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King v. Burwell: Supreme Court to Decide

By Sumita Saxena, Senior Consultant, The Verden Group

Just when you thought it was safe to say “Obamacare” . . .

In breaking news, the U.S. Supreme Court unexpectedly agreed this past Friday to hear the King v. Burwell case next year. What hangs in the balance is whether federal premium subsidies will be upheld or invalidated in 36 states. If those subsidies are invalidated, it will most likely result in millions of people losing health insurance because they won’t be able to afford the premiums.

This case harkens back to 2012 when the court was sharply divided in the ruling upholding the constitutionality of the Patient Protection and Affordable Care Act.

The case focuses on whether the ACA’s language allows consumers to receive premium tax credits in the 36 states relying on the federal HealthCare.gov exchange. Experts anticipate the court will issue its ruling around June 2015. Specifically at issue is language in the law which says that tax credits are only available to people who are enrolled “through an exchange established by the state.” The Obama administration is arguing that the law’s unequivocal intention was to offer subsidies and expand coverage to Americans in every state, and that other provisions support this intention. Proponents of the law explain the inconsistency as a drafting error, borne from the painstaking process it took to pass the law.

If the subsidies are held invalid in these 36 states, it could very well lead to undermining any reform with steep increase in premium cost and millions being unable to afford it. 5.4 million people signed up for coverage in 2014 through the federal exchange, with the majority of those consumers receiving subsidies.

Experts have talked about the option for states to establish their own exchanges before the ruling, but they are skeptical that will happen – it’s expensive and difficult.

Chief Justice Roberts is largely regarded among experts as the one the decision will depend on. Kermit Roosevelt, a constitutional law professor at the University of Pennsylvania Law School, has been quoted as saying “I could see (Roberts) either saying ‘the Affordable Care Act is here to stay’ and siding with the government, or ‘Congress made a mistake, and we’re not doing anything wrong by enforcing the law the way it’s written.”

I wonder what Obama will be expressing gratitude for this Thanksgiving . . . what a week.


By Robert Goff, Senior Advisor, The Verden Group

One of the puzzling questions about the Health Insurance Exchanges (a key component of the Patient Protection and Affordable Care Act) is, “How can the same products have such variations in premium pricing?” Differentials of between $200 and $500 a month are noted for the same metallically labeled products.  Why the difference? Answer: the insurance carrier.

The lowest prices have been associated with the newest entrants into the NY market, Heath Republic and OSCAR. The established payers, such as Empire and, in particular, United Healthcare, were priced at the high end.

Since all products are essentially the same in terms of benefits, the difference would be in the costs of the network that supports the payer’s product and the pricing philosophy of the company.

OSCAR and Health Republic are using the MagnaCare network (not known for better rates to physicians and other providers), while Empire uses a stripped down network, excluding at a minimum all academic medical centers and their associated physicians. United uses the Oxford Liberty Network making it the largest network supporting products on the exchange.  Some of the physicians, like UPN members, have rates with a very positive differential from the street rates. These higher rates translate into a larger network and higher premium.

However, corporate strategy may also be at work in the pricing of exchange products. United, , concerned that they could attract adverse selection by their wider network, took a very conservative approach. OSCAR and Health Republic moved to a more aggressive approach, resulting in some accusations that they were offering unsustainable rates to buy their way into the market. Aetna stayed off the exchange, and thought they would escape adverse selection by doing so, but was found affordable by those not needing income subsidies to purchase health benefits, and attracted by the wide Aetna network.

Another element of the pricing strategy was to consider the federal “adjustment”, or the price for expected utilization and costs.  As an enticement to participate, Payers who took the “risk” of being on the exchange have been promised economic bailout during the first 3 years. Some payers priced these plans expecting that they will get federal support for medical losses in this initial period, as well as a severity of illness adjustor, worth more than the premiums.

Severity of illness medical record requests can be expected to increase, as diagnosis coding — and its importance in payment to the payers — will play a more important roll.  Right now, only Medicare for the Medicare Advantage Plans has a severity of illness adjustment factor.

How this plays out will be seen in the rate filing for 2015 and 2016, as payers price for growth, or for financial stability. In any case, as financial viability is squeezed, payers will squeeze providers.

Creating a Life Plan

by Susanne Madden

It’s been a while since any of us at Verden have taken the time to add a blog post. Things have been so very busy and the micro-blogging capabilities of Facebook and Twitter have distracted us from this space.

But this topic deserves a little more room. I spend a lot of time here at the Verden Group helping our clients plan for the future. Planning for growth of their practices, planning for succession and sales, planning for mergers or acquisitions – you name it, we help you plan for it.

Recently it struck me that while I am busy planning out the professional and business lives of my clients, I’ve been giving very little thought to my own life. It’s easy to get too busy, work more hours to meet obligations and to prevent being overwhelmed, and generally put life on hold in the process. Many entrepreneurs, executives and small business owners face the same issues. The problem is, most of us don’t pay enough attention until there are serious consequences. We face major fatigue. We burn out. Worst case, we face serious illness and have heart-attacks. . .

So, how is one suppose to manage a busy career and live life more fully, without ending up in the emergency room?  It comes back to planning.

Yesterday, I stumbled across an e-book titled ‘Creating Your Personal Life Plan’ by Michael Hyatt, that really appealed to me. While I have not yet carved out some precious time to implement the tools in the plan, reading through it has motivated me to get started, and has given me some sense of hope that things can be different, if only we can plan for it.

Now, Mr. Hyatt is certainly more religious than I, but don’t let that put you off. The principles seem sound and grounded, to me. And I’m a big believer in ‘process’ as a game-changer. Every time we work through a planning exercise with a client, it is the process of planning that facilitates the changes needed to improve, grow, learn.

It’s time I took my own advice and put myself through the process of planning for life.

You can find more information on the FREE e-book* here: http://michaelhyatt.com/creating-a-life-plan.html

(*I have no affiliation or business interest with this person or his company)

“If we would only give, just once, the same amount of reflection to what we want to get out of life that we give to the question of what to do with a two weeks’ vacation, we would be startled at our false standards and the aimless procession of our busy days.”
Dorothy Canfield Fisher

Using Evidence-Based Medicine Resources

By Tiffany Lauria

Two recently released reports have brought to light an interesting point regarding evidence based medicine- that it may not be as widely used as thought, or should be.

In a retrospective cohort study of cases submitted to the National Cardiovascular Data Registry-ICD Registry[1] between January 1, 2006, and June 30, 2009, researchers found that out of 111,707 patients, 25,145 received implantable cardioverter-defibrillators (ICDs) that were not recommended by evidence-based guidelines. In other news, a study published in Arthritis Care & Research[2] highlights that physicians treating patients with osteoarthritis (OA) may not be adhering to the recommended guidelines and that clinical practice often diverges from the medical evidence.   

So why the big deal? Simply put, evidence-based medicine works, and not adhering to it on a routine basis puts patients at risk and continues to add increased costs to our already over-burdened system. The patients who had non-evidence based ICDs in the above referenced study experienced a 0.57% risk of in-hospital death, compared to 0.18% in the patients who received an implant following standard approved guidelines. The same group also had an increased risk of post-procedure complications. How does a physician go about explaining this situation to the family of a patient that passed away, despite having clear guidelines to follow?

Ultimately, our healthcare boils down to trusting in our provider’s clinical expertise. Granted, the clinical experience of our provider is often comprehensive and trustworthy-  caring for thousands of patients with the same problems over the years, does tend to make one qualified to judge what works and what doesn’t. However, clinical expertise is largely dependent on staying abreast of new techniques and updated guidelines. It requires that providers know what works and what doesn’t in the national and international population, not just in their patient base over their years of practice. And, while each of us personally may be comfortable with our physician’s clinical judgment, regardless of what the evidence suggests, it is undoubtedly dependent on the provider to justify any decision-making that varies from evidence-based proof.

I certainly don’t make the statement that EBM is in-fallible, or that in all cases it is the right way to go. It is possible to mis-use or over-use the guidelines to the patient’s detriment. Blindly following a ‘proved’ algorithm of care eliminates the very essence of personalized healthcare. All patients are entitled to care that considers the patient as a whole. The EBM guidelines for two different conditions may cancel each other out, or worse yet, do more damage than good. And the personal opinions and circumstances of your patients must be considered. After all, what good is evidence when it can’t (or won’t) be followed? So where clinician training, experience and judgment dovetail with the evidence is where you want your medical practice to be. Without this quadrant of care, the potential for good medicine is lacking.

We can look, however, to the mentioned studies for some ideas on why physicians may be thwarting the evidence. For example, in the ICD study, the number of non-evidence based implants was significantly different according to physician specialty and hospital. Therefore, it is reasonable to conclude that the practicing environment and specialty culture may have a large impact on a provider’s commitment to adhering to recognized guidelines. In addition, the extent in which a facility appropriately enables provider staff to maintain up-to-date knowledge of evidence-based guidelines, by the provision of educational and other resources, is likely to be largely diverse across organizations. As the old saying goes- he that is walking with wise ones, becomes wise. If providers surround themselves with an environment conducive to learning and a culture of evidence-based decision making, then using proven treatment guidelines will become their standard of care. Supplemented, of course, by their years of trusted judgment based on clinical experience in the patient arena.

As medical evidence increasingly becomes more accessible to the general population, providers will have additional reasons for ensuring that their clinical practice remains within the close confines of what has been proven and substantiated. With the advent of the internet, construction worker John Smith need only go to any number of medically oriented websites or patient forums to determine what tests and treatments are routinely prescribed and what is the ‘norm’ for a particular illness or condition. A particularly savvy patient, with persistent researching skills, may ultimately wind up uncovering the specifics of the national guidelines that pertain to their condition…and bring that in to face you, the provider, who may be doing otherwise.

Certainly, no one is advocating for cookie cutter medicine or a one-size-fits-all approach to healthcare. Clinical experience and a provider that is willing to step out of the box in their effort to best treat their patients are more than needed in today’s climate of increasingly complex conditions and new advances. However, the question of why evidence-based medicine is not common practice yet needs to be addressed by providers, facilities and regulators in order to determine the best means of integrating proven care strategies into everyday care. It shouldn’t take a health reform initiative to convince people that making decisions based on evidence, just plain works.

[1] Al-Khatib SM, et al.”Non–evidence-based ICD implantations in the United States” JAMA 2011; 305: 43-49. Retrieved from: http://jama.ama-assn.org/content/305/1/43.full

[2] David J. Hunter, Tuhina Neogi, and Marc C. Hochberg. “Quality of Osteoarthritis Management and the Need for Reform in the US.” Arthritis Care and Research; Published Online: June 25, 2010 (DOI: 10.1002/acr.20278); Print Issue Date: January 2011. http://onlinelibrary.wiley.com/doi/10.1002/acr.20278/abstract

HIPAA Patient Privacy Update

by Jason Lopata

Patient privacy concerns continue to be in the headlines recently as more and more opportunities for possible breaches exist in our electronic, and ever more interconnected, world.   Importantly for private practices and hospitals alike, a recent hospital survey (published by Press Ganey Associates, Inc., a patient-satisfaction measurement firm) suggested that patients are viewing privacy concerns an increasing important component of patient satisfaction.   This suggests that practices must guard against breaches of personal health information (PHI) disclosure for not only HIPAA compliance purposes, but in order to avoid the loss of patients or a potential marketing disaster.  HITECH now requires disclosure of any privacy or information breach to not only a practice’s patient list, but if the breach affects more than 500 patients, the local media must also be notified.  Clearly this is an occurrence that could affect a practice’s reputation and in turn, their financial bottom line.

As reported by HHS officials in November of this year, the number one source of health data breaches is the theft of a laptop computer.   Practices must put safeguards in place and enforce proper protocols for all employees who may be using laptop computers that contain any form of PHI.  For those practices that use laptops, proper encryption of data remains the best safeguard to unfettered access to the data contained in a laptop, should it fall into the wrong hands.  While there is a cost with such enabling these security measures, it pales in comparison to the potential damage that could be done to your practice without it.

Not all security or privacy breaches involve laptops or “hacker”-like behavior tapping into an otherwise secure computer system.   Rather, as you can see from recent headlines, they come in all forms, such as these recent incidents:

  • A Mesa, AZ medical center lost data cards that contained information on about 2,300 patients.  Memory cards from endoscopic machines went missing, each which contained PHI for patients whose procedures took place between 2008 and 2010.  Notice was required to all patients, and while no credit information was contained on the memory cards, enough personal information existed on the cards such that the medical center offered credit protection and monitoring for one year to all affected patients.
  • An identity theft ring was arrested near Orlando, FL. after stealing nearly 1,500 patient data sheets from an emergency room and associated doctor’s office.  The compromised information includes names, addresses, dates of birth, Social Security numbers and brief initial diagnosis descriptions from ER visits, according to the hospital.  A press release was issued immediately and credit protection monitoring was offered to those who may have been affected.  Interestingly, this did not involve a computer or systems breach, but simply paper data sheets being lifted from the medical facilities.  (Goes to show that some security and privacy breaches can be fairly low-tech!)
  • A hospital in Long Beach, CA was hit with a $225,000 fine by the state compliance division after an employee used nine patients’ medical information to set up fake Verizon telephone accounts.  The employee admitted to memorizing personal patient information during a project to purge the hospital’s older ER records.
  • A medical center in Tennessee had to notify approximately 8,000 patients of a possible privacy breach after patient information was thrown in the trash instead of being shredded.

So the lessons to be learned from these occurrences?  Never stop being on guard for how patient health information can get into the wrong hands or be mishandled.  Constantly review policies for the handling of such data, and make sure that both physician, and non-physician staff, is keenly aware of the proper protocol and properly trained on how to deal with the necessary handling, transfer, and if needed, disposal, of PHI.  Keep this information secure, and avoid making headlines for all the wrong reasons.

From A-B-C to C-A-B

by Tiffany Lauria

‘Look, Listen and Feel’ is a thing of the past….

After years of drilling ‘Look, Listen and Feel’ into first responders heads as step one of the basic CPR process, the American Heart Association has released their 2010 guidelines which changes the sequence of CPR steps from Airway-Breathing-Chest Compressions (ABC) to Chest Compressions-Airway-Breathing (CAB)[1] to emphasize the importance of minimizing delay in starting the chest compressions component of care. Included among the other 2010 recommendations is the total elimination of ‘Look, Listen and Feel’ from the steps. Interestingly, the AHA states that rescuers often find it difficult to open the airway and begin delivering breaths, so the change in sequence is expected to encourage more people to begin CPR immediately without hesitation.

This is actually quite a big change, considering the scope of re-training that needs to be accomplished across a spectrum of populations. From babysitters and school teachers to flight attendants and lifeguards, numerous people in varying professions will now need to be educated and certified on the 2010 changes.  Most importantly, of course, are the healthcare providers that perform this procedure, or stand ready to perform this procedure, routinely as part of their daily tasks. And don’t just think doctors and nurses, there are midwives and radiology technicians and physical therapists, etc. The list goes on.

The American Heart Association has always done a great job in reaching the public to broadcast a message of the importance of CPR training for lay people as well as healthcare workers. Everyone- moms, waitresses, bank tellers, construction workers- everyone may at one point be faced with a life or death crisis that affords them the opportunity to try and help. Still, most people today have never been educated on CPR outside of possibly a high school health class (where the thought of giving mouth-to-mouth to the dorky kid next to you was not much of an enticement to learning). The number of professions that are now requiring CPR training, and the numerous regulations regarding the presence of Automatic External Defibrillators, is an encouraging sign that the AHA is reaching the right sectors with timely information and vital instruction.

There are two steps that you and your facility should take now to prepare for the implementation of the new CPR recommendations.

Step one: Make sure your staff have heard of the changes

Believe it or not, as busy as healthcare workers are on the job, they are just as busy in their personal lives! Many of your staff may have not had a chance in the last week or two to jump online for a news fix or to read a newspaper or journal that updates on important industry topics. But, what they don’t know can hurt them and their patients, so include information on the updated regulations in your next facility newsletter or scheduled staff meeting. Also, be sure to assign department heads or managers the responsibility of informing all staff that changes have occurred and that they will need to be re-trained and certified. You may want to include information on the scientific rationale behind the new recommendations, adjusted for use by clinical, administrative or ancillary staff.

Step two: Construct your training plan to implement the new recommendations

This step is actually a staircase that encompasses-

  • Working with human resources to determine which departments and staff require certification and training and the dates when all personnel are due for training based on their past certifications (The AHA has not released guidelines or recommendations yet on whether previous certifications will be revoked early)
  • Working with your facility’s education department, local Red Cross or other corporate instructional agency to determine training options, such as on-site or off-site training, scheduling and learning materials
  • Project a reasonable budget, allowing for staff overtime and any scheduling changes that will be needed to allow staff to participate in training, and any program and material costs
  • Begin cycling all needed personnel through the selected training programs, updating their personnel files accordingly to reflect up-to-date certification. Prioritize training according to need- clinical staff, then administrative, and so on
  • It may be necessary to revise facility or practice clinical protocols or other protocols related to emergency procedures. Always keep your practice, facility and department Operating Procedures and Clinical Protocols up-to-date


How can you assist in the efforts to inform the public about the importance of CPR training while making it worthwhile to your practice? Keep current brochures from the local Red Cross or continuing education providers handy in your office and share them with patients and parents and caregivers of patients, especially caregivers of young children and older patients. During routine well exams or care appointments for chronic conditions, make it routine to ask if anyone in the household has been CPR certified and talk to them about the importance of CPR education in their personal lives. Consider reaching out to community instructors and offer them use of your waiting room or conference area for holding classes. This allows you to advertise the courses to the public, maximizing your exposure while bringing in potential patients into the practice.

The AHA has scheduled instructor training sessions for November 2010, so while instructors are gearing up to teach the new recommendations to the masses, use your time wisely and start planning now on how to best educate and train your staff in an organized and efficient way.

[1] The sequence has not changed for newborns. To review the full 2010 recommendations, visit: http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf

Telemedicine & Licensure – Will the Law Allow Changes to the Way Medicine is Practiced in the 21st Century?

By Jason E. Lopata, Esq.   There can be no question that the internet has changed the way most of society operates, from our homes and offices, to each and everyone’s smart phone located in their pocket or purse.  Medicine is not immune from the use and development of technologies to bridge the gap in physical distance between two non-electronic parties.  We may have to soon get used to the idea of a physician on one end of teleconferencing or video technology, and a patient on the other end.  Whether that physician is at a video screen at his office desk or holding a hand held device while vacationing in another part of the country, a physician’s office can be boundless in today’s world.

But how does a physician know that he is properly licensed to practice medicine by way of these new technologies?  Does the location of the doctor or the patient (or both) dictate what jurisdiction is relevant to any licensure questions?  While telemedicine has the potential to overcome barriers of distance and improve access to needed health care services, the current state-by-state licensure laws pose an obstacle to achieving this goal.  Requiring licensure in each state where patients may receive care is a disincentive to utilize the new technology and provide specialty care to rural and underserved areas of the country.  As a physician, one must stay informed of your jurisdiction’s regulations, as well as any neighboring states where your patients may be traveling to receive your care and treatment.

With limited exceptions, most states still require full in-state licensure for out-of-state telemedicine providers.  But in New York, like many other jurisdictions that do not specifically address the practice of telemedicine, there are some exceptions that allow out-of-state practice.   These may be applied to telemedicine, such as a physician who is either (1) licensed in a bordering state and who resides near a border of this state, provided such practice is limited in this state to the vicinity of such border and provided such physician does not maintain an office or place to meet patients or receive calls within this state, or (2) Is licensed in another state or country and who is meeting a physician licensed in this state, for purposes of consultation, provided such practice is limited to such consultation.  Most current regulations allow for this doctor to doctor contact, but do not address doctor to patient relationships in the consultation or specialty realm.

On the other hand, states such as Illinois, Mississippi, and Texas all have regulations specifically to deal with the practice of telemedicine, giving specific guidance as to what constitutes telemedicine. An example is Illinois’ definition that  “telemedicine”” means the “rendering written or oral opinions concerning diagnosis or treatment of a patient in Illinois by a person located outside the State of Illinois as a result of transmission of individual patient data by telephonic, electronic, or other means of communication from within this State.”  When regulations exist, specific requirements are spelled out for out-of-state physicians to treat their in-state population.  Physicians who practice telemedicine “without a license” risk criminal and civil penalties, state disciplinary proceedings, and denial of coverage under medical malpractice insurance policies which generally require licensure as a condition of coverage.  This occurs despite the fact that most state licensure procedures have become fairly uniform from jurisdiction to jurisdiction.

The American Bar Association (ABA), in a August 2008 report on telemedicine, believes that the most straightforward method to reduce such barriers to telemedicine is to institute a system of mutual licensure recognition whereby a physician with a current, valid and unencumbered license in any state could file a single application which would permit the physician to practice telemedicine in some or all other states.  The physician would be subject to continuing compliance with those states’ licensure fees, discipline, and other applicable laws and regulations, and adherence to professional standards of medical care.  The ABA further recommends any federal legislation set a uniform definition of “out-of-state telemedicine practice” (e.g., that the physician does not set up an office, appoint a place for meeting patients, or routinely receive calls within the state), the requisite procedures for telemedical licensure, and a requirement that the telemedicine provider must agree to the jurisdiction of the patient’s home state for medical malpractice actions.  But even amidst all the federal legislation affecting the health care industry, uniform telemedicine licensure issues have not yet been proposed.

While a good idea, I don’t yet see a federal standard evolving, as states are going to maintain their regulatory control of the industry.   So as a physician, one must still be prepared for these licensure and liability questions to emerge as you start to adopt technologies that widen the scope and “footprint” of your practice.  Physicians should consult an attorney with any questions whether borders are being “virtually” or literally crossed for purposes of your licensure.

Hospital Gone Mad?

by Tiffany Lauria

In a recent court document[1] , filed against Dimensions Health Corporation, Joseph and Felicia Ann Wheeler allege that while recovering from auto accident injuries at Prince George’s Hospital Center, Mr. Wheeler was misidentified as a female cancer patient 13 years his junior that was scheduled for chest tumor surgery. In the disturbing events that ensued, Mr. Wheeler’s complaint includes physical assault and battery, false imprisonment and infliction of emotional distress.

While the egregious complaint cannot be stated as fact until the matter is settled, a read through the actual complaint brings up multiple areas in which hospitals, indeed all facilities, could benefit by reviewing their operating procedures and more importantly, the extent that these procedures are followed. Two obvious areas of risk  highlighted by the complaint are as follows:

1. Patient Identification Protocols: From his first contact with clinical staff, right down to his interactions with hospital security, not only did staff neglect to check Mr. Wheeler’s ID bracelet, but upon checking and finding a female name, a nurse failed to exhibit common-sense and flag concern over the patient’s identity. A physician brought in to answer the patient’s questions was apparently upset over Mr. Wheeler’s ignorance of the surgical procedure and as a previous nurse did, failed to check Mr. Wheeler’s ID bracelet. The next time Mr. Wheeler states someone at the hospital checked his ID bracelet was following a period of alleged battery at the hands of hospital security.

Some things to consider when reviewing your organizational policies:

– Does your protocol contain enough checks and balances to ensure that the right identification bracelet is placed on the correct patient from the beginning?

– Are there mandatory sign off sheets or tick screens for clinical staff to mark identity checks completed with each interaction?

– Does your protocol also include physicians, obliging them to check patient identification with every patient interaction?

A proper identification protocol will include each of the aforementioned, as well as stated consequences for staff and physicians not performing up to task, the dates of training sessions completed on the importance of correct identification procedures, and proper procedures for following up on any concerns or deviations.

Remind your staff that common sense should always prevail, and the hospital would rather conduct an investigation into correct identity, than defend itself against allegations of misconduct or malpractice. Make that part of your organizational culture – safety comes first.

2. Incidence Response Protocols:

Mr. Wheeler indicates that as soon as he walked out of his exam room to leave the hospital, nursing staff began to argue with him and call for security. The two officers that responded, according to the allegations, immediately unleashed a barrage of physical abuse and verbal expletives in their attempt to hold the patient against his will in the hospital. This abuse subsequently continued through an interaction with the ranking Lieutenant, the apparent wrestling of a cell phone out of Mr. Wheeler’s hands as he attempted to call 911, and culminated in a hospital administrator begging Mr. Wheeler to stay and promising to provide Mr. Wheeler with a private room and any medications or pain killers that he requested.

One has to wonder about the sensitivity training provided to the security staff in dealing with patients, whether they are leaving against medical advice or truly combative. Regardless of whether your facility contracts out for security or hires in-house, it ultimately falls to you to ensure that all personnel have undergone extensive background checks and targeted training on dealing with your patients and their family members. At one point during the alleged physical abuse, Mrs. Wheeler was prohibited from being with her husband and told she could not enter into an elevator with her husband and the two security officers.

Incident training encompasses much more than security, however. Your Incidence Response Manual must be reviewed and updated annually, with revised versions of protocols and documentation logs, and emergency contact information for management and legal staff. A well-done manual is not only written with legal assistance, but final approval on all revisions must be approved by an attorney familiar with healthcare law. Staff training should include all clinical, administrative and ancillary personnel and it is highly recommended that drills be enacted for various situations.

Oh, and regarding the administrator offering patients any drugs or pain killers they want? One word- Don’t.

As Mr. Wheeler’s complaints play out in the judicial system, there will likely be some more points to be gleaned on how not to run hospital operations. In the end, it would benefit all facilities to take a good, hard look at what you have down on paper, and what really happens when things go awry.

[1] http://www.courthousenews.com/2010/08/25/HospitalAssault.pdf

A good day at Physician’s Practice LIVE

by Susanne Madden

Last Wednesday we participated in Physician’s Practice LIVE, a virtual conference for practices, for the second time this year. This second conference was even better than the last, with several presentations to listen to and five individual Ask the Expert hours, where attendees could pose questions and get advice.

The presentation session I was lucky enough to do was titled Session: “Advanced Tactics for Negotiating with Payers”. We had a great response to it, and the questions were excellent! You can listen to it here: http://www.physicianspractice.com/live/

In the next couple of months we will be bringing you all kinds of interesting media via the Verden website. From hosted chats in our Thought Swap chat-room, to short podcasts of discussions overheard in the Verden office, to compilations of the most interesting industry news of the day, we hope to inform and enlighten our visitors daily.

Any ideas you have for our new site? Any topics you’d like to see posted here? Just let us know!



Fraud & Abuse News for Your Practice

By Jason E. Lopata, Esq.

Received a take-back letter recently or had a claims audit by an RAC?  Amid the changes found with health care reform laws passed earlier this year are new fraud enforcement powers that have the potential for impacting all medical practices, big and small.  Recently, President Obama took steps to target Medicare and Medicaid fraud and cut down on wasteful healthcare spending.  On August 26, 2010, his administration outlined new federal enforcement efforts to combat healthcare fraud, stating that fraudulent conduct is costing taxpayers billions of dollars each year.  During a healthcare fraud summit in California, Attorney General Eric Holder Jr. and Health and Human Services Secretary Kathleen Sebelius said their agencies were jointly targeting fraud in the federal Medicare and Medicaid programs.

The government initiative, originally launched in May 2009, had so far produced more than 580 criminal convictions and recovered more than $2.5 billion in fraudulent proceeds.  However, while $835 million in questionable Medicare payments were identified by private contractors in 2007, the government managed to recover only $55 million (7 percent) according to a recent report from the Office of the Inspector General.  Congressional investigators found that the average investigation lasted 178 days, long enough for many cases to go cold, making it hard to identify the individuals involved or recover money owed taxpayers.  The Obama administration said it is now reorganizing contracts with private investigators and trying to help them coordinate better with claims processors and law enforcement.

As part of the recent efforts, The Centers for Medicare and Medicaid Services (CMS) expects to transition from some previously used private investigators to zone program integrity contractors (ZPICs) to solve many of the over-spending problems identified.  Two ZPICs became fully operational in February 2009, and all program safeguarding work will be transitioned to the remaining five by the end 0f 2010. The goal is to consolidate all Part A, B, C and D fraud-fighting activities under the ZPICs.   With the transition to more ZPIC enforcement, and the increased use of Recovery Audit Contractors (RACs), CMS is taking multiple avenues toward combating fraud and abuse.

But you’re a good doctor – not engaged in any fraudulent conduct.  How might this still affect your practice?  According to the new legislation, government overpayments must be reported and returned within 60 days of identification.  So constant monitoring for overpayment situations in your office is a must.  Further, since all government payments can be suspended by CMS pending a “credible allegation of fraud,” make certain that you are taking steps to not let the appearance of impropriety arise.  Lastly, HHS’ Office of the Interior General now has greater and broader subpoena power in the event of a government audit, where failure to timely reply to requests for information could be penalized up to $15,000 per day.  So should CMS request supporting documentation from your office in the event of an audit, take immediate measures to collect the data and submit it in a timely fashion.

Other steps your practice can take to prevent fraud include understanding and complying with all state and federal laws.  It sounds simple enough, but make sure that you are staying on top of all regulatory changes that may take place in your jurisdiction.   Also, create a culture of compliance in your office, making it a part of all partnership and staff meetings that take place, as well as employee training and education.   Part of that culture allows for the self-disclosure of any overpayments that are received from Medicare or Medicaid.  Another benefit of such an environment is that your practice does not have to fear for “whistleblowers,” since disclosure of misconduct is encouraged and addressed properly.  Practices that self-disclosure overpayments of government proceeds have more success working with CMS in resolving payment problems.