The Unified Program Integrity Contractors (UPICs) may need lessons in reading patient notes. Should they be "defunded?"
These days, everyone has a horror story about an audit. There are arrogant know-it-alls that show up unexpected, embarrassing the provider in front of their patients. "He must have done something wrong, otherwise they wouldn't be here," patients say. "Should we go somewhere else?"
There are those nasty letters from cutthroat collection agencies subcontracted to the U.S. Department of the Treasury. And the delays. Endless delays. An inquiry might take a full five minutes of an auditor's time. Yet if they have 30 days to answer, they will get to it on the afternoon of the 29th day, and use the “mailbox rule” to say they answered on time. I can guarantee you that. Of course, that is the case only if they bother to answer. Often, they don’t.
Then there are more delays. The backlog. It takes years before the provider gets their day with an administrative law judge (ALJ): the day in court, so to speak. It finally arrives. By that time, the provider has been taken through a lengthy ordeal. I don't think anyone keeps the statistics, but one wonders how many providers actually die waiting for their hearing. We can be sure that some do. But if they don't die, what they go through can be enough to kill them. Endless work, with fees being taken away. Vague letters from the Unified Program Integrity Contractor (UPIC). All boiler-plate language, full of repetition; vapid, dry, cardboard language that simply restates platitudes.
"We went through the LCD 20 times already. Checked everything. The patient notes look good. What are they talking about?"
Here is an example: a true story, a real audit, a real provider. The UPIC swept in, demanding a number of claims to review. That's their right. We’ve got to stop fraud and all. Everything gets rejected. A sloppy extrapolation, so inaccurate you could drive a semi-truck through it, a huge demand for recoupment, and now the practice is in jeopardy.
What are the reasons? Here is one, right out of the UPIC notes:
Per LCD L28529, The diagnosis of trigger points requires a detailed history and thorough physical examination. There is insufficient documentation of the history of onset of the condition, its presumed cause, and muscular deconditioning in the affected area.
Of course, you, as the reader, need to know what “LCD L28529” is. That is a trigger point injection. The patient is in such bad pain that other treatments such as osteopathic manipulation do not work. So it is necessary to inject some painkiller like lidocaine into the muscle to bring the patient out of their misery. Of course, it is a last-ditch effort, when other things have failed.
So what has the UPIC said, when they rejected all of the claims? There needs to be a detailed history and thorough examination of the patient.
Of course, that sounds reasonable enough. We can’t just go shooting people up with painkillers without making a diagnosis, understanding how the pain came about, and verifying everything with a physical examination. After all, doctors who practice osteopathic medicine are not drug dealers. But reading the comments from the UPIC, you would think the doctor was acting like one.
So in this particular instance –– yes, this is based on a real case –– we scrambled to take a look at the patient notes. These are the exact same notes that the UPIC auditor had to read when they rejected the claim.
One would expect to find shoddy note-keeping, omissions, vague statements, incomprehensible gibberish. A lazy doctor, not paying attention to details, taking shortcuts, bilking Medicare out of money, and laughing all the way to the bank.
Is that what the patient notes reveal? No. Absolutely not.
The actual patient notes have a history of the present illness, a past medical history, a social history, and a family history. Four separate histories. Say Whaaaat? The auditor has four separate history comments in front of them, then has the temerity to write that the doctor did not provide a detailed history.
There must be some other problem. Yes, that’s it. The doctor confused things by using codes and abbreviations –– HPI, PMH, SH, FH. After all, medical documentation should be clear, easy to understand.
But what happens when we look at the 1997 Documentation Guidelines for Evaluation and Management Services, published by the Centers for Medicare & Medicaid Services (CMS)? What does it say? The section on “documentation of history” says the doctor has to note the “CC,” or chief complaint, the “HPI,” or history of present
illness, a “ROS,” review of systems, and a “PFSH,” which is a past, family and/or social history.
Surely the doctor was lazy and did not make a note of all of this, right? No! The notes do in fact have a CC, HPI, and ROS. But what about the PFSH? What do we find? We find that the doctor also made note of a social history and family history.
There still must be something wrong? Let’s look at the details. The CMS document on Page 9 says that the PFSH includes a past history, family history, and social history. We see that the doctor has included each of those. Something must still be missing. Let’s read the CMS document further. “At least one specific item from any of the three history areas must be documented for a pertinent PFSH.” But the doctor’s patient notes have all three histories. The patient notes actually have three times as much detail on history than is required!
What is the UPIC auditor talking about? Did they read the patient notes? Surely they must understand the abbreviations, because they are found in the CMS documentation.
It must be the physical exam. Perhaps the doctor did not do a thorough physical exam? Right? No!
The physical exam notes have specific evaluations of the abdomen, upper extremities, lower extremities, left hip, pelvis, sacrum, lumbar L2-3RI, thoracic T12RI, and others. For each of these areas, there are comments on muscles, somatic function, tone, whether or not there is tenderness, and so on. There are measurements of what degree of bending produces pain.
And the UPIC auditor says there is an insufficient physical examination? This is complete and utter nonsense. Can’t they read? And the auditor has “cloned” the same rejection reason down for dozens of claims. The doctor has kept the same level of detail on every single claim.
So the auditor read through dozens of claims, all having this excessive level of detail, and they say there is “no detailed history” and “no physical examination?”
Look here. I don’t want to be unfairly critical. Audits are necessary to catch fraud. Fraud is bad. But this example is ridiculous. It is actually abusive and crooked. This has nothing to do with fraud. This is an example of a professional assassination. The doctor goes through hell, has hundreds of thousands of dollars tied up in litigation, and has to wait around five years to get to a hearing.
Oh, and one more thing. Over this entire period, the UPIC never answered the telephone. Not once. What about National Government Services (NGS)? On their website they boast about being ISO 9001 “certified.” They never answered a single letter. Never. How about them apples?
This system needs to be reformed. The auditor who did this should be fired. The doctor should be able to sue the UPIC for egregious abuse. Here, it is the UPIC that is committing fraud, not the doctor. Perhaps the threat of defunding might help? But don’t bet on reform any time soon.
A doctor of osteopathy helps people manage their pain, but there may be no cure for an incompetent audit.