How ObamaCare Will Affect Your Doctor?

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How ObamaCare Will Affect Your Doctor? Expect
longer waits for appointments as physicians get
pinched on reimbursements
Wall Street Journal Scott Gottlied
May 12th, 2009
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SPECIALTY ANNUAL PRACTICE EXPENSE MALPRACTICE PREMIUM OF ANNUAL EXPENSES
Internal Medicine 305, 121 23, 104 8
General Surgery 369, 169 79, 596 22
OB 364, 708 96, 848 27
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Physician incomes have fallen in inflation
adjusted dollars for 13 of the last 20 years!
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Nothing is as powerful as an idea whose time has
come  Victor Hugo
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The best defense  Premium cost levels  Low
hassle factor
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Presentation to theAssociation of Black
Cardiologists

• Ralph Tribendis , Vice President

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Differences between an Alternative Risk PL
Program and the Traditional Approach (Insurance
Company) (From a PL claims perspective)
Category Traditional Captive
Control of the Claim Process NONE Standard insurance company dictates this process Complete control CSIs developed and approved by membership
Claim Personnel (Adjusters) Varies different adjusters with diverse experience handle claims PL claims experts dedicated to the program
Claim Philosophy Dictated by the insurance carrier (laws of insurance probability) Developed by the captive and approved by membership
Ownership of Process Traditional insurance company owns and issues the policy Captive ownership (membership)
Value added NONE services are standardized EX-loss control visits Total services tailored to individual member
Service Offerings (medical bill review, PPO, IME, etc.) Outsourced and not in-house or non-existent. Transparency issues (financial and process). TPA owns all services in an integrated model. Complete transparency and applied specifically.
Legal Council Dictated completely by the insurance company Dictated by the captive and specific to each practice and geographic considerations.
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Differences between an Alternative Risk PL
Program and the Traditional Approach (Insurance
Company) (From a PL claims perspective)
Category Traditional Captive
Nuisance claims Typically paid by the insurance company with no input from physician, regardless of liability. Physician consulted for input before claim disposition.
Legal Costs Program lawsuits are defended and settled by insurance carriers attorneys with little input from physician. We can identify legal counsel selected jointly with physicians and all settlements would be pre-approved with physicians input.
Ongoing Changes to the Program NONE one size fits all. Changes expected and completed to fine tune the process.
Dedicated Client Service Person Claim Program NONE Yes Ralph Tribendis
Communication Dictated by the insurance company (non-existent) On-going throughout the entire life of the claim.
Information Data Standard offering Tailored to specific physician and practice.
Loss Runs One size fits all Online access to your claim information.
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RAC Audit

• Contract Compliance
• Some of the areas for review include the
  following
• Stop loss
• Carve-out provisions
• Non-applied per diem
• Capitated services paid as service fees
• Retroactive rate reductions
• Incorrect level of care paid
• Missed or inappropriate provider discounts
• Episode of care analysis
• Cap on reimbursement

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• Coordination of benefits
• Identification and recovery for other party
  liability,
• including other commercial insurance, Medicare,
  or
• Medicaid, or other state-sponsored plans.

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• Medical Chart Review
• Obtaining medical charts and health reports,
  either electronically or by scanning hard copies,
  and then reviewing for improper payments. This
  can be done post-pay or pre-pay. Examples
  include
• DRG Validation
• CMS to MS DRG conversion
• Outliers
• AP/APR DRGs Classification

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• 3. Medical Chart Review (continued)
• Post acute transfers
• I/P rehab
• Debridement (excisional vs. non-excisional)
• Coagulopathy
• Non-par hospital chart review
• Coding errors
• Contract compliance issues
• High cost carve-out services
• Services that could have been provided on an
  outpatient basis
• ASC/APC list violations
• Drug code review, JQ codes, verification of
  dosage
• Lab services-outpatients vs. inpatient
• Dialysis-multiple sessions within one day

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• 3. Medical Chart Review (continued)
• EM global surgery periods-separate billing
• High density of diagnostic testing
• ESRD-per treatment vs. cap payment
• Elective surgeries canceled but billed
• Incorrect units
• Colonoscopy
• Cataracts
• Cardiac catheterizations
• Provider Billing Compliance
• This encompasses reviewing provider billing in
  conjunction with payer contracts and payment
  guidelines to ensure proper payment. Areas
  include

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• Provider Billing Compliance (continued)
• Procedures
• Incidental
• Mutually exclusive services
• Transplants
• Implants
• CPT coding modifiers
• Bundling and unbundling
• Ambulance related services
• Anesthesia
• Observation
• DRG

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• 4. Provider Billing Compliance (continued)
• -High cost drug analysis
• -ESRD
• -Quantity differences
• -Rate analysis
• -Billed unit analysis
• -Multiple surgeries
• -Assistant surgeon
• -Split bill

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U.S. Department of Justice United States
Attorney District of Maryland Rod J. Rosenstein
410-209-4800 United States Attorney
TTY/TDD410-962-4462

410-209-4885 36 S. Charles Street
FAX [phone] Fourth Floor
Vickie.LeDuc_at_usdoj.gov Baltimore, Maryland
21201-2692 Vickie E. LeDuc Public
Information Officer September 1, 2010
CONTACT AUSA VICKIE E. LEDUC FOR IMMEDIATE
RELEASE or MARCIA MURPHY at (410)
209-4885 www.justice.gov/usao/md
SALISBURY CARDIOLOGIST INDICTED FOR
IMPLANTING UNNECESSARY CARDIAC STENTS Allegedly
Inserted Unnecessary Stents in Patients and
Submitted Over 515,000 in Insurance Claims for
Unnecessary Procedures, Services and Testing

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Baltimore, Maryland - A federal grand jury
in Baltimore indicted cardiologist John R.
McLean, age 58, of Salisbury, Maryland, late
yesterday on health care fraud charges in
connection with a scheme in which Dr. McLean
allegedly submitted insurance claims for
inserting unnecessary cardiac stents, ordering
unnecessary testing and procedures and falsely
documenting patient medical records. In addition
to charges that could send McLean to federal
prison, the indictment seeks the forfeiture of
over 519,000 and two parcels of real estate.
The indictment was announced by United States
Attorney for the District of Maryland Rod J.
Rosenstein Special Agent in Charge Richard A.
McFeely of the Federal Bureau of Investigation
and Special Agent in Charge Nicholas DiGiulio,
Office of Inspector General of the Department of
Health and Human Services, Philadelphia Region
which includes Maryland. The indictment
charges that Dr. McLean egregiously violated the
trust of his patients and made false entries in
their medical records to justify implanting
unneeded cardiac stents and billing for the
surgery and follow-up care, said U.S. Attorney
Rod J. Rosenstein. The indictment alleges fraud
and false statements we do not bring federal
prosecutions for discretionary judgments about
which reasonable medical professionals might
disagree.
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According to the seven count indictment,
McLean had a private medical practice known as
John R. McLean M.D. and Associates, located at
1315 S. Division Street in Salisbury. He had
hospital privileges at the Peninsula Regional
Medical Center (PRMC). From at least 2003 to
May 2007, McLean allegedly performed cardiac
catheterizations on patients at PRMC and falsely
recorded in the patients medical records the
existence or extent of any coronary artery
blockage, known as lesions, observed during the
procedures. A coronary stent was not considered
medically necessary absent a diagnosis of at
least a 70 percent lesion and symptoms of
blockage. In order to increase his profit, McLean
allegedly implanted cardiac stents in patients
who had neither a 70 percent or more blockage nor
symptoms of blockage. The indictment
alleges that McLean ordered that his cardiac
patients have routine follow up visits and
undergo unnecessary diagnostic testing such as
Cardiolite Stress Tests, echocardiograms and
electrocardiograms. McLean allegedly caused
claims in the total amount of 519,063 for
medically unnecessary procedures, services and
testing to be submitted to health care benefit
programs, including Medicare. McLean is
alleged to have shredded and attempted to shred
documents that were subpoenaed by the Maryland
Board of Physicians and the United States
Attorneys Office for the District of Maryland
during an investigation of his medical practice.

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The indictment seeks forfeiture of 519,
063 and two properties located in Ocean City and
Salisbury, Maryland. McLean faces a maximum
sentence of 10 years in prison for health care
fraud and five years in prison on each of six
counts of making false statements relating to
health care matters. No court proceedings have
been scheduled yet. An indictment is
not a finding of guilt. An individual charged by
indictment is presumed innocent unless and until
proven guilty at some later criminal proceedings.
United States Attorney Rod J. Rosenstein
thanked the Federal Bureau of Investigation and
the Office of Inspector General of the Department
of Health and Human Services for their assistance
in the investigation. Mr. Rosenstein commended
Assistant United States Attorneys Sandra
Wilkinson and Thomas Corcoran, who are
prosecuting the case.
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The New Reality

• RAC will start focusing on doctors in 2011. CMS
  requires that each RAC post issues that have been
  approved for review on each of the RAC's Website
• Area (A) Northeast - DCS www.dcsrac.com
• Area (B) Central - CGI racb.cgi.com
  lthttp//www.racb.cgi.comgt
• Area (C) Southeast to Southwest - Connolly
  connollyhealthcare.com/rac lthttp//www.connollyhea
  lthcare.com/racgt
• Area (D) West - Health Data Insights
  racinfo.healthdatainsights.com lthttp//www.racinfo
  .healthdatainsights.comgt

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Physician Compliance Plan
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Components of Compliance

• Auditing and monitoring
• Claims Submission Audit
• -Baseline Audit
• -Yearly Follow Up Audits (OIG recommends five or
  more charts from each Federal payor or five to
  ten records for each physician.

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• Auditing and monitoring (continued)
• Billing and reimbursement
• -Written Billing and Reimbursement Policies.
• -Written Standards for Documentation of Patient
  Records
• -Written Balance Billing Policies.
• -Written Waiver of Copay and Deductible Policy.
• -Written Policy for Internal and/or External
  Audits both Prospective and Retrospective.
• -Written Policies to Respond to Allegations of
  Non-Compliance.
• -Written Policies to Address Violations

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• Billing and reimbursement (continued)
• -Written Policies to Address Inquiries and
  Outcomes to Inquiries to National Practitioner
  Data Bank, Cumulative Sanction Report and GAO
  Debarred Contractors Listing.
• Standards and Procedures
• Periodic review of standards and procedures to
  ensure they are current and complete.
  Example-updating fee schedule, encounter form to
  reflect latest changes to CPT and ICD-9 updates

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• Designate a Compliance Officer
• Conduct Training Education
• Respond to Detected Offenses
• Open lines of communication

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7. Enforcing Disciplinary Standards

• Employment Compliance
• -Written Personnel Policy Manual.
• -Written Policy on Sexual Harassment.
• -Written Policy on Hostile Work Environment.
• -Written Policy on Leave of Absence/Military
  Leave.
• -Written Policy on Patient and Practice
  Confidentiality.

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• Employment Compliance (continued)
• -Written Policy on Release of Employee
  Information, Including Storage of Medical
  Records.
• -Written Policy on Signed Acknowledgement of
  Receipt of Personnel Policy.
• -Written Policy Regarding Payment of Overtime
  Compensation and Knowing It Is Correct
• -Written Policy Regarding Compliance with ADA
  FMLA (knowing when it applies to you).

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• ERISA Compliance
• -Identifying the type of retirement plan or
  welfare benefit plan and knowing what ERISA rules
  apply.
• -Making certain plan documents are up to date.
• -Written policy requiring all qualified
  employees receive a Summary Plan Description
  within 90 days of becoming a participant.
• -Written policy and actual practice of
  distributing Summary Annual Reports and Plan
  Participant Statements in a timely manner.
• -Determine of appropriate fiduciary bond is in
  place.

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• CLIA Compliance
• Reviewing in-office clinical laboratory setup.
• Written policies procedures regarding quality
  control
• Written current Laboratory Procedures Manual
• Written policies concerning annual training and
  retention of records.

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• HIPAA
• Written policies regarding confidentiality of
  patient information.
• Reviewing policies procedures regarding quality
  control.
• Written policies regarding fax requests for
  information
• Formalized process for release of information,
  including what information requires specific
  authorization to disclose.
• Keeping patient information readily available
  while protecting patient rights.

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• Stark
• Reviewing all policies with contrators, vendors,
  etc. to ensure no potential exists for
  anti-kickback violations.
• Reviewing Designated Health Services to
  determine if liability exists.
• Reviewing Joint Venture Agreements for liability

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• Issue Name Left-sided Cardiac Catheterization
• Description CPT Code 93510 (described as
  Left heart catheterization, retrograde, from
  the brachial artery, axillary artery or
  femoral artery percutaneous) should only
  be billed once per patient per date of
  service. (Excluding claims with Modifiers
  -73 and -52)
• Provider Type Affected Outpatient Hospital
• Date of Service 10/01/2007 Open
• States Affected Alabama, Arkansas, Colorado,
  Florida, Georgia, Louisiana, Mississippi, New
  Mexico, North Carolina, Oklahoma, Puerto
  Rico, South Carolina, Tennessee, Texas,
  Virgin Islands, Virginia, West Virginia 

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• Issue Name Left-sided Cardiac Catheterization
• Description CPT Code 93510 (described asLeft
  heart catheterization, retrograde, from
  the brachial artery, axillary artery or
  femoral artery percutaneous) should only
  be billed once per patient per date of
  service. (Excluding claims with Modifiers -73
  and -52 and -26)
• Provider Type Affected Physician (Carrier)
• Date of Service 10/01/2007 Open
• States Affected Alabama, Arkansas, Colorado,
  Florida, Georgia, Louisiana, Mississippi, New
  Mexico, North Carolina, Oklahoma, Puerto
  Rico, South Carolina, Tennessee, Texas,
  Virgin Islands, Virginia, West Virginia

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