An Overweight Uterus, Low-Value Interventions, and Medicare Advantage Auditors Behaving Badly

Providers should take a close look at what traditionally accepted forms of care are, in fact, unnecessary.

Let’s start today with a silly denial. Now, unfortunately, I don’t recall the insurer, so I cannot publicly shame them, but here is the story.

A physician obtained prior authorization for an outpatient laparoscopic hysterectomy. The surgery proceeded uneventfully, and the patient was discharged. When the hospital submitted the claim, it was rejected.

The coding was correct, the indication for the surgery was proper, so what was wrong? Well, the uterus, once removed, weighed more than expected, so the CPT® code for the surgery changed and the claim was denied for not matching the authorized code.

Now, why does a hysterectomy for a uterus that weighs over or under 250 grams need different codes? I have no idea, but it does. The same applies to many surgeries, wherein the specimen size affects the code. Now, I am sure they will get paid eventually for the CPT code that properly describes the surgery that was performed, but the time and effort to get that payment just multiplied considerably.

Moving on, last week Choosing Wisely and the Society of General Internal Medicine released five updated recommendations. You may know that these are from professional societies, offering what are commonly called “things we do for no reason.” This time the list includes advice such as that asymptomatic healthy adults do not need a yearly physical exam and labs, routine pre-op labs before low-risk surgeries are not necessary, we should not perform cancer screening for patients with a life expectancy of under 10 years, PICC lines should not be used for patient or physician convenience, and type 2 diabetics not on insulin do not need to perform daily home blood glucose monitoring. Why do I talk about these to this audience? Well, we all have a role in ensuring that the medical care we provide to patients is appropriate. Millions of dollars are spent on these low-value and potentially harmful interventions, all money that can be better spent on improving health equity and reducing food insecurity (and so much more).

Here’s a little anecdote about the diabetes recommendation. I stopped recommending that my patients with type 2 diabetes check their glucose every day about 15 years ago, when the studies showed it was not beneficial. I sent all my patients to a diabetic educator to learn about diet and so on. One of those patients came back to me and said “the educator taught me to check my fingerstick glucose and to check it daily. She said you were old-fashioned, and up-to-date doctors recommend daily checks.” I explained the evidence, and the patient was happy not to have to buy the testing supplies and stick their finger every day for no good reason.  

If you listened to Monitor Mondays recently, you heard Dr. John Hall talk about the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report on hospital harm to patients, with a figure of 25 percent cited. There is an easy way for us to reduce hospital harm; we should stop treating patients’ illnesses. If a patient with decompensated heart failure is given diuretics and develops low potassium, that patient is “harmed.” Yet there is no way to 100-percent prevent hypokalemia in this situation. Doctors routinely supplement potassium, but there is no direct-dose effect relationship, and giving too much potassium can cause harm in itself. If a patient gets chemotherapy and develops (the expected) bone marrow suppression, they are “harmed,” even though that cytopenia also demonstrates that the chemotherapy is working. This issue of “hospital safety” was also recently highlighted in an article in the New England Journal of Medicine. It is crucial that such studies be analyzed carefully to properly balance the risks and “rewards” of medical care. Who knew it was so complicated?

Finally, I want to be sure that all of you have read my RACmonitor article from last week and submitted a comment to the Centers for Medicare & Medicaid Services (CMS) on the proposed rule. As a reminder, there is a link in the article to a letter template provided by the American College of Physician Advisors to help guide your thoughts.

Tell your Medicare Advantage (MA) horror stories about how they put up roadblocks to necessary care and adversely affected the patient (but of course, no PHI). And, as I describe, think about using the Two-Midnight Rule for all MA patients, starting now.

Programming note: Listen to Dr. Ronald Hirsch as he makes his rounds during Monitor Mondays at 10 a.m. EST, sponsored by R1-RCM.

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Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, 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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