Author: Joe Paduda

Sep
27

Health reform explained – simply!

Posted by Joe Paduda on Monday, September 27th, 2010 | Comments

Health reform’s complicated – but it can be easily explained. The good folks at the Kaiser Family Foundation have produced a terrific video – that’s entertaining to boot – laying out pros and cons, explaining the rationale behind and opposition to reform, and all from a neutral perspective.
Kaiser’s reform site also has an interactive timeline, detailing the changes by year, and a detailed, here-it-all-is view here.
If you’re interested in how reform affects Medicare, Medicaid, employes, taxes – whatever – the timeline page allows you to sort and select only what you want. Seniors concerned about death panels and reductions in the Medicare program would find a lot of comfort here.
One part of reform I’m really looking forward to – simplified administration. Here’s KFF’s synopsis:
Simplify health insurance administration by adopting a single set of operating rules for eligibility verification and claims status (rules adopted July 1, 2011; effective January 1, 2013), electronic funds transfers and health care payment and remittance (rules adopted July 1, 2012; effective January 1, 2014), and health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization (rules adopted July 1, 2014; effective January 1, 2016). Health plans must document compliance with these standards or face a penalty of no more than $1 per covered life. (Effective April 1, 2014).
Good work by the good folks at KFF!

Sep
24

AHCS – what’s NOT in the suit

Posted by Joe Paduda on Friday, September 24th, 2010 | Comments

A couple days ago my evening was interrupted by a call from a reporter, who wanted my comment on ‘the suit’. I had to confess I didn’t know what he was talking about, whereupon he somewhat incredulously asked if I hadn’t seen ‘it’.
I said I didn’t know what ‘it’ was, whereupon he proceeded to tell me that he had just got off the phone with Ron Sachs, who evidently was hired to do PR for Automated Healthcare Solutions. (Later, after other, similar calls, I learned that Sachs had evidently been hitting the phone pretty hard, informing all about the suit that AHCS had filed naming me and my consulting firm, Health Strategy Associates LLC, as defendants.)
By the way, Ron Sachs Communications’ website has this to say: “Sachs also distinguished himself by serving as former Florida Governor Lawton Chiles’ Director of Communications. The deeply experienced senior management team includes two communications directors to two governors (Bush and Chiles), a seven-time Emmy Award-winning producer, a former Senate staff director, and communications directors to state agencies, the Cabinet and a Senate President…Serving clients with 25 full-time professionals and offices in Tallahassee and Orlando”
Pretty impressive resumes, AND Mr Sachs has 24 times more staff than I do, and that’s just the PR firm…
Now, I still haven’t been ‘served’, but I’ve been informed that the suit charges me with a variety of offenses related to my blog posts of September 2 and 9. And I do know that the AHCS folks are plenty mad, and have lots of money – my guess is Ron Sachs doesn’t come cheap.
Here’s a bit of history. AHCS sent me a letter and email a week or so ago calling me out on a number of issues related to the afore-mentioned posts. Here’s a bit of what I wrote back:
“…I’m only too happy to publicly acknowledge and correct any errors in the two posts. In the six years I have been writing MCM, I’ve worked hard to establish and maintain a reputation for veracity; on occasion that effort has required a correction and I’ve been more than willing to write one. I’d note that in the past I’ve left my mistakes on the blog as I believe it’s important for readers to be able to see the entire span of my work, warts and all. Happy to discuss this further as the situation dictates.”
I then went on to address each of their issues point by point, again offering to review any materials and correct and apologize for any errors,
Apparently that good-faith offer wasn’t good enough, as they spent loads of time last weekend hitting my blog, then filed what I understand is a 21-page charge in Federal District Court on Monday. In fact, AHCS still hasn’t responded to my letter – Perhaps they were going to file no matter what I said…
The main point in the suit appears to revolve around my characterization of AHCS as a ‘repackager’. According to AHCS, they are NOT a repackager, but a healthcare IT company. My mistake; from reading their website they sure sounded like a repackager to me. I’ll discuss this in more detail in a later post.
What I want to talk about now is what ISN’T in the suit, and why that’s important.
There were at least two statements in the letter that evidently aren’t in the suit.
One involved a statement questioning Paul Zimmerman MD’s claim to have been a Medical Director for several firms. In the letter, they demanded I retract that statement; that demand evidently isn’t in the suit itself.
My guess – and this is only a guess – is Zimmerman et al decided they couldn’t prove that he was a ‘Medical Director’. However, as of today, their site still says:
“Dr. Zimmerman is considered an expert in workers’ compensation who has served as medical director for a number of workers’ compensation insurers, third party administrators, and self-funded employer programs including Liberty Mutual, The Home Depot, Pan American Airlines, Baxter Healthcare and Sears.”
What’s my point? AHCS’ letter was pretty, well, demanding. Strident. Threatening – really threatening. It also didn’t include any documentation, materials, or evidence supporting these claims. AHCS was demanding I retract my posts on the basis of nothing more than their say-so. Then, when they decided to file charges in Federal Court, they didn’t include their assertions that Zimmerman was a ‘Medical Director’ at Sears, Liberty, Baxter, etc.
Why? Was this an error or oversight? Highly doubtful.
Next, the letter said that Zimmerman had sued Dr Richard Dolsey (since deceased) for slander and won. That claim is apparently not contained in the suit either. I could not find any record in the Miami-Dade or Broward court records of Zimmerman suing Dolsey for slander (I’m not a legal researcher, so perhaps it’s in there somewhere). Again, in my letter I asked AHCS for documentation; I’m still waiting.
And my point is…?
AHCS attempted to bully me into retracting my statements on the basis of nothing more than their say-so. When I offered to review any materials they’d provide, retract any statements in error and apologize publicly, they ignored my letter and filed suit.
I find this, well, weird. Here they had the opportunity to get me to publicly acknowledge errors, publish a retraction, and apologize for those errors, yet they decided to hire Ron Sachs and a high-powered law firm to file suit against me. If they had provided that documentation, and we had a chance to discuss their issues, this might well have been a post of apology and correction, which would have resolved the entire issue in a couple of weeks at zero expense.

Sep
23

Where were those deficit hawks when Part D was passed?

Posted by Joe Paduda on Thursday, September 23rd, 2010 | Comments

Today’s pending announcement that the GOP will introduce a ‘Pledge for America’ includes rhetoric about cutting taxes, reducing the size of the government, repealing health reform, and eliminating $100 billion in discretionary spending among other chestnuts.
It’s good to hear talk about fiscal restraint. Too bad they didn’t hew to those principals when they were in power. Here’s a brief reprise of a post from a ways back.
This from the party that added over $9 trillion to the deficit the last time they passed a health care bill.
Let’s return, for just a moment, to the early and mid oughts, the halcyon days of the Bush Administration, when the entire government was under the firm control of the fiscally prudent.
Here’s what those wise stewards of the nation’s wealth did.
Pass Medicare Part D with no funding – short term, long term, any term. Hell, they would’ve been more fiscally prudent if they’d included a few hundred million to bet on the horses. At least that would have shown some desire to pay for the thing. But no, the GOP decided to NOT set aside funds, or raise taxes, or cut other programs; they just passed Part D, committed to paying for it out of ‘general funds’ and to hell with the future.
The latest Medicare Actuary report indicates the GOP-passed Part D program has contributed $9.4 trillion to the $38 trillion Federal healthcare deficit. (page 126)
The Bush-era GOP makes President Obama, Pelosi, Reid, and the rest of those spendthrift Dems look like a bunch of cheapskates; even a GOP analysis finds “the new reform law will raise the deficit by more than $500 billion during the first ten years and by nearly $1.5 trillion in the following decade.”
It remains to be seen if the voters will be duped by this blatantly political ploy. So far, it looks like it’s succeeding.
As HL Mencken said, “People deserve the government they get, and they deserve to get it good and hard.”

Sep
22

Survey of Workers Comp Claims IT Systems

Posted by Joe Paduda on Wednesday, September 22nd, 2010 | Comments

Health Strategy Associates’ First Annual Survey of Workers Comp Claims IT Systems is well underway, and we’re well on our way to reaching our goal. Respondents will be receiving a detailed copy of the Survey Report.
We’re using SurveyMonkey to collect and tabulate responses; the survey takes about 15 minutes to complete. Click here for the Survey.
We’ll have a couple preliminary revelations posted here shortly; early indications are there’s lots of ‘opportunity’ for improvements among vendors…
Here’s one not-surprising-and-quite-revealing item:
88% of the front-line representatives and managers said their current system is NOT fully integrated with their bill review and utilization review system (75% wish that it was); conversely, 68% of the executive leadership responses state that their system IS fully integrated with their bill review and utilization review system.
Disconnect, indeed.
The Survey seeks input from front-line folks and execs in claims and IT, and we’ll be comparing and contrasting responses to see if – or perhaps more accurately where – there’s a disconnect or differences in opinions between the two groups.
A brief summary version will also be available to the general public. Customized analyses of and presentations on Survey findings will be offered as well. Of course, no respondent-specific information will be provided in any version of the Survey report.

Sep
21

Patient confidentiality? Not in Texas

Posted by Joe Paduda on Tuesday, September 21st, 2010 | Comments

Q – When is it legal for someone to examine patient records?
A – when they are a legislator seeking to “defend doctors he believes were wrongly the subjects of misconduct investigations by the [Texas Medical} board, which licenses the state’s physicians.”
According to an article in the Texas Tribune, that’s exactly what happened in Texas. As a state legislator, former state Rep. Bill Zedler, R-Arlington, “had authority to obtain and review private patient and physician records. The Texas Medical Board provides such records — which also detail patient treatment — only by special request and solely for official legislative purposes.”
Wait. Did I just write that? How does a state law supersede HIPPA, which mandates confidentiality of patient records?
And it turns out Zedler did NOT review the records for legislative purposes, but rather to assist specific physicians, two of whom were – you guessed it – large campaign donors. According to the Texas Tribune, Zedler requested records from the Texas Medical Board for:
“Houston anesthesiologist Vladimir Redko and Dallas thoracic surgeon Dr. William Rea, neither of whom were constituents. According to the board’s disciplinary orders, both were ultimately sanctioned for “egregious” treatment violations ranging from performing invasive procedures to injecting natural gas and jet fuel into the patients in order to diagnose chemical sensitivities. Records show that the doctors gave Zedler a combined total of $25,000 in the past half-decade and that some contributions were made just weeks before Zedler requested their case files.”
Zedler reviewed the medical records himself; while he’s not a physician, or nurse, he was a medical equipment salesman, so “I know what appropriate treatment is and isn’t,” he says. “I sold equipment, so a lot of times my customers were doctors. I’ve been inside surgical suites before — that kind of stuff.”
Zedler didn’t limit his investigations to the Texas Medical Board. Again, according to the Tribune, “Physician investigators at a separate agency, the Division of Workers’ Compensation of the Texas Department of Insurance, recall that Zedler also took great interest in doctors who were under investigation at workers’ comp.[emphasis added] Dr. Bill Nemeth, the division’s former medical advisor, says Zedler had some success in stopping investigations of the doctors on whose behalf he intervened.”
On the basis of his experience selling medical equipment, Zedler took it upon himself to examine what would normally be considered confidential patient records, then contact the state regulatory authorities in an effort to get them to drop investigations of at least two physicians who were significant campaign donors.
And this guy is running for election.

Sep
17

What’s bugging comp insurers

Posted by Joe Paduda on Friday, September 17th, 2010 | Comments

Here in no particular order is a list of concerns/issues/problems that have recently come up in conversations with work comp insurers large and small.
1. Repackaging and physician dispensing of drugs – I’m still getting calls from payers (first came right after my post a couple weeks back); about this issue. Physician dispensing in itself isn’t so much the problem as the potential for much higher prices when a repackaged bunch of pills is billed at some multiple over the cost for a similar non-repackaged drug.
2. Too much utilization review and not enough utilization control – there’s a growing awareness that much if not most of the precert and concurrent review is little more than a rubber stamp followed quickly by a bill. UR has to – absolutely has to – deliver more value.
3. Claim counts are increasing ever so slightly. The trend has been up for a few months; it’s not yet a trend but if it keeps up for a couple more months we may be out of the proverbial woods.
4. The competition appears to be a little less brutal than a few months back. (An unscientific sample set of) agents report more consistency in rates across the board. While there are still some of those ‘they quoted what?’ incidents, they are fewer and further between.

Sep
16

Are workers comp claims ‘undercounted’?

Posted by Joe Paduda on Thursday, September 16th, 2010 | Comments

Good friends and colleagues Frank Pennachio and Susan Toussaint’s WorkComp Advisory Group is conducting their annual get together at the Blackstone Hotel in Chicago (scene for much of the movie ‘The Untouchables’. (Remember the scene with the baseball bat in the dining room after the big dinner?)
The keynote this morning was provided by Peter Rousmaniere, who spoke on, among other issues, what appears to be a significant problem with under-reporting of injuries to OSHA, and a more significant problem with low reporting rates for illnesses (which evidently OSHA does not require to be reported).
Peter described a couple of instances wherein employers asked clinicians to use Steri-strips to close a wound instead of stitches in the hope that this would reduce the need to report the injury as work-related. Evidently this may be more of an issue in food preparation, construction, and seasonal work.
A major airline reported no injuries at one airport, and four airports with no lost time injuries. Meanwhile, the national average injury rate was 11.9% – almost one in six employees were injured during the year, and the lost time injury rate was about one in thirty employees per year. It could be that the five facilities were particularly safety conscious, or perhaps claims were not reported due to other motivations.
Peter supported these – and other anecdotes, with citations from work done by Dr Glenn Pransky that also described some significant concerns with under-reporting of OSHA claims. I’d note this is separate from workers comp – OSHA claims don’t always have to be reported as work comp claims.
There’s the segue into comp.
That also spurred a lively conversation with several of the agents and brokers in attendance discussing the pros and cons of self-management of occ injuries.
Peter’s discussion reminded me of research I’d come across some months ago that provided more depth to the issue.
And here’s one item that should get anyone thinking.
More than 75,000 work comp injuries were not reported in just three cities last year [2008]. Close to a million may have gone unreported nationally.

Sep
15

Comp medical bills – those devilish details

Posted by Joe Paduda on Wednesday, September 15th, 2010 | Comments

Earlier this week I attended the Maine Workers Comp Summit; spoke on the impact of health reform on workers’ comp. One of the sessions pertained to coding medical bills, and some of the intricacies thereof.
For one (me) who spends the majority of their time dealing with higher level, strategic and tactical issues and concerns, this deep dive into medical coding brought me back to my days as an HMO data analyst – and reminded me that there’s more than one devil in the details…
These days, its more important than ever to avoid paying for diagnoses that are not directly related to the work comp injury or illness, as those payments may well trigger higher MSA allocations. Reportedly, CMS’ Boston office has stated their position on a payer’s responsibility is rather definitive; if more than $300 is reimbursed for a condition, the payer ‘owns’ that condition.
An interesting issue – well, kind of interesting to those of us who find this stuff interesting – regards the lack of coding for left or right. several in the audience noted they’d had problems in the past when they paid bills for procedures/therapy on one arm or leg when it was the other appendage that was injured at work. Evidently, the provider had not, and does not have to, send medical records or notes for the non-comp condition, therefore the payer wasn’t aware of the other injury. So when the bill for the right knee/shoulder/hand came in, the bill reviewer/adjuster saw it was the correct body part and authorized payment.
This is most definitely not new news to anyone who’s spent a big portion of their waking hours immersed in the intricacies of coding, but served as a welcome reminder to the rest of us of the challenges inherent in what looks to be a very straightforward, if not simple, methodology.
What does this mean for you?
It’s far too easy to measure bill processing by throughput, but neglecting the quality and accuracy of the coding may well be missing the forest for the trees.

Sep
14

The recovery is real – early indications of increasing employment, comp claims

Posted by Joe Paduda on Tuesday, September 14th, 2010 | Comments

Under the radar, there’s increasing evidence that employment is up, hiring is up, and the economy is recovering – and with it, the workers comp industry.
I had several conversations today that validated what I’ve been hearing for several weeks – there’s a good bit more new activity in manufacturing, construction, and logistics/transportation than there was a few months ago – activity that requires new hiring.
Evidence of this not-yet-in-the-official-reports trend comes from several sources, most importantly activity at occ health clinics. There’s been a lot of pre-employment screenings and physicals, drug testing for truck drivers and equipment operators, and a significant uptick in new workers comp injuries of late. The screenings and testings are obvious indicators of hiring, while the new injuries likely result from a faster pace of work, more overtime, and more temp workers doing jobs they are less than familiar with. (The data do indicate significant additional hiring of temp workers, with 17,000 new hires last month)
Last week’s employment report provides additional color – emplloyment was up for temporary workers and in construction. And, revisions for the two previous months indicated employment was actually higher than the original estimates.
Several work comp specialty managed care vendors are also seeing an influx of new claims, particularly among vendors that provide services common in the initial stages of a claim.
Anecdotally, (I know, a lot of this is anecdotal), I was speaking with the hiring manager for a Maine manufacturer; they have a bunch of open jobs that they can’t find ‘just the right person’ to fill. The manager was frustrated by the ops head’s inability to understand that the applicant pool wasn’t as deep or wide as he wanted. The net? There were several – actually, more than ‘several’, jobs that were going to be filled with people that may not have fit the ops boss’ specific criteria.
I bring this to your attention, dear reader, to suggest there are lots of employers looking for lots of workers, (three million workers, to be precise) but many of these employers are waiting to find just the right worker. It may well be they’ll soon give up their persnicketiness and start hiring who’s available. If – and when – that occurs, things will get better in a hurry.
What does this mean for you?
Very, very welcome news that the worst is almost behind us.