Lest we forget: Focus still on medical necessity

December 6th, 2017 / By Barbara Aubry, RN

Can you believe 2017 is coming to a close? Did this year fly by for everyone, or is it just me? Some pretty interesting ideas were put forth in 2017, I think. For example, CVS announced they are buying Aetna and rumors are circulating that Amazon is thinking of getting involved in health care—possibly generic pharmaceutical delivery? Also, CMS approved a breakthrough test to identify multiple cancer biomarkers in one biopsy. Artificial intelligence (AI) is heating up in health care. As an RN, I find AI really exciting. I realize it’s often a challenge for patients to take medications and accurately monitor symptoms requested by their providers. I would love to see wearable devices that routinely transmit blood glucose levels and other vital signs to centers where AI is deployed in order to identify and suggest predetermined provider-guided medication modifications—what a boon to patients with chronic health conditions. Plus, it would enable real-time management of high-risk pregnancies and be especially helpful to those who do not have reliable access to transportation to and from provider locations.

With all the excitement and change, some things remain the same. Medical necessity is so ingrained in the system, it surprises me when I read there are still issues with medical necessity rules according to the OIG’s Semiannual Report to Congress which was delivered to my inbox last week. I think the policy reconsiderations, redesigns, improvements, technology advances and sundry-related changes in health care are distracting and consume precious little free time. Focus seems to be on MIPS, MACRA, ACOs, quality reporting, data management, new measures, EHR redesign, telehealth and wearables. While the disruption is keeping us busy, we tend to lose sight of what remains essential: Code and bill only what is medically necessary and appropriate.

CMS is releasing new strategies to guide the industry and providers. In fact, just prior to reading the OIG report, I reviewed the list of the 42 latest quality and efficiency “measures under consideration for December 1, 2017.” I am encouraged by increased focus on clinical practice and technology disruption resulting in CMS requesting more feedback from providers. But then, I was surprised to read the OIG is still finding millions of dollars in misplaced payments for medically unnecessary services.

Thinking about medical necessity compliance made me realize that 2017 was not the “year of the audit” (as others have been saying – remember RACs?), which may give a false sense that CMS and OIG are engaged elsewhere and not paying attention. It seems provider focus on internal auditing decreased this year—maybe because everyone became at least quasi comfortable with ICD-10 implementation? However, OIG did not take a break; perhaps after learning what the OIG reported, audits will become important again. Remember, it’s more cost effective to identify and correct than appeal—or worse, have to pay back or be fined. I’m not going to cover the OIG findings in their entirety but I will share two I think deserve consideration since they are easily impacted by everyday processes.

Challenges with ZPIC and UPIC audits

From the Semiannual Report:

“Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractors (PSCs) referred a total of $559 million in overpayments to Medicare Administrative Contractors (MACs) in FY 2014; however, the dollar amounts referred varied widely across ZPICs and PSCs. MACs did not collect 80 percent of the $482 million they sought to collect from these overpayment referrals. MACs’ collection rates varied, depending on the type of claim, with home health and hospice overpayments having a collection rate of just 11 percent. Furthermore, ZPICs, PSCs, and MACs continued to experience challenges in tracking referrals and collections of overpayments. Because CMS began transitioning PSCs and ZPICs to Unified Program Integrity Contractors (UPICs) in 2016, our recommendations included these new contractors”

CMS concurred with OIG recommendations to address auditor challenges, assist MACs in collection of overpayments, create a standard audit report format and require auditors to use a unique identifier for each audit overpayment.

So, if you thought all was well or at least quiet with these auditors and MACs, I suggest 2018 may be an audit renaissance.  It appears the auditors will get support from CMS to be more administratively in tune, which can mean more record requests and positive—or negative—findings for providers. There is still $482 million in improper payments that remains uncollected.

Issues with outpatient therapy services provider

A major provider of outpatient therapy services between 2013 and 2015 was found to have medical necessity issues with outpatient therapy claims. The OIG reviewed 100 claims and found:

“From our medical review, we determined that all 85 claims had services that were not medically necessary.  For nearly all of these claims, the amount, frequency, and duration of services were not reasonable and consistent with acceptable standards of practice. Further, some services did not require the skills of a licensed therapist or were not an effective treatment for the Medicare beneficiary’s condition.”

While managing change keeps us busy, we need to retain focus on compliance premises as well. Extrapolation of errors to the claims universe can make a negative audit finding extraordinarily costly for a provider. Because OIG is watching, I suggest reinvigorating internal processes to focus on the tried-and-true medical necessity core. And yes, I agree: The more complicated healthcare processes and regulations become, the more margin for administrative error. I spoke recently with a busy nurse practitioner who works for a large, highly respected imaging provider. She said she chose to work for an entity rather than private practice because coding terrified her. She believes providers ”need experts to code because it’s so complicated and errors can cause so many problems.” Avoid those problems by using trained coders, always check medical necessity policies, depend on reliable vendors with analysts who specialize in medical necessity data, support your documentation improvement professionals and don’t ever lose sight of the importance of your HIM department. They are essential to the core.

Wishing everyone a healthy, happy holiday season! See you in 2018!

View the OIG Semiannual Report to Congress.

Barbara Aubry is a regulatory analyst for 3M Health Information Systems.