For the most part clinicians are not concerned with billing codes, modifiers, CPT, ICD-10, RVUs, case rate adjustors or any billing matter until something or someone says, “There’s a problem and we’re not getting paid for what you did.” Likewise, the people in the back office compiling the information required to squeeze every cent out of a payer that the provider is entitled to rarely concern themselves with the effectiveness or cost of care given to any particular patient until something or someone says, “revenue is off and we are over budget.” For years, and still in evidence today, hospitals operate with this separation of clinic effectiveness and financial accountability at the patient centric level. Yes, systems and procedures are in place to ensure what is required is done. Alarms sound when it isn’t. However, the continuous exchange of clinic and financial information does not exist to guide or influence patient care decisions. Consequently, accusations about waste and ineffective care are constant reminders that scrutiny lurks.
CMS’ priority to reduce fraud, waste and abuse in the Medicare program is at an all-time high. CMS has extended its scrutiny to contractors who will assist with its goal to return $25 billion to the Medicare Trust Fund. The common theme for all CERT, MAC, RAC, PEPPER, ZPIC and PCS contractors is to recoup payment based on inappropriate billing for patient care services and measured as the paid claims error rate.
Hospitals are launching their defensive strategy to ensure coding accuracy to avert payment recoupment after the care has been rendered. For acute care hospitals, MS-DRG accuracy is the metric for measuring coding accuracy and an indirect measure of improper payment due to coding. The CERT program, and its contractors, has not yet figured how to apply these methods to the IRF CMG assignment methodology. Without a doubt, the algorithms are being written for this sector. Improvements in the coding process as well as implementation of costly controls, automation and training efforts may or may not correct patterns of improper payment due to coding.
Perhaps a more direct approach could save time and expense if the relationship between code assignments, the care rendered and improper payments were known by clinicians before they delivered care; and if coders would affirm the appropriateness before the UB has been completed many denials would be averted. Crossing this chasm would reduce considerable waste and minimize recoupment threats.
I cannot imagine this not having been attempted before; it seems so simple to do. Are our hospital’s clinical and financial silos that far apart? If so, perhaps an examination of the organization’s culture will reveal the limits to bridge building.