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.

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

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

RepoortingOnHealth.com 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:
http://www.reportingonhealth.org/blogs/doctors-behaving-badly-medical-boards-should-drop-stone-tools-join-digital-age

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:
http://www.ama-assn.org/ama1/pub/upload/mm/363/prp-201001-claim-freq.pdf

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