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, 911łÔąĎ 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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At Kaiser Permanente, virtual patient encounters now outnumber in-person visits. , his health system saw more than 110 million people last year, with some 59 million connecting through online portals, virtual visits or the health system’s apps. That figure represents more than half of the organization’s total 2016 visits.

“We are going through a major transformation in healthcare,” said Tyson.

At (NYP), their suite of telemedicine services includes adult and pediatric emergency and urgent care, virtual follow-up visits for surgical and psychiatric patients, and a second opinion program.  Such telehealth adoption has yielded dramatic results. In the ER, for example, low-acuity patients are now seen virtually by an ER physician elsewhere in the health system, reducing average wait times from 2.5 hours to 31 minutes.

Moving forward, NYP aims to make 20 percent of all patient visits virtual, a goal that seems readily attainable given its volume of virtual visits has increased 100 percent every month since it began piloting telehealth services in 2015.

Although telemedicine has yet to significantly impact workers’ compensation or auto, its day is coming. Workplace health clinics, such as the kind operated by , are now augmenting onsite occupational care with telemedicine services. Consider the case of a California factory worker with a blistery hand rash who had her condition treated via a teledermatology visit at her employer-sponsored clinic. It’s only a matter of time before onsite injury assessments, follow-up status calls, and prescription management are conducted virtually, with great cost, comfort and convenience benefits for all parties involved.

The post The Future is Now – Telemedicine in the Marketplace appeared first on 911łÔąĎ.

The tragedy at Orlando’s Pulse nightclub was horrific, with 50 total deaths.  Everyone can understand and see the sheer scale of the largest shooting in US history.

Our nation has 8,000 times that many people die each year from medical mistakes – or 400,000 deaths annually. That’s equivalent to 22 of these shootings…every single day of the year. These deaths may not be making daily headlines, but they are happening – one person at a time, one treatment at a time, all across the United States.

A recent news story on the subject shows how easily it can happen. If you , the story of how this child died is at the end of the clip. She was given the wrong medicine, a compound medication, 20+ times stronger than what she needed. The pharmacist signed off, without making it or reviewing it. Her father found the IV bag in the trash, so it’s likely nobody would have told him had he not caught it. It’s also very telling that his settlement would have been significantly higher had he agreed to a confidentiality clause, but he thought it was important for the memory of his daughter to speak out. These cases are usually not spoken about publicly.

I am a big proponent that less is usually more in healthcare. I am very proud of what we do at 911łÔąĎ. For patients involved in 911łÔąĎ’s medical care management, utilization review and surgical care programs, every unnecessary medical service we prevent could be the one that saves a life. Every surgery we keep out of a hospital can reduce the risk of error or infection and increase the odds of a successful recovery. There is no doubt that these precautions help reduce devastating health issues for our patients every day.

The post An Observation – Deadly Healthcare Mistakes & Orlando’s Tragedy appeared first on 911łÔąĎ.

An estimated​ 440,000 people die each year in the hospital – and not from the cause that initiated their hospital treatment.  That represents the third leading cause of death in this country, behind only cancer and heart disease.

Consider this:

40,000 people die annually in automobile accidents.  Mothers Against Drunk Driving (MADD) and other groups focus on drunk drivers and car safety, saving lives every year.  It’s a worthy cause, and to be commended—but does anyone know that approximately 10 times more people die each year from medical errors in hospitals, than from all auto accidents in the US?

Less than 12,000 people a year are murdered in this country.  A horrible statistic, to be sure—but 3,688% more are accidentally killed by our own hospital system on an annual basis.  Which do we hear about on the news?

It is a terrible situation.

When it comes to hospital treatment, here are a few points to keep in mind:

• Avoid summer treatment.  New doctors (residents) start in the summer, and they have very little experience. The more experienced residents are looking for jobs to pay for their massive debt and are not as engaged.  A lot more full-time doctors are on vacation.  Due to these dynamics, the hospital accident rate is highest during the summer months.
• Ask about every medication being administered.  If it does not feel right or necessary, do not take it.  You can ask for a case manager or advocate if you do not understand or agree with treatment or medication.  Overtreatment and/or overmedicating are primary causes of accidental deaths.
• When possible, avoid procedures in the hospital.  If something can be done in an office or outpatient surgical center setting, try to have it performed there.  Remember, many physician groups are being purchased by hospital groups, and they are now incentivized to drive care to the hospital setting.  The bottom line is, as an individual patient, you need to look out for yourself. You are your own best health advocate.

As a company, this is why discharge management is one of the top goals of our care management programs—to get patients out of inpatient treatment as quickly and safely as possible. It is also a main driver and value proposition of our Surgical Care Program (SCP), which moves surgical care out of hospitals and into quality, ambulatory surgical center settings. It just makes good healthcare sense to mitigate these very real risks whenever we can.

The post Third Leading Cause of Death in the US? Hospitals. appeared first on 911łÔąĎ.

After the ACA’s first two years, it appears that the law has had the opposite impact on patient behavior—and ER visits are increasing. A lot.

The root cause is theorized to be the lack of medical providers, combined with an increase in Medicaid and insured people.  We already have a shortage of doctors, which is projected to be .  Many doctors will not accept Medicaid patients.  The result is patients who now have coverage, but no doctor, so patients feel comfortable going to the ER for smaller issues.

According to a on a survey of 2,098 emergency-room doctors conducted by the American College of Emergency Physicians (ACEP):

Many doctors don’t accept Medicaid patients because the state-federal coverage provides lower reimbursement rates than many private health-insurance plans. The waits for primary and specialty care by participating doctors appear to be leaving some Medicaid patients with the ER as the only option, according to ACEP.

This unexpected trend provides our industry with another metric to focus on going forward—reduced ER visits. It will be a good future indicator of the effectiveness of initiatives such as early intervention, case management and providers panels, as well as direction of care. These are the tools that will help us to avoid the unintended consequences of the ACA.

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