Thursday, July 18, 2013

Humana Inc. to Release Second Quarter 2013 Results on July 31, 2013 | Humana Healthcare

LOUISVILLE, Ky.--(BUSINESS WIRE)--Humana Inc. (NYSE: HUM) will release its financial results for the second quarter 2013 (2Q13) on Wednesday, July 31, 2013 at 6:00 a.m. eastern time. The company will host a conference call, as well as a virtual slide presentation at 9:00 a.m. eastern time that same morning to discuss its financial results for the quarter and earnings guidance for 2013.
The live virtual presentation (audio with slides) of the 2Q13 earnings call may be accessed via Humana’s Investor Relations page at The company suggests web participants sign on approximately 15 minutes in advance of the call. The company also suggests web participants visit the site well in advance of the call to run a system test and to download any free software needed to view the presentation.
All parties interested in the audio only portion of the call are invited to dial 888-625-7430. No password is required. The company suggests participants dial in at least ten minutes in advance of the call.
For those unable to participate in the live event, the virtual presentation archive will be available in the Presentations section of the Investor Relations page at, approximately two hours following the live webcast. Telephone replays will be available from 12:00 p.m. eastern time on July 31, 2013 until midnight eastern time on August 2, 2013 and can be accessed by dialing 855-859-2056 and providing the conference ID # 14857032.
The company’s 2Q13 earnings news release may include financial measures that are not in accordance with Generally Accepted Accounting Principles (“GAAP”). If so, a reconciliation of non-GAAP financial measures to financial results under GAAP, as well as management’s reasons for including non-GAAP financial measures, will be included in the company’s 2Q13 earnings news release, a copy of which will be available on the Investor Relations page of on July 31, 2013.
Humana Inc., headquartered in Louisville, Kentucky, is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.
More information regarding Humana is available to investors via the Investor Relations page of the company’s web site at, including copies of:
  • Annual reports to stockholders;
  • Securities and Exchange Commission filings;
  • Most recent investor conference presentations;
  • Quarterly earnings news releases;
  • Replays of most recent earnings release conference calls;
  • Calendar of events (including upcoming earnings conference call dates and times, as well as planned interaction with research analysts and institutional investors);
  • Corporate Governance information

Humana Inc. to Release Second Quarter 2013 Results on July 31, 2013 | Humana Healthcare

The Greatest Investment You Will Ever Make in Your Practice

Who spends the most time on the phone with your patients? Who is responsible for distributing incoming faxes to the appropriate person?
When was the last time that you invested in educating your entire team? 
Continuing medical education is a requirement for physicians, nurses and coders, but what about every other position in the practice?
High performing medical practices understand that staff training, development and education, at the right time, provides big payoffs for the employer in increased productivity, knowledge, loyalty, and contribution.
Champion practice managers and providers also know that sending one or two employees to training will never be enough to interject true change in a practice.
Employees want to learn new skills, develop their capabilities, and grow their knowledge and careers. Making developmental opportunities available to each employee demonstrates your commitment to helping them develop their careers. They appreciate this.
Empirical Risk Management has developed a 3 day RAPID PRACTICE INNOVATION PROGRAM has an alternative to traditional education and training options.
Our innovating program comes to your office and works around your schedule. We provide Lean Tools that encourage more efficient processes and happier, more engaged employees. Our program is completely customizable to fit your needs and we offer specialized training for Medicare Risk Adjustment, ICD-10, and Clinical Documentation Improvement.
If you believe that there might be room for improvement , there probably is…

Kameron Gifford, CPC

How the NHS can build partnerships with other organisations

  • Guardian Professional

Meeting the challenge: commissioning support units are being encouraged to build partnerships with other organisations. Photograph: Graeme Robertson/Getty Images
Many NHS staff have already been looking beyond business-as-usual, to really get to grips with the challenge of major clinical service change.
There is no silver bullet. Health services will continue to experience increasing demands, both demographically and societally driven. Against this backdrop, the challenges of maintaining and improving quality standards and improving things for patients, at the same time as reducing spend, have been brought into sharp relief by recent events in Staffordshire and elsewhere.
But how does the NHS affect the cultural and practical changes to patient behaviours? How do they achieve the investment in technology and other resources? How, without surrendering control of the clinical decision-making agenda, do they seek the funding and additional, commercial and other skills that they require?
To meet this challenge, commissioning support units (CSUs) are being encouraged to start building partnerships with other NHS, commercial and third-sector organisations, who can bring fresh thinking and wider expertise to the NHS.
For clinical commissioning groups (CCGs) as customers, dealing with a CSU-led commissioning support partnership may also help to simplify contractual arrangements. CCGs will also be looking for ways to better align the incentives of commissioning support organisations with their own successful delivery of the quality, innovation, productivity and prevention (QIPP) agenda. A broader CSU partnership, where there is greater ability to invest, manage risk and explore outcomes-based risk and reward contracts may be the way to move towards this.
Between 2008 and 2011, my team partnered with NHS Ashton Leigh and Wigan to deliver Transforming Commissioning Saving Lives, one of the first large-scale commissioning transformation programmes under the national framework. Ashton Leigh and Wigan undertook the programme in response to a number of challenges; mounting financial pressure to reduce acute activity, poor health outcomes (compared with national benchmarks), and commissioners struggling to gain control in a health economy dominated by the local hospital trust.
Working together, we devised and implemented a number of strategies to improve commissioning of clinical care services, to both enhance performance and achieve savings. We undertook organisational development and leadership coaching – working with the chief executive and his team and in joint programmes with the local authority.
We worked closely with commissioning managers, clinical commissioners, patients, doctors, nurses and health systems partners to redesign local stroke services, commissioning a pathway to diagnose and manage patients following a transient ischemic attack (TIA) or mini stroke, and to provide holistic and person-centered health and social rehabilitation for people who have had a full stroke.
This resulted in a reduced average length of time a patient spends in hospital – from 56 days to 12 days. It achieved £14.39m worth of savings. But it also achieved more long-term, fundamental changes through the skills and knowledge transferred.
My experience leads me to believe successful partnerships can offer significant benefits to both the public sector service delivery organisation (for example, a local authority or, in this case, a CSU) and the private or third sector partner. They offer greater resilience in terms of both capacity and capability.
Partnerships also mean that risks can be shared and that investment can be attracted from partners who are more able to fund new technology and other resources. And lessons can be learnt from the experience of other parts of the private and public sector about innovative ways to get service users and their families engaged, and providers of healthcare services doing things differently.
Matthew Harker is director of healthcare consulting at Capita.

The Stark Law and Federal Anti-Kickback Laws: What You Need to Know

7/18/2013 - Kameron Gifford, CPC

Could my organization be at risk? What areas exist for potential violations?

Anti Kickback Enforcement - 
In the past, kickback enforcement actions have concentrated on three areas: kickbacks related to costs shown on cost re-ports; physician referrals to hospitals, suppliers, and ancillary services; and hospital referrals to entities that provide services to patients after hospitalization, such as medical equipment suppliers or nursing services. However, there is an increasing role in healthcare for payors and middlemen who control or influence purchasing decisions by using access to patient health and utilization information and provider data. These payors and middlemen may pay kickbacks to obtain or retain contracts, to receive favorable treatment in contracts, to obtain confidential patient or provider data, or to influence agents or fiduciaries to exercise discretion on behalf of a principal in favor of the payor. This body of law can be complex because the techniques used by payors and recipients vary by industry, and there are more extensive and complicated money flows among the parties and related entities. 

Stark Act Definitions.

Before addressing some of the exceptions, it is important to define the key terms of the general rule. The fundamental way to avoid the application of the general rule is to distinguish oneself from the definition of critical terms. First and foremost, it should be noted that the Stark Act only prohibits referrals to entities for a DHS. Designated health services include:
  1. clinical laboratory services;
  2. physical therapy services;
  3. occupation therapy services;
  4. radiology services (including MRIs, Ultrasounds, and CAT scans);
  5. radiation therapy and supplies;
  6. durable medical equipment and supplies;
  7. parenteral and enteral nutrients, equipment, and supplies;
  8. prosthetics, orthotics, and prosthetic devices and supplies;
  9. home health services;
  10. outpatient prescription drugs; and
  11. inpatient and outpatient hospital services.
If that seems like pretty much everything, it is.

Who is part of my immediate family?

Physicians must take note that the direct or indirect financial relationships of an “immediate family member” will be imputed to them for the purpose of determining whether a referral was a prohibited one. “Immediate family member” is defined as a “husband or wife; birth or adoptive parent, child, or sibling; stepparent, stepchild, stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; grandparent or grandchild; and spouse of a grandparent or grandchild.” Once again, the regulations use a broad definition that should give physicians and health care providers pause.

What counts as a financial relationship?

The most critical definition for physicians wishing to comply with Stark entails understanding what constitutes a “direct or indirect financial relationship.” In general, a “financial relationship” is a direct or indirect ownership interest, investment interest, or compensation arrangement with any entity that furnishes DHS. What constitutes a direct financial relationship is fairly straightforward, with one twist: A direct relationship exists if the investment interest or the compensation passes between either the referring physician or a member of his or her immediate family and the entity furnishing the designated health service without any intervening persons or entities. Thus, even if a physician has no contact with a DHS-providing entity, he or she may still have a direct financial relationship with the entity through an immediate family member. In contrast to a direct relationship, what constitutes an indirect relationship is more complex, and requires analysis in the context of the three different types of “financial relationships.”

What is an Ownership or Investment Interest? What counts as an Indirect Ownership or Investment Interest?

An ownership or investment interest in a DHS entity can take the form of equity, debt, stock, certain stock options, partnership interests, memberships interests in an LLC, etc. An ownership or investment interest “includes an interest in an entity that holds an ownership or investment interest” in the DHS entity. Thus, an ownership interest in a subsidiary company is not an ownership interest in the parent or another subsidiary of the parent unless the subsidiary has an interest in the parent or another subsidiary of the parent. An interest in a retirement plan is specifically excluded from the definition of ownership or investment interest. The following, while specifically excluded from the definition of ownership or investment interest, are
nonetheless considered a form of “compensation arrangement”:

1) stock options or convertible securities until executed;
2) an “under arrangement” contract between a hospital and a physician-owned entity;
3) a security interest held by a physician in equipment sold to a hospital and financed
through a loan from the physician; and
4) an unsecured loan subordinated to a credit facility.

An indirect ownership or investment interest exists if there is “an unbroken chain” of persons having an ownership or investment interest and the entity providing DHS has actual knowledge or acts in “reckless disregard or deliberate ignorance” that the referring physician has an indirect ownership interest in the entity, no matter how many “intermediary” interests exist. In fact, an indirect ownership or investment interest exists even though the entity providing DHS does not know the “precise composition of the unbroken chain.” Referring physicians and DHS entities must therefore be careful to check that no “unbroken chain” establishes an indirect ownership or investment interest. As noted above, the DHS entity will be denied payment despite its lack of knowledge if, depending on the circumstances, CMS determines that the entity has acted with reckless disregard or ignorance of the referring physician’s investment and ownership interests along the chain. A DHS entity therefore should make certain it knows exactly whom they are dealing with before accepting a referral.

What is a Compensation Arrangement? What counts as an Indirect Compensation Arrangement?

If you thought the definition of an ownership or investment interest was complex, it gets worse. Of the types of financial relationships prohibited by the Stark law, compensation arrangements are the most onerous to grasp. A compensation arrangement is “any arrangement involving remuneration, direct or indirect, between a physician (or a member of a physician’s immediate family) and an entity,” including “under arrangement” contracts. In addition to the twist involving members of the physician’s immediate family noted above, a physician is deemed to have a direct compensation arrangement with a DHS entity if “the only intervening entity between the physician and the entity furnishing DHS is his or her physician organization. In such situations, for purposes of this section, the physician is deemed to stand in the shoes of the physician organization.”
The regulations entail a long definition of an indirect compensation arrangement. First, an indirect compensation, like an indirect investment or ownership interest, requires an “unbroken chain” of persons or entities having a financial interest between the referring physician and the DHS entity. However, unlike the indirect investment or ownership interest, an indirect compensation arrangement can exist if the intervening interest is either an investment or ownership interest or a compensation arrangement. Second, the referring physician must receive compensation from a person or entity in the chain with which the physician has a direct financial relationship that varies with the volume or value of referrals generated by the physician for the DHS entity. Finally, just as in the context of an indirect ownership or investment interest, the DHS entity must have “actual knowledge of, or act in reckless disregard or deliberate ignorance of” the referring physician’s compensation varying with the volume or value of referrals. For the purposes of determining whether an unbroken chain exists, the physician will “stand in the shoes” of his or her physician organization.

Concerned your Financial Relationships Might Implicate the Stark Act?

You should be. Violation of the Act will result in a denial of payment by Medicare to the DHS and could result in a civil penalty of up to $100,000 for the DHS entity, referring physician, or both. A physician or other entity wishing to determine compliance with the Stark act has several options. The physician or entity can contact our offices with their questions and receive guidance based on their situation. Further, a physician or entity can request an “advisory opinion” from CMS regarding whether their referral arrangement violates the Act and regulations promulgated under it. It should be noted that advisory opinions are binding on both the requesting party and CMS. This can be a useful tool because it will give assurance to the physician or DHS-providing entity. Although both options entail costs, those costs are dwarfed by the potential costs associated with the CMS determining a referral to be “prohibited.”

What is the Anti-Kickback Law and How is it Different from Stark?

Although similar in purpose, the statute colloquially known as the “Anti-Kickback” law imposes even more severe penalties on entities violating its provisions. The Anti-Kickback law makes it a felony for anyone who receives a form of payment in return for referring a patient to another for Medicare or Medicaid-covered services. The law also forbids payment in return for purchasing, leasing, or ordering any good, facility, service or item which would be paid for under either Medicare or Medicaid. Violating the act comes with a heavy penalty – a felony conviction punishable by a fine up to $25,000 and/or five years in jail. Both sides of the transaction are forbidden – the law forbids both the receipt of and the offering to pay or payment of the kickback. Recently, Physician-Vendor relationships have come under heightened scrutiny by federal and state regulators. It is important for physicians and their vendors to carefully structure their relationships to avoid potentially violating the Anti-Kickback law.

“Safe Harbor” Transactions

Congress and the Department of Health and Human Services (“HHS”) have provided several “safe harbors” allowing entities to avoid violations of the Anti-Kickback law. Many of the excepts are made to exclude certain arrangements or transfers from the definition of payment, thus shielding the parties from potential criminal liability under the Anti-Kickback law. The safe harbors include:
1. Investment Interests:
Three types of payments are exempted under the safe harbor for “investment interests.” To fit in the first exemption, the entity must have less than $50 million in assets related to the furnishing of health care items and services. With active and passive investors, there are restrictions on the respective ownership interests that may be held by those capable of making referrals or furnishing Medicare or Medicaid covered health services. These restrictions are relaxed somewhat if the entity is located in an “underserved area.” The exemption for investment interests allows that, in certain circumstances, dividends or interest are deemed not to be payments as far as the Anti-Kickback law is concerned. However, the regulations impose very precise and lengthy conditions on compliance with the exemption. Entities wishing to use this exemption should consult with their attorney to ensure full compliance with the investment interest safe harbor.
2. Space Rental:
Remember that the Anti-Kickback law forbids certain leasing arrangements. Recognizing that this could put a strain on health care providers attempting to find a place to set up shop, HHS provided a safe harbor for space rental. This safe harbor requires the lease to be in writing, cover all the premises leased between the parties and specify those premises, be for at least one year, be for fair market value rent, which is set in advance, and not lease more space than is “reasonably necessary” to provide the desired service. The rent can in no way reflect the volume or value of referrals between the parties for Medicare or Medicaid covered services.
3. Equipment Rental:
What good is an empty office? Modern health care requires some very complicated and very expense equipment. Many health care providers find it more economical to rent rather than own their equipment. In a corollary to the safe harbor for space rental, HHS has provided a safe harbor for equipment rental. The same conditions as applied to the space rental lease apply to the equipment lease.
4. Personal Services / Management Contracts:
A safe harbor exists for payment made to agents (persons authorized to act for another) as compensation, so long as the agency agreement is set out in writing and covers all the services the agent will provide, be for not less than one year, be for an amount equal to the fair market value for such services, be for an amount set out in advance, and in no way take into account the volume or value of any referrals or business generated payable by Medicare or Medicaid.
5. Referral Services:
Payment can even be made to a referral service under a safe harbor promulgated by HHS. The payment, as you’ve probably guessed, cannot be based on the volume or value of referrals, but only on the costs of operating the referral service. There can be no restrictions on the manner in which the services referred are provided. Further, the referral service must make certain disclosures to the person seeking the referral and maintain a written record certifying those disclosures.
6. Payments made to Bona Fide Employees:
Payments to an employee will be safe so long as there is a “bona fide” (real) employment relationship and the payments do not take into account the value or volume of referrals for Medicare or Medicaid covered services.
7. Recruitment:
Just as there were relaxations under STARK for physician recruitment, there exists a safe harbor under the Anti-Kickback regulations for payments made to induce a practitioner to join with an entity. There is a litany of conditions that must be met for this safe harbor to be met. For example, if the recruit is leaving an established practice, the revenues at the recruiting entity must generate 75% of its revenue from new patients; that is, the recruit can only bring 25% worth of patients with him from his old practice. Further, there can be no condition that the recruit make referrals, influence referrals, or otherwise generate business for the new entity as a condition of receiving the benefits of his or her new employ.

Medical neighborhood project aims to connect primary care practices, community providers

By: Cody Erbacher
A nationwide “medical neighborhood” pilot project aims to connect primary care practices with community-based health providers to improve care and lower costs.
The Patient-Centered Medical Neighborhood (PCMN) builds on the Patient-Centered Medical Home (PCMH) concept that’s designed to improve care coordination between primary care practices and specialists.
A total of 90 primary care practices will participate in the project, according to TransforMED, a subsidiary of the American Academy of Family Physicians (AAFP).  
“Implementing the PCMH model is critically important,” said Bruce Bagley, MD, FAAFP, interim president and CEO of TransforMED. “The context of a well-coordinated and connected medical neighborhood will not only give patients the safe, reliable and efficient care they desire, but also will increasingly empower them to manage their health in a proactive way.”
TransforMED, whose purpose is to give consultation and support to physicians transforming their practices to PCMHs, believes the project could lead to a more efficient, coordinated healthcare delivery network that improves care at a lower cost.
In attempts to understand current process and identify areas of improvement, TransforMED will meet with practice leaders to assess four areas: costs, health, patient experience, and scalability.
This three-year project, funded by a $20.75 million award by the CMS Center for Medicare and Medicaid Innovation, will involve 15 health systems in 65 cities across the country.
TransforMED plans to attain the following goals by 2015:
Reduce overall costs for Medicare and Medicaid beneficiaries by 4% ($49.5 million).
Improve the health of the eligible population by an average of 15% - and at least 3% improvement – in each selected quality measure.
A 25% improvement in patient experience measures that reflect patient engagement, access, and quality.
Demonstrate the ability to scale to additional practices within each community.