Hospital Credentialing and Board Certification
HCFA has had a statement in the Conditions of Participation that it would not be legal to use board certification or eligibility for the sole reason to allow or not allow physicians on the medical staff. Most hospitals used several criteria for allowing physicians on the staff. If those who were board eligible did not become certified within a certain number of years they could no longer be on the staff. Other hospitals for credentialing used multiple criteria among them training and experience. HCFA in 1997 announced a new COP that stated they intend to eliminate the above section since board certification may or may not be an important element of competence. They would allow each hospital with consultation with its medical staff to determine whether or not boards are required. To date, elimination of the rule has not taken effect.
President Clinton signed the new HIPAA privacy rules into law that start in two years. These have changed to now covering not only electronic but paper records and oral statements as well. The rules apply to all health providers, insurers and clearing houses that use electronic transmission of financial or administrative information.
Physicians must get a one time written permission from the patient in order to release billing or general medical information and specific consent to release records for other uses. This may mean that if a patient withholds consent there may be a problem with insurance companies and doctors trading information used in UM or QA. All patients will need to be provided written information on privacy and how the information will be used. Patients have the right to see, copy and add corrections to their records. Psychological notes are held to an even a higher standard and always need special consent to release information.
All health care providers will have to change their contracts with all business partners to address these laws as they will be liable if there partners divulge information and the medical entity knew about the violations.
All providers will have to provide training for all in the offices or hospitals as to which information may be divulged and under what conditions as well as appointing a privacy officer. Grievance procedures will need to be set up for handling inquiries and complaints about privacy. All patients will need to have the law explained in writing to them in order to get an informed consent to the information release. All who use electronic record transfer or billing will need security software.
Other changes are high fines and possible jail for criminal use of medical information, no court subpoena needed for law enforcement agents to obtain the information, a prohibition against employers to read medical records of its employees or use any medical information in any way except for health care. Patients are not allowed to sue if their records are used improperly. Therefore the money collected goes to the government and not the people injured. Either Mr. Bush or the Congress may change these rules. States may enact stricter rules and thereby removing any uniformity. The cost for this has been estimated at $3.8 billion by the DHS and up to $22.5 billion by the American Hospital Assn.
Texas has placed PacifiCare under administrative oversight due to not offering patients adequate access to hospitals and doctors, and is late in paying physician claims.
Georgia has also fined insurance companies for not timely paying of debts. State law requires the payment of clean claims in 15 days. This raises to 17 the number of fines this year issued by the State Insurance Commissioner. California could use this type of oversight.
Canada is to begin testing immigrants for AIDS and Hepatitis B prior to allowing them into the country. Those that test positive will be barred from entry. Currently, Canada tests for TB and syphilis. The current statistics show that about 1 in 1000 entering the country has the HIV virus. The government is also studying whether to test for Malaria.
JCAHO has issued a sentinel event alert. There have been several incidents regarding infusion pumps. The problems have included human error problems such as wrong drug, wrong concentrations and wrong rate of infusion. The inspectors will be looking for pumps without free-flow protection.
Hawaii has established rules for the use and possession of marijuana. Physicians will issue permits for the use and must tell the state when the drug is no longer needed. The state will charge $25 for the permit and allow 3 oz. and 7 plants. The US Supreme Court currently has this issue on this year’s agenda.
The FDA issued the rules for hospitals to follow if they wish to reuse one-time use items. The regulations may be found at www.fda.gov/cdrh/1168.html.
A web site is available for patients to register their advance directives for free and allows the retrieval of those directives by any hospital also for free. Call (800) 548 9455 or www.uslivingwillregistry.com
The OIG has in Advisory Opinion No. 00-7 allowed free transportation of patients by a hospital. This activity could be construed as not allowed under the anti-kickback statute that prohibits anything of value to any person to reward or induce referrals under any Federal program. The OIG allowed the free transportation because there was limited economical public transportation, the transportation is only for those already referred or being treated by the hospital, the transportation need is individualized, it is for all patients in need of multiple treatments not just those with profitable diagnosis, the hospital was rural and not-for-profit. This advisory only pertains to this hospital but gives guidance as to the possibility of your hospital offering that service.
The Oregon Health Plan has 15 health plans with which it contracts. Some of these insurers are opting out due to low payments. Gov. Kitzhaber, a physician, has asked for a 20% pay increase to the insurers over two years as well as a decrease in regulations to lower overhead for the plans. In recent months all the commercial health plans have cancelled or limited their obligations to provide care. The patients who lose this coverage are still covered under Medicaid but must find a physician willing to accept them.
Again the People’s Republic of Massachusetts is resurrecting universal health care. After their defeat in the November election of Question 5, it returns in another form. The new plan is for a 15 person (the last one was 17) board to collect money paid for healthcare services and give the funds to hospitals and other providers for care for all. There is nothing I can think of as efficient as a state or federal bureaucracy deciding who gets how much.
The same group also wants an additional 50 cent per pack tax on cigarettes to fund additional money the Medicaid program and prescription drug coverage for seniors, no matter their financial situation. Gee, the Kennedy clan really needs this.
The hospitals have applied en masse for "distressed funds". The hospitals state that without the $35 million asked for, they will have to cut services. Problem: only $10 million in the fund. They state the State is only paying 80% of the cost of care. Could it be that the State allows too many people on Medicaid and then doesn’t fund for the amount of people. This State is always interesting.
Massachusetts has lost a lawsuit over the length mentally retarded adults had to wait for state services. The judge stated 90 days is enough time to provide requested services. The state agreed to increase funding from $29 million to $114 million over five years. I wonder what their state taxes will be.
The government has changed its mind again. The New York Times states that the Part A Medicare will run out of money in 2021 instead of 2025 due to advances in medical technology.
Medicare has now allowed cryosurgery for prostate cancer that has failed radiation therapy. Information is at www.endocare.com.
Medicare is going to allow the $2000 per test PET Scan for six cancers and as a backup test for heart disease. These are lung, melanoma, esophagus, colon and rectum, lymphoma, and mouth and throat. If a patient has one of these diagnoses the physicians will not be questioned on the PET Scan use.
Congress passed the bill to increase payments reduced by the BBA. The bill will provide an additional $11.55 billion, almost all to hospitals.
Governor Davis has appointed, subject to Senate confirmation, Dr. Bernard Alpert to the Licensing Division, Dr. Hazem Chehabi and Dr. Ronald Wender to the Medical Quality Division. Dr. Alpert is a practicing plastic surgeon and past vice president of the licensing division. Dr. Chehabi is an assistant professor in radiology at UCI. Dr. Wender is co-chair of the Department of anesthesiology at Cedars-Sinai.
An article in the December 11, 2000 Modern Healthcare discusses the lack of antitrust legislation. This dovetails into my last legislative newsletter regarding the reasons for lack of movement of the issue in the US Senate. In this article the states refusal to go forward is discussed. The reason for the delay is the need for both a vote for the exception plus an active state participation in the oversight of the exception. California will consider the law again in the next year.
When the overtime law went from 40 hours per week to 8 hours per day employed emergency room physicians were not made exempt. Physicians employees of a medical group that enjoy working 12 hour shifts may be barred from doing that due to the need to pay them overtime. This law will create a huge burden for the employers of these physicians such as Kaiser who contracts with independent physicians. If the groups do not pay the time and one half for the time over eight hours they could be fined. This will probably mean more shifts for the physicians with less consolidated time off. Some of the ED physicians may also move to other states to improve their quality of life.
In Alberta physicians staged a three-day office closing to protest the low funding for physicians. Radiologists are especially in short supply due to decreased funding and increased US recruiting. The salary in the US is about twice that in Alberta. Physicians are seeking a 50% increase in funding and the government is offering 28%.
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 information presented