Fraud? Abuse? Ignorance?

I promise your eyes will NOT glaze over – but you need to know what’s going on in the arcane world of procedure coding. Why?

Because your PT costs may be $15-$19 per visit higher than they should be.  And the savings your vendor is touting might be even more inflated.

Here’s what’s going on – and remember, this is specific to PT.

It’s common for therapists to perform multiple procedures at the same time – on a single body part.  There’s a list of procedures that are commonly performed together, and unless the therapist adds a specific modifier to the procedure code, only one will be reimbursed.

Nationally accepted standards (under CMS’ National Correct Coding Initiative) allow the therapist to be reimbursed for only one of these procedures.  Sometimes it is appropriate for the PT to bill for multiple procedures – for example, if two procedures commonly done simultaneously are performed at separate and distinct times.

In this circumstance, the treating provider documents the reason for the variance in coding in the medical notes.  On the bill, the “59 modifier” is added to the end of the CPT code to indicate that the code should be paid.

Hang in there – almost done…btw there’s a good overview of the latest info on this courtesy of medical bill review company Equian here

National average statistics (from two HSA customers I’ve been working with on this) indicate the 59 modifier should be on about 11%-15% of lines on PT bills.

Which brings me to the crux of the matter.  Some payers are seeing 59 modifiers on almost ALL BILLs.  After a lot of research, digging thru billing data, and back-and-forth with therapists and PT networks, it appears the 59 modifiers were NOT added by the therapist; they were added by a PT network company.

Further, there’s no explanation in the treatment notes for this billing practice; no evidence the affected procedures were actually performed at separate and distinct times; no indication the PT network company reviewed the treating provider’s notes prior to upcoding.  No documentation, no record, no history.

It appears that the intermediary was adding the 59 modifier as an automated system edit without reviewing the treatment notes. Without putting too fine a point on this, the systemic upcoding has resulted in higher costs for payers, along with significantly exaggerated savings as the bills show higher billed charges.

Perhaps there is a perfectly reasonable explanation for this, however I’ve not heard one to date.  And the coding experts I’ve spoken with can’t seem to come up with one either.

Let me be clear – this is specific to the use – appropriate, inappropriate, or questionable – of the 59 modifier, and only the 59 modifier. Ongoing research has not turned up other billing-related issues.

What does this mean for you?

You need to ask your billing folks to review their PT billing data to determine if:

  • You’ve been paying too much for PT

  • You have made decisions on PT vendors based on inaccurate information

  • Your employer clients have been billed for too much PT, and paid too much for managed care services.

How will you know if this is a problem?
Look at bills processed between 2009 and 2014 -

  • If more than 20 percent of lines on your PT bills have the 59 modifier, you MAY have a problem.
  • If more than 40 percent of the lines on your PT bills have this modifier, you DO have a problem.

What do you do if you think you’ve got a problem?

  • Ask your PT network/billing intermediary to explain, and require them to show why they are adding the modifier and how they are justifying doing this without reviewing the treating provider’s bills.

That will be a very interesting conversation…

Indiana expands Medicaid

A remarkable experiment is about to begin in Indiana; the state will expand Medicaid, but recipients with incomes above the poverty line will have to contribute to the cost and pay something towards doctor and hospital visits.

I don’t buy the argument that this is a step onto the proverbial slippery slope, that next we know Medicaid beneficiaries will be forced to pay higher and higher deductibles and copays.

That’s as specious as the argument that states shouldn’t expand Medicaid because some day in the non-defined future the feds will pull the funding.

Nope, it is high time beneficiaries had some skin in the game.  Heck, I’d even go for giving the lower-income recipients a cash account they can use for similar deductibles and copays, with any balance at the end of the year going into a fund for education, child care, food, whatever.

Indiana follows in the footsteps of Iowa; several other states are looking into a similar program.  This is exactly what we need, states trying different things, seeing what works and what doesn’t.  We’ve learned a lot from Massachusetts – the state’s Connector plan has produced remarkably positive results.

Here’s hoping IN, IA and the other experimenting states learn a lot, and learn it quickly.



NOT taking risks is what’s risky

I’m talking about marketing here folks, and not the typical work comp service marketing, which is not much more than a big party at NWCDC &/or RIMS plus some folks doing RFP responses and the (very) occasional website re-do.

Nope – real marketing – creative brand promotion that dramatically raises awareness.  Campaigns that make the market sit up and take notice. Smacking them in their eyeballs with innovative, aggressive, creative messaging.

When was the last time you saw really good marketing in this boooooring business of ours?  Stuff like the Newcastle campaign?  Campaigns like Kinaxis‘ that produce brilliantly simple and quite funny brand messages for pretty dry products?

(This video on implementation as a differentiator is hysterical)

Or Microsoft’s Camp Network? (I can already see execs cringing over the “nobody eat the berries” bit…)

Not taking risks is what’s risky.  Staid, boring, yawn-inducing plain-vanilla stuff is, well, safe – if you define “safe” as no one will ever pay attention to it, so you won’t get fired.

It also won’t get you any results.

What gets results is risky, aggressive, out-there marketing.  If it doesn’t make the denizens of the C-suite at least a little nervous, its probably not worth doing.  Because it can be holy-smokes-effective, as in millions of impressions and millions in new revenue.

Let’s be clear – we aren’t talking “risky” as in “stupid”.  Not offensive, but rather “we think this works but it may not”; “this is a big departure from stuff we’ve done in the past”; “no one else in our niche has ever done anything like this”. To break through, you have to take that risk. In a world of grey and greyblue, bright orange will stand out and grab the viewer.

Which gets you their attention, for about a nanosecond.  Great marketing grabs and holds the viewer’s attention while communicating your message clearly and completely. 

And you can’t do that if you go immediately from orange back to your usual greyblue.

What does this mean for you?

Success favors the smart risk taker.

Misunderstanding “Obamacare”

There’s much confusion, conflation, and outright nonsense out there about “Obamacare” and the implications and effects thereof, most of it based on a lack of understanding, and a lot of that seemingly willful.

This was brought home in recent conversations with friends; one on the board of a local hospital here in upstate New York, another who is close friends with a brand-new neurosurgeon, a third a child psychiatrist in the South.

The general issue is simple: every problem – great, small; clinical, financial, or administrative; access-, process-, or outcome-based; that involves health insurance, health plans, governmental programs is blamed on Obamacare.

That asteroid coming within a mere 745,000 miles?  Damn Obamacare!

The Ukrainian war? Due to Obamacare!

My kid didn’t get into the elite kindergarten?  Obamacare AGAIN!

Ok, a reality check…

First, while some facilities are shutting their doors, hospitals have been closing for decades, looooong before PPACA was even dreamt of. If anything, the closure rate has declined significantly of late.  That’s because the country was seriously over-bedded, a situation which led to too many inappropriate admissions.  65% occupancy rates are not sustainable and inefficient so hospitals have to either get efficient or close.  Harsh as that is, we just can’t afford them.  Yes, that will hurt some health systems and may well lead to access issues in smaller communities.  And yes, that will lead to lower health care costs and more dollars for education, tax relief, roads and infrastructure.

More to the point, hospitals are in much worse peril in states that have not expanded Medicaid.  

Second, on balance, PPACA has been good for hospitals; many are doing better these days than they were for years.  In large part this is due to higher coverage rates among the employed as well as the expansion of Medicaid in states that weren’t so blinded by misplaced ideology that they refused the federal dollars.

Third, beyond the odd anecdote, there haven’t been any credible reports of increases in waiting times, access difficulty, or lack of care that can be attributed to PPACA.  (notably I was told this was a big problem in Florida, a puzzlement as the Sunshiners have yet to expand Medicaid).

Fourth, cost.  Health insurance premiums have gone up due to health care cost increases, not due to “Obamacare”.  From a Commonwealth Fund analysis of plans with price increases >10% (insurers are required to report reasons for the increase) :

rising cost of doctor visits, hospital stays, surgeries, tests, medications and other types of direct care were responsible for 84% of the premium hikes in the individual market and 78% in the small group market (which typically includes small-company plans and others with only a minor volume discount).

Finally, PPACA’s costs continue to come down, with the latest figures indicating it will cost $139 billion less than the previous CBO estimate.

That’s $139 billion that can be spent on education, job training, infrastructure, tax relief, pre-K…

What does this mean for you?

Don’t just repeat what you hear on talk radio.  It is likely wrong.

UPDATE – Friday catch up, and follow up on the Aetna-CWCS story

Congratulations to Accident Fund’s Jeffrey Austin White – Jeff has been named Director of Innovation at the top-ten workers’ comp insurer.  I’m honored to consider Jeff a good friend.  He’s also one of the smartest people I know, and has two other all-too-rare abilities; he gets to the crux of knotty issues very, very quickly, and communicates really technical, complex stuff clearly and simply - so much so that we far-less-brilliant folks can actually understand it.

Kudos to Lisa Corless, AF’s Chief Administrative Officer for creating the position.  Innovation at a work comp carrier – there is hope for the industry yet!

Thanks to WorkCompWire for highlighting Liberty Mutual Research Institute’s recently released Workplace Safety Index.  The top two causes of injuries – overexertion and falls.  C’mon folks, let’s get in better shape!

Health Reform Implementation and health insurance

Great article by Steve Davis in Health Business Daily on the public health exchanges - couple key data points:

  • the average benchmark health plan premium increase this year was 0 percent.
  • this despite only a 1 percent increase in the average deductible
  • a lot more health insurers are offering plans on the Exchanges; McKinsey reports a 27% increase in available plan options and 19% bump in the number of insurers participating.

It’s about the prices, stupid!

It’s long been known that the primary reason health care costs in the US are so much higher than in other industrialized countries is that medical services prices are way higher.  The good news is there’s more price transparency now than ever.

The latest comes to us from WaPo’s Wonkblog, reporting the price of a knee replacement varies from $17k to $62k – in the same city (Dallas). Hip replacement costs in Boston show an even greater range – $18k – $74k.

What’s interesting about this report (which comes originally from the Blue Cross and Blue Shield Association) is it is based on the price PAID for the service by Blues plans.

UPDATE – after a query from sharp-eyed reader PW, I spoke with the Blues about the price v cost question. Media contact Robert Elfinger told me the dollar figures are, in fact, the Blues Claims Rate.  That is, what was PAID for the service.  The report was not clear on this as it mixed “price” and “cost” repeatedly.

For those who bitch about “narrow networks”, this is precisely why narrow network plans will become the industry standard in the near future; health insurers must identify low-cost, high-quality providers and direct their members to those providers if they are going to survive in the hyper-competitive Exchange-based health insurance marketplace.

Low cost or wide networks – pick one.

And health insurers are doing just fine, thank you.  From UBS comes a brief summary of Unitedhealth Group’s recent financials, and they look pretty darn good. Medical costs are coming in lower than projected despite a pretty nasty flu season, and membership growth has been higher than projected (in part due to narrow network products).

Aetna and the layoff at Coventry Workers’ Comp Services

Last week I wrote about Aetna’s decision to raise the company’s minimum wage to $16 an hour and the subsequent layoff of 11 workers at subsidiary CWCS’ office in Franklin, TN.

I’ve been talking (via email) with Aetna’s Communications folks in an effort to a) make sure I get the details right; b) get their side of the story; and c) find out what the future holds.  To their credit, my sense is they’ve been really trying to be helpful - however for some reason they’ve not been able to provide much information.  Of late, they’ve been radio silent. Here’s what I have so far.

First, I said there were 11 workers fired; Aetna says there were only 8.  It appears that there were indeed only 8 laid off, however sources indicate an additional 3 will be.

Second, in their internal announcement of the increase in the minimum wage, Aetna said there would be no layoffs, that these would of happened in December if we were going to do anything like that.”  I reviewed all press releases after April 2013, and didn’t see anything about CWCS layoffs.  In talking with some of the laid-off workers, they told me they had no indication a layoff was coming and couldn’t recall any communication of any kind about a layoff. I’m not sure the “communication” over a year ago about “targeted job reductions” can be counted as a notice by any reasonable standard. Via email, I asked Aetna if the CWCS layoff had been communicated, and was told:

in the fall of 2013 after we closed [on the deal to purchase] Coventry (in May), we communicated integration activities over at least three years, including targeted job reductions as business units conducted the activities. 

This is obviously just an oversight; CWCS is a tiny part of Aetna, and on balance Aetna is clearly doing the right thing for the vast majority of its lower-paid workers.  For several thousand employees, the wage increase is a very big deal and one Aetna should be lauded for.

CWCS is a slightly different matter.  Clearly Aetna is looking to unload the division; equally clearly (at least to me) unless they accept a very low price, that’s not going to happen. While things play out, CWCS management is doing the cash-cow thing; slashing costs and outsourcing whatever they can in an effort to maximize profits.  I get it; it makes sense from a business perspective.  However, one would hope that CWCS would follow mother Aetna’s kinder and gentler employee relations philosophy.

Note – I informed my Aetna contact I’d be posting about this today and asked three questions about possible future layoffs and any efforts to help laid-off workers find other jobs; as of now they’ve not responded.  Fortunately, after reading the post, two area employers got in touch with some of the laid-off workers as they have open positions.


Drugs dispensed by docs may well be dangerous

Greg Jones has done a masterful job finding out just who is manufacturing the new “novel” drugs being dispensed by docs to workers’ comp claimants.

In his piece in today’s WorkCompCentral, Jones finds there are just seven companies manufacturing the three novel drugs with unique strengths about which WCRI concluded “it is likely that financial incentives drove some physicians to choose the strength for their patients.” [link leads to abstract, full report available for purchase here]

According to the piece;

Several of the companies [manufacturing the novel drugs] have been fined or warned by the federal government for engaging in unsafe practices, while another paid $12 million to resolve allegations that it paid kickbacks to doctors to prescribe its products. [emphasis added]

We aren’t talking minor misdemeanors, the FDA’s equivalent of parking tickets.  Here’s a quick summary of just a few of these companies’ transgressions.

  • Ranbaxy pleaded guilty to seven felonies and paid fines of $500 million for shipping drugs that weren’t tested for impurities and making fraudulent statements about quality-control tests.
  • Victory Pharma paid $11.4 million to settle criminal and civil allegations re paying kickbacks to prescribing physicians
  • Bryant Ranch was warned by the FDA for failure to put in place systems to prevent contamination during drug manufacturing.  Bryant was also manufacturing at least 10 drugs that were unapproved by the FDA.

There’s much more in Jones’ article, which should be required reading for legislators and regulators dealing with workers’ comp.  

The net is this – putting price controls on doc dispensing doesn’t work; it is blatantly obvious the doc dispensing industry has figured out how to keep generating huge profits despite legislation or regulations in 18 states intended to limit profiteering.

Those profits come from employers and taxpayers, and they come at the risk of sickening or killing claimants.

Thanks to Greg Jones and WorkCompCentral for this - it is wonderful to see that investigative reporting isn’t dead. It is also inspiring to see how real reporters work.

What does this mean for you?

Just say no.  Refuse to pay for doc dispensed drugs.  If providers in your network are dispensing, kick them out.

If your state forces you to pay, use whatever legal methods exist – and every state has them – to delay and deny payment.

Oh, and subscribe to WorkCompCentral, too…


Tuesday catch-up

Here’s what happened over the MLK weekend…

Kudos to Sen. Amy Klobuchar (D Minn) for her efforts to reduce Medicare drug prices.  She introduced a bill that would allow CMS to negotiate drug prices, a seeming no-brainer.  Reasons to support the bill:

  • reduces Medicare recipients’ drug costs
  • reduces taxpayers costs
  • reduces the Federal deficit

Reasons to oppose the bill:

  • Big pharma, which donates gazillions to politicians, hates it.

Speaking of which, two states are suing Bug Pharma for damages associated with opioid abuse.  A lawsuit against Purdue, manufacturer of OxyContin, is proceeding in Kentucky - a state that has been devastated by opioid abuse.  The big drug maker missed a crucial deadline to file papers in the case, putting them in a even tenuous position.

Their neighbor to the north is suing a dozen pharma distributors and manufacturers, claiming the firms failed to implement adequate anti-diversion controls.  The suit was filed by the former Attorney General. This one is…complicated, as the current West Virginia Attorney General used to be a lobbyist for a big drug distributor that may be added to the suit. And, his wife is currently a lobbyist for one of the companies that is named in the suit.

Meanwhile, the explosive growth in heroin usage continues, driven in large part by folks who got addicted to prescription drugs and now seek their highs from heroin.  Which is even more deadly than Oxy; the CDC reports deaths were up 39% in 2013.

WCRI Annual Meeting

is coming up!  Scheduled for March 5-6 in Boston, the agenda includes details on WCRI’s new research on the costs and consequences of physician dispensing of drugs; the impact of the Affordable Care Act on workers’ comp, and a deep dive into the effect of low fee schedules on medical prices.  Among other luminaries, CWCI President Alex Swedlow will be there talking about the impact of doc dispensing on return to work.

The estimable Ramona Tanabe will review the “State of the States”, a must-see for payers focused on specific jurisdictions.

If you haven’t signed up yet, do it here now before it fills up – which is always does.

 Implementing Health Reform

First, the big news is…there isn’t any news about the Federal Exchange site crashing.  You can almost hear the sighs of relief coming from the White House and CMS.

A couple of items reform-related:

The percentage of people who had problems paying a medical bill declined from 41% in 2012 to 35% last year.

Even better, fewer people are avoiding medical care due to the cost; the percentage dropped from 43% to 36%.


Ascential Care is looking for case management staff in several jurisdictions. Contact info


I’m not working Monday

Instead I’ll be finishing ‘The Half has Never Been Told’, the most disturbing book I’ve ever read.

Like many, or perhaps most, I’ve not taken Martin Luther King Day seriously in the past.  When I had it off, I used it as a catch-up day.  When I didn’t (the last 18 years) I almost always worked.

My decision is not so much about Dr. King as it is about values.  What he stood for, what he died for, what he worked for is in peril.  The events of the last few months coupled with the lack of economic progress over decades for many people of color have been a wake-up call.  We are better, far better than this.

A quote from Ohio Gov. John Kasich’s inauguration speech makes the point very well:

It’s all about me. And somehow we have lost the beautiful sound of our neighbor’s voices. Moving beyond ourselves and trying to share in the experience of others helps us open our minds, allows us to grow as people. It helps us become less self-righteous. Did you ever find that in yourself? I do…self-righteous. Allows you to be more righteous. Empathy is the first ingredient in compassion and makes it possible for us to care enough to begin to reach out to those who have been forgotten, disenfranchised, ignored, or who are suffering, and to reach out to them in the way they need.

A while back I received an email from a very successful businessman that quoted from Pat Buchanan’s unbelievably racist, stupid, ill-informed and hurtful column about racism.  To wit:

America has been the best country on earth for black folks. It was here that 600,000 black people, brought from Africa in slave ships, grew into a community of 40 million, were introduced to Christian salvation, and reached the greatest levels of freedom and prosperity blacks have ever known.

Buchanan goes on to blame blacks for pretty much everything negative affecting the black community.  I responded immediately to his email, then promptly forgot about it.

Then, I found ‘The Half’.

The book links slavery and economics tightly together, so much so that on occasion I’ve found myself forgetting that author Edward Baptist is writing about slavery – the ownership of one human being by another. Baptist seems to have recognized that risk, as he intersperses graphic and wholly terrifying descriptions of rape and child rape, family-splitting, flogging, murder and whipping throughout. He doesn’t do this gratuitously, but rather to make two points;

  • slavery is the most evil one human can do to another; and
  • without the mundane brutality employed by slave owners  the geographic expansion and economic development of the United States would have been much, much different.

For a very smart, very successful American businessman to say anything positive about slavery is just appalling.  That statement endorses absolutely horrific behavior, while perpetuating the false meme that the poor and underprivileged are solely responsible for their condition.

What utter bullshit.

If you don’t believe it, read ‘The Half’.

That’s not to say our various, sundry, and very expensive public policy efforts to alleviate poverty and racism have been universally successful – far from it.  But just because we continually screw up doesn’t mean we shouldn’t keep trying.

How a nation treats its poorest, most vulnerable, least able and least fortunate defines that nation.  And we have failed those people, and failed them miserably.

Today’s the day to think about what we can do to help.  Tomorrow – and the days after – are the days to do it.

Aetna raises minimum wage, then cuts work comp staff

Monday, Aetna announced it will be increasing the company’s minimum wage to $16/hour.  In the internal memorandum provided to managers, the company said “We will not be funding this program through job eliminations…

According to a source, during a company-wide webcast earlier this week, CEO Mark Bertolini said “We do NOT anticipate any lay offs. There is plenty of room for employment within the company.  That would of happened in December if we were going to do anything like that.  We are past that.”  

Wednesday, 11 employees in Coventry Workers’ Comp Services Franklin, TN office were fired.  Sources indicate layoffs have happened in several other CWCS locations as well.

While it may well be that the giant healthplan’s financial plan doesn’t directly link the firings to funding the higher wages, the timing and the details provided to this reporter show a rather unfortunate lack of planning and coordination.

Telling low-wage workers they’re getting a big raise, then, after they’ve gone home, told their spouses and kids, perhaps planned on a celebratory dinner with chuck roast instead of the usual hamburger, bought that winter coat they’d been unable to afford, and maybe even paid a couple bills, they get the “just kidding! you’re fired!” notice is, if not intentionally cruel, certainly unintentionally so.

And pretty dumb.  The company got lots of (well-deserved) positive press and supportive comments from around the country for the wage and benefits upgrade.  Then, they turn around and fire some of those same low-wage workers they’re saying they want to help.

What’s more troubling is why.

Sources indicate the jobs lost are in Coventry Work Comp Services unit, primarily handling administrative tasks including preparing network panel postings for the Hartford’s workers’ comp customers, scheduling claimant appointments, and Quality Assurance.  But they aren’t going away, rather Aetna is off-shoring them to the Philippines.  Several management staff remain on payroll for now, but their positions are also going to be eliminated after they train their Filipino replacements.

By most accounts Aetna CEO Mark Bertolini is a good guy.  He’s aware of and quite concerned about income inequality.  He asked his execs to read Thomas Piketty’s treatise on the subject.  Aetna is also significantly improving benefits for the company’s lower-wage workers. In a statement, Bertolini said:

“Since I became CEO, one of my goals has been to help re-establish the credibility of corporate America…I firmly believe that companies can ‘do well by doing good.’ With these investments, we are leaning into the recovering economy and working to bring everyone along instead of just a few.”

My read on this is Aetna is not a bad company and its execs are not bad people. There’s no intentional cruelty here, this isn’t a heartless oligarch playing God without any regard for the little gal.

While Bertolini is a good guy, some of his underlings are not.  This is a dumb decision made by a tiny division executed by crappy managers with no regard for how it affects folks making low wages doing important work for years.

My characterization of the managers is based on the timing and their petty. small-minded, and just plain stupid cost-cutting moves which included no Christmas bonuses, no holiday celebration of any kind (not even the traditional dinner), paying laid-off workers only 50% for their unused vacation time, and a paltry 4 weeks of severance for workers with more than 2 years at CWCS.

One wonders if those managers at least handed out “Merry Christmas, now get the hell out of here” cards.

What does this mean for you?

A pretty awful winter for folks who thought they were going to get a nice raise.

note- I reached out to Aetna several times, delayed this post in an effort to get their side of the story. After waiting all day, i informed them I had to go to press.

If I hear from Aetna I will let you know…