Healthcare medical compliance
INTRODUCTION
Barbara McMahon sat at her desk, deep in thought. She had just returned to her office from the March compliance committee meeting and her head was swimming. It was her fourth week as Vice President Revenue Cycle Management for Texas Physician Group – a medical group practice based out of San Antonio Texas with over 400 Physicians. Barbara had briefed the committee on the results of an internal medical coding audit the Central Business Office conducted in February 2018. The audit identified over $300,000 in incorrect Medicare payments. Also troubling Barbara, were the results of a government Certified Error Rate Testing Audit spanning claims from 2015 to 2018. According to Barbara’s analysis, 49.9% of the payments received for the sample claims audited, were incorrect. Barbara stared at the barren walls of her office – still void of any decoration or personal effects – how was she going to get coding compliance under control.
With such an egregious improper payment rate, Barbara feared Texas Physician Group could become the target of the Recovery Audit Program, or even worse, the Office of Inspector General could extrapolate this error rate across all TPG’s Medicare payments. This type of extrapolation could result in a recoupment demand of more than 70 million, which of course TPG would have to vigorously appeal. Barbara assured herself that this worse-case scenario was unlikely, but it was clear to her she needed to fix coding compliance and fast!
TPG was not oblivious to its coding compliance issues. In 2016 it began to ramp up its efforts to improve coding accuracy. First, TPG hired certified coders to centralize 25% of its coding operations. Then it began looking for a cost-effective solution to centralize the remaining 75%. In December 2017, TPG entered into an agreement with MModal, a healthcare technology company, to outsource the balance of its coding operations. MModal planned to leverage its natural language processing software to codify the medical documentation to derive the appropriate medical billing codes. Coders based in India would then validate the accuracy of the codes. Barbara closed her eyes, thinking back to her unsuccessful ventures with offshore coding vendors. To further complicate matters, the technological component of the solution was still in its conceptual stage – MModal has never used its natural language processing software for this purpose. Barbara knew she needed to make the project a success or she had to quickly convince the CEO and the compliance committee of an alternative course of action. But what were her options?
COMPANY BACKGROUND
Texas Physician Group was founded in 1993, in a partnership of 13 family medicine physicians in San Antonio, Texas. The Physicians came together in a merger of their independent practices and hired Michael DaSilva as CEO to oversee the professional management of the Physician Group. Today, TPG is a $300 million privately held organization with 400 Providers (physicians, nurse practitioners, physician assistants) and 35 medical specialties in 50 locations. TPG employs 1,724 employees including 160 employees in its central business office and 700 supporting staff members (non-clinicians) in its clinics. In 2017, TPG billed for over 3 million patient encounters, over half of which were Medicare beneficiaries.
Physician Compensation at TPG
The compensation model makes it very attractive for Physicians who want to focus on a clinical practice but not the administrative burdens inherent in running a medical practice. Each Physician pays a percentage of their revenues for the administrative support of the TPG management group. Support includes marketing, financial planning, real estate management and billing support from the central business office.
· Newly practicing physicians who join the group receive a negotiated salary for two years. After this grace period, net revenues in excess of their salary are paid out in a quarterly bonus. Deficits are carried on their profit and loss statement until they generate a positive net income.
· Physicians with an existing patient roster are not granted a grace-period. Bonuses are paid when net revenues exceed their negotiated salary and withheld in deficit situations.
All Physicians receive ownership shares after two years with TPG and participate in any Physician Group distribution to shareholders.
TPGs Central Business Office
The central business office is a shared support service that provides billing support and manages the account receivables for the Physician Group. The responsibilities of the central business office, shown in Exhibit 1, include medical charge coding, charge billing, patient billing, revenue recovery, fee schedule management and physician coding compliance. Ultimately Barbara, as the head of the central business office, is responsible to TPG Physicians for their cash flow and to insurance companies, including government payers, for compliant medical claims.
TPG’s growth was partly why it needed to retrench and focus on its compliance infrastructure. During Barbara’s interview in February 2018, the CFO, Aharon Yoki explained:
“…. growth has always been our number one priority. Now, growth is a secondary priority to coding compliance. We have moved ….. to an organization that must now centralize all coding. Our size makes us an easy target.”
Growth, which was the CEO’s top priority for the last twenty years, was suddenly a second priority to managing coding compliance. Michael DaSilva, the CEO, explained his priorities this way:
I have three primary goals for the CBO this year. 1) improve relationships with the physician’s 2) improve patient collections and 3) implement the coding project – we must improve our coding compliance.
Company Culture
Staying true to their origin, TPG prided itself for being a large company with a “personal” feel. The original founding partners wanted Physicians to maintain complete ownership of their practice. In fact, in recruiting Physicians to join the group, Michael assures them that they will continue to run their practice as they always had. “Nothing is going to change for you” was his standard pitch. According to Michael, this was a key differentiator in attracting top talent in the San Antonio area.
During her first two weeks, as Barbara was introduced to other members of the Senior Management team, she was struck by their personal histories with TPG. Diane Kuntz, the Vice President of Operations, was originally the babysitter for one of the original partners. After high school, she began working part-time in his office, was promoted to Office Manager, and eventually worked her way up to a Senior Management role. Today, she is responsible for operational performance of all TPG Physician clinics and according to many sources, she is one of the most knowledgeable and influential employees at TPG. Many of the senior leaders shared similar stories.
INDUSTRY BACKGROUND
Medical Transcription
During a patient/doctor encounter, the doctor records his discussion with the patient including procedures performed, examinations conducted, and an ongoing plan of treatment. At the onset of the medical transcription industry in the early 20th century, the Physician often recorded this medical information in abbreviated handwritten notes that were stored in the patient’s file[footnoteRef:1] – usually along a wall of dusty filing cabinets. Handwritten notes eventually gave way to dictation using audio recording devices, which could then be handed off to a medical transcriptionist. Medical transcriptionists then transcribed the oral dictation which could be printed and stored in the patient’s file or retained digitally. Accurate medical documentation relies heavily on critical skills of a medical transcriptionists such as mastery of medical terminology, anatomy and the English language. In recent years, speech recognition software is increasingly being used as a method of transcription. In this transcription process, medical providers send their dictation by digital voice files which the software converts to text. For dictators to utilize this software, they must first train the program to learn their speech patterns. Poor speech habits and other problems such as heavy foreign accents and mumbling complicate the process for the recognition software. These flaws trigger concerns that the present technology could have adverse effects on patient care. Some providers, to mitigate the risk of transcription errors, continue to use medical transcriptionists to edit the language interpretations of the software. [1: Gruber, N. P., Shepherd, H., & Varner, R. V. (2002). Role of a medical staff coding committee in documentation, coding, and billing compliance. Psychiatric Services, 53(12), 1629-1631. 10.1176/appi.ps.53.12.1629 Retrieved from http://dx.doi.org/10.1176/appi.ps.53.12.1629]
Despite which transcription process is used, medical transcription is the primary mechanism for a physician to clearly communicate with other healthcare providers who access the patient record, to advise them of the state of the patients’ health and past/current treatment.
Electronic Medical Records
The transition to Electronic Medical Records (often referred to as Electronic Health Records) began to take off after 2009 when President Obama signed into law the American Reinvestment and Recovery Act. The Act created financial incentives for Electronic Medical Record adoption and penalties for continued use of paper records. While some Physicians continue to store their medical records on paper (citing the cost of EMRs far outweigh the financial disincentives), most physicians have migrated to electronic medical records. Electronic Medical Records systems eliminate the need to track down a patient’s previous paper medical records and assists in ensuring data is accurate and legible. Electronic Medical Records are particularly useful in Physician Groups such as TPG for coordination of care across multiple Physicians and care settings.
Medical Coding and Healthcare Reimbursement in the US
Medical coding is a critical part of healthcare services in the United States. Medical coding is the process of transforming the work performed by a healthcare provider (medical diagnosis, procedures, tests, equipment used etc.) into two sets of codes. Current Procedure Terminology codes describe all the expenses, equipment and medication charges involved in the medical treatment of a patient. International classification of disease codes describes the disease and diagnosis of a medical condition. Simply put, CPT codes are procedural codes that describe what kind of procedure a patient has received while ICD codes are diagnostic codes that describe why the patient needed to have these procedures. Together, these two sets of codes form the basis of healthcare reimbursement in the United States.
International Classification of Diseases
Since the 1970s, the US relied on the 9th revision of the International Classification of Diseases (ICD-9). The ICD code set is an internationally standardized diagnostic classification that is maintained by the World Health Organization. It was designed to study and analyze the health and illnesses of different populations on a global scale. Not only does it collect data, it also helps to improve healthcare by gathering data on processes such as clinical research, reimbursement, and resource allocation[footnoteRef:2]. Effective October 2015, the US adopted the 10th revision of the ICD codes – arguably the most disruptive change to medical coding in the U.S. in 30 years. While ICD-9 had approximately 14,000 codes, ICD-10 has 68,000 codes from which a Provider must choose. [footnoteRef:3] The ICD-10 codes are much more specific, requiring increased levels of detail in describing a diagnosis, illness, and procedure. To illustrate this point, the medical diagnosis code for a patient diagnosed with a non-pressure foot ulcer using ICD-9 is 707.15. In ICD-10, the Physician now has 15 diagnosis code choices, each code choice specifying the location (right or left foot) and the depth (skin, fat layer, muscle or bone) of the ulcer (see exhibit 2). Critics of the new code set however, argue that ICD has become too granular with the creation of ludicrous codes such as V91.07XA: “burn due to waterskies on fire” and “W22.02X: walked into a lamppost, second encounter”[footnoteRef:4]. Nonetheless, the ICD-10 codes, which were developed over many years through the guidance of many stakeholders such as government entities, healthcare providers, health plans, and vendors, are expected to achieve more efficiencies while improving the effectiveness of healthcare systems. [2: Examining ICD-10 implementation (2015). Retrieved from https://search.proquest.com/congressional/view/app-gis/hearing/h36-20150211-03 ] [3: McNeill, T. D. (2013). ICD-10-CM and the documentation gap Available from ProQuest Health Management. Retrieved from https://search.proquest.com/docview/1465430274] [4: Anna Wilde Mathews. (2011, Sep 13,). Walked into a lamppost? hurt while crocheting? help is on the way; new medical-billing system provides precision; nine codes for macaw mishaps. Wall Street Journal (Online) Retrieved from https://search.proquest.com/docview/888604105]
Current Procedure Terminology
In addition to the correct ICD-10 code selection, the medical biller/coder must also select the correct CPT code. Each CPT code is described in a CPT book – which is electronically maintained and copyrighted by the American Medical Association. Healthcare Providers do not get paid without correct CPT code selection, but the selection process is also very complex. Let’s say our patient with the foot ulcer has a procedure to remove the wound. The medical biller/coder has 10 possible codes from which to choose to bill this procedure. To select the correct code, they will need to know specific details such as the anatomical site, how the ulcer was removed, instruments used, size, condition, and depth of the ulcer. Selecting the correct code is critical as it could lead to an incorrect payment of over 200% (see exhibit 3).
Each reported CPT procedure code on the healthcare claim, must be accompanied by an ICD diagnosis code that supports the medical necessity of the healthcare services provided. The insurance payer scrutinizes the connection between these two codes and may either deny payment, make payment or request additional medical records to substantiate the request for payment. The Provider’s medical documentation, which must have sufficient granularity to substantiate the medical codes on the claim, is often the determining factor for a payment decision. This healthcare model is often referred to as “fee-for-service” denoting the fee (in the form of medical codes) that providers bill insurance companies for the healthcare services they provide.
From Medical Coding to Medical Billing
After determining the correct ICD-10 and CPT codes, medical billers or coders, data-enter these codes into a billing software (which is commonly integrated with the electronic medical record software). The billing software creates and electronically transmits a medical claim for payment by government agencies and other insurance companies. The complete steps involved in medical billing and coding are shown in exhibit 1.
Centers for Medicare & Medicaid Services
Through the Social Security Act of 1965, the government enacted Medicare and Medicaid adopting the fee-for-service insurance model. Medicare is a social insurance program for the elderly that serves more than 58 million enrollees and costs about $500 billion annually. Medicaid is a social welfare (or social protection) program that serves about 78 million enrollees and costs about $400 billion annually[footnoteRef:5]. Together, Medicare and Medicaid cover over one-third of the US population. Unlike most other developed countries where national health insurance is the norm, the United States healthcare system is primarily employer-based. Employer sponsored insurance coverage accounts for roughly half of the population in the United States (see exhibit 4). [5: Https://Www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNProducts/downloads/MCRP-bookletement organization program. (2006). ]
The Centers for Medicare and Medicaid (CMS) is the federal agency that administers Medicare, Medicaid and several other health-related programs. Since its inception, government spending on healthcare continued to increase at an alarming rate (see exhibit 5). With escalating healthcare costs, the CMS empowered several agencies to use criminal and civil penalties against those found guilty of committing abuse of or fraud against the government program. These agencies took several steps, including increased auditing of healthcare providers aiming to improve coding accuracy, curb inappropriate spending and eliminate abuse of the federal program.
Government Auditing
CMS employs hundreds of programs and processes to curb improper payments, the most prevalent of them are shown here:
Office of Inspector General for Health and Human Services – The Office of Inspector General is an independent organization of approximately 1600 commissioned by the federal government to fight fraud and abuse. The investigations result in criminal convictions and penalties, civil settlements, and administrative actions against those who commit fraud.
Certified Error Rate Testing Audits – The objective of Certified Error testing is to measure improper payments in the Medicare fee-for-service program. The audits are conducted annually using a statistically valid stratified random sample of claims. The practice will receive a demand letter from CMS notifying them of their intent to recoup monies for any improper payments found. In 2016, the program identified $42 billion in improper payments.
Recovery Audit Contractor Audits – The Recovery Audit Contractors reclaim money by performing retrospective reviews of previously paid claims. The Audit program targets providers with a high propensity for error as identified by the Certified Error Testing Audits and other CMS audits. The Recovery Audit Contractors are paid a contingency fee between 9% and 12.5% of all improper payments identified.
If any of these audit programs uncover suspicions of fraud or error rates outside of the national averages, the practice is referred to the appropriate jurisdiction agency for further audits and investigation. In addition to recouping improper payments, the findings of these audits are used to develop claim processing process controls and provider education[footnoteRef:6]. [6: Https://Www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNProducts/downloads/MCRP-bookletement organization program. (2006). ]
With government audits on the rise, Providers are fearful of becoming the next investigative target. A Provider making unintentional errors, could be found guilty of Medicare fraud or abuse if the errors result in unnecessary costs to the US government. The Office of Inspector General in a 2010 medical records review, reported Medicare inappropriately paid 46.7 billion that year for incorrectly coded claims and those lacking proper documentation. While blatant examples of fraud – such as the Texas Home Health Physician from Texas who defrauded CMS of $17 million by billing for services never performed[footnoteRef:7] – engender little sympathy from the medical community, the innocent offenses are scarier for Providers who may make errors out of ignorance or carelessness. [7: OIG most wanted fugitives.Https://Oig.hhs.gov/fraud/fugitives/index.asp.]
In Barbara’s experience, these types of innocent offenses often occur when the Provider’s documentation is not sufficiently thorough to support the services billed. In our foot ulcer example, a Provider who bills CPT code 11044 and 11047 is requesting payment of $447 by attesting he surgically removed over 25 square cm of skin down to the bone. However, if his medical documentation fails to support the depth of the wound or the surgical method of removal, the correct CPT code could be 97597 with a reimbursement of only $82.
Billing and Coding Software at TPG
Texas Physician Group utilizes the Intergy Practice Management (PM) System created by Greenway Health for its billing and coding processes. The software has a fully integrated set of tools that help manage the entire practice from scheduling patients, to medical documentation in the integrated electronic medical record, to billing insurance claims and managing account receivables. Exhibit 1 shows the entire sequence of processes TPG manages within Intergy. Intergy can deployed as both web-based solution however TPG chooses to maintain it on its over servers. This section needs more but not sure what more needs to be said.
COMPLIANCE AT TEXAS PHYSICIAN GROUP
For twenty-five years, Providers at TPG were responsible for their own medical coding. As the company grew, it gained new perspectives of the risks associated with decentralized coding – as new Providers were added to the enterprise, more compliance issues surfaced both through internal and government audits.
· In 2016, during a nationwide audit of Home Health services, one of TPGs Home Health Physicians was fined for incorrect documentation.
· In 2015, the Comprehensive Error Rate Program began audits of TPG Physicians. Between 2015 and 2018 the contractor identified errors in 35% of the claims and 49.9% of the payments. Types of errors included:
· No documentation – Provider did not have the requested documentation
· Insufficient documentation – Medical documentation is inadequate to support payment for the services billed.
· Medical Necessity – The documentation in the medical records does not substantiate the medical necessity of the services provided.
· Incorrect Coding – Medical documentation supports a different code that was billed.
· In 2016, the central business office launched several internal audits aimed at identifying compliance risks and educating physicians. The results were reported to the Compliance Committee and Board of Directors.
In 2016, TPG slowly began to centralize its coding operations. To minimize financial exposure from a coding audit, TPG first centralized the coding of high dollar medical procedures (such as those performed in a hospital setting). Today, the centralized coding team comprises 15 certified coders and supports 100 TPG Providers. The remaining 300 Providers, who primarily practice in office-based settings, continue to perform their own medical coding.
Searching for a cost-effective solution to centralize the remaining 300 Providers, TPG turned to MModal – a leader in the coding transcription industry and a current vendor at TPG. Still in the planning phase, the coding project with MModal would leverage cloud-based natural language processing software to transcribe digital dictation to text in the electronic medical record and then to medical codes. Medical coders located in four cities in India, would then validate the transcribed medical codes for accuracy.
TPG’s Coding Process
Not all TPG Physicians were keen on relinquishing their coding authority. Some believed their extensive experience made them more qualified to accurately code than a certified physician coder. To accommodate those concerns, the Board of Directors agreed to allow the Physicians to continue to derive their own medical codes given that they allow the certified coders to review their work and inform them of any recommended changes. In this process, the coder notifies the Physician – via email – of recommended changes to their coding and of any documentation deficiencies. If the Physician disagrees with the recommendations, they must respond to the coder within one week. If the Provider fails to respond, the coder updates the codes in Intergy, (TPG’s electronic medical record system owned by Greenway Health). This process created some troubling issues for Barbara:
1) First, there was no arbitration process in place to resolve disagreements between the Physician and coder’s medical code choices. Relationships between coder and Physician quickly deteriorated when consensus could not be reached.
2) Second, some Physicians did not review the email recommendations from the coders. Without their participation in the process, documentation deficiencies – which was critical to accurate coding – could not improve.
TPG’s Coding Audit Process
TPG launched its auditing program in 2014. TPG performs an annual audit on the remaining 300 Providers who perform their own coding. The audit plan calls for each Provider to receive an audit of ten randomly selected Medicare accounts once every two years. Providers with a 30% or higher error rate are re-audited in six-months. After three failed audits, the compliance committee reviews the case and determines an appropriate course of corrective action, which may include requiring the Provider to absorb the cost of relinquishing his coding to certified coder.
TPG’s Coding Compliance Committee
TPG’s compliance committee was formed in 2000. The committee meets monthly to review new and outstanding compliance concerns. In preparation for the March meeting, Barbara looked over the agenda and minutes from the previous month.
1. Outstanding Documentation concerns – Fines for Physicians who failed to complete their medical record documentation within 30 days of the patient encounter. Committee reviewed the appeals of the Physician’s with outstanding documentation. Based on the personal circumstances of Dr. Shankar he will not be fined. Dr. Jones shows great improvement, his fine will be excused. Dr. Barry has no excuse and will be fined per our policy.
2. Internal Audits
a. Physicians with three consecutive failed audits – discussion of next steps. Dr. Choufib has failed 3 audits. He believes his documentation template is the root cause. Deborah will work with him to get corrected and then he will be re-audited.
b. Medical claims billed incorrectly –The CBO will correct all errors and rebill the corrected claims to Medicare.
3. Compliance Committee Charter – developing and implementing a formal charter to define scope, roles and responsibilities for the compliance committee. Committee ran out of time. Discussion tabled for next month.
MMODAL
Company History
MModal is a healthcare technology company, based out of Franklin, TN. MModal provides clinical documentation technology for the healthcare industry (Bloomberg, xax). Since its inception in 1998, the company has grown to over 12,000 employees and operates in six different countries.
MModal offers a wide variety of products that center around medical coding and transcription that utilize the latest technology platforms. They are an industry leader advanced Speech and Natural Language Understanding Technology (MModal, xax). This technology can transform a physician’s narrative into structured, encoded information that can be translated into clinical intelligence (MModal, xax). Their technology focuses on ease of use for the end-user while providing high quality diagnostic interpretations. Several of their product offerings, including the Fluency Direct product, have earned Best in KLAS – a designation of excellence for health information technology software – for both innovation and accuracy. Currently, they boast a client list of over 800 healthcare organizations that utilize their technology to increase the quality of care and clinical outcomes.
Products/Services
A brief description of their most popular products (M*Modal, xax):
· MModal Scout®: a business intelligence/analytics tool (BIA) that improves performance and efficiency of documentation quality and reporting.
· Fluency Flex®: technology platform that enables physicians to create patient documentation by using MModal’s Speech Understanding Technology and their Computer Assisted Physician Documentation (CAPD)
· Fluency for Transcription®: medical transcription software that provides real-time clinical documentation when used with their clinical documentation improvement platform (CDI)
· Fluency Direct®: helps clinicians to improve medical documentation, ensuring better coding and compliance and reducing retrospective notes and adjustments
· Fluency for Coding®: a cloud-based enterprise medical coding platform aimed at driving medical coding productivity and quality.
In addition to these services, MModal also offers: transcription/coding services, medical scribing services, and adaption service (MModal, xax).
Financial Background
Despite its strong product offerings and its leading technology applications, MModal was not without financial challenges. In 2011, MedQuist Holdings, another leading provider of integrated clinical documentation technology, merged with MModal. MedQuist purchased MModal, in a reverse takeover, for $130 million – both cash and stock. After this transaction was finalized, MedQuist assumed the MModal name and began trading publicly on the NASDAQ Exchange. Within 11 months, One Equity Partners (a JP Morgan Chase subsidiary), purchased MModal for: $48.4 million in cash, 4.1 million shares of common stock, and $28.8 million in cash installments (to be paid over the next three years) (MedQuist, xax). In addition to this initial merger price, One Equity Partners will invest an additional $13 million in integration costs. The deal was finalized in 2012 for a total merger price (including common stock value) of roughly $1.1 billion.
In 2014, after this $1.1 billion-dollar deal was finalized, MModal filed for bankruptcy. In roughly two years, MModal acquired roughly $750 million in new debt. At the time of the filing, MModal owed $500 million to an investment group with the Royal Bank of Canada and $250 million in unsecured notes (Milliard, HealthCare News). According to MModal’s company executives, the acquisition with MedQuist was financed with a capital structure that was aligned with a set of assumptions that are no longer relevant (Miliard, HealthCare News). The company plans to use the bankruptcy protection to improve their balance sheet while creating more financial flexibility to support new growth.
THE CODING PROJECT
TPG currently utilizes MModal’s “Fluency for Transcription” product for their medical transcription service. By integrating directly into Intergy, the patient’s medical record is updated with the text from the digital recording. Certified medical coders produce the appropriate ICD-10 and CPT codes for TPG Physicians who practice in Hospitals. Seeking a creative solution to cost effectively centralize the remainder of its coding operations, TPG asked MModal to customize a technological solution to address this problem.
Needing to get up to speed, Barbara requested MModal provide a project status update. Kris, the MModal project manager copied Denis the CIO, and Ahraon the CFO on her response:
…. “your team provided MModal with good information on the Inpatient side of TPG, the engagement is for Professional Billing services and Technology so as long as we have a contact that can walk MModal through the physician coding workflow for the clinics that will be fantastic for when we determine onsite discovery dates.”
Confused by this response, Ahraon responded:
“Kris, … any discussion related to physician coding workflow will need to be conducted with Denis and/or members of his team. I thought that type meeting was previously coordinated….”
Kris replied,
“This meeting would be to discuss scope of the project and setting up timing for onsite discovery … we never had any of the discussions regarding this because the previous meeting concentrated on Inpatient Coding Workflow which was not in scope. Thank you.”
Taking matters into her own hands, Barbara scheduled a demo with the MModal project team. After about an hour, Barbara summarized what she had learned this way:
Your natural language processing software will codify the medical record documentation by looking for patterns, trends and key words. You will then overlay this information onto the billing coding guidelines established by the American Medical Association. Your software will analyze the results and produce a CPT code which is then compared to the CPT code selected by our Physician. ICD codes are out of scope. This approach is experimental in nature, meaning that no one in the industry has successfully used natural language processing software for this intended purpose.”
The software uses an iterative machine learning process – as errors are found, the software learns and updates its algorithms. Together with is natural learning process, machine learning, rules and algorithms, the software suggests medical codes based on reading and interpreting the medical documentation. MModal explained that during the development process, and for the first year, they planned to utilize coders based in India to validate 100% of the codes produced by the software. Over time, as the machine learns and increases in accuracy, the software would provide coders without coder review. Once the MModal code is deemed accurate, it is compared to the TPG Physician’s code. Discrepancies are considered potential TPG errors and are sent back to TPG to review and possibly re-code.
To ensure sufficient volume to facilitate the machine learning process, the contract terms specify a 40,000-chart minimum at $0.49 per chart. It is anticipated that the software would achieve a 60% accuracy rate by May 2019 after which time the per chart fees increase to $0.69. MModal coders would continue to audit 10% of the their output to ensure the software’s ongoing coding accuracy. It was not yet determined how MModal will access the Physician’s coding in the EMR, or how TPG would receive notification of codes that do not match the Physician’s codes.
THE DECISON
It was clear to Barbara that compliance was a priority for TPG. While TPG had already taken steps to mitigate compliance risk, Barbara was not convinced that the steps taken were the right solutions. Successfully leveraging natural language processing and machine learning to increase coding accuracy was not yet proven and in fact in early adoption stages within the healthcare industry. Could MModal deliver on what they were promising? And what if it failed? What were her options then?
Option One: Create a project management team and a project governance team to oversee the project deliverables, the timing of the deliverables and establish accountable owners. TPG had a history of implementing large projects without project governance. Would they accept this recommendation from a ‘outsider” when it was not how things were done at TPG?
Option Two: Convince the C-suite that the project is too risky to move forward. TPG could hire more certified physician coders to fully centralize all medical coding. With fifteen coders, TPG currently supported about 10% of all coding volume. TPG would need to hire over 100 coders to support all Physician coding. TPG had already decided that this option was cost prohibitive. But how did that cost compare against the cost of failing at this project?
Option Three: Do nothing. TPG had decided on the coding project prior to Barbara’s arrival. Could she integrate into TPG’s way of doing things, adopting their cultural norms for project management?
References
Anna Wilde Mathews . Wall Street Journal (Online); New York, N.Y. [New York, & N.Y]13 Sep 2011: n/a. Walked into a lamppost? hurt while crocheting? help is on the way; new medical-billing system provides precision; nine codes for macaw mishaps.
https://canscribe.com/frequently-asked-questions/
Bocchino, Carmella. “Examining ICD-10 Implementation”. (February 11, 2015). Hearing Before the Subcommittee on Health of the Committee on Energy & Commerce. House of Representatives, 114th Congress, Washington, DC.
Cearley, David W., Burke, Brian, Searle, Samantha, Walker, Mike J. (October 3, 2017). “Top 10 Strategic Technology Trends for 2018”. Retrieved from: https://www.gartner.com/document/3865406?ref=feed
Gruber, N. P., Shepherd, H., & Varner, R. V. (2002). Role of a medical staff coding committee in documentation, coding, and billing compliance. Psychiatric Services, 53(12), 1629-1631. 10.1176/appi.ps.53.12.1629 Retrieved from http://dx.doi.org/10.1176/appi.ps.53.12.1629
ICD-10 codes and various types of quackery; you can imagine the ER doctor’s astonishment: “What a bizarre personal appearance, struck by a duck, and accident while knitting.”. (2015, Oct 17,). Wall Street Journal (Online) Retrieved from https://search.proquest.com/docview/1722487363
McGovern, M. A. (2013). Treble what? calculating the federal government’s “damages” under the civil false claims act: Until now, there has been minimal discussion about the methodology used to calculate damages. Journal of Health Care Compliance, 15(4), 57.
McNeill, T. D. (2013). ICD-10-CM and the documentation gap Available from ProQuest Health Management. Retrieved from https://search.proquest.com/docview/1465430274
Melinda Beck. (2015, Sep 28,). 70,000 ways to classify ailments — enormous expansion of codes doctors use will change paperwork, insurance, monitoring. Wall Street Journal Retrieved from https://search.proquest.com/docview/1716883262
Organizations Typically Contemplate Three, General Approaches When Determining the Role, & of Internal Auditor. Dissecting the internal audit function in health care
Oxley, H., & MacFarlan, M. (1995). Health care reform: Controlling spending and increasing efficiency. OECD Economic Studies, 24(24), 7-55. Retrieved from https://search.proquest.com/docview/1297991091
Scichilone, R. A. (2009). Are we there yet? compliance-ready computer-assisted coding: New technologies help organizations work smarter toward compliance-ready systems. Journal of Health Care Compliance, 11(4), 55.
“M*Modal”. Bloomberg News. (web address)
“MedQuist”. MedQuist Holdings, Inc. Press Release: August 2011.
Miliard, “M*Modal files for bankruptcy protection”. HealthCare IT News. March 2014.
“M*Modal Launches Virtual Scribing Program.” M*Modal. Press Release: February 2017.
EXHIBITS
Exhibit 1 – Medical Billing and Coding Process. Steps three through nine are performed by TPG’s Central Billing Office
http://www.medical-billing.com/blog/wp-content/uploads/2014/03/Medical-Billing-Process1.gif
Source: http://libguides.reynolds.edu/Medical_Coding
Exhibit 2 – Example of Increased Complexity in Coding from ICD- 9 to ICD-10
Source: Optum360 ICD-10-CM: Professional for Physicians.
Exhibit 3 – Relationship between CPT codes for removing an ulcer and impact to reimbursement
Example – Skin Debridement
CPT Code
Description
Average Medicare Payment
11042
Debridement of first 20 square cm of skin tissue (including epidermis and dermis)
$120
11043
Debridement of first 20 square cm of muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue)
11044
Debridement of first 20 square cm of bone (includes epidermis, dermis, subcutaneous tissue, muscle or fascia)
$319
11045
Debridement of each additional 20 square cm of skin tissue (including epidermis and dermis
$42
11046
Debridement of each additional 20 square cm of muscle (including epidermis and dermis
11047
Debridement of each additional 20 square cm of bone (includes epidermis, dermis, subcutaneous tissue, muscle or fascia)
$128
97597
Debridement of first 20 square cm of open wound including topical applications, wound assessment.
$82
97598
Debridement of each additional 20 square cm of open wound including topical applications, wound assessment
97602
Removal of devitalized tissue from wounds including topical applications, wound assessment and instructions.
*Descriptions are generally representative of the procedure and not intended to be the official AMA description of CPT codes. Not an inclusive list of all relevant debridement codes. Medicare Payments lifted from CMS Physician Fee Schedule for locality 99.
Source: www.Medicarepaymentand reimbursement.com/2016/10/procedure-codes
Exhibit 4 – Distribution of Health Insurance Coverage in the US (by type of insurance)
Exhibit 5 – Rising Government Spending on Healthcare
Exhibit 6 – Texas Physician Group Partial Organization Chart (as of March 2018)
Compliance committee members are shown with an asterisk
Exhibit 7 – Glossary of Key Terms
1 | Page
14 Volume #, Number #, 2016
2
Term
ACO
CERT
CMS
RAC
OIG
CPT
EMR
HER
Fee for Service
ICD
Transcription
WHO
Medicaid
Medicare
Medicare Fraud
Medicare Abuse
Natural Language
Processing Technology
Speech Recognition
Speech recognition is the inter-disciplinary sub-field of computational linguistics that enables the recognition and translation of spoken language into text by
computers.
A healthcare payment model where services are paid for separately. It can give Physicians an incentive to provide more treatments because payment is
dependent on the quantity of care rather than the quality of care.
An Accountable Care Organzation is a healthcare organization that ties payments to quality metrics and the cost of care.
Definition
NLP is a branch of artificial intelligence that helps computers understand, interpret and manipulate human language. NLP is often used in combination with
machine learning and text analytics to analyze large amounts of unstructured data to identify issues, evaluate sentiment, detect emerging trends and spot
hidden opportunities
International Classification of Diseases. Medical Diagnosis codes created and maintained by the World Health Organization. Used Internationally by members of
the United Nations. In use in the US sicne 1999 to report mortality rates. Adopted in 2014 in the US as the official code set for healthcare reimbursement.
A National health insurance program administered by the US federal government since 1966. Provides health insurance for Americans aged 65 and older who
have worked and paid into the system through payroll tax.
Medicaid in the US is a joint federal and state program that helps with medical costs for some people with limited income.
Longitudinal collection of electronic health information of individual patients. Often synonymous with Electronic Medical Record
Medicare Abuse is defined as practices that either directly or indirectly result in unnecessary costs to the Medicare program.
Medicare Fraud is defined as knowingly and willfully executing a scheme to defraud federal healthcare programs
The World Health Organization is the directing and coordinating authority on international health within the United Nations system. Objectives include provding
leadership, sharing medical research agenda, setting norms and standards, creating ethical and evidence based healthcare policy options assessing health trends
The Comprehensive Error Rate program measures improper payments. Each year CERT evaluates a statistically valid sample of claims to determin if they were
paid properly udner Medicare coverage, coding and billing rules.
Center for Medicare and Medicaid Services previously known as the Health Care Financing Administration. A federal agency within the Department of Health
and Human Services that administers the Medicare and works in conjunction with state government to administer Medicaid.
The Recovery Audit Contractor program is commissioned by CMS in 2010 to identify and correct improper payments. Providers shown to have high rates of
improper payments are specifically targeted for audits. Providers who continue to have high error rates may be subject to a demand for repayment
The Office of Inspector General of Health and Human Services is an independent organization commissioned the federal government to fight fraud, waste and
abuse. Their investigations result in criminal convections and penalties, civil settlements and administrative actions against those who committee fraud.
Electronic patient record created by providers for specific encounters. Serves as the data source fort he HER.
Current Procedure Terminology. Updated Annually, maintained and copyrighted by the American Medical Association
The systematic representation of language in written form
