Medicare Appeals

Talk about beating a dead horse. I am once again blogging about my what has become my new favorite topic, Medicare appeals or the Recovery Audit Contracting process.  Today, I read a great article by our RAC consultant, Tom Herrmann in the January - February edition of the Journal of Health Care Compliance.  The article is on the latest announcement from the Office of Medicare Appeal Hearings on delays in adjudicating cases due to the massive backlog of appeals.  Tom also provides a great overview of the RAC process.  

The item where I take issue is where he describes what we as providers need to do to facilitate the ALJ adjudication process.  It's always about what we as providers can do.  What is rarely mentioned is the albatross created by Health and Human Services to root out improper Medicare payments, i.e, catch fraudulent providers to facilitate the process.  

Very little of the Government's role related to the RAC process is automated.  They open mail and process appeals manually; can you believe it in this day and age?  They are well over a year away from any automation and we know how well the Feds are at bringing systems up these days.  

They created a RAC process that is wrought with problems.  As I have blogged previously, they expected hospitals to roll over and simply budget for the RAC process in our operating budgets as most hospitals did initially.  We never did at WMHS; we challenge every case where we believe the correct care was provided.  Isn't it interesting that we have never won an appeal by the RAC auditor who is incentivized by the number of cases that they target?  We have never won an appeal at the Qualified Independent Contractor level either.  We have won almost every case at the Administrative Law Judge level as have most hospitals because the ALJs are not incentivized.  They adjudicate the cases appropriately and as a result, the appeals at this level have proliferated. So, why not restructure the process up front.  

Marilyn Tavenner, the CMS administrator, is now trying to convince us that CMS is exploring ways to improve  the RAC process.  I am sure they are but it's time to ask the people who they are burdening financially and administratively with this boondoggle for our advice and guidance.

Separating the Useful Information from the Gibberish

I read Dr. Mark Thoma’s blog over the weekend that 120 computer-generated, non-sensical research papers were published in scholarly journals.  Apparently, MIT created software that presents nonsense information in a correct format with tables and graphs along with references for the "papers.”  These papers, which are computer generated fakes, have found their way into both the scholarly journals but also cited at various conferences around the world.  Is this new, no?  But, it is increasing.  

After reading the article, it made me wonder if the same thing can be said for the thousands of pages in Congressional bills or bills before the Maryland General Assembly.  Have you ever read some of these bills?  Some of the contents many times appears to be gibberish, but then again these bills still become law even with the actual specifics of the contents being unknown to so many, including those who are required to vote on them.   

It also made me wonder if publications like the Harvard Business Review (HBR) intentionally publish non-sensical gibberish from time to time.  I am half kidding.  There are many excellent articles in the HBR, but there are times that I read an article and I have absolutely no idea as to what the author is trying to say.  Then I think, are these authors simply trying to convey just how much smarter they really are or do I need to simply eliminate the distractions around me and better concentrate on the article that I am reading?  Nine times out of ten, it is the latter.  

Anyway, I find it amazing that computer generated fakes can be cited in the work of "bonafide" researchers and academic institutions around the world. Their credibility has to be and should be shaken in letting these fakes into their academic publishing.

A Perspective on the Week

I have been so busy that I haven't had time to blog with everything going on from a business and personal perspective.  I have found that I really miss blogging during weeks like this one.  So, some things that I think that I think at the end of this week............first, thanks to all who responded to Friday's blog.  I received a number of great suggestions on a name for the Alliance between WMHS, Meritus and Frederick health systems.  At this point in the time, Trivergent looks like a winner (thanks, Clay Jones) provided we can get it trademarked.  We had our first candidate for the Chief Medical Officer's position in for an interview, which is great.  He is a seasoned, experienced CMO and on the surface could be a good fit at WMHS.  Our interim CMO is doing a great job and has thrown his hat into the ring, which is also great.  We had our second Board Planning Committee meeting this week.  Two major initiatives that the Committee is dealing with are the creation of our strategic plan for Fiscal Years 15-17 and completing a Master Facility Plan for our campus as well as all of our properties.  Our business is changing so rapidly that we are already doing a MFP on a new hospital.  Go figure.  I guess that it is important to remember that the new hospital was designed between 2004 and 2006; a lot of what exists today or is on the horizon for the future wasn't even being contemplated back in 2006 when construction began.  

Now for the personal.  I have had a cold for the last three weeks and I hate colds.  Last night it expanded into a fever and I was just feeling really lousy.   But, then you hear around the health system about the granddaughter of one of our employees dealing with brain cancer, an Alliance attorney diagnosed with pancreatic cancer and my own son-in-law not knowing whether or not the large tumors on his knee and femur are cancerous.  No matter what the diagnosis, he is in for a rough road ahead.  My problems under those circumstances were absolutely minuscule compared to theirs. Well, God speed to the three previously mentioned and their families. You all are in my prayers. Have a great weekend and get ready for more snow.............when will this winter end?????

Finding a Name for the Alliance

For the last nine months, the alliance of Western Maryland Health System, Frederick Regional Health System and Meritus Health has been trying to find a name.  We thought that we were okay with Alliance Health, and it turned out that there was an insurance company somewhere in the Midwest with the name Alliance Healthcare.  Then, we tried to move forward with Concordant Health; not the best name, but it seems that there are less and less names out there.  We just learned today that name is not available.  Concordant Health Solutions is a Michigan-based consulting company so, that name is out.  I don't quite understand that there can be derivations of the name Alliance Health and Concordant Health that others such as insurers, consultants and providers have used, but we can't.  

Now, I do remember a few years ago when Allegany College of Maryland dropped "Community" and added "of Maryland" to its name.  Allegany College of Maryland received cease and desist letters from Allegheny College in Meadville, PA, just north of Pittsburgh.  They said that the name was too confusing for potential students applying to their college.  Really?  If their students can't figure out the difference between Maryland and Pennsylvania, who would want them as a student at their college.  Then, it was that Allegany College of Maryland has campuses in Pennsylvania and that was too confusing for their prospective students.  I rest my case; who would want those navigationally challenged students anyway.  Allegany College of Maryland pretty much told them that we will use "of Maryland" extensively, but other than that, we weren't changing the name.

Getting back to the issue at hand, we need a name for our three health system alliance.  At this point, I would welcome any suggestions that you may have.  Give it some thought and let me know.  Thanks!

Contrasting Writing Styles

Each day, I read the Wall Street Journal and the Washington Post in order to get two different perspectives on issues.  Yesterday was no different.  In reading the story about the Congressional Budget Office's announcement that increasing the minimum wage to $10.10 per hour by 2016 from $7.25 (a 40% increase) would eliminate 500,000 jobs; the spin that each newspaper put on the story was interesting.  

The Wall Street Journal focused on the benefits of such an increase on teenagers and the middle class; an unintended consequence and not really the poor.  That perspective was never given in the Washington Post article.  WP focused on a nationwide survey that said that the majority of Americans want to see an increased minimum wage to $10.10.  A perspective that the WSJ never mentioned.  The WP also interpreted the same CBO numbers as greatly benefiting the poor.   The rest of the articles pretty much mirrored each other.  

The articles continued with the White House economist saying that increasing the minimum wage would have zero effect on jobs.  Really?  Pretty much every article written about minimum wage speaks of some job loss with those who are supposed to benefit from the increase being negatively impacted. 

From my perspective, the minimum wage should be set by each city / county in a state and not national level.  The cost of living in NYC, Washington DC and LA is dramatically different than rural America.  This is the approach that is being encouraged in Maryland.  In those jurisdictions surrounding DC and in Baltimore, a higher minimum wage may be justified.  In western Maryland, a statewide or federally mandated minimum wage could possibly force many small businesses to close.  Tough issue with lots of different perspectives.

Way To Go Bill Russell

Yesterday, Jeannie Seifarth of the WMHS Leadership Institute shared a leadership tip on teamwork and it had a very recent quote from Bill Russell, the basketball great.  

You see, last week LeBron James was asked who his Mount Rushmore of all time professional basketball greats consisted of.  LeBron responded with his choices: Michael Jordan, Larry Bird, Magic Johnson and Oscar Robertson.  He added that he will be one of the top four greatest who will have ever played the game, as well.  

Left off of that list was Bill Russell the former Boston Celtic who was one of the greatest basketball players of all time.  Bill Russell's response to LeBron when asked by a sport's reporter about being excluded, "Hey thank you for leaving me off your Mount Rushmore.  I'm glad you did.  Basketball is a team game, it's not for individual honors.  I won back-to-back state championships in high school, back-to-back NCAA championships in college, I won an NBA championship my first year in the league, an NBA championship in my last year and nine in between.  That, Mr. James, is etched in stone.”  

Good for you, Bill, still blocking shots at 80 something. I am sure Bill was kidding to an extent with his comments because he has a great sense of humor.  But, his points are well taken—it takes a team.  

Certainly, LeBron is entitled to his opinion as well as his Mount Rushmore choices of basketball greats.  My problem is with his self-promotion that he will be the greatest to play the game.  Is he a great player, certainly, but we all know it.  We don't need to be reminded of it by him.  

Also, while I am at it, why does ESPN have to constantly generate a media controversy.  You would hope that players former and present wouldn't fall into the media's trap, but they do almost every time.  Thanks, Jeannie, I so enjoyed reading Bill Russell's response after reading LeBron's self-centered remark last week.

Treating Hunger As a Health Issue at WMHS

At WMHS, we are already doing a variety things in dealing with hunger in our region.  We have both a financial and governance relationship with the Western Maryland Food Bank.  Our Ladies of Charity pack backpacks for students in need each Friday and we support the Union Rescue Mission in a variety of ways from food to Christmas families.  Our Community Benefit contribution was $40 million in 2013 of which some of those monies addressed hunger in our region.  

In early March, we have a Ruby Potter disciple, Terie Dreussi-Smith, coming to present on "Bridges into Health: Strategies to Reduce Inequities and Improve Health Outcomes.” With the growing social needs, including hunger, we have invited Terie to present on strategies to assist us with our growing safety net responsibilities.  As a health system, we need increase food security for families in our community as there is a direct correlation between hunger and health status.  We also need to guarantee appropriate food intake, especially for our diabetic patients and others with diet-sensitive diseases.  

The care of our patients has changed so dramatically over the last three plus years, so treating hunger as a health issue makes perfect sense.