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Audits on heart and joint procedures chill Florida doctors

The Medicare contractor for Florida has announced that as of Jan. 1, it will hold up all hospital payments for joint replacements, pacemakers and other common procedures until audits show they were necessary.

The 15 types of procedures affected are "high dollar claims at great risk for payment error," according to information provided to physicians by the contractor, First Coast Service Options of Jacksonville.

The Florida chapter of the American College of Cardiology has posted a lettercalling the maneuver "unfair and unprecedented" and complaining that First Coast has not made clear what information it's looking for. Some worry that Medicare patients may have trouble getting these procedures done until the matter is cleared up.

"They are able to limit access to care by blaming the docs," said Tampa orthopedic surgeon Michael Wasylik. "Deceptive but brilliant."

First Coast says in an online statementthat it is holding up payments because of a high "error rate" in these procedures. First Coast has conducted training to show hospitals and doctors how to document the necessity of these procedures but has seen no improvement, the statement says.

A web program that First Coast made available to physicians this week cited an error rate for four orthopedic procedures of 62 per cent. Fraser Cobbe of the Florida Orthopedic Society said First Coast surely can't mean that the way it sounds.

While the documentation in the records may not have satisfied Medicare auditors, he said, "I don't think anybody believes that 62 percent of people are getting unnecessary hip and knee replacements."

Cobbe said his group has asked for a delay in implementation in the pre-payment audits until hospitals and doctors figure out what kinds of documentation the auditors want. "We have not had a response back from that request as of yet," he said today.

Health News Florida asked First Coast to clarify some of the questions, but a spokesman said via e-mail that the Centers for Medicare and Medicaid Services (CMS) asked the company not to comment beyond the statement posted online. Health News Florida has asked for clarification from CMS.

While the prepayment reviews are bad news for hospitals, they're even scarier for physicians involved in the care of the patients, mainly cardiologists and orthopedists. That's because the contractor will continue to pay their claims but will demand the money back if the audits find problems.

It is unclear at this point whether CMS intends for Florida alone to have hospital prepayment audits; that is what Bloomberg reported this week, but others have said that similar payment holdups are scheduled for other states.

CMS contracts with companies by region to review payments for hospitals (Part A) and all outpatient care (Part B). First Coast has the contract for Florida, Puerto Rico and the Virgin Islands, but its statement online says that only Florida will be placed on prepayment audits.

Cobbe said CMS has so many audit grants and programs going on that it is difficult to tell how many states will be affected, or when.

In any event, the rule covers 15 "diagnosis-related group" (DRG) categories, including hip and knee joint replacement, spinal fusion, and insertion of cardiac stents, pacemakers and defibrillators.

The list of DRGs affected can be found on the First Coast website.

--Health News Florida is an independent online publication dedicated to public-service journalism. Editor Carol Gentry can be reached at 727-410-3266 or by e-mail.


Carol Gentry, founder and special correspondent of Health News Florida, has four decades of experience covering health finance and policy, with an emphasis on consumer education and protection.