The Joint Commission has dictated that as of January 1 it will require all hospitals, home health agencies, nursing homes, ambulatory care facilities and labs that are accredited by the organization to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior. This comes from poor communication causing sentinel events. It allows each hospital to set its own standards and how it deals with the behavior. This could be very good for all so that if someone is doing unacceptable things there could be a step ladder and not an out of the blue peer review hearing. This would give the practitioner a chance to know what he/she is doing and change. This should also apply to all personnel and administration and not just physicians.
The new Medicare bill also takes away the Joint Commission's deeming authority and requires it to apply on a regular basis for the authority like all others need to do. Top
WellPoint states it will pay hospitals $11.8 million to settle its illegal patient rescissions. These are the cases where the hospitals gave care in good faith and then were told after the fact that WellPoint has decided unilaterally that the patient's insurance was rescinded. The hospitals have agreed to stop patient collection actions on these patients. This does not stop the multiple law suits against the insurer by the physicians for the illegal actions nor by the patients for their non payments and stress caused by same. California will also go after the insurer for their actions.
California did what they promised. The state has fined Anthem Blue Cross $10 million and offer new policies to 1760 patients they illegally rescinded. Blue Shield will pay $3 million and offer new policies to 450 patients that they illegally terminated. These patients will not have to pay any back premiums. Blue Shield will be fined an additional $2 million in 18 months if it does not finish offering the policies to the patients. Blue Cross has the same time line but the fine if they do not comply has not been determined. The insurers will also pay the insureds for all out of pocket medical costs since the rescission plus other damages such as loss of home resulting from bad credit due to unpaid medical debts. These settlements do not deal with the PPO problems and the suits by the patients or now by the LA City Attorney.
The California Governator has signed a bill banning health insurer companies from rewarding employees for canceling or limiting patient coverage.
There is also a problem with the California Department of Managed Care getting all this money from the insurers. The money reduces the money the insurers owe the Department for the next years assessments.
A bill forcing insurers to pay physicians reasonably and promptly on face large fines has passed both sides but may face a veto by the Governator. The bill is being fought by the insurers and by the regulators who want to focus on the really bad actors and not be the bill collectors for the physicians.
California is also suing Prime Healthcare for billing patients with insurance they don't have a contract with for money the insurers do not pay. The suit is by the Department of Managed Care which has no jurisdiction over hospitals. This is the second suit against Prime for balance billing. The other was by Kaiser for Prime billing its members for money Kaiser refused to pay. Kaiser also sued Cedar Sinai for the same thing.
The largest insurer, Medicare, has issued a report on the RACs. These organizations have been a bane on hospitals but have collected almost $700 million in overpayments by the inefficient Medicare to hospitals. The program will go from a sectional to a national program. The real problem continues to be the contingency basis for paying the RAC. It is in their interest to at the least get all due and sometimes over in order to be paid more. They know that it is not worthwhile for some hospitals to appeal all the challenges. The new rules will only allow a lookback to October 1, 2007, the RAC will be required to hire a physician medical director to oversee the medical record review process and RAC contingency fees will be disclosed.
Medicare will also offer bonuses to physicians who e-prescribe. Whoopdee do! By buying all the equipment and software the physician will get the massive amount of a 2% increase in 2009 and 2010, a 1% increase in 2011 and 2012 and a 0.5% increase in 2013. I hope they don't spend the $10 all in one place.
The beauty of universal health is the government is on top of all the problems. On July 9, the US Senate found that about $92 million of durable medical equipment and other payments went for the UPINs of dead physicians. CMS believes the new NPIs will reduce the chance of dead doctors billing Medicare. This is doubtful in the future.
HealthNow was fined by New York over $1 million for denying infertility claims. They must pay all the denied 2500 claims plus interest.
Georgia has removed the Blues and Kaiser from covering the state employees. The insurers are not happy but it is interesting that Kaiser never complained when they were left a one of two or three insurers for CalPERS. Both organizations dropped the insurers to save money. Georgia now has Cigna and United Healthcare and is saving over $100 million. Top
The People's Republic of Massachusetts continues its march into insolvency. The House has approved a bill to lift existing limits on visits for mental health problems. There is no funding mandate for this bill within the state's universal health system.
The Republic also has a huge gap of funding for the program. The Governor does not want the people of the Republic to pay for it. He wants business to pay $100 million more for it. If this goes through the legislature it is possible that business will pull out of the coalition and bring down the overstuffed healthcare. The hospitals will support the plan but only if the legislature does not pass the expensive nurse ratio bill. There was a survey of all of 1000 people in the Republic and by golly they thought it would be a good idea if business and insurers would pay more so they would not have to. What a surprise! By the way, in case you did not know, The Big Dig in Boston was not paid for by the citizens of the Republic alone. It was paid for and paid for and paid for by US tax dollars with 100% of the benefit going to Boston.
The Republic's insurers and businesses have teamed up to fight the Governor's plan to have them pay the deficit instead of the state that created the deficit. The new coalition wants managed care to come in to fight the deficit. Of course, it is well known that the people do not want this and over time it will fail.
California has a budget problem where the legislature is not able to agree. This is a yearly happening. This means Medicaid clinics and all paid by Medicaid except physicians and pharmacists will not get any payments until the budget is passed. Clinics who rely on Medicaid are now attempting to get lines of credit. These will not be paid for by the state and will entice physicians to stop taking the Medicaid patient.
Congress has passed the bill to stop the regressive 10.5% reduction of Medicare payments to physicians and instead gives the physicians a 0.5% increase for the remainder of this year and a 1.1% increase in 2009. The President has vetoed the measure and the Congress has overridden the veto. The problem was where the money was to come from to pay the physicians. The final answer is the Medicare HMOs. The bill also gives more mental health coverage and puts more drugs on the formulary. Pharmacists will now have to be paid within 14 days of submitting electronic bills. The bill also stopped the bidding for durable medical equipment and allows it to be paid on a fee schedule. What the bill doesn't do is to take care of the problem on a permanent basis. Congress doesn't have the stones for that.
The DEA has proposed that narcotics can be e-prescribed providing that the physician register for the e-prescribing in person with law enforcement agencies and is personally liable if something goes amiss. Pharmacist must check weekly that the physician is still registered. These regs may be too restrictive to have physicians use e-prescribing for narcotics and instead just use pen and paper.
California has found that Providence Saint Joseph Medical Center in Burbank is a cesspool of infection. The hospital did not meet standards for infection control. It had allowed an anesthesiologist to wear an outside vest over his scrubs in the OR and the OR had old tape holding up old signs. The infractions have to be very bad to get CMS involved as it was. Providence got caught with having one infection control officer for two hospitals to save money. They have now had to hire one and possibly two more.
USC-LA County Hospital was stripped of its cardiology training program by the ACGME. There was insufficient teaching time by faculty. The ban takes effect next year unless the hospital cleans up its act. The University plans to hire more physicians and nurse practitioners so that more face to face teaching can occur. If they lose their accreditation they would pay a stiff financial penalty because they would have to hire experienced cardiologists to take the place of the cheap residents and fellows.
Bakersfield, California, nursing home Bakersfield Healthcare Center was fined $100,000 by the state for wrong meds causing a patient death. The home gave Coumadin and an anti-inflammatory to a patient who bled out and died. The Center went bankrupt and was sold. The original owner paid the fine.
South Carolina has decided to publish on its Medical website how much money each physician has received from Medicaid. This is a meaningless statistic along with how many Medicaid patients were seen by hospitals, nursing homes and providers. One more thing to confuse the public. Top
The EMTALA has been amended. Now if the ED physician agrees and the state and the hospital have policies and procedures, mid level practitioners may see patients in the ED for the call panel provider. If the ED physician (treating physician) insists that the patient be seen by the physician, the physician must see the patient. Top
The first fine in the country for HIPAA violations has been levied against Providence Healthcare in Seattle. The $100,000 fine was for failing to properly secure backup tapes etc. in laptops that were stolen. Providence has agreed to pay, change its policies and train employees. This is the same company that was found guilty of antitrust violations. Top
The North Carolina Medical Board has backed down somewhat from its prior stance in putting physician med mal information regarding settlements on its web site. The new rule will only put on settlements greater than $25,000 and after October, 2007. Originally it was to go back seven years, a most unfair proposition. The web information will appear magically in the fall of 2009. Also on the site will be if the settlements led to any discipline and any comments by those reported. Top
Massachusetts has suspended the license of a physician, Dr. Loren Borad, impaired and who fell asleep while doing a liposuction. He was also fired from the hospital Deaconess Beth Israel. The second time recently the hospital has been in the news for a gaffe. He also had a long history of drug and alcohol abuse. Top
DISCLAIMER: Although this
article is updated periodically, it reflects the author's point of view at the
time of publication. Nothing in this article constitutes legal advice. Readers
should consult with their own legal counsel before acting on any of the