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Top 4 Dos and Don’ts For Audits and Investigations

Top 4 Dos and Don’ts For Audits and Investigations

In the spirit of college football season and the inevitable argument about which four college football teams are in the college football playoffs, this article addresses the undisputed top 4 dos and don’ts that physicians should follow during an audit or investigation.  I have represented countless medical practices and individual physicians with a variety of federal payor audits, false claims investigations and DEA investigations.  The following top 4 dos and don’ts are the top issues I see frequently repeated, oftentimes to the detriment of the provider under investigation.

# 4 – Keep an Exact Copy of Everything Produced or Viewed Most of the time I am not retained until after the practice has turned over the requested documents and, in some cases, has also turned over non-requested documents. The usual response by the practice, when asked why it did not keep a copy of what was released, is something along the lines of “we did nothing wrong” or “we know what we turned over and can make a copy if needed.”  However, when I ask for the documents produced, the practice oftentimes cannot replicate what was produced. This puts the practice at a competitive disadvantage from the start. It also makes citing to a particular document extremely difficult when legal counsel does not know (1) if a particular document was actually produced, or (2) if it was produced, where in the mountain of records the document is located. Defending the practice’s conduct or fighting a recoupment becomes challenging without a copy of the documents. Thus, the practice should go ahead and make an exact copy of what is produced and maintain the copy until the practice is reasonably sure nothing will come from the audit or investigation. It is also recommended that the practice hire legal counsel before producing records, so as to ensure that only responsive documents are produced.

# 3 – Review All of the Medical Records Before Producing.  While this seems like a no brainer, I cannot state the number of times a medical practice has printed what it believes to be the entire medical record only to learn when receiving a recoupment demand or allegation of false claims that the entire medical record was not produced.  Another common issue in this age of electronic medical records (“EMR”) is that the printed record looks substantially different than the electronic record.  Some EMR systems will print a paper copy differently if the “print” function is used versus the “print screen” function.  I have experienced numerous occasions when the paper copy looks suspicious or incomplete, particularly the patient’s history or prescription records, because of the way the EMR prints the record.  On a related note, if the practice wishes to use a consultant to conduct a simulated audit, it is important to make sure that the consultant either has access to the EMR or that the printed paper records are complete and identical to the electronic records.

# 2 – Maintain Signature Logs of Alabama Medicaid Patients.  The Alabama Medicaid Agency requires that providers maintain evidence that the patient actually attended the appointment.  It does this by requiring providers to keep a signature on file to prove the patient’s attendance at each appointment. I have represented quite a few physicians and practices in Medicaid audits, and I do not recall an audit that did not request copies of the patients’ signatures.  However, the signature requirement is not well known by Alabama providers, as many of my clients are unaware of the requirement and fail to keep a copy of the signatures. While there are other ways to prove that a patient attended the visit, it is very simple to satisfy the signature requirement and avoid having to gather other forms of proof–simply use the removable signature logs and paste the patient’s signature into the record for that particular visit.

#1 Never, Ever, Ever Voluntarily Surrender A License/Permit/Participation Without First Obtaining Advice of Counsel.  Without question, the undisputed defending champion and current #1 is never ever voluntarily surrender a license, permit or participation in a payor’s program without first obtaining advice of counsel. I have heard on multiple occasions that a particular investigator says something along the lines of the following to a licensee “Things will go much easier if you voluntarily surrender your license.”  I have never in my experience seen where things have gone easier for the physician when he/she has voluntarily surrendered his/her license. However, it does is make things easier for the licensing body, so the statement above is true as phrased. The voluntary surrender substantially compromises the physician’s ability to defend his/her case, as the physician has lost any leverage he/she may have had – the agency already has what it wants – the physician’s license.  Most licensing agencies have due process requirements that must be followed before it can revoke, suspend, or take any adverse action on a license.  One of the most important due process requirements is giving the physician the right to a hearing where the physician can be represented by counsel and present evidence. The hearing process affords the physician the ability to test the agency’s evidence and interpretation of its regulations, which are oftentimes flawed.  The hearing process also gives the physician the ability to reach a compromised resolution of the matter, oftentimes allowing the physician to keep his/her license.  By voluntarily surrendering a license, the physician loses such rights and ability.


Jim Hoover practices with Burr & Forman LLP and works exclusively within the firm’s Health Care Industry Group. Jim primarily handles healthcare litigation and compliance matters.

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Staff Retention Leads to a Successful Practice

Staff Retention Leads to a Successful Practice

I visit many practices throughout the year performing medical practice assessments.  One of the first items to review is staffing levels, length of service and each staff member’s role.  The administrator is a key component to engaging the staff.  Increasing the level of staff engagement can raise productivity 20% and reduce the probability of a staff member leaving by 87%.

Administrators who hire an employee for a specific position which is detailed in a job description makes the first step to communicating effectively.  Proper preparation for onboarding is essential to adding value to the employee/employer relationship.  The first day should begin with orientation, discussion of the handbook, employment paperwork and the introduction of the training plan.  More than 5% of employees leave a new job due to a disastrous first day.  It is important to equip a new employee with the tools to learn the job, such as a mentor and a checklist of key tasks they should be able to perform within a 90-day probationary period.

Once an employee is past the probationary period, goals should be set for development.  Ongoing communication and training are essential to engaging the employee and creating buy-in within the organization.

Annual evaluations are useful in rewarding good performance, and also setting goals for development.  An evaluation should not be the first time an employee learns of a performance problem.  Problems should be addressed at regular intervals with specific directions for improvement.  The evaluation should only report the need for continued improvement or acknowledgment of success.

During an office review, I sometimes find the administrator has simply turned new staff members over to the most knowledgeable employee. If the seasoned employee was not trained effectively, how successful could he or she be at preparing the new employee? The better performing practices have an effective training program, regular staff meetings and incentive programs to engage the staff.  I recently assisted a practice that had lost several key employees; they were paralyzed.  They could not even generate financial reports to realize the extent of their problems.  Your staff is your most valuable asset and losing them can be costly. It can cost 150% to replace a valuable employee considering loss of production and training time.

Cross-training staff to perform multiple task is a good way to assure you can get through a short-term absence or the timeline to replace an employee. Documented best practice workflows should be obtained from your practice management vendor and EHR vendor to ensure you can train appropriately. We are assisting practices in changing their employee bonus structure to reward performance and buy-in. Take care of your best asset, the staff you have trained and who know your practice. Warren Averett can assist you with all your recruiting and staff management projects.

MBI Transition Ends This Month: WILL YOU BE PAID ON JANUARY 1?

The 21 month transition period will end on December 31; use Medicare Beneficiary identifiers (MBIs) now.

  • You are currently submitting 86% of claims with MBIs.
  • Get MBIs from your patients and through the MAC portals (sign up) now and after the transition period. You can also find the MBI on the remittance advice.
  • Protect your patients from identity theft – use MBIs.

Starting January 1, if you do not use the MBI (regardless of the date of service) for Medicare transactions:

  • We will reject your claims with a few exceptions
  • We will reject all eligibility transactions

See the MLN Matters Article for more information on getting and using MBIs.


Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

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Better Together: Physician-Lead, Team-Based Care

Better Together: Physician-Lead, Team-Based Care

Working as a team is unquestionably the best and most efficient way to maximize the skill sets of a specific group of people. In medicine and depending on the particular needs of the practice, a team-based approach can include various combinations of physicians, nurses, physician assistants, pharmacists, social workers, case managers and other health care professionals. The unique strengths and perspectives of each team member are an asset when providing the safest, best possible care to patients. The best place for physicians to learn how to work as a team is while they are still in training.

“So in a residency world, the team in a hospital setting is going to be the attending physician, usually one or two upper-level residents, and then usually two first-year residents. And in this setting, we have a couple of medical students. That’s our team,” explained Tom Kincer, M.D., Director for the Montgomery Family Medicine Residency Program. “The way that team works in the hospital setting is built on varying levels of responsibility so that as students and residents gain more knowledge and more skills, they’re given more independence yet have oversight of upper levels. So the first-year residents have oversight by the upper-level residents, and the upper-level residents have oversight by the faculty physicians.”

According to Dr. Kincer, the Montgomery Family Medicine Residency Program’s success has been built on this hierarchy of educational independence that has worked for many years and allows for a “symbiotic relationship” between a  mix of disciplines in health care that is patient-centric but always led by a physician. For Dr. Kincer, the ultimate goal of a physician-led team-based model of care will always be to affect change in the health of the population. To do this, there are numerous hurdles to overcome.

“So the team-based model for population health is the best model for patient care,” Dr. Kincer said. “When it comes to providing that one individual patient the best care possible because they can have a physician, right? They could have the physician, lead nurse practitioner, or the pharmacist, or the social worker, or the occupational therapist. All of that is part of the bigger team, but the problem comes in a fee-for-service model with MACRA. How do we pay for all that? Physicians can’t afford to pay for everything out of their pockets, because there’s no direct reimbursement. Once we tackle that, I don’t think we can move forward with a true team-lead model. But it doesn’t exist unless you’re in a health care facility that’s willing to sponsor this team-based model. There are too many competing forces against it.”

While it may appear that the deck is stacked against the physician-led team-based model, as Dr. Kincer noted, if there is a health care facility willing to sponsor it, the advantages to the community are overwhelming.

Perhaps the most frustrating stumbling block in modern medicine today is access to care. For patients who do not have a physician of their own, these patients will use a hospital’s emergency department for all the wrong reasons. Not only does this cause lengthy wait time for patients who need emergency services, but it creates billions in health care treatment costs over time for the hospital. Dr. Kincer’s solution? Spend some money to save not only money but also lives in the long run.

“It’s very difficult for a private practice, primary care physician to have a team-based approach in their office. Other than maybe the physician, a nurse practitioner and their staff. In that model, people need to work to their highest level. So the physician needs to be taking care of patients that require that expert level from the physician, and the nurse practitioner needs to be working at their level and so on to allow the physician to work at their highest level. All this allows the staff to do some of the things the staff needs to do, whether that’s teaching the staff how to apply for drug assistance programs, or to have patients come in and monitor without them actually having to see the nurse practitioner or their physician. If the physician or the nurse practitioner is not seeing the patient, they’re not generating income. There’s got to be enough volume going through the physician and the nurse practitioner over the PA to be able to generate an income to run the office,” Dr. Kincer said.

In an employed physician model, it begins by playing to the institution’s strengths and weaknesses. If the revenue in one department is higher than another, there needs to be a fundamental understanding that the institution can’t work without all departments at the top of their game, so it comes down to budgeting.

“After you find out what the goal of the organization is, you can utilize your resources better for a stronger team-based care model. Certain parts of that model are profit-creating and other parts are patient-oriented that don’t really make the profit, but you can still support the whole team. That’s how most residency programs function as part of the bigger system,” Dr. Kincer said.

The model he created for Baptist Health to use for the Family Medicine Residency Program in Montgomery is called the Care Advisor Program. By identifying a specific group of 250 patients from the tri-county area with chronic illnesses and no insurance who tend to use the emergency department instead of a regular physician to monitor their health issues, the program instituted a team-based model and brought them into their office. Here, patients have access to physicians, nurses, social workers, pharmacy, labs, x-rays, etc., at no cost.

“What we’ve been able to do in our Care Advisor Program in the past 10 years is to save our hospital system about $6 million a year by providing these patients with free medical care. However, it cost us about $4 million a year to take care of this population, but in return, it saves us $6 million a year because prior to the program, it cost the hospital $10 in ER visits to take care of this population that was uninsured. Now with our team-based approach out of the residency program, which is run very efficiently, we’ve taken the average number of ER visits and hospitalizations combined for each patient from 10 to 12 visits a year to less than one per year. The patients get their care in the office, their medications, and follow-up care. We’ve cut expenditures and improved the health of all these patients. The average patients stay in the program for about two years, and their health is improved. Now THAT is population health,” Dr. Kincer said.

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Physician Burnout

Physician Burnout

BACKGROUND                                   

While employees in many professions report burnout, physicians appear uniquely susceptible and the consequences can be detrimental. Physicians are fifteen times more likely to suffer burnout than other professions and statistics indicate that at a given time nearly a third of physicians are experiencing symptoms of burnout.[1] Throughout the course of a career nearly one in two physicians are likely to suffer from burnout, and depending on specialty, it can range from 30 to 65% of physicians. Physicians in the mid-point of their career are the most likely sufferers, but the rates and trends across age groups continue to worsen.[2]  Indicated in a Mayo Clinic study, about 50% of physicians will experience symptoms of burnout at some point in his or her career.[3]

CAUSES & IMPACT

Various theories are offered as to why the problem is reaching epidemic proportions for physicians. One commonly identified contributing factor is that physicians feel increasingly overworked. One study identified the lack of control over a physician’s daily schedule as a primary driver for experiencing burnout.[4] Technology is also recognized as a culprit and studies show doctors are increasingly spending time on the computer instead of interacting with patients.[5] Yet another modern contributor to physician stress can be negative online reviews.[6] Physicians may be feeling increasingly judged and scrutinized by the patients they are dedicated to helping. Outside technology, a decrease in healthy eating habits or exercise is also shown to lead to or exacerbate the problem.[7] This decrease in quality of life is likely driving physicians from the practice of medicine, which further increases stress on the health care system already facing a looming physician shortage as baby boomers retire.[8]

The impact of physician burnout can be enormous. On an individual level, it is destroying quality of life for physicians to the point that many leave the practice of medicine or even turn to suicide. Rates for physician suicide are double that of other professions, with female physicians three times as likely.[9] Increased suicide rates are not only high throughout a physician’s career, but are also evident in medical students with 9.4% of students reporting suicidal thoughts.[10] Physician burnout has also been associated with significant decreases in patient care and safety.[11]

SOLUTIONS

While there are no simple or obvious solutions to physician burnout, there are multiple approaches to consider. For starters, physicians and the greater medical community cannot afford to ignore the impact burnout is having on both individual physicians and the practice of medicine.  The impact of burnout continues to worsen and may be approaching epidemic proportions. One component physicians should recognize is that shouldering the burden themselves is not enough; to paraphrase a classic literary character, you can’t just work harder.[12]  Physicians may need to change the way they practice medicine; by recognizing limitations and learning to say “no.”

Other studies point to promoting lifestyle decisions as a way to combat burnout. Specifically, physicians should find ways to maintain a healthy lifestyle. This can involve eating a healthy diet, sleeping 7-9 hours regularly, and exercising appropriate amounts.[13] Besides physical health, physicians should be encouraged to have creative outlets such as hobbies, sports, leisure activities, and vacations.

PROASSURANCE’S EFFORTS

ProAssurance is also seeking ways to support physicians and the medical community regarding burnout and the implications it may have on patient care.  In September 2017, ProAssurance established a $1.5 million gift to the University of Alabama at Birmingham (UAB) School of Medicine to endow a chair to support physician wellness.  This endowment was to support research and efforts addressing the issues and challenges related to physician burnout. UAB combined the endowed chair with the existing Chief Wellness Officer position, which was filled by David Rogers, MD, MHPE in January 2018.

In a recent interview with Dr. Rogers, he stated, “Many people talk about burnout as though you’re burned out or you’re not.  But it isn’t that simple. There are degrees of burnout or being engaged. Month by month tracking lets you see a pattern and reevaluate before things spiral in a negative way.”

The use of month to month well-being assessments such as the Mayo Clinic Well-Being Index[14] may help identify and track individual physicians’ well-being.   Hospitals may utilize this assessment to identify certain departments where stress and/or engagement are particularly high. These results could customize resilience training for these groups.

Accomplishing goals to reduce burnout in the medical community means that there must be a systemic and cultural shift. Physicians need to be free from judgment in seeking solutions to this crisis. From his experience, Dr. Rogers would also like to focus on training for frontline leaders in the medical industry. Leaders often set the tone for their employees, so teaching them to identify and mitigate stress is essential. Dr. Rogers believes the medical community is at a crucial point and must start having conversations about physician burnout. “There has to be a change in culture,” he concludes. “It’s hard, but critical to think about what happened to the industry, what we can do to correct it, and what lessons we can learn for the future.”

As professional liability insurers, ProAssurance recognizes the increasing danger of physician burnout and the potential harm to our insured physicians and organizations. Although we have identified the increasing seriousness of this problem, but still struggle with how to identify or prevent it.  We are committed to finding ways to discover the problem before it manifests in professional liability claims, and we encourage our physicians to reach out for solutions if they are feeling overwhelmed or at risk for burnout.

Physicians insured by ProAssurance may contact our Risk Resource department for prompt answers to liability questions by calling 844.223.9648 or via e-mail at RiskAdvisor@ProAssurance.com.


[1] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, https://health.usnews.com/health-news/patient-advice/articles/2016-04-12/doctor-burnout-stress-and-depression-not-an-easy-fix accessed September 29, 2017.

[2] Staff, “Medical specialties with the highest burnout rates,” AMA Wire, Jan 15, 2016. https://wire.ama-assn.org/life-career/medical-specialties-highest-burnout-rates accessed September 29, 2017.

[3] Tait D. Shanafelt, M.D. et al,  “Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014,” Mayo Clinic Proceedings , Volume 90 , Issue 12 , 1600 – 1613 http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract  accessed September 29, 2017.

[4] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, https://health.usnews.com/health-news/patient-advice/articles/2016-04-12/doctor-burnout-stress-and-depression-not-an-easy-fix accessed September 29, 2017.

[5] Paige Minemyer, “Study: Docs spend more time with computers than patients,” Jan 31, 2017, http://www.fiercehealthcare.com/it/study-docs-spend-more-time-computers-than-patients accessed September 29, 2017.

[6] http://www.upi.com/Health_News/2017/02/02/New-study-shows-online-reviews-stressful-for-doctors/9561486052157/

[7] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, https://health.usnews.com/health-news/patient-advice/articles/2016-04-12/doctor-burnout-stress-and-depression-not-an-easy-fix accessed September 29, 2017.

[8] “Physician Supply and Demand Through 2025: Key Findings,” AAMC https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf

Accessed September 29, 2017.

[9] Pranay Sinha, “Why Do Doctors Commit Suicide?,” New York Times, Sept 4, 2014, https://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html  Accessed September 29, 2017.

[10] Louise B Andrew, MD, JD, “Physician Suicide,” Medscape, June 12, 2017. https://emedicine.medscape.com/article/806779-overview accessed September 29, 2017.

[11] Megan Brooks, “Provider Burnout Tied to Lower Levels of Patient Safety, Care,” MedScape,  http://www.medscape.com/viewarticle/873434 accessed September 29, 2017.

[12] https://en.wikipedia.org/wiki/Boxer_(Animal_Farm)

[13] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, https://health.usnews.com/health-news/patient-advice/articles/2016-04-12/doctor-burnout-stress-and-depression-not-an-easy-fix accessed September 29, 2017.

[14] https://www.mayo.edu/research/centers-programs/program-physician-well-being/mayos-approach-physician-well-being/mayo-clinic-well-being-index  Accessed December 20, 2018.

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Outpatient Visit Evaluation & Management Changes for 2021

Outpatient Visit Evaluation & Management Changes for 2021

For more than 25 years, the American Medical Association has utilized the 1995 or 1997 guidelines for Evaluation and Management (E/M) services in the Current Procedural Terminology (CPT).  The E/M codes have expanded over the years but until now, there has been no update to the elements, in which, we choose a level of service. The Centers for Medicare and Medicaid Services in partnership with the American Medical Association (AMA) collaborated on changes to reduce the administrative burden in documenting outpatient visits for new and established patients.  

The revised guidelines pertain to the new patient codes 99201-99205 and established patient codes 99211-99215.  The revision was announced as part of the 2020 Physician Fee Schedule but does not occur until 2021 due to the many preparations to support this endeavor. The AMA is actually updating the code description for the specified codes, which affects all carriers, not just CMS.  The 99201 code is eliminated for 2021; the remaining codes will retain reimbursement for each code, which is a change from the proposal to condense some codes to a combined rate.  

The inclusion of time has been an explicit factor in the definitions of E/M services in the CPT codebook since 1992.  Beginning in 2021, with the exception of 99211, time alone may be used to select the appropriate level of service. For coding purposes, total time includes both face-to-face and non-face-to-face time spent by the physician or other billable healthcare professional the day of the encounter.  Total time does not include staff preparation time.  

Physician or other provider professional time includes the following:

  • Preparing to see the patient (review test, past visits)
  • Obtaining or reviewing separately obtained history
  • Performing a medically appropriate exam
  • Counseling and education for the patient/family
  • Ordering medication, tests or procedures
  • Referring and communicating with other providers
  • Documenting clinical information 
  • Independently interpreting results (not separately reported) and communicating results
  • Care coordination

Another option for choosing the level of the new or established E/M in 2021 is medical decision-making.  Medical decision-making has always been an element in the level of each new and established visit but never as a standalone element.  The concept of MDM does not apply to CPT 99211. When using MDM in selecting the level of the visit, the documentation should reflect the number and complexity of diagnosis addressed in the encounter.  The amount and complexity of data reviewed or analyzed is also required. The risk of morbidity should be documented to support the level of medical decision-making.  

These changes will most likely reduce the administrative burden for all specialties, but it is also disruptive.  The implementation of electronic medical records has had a huge impact on workflow at the physician/provider level as well as the staff.  Large and small practices have spent time developing comprehensive templates, triage teams, scribe teams, etc. to reduce the physician burden and feed quality data to the EMR.  Each practice will need to analyze the process in which they prepare a patient and how they decide medical necessity of history obtained. Each provider has a different patient schedule; in the past time spent with the patient was explicit.  In 2021, billing on total time spent could send a message of compliance. If a provider sees 25 patients a day coding a level 4 visit, they would be stating they spent 49-60 minutes per patient or 20 hours on that date of service inpatient care.  I do not anticipate providers seeing a higher volume of patients will bill on total time, it is not a common practice for providers to assess time spent with each patient.  

Most providers will probably code using the medical decision-making component. In the past, providers could reach a level 4 established visit based solely on the history and exam, which is not so in 2021! There will be prolonged service codes available to bill in addition to a new or established visit in cases when extended direct patient time is spent with clinical staff and supervised by the physician. 

Managers will spend 2020 assessing the many facets to consider the 2021 changes.  How will they maintain quality data entry in the EMR without the many clicks feeding the data?  Providers may use voice recognition to transcribe the medical decision-making as they did before the EMR.  In a potentially massive cost rebalance, CMS also finalized the relative value units (RVU) for the group of oft-used E/M services, which will determine 2021 pay rates. The RVU changes, for example, would boost payments for code 99214 – the most-reported E/M code – from $109 to $136 per claim, a 25 percent increase. Rates for 99213 would jump nearly 30 percent.  

Changes could occur before 2021, but it’s not likely we will move totally away from the decisions already made by CMS and the AMA.


Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

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Call for Elective Offices

Call for Elective Offices

The following are positions for offices in the Medical Association which will be elected at the 2020 Business Session. Nominations for statewide offices are presented through a Nominating Committee process. District offices (*) are nominated from district caucuses.  Qualified candidates shall have been regular, government or academic employee members of the association for at least three years after completion of their residency or fellowship.

 

Officers

President-Elect

Vice President

Board of Censors (3-year term)

District 1          Charles Max Rogers, MD*                    Eligible for re-election

District 2          Michael T. Flanagan, MD*                   Eligible for re-election

At-Large 1        Mark H. LeQuire, MD                          Eligible for re-election

At-Large 2        Beverly Jordan, MD                             Eligible for re-election

AMA Delegation (2-year term)

Delegate 2        Boyde J. “Jerry” Harrison, MD              Eligible for re-election

Delegate 4        George “Buddy” Smith, Jr., MD            Eligible for re-election

Alt. Delegate 1 John S. Meigs, M.D.                             Eligible for re-election

Alt. Delegate 2 William Schneider, M.D.                      Eligible for re-election

Alt. Delegate 3 Harry Kuberg, M.D.                             Eligible for re-election

Alt. Delegate 4 Raymond Broughton, M.D.                   Eligible for re-election

Council on Medical Education (3-year term)

District 1          Holly G. Pursley, MD*                         Not eligible for re-election

District 6          Tracy Jacobs, MD*                               Eligible for re-election

District 7          Catherine Skinner, MD*                       Eligible for re-election

At-Large 1        Russell Barr, MD                                  Not eligible for re-election

Council on Medical Service (3-year term)

District 3          Arden Aylor, MD*                               Eligible for re-election

District 7          Matthew R. Thom, MD*                       Not eligible for re-election

At-Large 3        Deborah Kolb, MD                               Eligible for re-election

 

The deadline for submitting nominations to the nominating committee is Thursday, January 9, 2020. Please submit nominations to abarentine@alamedical.org.

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PEEHIP Transitioning to Humana Effective January 1st

PEEHIP Transitioning to Humana Effective January 1st

Medicare-eligible retirees of the Public Education Employees’ Health Insurance Plan (PEEHIP) will be moving to the Humana Group Medicare Advantage Preferred Provider Organization (PPO) plan for their healthcare coverage, effective January 1, 2020.

Humana will be hosting a series of webinars as they lead up to the PEEHIP transition on January 1st.  These will be educational seminars on doing business with Humana.  Topics will include claims filing, claims disputes, overpayment processes and Availity functions.

HUMANA WEBINARS

Nov 11, 2019 12:00 PM EST

https://global.gotowebinar.com/pjoin/3417252854907848705/5753995439459405058
Webinar ID: 665-901-411

Dec 11, 2019 1:00 PM EST
https://global.gotowebinar.com/pjoin/8804459608777738241/5753995439459405058
Webinar ID: 722-111-459

Dec 16, 2019 1:00 PM EST
https://global.gotowebinar.com/pjoin/3634599915440097281/5753995439459405058
Webinar ID: 823-226-851

2. Choose one of the following audio options:

TO USE YOUR COMPUTER’S AUDIO:
When the Webinar begins, you will be connected to audio using your computer’s microphone and speakers (VoIP). A headset is recommended.

— OR —

TO USE YOUR TELEPHONE:
If you prefer to use your phone, you must select “Use Telephone” after joining the webinar and call in using the numbers below.

United States: +1 (914) 614-3221
Access Code: 825-036-259
Audio PIN: Shown after joining the webinar

Questions? Contact Shawn Kent.

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Closing Your Medical Practice – Calling it Quits!

Closing Your Medical Practice – Calling it Quits!

There is a lot of media attention to “Baby Boomers” retiring with more than 10,000 leaving the workplace every day.  Anyone closing a business has a list of items to address before selling the business or closing the doors, but there is a unique set of considerations when a physician practice owner elects to retire or stop providing service.  A medical practice provides a needed service to patients and a community unlike other businesses. The Board of Medical Examiners in each state has rules, in which the physicians should notify the patients and transfer care timely without restricting the medical records needed to continue care.

I recently worked with a practice that was receiving calls from patients who were trying to find a new physician.  A physician had left town and his patient records were in an electronic medical record, in which the patients had no access.  These patients were suffering from chronic disease and receiving biologic treatment; the new practice trying to assist these patients would need the patient record to care for them.

If a physician plans to retire, leave town or sell his practice, he should contact an accountant or legal representative to assist in a plan. It is important to notify your local medical society of your plan to sell or close so they can assist you. If there is value in the practice, a valuation may be performed to facilitate a sale to the hospital or another physician or group.  The value of a practice is determined by fair market value of accounts receivable, assets and other considerations. If a physician owner has fallen ill, the plan or timeline to work through a checklist could be limited.

Once a physician has chosen an advisor, a plan is prepared to sell or close the practice.  A timeline of no less than six months should be set to notify patients and staff, transfer records and value the building and assets for sale.  The practice should no longer accept new patients to the practice if it is closing. The patients must be notified in writing at least thirty days before closure and the practice must facilitate the transfer of medical records to a physician of the patient’s choosing.  If another physician will “take over” the practice, a custodianship of medical record arrangement can release the physician owner of the responsibility of maintaining the paper or electronic charts. The patient must be notified who is responsible for the medical record should the patient decide to change providers after the physician is retired.

A checklist will provide guidance regarding the many notifications that must take place after the last date of service to patients.  The accounts receivable are generally finalized in 60-90 days; insurance companies should be given a forwarding address for residual payments.  Vendor contracts should be reviewed for “out clauses.” Insurance agents who cover the business should be notified along with state agencies. Business records, such as payroll records, tax records, etc. have retention guidelines you should follow.

Calling it quits is easier in other industries than healthcare.  Physicians provide a service that includes a relationship and a valuable record to a patient; it is not to be taken lightly.  If you are planning a change in ownership or retirement, reach out to an advisor for assistance.

 

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

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Doctors Unite in Support of Physician Office Exemption

Doctors Unite in Support of Physician Office Exemption

We called and you answered!  Thank you to all the physicians who answered the urgent call-to-action and quickly signed on to the Medical Association letter (more than 600 doctors to date!) challenging the Alabama Hospital Association (ALAHA) and its member facilities’ contentions about the appropriateness of the physician office exemption (POE) from CON review.

As you know, ALAHA recently submitted a letter complaining of increasing instances of physicians performing interventional procedures in their offices instead of in acute care hospitals. ALAHA’s complaints are not in line with Alabama law and their letter was an attack on the practice of medicine and the services physicians safely provide patients in their offices.

Below is the letter the Medical Association sent in response to ALAHA’s assertions. We will continue to update you as things progress.

Thanks again!

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Fraud and Abuse Facelift: Proposed Changes to Stark, AKS, and Beneficiary Inducements CMP

Fraud and Abuse Facelift: Proposed Changes to Stark, AKS, and Beneficiary Inducements CMP

As part of its “Regulatory Sprint to Coordinated Care,” the Centers for Medicare and Medicaid Services (“CMS”) and the Health and Human Services Office of Inspector General (“OIG”) released proposals to modernize the Medicare Physician Self-Referral Law (“Stark Law”), Anti-Kickback Statute (“AKS”), and Beneficiary Inducements Civil Money Penalty (“CMP”) (collectively, the “Proposed Rules”). The Proposed Rules add five new Stark Law exceptions, seven new AKS safe harbors, and an additional exception to the definition of “remuneration” under the CMP. Several of the new Stark exceptions and AKS safe harbors relate to value-based arrangements and largely mirror each other. Other new exceptions and safe harbors relate to the donation or use of cybersecurity items and beneficiary incentives in the coordination of patient care. These proposals are by no means final (stakeholders have until December 31, 2019 to comment on them), but if finalized, they may provide more flexibility for physicians and other providers to pursue value-based arrangements, as well as greater clarity with respect to existing Stark Law requirements.

 

Value-Based Arrangements under Stark and AKS

Three new Stark exceptions and four new AKS safe harbors relate to value-based arrangements in which one or more participants in a value-based enterprise (“VBE”) pursue one or more value-based activities and purposes. Value-based purposes include coordinating and managing care, improving quality, reducing costs or growth of expenditures (without reducing quality), and transitioning from fee-for-service care to quality care for a target patient population. Value-based activities include providing items or services (not including a referral), taking an action, or refraining from taking an action, in furtherance of a value-based purpose.

There are separate exceptions and safe harbors for value-based arrangements involving: (i) full financial risk, (ii) meaningful/substantial downside financial risk, and (iii) remuneration for improving quality, health outcomes, and efficiency. Full financial risk means that the VBE is prospectively financially responsible for the cost of all patient care items and services covered by the applicable payor for each patient in a target patient population over a specified period of time. Meaningful/substantial financial downside risk means that a physician is responsible to the VBE for specified percentages of the value of the remuneration paid to the physician or is responsible on a prospective basis for the cost of all or a defined set of patient care items and services for each patient in the target patient population over a specified period of time. For value-based arrangements incentivizing improvements in quality, health outcomes, and efficiency, the proposed Stark exception would allow both financial and in-kind remuneration related to value-based activities and meeting objective and measurable quality and performance targets. By contrast, the similar proposed AKS safe harbors focus more on in-kind remuneration, including anything of value given either to VBE participants to help coordinate and manage patient care and patient engagement tools and supports given to patients to address social determinants of health and incentivize the patient’s participation in their health care. In addition to the mirror exceptions and safe harbors generally described above, the AKS Proposed Rule sets forth an additional safe harbor for remuneration exchanged between participants in a CMS-sponsored model, such as an ACO or bundled payment model.

There are common requirements for each of the exceptions and safe harbors listed above. For instance, the VBE must generally set forth in a signed writing the terms of the value-based arrangement, including a description of the nature and extent of the risk assumed under the arrangement, the value-based activities involved, the target patient population, and the type and cost of the remuneration involved. Additionally, the VBE or VBE participant offering remuneration under a value-based arrangement must not take into account the volume or value of referrals or otherwise condition the remuneration on referrals of patients who are not a part of the target patient population or business not covered by the value-based arrangement.

 

Other Stark Additions and Clarifications

The Stark Proposed Rule contains an additional exception for nominal payments to physicians ($3,500 annually, indexed for inflation) for the provision of items and services to an entity. The new exception applies even if there is no written agreement, provided the compensation does not relate to the volume or value of referrals or other business generated by the physician, does not exceed fair market value, and is commercially reasonable, among other requirements. The Stark Proposal also modifies certain existing Stark exceptions and clarifies a number of definitions. For instance, it adds flexibility to the “Electronic health records items and services” exception to include nonmonetary remuneration in the form of cybersecurity software and services. It also purports to clarify the meaning of “fair market value” and “commercially reasonable.” Although additional clarification of these terms would probably be useful, the Stark Proposed Rule at least clarifies that an arrangement does not have to result in a profit for one or more of the parties in order to be commercially reasonable.

 

Beneficiary Inducements

The Proposed Rules provide additional protection for remuneration to beneficiaries under AKS and the CMP. Under a new AKS safe harbor, beneficiary incentive payments to beneficiaries assigned to an Accountable Care Organization (“ACO”) under the Medicare Shared Savings Program (“MSSP”) would not constitute “remuneration” for purposes of AKS, if they meet the ACO beneficiary incentive requirements under MSSP. Somewhat similarly, the provision of telehealth technologies to patients with end-stage renal disease (“ESRD”) is not considered “remuneration” for purposes of the CMP if the technologies contribute to the provision of telehealth services related to the patient’s ESRD, is not of excessive value, and meets other requirements.

 

Conclusion

This article simply provides a high-level overview of the concepts addressed in the Proposed Rule. A more in-depth review of the Proposed Rules reveals additional requirements and subtle differences in the rules that will be material to parties trying to navigate them successfully.  Again, these rules are far from final. However, they indicate an intentional shift toward value-based care and relaxed regulatory requirements to help foster such care. Physicians and other providers have an opportunity to provide feedback on these proposals and hopefully refine them to workable exceptions that will enable the further adoption of value-based arrangements which are being promoted by current payment policy.

Article submitted by Christopher L. Richard, Esq. with Gilpin Givhan, PC in Montgomery, AL.

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