Chair
Practicing Physicians Advisory
Council
Last Updated July 20, 1999
 |
 |
Return to the Previous Page