How ObamaCare Will Affect Your Doctor?

7. 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

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

12. “Nothing is as powerful as an idea whose time has come”  Victor Hugo

13. *The best defense  *Premium cost levels  *Low hassle factor

15. Presentation to theAssociation of Black Cardiologists Ralph Tribendis , Vice President

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

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

19. 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

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

21. 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

22. 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

23. 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 • Provider Billing Compliance This encompasses reviewing provider billing in conjunction with payer contracts and payment guidelines to ensure proper payment. Areas include:

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

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

32. U.S. Department of Justice United States Attorney District of Maryland Rod J. Rosenstein 410-209-4800 United States Attorney TTY/TDD:410-962-4462 410-209-4885 36 S. Charles Street FAX 410-962-3091 Fourth Floor Vickie.LeDuc@usdoj.gov Baltimore, Maryland 21201-2692 Vickie E. LeDuc Public Information Officer September 1, 2010 CONTACT AUSA VICKIE E. LEDUC FOR IMMEDIATE RELEASE orMARCIA 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

33. 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.”

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

35. 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.

36. 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>

37. Physician Compliance Plan

38. 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.

39. 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

40. 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

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

42. 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.

43. 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).

44. 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.

45. 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.

46. 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.

47. 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

48. 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 

49. 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