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.
Researchers at Brigham and Women's Hospital (BWH) and Massachusetts General Hospital (MGH) in Boston have found that the use of a better-integrated computer system and process redesign could reduce the number of potential medication errors present in the medication reconciliation process.
The study, published in the April 27 Archives of Internal Medicine, took place during May and June 2006, and focused on using existing technology to compare patients' medication lists to prevent adverse events.
"We know that good medication reconciliation is not occurring," says Jeffrey Schnipper, MD, MPH, senior author on the study and hospitalist at BWH.
There are usually 1.44 errors with potential for medication harm, says Schnipper, and his team's randomized controlled clinical trial lowered that number to 1.05 during the course of their study.
Of the 322 total patients who were part of the study, 160 patients in the control group receiving the hospital's normal medication reconciliation processes could have suffered 230 potential adverse events; the 162 patients who were part of the intervention could have suffered 170 potential adverse events.
The Joint Commission's National Patient Safety Goals have contained a goal concerning medication reconciliation since 2005. The Joint Commission is currently reviewing that goal to determine how to better use it to prevent medical errors, as many hospitals have struggled to effectively reconcile medications across the continuum of care and comply with the goal.
Both BWH and MGH were using computer physician order entry (CPOE) systems already, so researchers designed the study around using the existing system and workflow. The study took the existing system and made it easier for staff members to compare a patient's preadmission medication list with both their inpatient and discharge medication lists. This is one area where many hospitals create their own medication reconciliation problems, says Schnipper.
"In many hospitals, a lot of people take a patient's medication history, but it's done in silos—all of these people keeping separate, different lists," says Schnipper, who gave examples of various entry points, such as an emergency room nurse, inpatient nurse, or pharmacist.
The goal of this study, he says, was to reduce redundancy; create only one in-hospital medication list that staff members could refine, but with increased attention on verification and communication among caregivers.
Since the study ended, BWH and MGH staff members have worked on further refining the computer application so that it can detect even more detailed differences in the three medication lists, down to distinctions in the class and dose of medications, says Schnipper. The application alerts caregivers to any of these differences, which could help in preventing adverse drug events.
Process Redesign
Another part of the study involved redefining the roles that certain caregivers play in reconciling medications, specifically the home and the discharge medication lists. Pharmacists and nurses were given a larger role in checking to be sure that patients' preadmission medication lists were accurate.
"Pharmacists get this, and they were thrilled to be involved," says Schnipper.
Prior to the study, Schnipper's team found that pharmacists were spending more time finding and questioning discrepancies between patients' preadmission medication lists and the inpatient medication lists. However, it turned out that a bigger problem existed with the creation of the home medication, which was often inaccurate.
Now, pharmacists at BWH and MGH are doing whatever they can to make sure a correct and up-to-date home medication list is created when a patient enters the hospital. That might mean making an extra effort to find and speak with family members or call a patient's home pharmacy to discover his or her most recent home medications, says Schnipper.
Additionally, nurses, who often are in charge of educating patients about their medication regimens after discharge, have found that because there is one concise list to refer to, they can do a better job with discharge counseling.
:“Any hospital with CPOE should strongly consider having an integrated EMR," says Schnipper.
A computer system that can compare lists and serve as one place for medication data can be a good starting point to cut down on potential adverse events.
Also important is the allocation of personnel. Schnipper says hospitals should evaluate if they need to hire more pharmacists, or if they could use pharmacy techs for some of the tasks associated with a more integrated CPOE system.
Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.
The Senate on Tuesday approved the Fraud Enforcement and Recovery Act of 2009, which would give additional resources to law enforcement for fighting fraud and abuse, and strengthens fraud laws and statutes.
Although the bill's primary function it to prevent the growing number of mortgage fraud cases, it also broadens the scope of claims that fall under the False Claims Act, which can affect any organization that submits claims to the government for payment, including healthcare providers.
Specifically, the bill would extend the reach of the False Claims Act to include any false or fraudulent claim for government money or property, regardless of whether:
The claim is presented to a government official or employee
The U.S. government has physical custody of the money
The defendant specifically intended to defraud the U.S. government
"If the bill becomes law, it's easier for the government and private whistleblowers to succeed in false claims act cases," says Claire Turcotte, a healthcare attorney with Bricker & Ecker LLP in West Chester, OH.
Not that False Claims cases have been particularly unsuccessful. In a press release, the bill's co-author, Sen. Patrick Leahy (D-VT), called the False Claims Act "one of the best civil tools available to root out fraud in government." Leahy also said the Justice Department recovered more than $15 billion in fraud using the False Claims Act from 2000-2008.
According to Leahy, the bill redefines terms in the False Claims Act to more accurately reflect the intention of the law. In particular, the term "knowingly" has been redefined to in a way that overturns the Allison Engine Supreme Court decision of 2008, which required prosecutors to prove specific intent to defraud the government.
The new language specifically states intent is not a requirement of the False Claims Act and the prosecution only needs to show the violator did one of the following, in regards to information:
Had actual knowledge of the information
Acted in deliberate ignorance of the truth or falsity of the informationbr
Acted in reckless disregard of the truth or falsity of the information.
Turcotte says this change would take away a key tool organizations use to fight false claims allegations because now the government is not burdened with the difficult task of proving intent. But the new question is how can an organization show that it acted without "deliberate ignorance" or "reckless disregard"
Turcotte says time will tell how the courts will interpret these terms. However, she believes those terms could refer to compliance programs.
Turcotte says government representatives have said they are looking more closely at whether an organization has a prudent compliance program, and based on the severity of the violation, the government will likely offer more leniency to an organization that can prove it properly educated educate employees on claim submissions.
The bill is headed to the House of Representatives.
Ben Amirault is an editorial assistant for the revenue cycle division of HCPro. He manages the Compliance Monitor e-newsletter and has developed a number of online learning modules. He can be reached at bamirault@hcpro.com.
There are many ways that social media tools can benefit a hospital, says hospital Web manager and blogger Ed Bennett. In this posting, Bennett provides some success stories.