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Does this new era of regulation put an undue burden on medical providers or does it truly serve the best interest of patients?
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Stricter enforcement means greater administrative burden
 Riva Lee Asbell |
These new regulations will definitely require ophthalmologists to spend more time on administrative and coding issues. Most practices in this country are not mega practices; most are still small businesses, but the physicians are already busy trying to run them. These burdens combined with the quality initiatives equal a lot of extra personnel and, from a reimbursement and coding perspective, a lot of extra time and work.
It is easy to see where Medicare is coming from in all of this, but I think they are off base. If you look at the overall picture of improper payments and portion out what is from individual physicians, it is actually very small. The big hitters are hospitals and durable medical equipment. That is where the billions of dollars are. It is not with the physicians, and I do not think the government is correct in thinking that they are going to get that money from physicians to pay for health care reform.
There are physicians out there who are getting away with fraud and abuse. But the government does not have the expertise to go into ophthalmic practices and find, for example, fraudulent surgical coding. They have to use other criteria; they throw a big net and see what comes up. If they find something that looks a little bit funny, then they take a closer look. Sometimes, you catch a big fish.
Yet, it is patient complaints and whistle-blowing that usually lead the way to the big-ticket audits more than do random audits, unless it is a really flagrant violation. But random audits do tie up a lot of physician time — for instance, reviewing records or responding to requests for information from investigators who might not understand the intricacies of ophthalmology. The government auditors are not ophthalmology-specific and do not always have the expertise necessary to work in a specialty such as ophthalmology, which has so many subspecialties with so much depth.
Riva Lee Asbell is an OSN Practice Management Board Member and president of Riva Lee Asbell Associates, an ophthalmic reimbursement consulting firm.
A larger burden on smaller practices
 John B. Pinto |
Over the last two generations of ophthalmologists, there has been a steady increase in regulatory reform, with a resulting increase in paperwork. We are now starting to approach a “straw on the camel’s back” era, where the regulatory and paperwork demands are becoming vastly out of scale with the internal resources of the typical ophthalmology practice. The extra burdens in such practices are directly on providers, obliging them to shave time from patient care.
Certainly there is a great deal of reasonable anxiety that is arising in the profession. What is occurring right now is just another driver inching the profession toward a larger average practice scale. Only as one moves up the ladder in organizational scale from one to three doctors, to five, 10 or 25 doctors in a clinic, are you at the scale where you can afford regulatory specialists. Only in the largest practices can we stand toe-to-toe with these national regulatory efforts and shield the doctors from the paperwork burden.
The current rash of new regulatory oversight will be disproportionately hitting the solo doctor. As such, doctors are often the only people in the practice able to address these complex, high-stakes issues. The typical up-through-the-ranks office manager of a small solo practice is already beleaguered and does not often have the right background to deal with these issues.
What I would advocate, rather than putting a lot of federal budget into checking into the behavior of the little guy in small practices, is to do what is done in a lot of other highly regulated environments. If you are above a certain size, you are going to be reviewed a little more circumspectly. And that is just for a practical reason. If you are a larger clinic, you are going to have the resources to gather information and keep the practice on the straight and narrow, and if you are a practice that is doing things incorrectly, you are more likely to recover enough dollars to pay for the auditing effort. It is very much like the IRS. Very few individuals get their taxes audited, because what is recovered does not pay for the auditor’s time.
John B. Pinto is the OSN Practice Management Section Editor and president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm.