The HIT Transition Weblog

HITTG Throws a HISsies Script

Last night's HISsies Awards at the HIMSS conference were presented in a wholly new way. As a cartoon. We produced the seven-minute animated awards ceremony for the folks at the HIStalk blog and had no difficulty casting our co-stars, Cerner's Neal Patterson and athenahealth's Jonathan Bush. Of course, the anonymous Mr. HIStalk and Inga anchored the highjinx as awards presenters a la Oscar. Jon Bush's uncanny resemblance to Michael J. Fox, alongside Patterson's notorious hate-mail to middle management, gave us more than enough material to frolic with.

In case you forgot about Patterson's notorious management style, here's just a taste of that missive:

The parking lot is sparsely used at 8AM; likewise at 5PM. As managers -- you either do not know what your EMPLOYEES are doing; or YOU do not CARE. You have created expectations on the work effort which allowed this to happen inside Cerner, creating a very unhealthy environment. In either case, you have a problem and you will fix it or I will replace you. [Sic. sic sic sic.]

Oh, you didn't know that Healthcare IT Transition Group makes animated HIT videos? Catch up...

Don't Touch That Dial
Over the holidays we invested a few bucks and a lot more time in our media production capacity. This is just the beginning, with even more to come. Last fall, we quietly set up our (pre-beta)... 

Medicare: Expect Claims to Hang In Limbo for Months

Yesterday we told you about Medicare's NPI threats in red screaming italics: Thou shalt use NPI even when one does not exist. (NOTE: Medicare uses the screaming red italics. We're a little more discreet in our editorial standards. - Ed.)

Today they showed that to find the really bad news, you need to look in the footnotes:

Claims will reject when there is not a match on the Medicare NPI Crosswalk. You must correct any data which may be preventing an NPI/legacy match on the NPI crosswalk. The correction might require that you file a CMS-855 Medicare Provider Enrollment form with your Medicare carrier, A/B MAC, or DME MAC a process which can take a number of months to accomplish.

I had to add the emphasis and blow up the print a little from Medicare's SE0802: Upcoming Critical Dates for Medicare’s Fee-for-Service (FFS) Implementation of the National Provider Identifier (NPI).

Looks like the most critical date is when the carrier gets around to updating your enrollment to match your NPPES record.

The good news is that the federal budget deficit is trending sharply downward for the rest of the year.

Ingenix Chief Offers Transparent Denial

In a letter to the New York Times, Ingenix Chief Executive (what, no office for this guy?) Andy Slavitt offers a carefully-worded rebuttal to the charges that his company is helping insurers rip off policyholders, as NY Attorney General Andrew Cuomo and NYT editorial writers have accused.

We do not know the source of the $77 figure your editorial cites from the New York attorney general as Ingenix’s calculation of the “fair market rate in New York City and Nassau County for a 15-minute consultation with a doctor for an illness of low to moderate severity.” Instead, a health plan reimbursing this consultation using our Prevailing Healthcare Charges System data at the 80th percentile would price this service at $160.

Cuomo's office pointed out that pricing a service at $77 which actually cost $200 would result in a payment of about $62, leaving the patient responsible for a balance of almost $140.

These Bongs are for Novelty Purposes Only
Slavitt seems to be saying that his product could be used ethically. But note that even Slavitt's more optimistic calculation hints at a couple of important issues.  One is that his product allows lots of discretion to the user -- they can use geography, of course, and set percentile rankings.  Others have suggested that the tool offers a lot more capacity than that -- that certain "outliers" can be excluded, and who knows how many wheels and levers of severity and exception can be set to drive the estimates down.

In an underwhelming bit of double-speak, Slavitt asserts "[t]here is absolutely no systematic bias that eliminates high charges in the data."  So the bias must be coming from....?

And doesn't it look like even setting the price at the 80th percentile ranking already accelerates a discount, since the payer will use that price as the starting point for their 80/20 split with the patient? My guess is that payers would be a lot more likely to start their calculation at the 50th percentile of whatever PHCS turns out in any case. The whittling could begin from there.

Sometimes You Do the Math, Sometimes the Math Does You
Remember, also, that what's left doesn't necessarily go to the patient.  That $62 will, more often than not, come out of the patient's pocket and simply be counted toward a deductible -- that increasingly balooning number that keeps more and more patients from getting a dime of reimbursement for medical services.

In a high deductible health plan, you might do the math and say, "Well, after $2,000, it will start helping me out." Guess what? If the plan discounts every $200 you pay to $77 covered charges, you'd actually pay $2,000 and still have $1,230 deductible ($2,000 actual payments - $770 in "reasonable and customary" charges) left to satisfy.

If only 38.5% of your payments go toward the deductible (that's what $77 out of $200 means), then you would actually pay $5194 before the insurance company recognized the $2000 as being satisfied. (This takes a little algebra -- send me a note and I'll send you the worksheet. WARNING -- The numbers will scare you.)

I'm Not From the Government, Therefore I Must Be Here to Help You
Still, we should be grateful to Ingenix for providing this sophisticated pricing tool to the insurance industry.  The only alternative, according to Slavitt, is for  "health plans that offer out-of-network benefits...to make reimbursement decisions based on government-set pricing similar to Medicare or in the absence of any statistical data at all."

Not that he's limiting his market to his payer friends, mind you. You might see the market-expanding pitch he makes in his closing comment: "We look forward to an open and balanced dialogue about the very real need to provide more accessible information to all stakeholders in the health care industry."

We still think that the impact of PHCS on out-of-network patient visits pales in comparison to the death-by-four-million-cuts that Ingenix's iCES -- and the denial engines developed by other companies like ViPS, McKesson, HCI and Bloodhound -- apply to the entire claims stream. But it's nice to know a little bit more about how PHCS's "transparent methodology" actually works, isn't it?

Medicare to Paper Billers: NPI for All or Else!

Just as I'm starting to chill out after fronting off Medicare about its HIPAA-violating NPI-über-alles policy, which says that EDI submitters need to falsify claims when any secondary provider (referring, ordering, attending, etc.) does not have an NPI, I run across something even worse. Paper billers (whom Medicare would also like to edict out of existence) may be in for an even rougher ride.

Maybe I'm just reading too much into this, but here is what Transmittal 1432 (Change Request 5858) seems to say.  By which I mean, I am lifting direct quotes from the document, and staring on in disbelief. Let's put on our Medicare paper-biller hat for a minute and see how this reads....

Subject: Medicare Fee For Service Legacy Provider IDs Prohibited on Form CMS-1500 and Form CMS-1450 (UB-04) Claims

"Prohibited" seems like a pretty strong word...

Effective Date: May 23, 2008. Effective Date Refers to Date of Claim Receipt

Okay, so we have a few months to figure this out...

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required issuance of a unique national provider identifier (NPI) to each physician, supplier, and other provider of health care who conducts HIPAA standard electronic transactions.

Okay, that sounds like almost everybody -- everybody, except of course Dr. Simpkins, who we don't let near the computer.  And of course, all those dentists, mental health professionals, retirees, academics, Peak Oil types and administrators.... Oh, and us, since we are one of the few Medicare providers who has been granted an exception to file paper bills.  But of course, Medicare already told us to enumerate, so we got our NPI already. Thank heavens we're safe!

Policy: Medicare FFS will require transactions to report only an NPI; legacy provider identifier numbers will no longer be permitted on Form CMS-1500 or Form CMS-1450 claims, except in certain situations where an NPI is not required.

Cool! So you're allowing exceptions for Dr. Simpkins, who, as I recall, you told us wasn't required to obtain an NPI under HIPAA. And those thousands of other docs I mentioned. That's a relief!

Claims containing legacy provider identifiers will be returned, without appeal rights.

Wait, that sounds kinda harsh. Maybe I better check those "certain situations" you talked about.

Contractors shall return Form CMS-1500 and Form CMS-1450 (UB-04) claims, without appeal rights, that contain legacy provider identifiers, e.g., PINs, UPINs, or National Supplier Clearinghouse numbers.

Okay, that's getting pretty specific in the harsh category. What about those exceptions again?

Contractors shall not return claims in certain situations where an NPI is not required (e.g., foreign claims, deceased provider claims, other situations as allowed by CMS in the future) and legacy numbers are reported on the claim.

But Dr,. Simpkins isn't dead -- he's just not a covered entity. Remember when you clarified that for us on that Roundtable call back in aught-six?  And he's a pediatrician, so he pretty much doesn't treat Medicare patients. But when he's on call for one of the other docs, sometimes he calls in an order for, you know, like a mammogram or something. Or a blood test. Or an MRI. Or, you know, anything. I mean, we can try to get him to do that "two aspirins" thing, but he gets kinda testy when the billing staff second-guesses his treatment decisions.

Now, let's look at those form-specific details. Maybe it's not as bad as it looks.

Uncovering Providers without NPIs

Okay, people keep telling me it doesn't matter what the regulations say. It doesn't matter what the standards say. When it comes to HIPAA rules, the only thing that matters is what Medicare -- er, CMS -- says. I keep carping on about how there are all these providers that aren't required to obtain NPIs. That they are not "covered entities" under HIPAA. 

Yet Medicare seems to have coded its system to expect everybody who pokes, prods, sniffs or titrates anyone over age 65 to have one, come May 23.

How big a problem could this really be, Marty? They ask me.

So I turn it back around at them.  W-e-ell, let's just see what CMS has to say about it! Let's just see how specific they got about this very topic back on September 26, 2006, shall we?

Denial Engine Vendor Ingenix Keeps more than Usual and Customary Dollars

In my warnings to providers about denial engines -- those sophisticated analytics tools that payers are increasingly using to reduce, deny, or re-collect claims payments -- I try to emphasize that they can be used ethically.  One of the common features of such tools is that they allow the payer to produce a detailed "defense" for the dollars they are refusing to remit.

The argument I've been trying to focus on is that providers and their vendors need to understand these tools and respond -- not that this is some Good vs. Evil battle over payments that all providers unquestionably deserve.

It's not necessarily that the payers aren't fighting fair, I say.  It's that the providers aren't fighting back.

UnitedHealthcare and its Ingenix division seem to want to give the lie to that even-handed approach.  New York Attorney General Andrew Cuomo has accused them of employing "convoluted and dishonest systems for determining the rate of reimbursement" for use by both UHC and a lot of other insurers, including Aetna, Cigna Corp., Empire Blue Cross & Blue Shield and Humana. This post isn't about that issue. The phenomenon I'm concerned about is probably a lot bigger, since it applies to all claims and thousands of discount and denial codes, not just out-of-network "usual and customary" adjustments.

Okienomics and the Answer to the Question of Healthcare

It started when this blog and our HITSync email newsletter stuck our necks out on Super Tuesday.  Endorsing a political candidate was the kind of thing we never do, and endorsing a political candidate at the moment he closes up shop is the kind of thing no one should do.

One long-time reader even questioned our mental stability, suggesting it might be evidence of bipolar disorder. 

"Are you saying I need to see a therapist?" I asked. 

"Worse. I think you need to see a philosopher."

So I did what I always do in such circumstances.  I headed down to the Chili Bowl for a cheese coney.

As soon as I swung the door open, I saw him there at the lunch counter, hunched over a hot sausage burger smothered in jalapeños. I hung my coat on the wall and sat down on the stool next to him.

"How's it hangin' podner?" Yeah, people around here really talk like that.  At least a few of them do, and Fizzy Sweetwater is one of them.

"Not so good, Fizzy," I admitted. "I told all my readers I was going to fix healthcare, I endorsed John Edwards at the precise moment he dropped out of the campaign, and I challenged the Wall Street Journal to a battle of wits."

"Sounds like a pretty good day's work," said Fizzy.

"It took a couple of days, actually." It's easy to talk straight to somebody who listens straight, so I continued. "The way I see it, Fizzy, it's all about starting off with the wrong answer.  We've got one side saying the answer is the free market, and anything else is socialism.  We've got the other side saying the answer is to expand insurance coverage, like insurance is the solution rather than actual healthcare being the solution."

"Have I told you about my neighbor Clayton?" Fizzy asked.  It didn't sound like he had heard what I said, but after twenty years at Fizzy's elbow, I knew better than to head off one of his stories.

Wisconsin Wishes for RHIO Clarity; Tooth Fairy Alerted

Wisconsin has withdrawn its RFP for a statewide health information exchange, issued in December. Apparently, some of the major partners thought that the Request for Proposals hadn't nailed down just exactly how the HIE would be implemented and paid for. Well, those folks in Wisconsin know a lot about cows, but you won't find many cowboys. It takes a real buckaroo to haul off and whip up a RHIO. This here is uncleared land, partner.

Providers Can Sync NPPES and Medicare Enrollments Online

I was going to wait until the transcript was published before I shared any more of bad news from this week's Medicare NPI Roundtable.  Then I noticed some unexpected good news from the folks in Baltimore.

First the Bad News
Numerous callers reported various incidents of claims getting lost or systematically rejected by the Medicare NPI crosswalk process.  One of the responses that really troubled me was that various data elements in the NPPES record had to match corresponding entries in the provider's Medicare enrollment file. Our acronym-happy friends call this system the Provider Enrollment, Chain and Ownership System (PECOS).

So what's the problem? The provider had already submitted the corrections to their Medicare contractor via the appropriate version of the 855 enrollment form.  Months ago.  Many months ago.  Repeated calls had no apparent effect on the updating of their record, during which time their claims went unpaid.

This was one of those nightmare scenarios I imagined, but filed away in the "surely they wouldn't!" category, back when I was developing educational programs to help providers through the transition to NPI. My recommendation was (and is) to make the NPPES record -- the one you control -- the ultimate source of truth, and to update all your payer enrollments to match.

Now the Good News
Apparently, CMS wants to make that easier -- by taking the job out of the hands of the overworked and undermotived data entry people at their contractor sites, and putting it directly into the hands of the people who have the most to gain by keeping the records matched up: The providers themselves.

This was the gist, at least, of the notice that went out yesterday to Medicare providers.  At the risk of missing some nuance or abbreviating my way into an indefensible position, I'll copy and paste the notice and links to the end of this blog.

If the HISsies Fit...

We're dang sorry we won't be at HIMSS08 later this month.  Not because we want to run the gauntlet of HIT vendor account execs (tip: If "I'm just a consultant!" doesn't work, tell them you're an investigator from the SEC). No, we're just sorry to miss Mr. HIStalk's party Monday night.  But if you're going, we definitely want to extend you his invitation:

The initial response to HIStalk’s reception at HIMSS on Monday, 2/25 is strong. I peeked at the signup list and I’m impressed: informatics people, clinicians, CIOs, VPs, media people, investment folks, and 10 CEOs (!) have RSVP’ed in just the first few days. I’m immensely flattered and I’m honored that you’ve chosen to spend a little time with the HIStalk crowd and the sure to be dolled up Inga (incognito, but lookin’ fine, I predict). If you’re reading this, you are invited - please RSVP here so we can haul in enough liquor and fancy food to keep you happy. ... If you’ve never been to the Peabody Orlando, it’s really nice and is an easy stroll from the convention center (right on the property, pretty much).

Free booze and canapes is usually enough to get us to turn out, but the big deal will be when MrH (or his yet-to-be-identified surrogate) hands out the HISsie Awards for the best and worst of healthcare IT.  We'll be there in spirit, tough. And maybe more than spirit. Remember our little HealthFault video?

Speaking of videos, Michael has produced DVD versions of two of our most popular webinars, Real-Time Adjudication Drivers and Deliverables and Getting ROI from Health IT: An Independent Analysis.Unlike Mr. HIStalk, who claims to be gainfully employed, this is our day job.  Thanks for your support.

Medicare Repeats Noncompliant Directive on NPI Roundtable Call

I've been trying not to talk about this issue.  You know, about how Medicare published an absolutely slam-dunk HIPAA violation as its planned solution for the problem of nonexistent NPIs. You know, the one I told you about last week. The one in MM5890.

It's not that I want to let them off the hook.  It's just that I talked to somebody who talked to somebody and the first somebody (who is really somebody, if you know what I mean), said that the second somebody (who works inside Medicare, and was surprised to learn about the plan), said that it ought to get cleared up in a few days.

Did We Miss a Memo?
Apparently, nobody told the Medicare folks on the call. Because in answer to the specific question about what to do if a referring provider had no NPI, their response was to use the submitter's own NPI and name instead of leaving the NPI blank (because the referrer didn't have one) and using just the referrer's name.  This prompted a followup from the caller -- wouldn't this set off red flags for Medicare self-referrals? Don't worry, came the reply.  We'll ignore whatever you put in.  We are going to look at that data eventually, but that's how you need to code it to get the claims through on May 23.

The Good News is That the Bad News is Completely Unnecessary
Okay, so, for the 1.2 million Medicare providers who have to re-engineer their EDI systems -- and turn off the verification processes that prevent them from sending non-compliant data streams -- the good news is that Medicare isn't really going to look at the information?  And that the change is only temporary?

Let's hope these claim-losing, kluge-foisting, law-breaking instructions are what's temporary. In fact, count on it.

Or Else What?
I'm only posting this note because people will be Googling to see if what they heard on today's call was really true.  It isn't. They're going to fix it. To all my friends at CMS, my apologies for having to mention it again. 

HITSync to the Journal: "Prove It!"

No sooner had we made our vow to prove that covering everyone would cost less than the idiotic, immoral system of chinks and imbalances we have now, than the Wall Street Journal came out with a gleeful obituary of California's unsuccessful attempt to achieve a bipartisan consensus on Gov. Schwartzenegger's universal healthcare bill.

Sayeth the Journal:

You can't make coverage "universal" while at the same time keeping costs in check -- at least without prohibitive tax increases. Lowering cost and increasing access, in other words, are separate and irreconcilable issues.

Of course you can't!  Everybody knows that. Why it says so right here in...well, right here in the Journal. And who knows more about The Market -- oops, I mean the market -- than the Wall Street Journal?

In fact, I bet they have scads of researchers working on it right now, compiling a list of all those examples that prove their case.  You know, all those places where they cover everybody and spend so much more on healthcare than we do in the US.

I'll just wait for them to get back to me on that one.