Aetna Inc.'s first-quarter profit beat Wall Street's estimates, but higher than expected medical costs tied to the recession alarmed investors and drove the company's stock price down more than 10%. Net income at Hartford-based Aetna inched up 1% to $437.8 million, or 95 cents a share, from $431.6 million, or 85 cents a share, a year earlier.
Doctors from Spokane, WA, and Rwanda are working together to improve healthcare in that African nation. Teams of surgeons, nurses and other medical professionals from Spokane have traveled to the central African nation in the past year to treat patients and train people.
Now, two Rwandan doctors are working at Deaconess Medical Center to learn how U.S. hospitals function.
Health departments and hospitals are shifting into emergency mode as clusters of swine flu develop across the country, and some are activating pandemic plans for the first time. Many states have declared a public health emergency in anticipation of a pandemic. Some of these states have requested their share of the federal stockpile of flu medicine as at least 10 states have confirmed swine flu cases.
Nashville-based Southern Hills Medical Center has agreed to pay a former employee $70,000 in damages after denying him time off to make a pilgrimage to Mecca but admitted no wrongdoing when it settled the religious discrimination case. In late 2007, the U.S. Equal Employment Opportunity Commission filed suit on behalf of Wali Telwar, a Muslim former Southern Hills medical technician who lives in Nashville.
The recession has drained hundreds of millions of dollars and thousands of workers from the state and local health departments that are now the front line in the country's defense against a possible swine flu pandemic. Health officials in affected states said they had thus far been able to manage the testing and treatment of infected residents and mount public education campaigns. But many said they had been able to do so only by shifting workers from other public health priorities, and some questioned how their depleted departments might handle a pandemic.
Palomar Medical Center in Escondido, CA, has filed a lawsuit against HHS claiming that RACs violate CMS' rules.
CMS requires "good cause" for reopening and reviewing claims more than one year after payment, but RACs regularly reopened claims between one and four years old during the demonstration project without just cause.
Palomar is continuing its fight against this practice; it filed a complaint against HHS in U.S. District Court Southern District of California March 24.
Palomar's fight began in 2007 when PRG-Schultz—the RAC for California during the demonstration project—denied a 2005 claim. Palomar appealed the denial to the Administrative Law Judge level. In October 2008, the ALJ decided in Palomar's favor. The ALJ also found that PRG-Shultz "had not shown ‘good cause' to reopen the claim more than one year after payment, as required by Medicare regulations," according to the complaint Palomar filed in March. The ALJ also determined it had jurisdiction to determine whether the RAC properly reopened the claim.
However, the Medicare Appeals Counsel reversed the ALJ's decision that the reopening was improper and "held that the ALJ lacked jurisdiction to determine whether the RAC had lawfully reopened the claim," according to a February 13 letter to Palomar.
The complaint Palomar filed in March asserts the decision to overturn the ALJ ruling violates Palomar's right to due process and that the RAC violated Medicare rules for reopening claims in effect during the demonstration project.
Per 42 CFR § 405.980(b)(1), a contractor can reopen a claim for any reason within one year of payment, however to open a claim between one and four years post-payment, contractors must have "good cause" to do so per 42 CFR § 405.980(b)(2).
This has been a long-standing concern—many healthcare organizations believe the RACs bent CMS' own rules during the demonstration project.
The decision whether RACs can reopen claims more than one year after payment is important to many healthcare organizations with small operating margins.
Andrea Kraynak, CPC-A, is managing editor of The RAC Report, the Coding Educator, and for HCPro's Revenue Cycle Institute. She may be reached at akraynak@hcpro.com.