South Florida Hospital News
Saturday August 8, 2020

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July 2005 - Volume 2 - Issue 1


Business Muse …Reflections on the Business of Health Delivery

Et tu Medicare?

Not unlike the fate of Ceasar, there are forces currently trying to bring down the stature and majesty that is the practice of medicine. As it was with Caesar, the company that surrounds the physician is seeking to attack his vulnerabilities, while concealing their agenda with words of noble purpose.

Unlike a business, which tries to sell all it can to a consumer, Medicine, as a profession, tries to give people only what they need when they need it. Health care insurance companies see the world as a business and therefore expect that the medical profession is operating under the same premises. They believe a physician must be looking for consumer surplus and is selling more services than the patient’s problem requires. This is the framework upon which the forces are opposed. The carriers believe it’s not the patient’s need but the doctor’s greed that influences the services doctors recommend.

Enter the federal government and Medicare, the program that provides funds for the care of a significant part of our population. Medicare, through the CMS (Center for Medicare and Medicaid Services), has sharpened its dagger and begun a new initiative, the Recovery Audit Initiative, which they tout as a service to help providers. It goes like this: Auditors review your office records, billing and medical, in search of what they believe are discords that have resulted in overpayments made to you by Medicare. They are supposed to find underpayments as well. But which will they hunt for? What is their incentive? They, the auditors, are given a percentage of what they find in overpayments, and based on their findings the practice can be opened up to a fraud audit. So much for noble purpose.

The first targets? Practices in the big Medicare states: Florida, New York, and California. Can they find you? You bet! Forget random chance, a disgruntled patient or employee makes a phone call. That’s all it takes. You see a lot of Medicare visits. You may have made an honest mistake in coding, or the auditor does not believe you have the appropriate documentation to support the code you billed for - ergo you must be stealing.

In our current fiscal times, it is poor politics to raise taxes to balance budgets. Yet nobody is going to stand in the way of fees and fines, as you cry out against the inherent unfairness of the situation. Why should they come to your aid? The government is declaring you overcharged and committed billing fraud. You could be an easy target for both claims, however unjust. How?

Just look to a recent survey as reported in JAMA. Healthcare professionals reported missing important pieces of data in their records 13.6% of the time at the time of patient visits. Among the missing: History and Physical exams – 26.8%, Lab results – 45%, Current and prior meds – 23.2% and there are more. The missing data may be the very documentation needed to protect you against a charge of improper coding and fraudulent billing. Are you certain that an examination of your records wouldn’t support this data? Are you vulnerable?

To be sure there are Electronic Medical Records and other business systems and integrated solutions that can protect you and you practice. Spending your time finding the right fit for your situation can be like negotiating a minefield. Putting off developing and implementing the right integrated systems and solutions leaves you at risk.

Like Caesar, are you assuming it won’t happen to me, leaving your future to the fates? Are you without armor, and open to attack when the Brutus of today (Medicare) tries to strike that blow.

Are you wearing the emperor’s new clothes?

As of April of 2005, the security portion of HIPAA (the Health Insurance Portability and Accountability Act), the part pertaining to protected healthcare information (PHI), which is electronically transmitted or maintained, became effective. The requirements of the privacy portion of HIPAA have been in effect since 2003.

It is very difficult to separate privacy from security. Privacy is a big deal today. You get privacy statements from your accountant, bankers, insurance companies and more. They don’t participate in Medicare or other health programs as part of HIPAA, but they believe a complaint could damage their business. They follow the federal privacy standards. Keeping information private requires keeping it secure.

Just like the emperor in the old tale, are you and your practice (business), naked to the world when it comes to having systems in place to protect patients’ privacy and security. Are there systems in place to assure you’re the required level of compliance are maintained? Are new employees in-serviced and tested to make sure they understand and perform as expected? There are associated fines and penalties, civil as well as criminal, for non-compliance or willful disregard. Not to mention the additional costs incurred of defending yourself from the charges. Even if you win, what would the public knowledge of the charges do to you reputation and practice?

It is far better to have the systems in place to ensure your protection now and in the future. Take a look at your wardrobe and make sure the "bare" essentials are covered. It may be time the emperor bought a real suit.

J. Steven Kaufman, MD, CEM is with Phoenix HealthServices Consulting, LLC. PHC solicits and appreciates questions of a business nature relating to the health services industry to address in future columns. Please address your questions to Phoenix HealthServices Consulting, LLC at, phone (561) 799-1633 and fax (561) 799-4092.
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