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