Friday, April 11, 2014

Taking Aim at System Abusers

Past History- “Villainizing” the Service Providers
If you follow the news regarding entitlements like we do, then you have probably noticed a growing trend toward what we consider to be the “villainizing” of healthcare providers that bill Medicare and Medicaid. Everyone seems to want to blame the ills of the healthcare system on the providers.

Service Provider "Villian"
The knee-jerk reaction seems to be to attack healthcare providers for collecting “too many reimbursement dollars” and if we do that it will “fix” the overall insurance premium and payment problem in the U.S. The assumption is that because we collect Medicare and Medicaid dollars that all providers are becoming millionaires which we all know is not the case.

No doubt there are some rotten apples stinking up the barrel. Certainly there are those who are bilking State and Federal governments out of millions of dollars. That’s wrong and it hurts those of us who are playing by the rules.

But to paint a picture that only casts blame on the provider side misses one other very important factor and that is the patients who abuse the system.

We’ve Been Waiting
For a long time, we’ve been waiting to see when those who administer Medicare and Medicaid would finally go after the segment of the patient population who are using the system but don’t really need it.

New York State is doing just that with their Medicaid program.

The most recent New York State Medicaid bulletin described that State’s attempt to attack the problem of patients who are needlessly requesting transportation services that ultimately will be paid for by the State Medicaid system. The bulletin calls for transportation providers to report patients who are abusing the system by reporting the names of those patients to the Medicaid Transportation Policy Unit.

The bulletin made it clear that the State is asking for the help of the provider community to report the names of patients who habitually call for ambulances, but whose medical necessity does not fulfill the ability for an ambulance service to be paid for the runs in question.

This initiative has also has legislative “teeth” as the New York State penal code prescribes a Class A misdemeanor to be imposed on any State resident that ultimately is proven to be abusing the system. The New York State Office of Inspector General’s Medicaid Fraud Unit is working to follow on the tips provided to the Medicaid Transportation Policy Unit in an attempt to curb dollars that are being paid out unnecessarily.

In their own words…
The bulletin explains the initiative this way…
Media reports describe the frustration of ambulance service providers when Medicaid enrollees dial 911 in non-emergency situations in order to get a ride to the hospital. These inappropriate calls reduce the availability of emergency responders for true emergencies that may arise, expend staff time and medical supplies, and pose undue risk of operating an emergency response vehicle.

Somebody gets it!
When we read this we were excited because, finally, somebody gets it!

Auditing the ambulance industry to focus on the provider community will not alone solve the problem of the system’s making unnecessary payments. In our opinion, focusing alone on the provider community places an unfair indictment on the provider community that can potentially make, rule-abiding EMS organizations appear to be fraudulent or abusive just because they happen to be collecting a fair amount of Medicare and/or Medicaid dollars.

However, as we all know there are situations where the ambulance industry has no choice but to respond and transport- even when we know the patient probably didn’t need our services. If your ambulance service happens to be in the middle of a fairly economically depressed area with a sizable amount of Medicare- and Medicaid-primary patients to serve, then your organization’s numbers may well rise to the top of the list of reimbursements by no fault of your own.

Now enter Obamacare into the mix which has the potential to push even more people onto the Medicaid roles.

We applaud New York State’s open initiative. It’s long past time for the Federal and State governments to recognize that the patient public has a responsibility to police their own ranks and patients must realize there will be ramifications for over-use of the system. The only way that will happen is if there are ramifications for doing so.

Working Together
Enhanced will continue to work with our clients by communicating about those runs that fail to meet medical necessity guidelines. This interaction, along with the reports our client can run using Enhanced PulsePoint™ and Enhanced PulsePoint™ Mobile will help our New York State based clients and other clients too to identify those patients who may be over-utilizing the service provided by your organization.

If you don’t have that kind of capability at your disposal and your organization is not an Enhanced client, then it’s time to give Chuck Humphrey a call to find out how to become a client. You can reach Chuck via e-mail at chumphrey@enhancedms.com or by calling toll-free to (800) 369-7544, Extension 108.
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