House committee zeroes in on hospital downcoding
The Health and Environment Subcommittee of the House Commerce Committee put Health Care Financing Administration Deputy Director Mike Hash on the hot seat for much of last week’s four-hour hearing on the administration’s mismanagement of the Medicare program. The good news for health care providers is that Congress may be gearing up to rein in an agency that ties providers in knots through its complex regulations.
Signaling a major shift in emphasis, the subcommittee was talking about underpayments to providers instead of overpayments. For example, Robert Waller, chairman of the Washington, DC-based Healthcare Leadership Council (HLC), pointed to a recent Congressional Budget Office analysis of changes in hospital billing patterns that shows hospitals have been downcoding simple pneumonia to respiratory infection at a far greater rate than ever before.
Waller also noted a recent assertion by Gail Wilensky, head of the Medicare Payment Advisory Commission, that hospital undercoding has become a serious problem. "You don’t hear the OIG or the Department of Justice worrying about whether we are underpaying," said Wilensky.
"The environment is so hostile and the fear of being accused of fraud is so great that providers are not always seeking the appropriate level of payment and are being overly conservative," asserts HLC President Mary Grealy.
Michael Mangano, principal deputy inspector general of the Health and Human Services Office of Inspector General (OIG), told the subcommittee that among the OIG’s continuing concerns are Medicare payments to community mental health centers for partial hospitalization services, outpatient psychiatric services, and Medicare contractors that falsify statements to improve their ratings on performance evaluations.
A spokesman for the subcommittee reports that any action stemming from the hearing is likely to be part of long-term reform rather than immediate legislation. Grealy argues the current program can’t be fixed. "Our position is that you need to restructure the whole program and get away from the micro-managed fee-for service model and move to something like the cafeteria-style Federal Employees Health Benefit Program."
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