Many providers contend the shift is the result of sicker patients coupled with the widespread implementation of electronic medical records, as treatment and documentation of more complex cases requires greater time and effort. But the persistent increase in costlier codes has made pursuing potential billing abuse a Justice Department priority.

One area of focus for federal investigators has been upcoding, the practice of deliberately billing for more extensive and costly services than were actually performed.

In February 2017, nationwide hospital staffing provider TeamHealth Holdings agreed to plus interest to settle allegations that its hospitalist group practice, IPC Healthcare, submitted upcoded bills to Medicare, Medicaid, the Defense Health Agency, and the Federal Employee Health Benefits Program.

In June 2017, Carolinas Healthcare System agreed to to resolve allegations that it billed federal health care programs for “high complexity” urine drug tests when the tests conducted were only of “moderate complexity.” According to court documents, this upcoding persisted for four years and cost the government an extra $80 per test.

In October 2017, multi-location New York Spine & Wellness Center agreed to to resolve improper billing claims after a federal inquiry determined the practice routinely billed for moderate sedation services – which require physicians spend at least 16 minutes with patients – despite its doctors not meeting the minimum time criteria.

But upcoding is not exclusive to tax-payer funded health care. In the case of New York Spine & Wellness Center, for example, a private insurer first detected the Center’s sedation upcoding in January 2015, initially rejecting two claims that fell short of the 16-minute rule. A subsequent audit by the same insurer resulted in more rejections, but the Center continued its upcoding abuse for two more years until the U.S. Attorney’s Office intervened, seeking to recover overpayments by the state’s Medicaid program. Indeed, of the $1.9 million settlement, more than $660,000 will be returned to the New York Medicaid coffers.

Outcomes such as these are terrific news for taxpayers, but such retrospective vigilance by the Feds has little to no impact on private insurers, employee organizations, and individual payers.

While the government concentrates on recouping federal dollars post-payment, medical cost containment firms must protect private payer clients from overpaying upfront. For example, 911�Թ� uses tools such as in-depth bill review by certified coders and nurse auditors and pre-negotiated, bundled rates to wean out upcoding and other billing abuses on a transactional level. Such proactive approaches are a key core competency of medical cost management, and continue to be as important today as they have been historically.

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To help combat this crisis, organizations such as the Official Disability Institute (ODG) and The American College of Occupational and Environmental Medicine (ACOEM) have released guidelines for prescribers in the appropriate use of opioids for treating pain specific to workplace injuries.

In a published in a recent edition of the Journal of Occupational and Environmental Medicine, researchers at the ReedGroup and Kaiser Permanente retroactively applied ACOEM’s April 2017 guidelines to 7,840 patients who underwent carpal tunnel release (CTR) surgery from 2007 to 2014. Of the 70 percent of cases prescribed an opioid, 29 percent were contrary to the guidelines, which recommend no more than a five-day supply of short-acting opioids for acute postoperative pain for new users. Patients given greater dosages averaged disability durations 1.9 days longer and medical costs $422 higher than their ACOEM-compliant counterparts.

While these cases were not exclusively workers’ compensation related, given the volume of injured workers who require CTR surgery annually, it’s easy to see how following the guidelines could substantially benefit payers and patients. The study estimates if 29 percent of the 577,000 CTR procedures performed annually were prescribed an opioid according to ACOEM’s guidelines, the potential medical cost savings is $71 million per year with a reduction in disability durations by 124,000 days. Incredible.

Clinicians at the Center for Surgery and Public Health at Brigham and Women’s Hospital took guideline research a step further by analyzing more than 200,000 postoperative opioid prescribing patterns to define the ideal prescription length by procedure type. Their , published by JAMA Surgery, determined the optimal length of opiate prescription was four to nine days for general surgery procedures, four to 13 days for women’s health procedures, and six to 15 days for musculoskeletal procedures.

While it’s too soon to know the time and monetary impact these guidelines could yield if implemented, it’s heartening to see that the risk of prescription opioid misuse is being considered when looking to alleviate temporary acute pain. We must all be mindful of what is in the patient’s long-term best interests and limiting opioid prescription duration is a critical step in that process.

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International Classification of Diseases (ICD) was created by the World Health Organization (WHO), which has served the healthcare community for over a century. While most industrialized countries moved to the ICD’s “tenth revision” – ICD-10 – ago (1983), the United States only transitioned in October 2015.

There are differences, however, between what WHO publishes and what the US actually utilizes.

WHO’s ICD-10 classification system is for diagnosis codes only, and does not contain any procedural codes.

ICD-10-CM (Clinical Modification) is a US clinical modification of WHO’s ICD-10, developed to support US health information needs. ICD-10-CM is designed for classifying and reporting diseases in all US healthcare settings. WHO gave the US permission for these modifications.  I have not been able to find out or what specifically was modified, but the technology systems of US healthcare organizations that operate internationally – either now or in the future – will need to accommodate for both the US ICD-10-CM codes and the WHO’s standard ICD-10 codes.

ICD-10-PCS (Procedure Classification System) was developed by the Centers for Medicare & Medicaid Services (CMS) and is not based on WHO’s coding system. ICD-10-PCS replaced the ICD-9-PCS and are only required for facilities reporting procedures on hospital inpatient services.

When speaking of these new classifications in the US, the term “ICD-10” is often used for both code sets (ICD-10-CM and ICD-10-PCS), but it is important to understand that they serve very different purposes.

…On the forefront, WHO has already released a BETA version of ICD-11.

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There is a picture now circulating of a fee charged to a mother for holding her child after birth. “Skin to Skin after C-Section” is what the hospital called it, and apparently it cost them $39.35 to provide.

The article’s author states that the mother holding her baby after a C-Section requires a second labor and delivery nurse to come into the room to ensure the baby’s safety. This could be a hospital regulation or a federal regulation, but it makes no sense to me personally. If there is already a nurse present who no longer has to hold the child, I cannot see how (other than mindless bureaucracy) it would require adding another nurse to the room.

Regardless, for thousands of years, mothers have figured out a way to hold their children after birth – for free. Now, it’s a service that requires two medical professionals and a bill charge.

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Many drugs are coming off of patent, meaning generics of those drugs can now be manufactured. Historically, this has always driven down costs and “generics” was synonymous with “cheaper.”

A may give us a clue as to why this is happening.  It turns out the pharmaceutical companies are buying smaller companies or their rivals, and jacking up their prices. Since 2008, branded drug prices have increased 127%, versus an 11% increase in the Consumer Price Index (CPI).

This is very similar to what is occurring in the hospital world. Hospitals are buying competing hospitals, medical groups and ambulatory surgery centers, and once they have established a virtual regional monopoly, they raise all the prices.

If you can’t beat them, buy them.

The post If You Can’t Beat Them, Buy Them: Why Some Drug Costs Are Going Up appeared first on 911�Թ�.

The University of California San Francisco researchers set out to find out how much an appendectomy cost in California. The price varied from $1,529 to $182,955.

The “recovery room” was over $7K for 2 hours. This room charge has always driven me nuts. For an inpatient stay, the patient already has a room they are paying to stay, sleep and “recover” in. That room rate does not get reduced when they are also charged for the “surgical room” to do the surgery, and then they throw in another room or two for “recovery” at massive hourly rates well beyond the cost.

The hospitals cite issues caused by Medicare, Medicaid, and other government programs, stating “…a more straightforward pricing system is only possible when reimbursement from government-sponsored patients covers actual costs.” They are flat out admitting they are cost-shifting to every other person who treats there to cover government plans. From what I’ve seen, many Medicare payments are well above what reasonable costs should be; however, there is likely some validity to this point as I’m sure some payments are unreasonable.

Making pricing transparent (fair to all parties) is critical to the long-term survival of healthcare. 911�Թ�’s surgical care program resolves all of these issues, eliminating the variability, moving treatment out of the arbitrary hospital system, and paying providers a fair rate, quickly.

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For those of you who do not know the trends in the industry, hospital groups are consolidating and buying physician practices and Ambulatory Surgery Centers (ASCs). They can charge more for government services than independent groups (Medicare, Medicaid, etc.) so the value of the purchased entity jumps as soon as they purchase it. In addition, with regional monopolistic power, they have more leverage negotiating PPO rates, which drives up costs to the general market.  This trend will continue with the national healthcare law changes.

This is why 911�Թ� has been focused on developing new techniques to attack this problem.   and focusing on has been at the forefront of our product development innovations for the last few years.  Having medical management programs that can impact this trend will become more and more critical as time goes on.

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