Um, 3% of physicians billed M’care B for services that should have taken 100 hours per week. https://t.co/P3mqRQlKSa pic.twitter.com/hDTReTFdth
— Janet Weiner (@weinerja) April 18, 2016
This has to be fraud, this has to be scandal?
Not really.
The study at the NBER argues that it has a good first step of an overbilling screening test:
Our idea is very simple. Every provider has a fixed number of hours in any given period; and most of the service codes that are submitted for reimbursement require that the provider spends certain amount of time with the patient. If
the hours worked implied from the service codes a provider submits to CMS are implausibly long, the provider is suspicious for overbilling.
I am very skeptical that this will have practical impact for a couple of reasons.
The biggest problem is how Medicare handles Master level clinician billing. Their data method does not address this problem.
Providers are uniquely identified by their National Provider Identifier (NPI) and characterized by a limited set of basic information (e.g. address, individual or organization indicator, gender and specialty). Places are categorized into office settings and facility (such as hospitals) settings, and reflect where the provider furnished a service. Services are identified by a 5-digit alpha-numeric code specified in the Healthcare Common Procedure Coding System (HCPCS).
The problem is simple. Some states allow master level clinicians to work to the full scope of their license and to bill under their own authority. Other states do not allow master level clinicians to operate independently. The certified nurse practicioners (CRNPs), nurse anthesiologists, physician assistants, physical therapists and other master level clinicians operate under the supervision of an MD or a DO. All of their billing rolls up to the MD or DO. Specialty clinics will often be set up so that one or two doctors will have half a dozen master level clinicians underneath them. Those master level clinicians will do most of the work but the doctor in an eight hour day could conceivably bill for twenty four to thirty hours worth of work. This study rolls up master level clinicians as providers in the states where they are allowed to bill independently.
The second issue is the time value of the Relative Value Unit.
I have a good auto mechanic. He is trustworthy in that he has told me that he could do $1,200 worth of work on my old Blue Beast and get her past inspection but by the end of the year, he would probably need to do another $1,000 worth of work. And that it would be a good idea to get a new car. He has called me and said that he could do the work on the exhaust system, but another garage could do the work at better quality and a better price because they are really good welders and he is just competent. He is a good mechanic. He also routinely bills 10 hours or more for eight hours in the garage itself. He bills off of a national time study book where each task is assigned a calculated time. When he is working he usually beats that time by a good margin.
RVU’s have the same problem. They are a skill and time estimate. Some providers out of a very large sample will naturally be more efficient than others. Some providers will be able to complete a task a bit faster than others. And this assumes the time value attributed to a particular procedure code is an honest mean time. There is a good argument that RVU’s, especially for specialty codes, overestimate the time needed to perform tasks. So there is a combination of providers who are naturally a bit more efficient interacting with codes that are unrealistically overtimed.
When Medicare started to release billing data, I was skeptical of simple division studies:
This means we can’t do a simple time management bullshit detection study based solely on “This provider is claiming he is doing 17 Medicare Part B procedures a day. Each of these procedures takes 30 minutes… IMPOSSIBLE”. That type of first level analysis might identify odd situations, but most will be explained
I’m still skeptical.
Riggsveda
I used to work for the state, Richard, and was paid by the hour. If I left the job after 5 hours because I so efficiently completed my work for the day, but told the state I worked 7.5 hours because that was my regular schedule, I would have been fired for falsification of records. I was excellent at my job and also trustworthy. Would that have made my falsification of time worked ok?
Can’t see cutting a break on this either to mechanics or physicians.
TG Chicago
While the “good mechanic” principle might indeed be in effect, I don’t think I like that idea.
I’d prefer that caregivers actually spend the time with their patients. If they can bill for an hour while rushing through things in 10 minutes, that’s good for their bottom line, but not necessarily good for the patient. Even if the doctor is doing everything right(*), if the patient feels like the doctor is rushing through their care, they may come out of it feeling less positive about their treatment, and that can make the treatment less effective. An important distinction, given that cars don’t have feelings.
(*)not an actual guarantee, as maybe the caregiver isn’t asking all the questions they should be asking.
jake the antisoshul soshulist
Off Topic (mostly)
What are the ramifications of UHC pulling out of exchanges?
Germy
How would they cope with a $5000 deductible?
Wag
RVU schedules are insanely out of date. The New England Journal of Medicine had an article addressing this issue. The current RVU reimbursement for cryotherapy for a precancerous skin lesion (an actinic keratosis) is based on the assumption that the procedure will take 22 minutes with an additional minute for each additional lesion. In reality, it takes about 5-10 minutes to treat 10 lesions. Despite the reality of how long it takes to treat the lesions, CMS assumes that the provider who performed the cryotherapy too 30 minutes to treat the lesions, not 5-10 minutes.
I am skeptical about he findings of the article for the reasons that Richard notes above, as well as problems with the RVU scale noted in the article that I linked to.
Richard Mayhew
@Riggsveda: It is not fraud. As @Wag: noted, it is a calculated time to accomplish a task. The study assumes those calculated times are realistic.
Mechanics bill on the calculated time not the actual time so they eat the cost if a job that is calculated to take 45 minutes took 90 minutes, but they gain the time if that same job only took 30 minutes. I am getting charged for 45 minutes worth of labor.
Richard Mayhew
@Wag: That was the other interesting thing, the specialties that were most likely to be “overbillers” were the ROAD specialties. There is a good argument that they are “high value” specialties because technology has increased productivity significantly without the billing structure catching up to them yet, so they can do 3 or 4 procedures in an hour that are being billed out as taking an hour apiece.
TG Chicago
Are the RVUs Billing by time or by task? If they bill by task and only the calculations in the study bring in time, then they are not committing fraud.
Your mechanic still is, though. If he takes eight hours to do a job and claims it t took ten, that’s not true. It is a lie. It is fraudulent.
guachi
Surgeons are basically human mechanics so the auto mechanic analogy is an apt one. Good auto mechanics make money by being fast and efficient. As long as that is the case for surgeons, I have no problem (in general) with them “overbilling”
Germy
@TG Chicago: I remember years ago taking my car to a mechanic who had a big glass window between his waiting room and the service area. I watched my car sit there for five hours. Three quarters of an hour the mechanics actually worked on it. The rest of the time they worked on other cars. For half an hour I watched them eat their sandwiches and drink soda.
After the show was over, the nice young lady at the reception desk tried to charge me for five hours labor.
Capitalism!
Lawrence
I had a few tries at this sort of thing when I was an analyst for a pro fee physician’s group. I took month or several of office visit codes and plotted them by specialty as a distribution curve. Our system had a slot for the billing and service provider, so I was using the clinician who (in theory) did the actual work. The ER group always had a nice normal distribution curve (they weren’t a trauma unit at the time). Some docs in the other specialties never billed less than a level 5 visit code. Yes, we had an RVU based incentive plan. There were reasons, which I believed about a fourth of the time. Management didn’t really care as long as Blue Cross and co didn’t come asking questions.
dollared
A prosperous lawyer suddenly falls dead at her desk, cut down in her prime. She ascends to heaven (she handled Social Security disability appeals), and is greeted by St. Peter. She says, “St. Peter, I am glad to be here, but why take me so young, I’m only 42? St. Peter says “That’s odd. I have your billing records right here, and it says you’ve been working for 51 years…..”
Germy
@dollared:
(Ambrose Bierce)
amygdala
@Lawrence:
Exactly. I used to work with someone like this and wondered when, oh, when Medicare or someone would notice the endless sea of high complexity codes even for straightforward diagnoses. Not to say that there aren’t situations when figuring out that a patient has something fairly simple isn’t considerable work, due to a complex medical background, language/cultural considerations, etc. Or that there aren’t clinical settings where those considerations aren’t the rule. But constant 5 level billing should be a flag.
Just to add to the fun, he used to lord his RVU numbers over everyone else. Nowadays, he would get bonuses for that and some of the “laggards,” the docs who take the extra time to explain things or comfort a patient in crisis don’t.
Another issue is defining what complexity means. Is it against some external, quasi-objective standard? Or does it depend on how challenging the practitioner finds it? The latter rewards the less skilled (and incompetent) and punishes ace clinicians.
TG Chicago
Other problems with mechanics “bill[ing] off of a national time study book”:
*Who comes up with this book? Are they free from pressures of inflating the times? Obviously it’s in the mechanics’ interest to have those times appear to be as high as possible.
*What about the less-efficient mechanics? Do they use the book? The more-efficient mechanic bills the book time (10 hours) for 8 hours of actual work. Is the less-efficient mechanic billing for the book time of 10 hours even though it takes him 12 hours to finish the job? Highly unlikely. He’ll pitch the book and bill 12 hours. Heads I win; tails you lose.
Dennis
I don’t agree. Any time I see a physician for an office visit, it is always an “intermediate” length visit for billing purposes, even if I see the doc for 5 minutes.
dr. bloor
As Richard mentioned, many physicians have a number of clinicians billing off their NPI numbers. Some are scam artists, for sure.
But it’s a shame we don’t see the whole curve in that tweet. It looks like a very tight, normal distribution, which is to say that in a system that is actually quite easy to scam, almost everyone is behaving. Would that every profession out there be limited to a 3% malfeasance rate.
Ukko
@TG Chicago: you can talk to your mechanic about what will be done and get the book times before work is started. The books we used (25 years ago) were not just dreamt up by the mechanics, they were what governed what the insurance or warranty folks would pay. Those moneyed folks would not accept padded numbers.
Book time is almost the opposite of fraud, since it gets the price out there before the work is done. There is no padding of the time sheets, and there is none of the stupid make-work my boss has us do to keep our ass in the chair when 2:00 rolls around and we have no more real work for the day.
Lawrence
@amygdala:
This was 8+ years ago that I did that work, so they were using paper encounter forms and the index card thingies for their inpatient rounding. Every doc I see now has their laptop in tow and does the documentation on that during the visit. I wonder if the time for that is built in to the new coding rules?
Wag
@Lawrence: it’s not.
No One You Know
Richard, thank you for your threads on the topic. I don’t often comment, but I do always read. I work in the industry myself, and appreciate what you have to say.