StrategicHealthSolutions and Our Medical Directors Help Sustain Medicare and Medicaid
As the Centers for Medicare & Medicaid Services (CMS) continue to innovate, StrategicHealthSolutions (Strategic’s) medical directors have proven to be a valuable resource in developing support and training materials that aid providers and consumers with best practices, understanding changing health regulations, and how to reduce overutilization of services and prescription drugs.
Strategic’s medical directors, Dr. Mark Pilley, Dr. Anton Piskac, and Dr. Manuel Pubillones, are heavily credentialed experts in their field. They have provided direct care to patients and have also served in various peer-review and auditing roles, which has given them a unique perspective on health care sustainability.
Drs. Piskac, Pubillones, and Pilley say the long-term solution to sustaining our nation’s Medicare and Medicaid programs is to stop waste and abuse before it occurs. Best practice requires standardizing documentation, following nationally accepted American Medical Association (AMA) guidelines and measurements, and changing behaviors in both providers and beneficiaries. These changes will lessen the delivery of unnecessary services and the overprescribing of drugs.
Dr. Piskac points to the gap between scientific discovery and application as a critical factor in doctors providing wrong or unnecessary services or prescriptions.
“Sometimes doctors just don’t know the new science and sometimes it takes a while for scientific innovation to be adopted,” says Dr. Piskac. “On average, it takes around 17 years for a new scientific discovery to be widely adopted. That may be about the same length of time a professional is in practice.”
Dr. Piskac believes the continuing education of doctors is a critical factor affecting healthcare sustainability, but that it also presents a big challenge.
“Even if you were to read medical journals 24 hours a day, you could only get a small fraction of what you’re supposed to absorb, so doctors can be overwhelmed,” says Dr. Piskac.
Through his work in peer-review organizations, Dr. Piskac also identified how doctors may be aware of AMA medically-accepted standards, but without proper controls in place, the standards aren’t always applied. “They had the best of intentions but they didn’t always put them into practice correctly. It was only after they standardized their approaches that they were able to improve their performance.”
By failing to follow the AMA standards and procedures, doctors increase their risk of overprescribing and/or providing improper treatment. This creates risk for the patient, the healthcare ecosystem, and the doctors themselves by increasing their likelihood of being audited by CMS or its contractors, like Strategic.
Through our SMRC contract, Strategic has identified over $280 million in improper payments for services that were unnecessary and/or documented inappropriately. This is but a fraction of the $44 billion in improper payments caused by insufficient documentation, reported in fiscal year 2016.
“To lessen the burden on the health care ecosystem, providers need to bill for services more accurately,” says Dr. Pubillones. “We need to review our claims prior to sending them to an insurer and take responsibility if the services were inaccurately documented or rendered.”
Dr. Pilley says that Strategic’s role, and goal, in an audit is not to punish providers, but rather to ensure that our nation’s health care providers are following AMA-prescribed procedures and meeting quality indicators that ensure Medicare and Medicaid is paying accurately. “When an audit identifies an imbalance or inaccuracy, we act accordingly in the best interest of the taxpayers,” says Dr. Pilley. “The goal is to help doctors and the system succeed. It’s a matter of process and efficiency, and we must work at it.”
Strategic’s medical directors agree that the health care ecosystem has systemic challenges; they also agree it is fixable and sustainable if we evolve together. It starts with health care leadership being willing to own and evolve their piece of the health care ecosystem.
“Part of our role as a government contractor is to provide educational toolkits for CMS to inform providers about issues affecting healthcare,” said Dr. Pubillones. These items appear in the many resources and training materials available through the CMS website. Continuing Education materials are available through Strategic, as well.
“There’s a plethora of resources available, but we must make it a priority to invest the time into ongoing training,” says Dr. Pilley. The payoff is great, and the risk to doctors for an audit and disciplinary action for improper payment will be minimized.
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About our StrategicHealthSolutions Medical Directors:
Dr. Pilley is board-certified in family practice, a Fellow of the American Academy of Family Physicians, a Fellow in the International Academy of Independent Medical Evaluators and has a Fellow board certification and sub-certification in risk management from the American Board of Quality Assurance and Utilization Review Physicians. He spent 19 years in direct family practice care before moving to helping insurers do peer review, quality assurance, and utilization review. His historic institutional experience and knowledge of health care delivery make him an asset as health care regulators roll out new plans and compliance rules to receive payment.
Dr. Pubilliones operated a medical technology practice for four years before completing medical school and becoming a practicing psychiatrist for 14 years. In the early ’90s, he joined the Puerto Rico Medicaid program before heading stateside and joining the Medicare program. While serving patients through his clinical practice he witnessed the prevalence of discrimination against persons with mental health conditions. Through participating in the Medicaid and Medicare program, he realized the need for improving a system that provides quality services, while eliminating malpractice, fraud, and abuse that had become a drain on the system. He is an advocate for providing coverage and offering mental health and substance abuse services in a similar way as for other clinical services.
Dr. Piskac practiced internal medicine in a private practice for 25 years. An additional 20 years of his career were spent in peer review organizations and hospital settings, identifying and improving provider performance to achieve better patient outcomes. He retired for 3 months before concluding that he wasn’t well-suited for retirement. He is an asset to StrategicHealthSolutions and in helping fellow providers. His skills have been used to improve processes and efficiencies within Strategic, and to provide oversight for CMS contracts.