Physicians and the Opioid Crisis

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.    


Comment on this article

Print Friendly, PDF & Email

Ronald Hirsch, MD, FACP, ACPA-C, 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, and the National Association of Healthcare Revenue Integrity, 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).

Related Stories

Remain Compliant – and Take the Money

Remain Compliant – and Take the Money

Our first topic today is local coverage determinations (LCDs) and variation. I have written in the past about national and local coverage determinations, and I

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 SDoH Update: Navigating Coding and Screening Assessment

2024 SDoH Update: Navigating Coding and Screening Assessment

Dive deep into the world of Social Determinants of Health (SDoH) coding with our comprehensive webcast. Explore the latest OPPS codes for 2024, understand SDoH assessments, and discover effective strategies for integrating coding seamlessly into healthcare practices. Gain invaluable insights and practical knowledge to navigate the complexities of SDoH coding confidently. Join us to unlock the potential of coding in promoting holistic patient care.

May 22, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →