An IMS Institute for Healthcare Informatics survey released April 4 shows a drop in physician office visits and prescription use. As patients struggle with high deductibles, co-pays, and general economic issues they are more likely to ask their physician about cheaper alternatives for tests and prescriptions, or to find other alternatives rather than seeing their doctor.
IMS’ report findings are similar to reports from the Kaiser Family Foundation and Chase health industry analyst John Rex. Their reports also found a decline in office visits. Another survey report, released November 2011 by Commonwealth Fund, said 42 percent of “sicker” adults had more cost-related access problems than in the previous year.
IMS’ report found that from 2010 to 2011:
- Retail pharmacy prescription spending declined 1.1 percent.
- Prescription spending by insured patients ages 19-25 went up 2 percent.
- Patients 65 and older spent 3.1 percent less out-of-pocket for prescriptions.
- Ages 65-69 had the biggest prescription decline, with a 4.3 percent drop.
- The biggest prescription decline was for those treating hypertension.
- Non-emergency hospital admissions declined 0.1 percent.
- Emergency admissions went up 7.4 percent.
The increase in emergency admissions is an indicator that patients are reluctant to seek medical treatment from their physician office or to take medications because of financial concerns. Larry Levitt, senior vice president of the Kaiser Family Foundation said, “It suggests people are putting off care, and they’re showing up sicker.”
According to the survey, here are the statistics showing the number of office visit changes from prior years:
2002 – 1,503,225,000: 2.7%
2003 – 1,589,694,000: 5.8%
2004 – 1,565,978,000: -1.5%
2005 – 1,654,375,000: 5.6%
2006 – 1,670,502,000: 1.0%
2007 – 1,624,189,000: -2.8%
2008 – 1,627,786,000: 0.2%
2009 – 1,602,354,000: -1.6%
2010 – 1,535,506,000: -4.2%
2011 – 1,468,265,000: -4.7%
Advice for Physicians Who are Seeing a Decline
According to an amednews.com article, here’s what physicians can do to make it more likely that financially strapped patients will follow advice for prevention and treatment:
- Explain the value of the recommended medication, test, or procedure even if the patient doesn’t ask. Barry Make, MD, a pulmonologist with National Jewish Health in Denver, said, “Patients will only do something if they understand what it is for, but patients are often reluctant or ashamed or embarrassed to ask.”
- Make it clear that some negotiation is possible if cost is a significant concern. For example, see a patient every four months rather than every three.
- Steer patients to lower-cost prescription resources and write prescriptions for drugs to be filled cheaper at big pharmacies.
- Guide patients to drug assistance programs or discount programs.
Source: IMS Institute for Healthcare Informatics “The Use of Medicines in the United States: Review of 2011“
April 27th, 2012
To keep designated health services in the clear, know Stark regulations and their exceptions.
By Julie E. Chicoine, Esq., RN, CPC
Physicians and their practices are undergoing increased government scrutiny with regard to their referrals and financial relationships for health care services. At the heart of this scrutiny lies the physician self-referral law, known as the Stark law (provided in full detail at section 1877 of the Social Security Act, and codified at 42 U.S.C. section 1395nn). As a coding professional, you should understand the basic principles of Stark law so that you are able to recognize when a possible infringement may be taking place.
Self Referrals Pose Conflict of Interest in Patient Care
Congress originally passed the Stark law in 1989 in response to a growing concern about physicians referring patients to laboratories where the physician had a financial interest. This posed a conflict of interest; Congress’ concern was that physicians who stood to benefit financially from ordering laboratory tests were likely to order more tests, including more complex tests, even when such services were unnecessary .
Following enactment, Congress expanded the Stark law’s prohibition to include additional designated health services (DHS) and extended its application to the Medicaid program. In 1997, Congress added a provision authorizing the secretary of the Department of Health & Human Services (HHS) to issue written advisory opinions concerning whether a referral relating to DHS (other than clinical laboratory services) is prohibited under the Stark law. Congress also authorized the secretary in 2003 to publish an exception to the physician self-referral prohibition for certain arrangements in which the physician receives necessary non-monetary remuneration used solely to receive and transmit electronic prescription information. They established a temporary moratorium on physician referrals to certain specialty hospitals in which the referring physician has an ownership or investment interest, as well.
The Centers for Medicare & Medicaid Services (CMS) has published a number of regulations interpreting the physician self-referral statute over the years. These rules were published in phases and are referred to as “Phase I, II, and III.” An overview of the Stark law’s regulatory history can be found on the CMS website.
Get to the Core of Stark Law
At its core, the Stark law prohibits physician referrals to entities providing certain DHS in which the physician (or his or her family member) has an ownership or compensation interest, unless an exception applies. The law further prohibits the entity from presenting, or causing to be presented, a claim to bill Medicare or Medicaid for any DHS provided pursuant to a prohibited referral. Due to this broad language, the law also establishes many exceptions.
Under Stark (42 CFR at § 411.351), physician means:
- A doctor of medicine or osteopathy
- A doctor of dental surgery or dental medicine
- A doctor of podiatric medicine
- A doctor of optometry
- A chiropractor
A referral is a request by a physician for, or ordering of, or certifying necessity for, any designated health service for which payment be made under Medicare Part B. DHS personally performed or provided by the referring physician are specifically excluded from the referral definition; however, the service is not considered to be personally performed by the referring physician if the designated health service is performed or provided by the referring physician’s employees, independent contractors, or group practice members.
DHS cover a broad range of health care items and services including:
- Clinical laboratory services
- Physical therapy services
- Occupational therapy services
- Outpatient speech-language pathology services
- Radiology and certain other imaging services
- Radiation therapy services and supplies
- Durable medical equipment (DME) and supplies
- Parenteral and enteral nutrients, equipment, and supplies
- Prosthetics, orthotics, and prosthetic devices and supplies
- Home health services
- Outpatient prescription drugs
- Inpatient and outpatient hospital services
CMS Identifies DHS Codes
Because the regulations define certain DHS by CPT® and HCPCS Level II codes, CMS maintains a list of CPT® and HCPCS Level II codes identifying those items and services included within the categories referenced above. CMS updates this list annually to correspond with CPT® and HCPCS Level II manual updates in Medicare coverage and payment policies. The updated code list is also published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule, which is published annually in November with a Jan. 1 effective date for the following year.
The DHS categories defined by the code list include:
- Clinical laboratory services
- Physical therapy services, occupational therapy services, outpatient speech-language pathology services
- Radiology and certain other imaging services
- Radiation therapy services and supplies
The following DHS categories are defined without reference to the code list (42 CFR §411.351):
- DME and supplies
- Parenteral and enteral nutrients, equipment, and supplies
- Prosthetics, orthotics, and prosthetic devices and supplies
- Home health services
- Outpatient prescription drugs
- Inpatient and outpatient hospital services
Bottom Line: Stay Stark Compliant
When analyzing physician referral activity, physicians and entities must ask two questions:
- Is there a physician referral of a Medicare or Medicaid patient for the provision of a designated health service?
- Is there a financial relationship (a compensation arrangement or an ownership interest) between the referring physician (or his or her family member) and the entity that will provide the designated health service?
If the answer to both of these questions is “yes,” the referral is prohibited under Stark law unless one of the statutory exceptions applies. Stark exceptions are generally divided into three categories, including:
1. General exceptions
2. Ownership/investment interest exceptions
3. Certain compensation arrangements
Learn more about these exceptions by visiting CMS’ physician self-referral website. Stark law exceptions can be viewed in their entirety.
Seek Professional Advice on Referrals
Penalties for referrals violating the Stark law can be substantial. If a referral is made violating the Stark law and payment is received by the entity providing the designated health service, penalties can include: civil penalties up to $15,000 for each illegal referral, exclusion from participation in federal health care programs, denial of payment for services, refunding of payments received, a fine of up to $100,000 for each illegal cross-referral arrangement, and civil penalties up to $10,000 per day for failing to report violations. Physician and entity compliance with the Stark law is mandatory.
Because non-compliance with the Stark law requirements poses financial impact, physicians and entities developing arrangements that include referrals for DHS should retain legal counsel to make sure these referrals fit within one of the Stark exceptions.
Julie E. Chicoine, Esq., RN, CPC, is senior attorney for Ohio State University Medical Center. Ms. Chicoine earned her Juris Doctor degree from the University of Houston Law Center. She also holds a Bachelor of Science and a nursing degree from the University of Texas Health Sciences Center at Houston. She has written and spoken widely on health care issues, and is an active member of the AAPC community.
April 1st, 2012
To cut back rising fraud and abuse in the federal health insurance program for the poor, disabled, and elderly, several states are looking at using biometric tools to better identify Medicaid patients. New York, Texas, and Georgia are either considering laws or piloting programs using the new technology. According to lawmakers, the technology would catch duplicate prescription requests and medical services, which costs the Medicaid program billions of dollars each year.
Under a New York proposal introduced April 6, the “Medicaid Identification and Anti-fraud Biometric Technology Program” would require the state to implement a program requiring the use of biometric technology in the form of palm scanners to be used by hospitals, clinics, and pharmacies for the purpose of patient identification and anti-fraud in the Medicaid program.
According to N.Y. state officials, New York will spend over $54 billion this year on Medicaid and about 10 percent or $5 billion will be fraudulent charges. This new legislation would implement biometric technology at a one-time cost of $20 million. The funds would be raised by implementing a 1 cent per prescription charge for a six-month period on Medicaid prescriptions written in New York.
Identification cards would be issued to physicians, clinical staff, and pharmacies for the purpose of authenticating patient visits and prescription orders. The ID cards would contain coded and encrypted biometric markers, as well as a computer code. Medicaid patients would receive their ID card in the mail. They would scan a palm and activate the card in person at a county social services office.
Checkups would begin and end with the card being scanned. Physician offices, facilities, and pharmacies would scan patients’ palms and swipe the card, allowing payment. New York state would outfit providers with the palm scanners, which cost about $300 each.
According to a timesunion.com report, Texas has experimented with fingerprinting, and Georgia has already approved a similar bill to institute Medicaid ID cards with biometric technology.
April 15th, 2011
To better safeguard the supply of food and medicines imported into the United States, the U.S. Department of Health and Human Services (HHS) will send the first U.S. Food and Drug Administration (FDA) staff to China, India, Europe, and Latin America before the end of 2008, HHS Secretary Mike Leavitt announced in an Oct. 16 news release.
“In the past year, we’ve upgraded labs and equipment, hired additional staff, and begun implementing product safety agreements with key trading partners, including China,” Secretary Leavitt said.
(more…)
November 3rd, 2008