28 May 2013

Make CMS Audits Less Burdensome

Healthcare providers are urging lawmakers to make CMS audits less burdensome. The Centers for Medicare and Medicaid Services is coming under fire for some of their audits. Knowing that they are vigilant for fraud, makes me wonder what healthcare providers are attempting to hide. A bipartisan group of six senators on the Finance Committee solicited the white papers from providers, insurers, contractors, and suppliers in May 2012.

In April 2013, the group issued a report based on the white papers received. There are some revealing facts that did come to light and many of these do need fixing. The biggest that I see is CMS auditor education and communication between CMS and the provider on a timely basis to resolve issues and let the providers continue operations in an efficient and effective manner. Many providers are upset with the education of auditors, particularly on medical necessity criteria.

Taking the last item, I do wonder how much agreement could be reached among providers on medical necessity criteria. This looks like an area for discussion and standardization by the professional medical associations before CMS auditors are educated on this. Two other areas received prominent support and I would agree that simplification could very well be a top priority. However, realize that when dealing with the government, simplification may not be in your best interest. You never want to have it come down to you against the government when papers turn up missing. The next problem is too common in dealing with the government. Duplication and even as high as five times the amount of paperwork has to be generated when often two copies should be enough. But for those of us outside the government, we should have gotten used to the saying that the right hand does not know what the left hand is doing. How else are they able to claim they don't know anything else about it. No one is willing to take ownership or responsibility for anything.

Now that I have given some sympathy to providers, I will take the other side. How many times has the item been billed to upscale it to a more expensive bill? How many times has something been billed multiple times? I know this is common practice by providers especially after done accidentally once and they have gotten by with it. This is very commonly done by most providers and especially by hospitals. The more labor they can cover many times the greater the chances of it being done. I have seen one nurse's half hour appear as many as seven times for the same patient and the nurse was only present in the room for 20 minutes. Since that nurse was only on that floor one time in three days, how was her time billed for three and one-half hours. It is little things like this that add up and hospitals love to do.

Another goodie that is profitable is a box of kleenex. I have seen the same box (distinctively marked by the way) billed on 19 patients and the box was never opened and always returned to the same recovery room. This $0.86 box of kleenex was billed 19 times over the course of five days for $18.00 on each bill. Did Medicare discover this? Did Medicaid discover this? Did other insurance companies discover this? The answer is no, and they just processed this through without question. Even after they had been told by auditors this was happening.

It takes too much manpower to dispute items like this, and hospitals make use of this knowledge to the extreme to over bill and overcharge on items unlikely to be questioned. We as patients are powerless to stop this and this goes on.

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