MAY 2007


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California Urological Association Update

Jeffrey Kaufman, M.D.
C
alifornia Medicare Carrier Advisory Committee

WSAUA Health Policy Chair

AACU Past-President

In this update, I want to tell you about some of the political activities California urologists have been involved in, remind you about the upcoming deadline to begin using your NPI, comment about our experience with the Recovery Audit Contractor pilot program and invite you all to the Western Section AUA Socioeconomic Forum this October in Scottsdale.


POLITICAL ADVOCACY
Considering that California is only one of the 50 states, it's always impressive how well we are represented in advocacy efforts at the national level. At this year's Joint Advocacy Conference sponsored by the AACU and AUA held in Washington, D.C. March 25-27, more than 10% of the record turn out was from our golden state.
 
READ MORE...


NPI (National Provider Identifier)
On a different note, Congress has seen fit to establish a single unique identifier to be used by every health care entity beginning later this month.  Every one of us should have already obtained his NPI and by the time you read this article, you should already have it in use. READ MORE...


RECOVERY AUDIT CONTRACTOR

It seems the same friendly folks who brought you the NPI harbor some suspicions that you might not be completely forthright in your Medicare billing habits.  As if reviews by the state carrier NHIC and the CERT random audits were not enough, in the Medicare Modernization Act, Congress established a bounty hunter program to review past Medicare payments known as the Recovery Audit Contractor. READ MORE...


WESTERN SECTION AUA SOCIOECONOMICS FORUM
Finally, I hope you and your partners are planning to join us at the Western Section meeting in Scottsdale this October. The socioeconomics forum already has an excellent program scheduled for Sunday, October 28. 
Emphasizing economic issues, we will have an update on the P4P program and new coding tips. READ MORE...



QUESTION & ANSWER
What are the specific guidelines regarding CPT codes for E & M services? How do insurance companies down code and the legality of this?

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The Mitomycin bladder instillation is a common procedure which requires drug code J9291. I find that Medicare only pays half of my suppliers cost. How are other urologists managing this issue?

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Concerning Blue Cross' proposed change in fee schedule for 2007, is this state wide or more of a local issue?

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California Urological Association
1950 Old Tustin Ave.
Santa Ana, CA 92705
TEL: 714-550-9155
FAX: 714-550-9234
EM:
info@cuanet.org
WEB: www.cuanet.org


American Urological Association Annual Meeting
Saturday - Thursday, May 19-24, 2007
Anaheim Marriott, Anaheim, CA
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CUA Interim Board Meeting
Sunday, May 20, 2007 - 11:30am - 1:30pm
Anaheim Marriott during AUA Annual Meeting
Marquis Ballroom, Northwest Salon

CUA Annual Meeting and Lunch
Tuesday, October 30, 2007 (12:00pm - 1:30pm)
During the Western Section AUA 83rd Annual Meeting
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Western Section AUA - 83rd Annual Meeting
October 28-November 1, 2007
Hyatt Regency at Gainey Ranch
MORE INFO... 

Share your best practice management tips, ideas, useful links, resources or questions with the CUA. (click below)  

 


POLITICAL ADVOCACY    

Considering that California is only one of the 50 states, it's always impressive how well we are represented in advocacy efforts at the national level.  At this year's Joint Advocacy Conference sponsored by the AACU and AUA held in Washington, D.C. March 25-27, more than 10% of the record turn out was from our golden state.  Before an intensive coordinated lobbying effort with Senate and House members, attendees heard updates on a wide range of health policy issues beginning with a briefing on options being considered to revise the Sustained Growth Rate formula used to update Medicare fees from year to year.  Ron Castellanos, M.D., the first urologist to be named to MedPAC (Congress' think tank responsible for recommendations regarding Medicare), gave us an insider's view on the program's budget challenges that will cause Medicare rates to fall 10% this coming January if nothing is done in the current Congress.  Learning how updates are determined and what alternatives are being considered gave us greater understanding and better prepared us to argue our case with Congressional staffers.  As legislation comes forward, each of you will need to contact your Congressman this Fall to demand a fair update and let them know how deep cuts in reimbursement are affecting your practice.  Unless the formula is altered, we face cuts up to 40% over the next 8 years at a time when inflation is predicted to increase your overhead over 20%.  Clearly, this is an unacceptable and unsustainable scenario.  


As if this wasn't motivation enough, our invited keynote speaker was California's own Bill Plested, M.D., president of the AMA.  This staunch advocate for physician independence challenged us to vigorously negotiate with private payers over their contract terms and accept nothing less than we deserve for the high quality care we provide.  We realize that's easier said than done but until we get tough and begin to refuse bad contracts, payments will continue to fall and restrictive regulations will continue to grow.  At some point, physicians have to stand up and say "enough!". 


California
's Dave Penson, M.D. presented the latest on Urology's efforts to take charge and participate with federal Pay for Performance programs that go into effect this July 1.  Congress feels so strongly that this initiative will improve quality and cut health care costs that they are willing to pay up to an additional 1.5% of all your Medicare allowable charges to you as a bonus for participation.  If you haven't already, you should be making preparations to choose criteria appropriate to your practice and start learning how to report in order to take advantage of this.  Whether or not we agree with the intent of P4P or believe it will actually have an impact on quality, since it appears to be here to stay, we cannot afford to allow others to establish the criteria by which we are judged.  By October, Dave will have more for us on 2008 P4P proposals in his talk to the Socioeconomic session in Scottsdale.

In addition to updates on several other chronic concerns, we considered the serious challenges that have been raised to urologists performing (and being fairly reimbursed for) imaging studies which have become such an integral part of our practices.  The American College of Radiology has taken an aggressive position to keep other physicians off their turf by lobbying public and private payers to deny payment for a number of different studies.  At the same time, the Deficit Reduction Act of 2005 cut back Medicare reimbursement for a range of studies that has cost Urology $9 million this year out of prostate ultrasound exams alone.  A select task force was created during the JAC to meet with the offices of the Senate Finance committee and House Ways and Means Health subcommittee (the two groups primarily responsible for Medicare legislation) to craft a bill that would exempt prostate ultrasound from the DRA cutbacks.  Our initial efforts were very well received and as a consequence, language is being crafted that hopefully will be passed returning fair payment to us.  At the same time, we made a very strong case that ultrasound in our offices is an extension of our clinical exam and should remain in the hands of practicing urologists.  Reviewing these issues and our options, Pat Fulgham, M.D., chair of the AUA's imaging task force, discussed strategies including the potential for special certification qualifying urologists as imaging experts.  Pat will give further updates on this during the Socioeconomic Forum at this year's Western section meeting.  I strongly urge you to attend.

With the joint support of the AACU and AUA as well as broad participation by numerous state urologic societies, the annual Washington update has become a major focal point for legislative advocacy.  I hope to see many more of you at next year's conference.

Less than a month later, we were able to put more of that advocacy training to use by joining with other California physicians in Sacramento at the annual CMA legislative conference.  At least 500 doctors (including at least 6 urologists by my count) were addressed by Governor Schwarzenegger, our CMA lobbyists and various other political speakers before heading to the capitol to discuss the multiple health care proposals now being debated.  2007 has been termed the year that a major overhaul of California's health care system is expected. Although the smart money says that little will come out of the current legislature (and that change when we see it will be incremental rather than revolutionary), some of these initiatives contain threats that could greatly impact our practice.  In an effort to "share the pain" and increase funding to cover the un-insured, several bills include a proposal for a 2% physician tax.  Although referred to in euphemisms, this "fee" is in fact a tax that would apply across the board on gross receipts.  For a specialty like urology with many expensive drugs administered at little or no mark up, such a tax would cause great hardship.  I cannot see continuing to carry the overhead for LHRH agonists or bladder cancer drugs if their purchase and reimbursement was subjected to another 2% tax.  However, organized medicine does support some of the other initiatives being considered.  We do support extending some type of insurance coverage to all and we insist on greater regulation of the insurance industry which has become a monopoly in California where 5 or 6 large companies control virtually all covered lives.  We demanded legislation that would increase penalties for delayed payment by health insurers.  We asked that more of the premium dollar be left in the system to pay for health care and that less be diverted to administration and profit-a reasonable regulation that the state can implement.  And we demanded stronger laws to prevent retroactive denial payment for pre-authorized care.  It's unclear which of the many legislative packages will finally pass into law but we should take advantage of the current atmosphere in Sacramento to demand greater oversight of the private payers to create a more equitable system dedicated more to providing for the health of Californians and less for the economic health of the insurance companies.

For those of you too busy to join us in Washington or Sacramento, take advantage of your Congressman's or state legislator's local office.  Drop in and have a chat. Let him know how you're doing, what your patients' concerns are and what he can do for you to improve your ability to properly care for your patients.  Advocacy is not limited to one or two meetings per year.  In order to protect our practice environment, we must maintain steady pressure on the system.


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NPI (National Provider Identifier)

On a different note, Congress has seen fit to establish a single unique identifier to be used by every health care entity beginning later this month.  Every one of us should have already obtained his NPI and by the time you read this article, you should already have it in use.  Many of us belong to large organizations, partnerships or groups who will have their own unique number.  However, a significant number of individual physicians are doing business as S corporations, LLCs or partnerships.  Even if you are a single provider but doing business as one of these entities, you should have obtained 2 NPI numbers, type 1 (individual) and type 2 (organization or entity).  One is for your corporation as the billing or pay-to entity and the other for you personally as the individual who ordered a test, requested a consult or performed the surgery as the Rendering provider.  These numbers are entered in different spaces on the 1500 Claim forms.  Many who accessed the system early and established their NPI soon after the website opened may not have understood this requirement.  Even now, a great deal of confusion exists on this point.  It does not apply if you are a sole proprietorship or solo practitioner in which case the Rendering provider is the same as the billing provider and a single NPI number suffices.  If you have any questions in this regard, please refer to the CUA web site cuanet.org for a published advisement letter on this point from Michelle Kelly, Manager Provider Outreach and Education, NHIC.

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RECOVERY AUDIT CONTRACTOR

It seems the same friendly folks who brought you the NPI harbor some suspicions that you might not be completely forthright in your Medicare billing habits.  As if reviews by the state carrier NHIC and the CERT random audits were not enough, in the Medicare Modernization Act, Congress established a bounty hunter program to review past Medicare payments known as the Recovery Audit Contractor.  This 3 year pilot program initially restricted to California, Florida and New York will end March 2008.  However, the funds recovered totaled over $300 million in the first year alone so Congress has now expanded the program to all 50 states and made it permanent.

California's contractor is PRG Schultz, headquartered in Atlanta.  The vice president of their Healthcare division is William Davis (william.davis@prgx.com) and their new medical director is Dr. Berman, formerly the carrier medical director for Georgia's Medicare carrier.  Areas chosen for review are entirely up to the contractor although certain areas are out of bounds.  They are not supposed to review E&M codes (unless they have reason to suspect a pattern of abuse), disputed claims, or claims already investigated for other reasons. Reviews are done by nurses and pharmacists but not by physicians, let alone specialists.  They are given 4 years of data by CMS which they are free to mine as they see fit but they are not to review claims from the current year.  Reviews are done on all health care providing entities but physicians have only been responsible for a small percentage of monies collected (hospitals make up the bulk of overpaid charges).  While doctors as a group are lumped with ambulances and labs for reporting purposes (and a profile of specific errors attributed to doctors has not yet been reported publicly), these 3 groups together are responsible for only 6% of recovered funds.  Although the program is now structured to reward the contractor for identifying underpayments as well as overpayments, out of some $304 million incorrectly paid fees from July 2005 to August 2006, only $10 million were underpayments. It seems the systems used to scan for errors are much more efficient and less costly when used to identify overpayments (and more attractive to the contractor who is paid only on a contingency fee basis).  Is anyone surprised at this?

Data available to us so far on this program indicates that the California contractor has had the most activity directed at doctors. Very little physician inquiries have been reported in New York or Florida.  Although many urologists received multiple demands for records related to LHRH agonists and other expensive medication treatments, I have personally not heard of a single urologist receiving a demand letter for reimbursement (if you know of any California urologist who has been asked by the RAC to refund money, please notify me through the CUA).  However, there is tremendous potential for the contractor to abuse this system and create a burden on the investigated physician.  A number of medical oncologists in California have reported receiving batches of inquiries numbering 50-100 at a time for charges up to 4 years old.  The amount of staff time necessary to respond even when all the original billings and payments were later found to be correct is enormous.  Many complaints have been filed with PRG Schultz and CMS in Washington but there has been little formal response.  The initial letters demanding records are poorly written as if to suggest that your case has already been screened and the contractor has reason to believe that payments was incorrect.  THIS IS FALSE.  The letters are fishing expeditions and there is nothing prior to your submitting records that would suggest you have made an error.  The letters are vague as to what particular issue is being investigated or what type or amount of records would be necessary to support your charges.  Moreover, if a demand is made for a refund, the letter from PRG Schultz does not clearly spell out your appeal rights.  If you have received a letter requesting records from this group, consider what aspect of your charges might be questionable and supply sufficient documentation to make it clear to someone with a nursing background that the charges were reasonable and necessary, not duplicative, and properly coded (do not assume the reviewer is a physician or familiar with urology practices who can read between the lines of your notes).  If you receive a letter demanding a refund, appeal if appropriate.  Resources are available to support your effort. Even if you feel the cost of an appeal isn't worth the effort due to the small amount of money involved, I urge you to fight for your rights.  Failure to appeal is an admission of an error which may very well encourage the contractor to investigate you further demanding many more records.  Even if you are in the right, this investigation can become very time consuming and expensive and is best avoided.

The CUA has already met with PRG Schultz and communicated with CMS regarding abuses in this system.  We have asked that the initial letter requesting records be re-worded, clarified and made less hostile.  We have asked that letters demanding refunds include details on your appeal rights and instructions on how to initiate that appeal.  We have demanded profiles on what physician errors have been determined so far and a specific breakdown of what dollar amounts have been returned to the system from physicians.  And we have requested that data from this program be used to educate physicians on how to bill correctly the first time.  It is our impression that an inordinate amount of stress has been placed on the physician community by this program which has not returned a significant amount of money (certainly not enough to justify the overhead costs involved in responding to multiple chart requests).   If you or your partners are so challenged, the CUA is available to provide support. Write us.  I have already submitted comments to CMS on their published draft for the next round of RAC contracting.


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WESTERN SECTION AUA SOCIOECONOMICS FORUM

Finally, I hope you and your partners are planning to join us at the Western Section meeting in Scottsdale this October.  The socioeconomic forum already has an excellent program scheduled for Sunday, October 28.  Emphasizing economic issues, we will have an update on the P4P program and new coding tips.  We will feature an extended presentation on enhancing revenue through ancillary services including legal advice on how to structure your programs properly and to your advantage.  News on the imaging wars (credentialing, certification and payment) from the AUA imaging task force chair and further updates on state, regional and national political and legislative challenges will round out the program.  You absolutely cannot afford to miss this program (and lunch is included!).  I look forward to seeing you there. For full meeting details please visit http://www.wsaua.org/Scottsdale07/2007.htm .

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Disclaimer: The "CUA 4.5 Frontline Briefing" e-bulletin is published by the California Urological Association as a service to CUA members. Your comments are welcomed. The California Urological Association, Inc. (CUA) believes the information in this newsletter is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice nor is the CUA engaged in rendering legal or other professional services.

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