Shasta Regional Medical Center (SRMC) has agreed to a comprehensive corrective action plan to settle an investigation by the U.S. Department of Health and Human Services (HHS) about potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and will pay a $275,000 monetary settlement.
The HHS Office for Civil Rights (OCR) opened a compliance review of SRMC following a Los Angeles Times article which indicated two SRMC senior leaders had met with media to discuss medical services provided to a patient. OCR’s investigation indicated that SRMC failed to safeguard the patient’s protected health information (PHI) from impermissible disclosure by intentionally disclosing PHI to multiple media outlets on at least three separate occasions, without a valid written authorization. OCR’s review indicated that senior management at SRMC impermissibly shared details about the patient’s medical condition, diagnosis and treatment in an email to the entire workforce. Further, SRMC failed to sanction its workforce members for impermissibly disclosing the patient’s records pursuant to its internal sanctions policy.
In addition to the $275,000 monetary settlement, a corrective action plan (CAP) requires SRMC to update its policies and procedures on safeguarding PHI from impermissible uses and disclosures and to train its workforce members. The CAP also requires fifteen other hospitals or medical centers under the same ownership or operational control as SRMC to attest to their understanding of permissible uses and disclosures of PHI, including disclosures to the media.
The Press Release can be found at:
And the Resolution Agreement can be found on the OCR website at:
Blaming low compensation and the hassles of healthcare reform, 34% of general practice physicians say they plan to leave the practice of medicine over the next decade, according to a new national survey. The survey of 2,218 physicians by recruiting firm Jackson Healthcare also found that 16% of the respondents said they will, or are strongly considering, retiring, leaving medicine, or going part-time in 2012.
Of those physicians who said they plan to retire or leave medicine this year, 56% cited economic factors and 51% cited health reform as among the major factors. Of those physicians who said they are strongly considering leaving medicine in 2012, 55% were under age 55.
"That's what we were most surprised about; that the majority of the folks that were considering leaving medicine or planning to leave medicine this year were under 55 years old. The key takeaway is that they're not retiring; they're quitting," say the researchers. The survey also found that specialists were more inclined to leave medicine in the next decade, including:
• Oncologists and hematologists - 57% said they would retire by 2022
• Otolaryngologists - 49% said they would retire in the next decade
• General Surgeons - 49% said they would retire by 2022
• Cardiologists - 45% said they would retire in the next decade
• Urologists - 42% said they would retire by 2022
◾ Review policies and procedures to ensure they are up to date and comprehensive.
◾ Review your files and documentation to ensure that appropriate patient information safeguards exist.
◾ Assess your organization's general management style to determine its effectiveness, specifically with respect to safeguarding information.
◾ With respect to the Security Rule, review your risk analysis process, risk management plan, incident response plan, emergency backup plan (if any), and breach response plan.
◾ Conduct regular internal audits. Self-evaluation should be standard practice
◾ Build and maintain a culture of compliance within your organization. This includes a regular review of policies and procedures to ensure full compliance with HIPAA.
◾ Provide regular training sessions for staff members.
◾ Create an action plan for prompt response to incidents.
Here are some typical actions by the medicadl practice:
- Notices to staff (do immediately after decision was made)
- Notices to patients (usually goes out about 45 days before departure date)
- Notices to referring physicians
- Malpractice tail
- Stock redemption (per shareholder agreement)
- Deferred compensation calculation (if applicable per employment agreement)
- Change checking account signatures (if he or she is a signer)
- Get back corporate credit card
- Recoupe any pre-paid expenses, e.g. licenses, hospital and professional association dues, etc. (depends on what your contract says and whether you want to go to that micro level)
- Notify payors the physician is no longer with group
- Review status of personal guarantees on practice financial obligations
- Clear out physician's office
- COBRA issues
- Retirement plan close-out
- Vacation reconciliation and payout or recoupment
HHS has provided online tools to assist providers protect patient data in mobile devices, such as laptops, tablets, and smartphones. The initiative is called Mobile Devices: Know the RISKS. Take the STEPS. PROTECT and SECURE Health Information and is available at:
It offers educational resources such as videos, fact sheets, and posters to promote best ways to safeguard patient health information. According to HHS, along with theft and loss of devices, other risks, such as the inadvertent download of viruses or other malware, are top among reasons for unintentional disclosure of patient data to unauthorized users.
On May 8, the DOL issued eagerly anticipated guidance regarding the notice of health insurance exchanges that employers must distribute to employees during 2013, including model notices that employers may use to satisfy the notice obligation.
The first model notice applies to employers who offer a health plan to some or all employees. The second model notice applies to employers who do not offer a health plan. Employers are permitted to modify the model notices as long as they still meet the content requirements specified in the health care reform law.
Employers must provide the notice to all current employees by October 1, 2013, though the notice may be provided sooner. Also starting October 1, 2013, new employees must receive the notice at the time of their hire. For 2014, the DOL will consider a notice to be timely provided at hire if it is provided within 14 days of the employee’s start date. The notice must be provided in writing and can be provided electronically if the DOL’s electronic disclosure safe-harbor requirements are met; otherwise, the notice may be provided by first-class mail.
Also in connection with the new exchange notice, the DOL released a revised COBRA Model Election Notice that includes information about the health insurance exchanges. The DOL included a redline document showing the changes made by the revised COBRA notice.
1. They Remove the Nonperformers
Average bosses sometimes hire somebody who can't do the job--but then keep that person on board, hoping that he or she will figure things out. This damages the the entire team, because it creates a lower level of performance and forces everyone else to do extra work to fill the gaps.
Extraordinary bosses monitor employee performance and provide constructive coaching when an employee falls short. However, once it's that clear a person can't perform, they either reassign that employee to a more appropriate job or do him or her a huge favor: suggest finding a job elsewhere.
2. They Coach But Don't Interfere
Average bosses can't "let go" of what they're good at. They're constantly intervening when things aren't done the way they'd prefer. This not only lowers motivation but also turns the manager into a "gatekeeper" for any activity--causing productive work to grind to a halt.
Extraordinary bosses know that their primary responsibility is to let people do their jobs and provide coaching when necessary or requested. Such bosses realize that it's impossible for workers to think strategically when their time and energy are getting consumed with details of tactical execution.
3. They Put Their Employees First
Average bosses put most of their attention on customers, investors, other managers, and their own career. In this priority scheme, employees rank dead last--if they're even on the list. Unfortunately, employees can sense when a boss doesn't care about them, and they respond by not caring about their jobs.
Extraordinary bosses know that the best way to please patients and peers is to put the employees first. They realize that it's employees who create, build, sell, and support the services that patients buy, thereby creating not only a great employment environment, but outstanding patient satisfaction as well.
4. They Manage People, Not Numbers
Average bosses focus on numbers rather than people. They jiggle revenue and profit numbers, monkey with statistics and data, and spend more time worrying about their spreadsheets than making things happen.
Extraordinary bosses know that numbers represent only the history of what's happened--and understand that the best way to have great numbers is to make sure that that the job gets done. They realize that their responsibility is to manage people and their activities so the numbers take care of themselves.
From the Health Law Daily by Wolters Kluwer:
On May 22, 2013, the Department of Justice (DOJ) filed a motion with the U.S. District Court of South Carolina Court requesting $237 million in additional fines and penalties from Toumey Healthcare System in Sumter, S.C., on top of the $39 million in illegal payments determined by a jury trial on May 8. Tuomey went to trial over whether it violated the Stark Law in its contracts with outside physicians to provide surgery exclusively in its facilities and pay the physicians a bonus for productivity. This case is sending shock waves to the hospital sector.
The $237 million in fines and penalties on top of the $39 million already leveled was calculated as the minimum of treble of the $39 million plus the minimum of $5,500 per claim, for the more than 21,000 claims the jury determined were tainted. The hospital has two weeks to respond to this motion. The DOJ opened the door to mitigating its request by saying it would consider discussions to settle at a lower rate upon other concessions by the hospital, which likely would mean a change in its leadership.
The background on this case is that Tuomey entered into exclusive part-time employment negotiations with affiliated specialist physicians to prevent these physicians from moving their outpatient business out of Tuomey’s ambulatory surgery center and into lower cost competing locations, some of which would be owned by the physicians themselves. The physicians agreed to enter into exclusive part-time employment agreements with Tuomey, thus keeping all of their outpatient business at Tuomey, in exchange for very favorable compensation arrangements.
A key issue in this case was that, under exclusive part-time employment agreements, Tuomey agreed to pay the physicians 131 percent of their net revenues collected (or 31 percent over the amount that the physicians actually generated in revenues) in return for their services and a noncompetition agreement. In developing the arrangement, Tuomey, through its legal counsel, obtained and relied upon the fair market value (FMV) opinion of an “expert” that agreed the rates being offered were at FMV and the compensation was unlikely to violate the Stark Law. One physician, an orthopedic surgeon, became the relator (i.e. “whistleblower”) in the federal government’s case against Tuomey. He concluded, and the government agreed, that the Tuomey employment agreements exceeded FMV, were commercially unreasonable, and took into account the volume or value of referrals all in contravention of the Stark Law. Ultimately, the jury agreed, as well.
There are a number of lessons to be learned from this case:
1. This case was built on the Stark Law, not Anti-Kickback Statute (AKS). This case was not coupled with the AKS and underscores the government’s continuing interest in Stark Law enforcement. This is significant in that the OIG recently downplayed its involvement with the AKS, stating its interests would be aroused only if it was coupled with the AKS. Also, the Tuomey case precedent will open doors to other prosecutions following the same legal arguments.
2. Many view the Stark Law as a checklist that has to be followed in the relation of agreements. This case dramatically makes it clear that the government does not view only the “four corners” of the document, but encompasses all the surrounding facts and evidence. The evidence at the trial focused on those surrounding factors.
3. Compensation for a referring physician for the services that he or she provides must be at FMV and the arrangement must be commercially reasonable. Both these standards must be supportable in the record. This includes any and all arrangements and understandings with the physician, written or verbal. It will be the total record that determines whether these standards were properly met, not just the written agreement.
4. Another key issue of note is that just finding someone who claims to be a FMV expert who will give the hospital whatever it wants in an arrangement is not sufficient to guard against violation of the law. You cannot buy a self-proclaimed expert and expect to have somehow have blocked the government on this issue. The government may have given wide latitude to hospitals developing a FMV determination, but any such efforts by recognized experts still need to be supported in a reasonable fashion along with the data they rely upon in generating their opinion.
5. This case underscores the importance of ongoing monitoring and auditing of all existing arrangement with referring physicians to ensure they comply with both the AKS and Stark Law standards, most particularly FMV and commercial reasonableness. The review should extend beyond the written agreement to the facts and circumstance surrounding its development, including the selection of, and methodology employed by, FMV experts.
This article was written by Richard P. Kusserow, who was the DHHS Inspector General for over eleven years. He is the founder and CEO of Strategic Management, a firm that provides specialized compliance advisory services. Richard can be contacted at email@example.com.
CPT designed modifiers to represent the extra physician work involved in performing a procedure because of extenuating circumstances present in a patient encounter. Modifier 22 represents those extenuating circumstances that don’t merit using an additional or alternative CPT code, but instead raise the reimbursement for a given procedure. The key to collecting reimbursement for increased procedures is all in the documentation. Sometimes a physician will tell you he did “x, y and z,” but when you look in the documentation, the support isn’t there. Documentation is your chance to demonstrate the special circumstance that warrants modifier 22.
Also, don’t forget to add on the additional dollar amount that you are asking for by using the modifier. Payers just don’t pay you extra with this modifier; you need to say I am asking for $____ extra and this is why.