Physicians and the Opioid Crisis

Original story posted on: February 6, 2019

MAC to audit physicians who prescribe opioids.

It is well-known to the medical community and to the general public that the opioid epidemic has taken too many lives.

The causes are myriad (I outlined these in a article in 2016, the second most-read article of the year on that site, shared over 97,000 times), as are the solutions proposed to stop the epidemic. On Oct. 26, 2017 the President even declared the epidemic a national public health emergency under federal law.

Many state and federal agencies, payers, pharmacy benefit managers, health systems, and medical societies have programs to ensure that opioid prescribing is appropriate and the treatment of opioid use disorder in all healthcare settings is growing, especially in emergency departments, where persons battling substance abuse often have their first encounter with our healthcare system.

In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced the targeted probe-and-educate process, tasking the Medicare Administrative Contractors (MACs) to use their data capabilities to target providers whose data appeared to deviate from the norm. This served two purposes; it allowed the MACs to use their limited resources in areas in which they are more likely to find errors, and it allowed providers that are not outliers to avoid expending time and effort on audit requests when the likelihood of passing is high.

At the end of 2018, these two seemingly disparate topics merged when CGS, the MAC for Jurisdiction 15, encompassing Ohio and Kentucky, announced that it will be initiating post-payment targeted probe-and-educate audits of physicians who bill for evaluation and management (E&M) visits that result in a prescription for an opioid or benzodiazepine. These audits seem appropriate; the opioid epidemic warrants an “all hands on deck” approach, but from the process standpoint, this topic raises a lot of questions. Fortunately, I have most of the answers.

Most obviously, how will the MACs be selecting providers for audit? As the saying from Sherlock Holmes goes, if the MAC told us that, they’d have to kill us. But it is clear that the MACs have access to all information for services billed with each physician’s National Physician Identifier (NPI), including testing ordered by the physician but billed by another provider, such as lab testing or imaging. They can use that data to look at claims by diagnosis, frequency of visits, distribution of E&M code levels, frequency of ordering of lab tests such as urine drug screening, and referrals to physicians such as pain management, anesthesia, or physical medicine.

At this point, many physicians are probably thinking that this is simply another “witch hunt” by a government trying to intervene in the relationship between a physician and their patient. It is not. This is a systematic effort to use data to target resources where they are most effective. These audits will not be conducted by law enforcement agencies and will not result in arrests, but if there are indications of fraud or illegal activity, the MAC could refer the provider to law enforcement, just as they would do with a provider that was billing for services not performed or billed, or billing services provided to deceased patients. The MACs will first request the medical record and carefully review all the documentation submitted. They will not draw any conclusions based solely on the billing codes or patterns.

Most providers that have undergone targeted probe audits find the education quite helpful, and in no way punitive.

This approach contrasts with that taken in California, as described in a recent Kaiser Health News article, whereby physicians are investigated by the Medical Board of California if they prescribe an opioid to a patient who later dies, even years later. In this process, a selection of records will be audited, the results presented to the provider with an open discussion of the issues found, and then a determination if a second audit is warranted will be made, or if the errors were determined to be minor, with easy resolution. This type of review is also limited to providers in the CGS jurisdiction area, but the MACs talk to each other and share audit findings, so it could expand to other areas.

If you are chosen for audit, the most important thing to do is to respond to the request in a timely manner. In most physician audits, almost 30 percent of providers never send the requested records, often assuming someone else will send them. Once the record is requested, review the documentation and send not only the record requested, but any supporting documentation, such as previous visit notes, imaging, or labs. Do not, for any case, alter the documentation in response to a request for records; that never works out well. Then, as with any medical care, any medication prescribed, any referral made, and any test ordered, there should be sufficient documentation to support each. The new CMS guidelines on physician documentation have lessened the burden of documenting the elements needed to select an E&M code, but that does not mean that documentation of medical necessity should be ignored or diminished in importance, especially with opioid and benzodiazepine prescriptions. Every note should support every prescription or test ordered. Those extra minutes do add up and can be seen as a burden, but the current crisis warrants the extra time and attention.

As I write this, snow is falling, and drivers will be slowing down and paying more attention to the roads, leaving more distance between their car and the car in front of them. They may arrive a few minutes later, but they will arrive intact.

Our care of patients requiring opioids or benzodiazepines warrants equal care and effort.    


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Ronald Hirsch, MD

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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