Wednesday, December 22, 2010

Hospital Researcher Found to Have Neither a Medical Degree Nor a PhD

A recent story in The Detroit News discusses the case of William Hamman, a researcher at Western Michigan University who claimed that he had a medical degree as well as a PhD. Hamman had allegedly been working on journal articles on patient safety and care before his credentials were found to be false.

Hamman had impressive credentials in the aviation industry and had worked with WMU on a project to study how aviation industry standards could be applied to improve safety in healthcare. In 2009, Hamman joined William Beaumont Hospital to help train the members of the medical staff on communication and teamwork skills. Hamman was never a member of the medical staff, nor did he provide patient care.

To read the full story, click here:


Thursday, December 9, 2010

House Passes Physician Pay Cut Delay

Today, the House passed H.R. 4994, a bill that delays a scheduled 25% Medicare physician pay cut for another year. President Obama is expected to sign the bill. The cut would have been effective January 1, 2011. The bill keeps reimbursement rates for 2011 at the 2010 levels.

The Senate passed the bill on December 8.

Source: BNA

Tuesday, December 7, 2010

Report Analyzes Tracking of Medical License Expiration in VHA Facilities

A November 29, 2010 report from the Department of Veterans Affairs Office of Inspector General reports that the processes used to monitor medical license expiration dates among Veterans Health Administration (VHA) were "inconsistent and fragmented." The report attributes this to the fact that the facilities were not provided with specific guidance on how to monitor license expiration dates and communicate with professionals whose licenses were approaching expiration.

The report recommends that the VHA provide facilities with detailed guidance outlining the actions that should be taken to monitor license expiration dates. It also recommends that facilities re-evaluate their practices based on this guidance when it is provided and that they alter their practices to conform with the VHA guidance.

The full report can be found here:


Monday, December 6, 2010

Are You HIPAA Compliant?

Has your organization conducted a risk analysis to ensure effective and appropriate administrative, physical and technical safeguards to secure electronic protected health information (e-PHI)? If not, every year, the Department of Health and Human Services Office of Civil Rights (OCR) develops guidance to help organizations comply with HIPAA privacy rules.

One recommendation from OCR's May 2010 guidance asks organizations if they have performed an analysis of possible risks and threats to health information. As technology has developed, so has the risk of committing a HIPAA violation, whether intentional or accidental. For example, social networking has made it easier for healthcare professionals to "vent" about a problem patient, and physicians are even starting to request that patient information be sent to them via text message. While not all of these may be HIPAA violations, the flow of patient information can certainly make employers and healthcare entities nervous.

For tips and guidelines on how to perform a risk analysis, see the following guidance and make sure that your employees and colleagues know the ins and outs of HIPAA:

Source: HHS

AHRQ Report Provides High Performance Work Practices to Maximize Quality

The Agency for Healthcare Research and Quality (AHRQ) has released a report describing how healthcare entities can attract, hire, develop, and retain staff members who can contribute to higher healthcare quality. The report, titled Using Workforce Practices to Drive Quality Improvement, provides four high-performance work practice (HPWP) models that can be implemented in a facility.

The HPWPs focus on practices such as rewarding performance, providing career development opportunities, aligned decision-making, and ensuring that leaders are developed to carry out an organization's goals and mission.

The report can be found here:

Source: AHRQ

Wednesday, December 1, 2010

CMS Will Postpone Denying Claims from Doctors Not in PECOS

The Centers for Medicare and Medicaid Services (CMS) announced that it will no longer enforce the January 3, 2011 deadline for denying claims for services performed by providers not listed in the Provider Enrollment, Chain and Ownership System (PECOS). PECOS was developed to move the Medicare enrollment process to an electronic format.

This is the second time PECOS enforcement has been postponed. CMS has not announced a new enforcement date; however, they encourage providers who have not enrolled in PECOS to do so sooner rather than later.

Source: BNA

Monday, November 29, 2010

Groups Weigh in on NCQA's Proposed ACO Standards

The Patient Protection and Affordable Care Act requires the creation of accountable care organizations (ACOs), which are defined as "an integrated group of providers that will be held accountable for the overall cost and quality of care for a defined set of patients. Under the law, ACOs that participate in the Medicare program would continue to be reimbursed under the fee-for-service system, but they would be eligible to share in any savings below benchmark cost levels, as long as they also meet quality performance standards."

NCQA released draft standards for ACOs. Various organizations such as the Federation of American Hospitals, American Medical Group Association, and the Campaign for Better Care commented on the standards, stating that until the government establishes rules for ACOs, any draft standards are prematurely developed. The groups also urged NCQA to draft standards that are focused on quality outcomes, rather than on how an ACO should be structured.

NCQA's draft standards can be found here:

AMGA's comments can be found here:

FAH's comments can be found here:

Source: BNA

Thursday, November 4, 2010

CMS Final Rule Cuts Physician Payments 24.9% in 2011

The Centers for Medicare and Medicaid Services (CMS) has released a final rule that will cut Medicare payments to physicians by 24.9 percent in 2011. CMS states that the reason for the cut is to provide a permanent fix for the sustainable growth rate and Medicare payment formula.

The rule also attempts to curb physician self-referral for services that may be obtained elsewhere in the area and implements rules on the expansion of preventative services, which went into effect as part of the Affordable Care Act.

The physician pay cut is effective January 1, 2011.

Source: Healthcare Finance News

Wednesday, November 3, 2010

Patient Deaths at CA Facility Allegedly a Result of Substandard Care

A discrimination lawsuit filed by a medical assistant and two cardiologists attributes a 2009 patient death to substandard care. Furthermore, the suit alleges that the level of substandard care was permitted to continue because they were "ignored, embarrassed, or terminated" for reporting problem.

The suit, filed against Santa Clara Valley Medical Center in California, alleges that after Dr. Geeta Singh suggested that a patient undergo a cardiac catherization rather than a stress test due to his history of heart attack. The patient was given a stress test and later died. After Singh and administrative assistant Theresa Walker submitted a report of substandard care to TJC, they claim that they were ignored by other members of the staff and abused through e-mail.

Dr. Kai Ihnken is also a plaintiff in the suit, alleging that administrators denied him the ability to perform cardiac surgery, leading to the patient's death. After reporting the incident, he claims that he was slandered and his contract was not renewed.

The Santa Clara County Executive stated that examiners have found no direct link indicating that negligence caused the patients' deaths; however, he did acknowledge that the hospital's cardiac department was prone to conflict and arguments.

This pending case sheds light on the importance of maintaining professional working relationships among members. It also calls on hospitals to look at their staff culture and to see if employees and members of the medical staff are provided with a comfortable environment that allows them to speak up if they witness an adverse event.


Wednesday, October 27, 2010

Employers Can Retroactively Amend FSA Reimbursement Policies for OTC Medicines

Under the Patient Protection and Affordable Care Act, all prescriptions submitted for reimbursement through a health flexible spending account (FSA) will now have to be prescribed by a physician, even if the treatment is available over-the-counter.

Employers have until June 30, 2011 to amend their plans to reflect this change. However, the IRS says that employers will be allowed to apply this change retroactively back to January 1, 2011. That means that even if the policy is not in place by January 1, 2011, employers may still deny reimbursements for over-the-counter purchases made after that date. Purchases made before January 1 may still be eligible for reimbursement.

As the provisions of health reform kick in, this serves as a reminder to all MSPs to keep up with the latest news from your employer on how your medical benefits may change.

Source: BNA

Monday, October 25, 2010

OIG Study Examines Medical School Education on Fraud and Abuse

There is and will continue to be more and more investigation into Medicare and Medicaid fraud and abuse which is costing the US taxpayers billions of dollars each year.

One question being discussed is where and when should medical students be provided with instruction on compliance with Medicare and Medicaid laws to prevent fraud and abuse, or is this better left to residency and fellowship training programs?

In the report from the Office of Inspector General (OIG), Department of Health and Human Services, it is reported that Medicare and Medicaid compliance is being provided in medical schools and graduate medical education programs:

44% of medical schools are providing instruction to students

66+% of graduate medical education programs and fellowship programs

The OIG realized that it is difficult for medical schools to incorporate comprehensive education on Medicare and Medicaid fraud and abuse into the medical curriculum. Therefore, it plans to develop educational materials that can be distributed to medical school programs and to engage in conversations with program directors regarding the usefulness of these materials.

To read the full report, click here:

State Insurance Commissioners Vote to Approve More Stringent Rules

The National Association of Insurance Commissioners voted unanimously to endorse standards requiring that "80 percent of premium revenue be spent on medical care and 'activities that improve health care quality' for patients." This requirement was set in place by health reform legislation.

The standards set limits on what revenue spending is defined as improvements to health care quality, and what is considered to be compensation or administrative spending. The goal of the standards is to make insurance companies function more as providers of healthcare and less as for-profit companies.

Secretary of Health and Human Services Kathleen Sebelius is expected to take the recommended standards and propose them as a new regulation for insurance companies. Opponents of the recommendations argue that they will negatively disrupt the insurance industry by forcing companies out of business and reducing consumer choice.

Source: The New York Times

Friday, October 22, 2010

VA Hospitals Implementing Airline Safety Tips

A study of over 108 Veterans Health Administration Hospitals showed an increased drop in patient deaths in facilities that implemented error prevention strategies created by airlines and NASA. Of the 108 facilities, the 74 that implemented the strategies had an 18 percent drop in deaths, compared to a 7 percent drop in facilities that did not implement them.

The Medical Team Training program was targeted at surgical teams, encouraging communication among members of the team, challenging each other to abide by safety practices, and encouraging the use of checklists in preoperative and postoperative briefings. Miscommunication among team members was identified by the aviation industry as a large factor contributing to errors.

The full study can be found in the October 20 Journal of the American Medical Association.

Source: Bloomberg Businessweek

Monday, October 18, 2010

Arkansas Court Strikes Down Economic Credentialing

The Arkansas Supreme Court upheld a 2009 decision stating that a hospital could not deny staff privileges to physicians with an ownership stake in competing hospital based on financial concerns because this policy violates state laws.

Baptist Health in Little Rock, Arkansas denied staff privileges to 12 physicians stating that its conflict of interest policy permitted the hospital to do so because of the economic interests of the facility.

Organizations such as the American Medical Association joined the physicians as plaintiffs, stating that restricting physician practice through economic credentialing restricts patient choice and that physicians should be evaluated on performance, not financial factors.

This is the highest court decision issued on the subject of economic credentialing. The AMA states that it is an issue that if challenged again, will be determined on a state-by-state basis.


Wednesday, October 13, 2010

Even Hospitals Aren't Immune to Bed Bugs

Nationally, residences, businesses, and even federal offices have been dealing with a resurgence of bed bug infestations. Now it appears that even hospitals are receiving visits from the pests.

Lenoir Memorial Hospital in Kinston, North Carolina recently had to implement a policy to prevent the spread of bedbugs in the facility. After exterminating and treating a room that had become infested, LMH imposed a policy that prohibits patients and visitors from bringing outside bedding into the facility, including blankets and pillows.

Hospitals have had to implement policies to prevent the spread of infections. If the number of reported infestations continues to increase, it may not be long until bed bug policies becoming common in facilities.

To read the full article, click here:


Tuesday, September 28, 2010

Whistleblower Physician Awarded $1 in Damages after Hospital Took Retaliatory Action

The US District Court for the District of Maine awarded Dr. Kristine Thayer $1 in damages, plus recovery of attorney's fees and court costs after a jury found that Eastern Maine Medical Center (EMMC) took retaliatory action against her in violation of Maine's Whistleblower Protection Act (Thayer v. Eastern Maine Medical Center).

Thayer, a pediatric surgeon, told her supervisor that pediatric gastroenterologist Dr. Mohammed Tabbah was providing substandard patient care. Following the report, the hospital began an investigation of Dr. Thayer as a disruptive physician and the medical staff executive committee recommended that she attend anger management counseling, with the threat of disciplinary action for further disruptive behavior. Thayer voluntarily chose to leave EMMC.

At trial, the jury found that the supervisor's initiation of peer review was retaliation for Dr. Thayer's actions and a violation of the Whistleblower Protection Act; however, they believe that that she suffered no injury that would entitle her to damages. Thayer filed an amended complaint for damages as well as the cost of court and attorneys' fees.

The district court ruled that Thayer was entitled to court and attorneys' fees. However, they limited her damages to $1, stating that the reinstatement of her professional reputation and the negative reputation cast on EMMC was an appropriate remedy that did not need to be supplemented by a further award of monetary damages.

Source: BNA

Friday, September 24, 2010

TJC Releases 2010 Report on Hospital Quality and Safety

The Joint Commission (TJC) has released their 2010 Annual Report on Quality and Safety. For the first time, the report focuses on accountability and performance and how they have a positive impact on patient care.

To read the full report, click here:

Source: The Joint Commission

Are Train Station Bathrooms Cleaner than Hospital Bathrooms?

A survey performed by MicrobeWorld, an educational branch of the American Society for Microbiology, shows that bathroom users in large public places such as Grand Central Station in New York City and Turner Field in Atlanta, may be more likely to wash their hands than those working in hospitals.

Turner Field scored the lowest out of all the public locations, with 65 percent of men washing their hands after using the bathroom. This is high compared to a study performed by McGuckin Methods International, which found that less than 50 percent of bathroom visitors in ICU and non-ICU units complied with baseline hand washing guidelines.

Organizations such as The Joint Commission have set hand hygiene goals for hospitals and have reported success in increasing compliance. Hospitals need to emphasize the importance of proper hand washing. This simple practice can help drastically cut the number of hospital-acquired infections, which are on the rise in facilities across the country.


Thursday, September 23, 2010

Six Major Health Reform Provisions Effective Today

Today, six of the major provisions of the Affordable Care Act go into effect. They are:

  • Extended coverage for young adults under their parents' plan
  • Plans must offer free preventative care services
  • Insurance companies are prohibited from rescinding coverage if a person becomes sick
  • The ability for Americans to select between two appeal processes when challenging an insurance decision
  • Elimination of lifetime caps on coverage
  • Regulation of insurers' ability to set dollar limits on coverage

To read more details about these provisions, click here:

Curious about when the other provisions of the Affordable Care Act will go into effect? Click here to see a full timeline of changes that will occur:

Sources:, EmblemHealth

Wednesday, September 22, 2010

OIG Report Shows CMS' Failure to Report Adverse Actions to HIPDB

A report from the Department of Health and Human Services Office of the Inspector General (OIG) shows that although the Centers for Medicare & Medicaid Services (CMS) took adverse actions against providers, it failed to report all of these actions to the Healthcare Integrity and Protection Data Bank (HIPDB).

The HIPDB is a repository of "all final adverse actions against health care practitioners, providers, and suppliers." The purpose of the HIPDB is to provide states, federal agencies, and health plans with a resource to help them prevent dealings with practitioners, providers, and suppliers with a history of fraud and abuse.

The report, titled "CMS Reporting to the Healthcare Integrity and Protection Data Bank," revealed that CMS failed to properly report actions taken against laboratories, DME suppliers, and nursing homes. These adverse actions either went unreported even when final action was taken, or were reported outside of the required reporting timeframe, which is about 30 days from the date action was taken, or the date that the reporting entity discovered the action.

The OIG recommended that CMS resolve the problem by providing staff and contractors with better education on reporting requirements. CMS agreed with the findings and pledged to work with the Health Resources and Services Administration (HRSA) to determine what actions are reportable.

This report reminds us that MSPs must be diligent when performing credentialing functions. The data we rely upon is only as good as the reporting source. You cannot evaluate data pulled from one source with a "vacuum mindset." When pulling reports, compare the information you collect along with other reports as well as the provider's history. This investigative step may help you to disclose adverse actions that may not be found in database reports.

To read the full OIG report, click here:

Source: Department of Health and Human Services, Office of the Inspector General

Tuesday, September 14, 2010

Study Shows Patients Are Provided with Insufficient Quality Physician Quality Data

Patients are encouraged to select physicians based on certain quality characteristics; however, a recent study reveals that patients don't have access to the information that should be used in order to make decisions on healthcare providers. This finding can be found in the September 13, 2010 issue of the American Medical Association's Archives of Internal Medicine.

The report states that the profile information given to the public to assist with the selection of a doctor does not strongly correlate with a doctor's ability to provide quality clinical care. For example, malpractice claims were found to be a weak indicator of performance. The study noted that there are three characteristics that are associated with higher performance --"female sex, board certification, and graduation from a domestic medical school;" however, even this data only indicated marginal differences in quality.

The report also notes the need for greater public access to physician quality data, so patients can make well-informed choices regarding their care. As MSPs know, one must search beyond the basic information on a physician's training to reveal the true level of quality that the physician can provide.

To view the report's abstract, click here (payment required for access to the full article):

Source: Archives of Internal Medicine

Tuesday, September 7, 2010

Report Encourages Disclosure of Large-Scale Medical Mistakes

The Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) recommends that large-scale adverse events and medical mistakes should be reported by facilities, even though they do not result in patient harm. This recommendation was noted in a study titled, "The Disclosure Dilemma -- Large Scale Adverse Events," which was published in the New England Journal of Medicine.

The AHRQ encouraged facilities to personally contact all patients that may be affected by a large-scale error such as the use of improperly sterilized medical tools and equipment malfunctions, even if the patients suffered no effect. Facilities are concerned that reporting these events will cause psychological distress on patients that would have had no worries had the event gone undisclosed. They are also concerned that reporting events will place a burden of negative press on facilities.

The AHRQ recommends that facilities have a policy in place that sets a structure for reporting errors and reaching out to all affected patients with follow-up care and compensation.

To read the full study, click here:

Source: BNA

Friday, September 3, 2010

Resident Suspected of Altering Performance Records

Dr. Eric George Batterson of the University of Michigan Health System is accused of accessing computers without authorization to alter his performance records.

Batterson allegedly used a program that tracks the typing of a computer's user. He used this information to obtain passwords for computers and e-mail accounts so he could alter his performance records and lower the performance records of his colleagues. Batterson's activities were discovered when employees realized that their computers and e-mails had been accessed without their permission.

A preliminary court hearing is scheduled for Sept. 29. Batterson is charged with "nine counts each of unauthorized access of computers and using computers to commit a crime, as well as one count of possessing a Taser."


Watch out for H.E.A.T.

The Obama Administration will be increasing the HEAT to help combat healthcare fraud. The US Attorney General and Secretary of Health of Human Services created the Healthcare Enforcement Action Team (HEAT) in 2009 to investigate cases of fraud. HEAT strike teams are currently present in seven cities. The increase will expand HEAT presence to twenty metropolitan areas.

The HEAT strike teams are responsible for targeting and investigating healthcare fraud cases, something that the FBI and Department of Justice have not been able to handle on their own. Billions of dollars are currently being wasted due to fraudulent claims. The Obama Administration hopes that the success of HEAT will help to prevent and recover these claims, so that money can be better spent on improving quality and controlling costs for Medicare beneficiaries.

Source: Lexology (log-in required)

Thursday, September 2, 2010

Former CEO of LA Hospital Sentenced for Role in Billing Scheme

On August 31, Rudra Sabaratnam, former CEO of the now-defunct City of Angels Medical Center in Los Angeles, CA was sentenced to two years in prison and ordered to pay $4.1 million in restitution for his role in a Medicare and Medi-Cal billing scheme (US v. Sabaratnam).

Sabaratnam, along with former board chairman Robert Bourseau, paid an employee of a homeless recruitment center in the "Skid Row" district of Los Angeles to refer homeless patients to the City of Angels Medical Center for unnecessary inpatient treatment so that the facility could bill Medicare and Medi-Cal. Bourseau was sentenced earlier this year for his role.

Often reports of fraudulent Medicare billing involve physicians and other providers. This case serves as a reminder that corruption and abuse of power can occur at all levels of healthcare delivery -- from the provider to the administrator.

Source: BNA

Tuesday, August 24, 2010

Court Allows HHS to Recover over $300k in Claims

The US Court of Appeals for the Eleventh Circuit ruled that the US Department of Health and Human Services was entitled to recover $311,263 in claims filed by Florida Medical Center of Clearwater, Inc. (FMC). FMC had argued that the government suffered no loss or injury as a result of the claims and that repayment of the claims would constitute an excessive fine, which is barred by the Eighth Amendment.

The court sided with HHS, stating that the amount was simply a recovery of losses, and not a fine.

Dr. Surindar S. Bedi was president and majority owner of FMC, despite being subject to a 10 year exclusion from Medicare due to a previous violation. FMC's application to CMS did not disclose Bedi's affiliation. The court ruled that CMS was allowed to recover the payments not because of Bedi's standing, but because FMC's application omitted information about Bedi in its application.

This case emphasizes the importance of checking the Medicare Exclusion list to ensure that providers are in good standing, and that appropriate disclosures are made, should a provider be found on this list.

Monday, August 23, 2010

MSPs Should Be on the Lookout for ACOs

A new acronym (ACO) to keep on our radar screen. The goal of such organizations is to keep patients healthy AND be cost-efficient. According to BNA, accountable care organizations "are designed to keep patients healthy and out of intensive care settings, while simultaneously shifting reimbursements to pay based on the achievement of top performance goals that drive improved patient outcomes and cost-effectiveness."

The Centers for Medicare & Medicaid Services (CMS) is working on draft regulations that will define what constitutes an ACO. The CMS-regulated ACO program is set to begin in 2012. Currently, there are some ACO models are emerging from Physician Group Practice organizations.

The purpose of the ACO program is to reward providers with higher reimbursement if they attain positive patient outcomes and are successful at promoting patient wellness. The idea is that it is more costly to reimburse providers for the treatment of illnesses; therefore, quality healthcare can be made more cost-efficient if they strive for the maintenance of patients' good health.

It will be interesting to see whether or not MSPs are asked to assist with monitoring "top performance goals" as part of the final ACO rules.

Source: BNA

Tuesday, August 17, 2010

Cynthia Grubbs, JD, RN Named New DPDB Director

Cynthia Grubbs, R.N., J.D. has been appointed the Director of the Division of Practitioner Data Banks (DPDB). Prior to accepting this position, Ms. Grubbs was Deputy Program Manager and Senior Policy Analyst for SRA International. She was the lead policy expert for SRA’s National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank project team. Ms. Grubbs has also held several prior roles with the NPDB and the Health Resources and Services Administration (HRSA).

In addition to her work with SRA and HRSA, Ms. Grubbs has worked as a staff attorney practicing in the medical malpractice and personal injury fields and has over 8 years of experience as a Registered Nurse.

Ms. Grubbs replaces Acting Director Mark Pincus, who will remain with HRSA.

Ms. Grubbs has been valuable in providing education to NAMSS' members on the NPDB. She presented a webinar on the NPDB's Section 1921 changes this past winter, and is scheduled to present at the NAMSS Annual Conference in October. NAMSS would like to congratulate Ms. Grubbs on her recent appointment.

Source: Health Resources and Services Administration (HRSA)

Map Highlights "Doctors Behaving Badly" Nationwide features a project focused on a map of disciplinary actions taken against doctors nationwide. For each state, the map features a news story of a misbehaving doctor and how the state's medical board took disciplinary action.

The creators of the map are also studying each state medical board's website to determine whether or not the public is given enough information to make a quality judgment on a provider. The study is not complete, but they currently rate California's site as one of the best since it provides visitors with detailed provider histories. Illinois is ranked as one of the worst sites when it comes to providing visitors with information.

To view the map and comments on the medical boards assessed so far, click here:

Thursday, August 12, 2010

AMA Report Shows about 42% of Physicians Are Sued

A 2007-2008 study of physicians by the American Medical Association (AMA) shows that about 42% of physicians have been sued during their career. The data was collected through the AMA's Physician Practice Information survey, which is used to develop relative value units (RVUs) for the Medicare Physician Fee Schedule.

The study provides MSPs with benchmarking data on medical malpractice, including the average amount of settled and tried claims, as well as frequency of claims based on the age, gender, and specialty of the physician.

To read the full report, click here:

Tuesday, August 3, 2010

Study Supports Use of CRNAs without Physician Supervision

A study in Health Affairs shows that patient death rates have not increased among states that allow nurse anesthetists to administer services without the supervision of an anesthesiologist or surgeon.

The Centers for Medicare & Medicaid Services currently require that nurse anesthetists perform under the supervision of an anesthesiologist or surgeon in order to bill under Medicare; however, states have the ability to opt out of this requirement by petitioning CMS. Currently, 14 states have opted out.

The study showed that in the states that have opted out, anesthesiologists have taken on more complicated cases, or cases where the private insurance reimbursement was higher, while unsupervised nurse anesthetists have taken on more routine and Medicare-funded cases. The study compared the performance of nurse anesthetists working unsupervised, supervised nurse anesthetists, and anesthesiologists and surgeons, and found no difference among the number of patient complications and deaths allocated to each group.

The authors of the study encourage CMS to eliminate the supervision requirement, stating that allowing nurse anesthetists to work unsupervised is cost-effective, with no negative impact on patient safety. This would be especially helpful to smaller hospitals, which may not have an anesthesiologist on staff. This study serves as a reminder to MSPs that patient safety does not always have to mean "physician supervision."

Sources: BNA, Health Affairs

Friday, July 30, 2010

AHA Responds to Recent CMS Telemedicine Expansion: "We Believe the Proposed Changes Do Not Go Far Enough"

In response to CMS' proposed changes regarding credentialing and privileging requirements for telemedicine, the American Hospital Association (AHA) submitted a letter to the new CMS Administrator, Donald Berwick, stating that it is in support of the rule but that the changes do not apply to physician groups or other entities that provide telemedicine service.

Click here to read the letter in it's entirety.

Thursday, July 29, 2010

AARP Pledges Support for Two House, One Senate Medicare Fraud-Fighting Bills

AARP endorsed three bills July 27, two in the House and one in the Senate, that focus on fighting Medicare fraud. The bills in question are the Medicare Fraud Enforcement and Prevention Act (H.R. 5044), a companion bill in the Senate (S. 3632), and the Fighting Fraud with Innovative Technology Act (H.R. 5546) (114 HCDR, 6/16/10).

H.R. 5044, sponsored by Reps. Ron Klein (D-Fla.) and Ileana Ros-Lehtinen (R-Fla.), would increase penalties for Medicare fraud, such as doubling monetary fines and doubling jail time.

H.R. 5044, would amend section 1128B of the Social Security Act, which governs criminal penalties for false statements involving federal health programs, removing the existing fine of $25,000 per claim and replacing it with a $50,000 fine per claim, and doubling jail sentences from five years to 10 years. Additionally, the bill would create new penalties for illegally purchasing, selling, or distributing Medicare or Medicaid beneficiary information, as well as billing information. Penalties for this violation would include up to three years in prison as well as monetary fines under Title 18 of the U.S. Code.

The bill would also establish a five-year pilot biometric program, designed to verify the identity of all Medicare beneficiaries. Upon receiving certain services or supplies, a beneficiary would have to undergo a biometric scan. The bill would allow the HHS secretary to create the list of services requiring a biometric test, and the secretary would be allowed to provide financial incentives to providers to take part in the pilot program.

Kevin G. McAnaney, an attorney with the Law Offices of Kevin G. McAnaney, Washington told BNA July 28 that the bill was a mixed bag, with some positive provisions, such as the penalties for selling Medicare beneficiary numbers, but several questionable sections.

“The bill would substantially expand the definition of ‘items and services' for purposes of civil monetary penalties from ‘medical care or services and items' to include ‘without limitation, any medical, social, management, administrative, or other item or service used in connection with or directly or indirectly related to a federal program',” McAnaney said.

H.R. 5546 would create a pre-payment review prevention system that would review Medicare claims, identifying high-risk claims using predictive modeling technology. All flagged claims would be fully reviewed by the HHS secretary, who would have the final say as to whether the claim was paid or denied. The system would work by assessing the risk level of all Medicare transactions on a near real-time basis and would identify suspicious patterns that increased the likelihood of fraud.

“I think this bill simply provides for a robust pre-payment review of claims akin to what the credit card companies do. I don't know if it will work, but it is certainly something they should be trying,” McAnaney said.

It should be made aware that these pieces of legislation highlight the fact that the House and Senate are continuously watching the Medicare program and taking measures to prevent fraud and abuse.

Swann, James. "AARP Pledges Support for Two House, One Senate Medicare Fraud-Fighting Bills." BNA Health Care Daily Report. 29 July 2010. Web. 29 July 2010.

Tuesday, July 27, 2010

Patient Protection and Affordable Care Act - How It Will be Funded

The big question on many people’s minds is where will the money come from to fund the deficit reduction and the Patient Protection and Affordable Care Act (PPACA). The Congressional Budget Office (CBO) estimates that the PPACA will cost $940 billion over the next 10 years. Even with the high cost of the PPACA, the CBO approximates that there will be a $143 billion reduction in the federal deficit over the next 10 years (2010-2019) and a $1.2 trillion reduction in the federal deficit in the 10 years following (2020-2029).

The PPACA and deficit reduction will be funded through new taxes, fees, and penalties on individuals, businesses, and the health care industry. This alert will touch upon the biggest changes individuals, businesses, and the health care industry will experience in the next few years.

Individual tax payers will contribute to the PPACA funding through an additional Medicare tax imposed on wages and investment income, penalties for failure to maintain health care coverage, a higher threshold for itemized medical expense deductions, a tax on indoor tanning, and an additional tax on distributions from health and medical savings accounts.

The health care industry will be a large source of the PPACA’s funding through fees on health insurance providers and pharmaceutical manufacturers and importers, excise taxes on medical devices and high cost employer sponsored health coverage, and a limitation on remuneration paid by health insurance providers.

Beginning this year, the deduction for employee remuneration paid by health insurance providers will be limited. The amount health insurance providers will be able deduct in applicable employee remuneration will decrease from $1 million to $500,000. The limit will apply to all officers, employees, directors, and other workers or services providers performing services for or on behalf of a health insurance provider.

Non-health care industry businesses will also face changes and penalties as part of the PPACA funding. Effective in 2010, the PPACA eliminated the cellulosic biofuel producer credit. Paper companies will now be barred from claiming $1.01 per gallon cellulosic biofuel producer credit for black liquor, a by-product of paper making. This change is estimated to raise $23.6 billion over the next ten years.

Hoffman, Larkin, Bruce Douglas and Kelly Burke. "Patient Protection and Affordable Care Act - How It Will be Funded." Lexology. 13 July 2010. Web. 27 July 2010.

Health System Reform: Small Businesses Will Pay Fines Rather Than Buy Health Insurance

From BNA's Health Care Daily:

Small business owners speaking at a Chamber of Commerce forum July 26 said they will pay fines imposed under the new health reform law rather than purchase health care coverage for their employees.

In addition, Chamber of Commerce Senior Vice President Randel Johnson said that the business organization is looking at legal options for challenging the Patient Protection and Affordable Care Act (PPACA, Pub. L. No. 111-148).

“We're going to have to live with it for awhile, and we're going to have to deal with it,” Johnson said. He and small business owners spoke at a forum in Washington, Behind the Curtain: the Health Care Law's Impact on Small Business, sponsored by the chamber, the National Federation of Independent Business, and the American Action Network. The Chamber of Commerce strongly opposed the new law.

“We'll absolutely be paying the penalty,” said Scott Womack, president of Womack Restaurants in Terra Haute, Ind. “There's no way we can buy the health insurance,” Womack said. Under PPACA employers with at least 50 employees must offer coverage to workers beginning in 2014 or pay penalties, which are not tax-deductible, of $2,000 per employee.

The cost of paying the penalty will total about $2,800 per employee because it is not tax-deductible, Womack said. But average profits per employee for the restaurant industry are only about $2,600, he said. “We've got a big problem in our industry,” he said. Raising prices is difficult in the current economy, he said.

Womack estimates it would cost his company about $8,000 per employee to cover the 360 full-time employees who would have to be covered under PPACA. Womack expects to reduce his payroll by 15 percent to 20 percent in response to the new law.

Sen. Mike Johanns (R-Neb.) was critical of the health care bill, which he said will increase taxes by $4.5 billion and will hit small businesses particularly hard. He called for passage of legislation he and other Republicans have introduced that would repeal a provision in PPACA requiring businesses, beginning in 2012, to file 1099 tax forms for all services totaling more than $600 per year from each vendor. The requirement will be overly burdensome for businesses, especially small businesses, he said.

“This mandate has absolutely nothing to do with improving the health care of any individual in this country and it should not be a part of this law or any other law,” Johanns said. “This administration bridles at the notion that they're anti-business. But I have to tell you, I haven't been around a more anti-business adminstration in my entire career,” Johanns said.

The "big picture" impact of Health Care Reform should be noted as it will inherently affect all medical personnel, including MSPs.

Hansard, Sara. "Small Businesses will Pay Fines Rather than Health Insurance." BNA's Health Care Daily Report. 27 July 2010. Web. 27 July 2010.

Tuesday, July 20, 2010

New Physician Survey Finds Medicare Payment Change Hurts Care Coordination Efforts - AMA

The elimination of Medicare’s consultation codes has had a negative impact on physician efforts to improve care coordination and reduced the treatment options available to Medicare patients, according to a new survey released today by medical specialty societies and the American Medical Association (AMA). Consultation codes are used most frequently by specialists after a patient referral from a primary care physician.

The survey indicates that the approximately 5,500 physicians who completed the survey have been forced to take a number of cost-cutting steps to offset revenue losses associated with the elimination of these codes.

After analyzing survey data, representatives of these specialties and the AMA identified several technical improvements that would make the policy more equitable. They joined with 16 other organizations in a letter outlining their concerns and asking the Centers for Medicare and Medicaid Services (CMS) to review and modify its current policy to prevent further deterioration of care coordination between physicians.

For more information on the survey results, the organization letter, and survey participants, please visit the American Medical Association website.

American Medical Association. "New Physician Survey Find Medicare Payment Change Hurts Care Coordination Efforts: Medical OrganizationsCall on CMS to Review Consultation Code Policy."
AMA. July 16, 2010. Web. July 201, 2010.

Monday, July 19, 2010

Peer Review: Federal Court Says Credentialing Documents Not Covered by Colorado Statutory Privilege

Recently a ruling was made that a Colorado peer review privilege statute does not apply to documents generated by a hospital's credentialing committee and sought by a physician alleging he was wrongfully terminated (Ryskin v. Banner Health Inc., D. Colo., No. 09-cv-1864, 7/9/10).

The U.S. District Court for the District of Colorado said the state law did not bar Dr. Michael Ryskin from seeking documents from the Sterling Regional MedCenter credentialing committee because he provided sufficient allegations that the hospital failed to follow provisions of professional review and fair hearing plans that guaranteed him certain due process rights in the event of adverse actions affecting medical staff privileges.

Of greater importance, the court said, was the fact that the hospital did not appear to have followed its applicable practices for professional review and credentialing activities in Ryskin's case. Because compliance with the statutory procedural requirements is a prerequisite to asserting the privileges, they were not available.

Although the hospital argued that Ryskin may have been entitled to some due process rights if the credentialing committee had made an adverse recommendation against his medical privileges, and although it also argued that no adverse determination was ever made, the court rejected those arguments

The court concluded that, while the state law privileges are designed primarily to shield peer review materials from production in medical malpractice cases, Ryskin's action was not concerned with quality of care issues but was, rather, focused on determining the motives behind his termination.

In a conclusive decision from the court: “Plaintiff seeks not the conclusions of the relevant committees, but their motives. To shield the documents in this lawsuit would be to frustrate the search for truth."

Source: BNA's Health Care Daily 7/19/2010: Federal Court Says Credentialing Documents
Not Covered by Colorado Statutory Privilege

Monday, July 12, 2010

139 ABIM Doctors Sanctioned for Sharing Exam Questions

The American Board of Internal Medicine (ABIM) has sanctioned 139 physicians accused of collecting and sharing board certification exam questions through the New Jersey-based Arora Board Review exam prep service.

ABIM has also settled its lawsuit with doctors Rajender Arora, M.D., and Anise Kachadourian, M.D., barring them from sitting for the ABIM for several years, and barring employees and representatives of the Arora Board Review from accessing, copying, or distributing ABIM materials.

Names of the 139 doctors who were sanctioned in connection with the incident have not been released. However, their status has been updated in the ABIM's online database.

Source: Modern Healthcare

Wednesday, July 7, 2010

Missouri Supreme Court Rules on "Same Specialty" Definition for Expert Testimony

The Missouri Supreme Court held that a radiologist who had performed similar procedures as a neurosurgeon was qualified to provide expert testimony in a case even though the two doctors held different board certifications.

In Spradling v. SSM Health Care St. Louis, Mo., a patient was suing Dr. William Sprich, alleging that he was negligent when performing a verteboplasty. Section 538.225.1 of the Missouri Code requires that a plaintiff bringing medical negligence charge must file an affidavit stating that he or she "has obtained the opinion of a 'legally qualified health care provider'" backing the claim of negligence. Section 538.225.2 defines the above term as "a health care provider license in this state or any other state in the same profession as the defendant and either actively practicing or within five years of retirement from actively practicing substantially the same specialty as the defendant."

The defense claimed that the plaintiff's expert witness was not qualified under this definition because his board specialty was in radiology, not neurosurgery. The court ruled that because the witness, Dr. John Mathis, had performed over 3,000 vertebroplasties and had written articles and presented lectures on the procedure, he was "practicing substantially the same specialty" as the defendant. Therefore, he was qualified to testify on the procedure, even though he was of a different specialty as the defendant.

Source: BNA

Thursday, July 1, 2010

CMS Delaying Rejection of Providers Not Enrolled in PECOS

The Centers for Medicare & Medicaid Services (CMS) has announced that they will not enforce the automatic rejection of claims from providers not enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS) until January 3, 2011.

By July 6, 2010, physicians who order or refer for covered Part B services must revalidate their enrollment in PECOS online. Several providers have reported issues in completing the application and revalidation process and called on CMS to delay the rule until problems with the system were worked out. This rule will still be effective by July 6; only the automatic rejection of claims will be delayed until January 2011.

Many hospitals are putting the responsibility on MSPs responsible for credentialing to verify enrollment in Medicare as part of the initial credentialing process. NAMSS will monitor this carefully during the next year. Best practice credentialing procedures include MSPs reviewing the OIG and/or the Medicare/Medicaid Exclusion List. Enforcement guidelines for the PECOS database will likely be developed over the remainder of the year.

Source: BNA

Wednesday, June 30, 2010

Anesthesiologist Sentenced for Research Fraud

Dr. Scott Reuben, a Massachusetts anesthesiologist, was sentenced to six months in prison after pleading guilty to the fabrication of data in a research study.

Reuben admitted to providing false data for a pain management study he performed for Pfizer, Inc. It was later discovered that he had fabricated data in several studies, dating back to 1996. Baystate Medical Center in Springfield, MA stripped him of educational and research duties after this discovery.

Reuben's defense claimed that his undiagnosed bipolar disorder made him unable to prevent his wrongful behavior.

This example highlights the need to take some caution when relying on research studies, and for medical facilities to monitor the research conducted by members of their staff.

Source: BNA

Tuesday, June 29, 2010

Minnesota Nurses Announce Plans for New Strike

The Minnesota Nurses Association (MNA) has filed a 10-day notice for a strike to begin on July 6 and last indefinitely. 10,000 of the MNA's nurses already held a one-day strike on June 21. The strike notice was filed as the union continues to negotiate a new labor and pension agreement with Twin Cities Hospital system, which serves the Minneapolis/St. Paul area.

Some observers believe that the 10-day strike notice is a tactic by the MNA to pressure the hospital system into an agreement before the July 6 deadline.

Hospitals were able to maintain care during the June strike by bringing in over 2,000 temporary staff members for a single day. The threat of an open-ended strike is a bigger concern for potentially affected hospitals, which must figure out how to remain open and maintain continuity in patient care should its nursing staff go on strike.


Monday, June 28, 2010

HHS Launches ESAR-VHP Website

The Department of Health and Human Services (HHS) has launched a new website with information on the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) program at

The ESAR-VHP program is intended to promote the efficient delivery of first response care in emergency and disaster situations through the creation of state plans and a registry of healthcare professionals. The new website provides reports and materials that communities can use in planning their own preparedness programs.

HHS has also established a YouTube channel at where visitors can view testimonials and videos made by volunteers.

Source: HHS

21 Percent Physician Pay Cut Delayed

On June 25, President Obama signed The Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.

The law cancels a 21 percent physician Medicare reimbursement cut that CMS began enforcing on June 18. The law also increases physician reimbursement by 2.2 percent through November.

The temporary increase is a sign that Congress still needs to take action to address the sustainable growth rate, which factors into the reimbursement rates. There have been estimates that the physician payment cut may reach as high as 30% by January if Congress does not find a long-term solution, or implement another "patch" when the reimbursement increase expires in November.

CMS will begin processing all claims at the new rate by July 1.

Source: BNA

Thursday, June 24, 2010

Study Shows Limiting Surgical Training Hours May Hurt, Not Improve Care

A study conducted in a Swiss hospital shows that most residents and surgical supervisors believe that limiting surgical training hours has a negative effect on training and performance. In Switzerland, residents are limited to 50 hour workweeks. In the US, residents have been capped at 80 hours a week since 2003.

Limiting surgical residents' working hours has been a recent strategy used to increase safety. It is believed that limiting hours decreases the likelihood that medical errors will be made by a tired resident. Respondents in the Swiss study stated that while their quality of life increased with less work hours, they felt that they did not have the adequate time to learn necessary skills and build endurance for long surgeries.

The study did not take into account whether or not nurses and patients perceived a lower quality of care.

Sources: Health Care Advisory Board, Medpage Today

Tuesday, June 22, 2010

HHS to Invest $250 Million to Boost Primary Care Workforce

The Department of Health and Human Services (HHS) announced that it will invest $250 million to boost the primary care workforce in an effort to address a predicted shortage of physicians in the field. The funds will be derived from the Prevention and Public Health Fund, which has $500 million for fiscal year 2010.

HHS intends to spend the $250 million on the following main initiatives:

  • $160 million for the creation of 500 new residency slots in primary care
  • $32 million to train 600 physician assistants
  • $30 million to fund the full-time education of 600 nursing students
  • $15 million to support nurse-managed clinics
  • $5 million to help states plan for the primary care shortage
  • Training of 16,000 new primary care providers over the next five years

The Association of American Medical Colleges is predicting that the US will face a shortage of 21,000 primary care providers by 2015. The shortage is due to a combination of various factors including: fewer medical school graduates going into primary care, an aging population, and the expected patient increase resulting from expanded health coverage.

Source: BNA

Wednesday, June 16, 2010

Study Highlights Shortage of Primary Care Physicians

A George Washington University study shows that medical schools are continuing to produce more graduates going into research and specialty professions and not enough primary care doctors. The study also found that graduates of public medical schools were more likely to promote a "social mission," encouraging graduates to go into primary care, especially in underserved communities. More prestigious schools were

Many analysts believe that the continued shortage of graduates entering the primary care field is due to the low reimbursement rate. After graduating with massive debt, graduates are hesitant to select a field that pays an average of $124,000 a year, the lowest rate among physician specialties.

The new health reform law sets aside $1.5 billion in funding for primary care physicians who work in underserved areas. Some hospitals are also working to attract physicians into primary care, fearing that without first-line care, patients will flood their emergency rooms with minor and preventable conditions. This study and others that have been released, continue to serve as indicators that improvments to the delivery of care are needed to support an increased patient population.

The full George Washington study can be found here:

Source: The Baltimore Sun,0,6289224.story

Thursday, June 10, 2010

12,000 Minnesota Nurses Go on Strike

12,000 nurses in Minnesota went on strike today in what has been reported as the largest nursing strike in US history. The Minnesota Nurses Association voted to approve the one-day strike last month after the union failed to reach a staffing agreement with Twin Cities Hospitals, a 14-hospital system located in the Minneapolis/St. Paul area.

The staffing plan proposed by Twin Cities Hospitals would allow hospitals to float nurses between departments to meet staffing needs. The MNA argued that this plan would lead to inconsistency in patient care and would burden an already stretched nursing staff. Twin Cities Hospitals argued that the staffing model proposed by the MNA was too costly in a time where hospitals are being asked to implement new technology while facing funding cuts.

Twin Cities hired temporary nurses to ensure that its facilities could remain open during the strike. The striking nurses are scheduled to return to work at 7 AM on June 11.

The Minnesota strike occurred as California nurses agreed to comply with a judge's temporary order stopping a strike against the University of California hospital system. The California strike was expected involve 12,000 nurses.

Source: ABC News

Wednesday, June 9, 2010

CMS Extends TJC's Telemedicine Hospital Standards

Hospitals and Critical Access Hospitals do not have to make changes to implement new telemedicine credentialing and privileging elements of performance by a July 15, 2010 deadline, says The Joint Commission (TJC). The deadline for implementing the new elements of performance has been pushed to March 2011.

TJC had issued new elements of performance which were in compliance with the Centers for Medicare & Medicaid Services' (CMS) requirements for telemedicine services. The CMS requirements currently disallow the "credentialing by proxy" system that is supported by The Joint Commission's current standards. The "credentialing by proxy" system is intended to support access to telemedicine services by allowing the hospital where the patient is located, to rely on the credentialing and privileging data of a hospital where the provider is currently privileged in making its own decisions on that provider.

CMS has issued a proposed rule that would make the CMS telemedicine requirements in accordance with TJC's "credentialing by proxy" system. For this reason, CMS allowed TJC to delay implementation of the new elements of performance that are aligned with the current CMS CoPs until March 2011.

Source: The Joint Commission

Thursday, June 3, 2010

CMS Anesthesia Guidelines Revised

The Centers for Medicare & Medicaid Services (CMS) have revised the interpretive guidelines for anesthesia delivered in hospitals. The changes focus on the differences between anesthesia and analgesia services, where the patient does not lose consciousness.

The memo released by CMS provides hospitals with information on what practitioners may provide anesthesia services, what hospital policies should include regarding who is allowed to administer these services, guidelines on the supervision of anesthesiology assistants, and a list of information that must be included in a patient's anesthesia record.

The American Society of Anesthesiologists has provided the following summary of the changes:

To read the CMS memo, click here:

Source: Health Leaders Media

Wednesday, June 2, 2010

ABMS Implements Continuous Reporting of MOC Pilot

The following announcement was made by the American Board of Medical Specialties on June 2:

The American Board of Medical Specialties (ABMS) announced that its data file now reflects continuous certification reporting information for diplomates certified by the American Board of Pediatrics (ABP). ABMS’ reporting pilot will begin with ABP, the first and only ABMS Member Board to eliminate specific certification “end dates” for its diplomates.

For all ABP diplomates who are initially certified in 2010 and beyond, as well as those whose certificate currently contains an expiration date, ongoing certification with the ABP is contingent upon meeting the requirements for Maintenance of Certification (MOC). To maintain ABP certification, diplomates must successfully complete numerous requirements throughout the ongoing MOC cycles; thus the ABP no longer provides a specific end date to certification.

ABMS recognizes that some credentialers may still require a certification end date to complete primary source verification. As ABP diplomate certification status only changes at the beginning of a calendar year, unless revoked for disciplinary reasons, conducting annual primary source verification on or after February 15 will ensure credentialers have accurate certification status for ABP diplomates. The practice of conducting annual primary source verification in mid-February of each calendar year will also serve as a reminder previously provided by an official end date.

Approximately 7,800 ABP diplomates whose certification expired December 31, 2009, are the first physicians to have this new designation.

“Although ABP’s policy does not affect other Member Boards, it aligns with the ABMS Maintenance of Certification® (ABMS MOC®) emphasis on continuous, life-long learning. For the credentialing community, the February 15 date will serve as an annual reminder to verify physicians’ credentials,” said Kevin B. Weiss, MD, president and CEO of ABMS. “We are pleased to be able to provide credentialers with this continuous MOC reporting data pilot program for ABP diplomates, and we look forward to hearing feedback from the credentialing community and further supporting their needs.”

For additional information visit the ABP website at

Thursday, May 27, 2010

TJC Makes Changes to Ambulatory Center Survey

The Joint Commission has made changes to its ambulatory center deemed status survey process to align with the Centers for Medicare and Medicaid Services Conditions of Participation. The changes include:
  • Additional credentials file review for physicians
  • Additional review of licensed non-physician practitioner personnel files
  • Completion of Infection Control Worksheet
  • Review of closed medical records
  • Observation of one full surgery or procedure

The changes will extend the survey process by one day for centers performing more than 600 cases a year.

The Survey Guide for Ambulatory Health Care Organizations has been updated to reflect these changes and can be found here:

Source: The Joint Commission Ambulatory Advisor

Monday, May 24, 2010

CMS to Announce Proposed Rule on Telemedicine Credentialing

The May 25 issue of the Federal Register will include a notice of proposed changes to the Medicare and Medicaid Conditions of Participation (CoPs) regarding the credentialing and privileging of telemedicine providers.

The proposed rule would permit the governing body at a hospital where a patient is receiving telemedicine services to rely on information from a hospital where the provider is currently privileged (distant-site) when making its own privileging decisions. In order to rely on information from the distant-site, the hospital where services are being received must ensure that
  • "the distant-site hospital providing the telemedicine services is a Medicare-participating hospital;
  • the individual distant-site physician or practitioner is privileged at the distant-site hospital providing telemedicine services, and that this distant-site hospital provides a current list of the physician's or practitioner's privileges;
  • the individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital, whose patients are receiving the telemedicine services, is located; and
  • with respect to a distant-site physician or practitioner granted privileges by the hospital, the hospital has evidence of an internal review of the distant-site physician's or practitioner's performance of these privileges and sends the distant-site hospital this information for use in its periodic appraisal of the individual distant-site physician or practitioner."

The proposed rule would also require that the periodic review information submitted to the distant-site include adverse events and complaints received about the physician or practitioner.

The proposed rule was created to address the redundant collection of information at both the distant-site and the site where services are received. CMS also recognized that the current requirements were burdensome on small hospitals where telemedicine would be an asset, but the collection of credentialing and privileging information for all telemedicine providers would be a burden.

Under the proposed rule, CMS estimates that the cost to hospitals to implement the rule will be minimal. In its cost analysis, CMS included a breakdown of the cost and time that would be spent by Medical Staff Coordinators or Medical Staff Credentialing Managers to prepare and send performance reports to hospitals receiving telemedicine services.

CMS is collecting comments through July 26. NAMSS has identified the telemedicine CoPs as a source of redundancy in the credentialing and privileging and is pleased to see that CMS is taking steps to streamline these processes.

To read the full announcement, click here:

Minnesota Preparing for Largest Nursing Strike in US History

Last Wednesday, the members of the Minnesota Nurses Association voted to approve a one-day strike that will affect hospitals in the Minneapolis-St. Paul area. The nurses are protesting proposed labor contracts that would set wage increases over the next three years at zero to two percent and proposed pension plans. The nurses are also protesting proposed staffing plans that would allow hospitals to send nurses home on slow days, or float nurses to other departments with higher need. The MNA argues that this staffing plan will overburden staff, leading to potential patient safety risks. The hospitals argue that these changes would allow them to maintain quality care without having to hire a larger volume of nurses, which would raise the cost of care to the patient.

12,000 nurses who are members of the MNA are currently contracted with hospitals in the Minneapolis-St. Paul area. The MNA provided the hospitals with notice of the planned strike. Hospital representatives are disappointed with the decision to strike, stating that there is still time to negotiate.

Several articles have raised questions on how the strike may affect patient safety. Some are worried that bringing in temporary nurses will cost hospitals millions of dollars. Others are worried that the strike will disrupt patient care, creating a higher safety risk to the patient.

Members of the MNA hope that an agreement with hospitals is reached prior to the June 1 contract expiration; however, they stated that they are ready to strike if a deal is not reached.

Sources: Minneapolis St. Paul Business Journal, Pioneer Press

Navigate MS.01.01.01 with NAMSS

Do you have questions about whether or not your bylaws are ready for the March 2011 implementation of MS.01.01.01? Are you still unsure about what changes need to be made? Register today to join attorney Michael Callahan of the American Health Lawyers Association and Harold Bressler, General Counsel of The Joint Commission, as they walk you through sample bylaws, explaining what meets the standard and what doesn’t.

In addition, learn how to re-evaluate the relationships among the medical staff, medical executive committee, and governing body under the new standard.

Upon registering for the webinar, you will receive a link to a site where you can submit your questions in advance, giving you the opportunity to “custom-design” the content of the session. Based on your questions, the speakers will provide substantive guidance on the most-pressing issues for MSPs.

Cost is $49 for NAMSS members, $69 for non-members, and $10 for each additional CE certificate. Participants will receive 1.5 CE credits.

This webinar also will be recorded and available in the NAMSS Online Store following the live event. If you have questions, please e-mail

Friday, May 21, 2010

FSMB Discusses the Collection of Physician Data under the Proposed MOL Framework

In April, the Federation of State Medical Boards (FSMB) released a report outlining the implementation of the Maintenance of Licensure (MOL) program. Many NAMSS members have already started to ask questions about how the MOL may affect the credentialing process.

Frances Cain, Director of Post-Licensure Services for FSMB has provided the following information. Feel free to leave any questions or comments that you may have for FSMB and Ms. Cain in the blog's comment field.

Although FSMB has adopted a framework for MOL, there are still some questions as to how state medical boards might implement MOL and how it may look “on the ground” for physicians. The FSMB has recently established a MOL Implementation Group, which has been charged to create a template to assist state medical boards in implementing MOL. This will include a more detailed exposition of the options for complying with MOL that fall outside of Board-certification. FSMB hopes to have this report out for comment in the fall, and will send a copy to NAMSS.

There have been many questions about the types of data physicians may have to collect in order to comply with MOL and how that information may be used by the state medical board. To date, all of the committees and workgroups that FSMB has convened to explore the issue of MOL and to develop the MOL framework that was adopted by our House of Delegates last month have all been very sensitive to the concerns of physicians about the privacy of their data. As such, the final report and MOL recommendations that were adopted by FSMB as policy includes the following statement:

“Practice performance data collected and used by physicians to comply with MOL requirements should not be reported to state medical boards. Third party attestation of collection and use of such data (as part of a professional development program) will satisfy reporting requirements.”

Therefore, under the proposed MOL framework, physicians could be able to comply with MOL through participation in the very same activities in which they are already participating (e.g., CME, procedural hospital privileging, 360 evaluations, medical professional society/organization clinical assessment/practice improvement programs, CMS and other similar institutional-based measures). Participation in these activities could be verified by the state medical board through third-party attestation, rather than direct reporting of the data. A more detailed listing of proposed activities that physicians could use to comply with each of the three components of MOL are provided in the MOL Advisory Group report (see pages 79-80 of the adopted MOL policy report at

To use the example of CME, under MOL a state medical board may choose to require that CME used for license renewal be related to the physician’s area of practice; however, the board could use the same system it currently has in place (i.e., a random audit of a small group of licensees) to verify physicians’ compliance with those requirements.

Although central to the FSMB’s proposed MOL framework is the concept that each state medical board would adopt its own guidelines for applying MOL, through our Implementation Group and future pilot projects with individual state medical boards, we would hope to develop recommendations that will be consistent across state lines. MOL will be an “evolutionary” process and will require much thought such that it provides public protection while paying attention to the concerns of physicians and the resources available to state medical boards.

FSMB encourages input from all stakeholders as we proceed with this task.

Tuesday, May 18, 2010

Utah Supreme Court Recognizes Negligent Credentialing as a Valid Claim

On May 14, the Utah Supreme Court recognized negligent credentialing as a valid cause of action in a legal claim against a hospital in Archuleta v. St. Mark's Hospital.

The plaintiff, Tina Archuleta, had undergone a laparotomy procedure performed by Dr. R. Chad Halversen at St. Mark's Hospital. Two days later, she was admitted to another facility, experiencing pain and complications from the procedure. Archuleta underwent six surgeries to correct the procedure.

Archuleta filed a suit against Halversen and St. Mark's Hospital. In her complaint against the hospital, she claimed that St. Mark's "failed to seek consult when appropriate, inadequately trained healthcare provider employees, negligently credentialed. . . [Dr.] Halversen and generally fell below the standard of care."

The district court dismissed her negligent credentialing claim, stating that such action was barred by the sections of the Utah Code that protect the dissemination of peer review information. The Utah Supreme Court ruled that the district court was incorrect in its application of the code, ruling that "the immunity contemplated under the statue operates between a doctor whose credentials are under review and the suppliers of information and decision makers; it does not contemplate immunity between a patient and a hospital."

In its opinion, the Utah Supreme Court stated that there is a public interest in recognizing negligent credentialing claims because there is a "foreseeability of harm to patients where hospitals fail to properly investigate a doctor's qualifications" (citing Johnson v. Misericordia), and because of the "superior position [of hospitals] to monitor and control physician performance" (citing Domingo v. Doe).

To read the full opinion, click here:

Monday, May 17, 2010

HASC Proposes Coordinated Care System

A proposal by the Hospital Association of Southern California (HASC) calls for the formation of a single foundation that would supply hospitals in the area with physicians and centralized administrative functions. The foundation would work with various physician groups and contract physicians on behalf of several hospitals. HASC says that the creation of a single foundation working with several hospitals, which is different from the current system where each hospital usually has its own foundation, would promote efficiency and better coordinated care.

The plan has raised some concerns from those who believe that the plan limits competition by area physicians who are not part of the foundation. HASC argues that competition will not be harmed since hospitals would not acquire their whole workforce from the foundation. The foundation will primarily help smaller facilities that have a harder time recruiting physicians.

The proposed plan has not been passed, but it does highlight the changing relationships between hospitals and physicians and the impact that it can have on the healthcare market.

The following article from The Wall Street Journal outlines the HASC plan and the arguments for and against it:

Source: The Wall Street Journal

Tuesday, May 11, 2010

Physician Specialties Generating Hospital Revenue

Modern Physician reports that the 2010 Merrit Hawkins Physician Inpatient/Outpatient Revenue Survey reported that the 17 physician specialties experienced a 3% increase in average annual net revenue generated since 2007. In 2010, the specialties reported an average annual net revenue of $1.54 million for their hospitals.

The article emphasizes that although the specialties may be revenue generating, hospitals must remember that health reform incentives will be based on the availability of access to primary care and preventative services. The survey results, which reported a drop in primary-care revenue, may look completely different in a few years once the health reform provisions are implemented.

To read the full article, click here (free subscription required):


Friday, May 7, 2010

Submit Your Thoughts for an Upcoming Synergy Article

This year, NAMSS and CAQH are collaborating on the shared goal of identifying ways to increase efficiencies in the credentialing process. An upcoming issue of Synergy will feature an article on CAQH’s Universal Provider Datasource (UPD) and application. For this article, we are looking for feedback from the membership with your thoughts as a user of the UPD and CAQH application. The article will highlight the feedback of the membership and will provide an update on how CAQH is working to make the UPD system easier to use.

The NAMSS Industry & Government Relations Committee has already provided comments to CAQH with ideas on how to improve their application for the hospital-user community. NAMSS is pleased that CAQH is reviewing the committee’s proposed changes for inclusion in a future version of their application. CAQH wants to hear more about your experiences so we can work together and can continue to make the application and UPD system more user-friendly for providers and credentialing professionals.

Here is your chance to share your experiences on using the system with both the NAMSS membership and CAQH. To provide your experiences for the article, complete the following survey by Friday, May 21:

Questions can be sent to

Thursday, May 6, 2010

VA Limiting Surgeries to Improve Care and Quality

Officials at the Department of Veterans' Affairs have announced that surgeries at some VA facilities will be limited based on the agency's "surgery complexity initiative." The initiative grades VA hospitals based on their medical staffing, equipment, and diagnostic capabilities. The complexity of surgical procedures are compared against the grade received by a facility to determine if the facility is capable of performing certain procedures.

66 facilities have been approved to perform complex procedures (cardiac, brain pancreas surgeries, etc.). 33 have been approved for intermediate procedures (joint replacement, colon ressections, etc.). 13 facilities are limited to standard procedures (hernia repair, ear, nose, and throat surgeries, etc.).

The VA said that they will assist with transportation to facilities if a patient needs to go to a distant hospital for a procedure due to the limitations. The VA said that this system is part of its response to improve quality after problems were discovered at the VA hospital in Marion, IL.

Source: Army Times

Tuesday, May 4, 2010

Angie's List Encourages Patients to Make Sure Their Healthcare Providers Are Licensed

Angie's List, a consumer-focused website that allows people to post review services and contractors, recently released an article encouraging patients to check to make sure their healthcare providers are practicing under a current license.

91 percent of respondents said that it is "crucial that their health care providers are licensed," yet most respondents do not check for licensure themselves.

The article presents several interesting situations of unlicensed medical professionals and the potential dangers of having these providers see patients. The article does recognize that many of the "unlicensed" professionals are simply professionals who have let their license expire. Matt Haddad, CEO of Medversant, noted the importance of seeing a properly credentialed provider.

This article is good at highlighting the value of the MSP from the consumer perspective. Patients should not have to ask their providers for proof of licensure when they enter a hospital or call an office to schedule an appointment. They should be able to seek care, knowing that their provider is licensed and competent. It is our job as MSPs to keep sanctioned providers away from patients, and to ensure that providers know the importance of licensure and do not let it lapse.

To read the full article, click here:

Source: Angie's List