This is a pretty simple question.  How is it that an investment firm owns stakes in a TPA, MSA company, subrogation firm – and a physician dispensing and billing company?

That’s the question I’ve tried to ask folks at ABRY Partners in the past, but they’ve never seen fit to return my calls.

Don’t they know that their TPA’s (York Risk Services) clients are being hammered by physician dispensing, paying millions more for drugs and driving up their loss costs?

Has it occurred to them that their MSA company’s (Gould and Lamb) settlement estimates are directly, and in some cases dramatically, affected by physician dispensing?

Is it not ironic that one of their investments (Trover Solutions) seeks to recover dollars spent in error or inadvertently, while another (Automated Healthcare Solutions) actually increases employers’ costs? 

Physician dispensing companies make lots of money charging employers and taxpayers outrageous amounts for drugs. That is so well-known as to be common knowledge.  And no, there’s no data that outcomes are better, but there is growing evidence that medical costs are higher and claimants are out of work longer when they get drugs from their docs.

Claims administrators flourish by controlling their employer clients’ workers comp costs. They do battle day in and day out with physician dispensers and their allies, striving to keep medical costs down while ensuring claimants get the drugs they need.  York is, by all accounts, a very good TPA, one that is doing all the right things on behalf of their employer clients. (disclosure – I’ve done work with York in the past, and have been universally impressed with their people, their focus, and their dedication to doing the right thing)

Yet in many states, employers’ workers comp costs are significantly higher than they should be, due to the massively higher prices for physician-dispensed drugs.

Medicare Set-Aside firms: “forecast future medical exposure and establish a medically accurate basis on which to set reserves for workers’ compensation and liability files or claims with limited medical records. By accurately forecasting future medical exposure, [the future medical care plan] becomes an invaluable negotiation tool for mediation and settlement.” (from Gould and Lamb’s website)

Obviously, the higher the drug cost, the higher the costs for the future medical care plan.  That’s not to say Gould and Lamb – or any other MSA firm – benefits from increasing their estimate of future medical costs.  They most certainly don’t.

With that said, there’s no question AHCS, and by extension ABRY, do benefit – a lot – by increasing claimants’ drug costs.

Another ABRY investment, Trover Solutions, Inc., is in the business of recovering claims dollars through subrogation; they’ve been in the P&C industry since 2000.  One wonders if their software, Troveris, is able to identify bills paid to AHCS for drugs in Florida, where some payers are finding success in denying physician dispensers’ high billed charges and repricing the bill to the same rate charged by their retail pharmacy networks for the same drug.

Given the recent report by WCRI that almost two-thirds of Florida’s work comp drug costs are from physician dispensed drugs, there may be an opportunity here for Trover.

I get that investment firms are in business to make money.  So am I, and there’s a very good chance you are too.  That’s fine.

But I’m puzzled by ABRY’s investment decisions.  What’s to think about an investment firm that owns businesses with apparently conflicting business goals?

Five Maryland orthopedic surgeons may lose their medical licenses after being charged with “suspect” billing practices including overcharging the state’s work comp fund for medications dispensed by the docs.

The five are all members of Maryland Orthopedics P.A.

One physician, Raymond Drabkin MD allegedly administered pain injections and simultaneously prescribed – and dispensed – significant quantities of narcotics to patients.  One of Drabkin’s colleagues, Michael Franchetti MD, stands accused of the same type of inappropriate behavior, as do three other docs in the practice.

According to an article [sub req] in the Daily Record, “IWIF [Maryland state work comp fund] said an internal audit of prescription payments showed that from 2001 to 2006, the annual reimbursement fees for prescriptions at Maryland Orthopedics jumped nearly 1,700 percent, going from $12,489 to $212,170 over the 5-year period.”

IWIF’s complaint to the state resulted in charges brought against all five physicians.  While the current status of the case is not known, a hearing before an administrative law judge was scheduled for last month.

What does this mean for you?

There are things payers can do when confronted by poor medical care delivered by physicians who appear more interested in their financial health than their patients’ well being.

A post last week addressed the influence of medical coding changes on billing practices and costs – net was providers are being paid more due to more sophisticated coding.

The care isn’t different, the patients aren’t sicker, it’s just the way the providers are coding their services.

Th NYTimes just published a piece that provides a lot more detail on the issue.  Here are a few of the findings of their rather extensive analysis.

– Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms

– 1,700 of the more than 440,000 doctors in the country — cost Medicare as much as $100 million in 2010 alone, federal regulators said in a recent report, noting that the largest share of those doctors specialized in family practice, internal medicine and emergency care.

There are two drivers behind the issue – for hospitals it is CMS’ switch to MS-DRGs from DRGS a couple years back.  By adjusting reimbursement based on severity, the new payment methodology encouraged hospitals to more accurately, or as some would suggest – more creatively code and bill.  CMS determined total costs went up around four percent due to the change, so they reduced reimbursements by about the same amount.

The other driver is CMS’ ongoing effort to get physicians to use electronic medical records (EMR).  While this will drive administrative costs down and provide much more accurate data for analysis and development of outcomes data, over the near term EMR vendors are selling their software in part on its ability to increase billing and reimbursement. As the NYT reported, “In an online demonstration, one vendor, Praxis EMR, promises that it “plays the level-of-service game on your behalf and beats them at their own game using their own rules.”

That’s not exactly…consistent with what actually happens. Turns out that some of these applications allow docs to simply check boxes indicating services were delivered without verifying the services actually WERE delivered.

As a result, payers – and yes, that includes you – are getting bills for services that did not occur.

So, what do you do about it?

First, look at your data to identify the providers whose billing has changed significantly at some point over the last couple years. Next, identify that inflection point, and find out if that occurred when they changed billing software/vendors. Third, look carefully at a few of the providers’ bills before and after the inflection point, figure out what’s happened, and then sit back and discuss next steps.

These could include:

• call to the provider asking what’s going on
• claim file audit
• referral to internal fraud and abuse
• onsite visit to provider
• flagging of provider’s future bills for special review

In Montana this week to deliver the keynote at the annual Governor’s Workers Comp Conference and get in a good bit of hiking in the mountains around Big Sky as well.

Truth be told, I hadn’t been tracking goings-on in the Big Sky state’s workers comp system, but in prepping for the conference, I learned a good deal.

MT has some state-specific challenges; doctors can be few and far between in many areas, making direction of care a significant challenge.  The culture is very labor-friendly which can lead to courts confusing over-treatment with good care. The growth in the energy sector in eastern Montana is adding jobs with potential for higher-severity injuries.

Then there are the similarities; the over-prescribing of opioids is likely as big a problem here as in most states.

Over the last couple years, a lot of progress has been made:

– hired a Medical Director for the Department of Labor and Industry’s Workplace Relations Division (equivalent to the work comp division in other states)

– developed and implemented medical treatment guidelines based on a combination of Colorado and ACOEM

– enabled employer direction of injured workers to specific physicians

– allowed payers to close some claims after sixty months (there’s a lot of detail here, but suffice it to say this was a big problem in MT)

While it is still too early to fully understand the impact of these changes, there’s no doubt these reforms will help improve care while reducing employers’ and taxpayers’ costs.

And Montana has been smart enough to ban physician dispensing of drugs to patients, a prescient stance that has protected injured workers, employers, and taxpayers from the “let’s see how we can soak employers for as much money as possible while pretending we’re all about patient care” set.

“Thousands of doctors and other medical professionals have steadily billed higher rates for treating elderly patients on Medicare over the last decade — adding $11 billion or more to their fees and signaling a possible rise in medical billing abuse.”

That’s a statement from a study of Medicare billing and coding practices released by the Center for Public Integrity, and is the lead on a lengthy and well-documented article detailing the dramatic increase in higher-complexity medical codes billed to Medicare over the last decade.

The implications for taxpayers, private insurers, workers comp and auto payers are obvious.  If docs and their billing departments are upcoding for Medicare office visits, they almost certainly are doing the same for all patients.

Interestingly, the increasing use of electronic medical record systems by many physician practices may be a contributing factor, as the systems “make it easy to create detailed patient files with just a few mouse clicks.”  These details are essential to demonstrating and documenting the level of work and time commitment involved in specific office visits.

That said, just because a doc has mostly higher-level office visits doesn’t mean they are doing anything wrong. Some providers’ patients are just sicker (“higher acuity”) than others’, requiring more time and effort.

What does this mean for you?

It is highly likely your mix of E&M codes has trended towards the more complex over time.  You may well want to identify those docs where the mix has swung dramatically at some point as that may indicate inappropriate billing.

Aetna’s presentation at an investor conference addressed the acquisition of Coventry and provided just a bit of insight into their plans for workers comp…

Here’s what CFO Joe Zubretsky  – who some have said is “no fan of workers’ comp) said…

“The second point I would make — so there is specialty revenue. The second point I would make is, and we didn’t count this as well, but I’m quite excited about it, because it’s been a vision of ours for many, many years, to unlock the value of workforce optimization by combining the skills of long-term disability, health care, and workers compensation. And when you think about it, all of those three lines of business and coverages intersect with the healthcare system, and somebody is not at their desk every day.

With this morning’s post, we’ve moved to WordPress as the publishing platform.  We’ve also updated the look and feel of MCM to make it a bit “sleeker”, easier to navigate, and more user-friendly.  Julie Ferguson and Chris Miller (boss at Artefact Design) have done all the work; I just write the checks (and the posts).

MCM has been around for eight years now, a lifetime in the brave new world of social media.  Over those years, we’ve published 2471 posts, all accessible via the search function on the home page (yup, kept my unfortunately wrong ones too; Rob Gelb you haven’t been forgotten).

We’re up to 3471 subscribers (after cleaning up the list a bit) and average around 1700 readers a day (with pretty wide swings).

Couple things worth noting

What is ‘publishable’

Folks either are a) eager to get their name/company/new product-customer-idea published in MCM or b) anything but.  Many of my conversations with industry execs start with “this is confidential, right?”  The answer is always “Yes”.  I could not survive in the consulting world if my clients feared they’d appear on MCM (without their express approval).

At the other end of the spectrum, I am often approached by people eager to use MCM to get some publicity.  Mostly, I gracefully decline (ok, sometimes not so gracefully).  Occasionally the approach is professional enough, and the ‘thing’ topical enough, that it merits publication.

MCM ‘attitude’
Every now and then I get myself into a bit of hot water (sometimes an ocean’s worth) over a post, a characterization within a post, or an honest mistake. I’ll continue to retract and apologize for errors. I will also continue to opine assertively when I think the issue merits assertive opining. When I hear something that’s newsworthy, I’ll post it (after verifying thru at least two sources). And of course you can always rely on MCM to debunk stories, press releases, and flat out BS, with the tone and histrionics directly in proportion to my level of outrage.

Comment policy
You would not believe the spam comments I get – over a hundred a day, and sometimes two hundred. We’ve tried everything to ensure your comments get thru (even ones I take issue with) while blocking spam; for now I have to review all comments before they go thru. Hopefully this new platform will help.

As always, rants and comments disagreeing with me will not be posted unless opinions are backed by sources cited accurately. That’s not to say I won’t post different opinions; always have and always will.

What’s coming up.

The election season – also known as the Silly Season – is upon us (painful sigh).  My politics are well known (sometimes to my detriment) but I won’t hide my views.  If you don’t like my stance, I’m happy to hear from you – keep it professional and courteous.  If you are tempted to insult, I’d suggest you consider this.

About a year ago, I received a particularly nasty string of emails from someone on the opposite end of the political spectrum calling me, among other things, a commie, socialist, leftist, idiot, liar.  This person’s boss’s boss is also a subscriber and has become a friend – even though he’s also very conservative. He offered to discuss the issue with my antagonist; I declined.

The internet is forever, folks.  Be smart, be professional, be respectful.