Two nurse anesthetists from Minnesota sacrificed their careers to pursue lawsuits against Allina Health Care, which ended with a settlement and changes to Medicare rules that helped save the profession, the Minneapolis Star Tribune reports. But despite the victory they helped bring about, Ladonna Schweer and Gayle McKay had to sue their own organization, the Minnesota Association of Nurse Anesthetists, in order to make the group honor its long-standing vow to compensate them for putting their ideals ahead of their jobs, the Star-Tribune reports.
The U.S. Justice Department announced that Michigan-based Genesys Health System has agreed to pay $669,413 to settle a lawsuit alleging that the healthcare provider submitted fraudulent claims to Medicare. The Justice Department alleged that Genesys violated the False Claims Act by billing Medicare for higher evaluation and management services than were actually given to cardiology patients.
The government is expanding a safety net to help the unemployed buy health insurance, but millions of people can't access the aid because of the way the program was designed, the Wall Street Journal reports. As a cornerstone of the economic stimulus plan, the Obama administration allocated $25 billion to pay 65% of health-insurance premiums for workers laid off this year. Earlier this month, Congress extended the program for people laid off through February 2010 and expanded the aid to 15 months from nine. But the program is eluding many people in need because it is tied to the narrow parameters of the Consolidated Omnibus Budget Reconciliation Act of 1985, the Wall Street Journal reports.
Pharmacies, supermarkets, and other retailers are jockeying to become the go-to provider for swine-flu vaccinations, in a bid to attract more customers and, in many cases, promote their in-store health clinics, the Wall Street Journal reports. With the vaccine becoming more widely available, Rite Aid Corp. is placing signs that read, "Protect Yourself: H1N1 Vaccinations Are Available," on the front doors of its drugstores and hanging similar banners inside, for example.
Taking certain preventive measures can go a long way toward preparing your facility for RAC audits. One of the first steps is for you to make sure your staff understands the issues. Educating staff members builds the foundation for a successful system to deal with RAC audits.
According to Marion Watson, PT, MBA, administrative director of rehabilitative medicine services at Glendale (CA) Adventists Medical Center, some other steps that providers can take to prepare are:
Create a RAC team and identify a "lead person." The team could include HIM, coding, patient financial services, and utilization review or management staff members, as well as medical directors, nursing staff members, nurse auditors, administrative representation, finance, IT, and compliance staff members.
Review your medical records for accuracy and completeness.
Get receipts for everything sent.
Log and track everything from initial requests.
Preparing a team to deal with RACs will better equip your organization to manage the audits. "It has to be a team effort," says Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital of Southern California in Arcadia. "You've got to find a way to get your physicians involved and educate them upfront on what RACs are, what their role is in [the RAC process], and work together as a team to really survive this."
What else can be done to mitigate the effects of RAC audits? Twist suggests the following:
Identify a physician to assist when appeals reach the administrative law judge level. "It really did make a big difference in our case [during the demonstration project]," Twist says. "We also had legal representation there as well."
Create a separate P.O. Box for RAC correspondence. "We're hopeful that this is going to be very fruitful for us," she says, alluding to the permanent program.
Decide on insourcing vs. out-sourcing your RAC appeals. "It's something you're really going to have to take a look at," Twist says. "And based on the volume, can you or should you do it?"
Identify risk areas. Steps in this process should include doing some validation audits and concurrent chart review, as well as figuring out where you can make the complex simple and practical to make improvements. Also, look at your billing edits. "What are your billers fixing? It's time to go back and fix it on a department-charging level."
Implement a physician document improvement program. This process will help in the long run, she says.
Educate the entire hospital. In particular, staff members need to know what various forms of RAC correspondence looks like so they can get it into the right person's hands quickly because items are so time sensitive.
Run some tests. "Set up a fake internal processes check," suggests Twist. "Have [a sample RAC request] go through your system." If it ends up in some strange department like the housing department, conduct the appropriate education to make sure everyone knows where RAC correspondence needs to go.
While the sheer size of this list may appear daunting at first, preparing for RAC audits is critical. "Make sure that you are prepared for this now while you still have time," says Twist. "Check the RAC Web sites regularly, and communicate and educate."
The Joint Commission recently asked hospitals to weigh in on the long disputed standard MS.01.01.01 (formerly MS.1.20). Hospitals only have until January 28, 2010 to read the revised standard and relay their responses to The Joint Commission.
Carol S. Cairns, CPMSM, CPCS, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, suggests that hospital and medical staff leaders who disagree with the latest draft standard of MS.01.01.01 communicate not only with The Joint Commission, but also with their associated professional organizations, such as the American Medical Association or the National Association Medical Staff Services. She also suggests that hospitals respond as an organized group, rather than as a handful of individuals.
For those who are unfamiliar with the standard, found in the Joint Commission's Comprehensive Accreditation Manual for Hospitals, and its resulting debate, here's a rundown: In 2007, The Joint Commission sent proposed revisions of the standard out for field review and met with heavy resistance. The Joint Commission felt the revised standard would improve the relationships between the hospital governing board, the medical staff, and the medical executive committee.
However, critics questioned the appropriateness of allowing the medical staff to circumvent the medical executive committee and bring matters straight to the governing board. Opponents also claimed that the requirement to incorporate the details usually found in rules, regulations, policies, and procedures into the bylaws were too costly and time consuming. The standard has gone through several revisions since then.
The latest draft was developed by a task force charged with finding a reasonable solution to this years-long debate. It has the backing of the American Hospital Association, American Medical Association, American College of Surgeons, American College of Physicians, American Dental Association, Federation of American Hospitals, and National Association Medical Staff Services.
The highlights of the latest version of the standard are:
Certain processes and procedures need to be mentioned in the bylaws, but their associated details, which are often lengthy, can be incorporated into rules, regulations, policies, and procedures. The previous draft of MS.01.01.01 would have required the associated details to be included in the bylaws. "The adoption of the associated details that reside outside of the bylaws has a process of approval that doesn't take the whole medical staff. In previous versions, that was not always clear or allowable," says Cairns.
The medical staff and the medical executive committee must design a process for resolving disputes. According to Michael Callahan, Esq., partner at Katten Muchin Rosenman in Chicago, leadership standard LD.02.04.01 requires the medical executive committee and the hospital governing board to develop a conflict resolution process. However, the requirement to develop a conflict-resolution process between the medical staff and the medical executive committee is new. "Everyone is going to have to change their bylaws to accommodate this change."
The medical staff can go directly to the governing board to amend or adopt a rule, regulation, or policy, but it needs to communicate its intention with the medical executive committee first. On the same note, if the medical executive committee wishes to adopt or amend a rule, regulation, or policy, it must also communicate that to the medical staff. "My guess is that this is going to be an infrequently used element of performance because most of the time, most medical staffs aren't that far of track with their medical executive committees," says Cairns. "However, there are medical staffs out there that have serious conflicts internally, and this allows the medical staff a route to make a bylaws change and send it to the board."
In its "Frequently Asked Questions Regarding Standard MS.01.01.01 (formerly MS.1.20)," The Joint Commission states that many medical staffs will only need to revise small portions of their bylaws, if they need to make any revisions at all, but it might not be that easy, says Cairns. "They say it isn't going to be a big deal for most organizations. I'm not sure it will be as simple as a little tweak here and a little tweak there, and that is why the field needs to speak up." To send your comments to The Joint Commission, visit www.jointcommission.org/Standards/FieldReviews.
Callahan expects that The Joint Commission will fast track the adoption of this standard and that the current working draft will be passed as is. "It is not a perfect document, but people are tired of dealing with it and want to move on," he says. "If they don't like it, they can vote with their feet and go to a different accrediting body, such as DNV or HFAP, but they need to carefully evaluate those options before they jump."
Visiting Physicians Association, a home health services group, will pay the federal government and the state of Michigan $9.5 million to settle whistleblower allegations that it reportedly submitted false claims to three government-sponsored healthcare programs, the U.S. Justice Department announced.
The government had alleged that VPA, based in Farmington Hills, MI, submitted claims to Medicare, TRICARE, and Michigan Medicaid for unnecessary home visits and care plan oversight services, for unnecessary tests and procedures, and for more complex evaluation and management services than the services that VPA provided.
The settlement involves four lawsuits filed by private plaintiffs under the whistleblower provisions of the False Claims Act, which permit private parties to file an action on the government's behalf and share in any recovery. The four whistleblowers named in the settlement will split $1.7 million.
"This settlement illustrates the government's commitment to pursuing those who defraud Medicare and other important programs and drive up the costs of healthcare," said Tony West, assistant attorney general for DOJ's Civil Division. "The Justice Department will continue to work with our federal and state partners to ensure that taxpayer dollars are spent on healthcare services for patients, not wasted on fraud and abuse."
VPA provides home health services in Michigan, Ohio, Georgia, and Wisconsin.
I am a person who makes resolutions each year, and actually sticks to (most of) them. To be fair, I don't make "resolutions," I set goals each January. I write down about five to 10 items and jot a few notes about how I intend to attain my objective and then twice a year I look at my goal list and I try to keep myself on track.
In the 10 years since I started doing this, I've accomplished a lot of what I set out to do. Sure, the 10 pounds have come off and come back, but the long awaited trip to Italy was realized this summer and my personal finances are in order.
Whether you want to call it a "resolution" or a "goal" doesn't really matter, the point is to give yourself a compass to achieve new heights. So here are my reflections on the past year and some suggestions for resolutions CFOs may want to consider as we bid adieu to 2009 and welcome 2010.
Resolution #1: Find Non-labor Cost Reductions. 2009 gave CFOs a valuable reminder of what their greatest asset really is: their employees. While many facilities struggled to keep their operating margins in check, to your credit, most financial leaders looked to their employees for suggestions, and cut supplies and capital spending budgets before personnel.
That's not to say some facilities didn't cut labor, but it wasn't the first line item to take a hit. In fact, as we exit 2009, healthcare is one of only a few economic areas showing employment growth. The healthcare sector reported 21,000 payroll additions in November, creating 249,700 new jobs in the first 11 months of 2009, according to U.S. Bureau of Labor statistics. Moreover, 613,000 payroll additions have been made since the start of the recession in December 2007.
New equipment and buildings are certainly important, and market share and growth are vital to every facility, but the recession is a reminder to look at your mission statement and take stock in it (it's safer than taking stock in Wall Street anyway these days). Hospitals are there to help people get well, and you simply can't do that without skilled medical teams. Not only should you look to other areas for cost reductions, you must dig in and find the money to keep hiring more physicians—your docs are your ticket to growth.
In 2010, make it your goal to continue to care about the employees that work at your hospital. Without a doubt, more cost reductions lay ahead, so look for creative solutions. If it comes down to labor, seek input from the very employees whose jobs are on the line. You'd be surprised how willing people are to make other sacrifices so that they, and their coworkers, can continue to work (perhaps less paid vacation time or flex hours). So, when looking at your bottom line, vow to consider creative solutions—you may find you come out ahead in the long run.
Resolution #2: Out with the Old Forecast; In with the Rolling One. Here's what the economy looked like in 2009: it was up, then down, then down, then up, then down, and so on—you know the picture all to well. The last two years have been a rollercoaster and that's the only trend you can predict will continue in 2010. What does that tell CFOs? Well, you can grab onto a tree when the wind blows and hope the storm ends quickly, or you can send up a kite and see where the wind blows you.
It's time to get your kites ready. If you haven't done so already, throw out your old notions about when and how you should do financial forecasting for your hospital's business plan. The national economy and even your local market aren't stable enough to have a business plan that's set in stone—even reviewing your plan every six months isn't good enough—it's time to start a rolling, monthly forecast. You'll be amazed at the insights you gather.
Resolution #3: Keep Communication Open. You hear a lot about healthcare transparency in terms of consumer information, but very little about it in terms of employee communication. You're a CFO, but you don't have all the answers and the sooner you admit that the recession is mind-boggling to even to the most seasoned financial pros, the sooner you'll be ready to communicate with employees.
Paul Levy, president and CEO of Beth Israel Deaconess Medical Center in Boston, who writes a blog called Running the Hospital, has embraced open, transparent, communication. He recently wrote a blog entry called "Listening to Staff," but it could just as easily have been dubbed, "Solving Problems Together." Here's an excerpt:
"Many people around the country followed the dramatic story last March when our employees generously gave up salary increases and benefits to help save hundreds of jobs of their fellow workers. A key part of that process was that staff members had multiple paths to contact me with suggestions and reactions to various proposals. Thousands of people did that, and it was very helpful as I made decisions on these matters.
"Several months have passed, and our financial situation has improved. We hope to be close to the time when we might restore salary increases and/or benefits. I needed to know which of those items would be most important to our workers, to help set the priorities for restoring them. It was time to check in again.
"Two emails follow. I sent out the first just before Thanksgiving and the second one yesterday.
"As I have talked about all this with people around the country, many have expressed surprise that, as CEO, I would 'take the risk' of consulting our staff on these matters. For some, this is considered an odd ceding of executive authority. My view is just the contrary. If a CEO cannot rely on the judgment and opinions of those doing the work in an organization to help him/her make the final decisions on matters affecting those very people, what does it say about the level of mutual respect in that institution?"
What a refreshing approach to communication and a great goal for every hospital financial leader.
Resolution #4: Failing to Plan; Means Planning to Fail. There is this omnipresent negativity about healthcare reform, but you literally cannot afford to wait and see what the fall out is from the latest initiative. Years of government legislation should have taught every CFO that you must expect government intervention to cause a hiccup with your financials.
The smartest resolution a CFO can make is to learn to always create a Plan A and a Plan B. Assume that reform will go forward and figure how you intend to deal with it. In some ways, your job has morphed—you are now CFO and strategic economist for your facility. That means your role is to make educated "guesses" as to what may happen and how to mitigate it.
I have spoken to numerous CFOs and one of the first statements they often make regarding anything from capital improvements to cost cutting is, "We'll have to wait and see what reform will do." Actually, you don't have to "wait and see"—in fact, it's bad business to do so. You need to anticipate all the likely financial ramifications that may take place from this legislation passing and then you need to keep your business moving in a steady course with an eye on the quick corrections you can make if and when legislation is enacted; that is when those monthly financial forecasts will come in handy.
So, while you may have breathed a sigh of relief when the Medicare reimbursement cuts were given a reprieve through March, you must have a plan in place for when the reimbursement cuts do take place—be it in March 2010 or March 2011—because they will happen eventually. This year resolve to move your organization in a direction that plans for the worst and you will likely end up with the best financial year yet.
When it comes to resolutions, remember they are only as good as the person who puts them into action. If you find that your goals lack teeth and conviction, you won't go far with them. So use these resolutions as your guides or create new ones. At the very least, every CFO should resolve to keep the bottom line black, the margin and operating costs reined in, and look for unique ways to grow. Happy 2010!
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One of the biggest selling points in both the House and Senate versions of the presumed-to-be enacted Patient Protection and Affordable Care Act is the expansion of health insurance to approximately 30 million people who now, for whatever reason, don't have coverage.
Most people agree that expanding health insurance coverage is a good idea. The fight is usually over how to do it. Providing care could prove problematic for these newly insured Americans, however. It's already hard enough to find a primary care physician in many parts of this country without putting another 30 million seats in the waiting room.
Lori Heim, MD, president of the American Academy of Family Physicians, says she is encouraged by several provisions in both the House and Senate reform bills that begin to address the nation's dire shortage of primary care physicians.
"It's a good bill. It shows the commitment to primary care that we have heard from the president and from both sides of the aisle," Heim says. "What I hope Congress also understands is that, like many other components of this bill, it is a good start but there is much more that needs to be done."
Heim, who is a hospitalist at Scotland Memorial Hospital in Laurinburg, NC, says the reform bill begins to address several of financial obstacles that have kept medical students and residents out of primary care.
"One of the reasons why students don't tend to go into primary care as much is because of their student loans, and the big salary discrepancy between primary care and other subspecialties," Heim says. As a result, the Senate bill attempts to decrease the impact of student loans, by increasing funding for the National Health Service Corps scholarship and loan repayments. It also reauthorizes Title 7 training money for family medicine programs. There is also a health professional state loan repayment tax relief program that will incentivize primary care physicians to locate in underserved areas.
"And, at least as of now, there is still in there the redistribution of unused residency slots to primary care. That has been a bit contentious but as of now it is surviving," Heim says. "Obviously, if you try to increase interest in primary care from the medical school students, you have to make sure you have the training slots available to train them."
Heim says the issue of bonus payments for primary care physicians in Medicare is still a work in progress. There is a bonus provision of 10% in both the House and Senate reform bills that Heim calls "a good start."
"We really want to have—and hopefully this will survive—Medicaid rates being the same as Medicare. That is very important for primary care," Heim says. "That 10% bonus needs to be at least 25%. We understand that may come about sequentially but a continued positive update for family and primary care is going to be important if we really are in fear about having students take an interest in primary care."
There are some other wrinkles that must be ironed out. Heim says the Senate version extends the bonuses for five years. "We think that needs to be permanent," she says. "They also have a limit for physicians who their primary care is 60% or more of their practice. We think 50% would be more realistic."
This is not a complicated issue. For healthcare reform to succeed there has to be a very strong base of primary care physicians serving as medical traffic cops, directing and coordinating care. It's not for lack of interest that this country has a shortage of primary care physicians. The money isn't there. That has to change, and that change has to be initiated by the federal government. It's that simple. Getting there is the problem.
"Medical students, when I talk with them, they want to go into primary care. That is what most of them thought about when they thought about being a doctor," Heim says. "Now as we are rolling out the patient-centered medical home and it's getting more accepted, students are excited about that way of providing care and getting off the treadmill and providing high quality personal care. But, they keep looking at their debt and the difference in salary, so going back to look at that is important."
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South Nassau Communities Hospital President/CEO Joseph A. Quagliata has been named chairman of the Healthcare Association of New York State Board of Trustees for a one-year term that begins Jan. 1. HANYS is the only statewide advocate for more than 550 non-profit and public hospitals, nursing homes, homecare agencies, and other healthcare organizations throughout New York State. HANYS' volunteer Board of Trustees is responsible for managing the Association's activities.
