The HIT Transition Weblog

NPI Delays: News Travels Half-Fast

We seem to remember saying something about Medicare NPI SNAFUs leaving providers unpaid sometime back (see Medicare: Expect Claims to Hang In Limbo for Months), but I guess it takes a real reporter to make news.

Good thing we have some -- like E.B. Solomont of the NY Sun. His article today, Glitch by the U.S. Government Is Delaying Medicare Payments, sheds light on the real problem with Medicare's double-blind NPI remediation (they won't publish their crosswalk, and they won't update provider enrollments even after they tell billers that claims are bouncing for unmatched fields).

Solomont gets the human side of the story. The Bronx doc who is borrowing from her kids' savings account to make up for a $20,000 Medicare backlog. The Queens MD with 200 unpaid claims, who's been working for free all year while his business runs on fumes.

Medicare's response is classic:

Yesterday, CMS officials said the agency was "very sensitive to any provider that's getting a claim rejected," but they said the number of rejected claims was small. "They've been given a lot of notice before we started rejecting claims," an agency spokesman said.

Sensitivity is great, but let's peel back the onion in those statements and see if we can work up some real live tears.

Size Does Matter
First, what does "small" mean to Medicare? Let's say that 1% is a small number. Based on the number of claims they processed in 2006 (the most recent year for which statistics are available), that would be just a hair (if your hair is 300,000 claims wide) over 11 million claims. That's less than a million claims a month!

And maybe "small" is a fraction of a percent.

Or maybe it's a couple percent. "Small" is not a number people who know the number use if the number really is small.

How Does It Feel to Be One of the Few, the Plowed?
Admittedly that problem really is tiny at the Medicare end -- at least when you compare it to what happens at the provider end. Because for a provider whose NPI crosswalk is failing, the number of rejects can jump to 100% of Medicare payments. And even for a provider who is getting some of the claims through, a crosswalk failure usually means that claims from a particular source (say a hospital's outpatient surgery unit) will fail at that consistent 100% rate.

Resistance Is Futile
Okay, what about that "notice" that providers are getting? A lot of times, those instructions will tell the provider that they need to update one of two records -- or perhaps both. One of those is their NPPES record: the NPI data itself. Maybe they need to add their legacy Medicare number (OSCAR, UPIN, PIN, whatever) as an "Other Identifier." Maybe they need to correct a typo in their business name. Okay, great. Most providers created those records themselves, and can go and fix many (not all) of those problems online.

Compliance, However, is Futile, Too
The sticky wicket is when the "notification" says the problem lies in their Medicare enrollment data.  That's a long and complicated application based on their 855 enrollment forms. The record is contained in Medicares PECOS system. And, guess what? Providers can't change what's in it -- they have to fill out a new paper form (with zero errors, if you please!), submit it to their Medicare contractor and wait.

And wait.

And wait.

While they are waiting, those notifications have been turning into rejections. Callers on a recent Medicare Roundtable complained that their submitted enrollment changes have been in limbo for months. The carriers are unresponsive, the claims are not getting paid, and the provider is helpless to do anything about it. Medicare claims to be prioritizing such updates, which seems to mean telling carriers how unhappy providers are getting.

Plans To Hasten Resolution Are In Process -- Please Hold
They also have an announced, but less than detailed, plan to give providers access to their own PECOS record. Problem is, no availabilty date has been set and -- you guessed it -- there's a long paper form that needs to be filled out in advance.

HITTG Hits Back
We've gotten kind of tired of seeing the bad things that are about to happen, telling people about them, watching them happen anyway, and waiting weeks or months for awareness to finally dawn, that we've decided to take matters into our own hands.

So, for instance, when we warned you about one of the next big provider-hostile, claim-bouncing SNAFUs Medicare has in store -- the kluge they devised to compensate for their own misunderstanding of the NPI rule regarding un-enumerated practitioners -- we discreetly moved to put a stop to it before it happened.

Freedom's Just Another Word
So far, that effort is going well. And it best be kept under wraps lest the gorillas send their thugs out to stop the process we set into motion (we're actually pretty sure they know, but we're hopeful they sent bonobos to make nice). We just came to realize that our puny little company has a lot less to lose than any of the physicians, labs, clinics or hospitals who will be affected by the logjam Medicare has planned for May 23. They don't see it coming, and we do.

But even if they did, they can't afford to raise a ruckus with CMS. And we can.

You're Probably Wondering, "But Marty, How Can I Help?"
We don't have much to lose, but we really have nothing to gain, either. There's not a lot of money in pro-active disaster avoidance. We make our living selling our webinars, videos, grant resource directories and publications. If you want us to keep at our feisty work, look for something on that list and buy it. (You can also buy something just because our independent analysis is worth a whole lot more than you pay for it -- and way, way more than most of the stuff that axe-grinding vendors and politically-sensitive associations give away for free.)

Or hire us to help you with NPI or any of our other areas of expertise. Operators are standing by.

Thanks.

Best Care, Lowest Price Under Attack

The Wall Street Journal offers a doomy, gloomy perspective on the state of primary care in the US: Primary Health Care Needs Fixing Before Universal Care Can Work

We don't train enough, we don't pay enough, and adding more patients to the load is not going to work, either at the state level or the national level.

I agree with the author, Dr. Benjamin Brewer, but I'm afraid he doesn't know the half of it. High deductible health plans are eating PCPs for lunch, and they don't even realize it yet.

Right about now, the final adjudications for January's billing will be coming in. That means the millions of new HDHP enrollments that shifted over on the calendar year are starting to move from claim-to-payer to patient-responsibility.

And patients, as we know, are deadbeats. At least collectively. And collections is going to become an even bigger component of the non-healthcare business of the PCP's business.

First In, Worst Off
There's a wierd sort of non-standardized "preventive care" benefit that is allowable (but not mandated) under HDHP, but as low-dollar, first-seen physicians, PCPs are going to be eating deductibles way out of proportion to both their number and their revenue.

Think about a broken wrist -- $10,000 according to my wife's recent unfortunate experience. ER gets paid by the payer (mostly), then come the hospital and surgeon's bills, along with the anaesthesiologist. That eats up the $2500-5000 deductible -- and then some.  The last providers in the door finally start to get paid by the health plan. Physical therapists, as the caboose on the train of care, have it made (except if the health plan declares them out of network and disputes the number of visits -- that's another story!).

But most patients don't spend $10K in a year. They get sick, they go to their PCP. They never meet their deductible. PCPs will take a disproportionate share of the hit as HDHP deductibles turn inevitably into bad debt.

Grants Roundup for March 2008

$25 Million Gift Seeks Match from Physicians, Includes Bleeding Edge IT

CDC Awards $38 Million to RHIOs

$150,000 for EMR/Cardiac Pilot Project

AHRQ Awards Millions for Clinical Decision Support Systems

Community Foundation Grants Hit Record, Health Tech-Heavy

FCC Grants to Expand Telemedicine in the Rural West

Vermont: Tax Health Plans to Pay for Health Tech?

Delta Dental Awards $50,000 to Prove Digital Expands Access

Practices Can Win $290,000 in Medicare Bonuses through EMR Adoption

UHC, Ingenix and...Hillary????

It's not like UnitedHealthcare needed any more bad news. First they and their Ingenix software division get the business-headline perp walk in New York Attorney General's investigation of the intentional skewing of "usual and customary" fee calculations that govern millions of Americans' out-of-network payments.  Then some uppity blogger points out that Cuomo planted his flag a the top of a very hefty deductible-sinking iceberg.

Then, adding insult to inquiry, they flat out lose a national popularity contest among hospital administrators. And they didn't lose by a little -- they doubled the score of their nearest competitor, Wellpoint.

Orangemen Take Football, Go Home
You'd think today's story would just be a minor piling-on thing, to look at it. Everybody wants to smack the gorilla when he's down, right? So, the lost business represented by University Hospital's decision to leave the UHC provider network over $1.5 billion in unpaid bills (okay, that's per the hospital's account, so I should say "allegedly unpaid bills" -- but why don't we ever read such disclaimers when the payers shout about the billions in fraud and abuse, when "abuse" is being determined unilaterally by the payers themselves? I digress.)

Other than the fact that I was born in or near that hospital (I was quite young at the time and haven't been able to follow the institutional mergers and acquisitions in the years since), this wouldn't have been much of a blip on my radar.

Why Let Readers Comment, Anyway?
But then alert reader Cyndee Weston, Executive Director of the American Medical Billing Association, sent me a note suggesting I read the story. And right under the press account, I found a comment from someone who had found a smoking gun tying presidential candidate Hillary Clinton to UHC.

When campaign finance reports first started coming out,  I wasn't too thrilled to hear that Hillary was accepting campaign donations from the insurance industry in disproportionate measure to the other candidates. Remember, though, that not all health care insurers are against universal care, and we at HITTG think that's the number one priority. So, I thought I'd judge her health care policy on its merits first, then dig for skeletons in her closet before I rendered judgment on the accusations that she was sleeping with the enemy.

I didn't realized she was the enemy.

Mathlete to the Line
According to the report she filed last June 15, and published at opensecrets.org, Ms. Clinton owns some stock in UnitedHealth Group, parent to UHC and Ingenix. I'm no accountant, nor am I a political snooper of much acumen, but the way I read page 38 of that report it looks like she checked the box under "Assets" in the $100,000 - $250,000 column, and the box under "Income" in the $50-100,000 with a "CG." Now, that CG looks like it might be referring to Capital Gains. So if the capital gain was at least $50,000 during the period covered by the report, then somebody with better financial brains than I have might be able to say whether that spread is closer to $100,000 than $250,000.

Can We Make Those Numbers Look A Little Better?
But for the sake of fairness, let's suggest it's right at the bottom and say, as far as we know, she owns merely $100,000 in UHG stock.  Heck, that's just 20 years worth of deductibles for a family on a HDHP plan.  Or, if you use a customized database to adjust the patient's payments, you can boost that $5K deductible to as much as $12,987 and whittle that down to a mere 7.7 years of deductibles (that's $100,000 divided by the $12,987 a family would actually have to pay to satisfy their annual deductible, using our proprietary U&HC deductible-skewing engine. Change the deductible amount from $2000 to $5000 when that spreadsheet loads and watch the magic happen!).

There's Nothing to See Here, Mister
So, when you do the math just right, she really only owns about 8 families-worth of unpaid claims, in the what hospitals say is the worst healthcare payer in the country. (Hey, don't shoot the messenger! I love UHC!).  And that's only if someone in the family gets really, really sick. What kind of story is that?

No story, really. But where she got the stock? That might be a story.

Luckily, this is a healthcare IT blog, and we don't do politics. The one time we tried, it really came out badly.

What's that? I seem to have some overdue editorial on curing the systemic economic failure that drives up healthcare costs. That's more up my alley than tracing individual money trails.

Cuomo's Probe Gets Bigger

Where's Andrew's Big Fat Lawsuit? posits a mid-afternoon WSJ blog post. The Journal wonders whether last month's warnings were just a matter of brinksmanship, leading up to quiet settlement prior to court action. They quickly pulled an Emily Latella, though, when they learned that the New York AG was broadening his inquiry, subpoenaing payer CEOs and internal emails.

Eet Eess Not My Dog!
Cuomo's missing the point, though, when he emphasizes that there is an inherent conflict of interest that the pricing engine is designed by a software company owned by a payer. UHC could spin Ingenix off tomorrow and they'd still be selling a secret -- I mean proprietary -- system that allows its clients to set prices by adjusting variables in ways they don't have to disclose to anyone.

Free Rider
Okay, here's a question for all you free marketeers.  How many markets allow one party to unilaterally name the price they will pay after the service has taken place and the other party has already taken on the commitment to pay a third party in full?

The University of Because I Said So
The payer community displayed no sense of irony when it suggested that the real culprits were the providers, for setting prices that needed to be discounted. They also cited a helpful academic who established the importance of including systematic bias in their calculations:

Contractually, the health coverage is linked to the in-network status of providers, explains Sara Rosenbaum, a law professor at George Washington University School of Public Health. "I must say I am at a loss to understand the investigation," she tells HPW. "The higher premium is to get the insurer to pay something for out-of-network care. If one buys PPO coverage that allows partial payment for out-of-network care, the insurer is completely free to come up with any methodology it wants to figure out the out-of-network amount. The UCR can be whatever it desires. Otherwise the premium would be astronomical, since it is in-network use that controls pricing for the plan."

Actually, I thought the difference was to be accounted for by establishing a copay or lowering the patient responsibility percentage to encourage use of in-network providers. The policyholder is warned  they will pay a much higher proportion of the fee for out-of-network. The "usual and customary" language is clearly in there to protect the payer from excessive fees, but I don't remember Whatsoever We Desire being in any of the many policies I've owned. Did I miss a footnote somewhere, professor?

I guess I thought "reasonable and customary" meant reasonable and/or customary, not "any methodology [we] want."

Four-F
It's not free, it's not fair, but is it fraud? That depends on what the AG's office finds when it looks under the electronic covers. Unlike a lot of my readers, I'm not one of those throw-em-in-the-clinker critics when it comes to payers' business practices. Our system is designed to propagate such systematic and innovative abuses of policyholders and patients. The reason that so many payers have adopted the Ingenix engine is that so many other payers have adopted the Ingenix engine. If they want to stay in business, they can't pay full price for claims that their competitors discount to a fraction.

(Bet you didn't think that was going to be the fourth F-word, did you? Sorta took me by surprise, too.)

Don't Forget to Wear Sunscreen
It won't be enough for the AG to kick some health plan booty, or even to put payer CEOs to work picking up litter on the Thruway. We need a common pricing system that's fair, open and visible. No more secret pricing.

Transparency has to work both ways, or it's just a mirror looking out on a lot of devastated patients, who put their trust in a system of premeditated avarice.

Are Cuomo's Estimates Too Low?

When we read the coverage of NY Attorney General Andrew Cuomo's accusation that Ingenix, United Healthcare and a host of other payers had systematically underestimated the "Reasonable and Customary" fees used to calculate reimbursements for out-of-network services, one frequently-repeated statement caught our eye:

Lacewell said, in one example, the office's investigation showed that when $200 was a fair market rate for a 15-minute doctor's visit for a common illness, Ingenix determined it was $77. Therefore, United would pay $62 when it should have paid $160, leaving the consumer with a $138 bill. [Emphasis added.]

Actually, the United would probably not pay a dime. The patient would have to pay the entire $200 bill -- at least until the deductible was satisfied. That got us thinking about deductibles, so we took our question over to the AskLeslie group -- those coding and billing folks that handle all those claims for providers and their patients.

We asked this question: When a non-participating plan estimates a U&C price lower than the actual fee, which value gets applied to the patient's deductible -- the actual payment, or just the discounted amount? The response was overwhelming: The patient only gets credit for what the plan says they "should" have paid for the service, not the amount of the check they actually had to write.

Be Careful What You Solve For...
So today, when I read where the Ingenix execs Andy Slavitt and David Ostler say, "We believe that the issue of how to calculate out-of-network charges and reimbursement is an important one, but we also believe that it is a small part of a larger issue: improving the healthcare system by improving the quality and quantity of information available to its participants," I thought maybe I would apply some rules of basic algebra to the "improve the quality and quantity" of information at hand.  To wit: How does such fee repricing affect annual expenses?