New Medicaid system starts Sunday in Palm Beach County

Thousands of low-income seniors in Southwest Florida and areas of the East Coast are poised this weekend to become part of the state's long-debated shift to a Medicaid managed-care system.

The change, which will take effect Sunday, will involve an estimated 13,450 people in 12 counties — including Palm Beach County — who need long-term care, most of them seniors.

Approved by lawmakers and Gov. Rick Scott in 2011, the changes have long been controversial, with critics questioning the care Medicaid beneficiaries will receive. But Liz Dudek, secretary of the state Agency for Health Care Administration, said this week that state officials are trying to address questions and concerns through "outreach'' to service providers and through other efforts.

"The agency and its partners are committed to making the transition to statewide Medicaid managed care as seamless as possible,'' Dudek said in a prepared statement. "However, if there is a hiccup along the way, we have put a number of tools in place to fast-track those issues to the individuals who can make things right.''

The state has started the changes by planning to move roughly 90,000 people who need long-term care into the new system. That process started Aug. 1 in a four-county region of Central Florida and will continue until March 1, 2014. AHCA then plans to turn to enrolling the broader Medicaid population in managed care.

Lawmakers have divided the state into 11 regions to carry out the plan, with the long-term care changes taking effect Sunday in two of the regions. The counties in those two regions are Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota, Indian River, Martin, Okeechobee, Palm Beach and St. Lucie.

Under the system, AHCA sought bids from health plans in each region and awarded varying numbers of contracts. In the Southwest Florida counties, the available plans are American Eldercare, Sunshine State Health Plan and UnitedHealthcare of Florida. In the East Coast counties, the available plans are American Eldercare, Coventry Health Plan, Sunshine State Health Plan and UnitedHealthcare of Florida.

Many of the new managed-care enrollees already receive care in nursing homes. But a broad goal of the program is to use managed care to provide services to help other seniors remain in their residences or communities, instead of needing to move into nursing facilities.

Groups such as AARP Florida, however, have expressed skepticism about shifting seniors into managed-care plans and have questioned the oversight of the care they will receive.

AHCA officials said they have focused heavily on issues such as trying to prevent disruptions in where people live and in the relationships between Medicaid beneficiaries and service providers. As an example, in the Central Florida region, AHCA said only one assisted-living facility declined to participate in the new system, and 10 Medicaid beneficiaries were moved elsewhere before the managed-care changes took effect Aug. 1.

AHCA will wait until Nov. 1 to make the long-term care changes in the next two regions. Broward County makes up one of those regions, while the other involves 14 North Florida counties stretching from Bay County to Madison County and including Tallahassee.

http://touch.sun-sentinel.com/#section/-1/article/p2p-77222235/

State temporarily suspends doctor charged in Sacred Heart health care fraud case

The state has temporarily suspended the license of a doctor charged in the Sacred Heart Hospital Medicaid and Medicare fraud scandal after his attorneys asked a judge in Indiana to delay his unrelated trial there because he is was "medically unfit."

Dr. Subir Maitra, one of four doctors named in the alleged Sacred Heart conspiracy, faces trial in November in the Northern District of Indiana on similar fraud charges. This week his attorneys asked a judge to delay the start of that trial, saying the 73-year-old was physically frail, had suffered several medical setbacks recently and had lost the ability to concentrate for long periods.

That filing prompted the Illinois Department of Financial and Professional Regulation on Friday to temporarily suspend Maitra's license, saying the filing indicates he "may be "physically and/or mentally impaired" and his practice "presents an immediate danger to the safety of the public."

A hearing on the suspension is set for next week. Thomas Anthony Durkin, Maitra's attorney, declined to comment.

Maitra and three other doctors are charged along with hospital CEO Edward Novak and its chief financial officer, Roy Payawal, in a scheme that allegedly involved paying kickbacks for patient referrals and performing unnecessary procedures, including tracheotomies. Five deaths tied to tracheotomies performed at the hospital are under investigation as part of the probe.

Novak sought to last month have his unusually high $10 million cash bond reduced, based on what his attorneys said were emerging questions about the evidence against him. U.S. Magistrate Judge Daniel Martin on Thursday denied the request, saying it was not appropriate for him to weigh the evidence. He also noted Novak's extraordinary wealth.

"Mr. Novak's personal wealth is estimated at approximately three times the amount posted on his behalf," Martin wrote in his order. "He has set forth no argument demonstrating any type of financial difficulty suffered as a result of the cash amount posted."

http://my.chicagotribune.com/#section/-1/article/p2p-77397961/

Health Literacy Could Reduce Medicare Expenses

By Clara Ritger | Friday, September 13, 2013 | 1:09 p.m.Photo: AP Photo/Anja Niedringhaus

Patients – particularly minorities and those on Medicare – are not actively making decisions about their treatments and procedures because doctor-patient communication is poor, according to a study presented Thursday to MedPAC, the Congressional advisory committee on Medicare.

The result is a greater expense for Medicare and a lack of empowerment among patients.

"Once patients understand the risks and benefits of expensive procedures, they tend to opt for more conservative treatment options," said Rita Redberg, a MedPAC member and professor at the University of California San Francisco School of Medicine.

It's the reason physicians and hospitals are resisting training programs that would teach care providers to include patients in the decision-making process, Redberg said, because they lose money when patients choose less-costly options.

The deliberations of the 17 MedPAC members will be presented as recommendations to Congress and the Department of Health and Human Services.

Improving health literacy, or the ability of patients to understand their health care and make informed decisions, is a stated priority for HHS Secretary Kathleen Sebelius.

It's a priority that could come with significant financial implications for the United States. In 2007, a team of researchers estimated that low health literacy costs the U.S. between $106 and $236 billion annually. A number of factors account for those costs, including a patient's inability to find the best provider, treatment and services for his or her condition. The researchers argue the savings would be enough to insure all of the more than 47 million patients who were uninsured in the U.S. in 2006.

There's room to grow – only 22 percent of Americans are reported to be "proficient" when it comes to their understanding of health care costs and services, according to a U.S. Department of Education study.

Low-income adults are disporportionally affected. Health literacy was lower on average for adults living below the poverty level than those living above, the DOE's 2003 National Assessment of Adult Literacy found. As income increased, so did health literacy.

Racial and ethnic minorities had lower average health literacy scores than White adults, the study showed. Forty-one percent of Hispanic adults and 24 percent of Black adults had below basic levels of health literacy, compared with 9 percent of White adults.

Those numbers complement MedPAC's findings that Hispanic and Black patients report poorer communication with providers than Whites and the 2012 National Healthcare Disparities Report which found that Hispanic and Black patients were less likely to be asked their preferences in treatment decisions.

The health literacy problem also poses a challenge for the success of the Affordable Care Act. Once the exchanges open on Oct. 1, the millions of new patients added to the system in the coming years are expected to have high rates of health illiteracy, as many of them may not have had health insurance before.

How to inform patients – and who to hold accountable for health information – remains controversial. Some MedPAC members argued that health literacy wasn't only the responsibility of the patient, but also the provider, to explain health options in ways patients can understand.

"What if patients were treated with dignity and respect?" said George Miller, a MedPAC member and CEO of CommUnityCare in Austin, Tex. "Maybe then they'd feel empowered."

The consensus among the group was that patient engagement was an important issue that needs to be addressed, but they were unsure how Medicare would play a role.

"Health literacy is a responsibility of the Medicare program in that we should be paying for care that supports shared decision-making," said Mary Naylor, MedPAC member and a professor at the University of Pennsylvania School of Nursing.

But that, commission members said, leaves the question of how MedPAC would measure success, and providing financial incentives for patient-inclusion appeared contentious.

The commission will wrap up its meeting Friday at the Ronald Reagan Building, International Trade Center in the Horizon Ballroom.

http://mobile.nationaljournal.com/congress/health-literacy-could-reduce-medicare-expenses-20130913

Fla. hospitals and clinics to pay $3.5 million

PENSACOLA, Fla. -- Radiation oncology providers in Pensacola will pay $3.5 million to the federal government and the state of Florida to resolve allegations they improperly billed government health-care programs.

The U.S. Department of Justice announced Friday that the providers — which included Sacred Heart Health System and West Florida Medical Center Clinic — had been accused of improperly billing Medicare, Medicaid and the health care program used by uniformed military.

The allegations included billing for services that were performed while doctors were on vacation as well as billing twice for the same services.

The improper billing is alleged to have taken place between 2007 and 2011 at locations in Pensacola and Destin. The allegations were first raised in a whistleblower lawsuit.

The whistleblower, Richard Koch, will receive nearly $610,000.

http://www.miamiherald.com/2013/09/14/3626034/fla-hospitals-and-clinics-to-pay.html

Read more here: http://www.miamiherald.com/2013/09/14/3626034/fla-hospitals-and-clinics-to-pay.html#storylink=cpy

Humana IT systems down Friday

Health care and insurance benefits provider Humana Inc. (NYSE: HUM) experienced some significant technical problems Friday, including problems with its online systems for customers.

A statement on the company’s website says:

“Humana.com is currently experiencing intermittent issues. We’re working hard to resolve all issues as soon as possible. We apologize for any inconvenience.”

In an email, Humana’s vice president for corporate communication Tom Noland said Humana also has been experiencing technical difficulties regarding its ability to receive inbound communications, such as telephone calls and emails.

“Connectivity is now being restored, and we are doing everything we can to complete this work as quickly as possible,” he said. “We apologize for any inconvenience anyone may have experienced.”

It is unclear whether the problems are limited to Humana's Louisville operations.

Humana provides insurance products and health and wellness services nationwide. In 2012, the company had revenue of $39.13 billion. Nationwide, the company has more than 43,000 employees. Locally it has more than 11,000 workers.

http://m.bizjournals.com/louisville/news/2013/09/13/humana-it-systems-down-friday.html?r=full

Ga. doctor finds simple way to pay for health care

Saturday, September 07, 2013, 7:22am

(NECN/NBC News: Lauren Walsh, Augusta, Ga.) - A Georgia doctor has a much simpler way of paying for health care.

He doesn't accept health insurance, Medicare, or Medicaid. Instead, his unique practice offers patients unlimited visits for a flat monthly rate.

Unlike most doctor's visits, Aubrielle Mills' parents aren't paying a copay or towards their deductible, and they say it's eliminating a lot of questions.

"Do we really want to sit in the waiting room? Do we really want to have that expense of being seen? Is it worth just trying to fix it on our own?"asked Nathan Mills, the patient's father.

Like all of Dr. Robert Lamberts' patients, the Mills pay a flat monthly rate for unlimited primary care.

"It is very nice to know each month that this is the amount we pay for our medical bills," said Aubrielle's mother, Meredith Mills.

Lamberts, who left his 18-year career in traditional medicine, admits his new business model is a learning process.

"If I can make each week just a tiny bit of progress, in a month, we've got a moderate amount of progress, and in a year we've got a whole lot of progress if we just keep turning in that direction," explained Dr. Lamberts.

Although all of Lamberts' patients visit him for their primary care, half of them still carry their own health insurance.

Many wonder what happens in case of emergency for those who choose not to have insurance with Lamberts' plan.

"That's where people say, well, then I'll just drop my insurance and take you. I say, you don't want to do that," suggests Lamberts. "You need to have some sort of insurance to cover if you do have those emergencies, or if you do have those problems."

Lamberts believes his patients are less likely to have one of those emergencies because his goal is to keep each of them healthy and out of the doctor's office. It's a concept that benefits his office financially, so that he can add new patients and gain new monthly payments.

"What is our purpose in health care? It's not to give medicines. It's not to draw lab tests. It's to get people healthy."

His latest challenge is selling that concept to patients and the medical community.

"And that's actually, to some extent, a hard sell to patients sometimes because I'm saying, it's not necessary to treat that, or we don't need to do all of those lab tests. Because truthfully, they don't show us anything to make you feel better or make you live longer," said Lamberts.

It's a new kind of thought process, at a time when our nation's health care laws are drastically changing. Lamberts thinks the Affordable Care Act may actually boost his business.

"That says that people can have a direct contract with a physician, along with a high deductible health care plan and that can qualify them for that type of insurance that they're actually covered," Lamberts said.

He believes this could incentivize businesses to offer his service to their employees.

"And I think from my standpoint, that's one of the real opportunities."

http://www.necn.com/09/07/13/Ga-doctor-finds-simple-way-to-pay-for-he/landing_mobile.html?blockID=851703&feedID=11106

South Florida Doctors Seek New Practice Options to Offset Rising Expenses

Individually and in groups, South Florida doctors are trying new business models for their practices that can reduce costs but may increase their risk.

Palm Beach County neurologist James Goldenberg says his practice is weighing a "risk" model where government or managed-care providers pay doctors a flat sum to care for patients. The doctors make money if they control their costs.

In Broward County, Dr. Brian Polner reduced the cost of business operations 20 percent after forming HealthwoRx, a group of cardiovascular, internal medicine and family practice physicians who share a testing lab and other expenses.

"We're seeing more doctors forming groups, or they're going to work for the hospitals," said Cynthia Peterson, executive vice president for the Broward County Medical Association. Nearly half of doctors who responded to a recent survey by the Florida Medical Association said they would pursue alternatives that included trimming their hours, retiring early, providing "concierge" care to a limited number of well-heeled patients, seeking hospital employment, or cutting back on the patients they see.

The trend "bears watching because it could negatively affect Florida patients' access to health care," the state group said.

Goldenberg said physicians are frustrated with ever-changing regulations, lower reimbursements for their services, and bureaucracy that often gets in the way of patient care.

To diagnose a diabetic for nerve damage, for example, he conducts a common test. But insurers and Medicare are reimbursing doctors at a rate 30 percent lower today than in previous years.

Goldenberg said his 75-doctor group, Medical Specialists of the Palm Beaches, is considering "all options" to offset declining reimbursements while maintaining quality care. That includes a model that would encourage doctors to think twice about ordering an expensive test — or assume the financial responsibility if they proceed.

"I think that's going to be a very important model in the future," he said.

Polner, chief executive of HealthwoRx, helped found the 20-doctor Broward County practice in 2005. The goal: to improve patient care through collaboration, which also helps lower costs for the doctors.

"You reduce the redundancy of testing, improve patient compliance by following up with doctors in the group, and have better control of medical records," he said.

By year-end, HealthworRx's number of doctors will double after it forms a new multispecialty model, he said.

But even a larger practice isn't enough to curb spiraling health care costs. A year ago, Polner launched PremierMD, an independent physicians association that contracts with major insurers to reduce costs. If the cost-cutting is a success, the group shares profits with the insurer. The physicians remain independent but benefit from the power of group purchasing for medical and office equipment and supplies.

So far, 80 local doctors have joined the association.

In January, PremierMD will introduce a group that will collect data with the goal of reducing Medicare costs.

"Doctors, especially in South Florida, are afraid of being in a group practice because they're afraid of losing their autonomy. But they want to collaborate with other doctors," Polner said.

Dr. Octavio "Tony" Prieto, who has been practicing family medicine for more than 30 years, is feeling the pinch as a solo practitioner. The Plantation doctor said insurance companies pay less — or nothing at all in some case — while patients cut back on visits to save on co-pays.

At one point, he considered selling his practice to a corporation, but "they couldn't come up with the money to buy my practice," he said.

So Prieto presses on, but has reduced his practice from 14 workers to six. He's also considering eliminating in-office X-rays because they cost more than insurers will pay.

South Florida patients, many who've lost jobs and employer insurance, try to talk their doctors into reducing their bills. "People arm-wrestle you for the $10 co-pay," he said.

Meanwhile, Prieto, 65, said he loves his work too much to give it up.

But someday, "If I can afford it, I will cut down my hours," he said.

http://touch.sun-sentinel.com/#section/-1/article/p2p-77089126/

Ambulance Company Owners Sentenced to Prison for Fraud Scheme

The two men have also been ordered to repay more than $3 million in restitution for their health care fraud scam that used falsified reports to bilk money out of the federal Medicare program.

The owners of a Feasterville-based ambulance company have been sentenced to federal prison after they pled guilty to 41 counts of health care fraud, wire fraud and related charges, according to a press release from the Department of Justice.

Aleksandr N. Zagorodony, 39, of Upper Southampton, was sentenced to 78 months in prison for a fraud scheme involving MedEx Ambulance Inc., located in Feasterville. Zagorodny was the president and a founder of MedEx Ambulance. 

MedEx Ambulance was ordered to be dissolved after it has been excluded from participation in Medicare and its assets are transferred to the government to satisfy restitution and forfeiture obligations. Each defendant had pleaded guilty to all counts in a 41-count indictment including health care fraud, false statements in connection with health care matters, wire fraud, and conspiracy to commit health care fraud and wire fraud.His 36 year-old brother, Sergey Zagorodny, from Philadelphia, the former vice-president and co-owner of the company, was sentenced to 60 months in prison for his involvement in the health care fraud scheme. 

Defendant MedEx Ambulance and its owners transported patients who were able to walk and could travel safely by means other than ambulance and who were not eligible for ambulance transportation under Medicare requirements. 

Falsified reports made it appear that the patients needed to be transported by ambulance when the defendants and their employees knew otherwise. The defendants billed for the ambulance services as if those services were medically necessary. The Medicare program was bilked out of more than $3.4 million through this fraud.

U.S. District Court Judge Berle M. Schiller also ordered restitution to Medicare in the amount of $3,418,358.81, a special assessment of $4,100 for each individual defendant and $16,400 for the corporation, and a three-year term of supervised release for the individuals and five years of probation for the corporation. 

The court ordered the forfeiture of four ambulances that had been purchased for more than $200,000, as well as forfeiture of bank accounts worth more than $40,000, and entered a money judgment against the defendants for $3,418,358.81. 

In connection with the sentencing, the company agreed to sell its base of operations and to provide the proceeds of that sale to the government in partial satisfaction of the defendants’ restitution obligations. The defendants and their wives also pledged to sell their family homes, as well as additional property, and to provide the proceeds of the sale of those assets to partially satisfy the defendants’ restitution obligations.

http://lowersouthampton.patch.com/groups/police-and-fire/p/ambulance-company-owners-sentenced-to-prison-for-health-care-fraud-scheme

Blue Cross Blue Shield of Texas Creates New Accountable Care Organization Alliance

Richardson-based Blue Cross and Blue Shield of Texas announced a new strategic alliance Thursday that it hopes will deliver improved, sustainable patient care while better managing healthcare costs, beginning in mid-2014.

The partnership—with Memorial Hermann Accountable Care Organization—is aiming to improve patients’ health while reducing costs through avoiding unnecessary hospital admissions, readmissions, emergency room visits, and duplication of services.

“This is a paradigm shift in paying for medical services,” Shara McClure, BCBSTX vice president for network management, said in a statement. ”The arrangement begins to move reimbursement away from fee for service to fee for value. In addition, the arrangement enables MHACO to harness clinical data to help drive medical care decision-making, enhance patient safety, and improve quality of care—all supporting the goals of better health and improved outcomes for BCBSTX members.”

The ACO model of healthcare delivery is designed to improve outcomes in three  categories: quality of care, patient experience and satisfaction, and cost efficiency. BlueCross will reach those goals by pursuing:

— Early identification of disease and illness through coordination of patient care

— Use of advanced technology and support services to make more informed decisions and facilitate transitions in care

— the implementation of an alternative or non-fee-for-service payment arrangement

— lower cost trends by increasing coordination among payers and providers

“Our relationship with Blue Cross Blue Shield of Texas around accountable care activities is consistent with Memorial Hermann’s commitment to quality outcomes and cost management,” said Chris Lloyd, CEO of MHACO. “The efforts we will undertake together will continue to advance the health of the populations we serve.”

BCBSTX is entering the ACO game just as another prominent North Texas healthcare organization is leaving it. Plus ACO—the accountable care organization comprised of Texas Health Resources and North Texas Specialty Physician— indicated to CMS in July that it intended to withdraw from the Pioneer ACO program, due to unmet financial goals.

“We look forward to working with CMS in other areas, and we will continue to support the accountable care framework’s fundamental components—reducing costs, improving patient outcomes through enhanced quality of care and care coordination across the continuum,” THR spokesman Wendell Watson said in an email to D Healthcare Daily in July.

Watson said Plus ACO was on track to save $10 million annually, yet was anticipating that it could be liable for a penalty between $6 million and $9 million at the end of the year. Watson said the group will continue to work with commercial plans to implement accountable care programs.

http://healthcare.dmagazine.com/2013/09/06/blue-cross-blue-shield-of-texas-creates-new-accountable-care-organization-alliance/

OIG: Medicare's Recovery Audit Program Generally Accurate

Medicare's recovery audit program is more accurate than critics claim, although it could detect more fraud, according to a report by HHS' Office of Inspector General, Modern Healthcare reports.

In 2006, Congress ordered Medicare to hire four private contractors -- known as recovery auditors -- to oversee Medicare payments and find cases in which providers and suppliers were being overpaid. The auditors have encountered criticism from the hospital industry, which claims that the companies are overly aggressive. Hospitals point to hospital-reported surveys that indicate at least 40% of all payments denials are appealed and 70% of those appeals are successful. Bills in the House and Senate to temper the auditors have garnered support from the American Hospital Association.

However, HHS OIG's report found that of the 1.1 million cases in 2010 and 2011 in which an auditor recommended denying Medicare reimbursements, just 6% were ever appealed and only 44% of those appeals were successful.

The report stated that CMS is falling short on investigating the leads it receives and does not provide enough training or regular updates to help generate new fraud leads. Further, the report noted that although CMS made 28 changes to its billing rules to close "vulnerabilities" found through examination of overpayment data, the department never measured the success of those changes.

In response, CMS Administrator Marilyn Tavenner said measuring the efficacy of such changes is challenging, because some require multiple steps over long periods. She added, "Some are implemented within a few months, while others take significantly longer, hindering CMS' ability to draw conclusions about the effectiveness of a specific corrective action"(Carlson, Modern Healthcare, 9/4).

http://www.californiahealthline.org/articles/2013/9/4/oig-medicares-recovery-audit-program-more-accurate-than-believed

Maryland Family Physicians Lead Health Care Efforts, Innovations

August 30, 2013 02:30 pm James Arvantes – Family physicians in Maryland practice and work in various settings and capacities, using their skills and expertise to deliver and improve health care for thousands of patients throughout the state. This diversity is one of the Maryland AFP's (MDAFP's) greatest attributes, enabling family physicians to forge alliances and common bonds across various agencies, commissions and practice modalities, thereby strengthening the chapter's commitment to public health and advocacy.

"We are a varied bunch," says Yvette Rooks, M.D., executive vice chair and residency program director in the Department of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore and head team physician at the University of Maryland in College Park. "We have folks who practice concierge medicine and folks who are medical directors, and we also have folks who run accountable care organizations. We represent a variety of specialties within our specialty of family medicine."

Although the chapter has only 700 active members, its power and influence extend well beyond its actual membership, putting family physicians in a position to drive fundamental and enduring health system change.

"We are small, yet vocal," says Patricia Czapp, M.D., a member of the governor's subcommittee on health care delivery reform and chair of clinical integration at the Anne Arundel Medical Center in Annapolis. "And we are at the table where decisions are being made."

STORY HIGHLIGHTS

• The Maryland AFP is one of the most diverse chapters in the country, enabling family physicians to forge alliances and common bonds across various agencies, commissions and practice modalities.
• Within their various roles, family physicians in the state are leading health care reform and innovation efforts in both the public and private sectors.
• By drawing on its diversity, the Maryland AFP is able to strengthen its commitment to public health and advocacy, resulting in improved health for thousands of state residents.

Encouraging Leadership

"I know the leaders of this chapter roll up their sleeves and get to work at placing our specialty of family medicine front and center in the most important role we play: improving the health of our state's patients, families and communities," says Yvette Oquendo, M.D., president of the MDAFP and a staff physician at Chase Brexton Health Services in Baltimore.

For example, family physician Niharika Khanna, M.D., serves as program director of the Maryland Learning Collaborative, which provides assistance to the state's multipayer patient-centered medical home (PCMH) initiative. The collaborative has helped 52 practices in the state achieve PCMH status during the past few years, effectively bringing about 250,000 patients into the PCMH model, according to Khanna, an associate professor of Family and Community Medicine, Pediatrics, and Psychiatry at the University of Maryland School of Medicine.

The collaborative has 339 physicians, and 266 of them are primary care physicians. Of that, 133 are family physicians, which gives family medicine a large stake in the learning collaborative.

State officials currently are in the process of expanding the PCMH model via a state innovation grant funded by CMS. Khanna, along with state officials, co-wrote the grant for the expansion.

Another family physician, Laura Herrera, M.D., deputy secretary for Public Health Services for the Maryland Department of Health and Mental Hygiene, is leading the design of the state innovation model. In their respective roles, Khanna and Herrera are spearheading the state's PCMH efforts and planning for the spread of the state's innovation model.

MARYLAND AFP PROVIDES   OPPORTUNITIES FOR CME CREDITS

The Maryland AFP (MDAFP) is one of the few AAFP chapters in the country with an accredited journal that enables family physicians to earn CME credit.

Each issue of the quarterly journal focuses on a clinical, policy or practice management theme and gives family physicians the opportunity to read the articles and take a quiz for CME credit.

"The Maryland chapter has its own credit requirement so that within the AAFP framework of mandating 150 credits every three years, with 75 being Prescribed, six Prescribed credits must be obtained from MDAFP CME," says Esther Rae Barr, C.A.E., executive director of the MDAFP.

Chapter-sponsored programming is offered via live conferences, journals with online quizzes and, new this year, online videos taped at live MDAFP conferences. The CME policy, initiated in 2000, has prompted the chapter "to hone its educational offerings so that members can acquire quality CME and, at the same time, meet the requirement," says Barr.

"We now are in a place where our journal and quizzes are online, allowing family physicians to earn over 12 credits a year from our chapter's website, which is significant."

Khanna is convinced that family physicians are best suited for the leadership role in the state innovation model because of their background and training. "We come in with the whole person orientation, the psychosocial model and a deep understanding of the patient as a partner in their health care," says Khanna. "Family physicians traditionally have been the go-to doctor, and (the) PCMH allows us to provide patient-centered care."

Family physician Donald Shell, M.D., M.A., director of the Cancer and Chronic Disease Bureau and interim director for the Center for Chronic Disease Prevention and Control at the Maryland Department of Health and Mental Hygiene, agrees with that assessment, saying that "family medicine really gives you a broad swath of medicine and health care," which makes family physicians natural leaders in the health care field.

In partnership with the Maryland Million Hearts program(dhmh.maryland.gov), Shell works with Khanna to educate PCMH practices about state resources that are available to help patients achieve better health outcomes in cardiovascular and other chronic diseases. "I recently spoke to some PCMH practices about tobacco-related initiatives and making sure the physicians in the PCMH practices are aware of tobacco cessation resources," says Shell.

The work of Shell, Khanna and other family physicians in helping practices achieve PCMH recognition and better health outcomes for their patients has earned attention beyond the borders of Maryland, too. For example, CMS awarded multiple Maryland applicants accountable care organization (ACO) status as part of the Medicare Shared Savings Program. To quality for ACO status, entities are required to demonstrate a strong foundation of primary care physicians who are able to improve health outcomes and achieve savings, notes Czapp.

Family physicians in the state also have encouraged adoption of electronic health records and have played key roles in connecting primary care practices with the state's health information exchange. "We have many primary care practices that are well down the road of the patient-centered medical home and achieving meaningful use with electronic medical records," says Czapp, who chairs the board of one of the state's ACOs. "Those are the qualifications that allow us to say to CMS, 'We are confident enough in our ability to sign up for this program and demonstrate some savings that we can share among our doctors.'"

Looking to the Future

Czapp and other family physicians in the state are quick to acknowledge that Maryland is a progressive state in terms of health care delivery and innovation. That factor has allowed family physicians in the state to "step up," according to Czapp.

She says she is "shocked" that some states are struggling to initiate PCMH initiatives because officials in those states consider the PCMH experimental. "Light bulbs are experimental," she jokes.

FACTS ABOUT THE MARYLAND AFP

Chapter executive director:Esther Rae Barr, C.A.E.
Date chapter was chartered:June 1948
Number of chapter members:1,200 total, 700 Active
Location of chapter headquarters: Catonsville
Website:(mdafp.org)
2014 annual conference: June 12-14, Holiday Inn, Frederick

In addition, the MDAFP, similar to other AAFP chapters, is experiencing a "generational shift," says Czapp. "We are seeing a lot of new energy coming in. This newer generation is excited about the future and what they see themselves doing as family physicians."

That applies to family physician Kisha Davis, M.D., M.P.H., president-elect of the MDAFP and one of its newer members.

Davis serves as the director of community health for the Casey Health Institute, an integrated primary care center that seeks to merge the best of east and west treatment modalities. "In addition to primary care, we also have an acupuncturist and a chiropractor, and we provide behavioral health, nutrition and wellness," says Davis. "We are not just trying to help people fix their diseases but really trying to address the preventive care and wellness piece and the lifestyle pieces that are a large part of health care and prevention."

In many ways, Davis's career is indicative of the versatility of family medicine. Before assuming her current position, Davis worked in a community health center in Columbia, Md., and served as a White House fellow from 2011-2012. As a White House fellow, Davis worked at the U.S. Department of Agriculture addressing food, nutrition and breastfeeding issues. In the process, she learned how the federal government really works.

"It was really eye-opening in terms of how few voices there are in government for medicine and seeing behind the scenes as to how things run -- where the right niches are to affect change," says Davis.

Similar to other MDAFP members, Davis cites the diversity of MDAFP members as one of the chapter's greatest strengths. But she also says that MDAFP members are "good at identifying potential talent and saying, "Why don't you come to this (MD)AFP meeting."

"A lot of people just need that little nudge," says Davis. 

http://www.aafp.org/news-now/chapter-of-the-month/20130830marylandchapspot0.html

Beth Israel Deaconess Medical Center Pays Over $5 Million for Allegedly Billing Medicare for Improper Inpatient Admissions

by ADMIN on AUGUST 23, 2013

When hospitals unnecessarily admit Medicare patients for short inpatient stays when the appropriate treatment would be outpatient or observation care, they improperly boost hospital profits at significant expense to taxpayers and patients. According to the Justice Department, Beth Israel Deaconess Medical Center (BIDMC) allegedly did just that, when it allegedly billed Medicare for inpatient admissions that should have been billed as lower reimbursed outpatient or observation services. These supposed false claims were submitted from June 1, 2004, through March 31, 2008.

Specifically, the government alleged that BIDMC inappropriately submitted claims to Medicare for one-day stay inpatient admissions for patients with congestive heart failure, chest pain, and certain digestive and nutritional disorders. These claims supposedly should have been billed as observation services, as the patients were briefly admitted for the limited purpose of observation and discharged the next day. In addition, the government alleged that BIDMC submitted claims to Medicare for less-than-one day (zero day) stays that should have been billed as outpatient or observation services.

Such improper inpatient admissions drain government dollars, for Medicare reimburses hospitals at significantly higher amounts for inpatient admissions compared to outpatient or observation services. When confronted by the government, BIDMC agreed to pay the United States $5.315 million to settle the alleged False Claims Act violations.

Of particular note, neither the government nor BIDMC credit a qui tamwhistleblower with raising these allegations. If this was a government-initiated False Claims Act case, this would be one of the few successful FCA cases that was not initiated by a whistleblower.

http://medicare-fraud.net/beth-israel-deaconess-medical-center-pays-over-5-million-for-allegedly-billing-medicare-for-improper-inpatient-admissions/

Health Insurance Overhaul - Florida Trends

As the implementation date for the Affordable Care Act nears, employers are scrambling to understand what it means for their business.

Lilly Rockwell | 9/3/2013

The Affordable Care Act is poised to transform our health insurance system, encouraging more people to buy insurance. But as the full implementation date nears, health insurers are raising rates, and employers are scrambling to understand what it means for them.

Before Congress passed a major health insurance reform law, before President Obama was even elected, health insurance company Florida Blue anticipated the emergence of a different health insurance market, with more people buying individual health insurance policies instead of the employer-driven system that most Americans use today.

The Affordable Care Act...

» Requires all Americans to obtain health insurance or pay a tax penalty

» Offers subsidies for low-income Americans
to afford health insurance

» Prohibits insurers from declining coverage

» Largely prohibits charging substantially more based on age or health

» Creates online government-run health insurance exchanges for people and small businesses

» Increases tax credits for small businesses to offset health insurance costs

» Mandates minimum benefits offered, including hospitalization, maternity leave and prescription drugs

» Requires all large employers to offer health insurance or pay a penalty

Jacksonville-based Florida Blue, then called Blue Cross Blue Shield of Florida, decided to open a retail store to cater to individual customers. This was a radical idea for a health insurance company at the time — a major shift from a business-to-business sales model working directly with employers to a business-to-consumer sales model. The first store opened in 2006 in Jacksonville at the St. Johns Town Center shopping center.

The move into retail stores turned out to be prescient. Today, the health insurance company operates 11 retail stores in Florida, with plans to open five more by the end of the year. Florida Blue has grown the number of Floridians it covers by individual policies from 277,048 in 2007 to 381,445 in 2011 — a 38% increase, representing more than half of the individual insurance marketplace in Florida.

In fact, Florida Blue holds more individually purchased policies than its top three competitors (Humana, Cigna and United Healthcare) combined. The company credits the Patient Protection and Affordable Care Act, passed in 2010 with its expansion into the individual market. “It put us in a great position,” says Jason Altmire, Florida Blue’s senior vice president of public policy, government and community affairs.

The affordable care law encourages more people to purchase health insurance regardless of their employment status. But even though the goal of the law is to reduce the number of people without health insurance, many may opt out of getting health insurance, choosing to pay a tax penalty or simply lie about whether they’re covered. The tax penalty the first year is only $95, much cheaper than the average unsubsidized individual insurance policy of $5,500.

How many of the 3.8 million uninsured Floridians will jump into the health insurance market next year, when the individual mandate kicks in? No one knows. “We’re doing everything we can to try to predict what decisions people and employers will make,” Altmire says.

The Congressional Budget Office believes 14 million people nationwide will buy new health insurance policies next year — only a quarter of the total uninsured. The Kaiser Commission on Medicaid and the Uninsured predicts that somewhere between a quarter to half of all uninsured Floridians will obtain health insurance.

http://www.floridatrend.com/article/16052/insurance-overhaul

HHS Extends Equal Medicare Advantage Coverage to Same-Sex SNF Residents

Jason Oliva | September 2, 2013 | 

Same-sex residents in skilled nursing facilities (SNFs) that are beneficiaries in private Medicare plans will now have access to equal coverage when it comes to care in a nursing home where their spouse lives. 

The Department of Health and Human Services (HHS) issued a memo last week in response to the recent Supreme Court ruling, which found section 3 of the Defense of Marriage Act unconstitutional. 

“HHS is working swiftly to implement the Supreme Court’s decision and maximize federal recognition of same-sex spouses in HHS programs,” said HHS Secretary Kathleen Sebelius in a statement. “[The] announcement is the first of many steps that we will be taking over the coming months to clarify the effects of the Supreme Court’s decision and to ensure that gay and lesbian married couples are treated equally under the law.”

Under current law, Medicare beneficiaries enrolled in a Medicare Advantage plan are entitled to care in skilled nursing facilities where their spouse resides. 

Seniors with Medicare Advantage previously may have faced the choice of receiving coverage in a nursing home away from their same-sex spouse, or dis-enrolling from the Medicare Advantage plan which would have meant paying more out-of-pocket for care in the same nursing home as their same-sex spouse, according to Marilynn Tavenner, administrator for the Centers for Medicare & Medicaid Services. 

“Today, Medicare is ensuring that all beneficiaries will have equal access to coverage in a nursing home where their spouse lives, regardless of their sexual orientation,” said Tavenner. “Prior to this, a beneficiary in a same-sex marriage enrolled in a Medicare Advantage plan did not have equal access to such coverage and, as a result, could have faced time away from his or her spouse or higher costs because of the way that marriage was defined for this purpose.”

The recently issued guidance from HHS specifically clarifies a guarantee of coverage applies equally to couples who are in a legally recognized same-sex marriage, regardless of where they live. 

http://seniorhousingnews.com/2013/09/02/hhs-extends-equal-medicare-advantage-coverage-to-same-sex-snf-residents/

Former Office Manager for Health Care Solutions Network Sentenced in $63 Million Medicare Fraud

U.S. Department of JusticeAugust 30, 2013

Office of Public Affairs(202) 514-2007/TDD (202) 514-1888

WASHINGTON—A former office manager at the defunct health care provider Health Care Solutions Network Inc. (HCSN) was sentenced today in Miami to serve 68 months in prison for her role in a fraud scheme that resulted in more than $63 million in fraudulent claims to Medicare and Florida Medicaid.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) Office of Investigations, Miami office, made the announcement.

Lisset Palmero, 45, of Miami, was sentenced by U.S. District Judge Cecilia M. Altonaga in the Southern District of Florida. In addition to her prison term, Palmero was sentenced to three years of supervised release and ordered to pay restitution in the amount of $17.4 million.

During the course of the conspiracy, Palmero was employed as a receptionist and office manager at HCSN, a mental health facility that purported to provide Partial Hospitalization Program (PHP) services. A PHP is a form of intensive treatment for severe mental illness.

HCSN of Florida (HCSN-FL) operated community mental health centers at two locations. According to court documents, Palmero was aware that HCSN-FL paid illegal kickbacks to owners and operators of Miami-Dade County Assisted Living Facilities (ALF) in exchange for patient referral information to be used to submit false and fraudulent claims to Medicare and Medicaid. Palmero also knew that many of the ALF referral patients were ineligible for PHP services because they suffered from mental retardation, dementia, or Alzheimer’s disease.

Court documents reveal that Palmero was aware that HCSN-FL personnel were fabricating patient medical records. Many of these medical records were created weeks or months after the patients were admitted to HCSN-FL for purported PHP treatment. Palmero was also aware that medical records were fabricated for “ghost patients” who were never admitted to the HCSN-FL PHP. During her employment at HCSN-FL, Palmero actively concealed the fabrication of medical records by preparing, and causing others to prepare, documentation that was later utilized to support false and fraudulent billing to government-sponsored health care benefit programs, including Medicare and Florida Medicaid.

According to court documents, from 2004 through 2011, HCSN billed Medicare and the Florida Medicaid program approximately $63 million for purported HCSN-FL mental health services.

This case is being investigated by the FBI and HHS-OIG and was brought as part of the Medicare Fraud Strike Force, under supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida. This case was prosecuted by Trial Attorney Allan J. Medina and former Special Trial Attorney William J. Parente.

http://m.fbi.gov/#http://www.fbi.gov/miami/press-releases/2013/former-office-manager-for-health-care-solutions-network-sentenced-in-63-million-medicare-fraud