By: Sean Weiss, Vice President and Chief Compliance Officer for Doctors-Management

Prior to being appointed as Secretary of HHS in 2009, Ms. Sebelius was Governor of Kansas-first elected in 2002 and then re-elected in 2006. Ms. Sebelius served as executive director and chief lobbyist for the Kansas Trial Lawyers Association (now Kansas Association for Justice) from 1977-1986. She was first elected to the Kansas House of Representatives in 1986. In 1994, Ms. Sebelius left the House to run for state Insurance Commissioner and in a stunning upset became the first Democrat in 10 years to win.

Ms. Sebelius has accomplished much in her professional career, but none more impressive to me then when she refused to take campaign contributions from the insurance industry and then blocked the proposed merger of Blue Cross Blue Shield of Kansas, the state's largest health insurer, with an Indiana-based company. Sebelius's decision marked the first time that the corporation had been rebuffed in its acquisition attempts. Though also considered as one of the most contentious administrations in recent history-namely due to the enactment of Health Reform (Obamacare/PPACA), Secretary Sebelius has proudly served during one of the most historic Presidencies of our time.

Among medical professionals, there are many questions attending the implementation date of ICD-10-CM as well as questions concerning various issues within health and human services. To discover insightful answers to many of these common inquiries, read the following informative interview with Secretary Kathleen Sebelius.

INTERVIEW

BC Advantage (BCA): Some health care providers and physician practices in particular, have seen the shift to ICD-10-CM diagnostic coding as an expensive, time-consuming, and unnecessary burden since it was first announced. Originally, it was to be implemented in October 2013, and HHS has now extended the implementation date to October 2014. What is the rationale for this one-year delay?

Secretary Kathleen Sebelius (KS): Let me begin by saying that a number of providers and provider associations support the transition to ICD-10. They recognize that ICD-9 is outdated and that the industry's use of ICD-10 will provide data to improve health care, provide cost effective approaches to delivering health care, and supply us with information for better research. But at the end of last year and early this year, three issues emerged that led us to reconsider the compliance date for ICD-10. First, the industrys transition to Version 5010 had some hiccups. Second, providers expressed concern that other statutory initiatives were stretching their resources. Lastly, after examination of data, we felt providers were not yet ready for the ICD-10 transition.

In the April 2012 proposed rule, which proposed delaying ICD-10 implementation, we examined a number of options. Based on our analysis and public comments on that proposed rule, we found that to go forward with the original compliance date could risk disruptions on a number of levels, while a delay of any more than a year would incur costs that could not be justified. Many sectors of the U.S. health care industry, including providers, have invested heavily in order to meet the regulatory requirements, and continued delays would negatively affect every level of the health care industry.

BCA: What would you tell skeptical health care providers who put off training because they expect additional implementation delays?

KS: We do not expect any further delays of the ICD-10 compliance date. The delay until October 1, 2014 is based on a number of very specific circumstances, and we want to ensure that ICD-10 is implemented without further delay because further delays would be costly to the industry at large. ICD-10 is integrated into other e-health initiatives and, as stated earlier, we anticipate it will contribute to improved quality and outcomes data, provide cost effective approaches to delivering health care, and supply us with information for better research. Any further delay would postpone the opportunity to reap those benefits.

BCA: What, if any, effect does the potential ICD-11 coding system have on the current and future status of ICD-10?

KS: ICD-11 is still in an early stage of development and isn't available in a version that can be analyzed in any comprehensive sense. Right now, were focused on the implementation of ICD-10 so that patients, providers, researchers, and the nation as a whole can benefit from this new coding system.

BCA: In the past few years, there has been a push to expand the preventive services coverage offered under Medicare. Do you expect to continue to look for new preventive services to cover?

KS: Originally, the law only allowed Medicare to cover services that were reasonable and necessary to detect and or treat a medical condition, and therefore, preventive services were excluded from coverage. However, over the years, Congress extended coverage to a growing list of preventive services. These included screenings for breast, cervical, prostate, and colorectal cancers to promote diagnosis at earlier and more treatable stages; certain vaccines, such as influenza and pneumonia; and laboratory screening tests for cardiovascular diseases and diabetes.

The Affordable Care Act gave us new tools that make it easier for people with Medicare to get the preventive care they need. Beginning in January 2011, the Affordable Care Act waived cost-sharing for many Medicare preventive services, including bone mass measurement, various cancer screenings, and hepatitis B vaccinations, among others. In addition, per the Affordable Care Act, Medicare now offers coverage for an Annual Wellness Visit, without cost to beneficiaries when furnished by qualified and participating physicians and health professionals, and began providing a 50 percent discount for the covered brand-name prescription medications people need to manage chronic conditions, when they are in the coverage gap known as the "donut hole." Taking medications when you're supposed to is critical if you want to keep a chronic condition from getting worse.

Any other new preventive services would be determined by statute or through the National Coverage Determination (NCD) process if they are recommended by the U.S. Preventive Services Task Force.

BCA: What preventive services do you see adding to the approved list in the coming year (2013)?

KS: Currently, no preventive services NCDs are pending.

BCA: CMS is required to offset most additional spending on Medicare services by taking funding from other services. If you were to expand your preventive services offerings, how would they be funded? Are there any Medicare service types you believe may be currently overpaid? How do you make that determination?

KS: Any other new preventive services would be determined by statute or through the National Coverage Determination process if they are recommended by the U.S. Preventive Services Task Force. National coverage determinations are made through an evidence-based process, with opportunities for public participation.

Over the long term, we believe that better access to preventive services will save Medicare and Medicare beneficiaries' money by preventing or identifying conditions, such as breast cancer or diabetes, which can be treated earlier and more effectively before conditions worsen. Studies have shown that removing cost-sharing requirements can increase the use of preventive services. For example, one study found that the rate of getting a mammogram went up as much as 9% when cost sharing was removed.

BCA: Please share with our readers HHS plans related to stepped-up auditing and enforcement efforts tied to Fraud and Abuse and how have you been able to target providers more accurately for review?

KS: CMS has recently implemented a twin pillar approach for advancing our fraud prevention strategy in Medicare. The first pillar is the new Fraud Prevention System that applies predictive analytic technology on claims prior to payment to identify unusual and suspicious billing patterns. The second pillar is the Automated Provider Screening system that is identifying ineligible providers and suppliers prior to enrollment or revalidation. Together, these two innovative, comprehensive new systems are growing in their capacity to protect patients and taxpayers from those intent on defrauding our programs. The Fraud Prevention System and the Automated Provider Screening represent an integrated approach to program integrity  preventing fraud before payments are made, keeping dishonest providers and suppliers out of Medicare in the first place, and quickly removing wrongdoers from the program once they are detected. We are confident that, over time, these two approaches will build on the other fraud tools we have and will help to more efficiently and effectively combat fraud, waste, and abuse, as well as reduce improper payments.

BCA: What impact has the RAC and ZPIC programs had on audit recoveries and do you see them playing a more active role in the future? If so, how do you see their expanded roles for CMS impacting your ability to make recoveries?

KS: CMS uses a variety of different contractors to administer and oversee the Medicare fee-for-service program. Each of these contractors has different roles and responsibilities. Some contractors specifically assist CMS in combating fraud and identifying improper payments, while others assist CMS' fraud fighting efforts as part of their broader responsibilities as fee-for-service contractors who process claims and recover overpayments. For example, last year alone, Recovery Auditors identified and corrected just under $940 million in improper payments. There was nearly $800 million collected in overpayments and over $140 million identified underpayments that have been paid back to providers.

BCA: How much of a spending increase do you anticipate for auditing and enforcement?

KS: We are currently maintaining the level of spending for audits being performed. But our focus has shifted beyond a "pay and chase" model to prevention and the search for fraud before it occurs.

BCA: The HEAT (Joint effort program between DOJ, HHS, and CMS) Program has had some incredible initial success; what do you attribute that to?

KS: Much of the success of the Health Care Fraud Prevention & Enforcement Action Team (HEAT) is attributable to the genuine partnership and cooperation that exists between HHS and the Department of Justice (DOJ), and specifically our focus on key areas for coordination and improvement. HEAT is comprised of top-level law enforcement agents, prosecutors, attorneys, auditors, evaluators, and other staff from HHS and DOJ and their operating divisions, and is dedicated to joint efforts across government to both prevent fraud and enforce current anti-fraud laws around the country.

For example, the Medicare Fraud Strike Force, a key component of HEAT, uses advanced data analysis techniques to identify high-billing levels in health care fraud hot spots so that interagency teams can target emerging or migrating schemes, along with chronic fraud by criminals masquerading as health care providers or suppliers. The impressive results garnered already are a product of this kind of teamwork.

BCA: How do you see this program expanding in the future and what impact financially will this have for the CMS programs?

KS: The HEAT partners continue to work together in finalizing future HEAT enforcement strategies. However, key components of a joint strategy will be flexibility and responsiveness to newly available data regarding trends in health care fraud. Our priority is to have sufficient Strike Force resources in the locations identified by our data analysis teams as those most vulnerable to health care fraud.

Sean M. Weiss, CPC, CPC-P, CCP-P, ACS-EM, Vice President and Chief Compliance Officer for Doctors-Management, specializes in audit and appeal representation for large and small healthcare practices that have been targeted by federal (Medicare), state (Medicaid), and commercial insurance payors. Sean has worked with thousands of physicians, medical practice groups, hospitals, and medical management societies, and he is recognized as an expert in the field of medical compliance. Sean delivers measurable financial results for healthcare facilities and helps physicians deliver quality care without sacrificing government compliance.

sweiss@drsmgmt.com
800-635-4040 X 123
DoctorsManagement, LLC
http://www.doctors-management.com/