March 2018 - Page 2 of 2 - Medical Association of the State of Alabama

Archive for March, 2018

STUDY: Independent Practice Declines Due Partially to EHRs

Posted by admin on March 2, 2018

A new study conducted by the Trump Administration suggests electronic health records are currently failing at reducing the cost of billing for medical facilities, especially for independent practices.

“Small physicians’ groups and solo providers could not afford to purchase and maintain electronic medical records and comply with government reporting requirements,” the White House report stated. “As a result, hospital mergers are booming, leading to horizontal integration, and large hospitals are buying up physicians’ practices and outpatient service providers to form large, vertically integrated health care networks.”

A study published in the Journal of the American Medical Association shows that billing costs consumed significant chunks of revenue even at a large academic center with a fully implemented EHR system. They represented about 14.5 percent of costs of primary care visits and 13.4 percent of costs for ambulatory surgical procedures. “These findings suggest that significant investments in certified health information technology have not reduced high billing costs in the United States,” the authors state in the report.

Independent physicians have also commented on the burdens of the EHR system. Three out of four physicians believe electronic health records (EHRs) increase practice costs, outweighing any efficiency savings, and seven out of 10 think EHRs reduce their productivity, according to a Deloitte’s recent 2016 Survey of U.S. Physicians.

The results of the survey also indicate physician satisfaction with EHRs varies by practice characteristics. About 70 percent of employed physicians are more likely to think that EHRs support the exchange of clinical information and help improve clinical outcomes compared to 50 percent of independent physicians. The results also revealed 72 percent of independent physicians are more likely to think that EHRs reduce productivity compared to 57 percent of employed physicians. Additionally, 80 percent of independent physicians think that EHRs increase practice costs, compared to 63 percent of employed physicians.

The federal government has financial interests in making it easier for physicians to cope with EHR requirements, according to President Trump’s 2018 Economic Report. As part of its 2018 economic report, released Feb. 21, the White House drew a direct connection between physicians’ struggles to purchase and operate EHR systems and the increase in consolidation among hospitals.

Tags: economic, EHR, electronic, employ, health, network, physician, provider, record, solo

Posted in: Advocacy

Just What the Doctor Ordered: An Alabama Perspective on the Opioid Epidemic

Posted by admin on March 1, 2018

Sometimes, Alabama is No. 1. In 2012, Alabama was the highest per capita painkiller prescribing state, with an average of 143 prescriptions written per 100 people — almost three times the rate of the lowest prescribing state.1 Alabama has been home to other No. 1s, too. In 2012, Dr. Shelinder Aggarwal, a former Huntsville-area pain doctor, was the top Medicare prescriber of prescription painkillers in the United States, until he was sentenced to 15 years in prison, had to pay back some $9.5 million in fraudulently billed claims, and surrendered his medical license in the wake of an examination by the Board of Medical Examiners.2

Many aspects of Aggarwal’s practice, which was described in the charging documents against him as a “pill mill,” are almost beyond belief. Aggarwal was seeing 80 to 145 patients in his office each day in 2012. Alabama pharmacies filled about 110,013 prescriptions (12,313,984 pills) in calendar year 2012 for controlled substances prescribed by Aggarwal. That equates to 423 prescriptions and 144 patients per day, assuming Aggarwal worked a five-day work week and wrote about three prescriptions per patient.3

Exactly how Aggarwal was able to prescribe controlled substances in such volumes is no less shocking. According to charging documents, initial visits entailed little more than a superficial physical exam and a urine drug test and lasted only five minutes. Follow-up visits could last as little as two minutes. Aggarwal allegedly did not retrieve a patient’s medical history, nor did he treat his patients with anything other than controlled substances. He was known to ask patients what medications they wanted, and he even wrote prescriptions for controlled substances to patients who admitted to using illegal drugs, or whose drug screen showed illegal drugs in their system.4

Aggarwal’s example, perhaps, is on the extreme end of the spectrum, but it highlights the gravity of the “opioid epidemic” Alabama and the United States are facing right now. Every physician has a role to play combating these opioid problems, and there are tools out there to help.

Prescription Drug Monitoring Program

The Alabama Prescription Drug Monitoring Program, or PDMP, is designed to “promote the public health and welfare by detecting diversion, abuse and misuse of prescription medications classified as controlled substances under the Alabama Uniform Controlled Substances Act.”5 Under the authorizing act and implementing regulations for the PDMP, any dispenser of Class II, III, IV or V controlled substances must report the dispensing of these drugs to the PDMP.6 Therefore, in most cases, you should be able to see any controlled substance (e.g. opioids) that have been dispensed to a patient if you check the PDMP. Although the PDMP authorizing act does not require prescribers to check the PDMP, they are allowed to access PDMP
information for a current or prospective patient,7 and their applicable licensure board may impose requirements to check the PDMP by regulation. Prescribers and dispensers should consult the PDMP and may suggest other health providers also consult the PDMP if there is information that may be important to the other health provider. Note: Neither the PDMP report nor any information from the PDMP report should be disclosed — that’s why you should suggest the other health provider consult the PDMP if you have a concern, rather than revealing information directly from the report.8

BME Risk and Mitigation Strategies Rule

The PDMP statute does not require prescribers to consult the PDMP, but certain licensure boards do. For instance, the BME recently finalized a new rule on risk and mitigation strategies (RMS) for prescribing physicians.9 The new rule requires prescribers to check the PDMP at frequencies that vary based on the morphine milligram equivalency (MME) of medications they are prescribing: (1) upon each prescription for controlled substances greater than 90 MME; (2) at least twice each year for controlled substances between 30 and 90 MME; and (3) consistent with “good clinical practice” for controlled substances less than 30 MME. Additionally, physicians are required to document the use of RMS in the patient’s medical record. Physicians should take care to adequately document appropriate RMS without running afoul of the PDMP prohibition on disclosing the PDMP report or the information contained therein. This can be a difficult task to fulfill when you can’t keep a copy of the PDMP report in the patient’s medical record.10 A simple notation in the patient’s medical record that you have checked the PDMP and that there are no contraindicated prescriptions likely would suffice.

The new RMS rule sets forth other RMS, including pill counts, urine drug screenings, patient education, and others, some of which are described below from the CDC. Physicians should note that failure to fulfill their obligations under this rule could lead to adverse licensure actions.11

CDC Guidelines for Prescribing Opioids for Chronic Pain

The Centers for Disease Control and Prevention, after a rigorous period of research, consultation and public comment, has also issued opioid prescribing guidelines for primary care physicians treating patients with chronic pain.12 Below is a brief description of the guidelines:

Consider nonpharmacologic therapy; only prescribe opioids if risks outweigh benefits;
Establish treatment goals;
Discuss known risks and benefits of opioid therapy with patients, as well as clinician responsibilities for managing therapy;
Consider prescribing immediate-release, rather than extended-release opioids;
Prescribe the lowest-effective dosage;
For short-term (acute) pain, prescribe the lowest-effective dose and only in the quantity needed for the expected duration of pain severe enough to require opioids;
Evaluate risk factors for opioid-related harms and implement a risk mitigation plan;
Review the PDMP for harmful quantities or combinations of controlled substances;
Conduct urine drug testing before starting opioid therapy;
Avoid prescribing opioids and benzodiazepines concurrently, if possible;
Offer evidence-based treatment for patients with opioid-use disorder.

A full report listing methods, clinical evidence, and a full discussion of the above recommendations are available from the CDC (see link in footnote 12 below for reference).

These are just a few tools to help you help your patients and mitigate the opioid epidemic. Let’s not win anymore No. 1s of the kind described above for the State of Alabama.

References

1 Prescribing Data, Centers for Disease Control and Prevention (Dec. 20, 2016), https://www.cdc.gov/drugoverdose/data/prescribing.html; Leonard J. Paulozzi, MD et al., Vital Signs: Variation Among States in Prescribing Opioid Pain Relievers and Benzodiazepines—United States, 2012, CDC: Morbidity and Mortality Weekly Report (July 4, 2014), available at https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm?s_cid=mm6326a2_w.

2 Huntsville Pill Mill Doctor Sentenced to 15 Years in Prison for Illegal Prescribing and Health Care Fraud, Department of Justice: U.S. Attorney’s Office, Northern District of Alabama (February 7, 2017), available at https://www.justice.gov/usao-ndal/pr/huntsville-pill-mill-doctor-sentenced-15-years-prison-illegal-prescribing-and-health.

3 United States v. Shelinder Aggarwal, Information Against Shelinder Aggarwal, Sept. 22, 2016.

4 Id.

5 Alabama Department of Public Health: Prescription Drug Monitoring Program Home (June 23, 2017), http://www.alabamapublichealth.gov/pdmp/index.html.

6 Ala. Code § 20-2-213 (1975); Ala. Admin. Code r. 420-7-2-.12 (Nov. 24, 2014).

7 Ala. Code § 20-2-214(2) (1975); Ala. Admin. Code r. 420-7-2-.13 (Nov. 24, 2014).

8 See Ala. Code §§ 20-2-215 to 20-2-216 (1975) (making records and information in the PDMP privileged and confidential and creating a Class A Misdemeanor for individuals who intentionally make an unauthorized disclosure of information from the PDMP); see also FAQ, Alabama Department of Public Health: Prescription Drug Monitoring Program (May 31, 2017), http://www.alabamapublichealth.gov/pdmp/faq.html.

9 See Ala. Admin. Code r. 540-X-4-.09 (March 9, 2017).

10 See FAQ, Alabama Department of Public Health: Prescription Drug Monitoring Program (May 31, 2017), http://www.alabamapublichealth.gov/pdmp/faq.html.

11 Ala. Admin. Code r. 540-X-4-.09(8) (March 9, 2017).

12 Deborah Dowell, MD et al., CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, CDC: Morbidity and Mortality Weekly Report (March 18, 2016), available at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm#suggestedcitation.

Article contributed by Christopher L. Richard with Gilpin Givhan, P.C. Gilpin Givhan, P.C., is a Bronze Partner with the Medical Association.

Tags: control, drug, epidemic, milligram, monitor, morphine, opioid, PDMP, pharmacy, substance

Posted in: Legal Watch

Liquid Gold or Reimbursement Trap? Payor Reimbursement Policies for Urine Drug Testing

Posted by admin on March 1, 2018

Last summer, we wrote about physician roles and responsibilities to implement best practices in pain management programs and other treatments involving the prescription of opioids.1 Here we discuss issues related to getting paid to implement one of these best practices — appropriate urine drug testing.

The urine drug testing field has been described as a huge profit center with a growing number of clinics that run their own testing operations instead of farming them out to independent labs;2 but the numbers don’t always add up. This article takes a closer look at urine drug testing guidance from the Alabama Board of Medical Examiners and the Centers for Disease Control and Prevention and examines the urine drug testing policies for Medicare and Blue Cross & Blue Shield of Alabama to highlight an area where best practice and payor policies don’t always agree.

The “Best Practices”

When the BME finalized a new rule last year regarding risk mitigation strategies (RMS) for physicians prescribing controlled substances, urine drug testing was one of several recommended aspects of the RMS.3 The BME’s rule does not specify the frequency with which physicians should use urine drug testing in their RMS, but the CDC’s guidance4 on opioid prescribing best practices is informative.

According to the CDC’s study, experts agreed clinicians should use urine drug testing before the initiation of treatment using opioids and periodically thereafter to assess for prescribed opioids, other controlled substances, and illicit substances that may increase the risk of overdose when
combined with opioids. However, experts disagreed on the frequency with which urine drug testing should be used to monitor treatment regimens
and patient compliance, as well as on the degree to which urine drug testing should apply to all patients uniformly, as compared to individual case-by-case determinations.

The study also addresses the appropriate use of qualitative “screening” panels and quantitative “confirmatory” or “definitive” testing. The CDC recommends relatively inexpensive screening panels for illicit drugs and commonly prescribed opioids prior to initiation of treatment. More expensive confirmatory testing should be reserved “for situations and substances for which results can reasonably be expected to affect patient management” (e.g. in the case of positive screenings or unexpected negative screenings).

These suggested best practices can have a positive impact on patient treatment involving opioids and other controlled substances, but they may put
physicians in the position of ordering tests for which reimbursement is not available. In fact, as the CDC report acknowledged, the direct costs of urine drug testing “often are not covered fully by insurance.”

Sometimes, it just doesn’t pay…

Payors impose different requirements regarding medical necessity and frequency of drug testing. If you read through the BCBSAL and Medicare urine drug testing policies, it may seem the differences between the two policies are minor. However, these two payors differ on the frequency of monitoring screenings (after the initiation of treatment) that are considered medically necessary, as well as on their coverage policies for confirmatory tests.5

The most notable coverage difference we have seen between the two programs is in their application of the confirmatory testing policies,
specifically each payor’s interpretation of the word “test.” To illustrate, consider the following G-codes for confirmatory/definitive drug testing: G0480 (definitive drug test for 1-7 drug class(es)), G0481 (definitive drug test for 8-14 drug class(es)), G0482 (definitive drug test for 15-21 drug class(es)), and G0483 (definitive drug test for 22 or more drug class(es)). Medicare treats each G-code as a “test” for purposes of counting tests toward a coverage or benefit limit.6

By contrast, it is our understanding from conversations with BCBSAL that they consider each drug or drug class to represent a “test” for coverage and benefit limits, despite the fact that each G-code comprises a range of drug classes in multiples of seven. Because BCBSAL limits coverage of confirmatory tests to three tests per qualitative drug screen, in theory, reimbursement to providers would only be covered by BCBSAL under G-code G0480 for up to three drug classes tested per qualitative screening. To the extent providers bill BCBSAL for additional confirmatory tests beyond the three-test limit, they would likely be non-covered or result in an overpayment. BCBSAL’s restrictive policies are certainly a limiting factor on physicians trying to implement the best practices described above, and physicians should be aware of the different coverage policies between Medicare and BCBSAL with regard to confirmatory tests.

We chose to highlight this particular coverage policy difference between Medicare and BCBSAL because it is not readily apparent from a reading of the two policies. However, there are other nuanced aspects of payor policies on urine drug testing. Physicians and billing/coding personnel should consult the relevant payor billing guidelines, with the assistance of counsel as necessary, in order to determine coverage for a particular test or service.

Sources

1 Christopher L. Richard, Just What the Doctor Ordered: An Alabama Perspective on the Opioid Epidemic, Alabama Medicine, Summer 2017, at 4.

2 See, e.g. David Segal, In Pursuit of Liquid Gold, New York Times (December 27, 2017), https://www.nytimes.com/interactive/2017/12/27/business/urine-test-cost.html.

3 Ala. Admin. Code r. 540-X-4-.09(2)(b) (March 9, 2017).

4 Deborah Dowell, MD et al., CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, CDC: Morbidity and Mortality Weekly Report (March 18, 2016), available at https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm#suggestedcitation.

5 See BlueCross BlueShield of Alabama Policy No. 566, Drug Testing (last reviewed December 2016), available at https://providers.bcbsal.org/portal/documents/10226/1791629/Drug+Testing/1c67985a-0c5d-4be9-aa3c-c49677cf6a93?version=1.1; Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L35724), CMS.gov, https://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx?from=~/overview-and-quick-search.aspx&npage=/medicare-coverage-database/details/lcd-details.aspx&LCDId=35724&ver=41&CntrctrSelected=381*1&Cntrctr=381&name=&DocType=Active&s=34%7c48%7c53%7c58&bc=AggAAAQBAAAA&.

6 2017 Controlled Substance Monitoring and Drugs of Abuse Coding and Billing Guidelines (M00128 V5), Palmetto GBA, https://www.palmettogba.com/palmetto/providers.nsf/docscat/Providers~JM%20Part%20B~Browse%20by%20Topic~Lab~2017%20Controlled%20Substance%20Monitoring%20and%20Drugs%20of%20Abuse%20Coding%20and%20Billing%20Guidelines%20(M00128%20V5 ) (describing each G-code as a “service” and providing that providers may only perform and report one G-code per date of service).

Article contributed by Christopher L. Richard with Gilpin Givhan, P.C. Gilpin Givhan, P.C., is an official Bronze Partner with the Medical Association

Tags: BCBS, BME, CDC, mitigation, payor, reimburse, risk, RMS, screen, urine

Posted in: Legal Watch