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Medicare Patient Denials Reversed
In Florida there were 392, 660 claims for Medicare denied last year that were contested by patients. More than half were reversed after review. Nationally 64% of denials regarding physicians, nursing homes and home healthcare services were overturned on review. For hospitals about 30% of denials were overturned. The total amount of money paid out for these claims were $552 million. This does not include the amount Medicare spent to review the claims. How much does it cost to do it right the first time! Top
There will be no more sterilizations at any Catholic hospitals or their joint ventured institutions. The Bishops proclaimed this at there meeting in Atlanta. This affects 1,140 facilities and 85 million patients. The way around this in the past has been to allow a portion of the hospital to be a private organization and sterilizations were done there. This option has now been removed. This proclamation could effect many current merger negotiations. Top
Governor Perry of Texas has vetoed a bi-partisan bill that defined a clean claim. Currently a claim is received when the insurer states it is received. The bill would have changed that to three days after being sent first class or 24 hour after sending it electronically. Following his veto he explained that it was too much toward the suing of plans and not enough toward negotiations. He then warned the plans that if they don't stop their stalling devices this bill would be like a small slap on the wrist. I don't know what he means but large fines per stalled claim would go a long way to stop the practice.
Meanwhile in Ohio both the House and Senate unanimously approved a prompt pay bill that will require insurers to pay claims within 30 days or 45 days if additional information is needed. It includes an 18% interest to the provider for late payments. The Governor still needs to sign the bill. Top
California Assembly Bill 1600 would exempt physicians from antitrust law and allow sharing information among physicians. The bill passed the Assembly 59-8 and is at the Senate which is favorably inclined toward the bill. The California Association of Health Plans stated the bill would allow solo practitioners to fix prices. The physicians state they only want a level playing field. Top
The JCAHO is now making part of their accreditation the Sentinel
Event Alerts Bulletin. Hospitals will be expected to use the Bulletin to
judge its own performance by evidencing review and implement
"suggestions". This is at the same time that a New Jersey Court
has ordered the release of a JCAHO mandated Sentinel Event root cause analysis to a
plaintiff' attorney. This was probably because New Jersey's peer review laws are
so weak.
There is also a national immigration away from the
JCAHO to State Department of Health inspections for the deemed Medicare status.
Some systems state the value is not there. The cost of the State exam is
free. The cost of JCAHO and all their standards and recommendations runs into the tens
of thousands of dollars. Even JCAHO has stated that maybe some of their
standards no longer have relevance. Hospitals should think about their
options especially now that money is tighter and the State is coming in for validation
inspections in any case. The real issue is if you run a hospital well and continuously
improve your internal workings you may be better off with the State. If you
only do things because the JCAHO is coming then you need that
inspection.
In an article the USA Today has finally found out that starting July 1, 2001 hospitals will have the illegal duty of forcing their independent physicians to tell patients when any type of misadventure occurs. (RI 1.2.2) I believe that all patient care problems should be trended and if significant should be examined within the institution possibly using the root-cause model. If there are any major errors, those need to looked at immediately to prevent future problems. I have in the past and continue to preach that the JCAHO has no authority to force hospitals to make physicians tell patients about untoward events unless those physicians are hospital employees. I believe strongly that the physicians should just say "no" when approached by hospital personnel to tell patients. If the hospital wants to tell patients and intercede in the physician patient relationship it is up to the hospital. The worse thing that can happen if one says no is one Type 1 recommendation. (please see above story about alternative accreditation) The worse thing that can happen by telling is a multimillion dollar suit, that even if won by the physician and/or hospital will cost a significant amount of money to defend and, even more damaging, a significant amount of physical and emotional damage to one's psyche. Top
San Jose Medical Group Going Bye Bye?
The San Jose Medical Group is in serious financial difficulty. Their problem is so great that Blue Shield wants to pull it 10,000 members out of the group. The Department of Managed Care has stepped in and refused to allow Blue Shield to pull its members stating this would destroy the group's financial stability. Blue Shield had wanted to transfer its members to the Santa Clara County IPA and Physicians Medical group of San Jose after conducting their own audit of the San Jose Group showed significant concern for its future. Top
USC- Los Angeles County Nursing Problem
The LA Times reported on patients dying at LA County due to lack of dialysis nurses and other mis- management problems. They had three patients who died due to no dialysis nurses who work on a contract from an outside agency. They had a patient die due to bleeding to death because of no one available to operate because of forms not filled out. Another patient had a 84 hour ED wait. These problems will probably go from my legislative news to my legal news sections in the near future. A LA supervisor said their should be an investigation into the allegations and that more nurses should be hired. She proposed pay relocation costs, pay tuition for nurses to expand their education. The union stated while they welcomed these words they accused the supervisors of not tapping into a $40 million federal grant to train dialysis nurses. Nobody speaks of the way nurses are treated nor their terrible pay scale. Top
California Dental Board is History
The California State legislature is on its way to disband the California Dental Board. The legislative body believes that they are more knowledgeable than the dentists. The main "bone" of contention is between activists who believe that mercury fillings are dangerous and that patients should be notified for potential "neurological and reproductive" harm and the dentists, including the American Dental Association, who believe that there has been no scientific proof of any harmful connection between mercury cavity fillings and any overall harm to the patients. The legislature wants to disband the Board and put it under the Board of Consumer affairs which is closely controlled by the legislature. Top
Sutter Affiliation With St. Luke's
The Attorney General has given the green light to the affiliation of St. Luke's Hospital, the last San Francisco un-affiliated hospital, with Sutter Health. The affiliation is predicated on St. Lukes continuing their charity clinic care, ICU and emergency room coverage. Since San Francisco General has now decided to stop accepting any insured patients, St. Luke's is now the only hospital south of Market Street that will accept those paying patients. If St. Luke's does not continue with their ICU, emergency department and clinics for five years Sutter must agree to provide $2 million annually for the care of treating the uninsured and poor. Sutter must also give $15 million to a fund if the hospital closes within five years or $3 million if it closes within nine years. Sutter will meet on July 12 to determine if these conditions are acceptable. St. Luke's has been bleeding money for years and without Sutter would need to close in the near future. They recently lost a wrongful termination suit for a significant amount of money due to punitive damages since there was proven malice on the part of the hospital's chief executives. The jury voted 7-0 on the issue of the malice. 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 information presented.