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

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%

Physician incomes have fallen in inflation adjusted dollars for 13 of the last 20 years!

“Nothing is as powerful as an idea whose time has come” 

Victor Hugo

*The best defense 

*Premium cost levels 

*Low hassle factor

Presentation to theAssociation of Black Cardiologists

Ralph Tribendis , Vice President

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 – CSI’s 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.

Differences between an Alternative Risk PL Program and the Traditional Approach (Insurance Company) (From a PL claims perspective)

Category Traditional CaptiveNuisance 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 carrier’s 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.

Demand Letter

Region C Audit Contractor (RAC) Letter Request ID: RAC Point of Contact Provider Name Address 1 Address 2 City, State Zip Re: Provider Name # 123456789 Dear Medicare Provider, The Centers for Medicare & Medicaid Services (CMS) has retained DCS to carry out the Recovery Audit Contracting (RAC) program in the State of _______. The RAC program is mandated by Congress aimed at identifying Medicare improper payments. This letter is to notify you that Medicare has made an overpayment to you for the amount of $_______. A brief description of the claims associated with this overpayment can be found on the “Overpayment Report” page. In order to correct this overpayment, please refund $______ by xx/xx/xxxx. This overpayment was identified through data analysis. Data analysis showed a billing pattern inconsistent with (insert LCD or policy in violation). (The policy in violation) states ______________________________________________. Data analysis showed that the claims paid by Medicare _________________. (The above lines are the rationale for the improper payment and the detailed explanation.) The results of our data analysis justified reopening your claim under §1869(b) (G) of the Social Security Act and 42 CFR 405.980(a)(1). These results also serve as good cause to reopen the claim, if required by 42 CFR 405.980(b) (2). Please make the check payable to Medicare and send it with a copy of this letter to the following address:

Accounting Dept P.O. Box 9999 City, State Zip

If you local claims processing contractor offers an immediate offset option contract (name of contractor) ______________________. NOTE: If the overpayment jis for services that are not medically reasonable and necessary per Medicare standards, and you collected the amount of the overpayment from the beneficiary, the beneficiary has the right to request payment from Medicare. Any such indemnification will be recovered from you. Thank you for your cooperation and prompt attention to this overpayment. If you have any questions regarding this letter or would like to discuss the overpayment identification, please direct your inquiry to customer service at (phone number) 1-866-201-0850. Sincerely, Julia Baker Customer Service Manager

RAC Audit

1. 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

2. Coordination of benefits

Identification and recovery for other party liability,

including other commercial insurance, Medicare, or

Medicaid, or other state-sponsored plans.

3. Medical Chart ReviewObtaining 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

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, J&Q codes, verification of dosage• Lab services-outpatients vs. inpatient• Dialysis-multiple sessions within one day

3. Medical Chart Review (continued)• E&M 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

4. Provider Billing ComplianceThis encompasses reviewing provider billing in conjunction with payer contracts and payment guidelines to ensure proper payment. Areas include:

4. Provider Billing Compliance (continued)• Procedures

– Incidental – Mutually exclusive services

• Transplants• Implants• CPT coding & modifiers• Bundling and unbundling• Ambulance related services• Anesthesia• Observation• DRG

4. Provider Billing Compliance (continued)

-High cost drug analysis

-ESRD-Quantity differences

-Rate analysis

-Billed unit analysis

-Multiple surgeries

-Assistant surgeon

-Split bill

FOR FURTHER INFORMATION CONTACT AUSA VICKIE E. LEDUC or MARCIA MURPHY at 410-209-4885 November 9, 2010 FOR IMMEDIATE RELEASE http://www.usdoj.gov/usao/md

ST. JOSEPH MEDICAL CENTER AGREES TO PAY $22 MILLION TO RESOLVE FALSE CLAIMS ACT ALLEGATIONS IN CONNECTION WITH KICKBACKS PAID

TO MIDATLANTIC CARDIOVASCULAR ASSOCIATES

Settlement Includes Repayment of Money Received for Medically Unnecessary Stents

BALTIMORE, MD – St. Joseph Medical Center (“SJMC”) in Towson Maryland agreed to pay $22 million to settle allegations under the False Claims Act that it paid unlawful remuneration under the Anti-Kickback Act and violated the Stark Law when it entered into a series of professional services contracts with the Pikesville, Maryland based cardiology group, MidAtlantic Cardiovascular Associates (“MACVA”). The settlement was announced by United States Attorney for the District of Maryland Rod J. Rosenstein, Assistant Attorney General Tony West of the Civil Division of the Department of Justice; Special Agent in Charge Nicholas DiGiulio, Office of Inspector General of the Department of Health and Human Services, Office of Investigations; Special Agent in Charge Robert Craig of the Defense Criminal Investigative Service - Mid-Atlantic Field Office; and Special Agent in Charge Drew Grimm of the Office of Personnel Management - Office of Inspector General.

The allegations resolved in the settlement include the payment of kickbacks to MACVA under the guise of professional services agreements, in return for MACVA’s referrals to SJMC of lucrative cardiovascular procedures, including cardiac surgery and interventional cardiology procedures, over the period from January 1, 1996 to January 1, 2006. The settlement agreement resolves issues relating to eleven professional services agreements between MACVA and SJMC under which MACVA received payments above fair market value, for services not rendered or that were not commercially reasonable and were entered into for the purpose of inducing referrals by MACVA to SJMC. Under the settlement the hospital also agrees to repay monies it received from federal health benefit programs between January 1, 2008 and May 12, 2009 for medically unnecessary stents performed by Mark Midei, M.D., a one time partner in MACVA who was later employed by SJMC.

“Kickbacks give doctors an incentive to pursue unnecessary treatments that are costly and sometimes even dangerous to patients,” said United States Attorney for the District of Maryland Rod J. Rosenstein. “Medical care providers are prohibited from giving or receiving kickbacks because of the risk that they will put their own financial interests ahead of their patients’ interests.” “Kickbacks for medical services undermine the integrity of our health care system,” said Tony West, Assistant Attorney General for the Civil Division of the Department of Justice. “When hospitals put their own financial interests ahead of the best interests of patients, we will take action.”

“Payoffs to influence health care decision-making too often result in inappropriate, unnecessary and harmful medical practices” said Daniel R. Levinson, Inspector General of the Department of Health and Human Services. “OIG is committed to protecting patients from needless medical procedures, such as the insertion of unnecessary cardiac stents -- as is alleged in this case.” The settlement resolves a lawsuit brought by whistleblowers, Stephen D. Lincoln, M.D., Peter Horneffer, M.D. and Garth McDonald, M.D., cardiac surgeons who practiced together as members of Cardiac Surgery Associates in Baltimore, Maryland. The lawsuit, which was filed in the District of Maryland in June, 2010 under the qui tam provisions of the False Claims Act, alleges that SJMC violated the Anti-Kickback Act, Stark Law and the False Claims Act by paying various forms of illegal remuneration to MACVA to induce referrals of patients insured by federal health care programs for cardiac procedures. Drs. Lincoln, Hornefer and McDonald brought their suit under the qui tam provisions of the False Claims Act, which permit private citizens with knowledge of fraud against the government to bring a lawsuit on behalf of the United States and to share in any recovery. Under the civil settlement announced today, the relators will receive a portion of the federal share of the recovery.

Saint Joseph's also signed a Corporate Integrity Agreement (CIA) with the Department of Health and Human Services, Office of Inspector General (HHS-OIG), which requires SJMC to ensure accurate billing and appropriate relationships with referral sources, and addresses patient care issues. The CIA also requires the hospital to, among other things, appoint physician executives to oversee medical staff quality-of-care matters. The settlement announced today was the result of an investigation by the U.S. Attorney’s Office for the District of Maryland and the Commercial Litigation Branch of the Justice Department’s Civil Division with assistance from the U.S. Department of Health and Human Services, Office of Inspector General; the Department of Defense Office of the Inspector General, Defense Criminal Investigative Service; and the Office of Personnel Management, Office of Inspector General. The case was handled by Maryland Assistant U.S. Attorney Jamie M. Bennett.

Five Arrested for Criminal Racketeering, Medicaid Fraud

~Former hospital administrator and medical staff arrested; more arrests pending ~

TALLAHASSEE, FL - Florida Attorney General Bill McCollum and the Florida Department of Law Enforcement (FDLE) today announced the arrest of five individuals on various felony charges including racketeering, Medicaid fraud, money laundering, aggravated white collar crime, and operating a scheme to defraud. The arrests are the culmination of a joint investigation between the Medicaid Fraud Control Unit, FDLE and the State Attorney’s Office for the Third Judicial Circuit into activities at the now closed Trinity Community Hospital and its affiliated clinics in Hamilton, Suwanee and Columbia counties. More arrests are pending. “This investigation exposed a pattern of corruption that has siphoned hundreds of thousands of dollars away from Florida taxpayers, and today that scheme will end,” said Attorney General McCollum. “Stopping Medicaid fraud, whether it is perpetuated by hospitals, doctors, or anyone else, will continue to be one of our primary focuses.” “We are not going to tolerate this sleazy activity in Florida medical facilities,” said FDLE Commissioner Gerald Bailey. “These crimes take resources from our citizens who need medical assistance and FDLE has no tolerance for such victimization.” Investigators with the Attorney General’s Medicaid Fraud Control Unit and FDLE arrested officers and employees of HC Healthcare, Inc. including owner Robert A. Krasnow, 36, of Gainesville; Dr. Yong Am Park, 66, of Lake City; Robert T. Krasnow, 58, of Gainesville, the father of Robert A. Krasnow; hospital administrator Christina L. Ortega, 42, of Lake City; and licensed practical nurse Ashley Lane Butler, 37, of Live Oak. According to the criminal charges, officers, employees and affiliates of HC Healthcare, Inc. engaged in a scheme of admitting Medicaid recipients to the hospital without medical necessity. Investigators determined that in some instances, medical records were altered to justify those hospital admissions. False claims for reimbursement were also submitted to the Florida Medicaid program for services performed outside the scope of Park’s limited physician license.

The investigation also established that over $660,000 in state grant funds dedicated to hospital improvements were received by the corporation, but little if any of these funds were used to make such improvements. Instead, the bulk of these funds were used to support the activities of the criminal enterprise and diverted to the personal use of hospital owner Robert A. Krasnow. Money gained through these fraudulent activities were laundered through various bank accounts controlled by Robert A. Krasnow. Investigators determined that more than $130,000 in Medicaid funds was fraudulently disbursed. Robert A. Krasnow is charged with one count of racketeering, one count of scheme to defraud, one count of money laundering, one count of aggravated white collar crime, and one count of grand theft, all first-degree felonies, and 10 counts of Medicaid fraud, a third-degree felony. If convicted on all charges, he faces a maximum sentence of 200 years and $100,000 in fines. Park is charged with one count of racketeering, a first-degree felony, and 10 counts of Medicaid provider fraud, a third-degree felony; if convicted on all charges, he could face a maximum of 80 years in prison and $60,000 in fines. Robert T. Krasnow is charged with one count of racketeering, a first-degree felony, and nine counts of Medicaid provider fraud, a third-degree felony; if convicted on all charges, he faces a maximum of 75 years in prison and $55,000 in fines. Ortega is charged with one count of racketeering, a first-degree felony, and three counts of Medicaid provider fraud, a third-degree felony; if convicted of all charges, she will face up to 45 years in prison and $25,000 in fines. Butler is charged with one count of conspiracy to commit racketeering, a first-degree felony, and if convicted could face up to 30 years in prison and $10,000 in fines. The case will be prosecuted by the State Attorney’s Office for the Third Judicial Circuit and specially designated attorneys from the Attorney General’s Medicaid Fraud Control Unit. The Federal Bureau of Investigations, the Internal Revenue Service, the Sheriffs of Hamilton, Columbia and Alachua counties, the Ocala Police Department and the McHenry County Sheriff’s Office in Illinois provided substantial assistance during the course of the investigation. Florida Statutes provides that persons who report Medicaid fraud may be entitled to a reward for their information. Tips can be reported by contacting the Attorney General’s Fraud Hotline at 1-866-966-7226. Rewards will only be paid after a case has resulted in a fine, penalty or forfeiture of property. The amount of the reward may be up to 25 percent of the amount recovered or a maximum of $500,000 per case. The Medicaid Fraud Control Unit has a process to protect the identities of confidential informants.

U.S. Department of JusticeUnited States AttorneyDistrict of Maryland Rod J. Rosenstein 410-209-4800United States Attorney TTY/TDD:410-962-4462

410-209-488536 S. Charles Street FAX 410-962-3091Fourth Floor Vickie.LeDuc@usdoj.govBaltimore, 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) 209-4885www.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

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.”

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 healthcare 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 Attorney’s Office for the District of Maryland during an investigation of his medical practice.

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.

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 <

http://www.racb.cgi.com> • Area (C) Southeast to Southwest - Connolly

connollyhealthcare.com/rac <http://www.connollyhealthcare.com/rac>

• Area (D) West - Health Data Insights racinfo.healthdatainsights.com <http://www.racinfo.healthdatainsights.com>

Physician Compliance Plan

Components of Compliance

1. 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.

1. 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

• 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.

2. Standards and ProceduresPeriodic 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

3. Designate a Compliance Officer

4. Conduct Training & Education

5. Respond to Detected Offenses

3. Open lines of communication

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.

• 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).

• 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.

• 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.

• 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.

• 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

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 HospitalDate of Service: 10/01/2007 – OpenStates Affected: Alabama, Arkansas, Colorado, Florida,

Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia 

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 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