Medicare and Government Contractors: Who Controls Them?

Thursday, January 15, 2009




MESSAGE FROM YOUR PRESIDENT:

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!

Medicare Fraud and Government Inaction

I just finished reading the complete 2007 report from the Office of Inspector General of the Department of Health and Human Services entitled ABERRANT BILLING IN SOUTH FLORIDA FOR BENEFICIARIES WITH HIV/AIDS.

The reports opens with the following finding:

" In the last half of 2006, three South Florida counties accounted for half the total amount, and 79 percent of the amount for drugs, billed nationally for Medicare beneficiaries with HIV/AIDS. Most of the charges originating in these counties were for nonoral drugs; drug claims represented just 16 percent of the submitted charges in other geographic areas. Aberrant claims patterns differentiated South Florida providers and beneficiaries from those in the rest of the country."

"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 are being 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!

So, they nickle and dime good doctors and impose arbitrary 100% prepayment review requirements BUT allow crooks to sail a cruiseship through their loopholes.
How do I call it? Incompetence, negligence and stupidity. Maybe even more?

Yes, we need more third party oversight of the largest CMS contractor, First Coast Service Options, operations. As a contractor they should be scrutinized by Congress. But maybe there is too much money involved and too many people may loose their job financed by taxpayers money.
Or maybe I am just paranoid and should let it go.I don't think so.



Bernd