Bob Gatty, a former congressional aide, covers news from Washington for Urology Times.

Bob Gatty

But urologists are being urged to become more involved than simply to vote on Election Day, because the decisions by the men and women who are elected can directly affect the way medicine is practiced and health care provided. 

Those decisions will determine whether physicians who treat Medicare are fairly reimbursed; whether the Independent Payment Advisory Board (IPAB) is allowed to continue; and even how government agencies, task forces, and advisory boards that make recommendations on specific testing and treatment protocols are allowed to function. 

"We are working together to get elected officials who will support legislation to replace the IPAB," he said. "We are optimistic that we may be able to succeed, particularly if there is a change in the White House in November." 

But jettisoning that board, which is to be established under the Affordable Care Act and charged with holding down Medicare costs in a way that largely targets physician reimbursement, is just one of the key objectives of many physician groups heading into the election. 

A second goal, of course, is gaining support in Congress for reform of the hated sustainable growth rate formula that is responsible for the annual havoc faced by physicians who serve Medicare patients. For example, the Centers for Medicare & Medicaid Services recently released its fee schedule for 2013, and it contains a 27% average reduction for physicians effective Jan. 1, 2013. 

However, Congress has never allowed such cuts to be imposed and each year it acts at the last minute, or sometimes after the last minute, to prevent them from taking place. 

So, most observers assume Congress will jump in, probably in a lame-duck session around Christmas, and enact another temporary fix. But then what will the new Congress do? Will there be even more lawmakers who will insist on cutting elsewhere to pay for the cost of reform no matter what? Or will there be an increased number of lawmakers who recognize the seriousness of the problem and work to develop some sort of practical and effective solution? 

A third key issue for urologists is the U.S. Preventive Services Task Force (USPSTF) and the process by which it makes formal recommendations regarding preventive care services. 

It was the USPSTF that recommended in May against performing PSA-based screening for prostate cancer in asymptomatic men, a recommendation that prompted organizations representing urology, as well as many prostate cancer advocacy groups, to criticize the manner in which the decision was reached as well as the conclusion itself. 

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The decisions by the men and women who are elected will determine whether physicians who treat Medicare are fairly reimbursed; whether the Independent Payment Advisory Board (IPAB) is allowed to continue; and even how government agencies, task forces, and advisory boards that make recommendations on specific testing and treatment protocols are allowed to function.

Election Day holds many keys to urologists' future

-For urologists who strongly oppose key provisions of the Patient Protection & Affordable Care Act (ACA), upheld by the U.S. Supreme Court in late June, the best hope for change may lie in the ballot box rather than in the halls of Congress. 

The ruling also means that the ACA's "value-based modifier" provisions, intended to tie physician Medicare payments to the quality and cost of care they provide, will go forward. 

"Since the [ACA] was passed in 2010, organizations representing urologists nationwide have been working with lawmakers and regulators to demonstrate how certain provisions-including the establishment of the Independent Payment Advisory Board and the value-based modifier-will negatively impact physicians' ability to provide quality care to patients. Though we applaud the altruistic motives behind the legislation, it is a disservice to millions to provide health care without also providing a strong infrastructure through which care can be provided." 

"There are parts of the law that we like," said David F. Penson, MD, MPH, the AUA's health policy chair, "like those assuring that more Americans will have health care coverage and those banning restrictions based on pre-existing conditions. But there are things that need to be changed." The IPAB, he said, "is effectively a rationing panel" whose decisions, designed to contain cost, will be directed essentially at physician Medicare payments. 

The Alliance of Specialty Medicine, of which the AUA is a member, warns that the IPAB's authority is such that it will be extremely difficult for Congress to reject its recommendations, subjecting physicians to fee payment cuts without the opportunity for redress. 

Regarding the value-based modifier, the ACA requires the Department of Health and Human Services to establish a separate, budget-neutral payment modifier to the Medicare fee schedule that is based on the relative quality and costs of care physicians or physician groups provide. The modifier is to be implemented in the 2013 rulemaking process and will become effective on Jan. 1, 2015, when the modifier will affect payments based on 2014 performance data. 

Dr. Penson expressed concern that the payment modifier could adversely affect the ability of many patients to have access to appropriate medical services if Medicare implements value-based purchasing in such a way that providers are penalized for ordering these often-appropriate services. 

"We need to take a good look at value-based purchasing," he said. "That gets to the concept of obtaining the best value for health care dollars, more appropriate use of health care services, and paying in a capitated manner. The payer agrees to pay 'x' amount of dollars for the episode of care-no more, no less-and it must meet certain quality standards. Urologists have to be sure their patients have access to appropriate medical services when needed. We want to make sure that patients have access to high-quality care. I worry that the value-based modifier may negatively affect this if not done properly." 

Under the provision, physicians who provide quality care at lower cost to Medicare will receive higher payments, while those who increase Medicare costs without better results will see their payments reduced. 

Dr. Penson said he is optimistic that change can be achieved through Congress.  

"We are working with elected officials who understand our position and think the same way we do, and want to see high-quality health care maintained for Americans," said Dr. Penson. 

That means putting the AUA's political action committee, UROPAC, to work, supporting candidates and lawmakers who agree with the organization's views on those key issues. 

Change in Oval Office called crucial 							

 "We are optimistic that we may be able to succeed," Dr. Penson said, "particularly if there is change in November. If Gov. Romney becomes president, he would be much more likely to sign a bill that would change the IPAB. That is a top priority for us." 

The IPAB, Dr. Penson asserted, will affect all urologists, regardless of their practices. 

"If that comes to pass in 2014, it will reduce reimbursement for health care providers," he warned. "It takes away Congress' responsibility and puts it in the hands of unelected individuals." 

All of that is in addition to the Medicare fee schedule cuts that loom once again in January, unless a solution to the sustainable growth rate formula is found or unless Congress, once again, provides a reprieve. 

If history is instructive, at least a temporary reprieve likely will occur during a lame duck session following the election, running up into the Christmas holidays. According to the published congressional schedule, the target date for the House to adjourn for the year is Dec. 14. The Senate has not set a date-no doubt a wise decision. 

 a former  congressional aide, covers news from Washington for 

For urologists who strongly oppose key provisions of the Patient Protection & Affordable Care Act (ACA), upheld by the U.S. Supreme Court in late June, the best hope for change may lie in the ballot box rather than in the halls of Congress.

Organized urology reiterates Independent Payment Advisory Board concerns

In Houston, a federal grand jury in May returned a three-count indictment against urologist Hossein Lahiji, MD, and his wife, attorney Najmeh Vahid Lahiji, charging that the Lahijis conspired to defraud multiple health care benefit programs, including Medicare and Medicaid and major health care insurers, from January 2003 through Feb. 24, 2012. 

The indictment alleges they submitted false and fraudulent claims in connection with the use of unlicensed, unqualified medical personnel and billed for medical services not rendered. The indictment says the Lahijis submitted claims for urology services performed by Dr. Lahiji when he was actually traveling outside the state of Texas and outside the U.S. The services were performed, according to the indictment, by medical assistants without supervision. 

In early May, the HHS Office of Inspector General (OIG) issued a report stating that physicians are billing Medicare for far more intensive E&M services than they did a decade ago. In 2010, OIG identified 1,669 physicians who consistently billed higher-level E&M codes within a visit type at least 95% of the time. Those physicians represented less than 1% of all physicians who performed E&M services in 2010, and OIG said they "substantially differed from others in their billing of E&M codes." Most other physicians billed for those codes 53% of the time, OIG said. 

When OIG broke down those potential violators by specialty, only 1.2% were urologists. Leading the list was internal medicine, 19.8%; family practice, 12.2%; emergency medicine, 9.9%; nurse practitioners, 4.4%; obstetrics and gynecology, 4.3%; and cardiovascular disease/cardiology, 4.0%. 

The report said Medicare paid approximately $108 million for E&M services performed by physicians who consistently billed the two highest-level E&M codes in 2010. 

"As a result, Medicare paid on average $205 more per beneficiary and $43 more per E&M service to physicians who consistently billed higher-level codes," OIG said. Of those 1,669 physicians, 916 billed the two highest-level codes 100% of the time, resulting in $54 million in Medicare payments. OIG also said that beneficiaries treated by those billing at the highest levels had diagnoses similar to those treated by other physicians. 

As a result of its investigation, OIG said the Centers for Medicare & Medicaid Services should continue to educate physicians regarding appropriate coding, in the form of letters, face-to-face meetings, telephone conferences, seminars, and workshops. OIG also recommended that CMS encourage its contractor to review physicians' billing for E&M services and produce comparative billing reports. CMS should also conduct additional reviews of physicians who consistently bill higher-level E&M codes to ensure their claims are appropriate, OIG said. If inappropriate claims have been paid, CMS should take steps to recover those payments. 

OIG said it has provided CMS the list of physicians who consistently billed at the highest levels in 2010 and will also consider those physicians for further review. 

Meanwhile, urologists can expect OIG to hone in on imaging services as part of its effort to uncover unnecessary expenditures. 

In its fiscal year 2012 work plan, OIG said it would review Medicare payments for Part B imaging services "to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices." 

"For selected imaging services, we will focus on the practice expense components (of the Medicare fee schedule formula), including the equipment utilization rate," OIG said. 

Majority of overpayments uncollected by CMS							

It is not enough to identify overpayments and report them to CMS, according to OIG. Late in May, OIG said that as of Oct. 8, 2010, CMS had not collected the majority of overpayment amounts identified in 1,564 audit reports, with sustained overpayment amounts totaling $83.3 million and $896,000 for eight reports. In addition, OIG said it could not verify the $84.2 million that CMS reported collecting. 

OIG made several recommendations to CMS, including pursuing legislation to extend the statute of limitations so the recovery period is sufficient and ensuring that its Audit Tracking and Reporting System (ATARS) is updated to accurately reflect recommendations. 

So not only is OIG keeping a wary eye on health care providers, hospitals, nursing homes, sellers of durable medical equipment, and more, but the agency is also staying after CMS to make sure it follows through on its recommendations. 

It's a good thing that very few urologists are in the ranks of top potential abusers, as reported by OIG. 

 a former congressional aide, covers news from Washington for Urology Times.

With all of the pressure on the federal government to curtail spending, the U.S. Department of Health and Human Services (HHS) is not kidding around when it comes to investigating and prosecuting Medicare fraud and abuse.

Feds crack down on urology billing fraud, abuse

That's exactly what will happen unless a regulation proposed by the Centers for Medicare & Medicaid Services is significantly revised. 

The rule, proposed in February by CMS as part of the Affordable Care Act (ACA), has drawn the wrath of physician and other medical groups across the nation, including the AUA, which submitted a detailed response on April 14. 

The "lookback" provision Dr. Schlossberg referred to would require physicians to review their records to determine whether any overpayments were made. 

Dr. Schlossberg said the AUA supports the proposed rule's requirement that overpayments should be reported and returned to the agency when a person "has actual knowledge of the existence of the overpayment" or "acts in disregard or deliberate ignorance of the existence of the overpayment." 

However, he said, "Clarifications should be made to ensure that the overpayment regulations only permit government entities and contractors to target bad faith retentions of overpayments" in order to avoid imposition of liability in cases involving technical errors, innocent mistakes, or "mere negligence" in the handling of overpayments. 

Dr. Schlossberg said the proposed rule provides insufficient guidance regarding when the 60-day time frame for reporting and reimbursement kicks in, and said it could be interpreted to be when the provider/supplier becomes aware of an overpayment but does not know the amount. He said the language should be clarified to state that the 60-day "clock" begins to run when there is knowledge not only of an overpayment but also the amount of the overpayment. 

The AUA also urged CMS to clarify a requirement that upon receiving information concerning a potential overpayment, "failure to make a reasonable inquiry, including failure to conduct such an inquiry with all deliberate speed" could result in the provider/supplier being in violation of the False Claims Act. 

"First and foremost, the AUA recommends that CMS clarify that a reasonable inquiry will only activate the 60-day clock when it reveals a 

How would you like to have to go back for 10 years and figure out if the feds have overpaid you on a Medicare or Medicaid claim and then be required to pay up within 60 days or face monetary penalties and maybe get kicked out of federal health care programs? That's exactly what will happen unless a regulation proposed by the Centers for Medicare & Medicaid Services is significantly revised.

Bob Gatty

Articles

Election Day holds many keys to urologists' future

Organized urology reiterates Independent Payment Advisory Board concerns

Feds crack down on urology billing fraud, abuse

Proposed overpayment rule draws ire from American Urological Association