Tuesday, February 17, 2009

First Coast Service Option

Thursday, January 15, 2009


Medicare Reimbursement and First Coast Service Option

In my last column I provided you with my midterm assessment. I indicated that we initiated a dialogue with representatives of First Coast Service Options (FCSO), the regional Medicare administrator and have met twice with their Chief Medical Director and their Executive Committee. I also reported that we discussed on how to clarify the claims payment process and that we agreed to limit and reduce the onerous prepayment review requirements. Unfortunately, these discussions led nowhere and I now question the competence of and integrity of their entire operation.
Who is FCSO?
FCSO and its parent, Blue Cross and Blue Shield (BCBS) of Florida, have been involved in Medicare program administration since the inception of the Medicare program. FCSO incorporated as a wholly owned subsidiary of BCBSF in May 1998, licensed in Florida as a Third Party Administrator and began operations in January 1999. BCBS Medicare contracts were formally transferred to FCSO effective October 2003. FCSO is one of the largest CMS Medicare contractors processing $ 17 Billion in claims annually.
What is the problem?
FCSO claims that “ as one of Florida’s largest payers of health care benefits. We are committed to making the most of this unique opportunity.” Well, they do indeed!
According to a 2007 report of the Office of the Inspector General at the Department of Health and Human Services South Florida health care clinics submitted $2.2 Billion in claims for HIV drug-infusion claims in 2005 – 22 times more than the rest of the country combined!
The reports states that “ CMS has had limited success in controlling the aberrant billing practices of South Florida infusion therapy providers. CMS and its contractors have used multiple approaches, but none has proven effective over time. The most common tools include payment suspensions, revocations, and claims-processing edits. CMS has taken limited action to strengthen the enrollment process for new providers “
A series for recommendation were made and the report summarizes its findings as follows:
“CMS’s positive response to our recommendations, including its initiation of the new demonstration project, indicates that the agency is now moving toward strategies that should more effectively protect the integrity of Medicare payments in South Florida.”
How do they define success:
“Although billing increased from $1.5 to $3.3 Billion (CY 2004-2006) ,Medicare payments in Florida dropped from $1 Billion to $890 Million ... as a direct result of CMS' containment efforts.”
Hardly a success story to me! Recent CMS data suggest that the "successful" containment efforts succeeded to contain as much (or little) as before.
Guess what; the party continues and First Coast Service Options continues to pay!
How do I call it? Incompetence and negligence.
The Miami Herald published a superb article series exposing these fraudulent activities but FCSO is still in denial that this problem exists!
So, they nickle and dime good doctors and impose arbitrary 100% prepayment review requirements BUT allow crooks to sail a cruise ship sized fraud operation through their loopholes.
FCSO promised to cooperate with us to reduce this onerous financial burden, which jeopardizes the viability of medical practices and will eventually limit access for Medicare recipients.
Despite multiple e-mails and communications they still continue this tactics. I suspect that they create a smoke screen on our expense to impress regulators and to conceal their true deficiencies.
What can we do? Well, now is time to play hardball! We need to notify members of Congress and the Senate and demand an audit and review of all FCSO activities. I consider a congressional hearing as necessary to address the intolerable waste of billions of taxpayer’s money!
The waste of money and abuse of physicians has to stop! The system can work if administered by smart and responsible managers. I have lost all confidence that FCSO can fulfill its charge and mandate to administer the Medicare program in Florida. I know that I will be attacked. I am aware that they are stronger. I am just a simple family doctor but I am not afraid to state the obvious failures and mistakes.
Now, its time to act! Enough is enough!

Cocaine Cowboys and Pain Clinics

Wednesday, February 11, 2009


Painless Choices: Cocaine Cowboys Version 2.0

“Cocaine Cowboys” is a 2006 documentary film, which chronicles the development of the illegal drug trade in Miami during the 1970s and 1980s with interviews of both law enforcement and organized crime leaders. The film reveals that much of the economic growth, which took place in Miami during this time period, was a benefit of the drug trade. As members of the drug trade made immense amounts of money, this money flowed in large amounts into legitimate businesses. As a result, drug money indirectly financed the construction of many of the modern high-rise buildings in southern Florida. Later, when law enforcement pressure drove many major players out of the picture, many high-end stores and businesses closed because of plummeting sales.
But drug dealers and their cronies do have learned their lessons and refined their approach. Their basic premise: why going underground if one can deal narcotics legally. What ingredients do you need? A medical office, a doctor’s license,a DEA number, on-site drug dispensing and plenty of advertisement space. All of the above results in a booming cash business in our midst, attracting clients from as far away as Alabama, Kentucky and Georgia. One street newspaper features a “Health & Wellness” section brimming with almost fifty (50) pain clinic ads strategically following the “adult business” section.
In those ads “renowned” pain “doctors” want you to “ get back the life you once knew”, to help you to “ break free from pain” and suggest that “in all this madness good doctors matter.” Naturally, most of those clinics are happy to provide you with any narcotics of your choice if you provide the “proof” to be in pain. An MRI indicating an abnormality suffices to qualify you as a legitimate pain patients. From then on one can receive a variety of narcotics of choice from their menu, dispensed on-site, and with an almost guaranteed refill option, otherwise their business model would suffer. In many cases these unscrupulous modern narco cowboys make millions of dollars a year in CASH!
I have had the “pleasure” encountering several of those “colleagues” who in many cases have no formal training in pain medicine, are semi-retired, had licensure problems, and appear to be board certified in predatory medicine.
The unprecedented concentration of those “pain clinics” in midst our community contributes to out-of-control opioid abuse, narcotic drug dealing and endangers the public health. In my opinion, several of those pain clinics are financed and operated by criminal gangs and the proceeds of their activities are being invested in local businesses, including real estate.It requires the concerted efforts of law-enforcement, political leadership and the medical community to root out his problem. Several steps can be taken right now:
1) Impose a moratorium of dispensing narcotics in physician’s offices, unless the prescribing physician is board-certified in anesthesiology and pain medicine and operates within a licensed and certified facility to be approved by a designated agency. This will immediately reduce the phenomenon of “ pill shoppers” who are pretending to suffer from pain, receive narcotics in numerous pain clinics and then sell those for a huge profit on the street.
2) Mandatory monthly inspection of all pain clinics in South Florida. Skilled inspectors can be trained to randomly audit charts, on-site pharmacies and monitor the patient flow at so-called pain clinics.
3) Criminal background checks of all operators and their financial backers to be reviewed and updated on a quarterly basis.
4) Implementation of a prescription drug monitoring system as a tool to identify drug-seekers and doctor-shoppers.
5) Requiring the Board of Medicine to suspend the license of any physician who violates the standards of care as it pertains to inappropriate prescription of narcotics.
I want to emphasize that the above proposed sanction DO NOT APPLY to most physicians in private practice who in almost all cases legitimately prescribe narcotics for pain. The “physicians” in questions in those pain clinics prescribe hundreds of powerful narcotics at a time to anyone pretending to be in pain! Their “standard of practice” does NOT equate our high standards of care. Les act together to rid our community from these narco cowboys. Lets protect our families, friends and patients from those predators.
Don’t be afraid to call them by their name: drug dealers in a white coat.