January 1, 2011 Legislation






California has ordered PacifiCare not to pay $120 million to its parent company.  The reason is the money may be needed to pay fines imposed by the Department of Insurance against the insurer.  The Department has accused the insurer of violating state law almost one million times from 2006-08 by mismanaging medical records, losing patient documents and failing to pay doctors what was owed.  The violations each carry a fine up to $10,000.  

South Carolina has a new rule that forbids insurers from charging patients more who continue to see their physicians for 90 days after the physician has been terminated from the plan.  Also insurers will be forced to continue coverage for those insureds who have serious diseases for several months.  The law state that it will be for 90 days or until the end of the term.  

HHS has issued a rule that they or the states will review all requests for insurer medical rate hikes over 10% next year.  This is part of Obamacare.  The administration is saying that anything over 10% is deemed unreasonable and needs to be reviewed.   This is in the small group or individual market.  Starting in 2012 the feds will establish different thresholds in different states.  The states rebuffed Sebelius by stating the job of the states is to protect the guarantee the solvency of insurance companies.  The insurance head in Sebelius' home state went on to state that scrutiny will not hold down costs for consumers doe to overuse or inappropriate use of health care.  The insurer's stock prices  rose on the news.       Top


San Francisco was never known as a city with much sense.  It continues its idiocy by having a $4.36 Billion shortfall for unfunded liability for healthcare for retirees.  This happens when the city is run by the unions.  The city gave lifetime health benefits for the employee and the family after five years.  There is no worker contribution.  Future workers or the city will have to pay for the past indiscretions. 

The new spending bill before the Senate and Congress that needs to be passed to keep the government running on an interim basis contains no money for Obamacare.  It will be up to the new Congress to fund or not fund the program.

CMS has issued a rule that all complex medical record reviews have Advanced Beneficiary Notice on any ADRs on those claims.  If the claim is determined not to be reasonable and necessary then the ABN will be validated.  If there is no ABN the provider loses all monies. 

CMS has put off the ridiculous rule that all lab tests need a signature.  They state that it will be implemented in the second quarter of 2011.  This would mean there could be no more standing orders at the lab as all new orders would need to signed.  CMS states that all orders would need to signed and faxed, hand carried or mailed to the lab.  A telephone call by the provider would also suffice as would email or other electronic means.  Watch for the CMS to delay this rule again since it means such hardship for the patients, hospitals and physicians.

EHR rules go into effect January 2, 2011.  On that date providers may start to register in the EHR incentive program.  Some states also will be starting their EHR Medicaid registration programs the same date.  Interestingly hospitals may register for both  Medicare and Medicaid incentive programs but physicians are only eligible to register for one or the other but may change one time per year.

Obama has signed the Red Flag laws into effect.  It excuses almost all physicians from compliance unless they use monthly or other payments such as for plastic surgery.  Those cases still need to comply with the Red Flag laws.

As all remember the "Death to Granny" Obamacare myths.  It was enough to get rid of the every five year advanced planning regulation in the bill.  Well, it's back and now on an every year basis.  Medicare by regulation has added payments for the end of life discussion as part of the annual Wellness visit.  The supporters of the original plan were elated when CMS added this but put out a memo not to publicize it in fear that the "kill Granny" will return.  The New York Times publicized it. I hope the government will keep it in since it such an important issues for patients and physicians to discuss. 

One of the fears against Obamacare is its increase of the government.  It has started.  Medicare has announced a new office for "duels".   This new office will oversee about 25% of Medicare spending and 45% of Medicaid spending.  It will be called the Federal Coordinated Health Care Office or CHCO.  See how easy it will be to get rid of those hired for the office.

CMS has also regulated that it will modernize its information technology so that it can do more than just pay claims.  It wants to be an active purchaser of quality healthcare, what ever that may mean. 

The above is good news since the OIG has found that Medicaid has paid 6.5 million undocumented personal service care claims due to undocumented qualifications of the attendants.  This added up to $724 million. Maybe the IT upgrades will not allow this to happen but I doubt it.  

Arizona continues to trim it's health budget.  First it was the elimination of transplants for Medicaid patients and now it is the cutting off of health care benefits for unmarried heterosexual domestic partners.  It wanted to add homosexual partners as well to the rule but was prohibited by the new federal law.

Florida is considering a law that would give immunity for med mal against all providers of care to Medicaid patients.  This is fine for the physicians but would cost the taxpayers about $69 million a year assuming the state paid all claims up to $300,000.  The rationale is to have more physicians see Medicaid patients.

Britain has banned Avastin for use in colorectal cancers stating it is too expensive.  This is according to NICE but the new Drug Fund will pay for it.   The US still allows it but removed it for breast cancer due to lack of effectiveness not cost.  

The British has also banned Votrient, a kidney cancer drug, but has now said it's okay since the company dropped the price.  How much is a life worth?  In England it's 19,000 pounds.   Top


The Medical Board of California has notified the family of a woman who died at a lap band factory that they are looking into the case.  It's about time.  All through Southern California are billboards advertising lap band weight loss.  The Board is now investigating Dr. Atul Madan, a Beverly hills surgeon connected to the campaign.  The coroner stated the patient died as a complication of her lap band surgery.  This is the second death at this institution.  The institution has lost its certification by the joint commission and lost its ability to bill Medicare.  The ad agency behind the lap band surgery is by a defrocked physician, Julian Omidi and his brother Michael who is on medical probation.  Another patient has also filed suit against the clinic and the operating surgeon.  The surgeon has defended the claim by stating the patient voluntarily agreed to the surgery.  That may be so but she did not agree to the malpractice.  The bills for the surgery on the later case are amazing.  The patient was told it would cost $15,000 but the insurance company was billed for $140,000.  This included $67,000 for the OR for one hour and $12,200 for endoscopy.  There is also a catch 22 here as the Medical Board only oversees physicians and the Department of Public Health states that they have no jurisdiction over a physician's private operating room, the Medical Board does.   

The Chicago Tribune reports that Illinois is monitoring physician sexual misconduct in secret.  This include some convicted of crimes.  Illinois has a confidential Professionals Health Program that is now being referred physicians who are "disruptive" and have boundary issues.    

The Saint Louis Post Dispatch has an expose on the Medical board of Missouri and their lax treatment of physicians.  They use confidential letters of concern to the physicians and do not discipline them.  They are also very secretive in all their dealings.  While I consider most state medical boards as fair, this is one of the ones I have some problem with. This is due to the Missouri legislature and not the board.  All information including where one went to medical school is deemed confidential by the legislature.  Top


Ohio has a new law that prohibits patients from switching pharmacies more than once per year.  It appears that each time a box or mega pharmacy has a special consumers change to that pharmacy.  That is their right but the pharmacists believe that it is dangerous as the new pharmacies may not know all the drugs the patient is taking and therefore errors may be more prevalent.  The main problem will be snowbirds who go to Florida or other warm weather places in the winter and then return in the late spring.  They may transfer their meds to the warm weather pharmacy but may not transfer them back when they return.  This means physicians will need to write two prescriptions for each one of these patients.        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.