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Tag Archives: Credentialing

Nurse Practitioner Credentialing

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Hello,
Our NP credentialing status is still pending. However our physician leader wants to know :
1. If a patient is seen in our office by a Nurse Practitioner, can the claim be submitted under the supervising physician’s name rather than the NP? The physician would not be directly involved in the care plan but would sign off on each note.

2. In this situation, does the NP need to be credentialed with insurance carriers?

Can you point out where I can find any related documentation from the major payers ?

Thanks!

Carine

Medical Billing and Coding Forum

Why Does Medical Credentialing Matter?

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Since qualified and reputable doctors are in such demand from medical establishments, it is important to refer to medical credentialing to accomplish this. The process is one that looks at the merits and historical data of medical practitioners and determines if they are able to uphold their organization’s reputation for offering good healthcare.

Is this process really thorough enough to tell a hospital or other organization whether the practitioner is qualified to provide health care? The only way to know for sure is to analyze all the elements of this process and decide whether or not it really is enough.

The steps of medical credentialing start by examining the educational history of the doctor, then the residency, licenses and any additional training. Special attention is also paid to any certificates awarded specific to their specialty. When compared to the generally accepted norms in the field, the practitioner’s qualifications should measure up.

Medical credentialing begins by collecting general information on the background and qualifications of the medical practitioner. This includes more than just doctors. Credentialing applies to chiropractors, podiatrists, physical therapists, nurse practitioners, psychotherapists, and anyone else that practices in the medical field.

After the data has been collected from the professionals, it has to go through a process that verifies it next to other credible, truthful sources such as the American Board of Medical specialties or the National Practitioner Data Bank. In this way, hearsay or preference is taken out of the picture completely.

The next step in the credentialing process requires that contact is made with the institutions or organizations that the practitioner has had an experience with. This means contacting the states that issued a medical license to the doctor or the schools, hospitals, and other organizations that the doctor was a part of. This is the only way to make sure there is no limitations imposed on the doctor, and that he or she received and completed all the requisite education and training.

Once that is completed, the review process can begin. Medical credentialing goes much further than just checking out the practitioner’s grades at medical school. This review process involves discovering how they actually performed throughout their careers. This requires examining personal conduct history, malpractice coverage and history, hospital privileges that may have been revoked, and their overall work history.

Medical credentialing can get complicated with every state, hospital, and insurance company espousing different rules, forms, and standards. The bureaucracy can really start to get complicated, which is why many companies that specialize in credentialing services have started to appear. It may be difficult, but organizations are learning quickly that the process will help them provide reliable, quality health care.

One of the most important things in medicine is understanding things your doctors have done previously in their careers. Medical credentialing enables you to do this effectively. This is the only way to ensure patient safety and organizational prosperity.

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Credentialing new provider

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We have a brand new NP that’s starting with our office. I was just wondering if anyone has a checklist of all of things needed to get her credentialed and it what order those things need to be obtained?!? I’ve never credentialed a new provider the others have always had their NPI, DEA etc… Any help would be greatly appreciated!!

Medical Billing and Coding Forum

Credentialing & Peer Review Legal Insider, August 2016

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New PSO guidance raises questions over patient safety work product privilege

In May, the U.S. Department of Health and Human Services (HHS) published Guidance Regarding Patient Safety Work Product and Providers’ External Obligations in the hopes of clarifying what documents are considered patient safety work product (PSWP) and thus protected from discovery during litigation. Because the guidance has far-reaching implications for the scope of the privilege and confidentiality protection, providers should consider reexamining their process for collecting information in the pursuit of improving patient safety.

Under the Patient Safety and Quality Improvement Act (PSQIA), providers collect and manage information through a patient safety evaluation system (PSES), which is then sent to a patient safety organization (PSO) for analysis and feedback. To motivate providers to participate in PSOs, PSQIA entitles the submitted information broad privilege and confidentiality protections.

According to Michael R. Callahan, Esq., partner at Katten Muchin Rosenman, LLP, in Chicago, the guidance may impact how discoverability disputes are handled in courts. To understand why, consider the three primary buckets of patient safety information:

  • Bucket one: All mandated reports. For example, some states like New York and Florida require mandated adverse reporting if a wrong site surgery is performed. For these incidents, hospitals are required to prepare and submit a report to the state. Reports that fall within this bucket shouldn’t be treated as PSWP.
  • Bucket two: All reports that hospitals are required to collect and maintain pursuant to state and federal law, such as the Medicare Conditions of Participation (CoP).
  • Bucket three: All other information collected and maintained in a hospital’s PSES to improve quality, safety, and patient outcomes. This information is PSWP.

Disputes will arise from reports that fall into bucket two, Callahan says. HHS’s guidance stated that this type of information isn’t PSWP, but not all state and federal laws have crystal clear language defining what information hospitals need to collect and maintain.

"You will seldom find in the state and federal laws a specific list of documents which identifies the kinds of records and reports a provider is required to maintain and collect and to make available for inspection by a governmental authority. It is not that clear cut and hospitals use different terminology," he says.

For example, Callahan points out that in the case Tibbs v. Bunnell, discussed later in this article, the dispute was over the question of whether an incident report collected and reported to a PSO by a defendant hospital was a bucket two document. "The language under Kentucky law obligated the hospital to maintain and collect ‘incident investigation reports’ but does this refer to the incident report, a resulting root cause analysis report or a peer review investigation report? Is it all or none of the above?"

 

The PSO guidance

The guidance, which was published in the Federal Register in May, clarifies what information can and cannot be called PSWP. Information can be PSWP if:

  • A provider prepares it for reporting to a PSO and follows through in the reporting
  • A PSO develops it for the conduct of patient safety activities
  • A provider places it in a PSES to be reported to a PSO

 

Information that can’t be PSWP includes:

  • Patient medical records, billing and discharge information, or any other original patient or provider information
  • Materials collected and maintained separately from a PSES
  • Records mandated by federal and state law
  • Information prepared to satisfy external obligations

 

One criticism of the guidance is its expansion of the concept of original patient and provider records, Callahan says. PSQIA states these records, such as medical records and billing information, can never be privileged. The guidance further clarified the scope of what these records include:

  • Original records required of a provider to meet any federal, state, or local public health or health oversight requirements regardless of whether they are maintained inside or outside of the PSES
  • Copies of records that reside within a provider’s PSES that were prepared to satisfy a federal, state, or local public health or health oversight record maintenance requirement if the records are maintained only within the PSES and any original records are either not maintained outside of the PSES or were lost or destroyed

Callahan takes issue with HHS’ expansion of the definition of an original patient and provider record to include bucket one and bucket two documents, especially since it was put forth in guidance and not a final rule.

Requirements under the Administrative Procedure Act require a notice and comment period before a final rule is adopted. However, HHS chose to issue the guidance without following this procedure and therefore it should only be viewed as an interpretative rule, Callahan says. The U.S. Supreme Court decision earlier this year in the case of Perez v. Mortgage Bankers Association found that interpretive rules "do not have the force and effect of law."

"The guidance is simply an interpretation provided by HHS. While it certainly expresses the position of HHS, the Office of Civil Rights and the Agency for Healthcare Research and Quality (AHRQ) from a regulatory enforcement standpoint, it is not binding on state or federal courts," he says.

As a result, different interpretations of PSQIA will likely lead to continued challenges to court orders to turn over documents hospitals believe to be PSWP. Some of these discoverability disputes have made their way to state supreme courts.

 

Southern Baptist Hospital of Florida v. Charles

In a case that will go before the Florida Supreme Court later this year, Southern Baptist Hospital of Florida v. Charles, the PSO guidance may play a role in determining whether occurrence reports?reports that hospital collects and maintains for events that are inconsistent with its routine operations or care of patients, or that could result in an injury?are PSWP.

The plaintiff sued Southern Baptist Hospital of Florida, claiming his sister suffered a catastrophic neurological injury due to negligence. During discovery, the plaintiff requested documents related to adverse medical incidents and the conduct of physicians who worked at the hospital. This request was made pursuant to Amendment 7 of the Florida Constitution, which provides patients with the right to access "any records made or received in the course of business by a healthcare facility or provider relating to any adverse medical incident."

Although the hospital produced some of the requested documents, it declined to turn over occurrence reports that were collected within its PSES and reported to its PSO, claiming they were PSWP and therefore privileged and confidential under PSQIA.

The plaintiff argued that PSQIA only protects documents generated exclusively for submission to a PSO, so anything collected to also satisfy a state law is not PSWP. The circuit court agreed, finding that information collected for dual purposes was not PSWP and ordered the hospital to produce the documents.

This order was later reversed by an appellate court, which said the documents were PSWP because they were collected in the hospital’s PSES and reported to a PSO. Further, documents can simultaneously be PSWP and meet a state reporting requirement. The plaintiff appealed to the state supreme court, which will hear the case in October.

Since the documents in question fall into bucket two, the plaintiff will likely cite the guidance to support a position that the reports can’t be treated as PSWP and therefore are discoverable, says Callahan. However, the argument can be made that the guidance is not legally binding on the courts.

 

Tibbs v. Bunnell

The release of the PSO guidance likely contributed to the U.S. Supreme Court’s denial to hear Tibbs v. Bunnell. The case would have provided a nationwide interpretation of the scope of privilege and confidentiality protections under PSQIA for reports submitted to PSO, as well as whether PSQIA preempted state laws.

In Tibbs, a patient’s estate brought a wrongful death and medical malpractice suit against three surgeons employed by University of Kentucky Hospital. The plaintiffs sought to discover a post-incident event report generated by a surgical nurse through the hospital’s PSES and subsequently sent to its PSO.

At trial, the hospital argued that the report was protected under PSQIA and therefore not subject to discovery. However, the trial court ruled that the report was not protected under PSQIA. The hospital appealed.

Although the appellate court found that the privilege provided by the PSQIA did preempt the Kentucky state law, it stipulated that protections afforded by PSQIA only apply to documents that contain "self-examining analysis," meaning those in which the provider analyzes his or her own actions. The court then sent the matter back to the trial court for evaluation of whether the report contained self-examining analysis.

The hospital appealed to the Kentucky Supreme Court, arguing that the appellate court erroneously limited the scope of privilege protections under PSQIA. The Supreme Court reversed the Court of Appeals’ interpretation of PSQIA, finding it too narrow. However, it also ruled that the incident report was not protected under PSQIA because its creation, maintenance, and utilization was required in the regular course of the hospital’s business, as well as under Kentucky state law. Therefore it cannot be collected within the hospital’s PSES and treated as PSWP.

In response, the hospital filed a petition for the U.S. Supreme Court to review the Kentucky Supreme Court’s decision. The petition had the support of more than 50 PSOs, hospitals, and health systems from across the country, as well as the American Hospital Association, AMA, and The Joint Commission. Last October, the court asked the U.S. solicitor general to file a brief on his views of the case and whether the petition should be granted or denied.

Just as the guidance was published, the solicitor general filed his brief to the court. The brief recommended that the court deny the petition in light of the guidance issued by HHS and because hearing the case would be premature until it is seen how the lower courts interpret and apply the guidance.

In June, the U.S. Supreme Court denied the petition without comment and without remanding the case back to the Kentucky Supreme Court to take the guidance into consideration. This leaves the Kentucky Supreme Court’s ruling in place, although the decision is only binding on Kentucky courts.

 

Carron v. Rosenthal

Regardless of the U.S. Supreme Court’s denial to hear Tibbs, discovery disputes are still playing out in other courts. The Rhode Island Supreme Court will be hearing an appeal of an order for a hospital to produce incident reports in Carron v. Rosenthal. In this case, the plaintiff is suing her obstetrician and Newport Hospital for medical malpractice after her newborn baby suffered irreversible brain damage following a failed labor induction and died days later.

Two nurses prepared incident reports known as Medical Event Reporting System (MERS) reports, which were submitted to the hospital’s PSO. The hospital also produced separate state-mandated adverse event reports.

Later during discovery, the nurses were deposed but had difficulty remembering what had happened, so the plaintiffs asked that the hospital produce the MERS reports. The hospital objected, citing PSQIA and the Rhode Island Patient Safety Act.

According to Callahan, much of the plaintiff’s argument was based on the Kentucky Supreme Court’s decision in Tibbs that reports required by state statutes can’t be treated as PSWP. However, Newport Hospital argued that in Tibbs, the University of Kentucky Hospital collected state mandated reports in its PSES. At Newport Hospital, state mandated reports are collected separately. The MERS reports were separate reports distinguishable from the mandated reports and therefore were PSWP, according to the hospital.

Despite this argument, the trial court ruled in favor of the plaintiff and order the hospital to show the MERS reports to the nurses?but not the plaintiff?to refresh their memories before they were to be deposed again. The hospital appealed and, because Rhode Island does not have an appellate court, the state supreme court exercised its discretion to hear the hospital’s appeal. A decision is expected later this year.

 

What can providers do?

With the U.S. Supreme Court declining to hear Tibbs, and ongoing confusion in regards to the guidance, providers that participate in a PSO have a few options for how to proceed.

Providers can choose not to do anything and simply maintain the status quo as they wait for further regulatory or judicial developments, says Callahan. "We have these other cases before state supreme courts and it’s conceivable one of those will be appealed. It doesn’t mean the U.S. Supreme Court is going to accept one of these other ones, but that’s a development that providers may want to wait on."

PSOs will also likely have questions about the guidance and will reach out to AHRQ for additional guidance, so providers will want to wait to see if there is any further clarification, he says.

Providers that choose to comply with the guidance will need to determine if any information they were previously collecting in their PSES for reporting to their PSO is no longer considered PSWP. These providers will need to review state and federal laws, including the Quality Assurance and Performance Improvement standards set forth in the Medicare CoP, to ensure the information doesn’t fall into buckets one or two, Callahan says. Anything that’s determined to fall into those two buckets will require modifications to the provider’s PSES policy.

Since the guidance is an interpretive rule, some providers may choose to fight requests to turn over disputed documents, Callahan says. Providers would choose this path if they believed a court would be more likely to side with their interpretation of PSQIA.

More drastically, providers could simply decide to abandon their PSOs altogether. However, there are several factors to consider before making that move, says Callahan.

The Affordable Care Act requires hospitals with more than 50 beds that want to provide healthcare services to patients enrolled in a state insurance exchange to be enrolled in a PSO. This was modified to allow hospitals to meet the requirement by contracting with a hospital engagement network (HEN) or quality improvement organization (QIO).

However, contracting with a HEN or QIO doesn’t offer providers the same privilege protection received from participating in a PSO. Those providers would still have their state law protections, but those vary and some states may not have any protections at all or limited protections, Callahan says.

Providers considering leaving their PSO will need to evaluate their state protections, including the scope of protected activities and entities.

"Using Illinois as an example, [state law protections] only generally apply to hospitals, surgery centers, and managed-care entities. The statutes do not apply to physicians, physician groups, labs, pharmacies, home health, or other licensed providers. So if you have formed a clinically integrated network with all these different provider boxes, only the hospital?for all practical purposes?will be protected," Callahan says.

Providers should also check to see if it’s possible under state law to inadvertently waive the privilege if protected information is not handled correctly (e.g., information is disclosed improperly). Under PSQIA, the protections afforded to PSWP can never be waived.

Callahan also notes it’s important for providers to know that state privilege protections only apply in state courts or state claims. So, for example, if a physician is terminated but falls under a protected class (race, age, sex, religion, etc.), he or she can file a federal claim. The physician can then request access to protected peer review documents. Although the hospital may try to argue that they are privileged and confidential under the state peer review statute, state privilege statutes cannot be asserted to preempt federal claims. However, if the documents were collected in a PSES and reported to a PSO, they would not be undiscoverable.

"The PSQIA has many advantages to offer. Part of the problem, however, is that there are not many appellate court interpretations of the law and most of those decision have only involved medical malpractice cases" Callahan says. "Unfortunately, because the U.S. Supreme Court denied the petition in Tibbs, these disputes will have to be decided on a state-by-state basis. This is great for the attorneys but not helpful for PSOs and participating providers."

 

Case summary

Texas Supreme Court grants writ of mandamus for peer review committee records

The Supreme Court of Texas (the "Court") recently held that a trial court failed to adequately review allegedly privileged documents?to determine if they were disclosable pursuant to an exception to the state’s peer review statute?before issuing an order compelling Christus Santa Rosa Health System to produce them. As a result, the Court granted a petition for writ of mandamus filed by Christus, ordering the lower court to inspect the documents in question.

The documents concerned a peer review committee convened to review an unsuccessful surgery performed by Gerald Marcus Franklin, MD, in March 2012 to remove the left lobe of a patient’s thyroid gland. Franklin instead removed thymus gland tissue, requiring the patient to undergo a second surgery.

According to Franklin’s deposition, several weeks after the failed surgery he met with a three-member medical peer review committee to provide a verbal report. He said that complications arose due to an abundance of scar tissue, which made it difficult to distinguish between thymus and thyroid tissue. The unavailability of a cryostat machine, a critical piece of equipment that Franklin would have used during the surgery to diagnose the removed tissue, led him to end the surgery. During the meeting, the committee concluded that Franklin’s actions were reasonable and the committee chose not to take action.

As a result of the failed surgery, the patient filed a malpractice lawsuit against Franklin and his medical group in March 2013. Franklin subsequently filed a motion to designate Christus as a responsible third party, alleging that the unavailability of the cryostat machine was responsible for the surgery’s failure. The patient went on to add Christus as a defendant in the suit.

In March 2014, Franklin served Christus with a request to produce documents from its medical peer review file. Christus objected, arguing that the documents were protected from discovery under the medical peer review committee privilege provided by the Texas Occupations Code section 160.007(a), which states, "[E]ach proceeding or record of a medical peer review committee is confidential, and any communication made to a medical peer review committee is privileged."

Following an in camera review, the trial court ordered Christus to produce the documents under a protective order that mandated that they be disclosed only to Franklin and his attorneys.

Christus filed a motion to reconsider, which the trial court denied. Christus then filed a petition for writ of mandamus in the court of appeals, which was also denied, leading to it filing the petition with the state supreme court.

At issue was the interpretation and scope of an exception provided by Texas Occupation Code section 160.007(d), which states, "If a medical peer review committee takes action that could result in censure, suspension, restriction, limitation, revocation, or denial of membership or privileges in a healthcare entity, the affected physician shall be provided a written copy of the recommendation of the medical peer review committee and a copy of the final decision, including a statement of the basis for the decision."

Franklin argued that the documents were subject to disclosure under the exception because, even though the committee opted not to take any action, the medical peer review committee had the opportunity to recommend discipline.

The Court disagreed with Franklin’s interpretation of the privilege: "Looking to the intent of the Legislature, as we must, we conclude that the Legislature intended a medical peer review committee do more than simply convene for review for the exception to apply."

The Court found that applying this interpretation would require disclosure of a medical peer review committee’s documents every time it conducted a review, regardless of its outcome.

"Under this interpretation, it is difficult to conceive of an instance where the physician would not be entitled to the documents and the documents would remain privileged. This would in turn enfeeble confidentiality and prevent physicians from engaging in candid and uninhibited communications, which is essential for improving the standard of medical care in the state," the Court wrote.

The Court also found that the trial court did not review the documents in camera sufficiently to determine if the medical peer review committee took any actions that could result in one of the disciplinary actions listed in the exception to the medical peer review committee privilege, such as censure, suspension, or denial of privileges.

The trial court judge had stated he went through the documents page by page only to ensure that patient’s health information and social security numbers were not disclosed and didn’t look at the documents "closely enough" to determine whether the committee had taken any actions. Christus had argued that an in camera inspection of the documents would clarify if the exception applied.

The Court concluded that the trial court abused its discretion when it ordered Christus to produce the medical peer review committee documents; and ordered the trial court to vacate its order compelling production of the documents and to review the documents further to see if the exception applies.

Source: In re Christus Santa Rosa Health Sys., No. 14-1077 (Tex. May 27, 2016).

 

What does this mean for you?

J. Michael Eisner, Esq., of Eisner & Lugli in New Haven, Connecticut: The Court’s decision stands for the fundamental proposition that a court must comply with the plain meaning of the statutes that it is interpreting. While this may seem to be a "no brainer," too many courts ignore the plain meaning of statutes and act as if they were legislative bodies. Here, the statute required that disclosure only be made if the peer review committee recommended certain actions. According to the Texas Supreme Court, in spite of the clear wording in the statute, the trial court ordered disclosure without making the requisite determination(s). The Supreme Court sent the matter back to the trial court, ordering it to follow the statute.

 

Legal and regulatory news roundup

Find out what’s happening in the world of federal healthcare regulations by reviewing some recent headlines from across the country.

 

Senate Finance Committee aims to reform Stark Law

The Senate Finance Committee hopes to introduce legislation to reform the federal physician self-referral law, commonly referred to as the Stark Law. During a recent hearing, Chairman Orrin Hatch (R-Utah) said the committee would take some action by the end of 2016 but did not elaborate on what that might be.

In June, Hatch released a white paper discussing potential reforms to the Stark Law. Several commenters suggested repealing the law in its entirety. Others suggested changes to the law that would allow providers to implement new payment models.

In a statement released with the white paper, Hatch said the Stark Law is "a real burden for hospitals and doctors trying to find new ways to provide high quality care while reducing costs as they work to implement recent healthcare reforms."

 

Hundreds charged with healthcare fraud in nationwide sweep

More than 300 physicians, nurses, and other medical professionals across the country allegedly involved in healthcare fraud schemes face criminal and civil charges following what the U.S. Department of Justice called the largest coordinated takedown in history. The Medicare Fraud Strike Force in 36 federal districts led the sweep, which also involved 23 state Medicaid Fraud Control Units and 26 U.S. Attorney’s Offices.

The individuals charged are suspected of collectively submitting approximately $ 900 million in fraudulent billing to Medicare and Medicaid. They face multiple healthcare fraud-related charges, including conspiracy to commit healthcare fraud, aggravated identity theft, money laundering, and violations of the anti-kickback laws for schemes in which they submitted claims for medically unnecessary treatments. Often the treatments were never provided. In some cases kickbacks were paid to Medicare beneficiaries, patient recruiters, and other co-conspirators in return for providing beneficiary information to providers to use in submitting fraudulent billing.

Some of the highlights of the sweep include:

  • One-hundred defendants from southern Florida were charged for their alleged involvement in schemes that resulted in $ 220 million in fraudulent billings for home healthcare, mental health services, and pharmacy fraud.
  • Eleven defendants in southern Texas were allegedly responsible for $ 47 million fraudulent billing, including one physician who allowed unlicensed individuals to perform services and then billed Medicare as if he had performed them.
  • Twenty-two defendants in central California allegedly defrauded Medicare of $ 162 million. One physician is believed to be responsible for nearly $ 12 million through fraudulently billing for medically necessary vein ablation procedures.

 

In an announcement of the arrests, Attorney General Loretta E. Lynch said, "The wrongdoers that we pursue in these operations seek to use public funds for private enrichment. They target real people?many of them in need of significant medical care. They promise effective cures and therapies, but they provide none. Above all, they abuse basic bonds of trust?between doctor and patient; between pharmacist and doctor; between taxpayer and government?and pervert them to their own ends."

 

Cardiologist agrees to pay $ 2 million to settle kickback, false billing lawsuit

Asad Qamar, MD, of the Institute of Cardiovascular Excellence (ICE) of Ocala, Florida, has agreed to pay $ 2 million to resolve a lawsuit alleging he paid kickbacks to patients and improperly billed Medicare, Medicaid, and TRICARE?a healthcare program of the U.S. Department of Defense Military Health System. Qamar will also release any claim to $ 5.3 million in suspended Medicare funds and agreed to a three-year exclusion from participating in any federal healthcare program. This will be followed by a three-year integrity agreement with the Department of Health and Human Services Office of the Inspector General.

According to the U.S. Department of Justice, the lawsuit against Qamar claimed that he and ICE billed for peripheral artery interventional services and other related procedures, many of which were medically unnecessary according to the patients’ medical histories or records, or by the severity of their symptoms.

The lawsuit also alleged that Qamar and ICE persuaded patients to agree to the unnecessary procedures by routinely and indiscriminately waiving the 20% Medicare copayment. The copayment is typically used to help patients be smarter healthcare consumers and deter them from unnecessary procedures.

According to The Wall Street Journal, following a legal effort by the paper, CMS made public Medicare payment data which showed that Qamar had collected more than $ 18 million from Medicare in 2012. That ranked him second highest paid among all physicians in the country and four times more than the third highest paid cardiologist.

The settlement resolves two consolidated lawsuits originally filed under the whistleblower provision of the False Claims Act. The two individuals who originally brought the suit will receive about $ 1.3 million for their share of the settlement.

 

Former Warner Chilcott president acquitted on anti-kickback charge

W. Carl Reichel, former president of Warner Chilcott, was found not guilty of conspiring to pay kickbacks to physicians to induce them to prescribe its drugs.

The government’s case against Reichel alleged that he encouraged members of the sales force to provide physicians with payments, meals, and other rewards. According to court documents, Reichel was acquitted on grounds that there wasn’t insufficient evidence to suggest that he had ever given the sales team any such direction.

HCPro.com – Credentialing and Peer Review Legal Insider

CPMA, Insurance Credentialing, Remote Position Wanted

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I am currently looking for a part-time remote coding, auditing, and/or credentialing position.

For many years I have worked in the medical industry, particularly in aspects of surgical scheduling and management as well as exam and procedural coding. To gain more substantial knowledge in medical coding and documentation, I earned a Certified Professional Medical Auditor (CPMA) certification from AAPC in December 2016. I have also taken the Inpatient coding course through AAPC and am working on obtaining both the Certified Professional Coder (CPC) and Certified Inpatient Coder (CIC) credentials.

Currently, I am employed full-time as the Administrative Coordinator for the Surgical Center of Greater Annapolis, an ambulatory surgery center located in Arnold, Maryland. The center presently holds credentials for ten surgeons specializing in ophthalmic and oculoplastic procedures. In many regards, I work hand-in-hand with the nurse manager and the medical director to ensure smooth operation of the daily functions of the center. I am responsible for all accounts receivable/payable, employee payroll, ensuring compliance with accreditation standards as well as the center’s policies and procedures, and coordinating the surgical schedule with each surgeon’s office.

Along with these responsibilities, my chief obligation is to review the surgical posting, operation report, and any supporting documentation to determine and correctly code the procedure in accordance with CPT and ICD-10-CM coding guidelines. I use this information to then submit and collect payment from insurance companies including tracking any non-payments. I have previously worked for two physician offices where my duties similarly included coding patient charts, billing patient insurances, collecting insurance payments, and conducting appeals on any insurance denials.

I currently also work part-time from home assisting physician practices with insurance credentialing. I work with the providers, practice administrators, staff and insurance companies to ensure insurance credentialing for new and existing providers. In this role, I obtain all appropriate information required for credentialing, compile and submit this information to insurance carriers. I also continually communicate with insurance companies to provide any additional information as needed. I maintain meticulous records and keep track of all re-credentialing material as well.

I have previously worked for the International Association of Forensic Nurses, an organization for educators and other members of the forensic nursing community. Daily, I was responsible for providing administrative support to other association staff. I also managed the publication of their quarterly online newsletter, On The Edge, which detailed the latest information and research of forensic nursing. I continued this work during my undergraduate studies (in a different state), giving me experience in a remote position. I was always able to effectively manage my responsibilities and time for the organization while still able to achieve high grades in my courses.

I am highly self-motivated, am able to work as a team player, and am great at multitasking. I believe my career history speaks volumes for my organizational skills and dedication. Both my career and educational history have put me in a variety of situations and given me a well-rounded skill set. I can adapt to and appropriately address any situation. I continue to further my education with webinars, lectures, and obtaining additional certifications which show my dedication to this career.

It would be my pleasure to bring my organizational and interpersonal skills to work for your company. I am not only highly-motivated, but I am enthusiastic and driven to help any organization that I am employed with excel.

Please feel free to reach me by phone at 301-943-8742 or by email at [email protected]. I will be happy to provide a resume and references upon request.
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Medical Billing and Coding Forum

Texas court grants writ of mandamus for credentialing file documents

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Case summary

The Court of Appeals for the Fifth District of Texas (the "Court") granted a petition for writ of mandamus, requiring the trial court to vacate its order requiring a hospital to produce documents it contended were protected from discovery by the Texas medical peer review committee and medical committee privileges.

In Gambreezzi, P.A. v. Rockwall Regional Hospital, LLC, Gambreezzi, P.A., which is owned by Joel Ciarochi, MD, sued Rockwall (Texas) Regional Hospital (the "Hospital"), a physician-owned hospital. Ciarochi had held clinical privileges to perform anesthesia services at the Hospital, in which Gambreezzi held shares. The Hospital attempted to purchase Gambreezzi’s shares after Ciarochi terminated his employment with the anesthesia practice through which he provided services to the Hospital. This was attempted pursuant to a buy-back provision in the contract between Gambreezzi and the Hospital.

In August 2014, Gambreezzi brought suit against the Hospital, asserting a number of claims, including breach of contract. Ciarochi’s fundamental problem was dissatisfaction with the Hospital’s calculation of the compensation it would pay for the shares. As part of those proceedings, Ciarochi requested to review his credentialing file at the Hospital. On December 24, 2015, the Hospital’s counsel sent Gambreezzi’s counsel a letter stating that Ciarochi would be allowed to review, but not copy, his file.

Gambreezzi then requested additional documents, including those related to the Hospital’s buy-back of shares from another physician?Dr. Timothy Bray?who had also terminated his affiliation with the Hospital. The purpose of this request was to determine whether Bray had received more favorable compensation. This request included Ciarochi’s and Bray’s peer review and credentialing files. The Hospital objected on the grounds that the files were protected by the Texas medical peer review committee and medical committee privileges.

At a hearing to determine if the Hospital had to produce the documents, Gambreezzi asserted that not all of the documents in the files were protected by the Texas privileges and identified 53 specific pages that he alleged were not protected. The trial court reviewed those pages in camera and ordered that 50 pages should be produced, one should be produced in redacted form, and two pages didn’t need to be produced.

The Hospital said it would produce four pages of documents, as ordered by the trial court, but filed a writ of mandamus against the judge contending that the Texas medical peer review committee and medical committee privileges applied and precluded discovery. ­Gambreezzi countered that the Hospital failed to show that the documents fell within the scope of the privileges and were in fact ordinary "business records." Additionally, ­Gambreezzi argued that the Hospital waived the privileges when it allowed Ciarochi to review his credentialing file and produced four pages from Bray’s credentialing file.

After reviewing the documents in camera, the Court found that they related to Ciarochi’s credentialing or recredentialing and a variance report review in Bray’s credentialing file, meaning they were protected by the medical peer review committee privilege.

With respect to Gambreezzi’s argument that the Hospital waived the privileges by allowing Ciarochi to review his credentialing file, the Court cited Texas Occupations Code, section 160.007(e), which states, "Unless disclosure is required or authorized by law, a record or determination of or a communication to a medical peer review committee is not subject to subpoena or discovery and is not admissible as evidence in any civil judicial or administrative proceeding without waiver of the privilege of confidentiality executed in writing by the committee."

Gambreezzi argued that the December 24, 2015, letter qualified as a written waiver of the privilege, but the Court stated that the occupations code requires a written waiver to be executed by the chair, vice chair, or secretary of the medical review committee. The letter did not meet this requirement.

The Court also found that the Hospital did not waive the medical peer review committee privilege when it produced the pages from Bray’s credentialing file as it was complying with the trial court’s order.

 

Source: In re Rockwall Reg’l Hosp., LLC, No. 05-15-01554-CV (Tex. App. Mar. 2, 2016)

 

What does this decision mean for you?

J. Michael Eisner, Esq., of Eisner & Lugli in New Haven, Connecticut: In this decision, the court upheld the validity and scope of the very broad Texas "medical peer review privilege." This privilege covers initial credentialing of a physician by a medical review committee, as well as the committee’s subsequent review of the physician for purposes of reappointment/recredentialing. It also protects documents "generated" by a peer review committee or "prepared by or at the direction of the committee for committee purposes." In addition, it covers the minutes and recommendations of the committee, and its inquiries to outside sources and their responses.

Note that the scope of this privilege is extremely broad, unlike the peer review privilege in most states.

The moral to this story is that if a broad peer review statute can be enacted by your state legislature, it will provide very significant protection to the activities of physicians engaged in peer review.

The secret, of course, is getting past the formidable lobbying power of the trial lawyers and convincing your state legislature that such privileges are in the interests of the patients. If physicians are protected, they will be able to do their job without fear of baseless litigation, and will be able to protect patients from physicians who could cause them harm. If they are not protected, physicians will be subject to harassment through litigation, which obviously will greatly reduce their willingness to participate in the peer review process.

As regular readers know, my view is that restrictive peer review statutes have a very chilling effect on physicians. Why engage in peer review if one can be sued and have to spend time, effort, money, and emotional capital on dealing with trial lawyers?

HCPro.com – Credentialing and Peer Review Legal Insider

Credentialing & Peer Review Legal Insider, July 2016

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CMS proposes rolling back 2-midnight rule

The controversial 2-midnight rule may be no more following CMS’ release of its latest proposed rule for the hospital inpatient prospective payment system (IPPS). When it was first put in place for fiscal year 2014, the 2-midnight rule established a benchmark for inpatient admissions where a Medicare Part A payment would be considered reasonable and necessary for patient stays that lasted at least two midnights. Stays that didn’t reach that benchmark would be billed as outpatient services, which are covered by Medicare Part B and tend to result in lower hospital reimbursements.

Under the new proposed rule, CMS would no longer impose a 0.2% payment cut for inpatient stays under the 2-midnight rule. Hospitals would also receive a one-time 0.6% payment in fiscal year 2017 to offset the reduction in inpatient payments over the previous three years.

In the proposed rule, CMS wrote, "We still believe the assumptions underlying the 0.2[%] reduction to the rates put in place beginning in FY 2014 were reasonable at the time we made them in 2013. Nevertheless … in the context of this case, we believe it would be appropriate to use our authority … to prospectively remove, beginning in FY 2017, the 0.2[%] reduction to the rates put in place beginning in FY 2014."

The proposed rule, which would affect about 3,330 acute care hospitals and 430 long-term care hospitals, would apply to patient discharges from October 1, 2016 and later.

Under the proposed rule, acute care hospitals that are meaningful use electronic health record (EHR) users and that successfully participate in the Hospital Inpatient Quality Reporting Program would receive a 0.9% payment increase.

Overall, CMS estimates that the elimination of the payment cut and proposed payment increases will result in an additional $ 539 million in payments in fiscal year 2017.

CMS held a comment period for the proposed rule, which ended in June. A final rule will be issued August 1.

The proposed rule comes as welcome news to some. Following the announcement of the proposed rule, the American Hospital Association (AHA) released a statement from President and CEO Rick Pollack that said, "[The] rule includes a very important outcome because it reverses the inappropriate and unfair 0.2[%] payment reduction for inpatient services that was implemented as part of the original ‘two-midnight’ policy. The AHA successfully challenged [CMS’] interpretation through the courts to convince them to restore the resources that hospitals are lawfully due."

 

Background

Two years ago, CMS enacted the payment cuts for inpatient stays to offset an anticipated increase in inpatient admissions as a result of the 2014 IPPS 2-midnight rule. The increase in admissions was predicted to cost $ 220 million.

Following the rule’s introduction, there was vocal opposition to the rule from hospitals that argued it arbitrarily complicated care for Medicare beneficiaries, and legal challenges were subsequently launched over the 0.2% cut.

In the case Shands Jacksonville Medical Center v. Burwell, several hospitals and hospital associations, including the AHA, questioned whether Sylvia Burwell, secretary of the Department of Health and Human Services (HHS), had the authority to make the proposed across-the-board reductions, and whether her prediction of the $ 220 million increase was valid.

In September, the U.S. District Court for the District of Columbia found that HHS did have the authority to reduce the reimbursement rates, but that the justification for the 0.2% cut was lacking.

In his ruling, District Judge Randolph Moss wrote, "The Court is unable to evaluate whether the [s]ecretary’s decision was reasonable because her omission prevented the public from offering meaningful comments. The [p]laintiffs never had the opportunity to explain where, in their view, she went wrong, and, thus, the [s]ecretary never had to provide a reasoned justification of her position."

Moss ordered Burwell to provide additional justification for the reimbursement cut and allow a public comment period. CMS issued a request for comments in December.

The following month, 55 additional hospitals filed a similar lawsuit over the 2-midnight rule’s 0.2% inpatient payment cut and the estimated increase in inpatient admissions the cut was based on.

 

CMS pauses reviews of short-stay claims

On a related note, in May, CMS put a temporary pause on reviews performed by Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) to determine if payments under Medicare Part A are appropriate for claims for inpatient stays that span less than two midnights.

In a message posted June 6, CMS explained it "became aware of inconsistencies in the BFCC-QIOs’ application of the two-midnight policy for short hospital stay reviews, and … we temporarily paused short stay patient status reviews to give us time to improve standardization in the BFCC-QIOs’ review process."

BFCC-QIOs will use the temporary pause to complete retraining on the two-midnight policy and to review all claims that were denied since last October. BFCC-QIOs began conducting the short-stay claim reviews in October, which were previously conducted by Medicare Administrative Contractors.

CMS believes audit activities will resume in 60?90 days, according to the update it posted in June. In the meantime, hospitals that previously had a claim denied should check with their BFCC-QIO to see if the claim has been denied before filing an appeal. Hospitals that have already filed appeals will have the findings of the re-review performed by the BFCC-QIO shared with the appeals adjudicators.

 

Five simple tips to help healthcare organizations prevent fraud

by Elizabeth Stepp, senior counsel at Oberheiden Law Group, in Dallas

It’s impossible to calculate the amount of healthcare fraud that exists, as much of it slips under the radar. However, healthcare fraud poses a serious problem, putting the health and welfare of beneficiaries at risk while costing taxpayers billions of dollars.

Preventing healthcare fraud and abuse is challenging, especially for hospitals, hospices, and other similar organizations. While there are a lot of honest and well-intentioned healthcare providers, there are quite a few perpetrators?ranging from street criminals to large companies. As such, owners of healthcare organizations need to be on their guard at all times. After all, allegations of fraud and abuse against low-level or top brass employees can affect the reputation of any healthcare organization.

But if you’re the owner of a small or large healthcare organization, don’t let this worry you. The following are some tips to help you prevent your organization’s reputation from taking a hit, and to avoid costly lawsuits.

 

Perform background checks before hiring

Pre-employment screening for employees, as well as contingent or temporary workers, is a common best practice for healthcare organizations. That being said, not all organizations have the time and resources to perform thorough background checks. Add to this a shortage of quality caregivers plus an increase in the number of patients, and employers find it easy to rely on trust instead of facts.

Since a single scam artist can taint your organization’s reputation, avoid employing or hiring individuals just because they appear to be trustworthy. Make sure pre-employment background checks include the following:

  • Education verification: Verify training and accreditation.
  • Employment verification: Crosscheck length of employment, position, and performance with previous companies. Note reasons for leaving and analyze gaps in employment history.
  • Record verification: Ensure that civil records are clean and confirm that there are no criminal records.

 

Additionally, check personal references, verify Social Security numbers, and have individuals undergo drug tests.

 

Have policies and procedures in place

Formalized policies and procedures promote regulatory compliance and workplace safety, and above all guarantee safe and quality patient care. Healthcare organizations also need to have policies and procedures in place to safeguard protected information. Start with defining access and authorization controls, and separate duties in order to reduce opportunities of fraud.

Make sure that policies and procedures are up-to-date and well written, so as to reduce practice variability. Practice that varies from one person to another can lead to sub-standard care and reliance on memory, which in turn can cause errors and oversights. Apart from this, organizations should have a defined set of internal controls to produce accurate financial reports, help comply with laws and regulations, oversee asset protection, and so on.

If you’re not sure about which policies to implement, getting in touch with a healthcare fraud defense attorney will be helpful. These lawyers can defend your case, and they know what it takes to prevent becoming a victim of fraud.

 

Perform audits regularly

Accurate and complete clinical documentation is important if you want to provide quality healthcare. The best way to improve documentation, and the care that your organization provides, is to conduct regular medical audits. Medical audits can also improve the financial health of your organization, and determine areas that need corrections and improvements.

Ensure that medical auditing and monitoring in your healthcare organizations is:

  • A regular and ongoing process
  • Conducted by qualified professionals who lay emphasis on government enforcement actions and ensure compliance with internal, state, and federal rules and regulations
  • Performed by keeping senior officials and board members in the loop

 

Protect data

For healthcare organizations, protecting data can mean reducing the number of emergent care cases, improving patient outcomes, providing better oversight and care, and increasing revenue. This makes it necessary for all healthcare organizations?big and small?to protect data. That being said, a lot of small- and mid-sized healthcare organizations think spending on data protection is pointless, as even organizations that take the appropriate steps are attacked by fraudsters.

Sure, data breaches keep happening. But, if you do what’s right, you can definitely protect your organization from being an easy target?and healthcare abusers like easy targets.

Here are some things to keep in mind:

  • Dumping data in the trash can gives dumpster divers an opportunity to steal and sell private data. Make a point to shred all data before it is discarded.
  • Conduct a risk assessment in accordance with government regulations to help you review security policies, identify threats posed to your organization, and expose system vulnerabilities.
  • Remind employees to keep a watchful eye on data and to never leave electronic devices or records unattended.
  • Encryption technology known as SSL, or Secure Socket Layer, can prevent data breaches.
  • Keep a note of who can access records and manage user identities. Also, allow employees access to information that is pertinent to their position.
  • Use complex passwords and two-factor authentication where possible.
  • Have a guest wireless network that’s separate from the main corporate network to offer additional protection.
  • Get in touch with a cloud vendor or a local security firm to host information systems. Clarify if you’ll be paying for a suite of services or just certain parts, such as encryption or threat management.
  • If you can’t afford to spend on data protection, turn to free open-source tools.

 

Make it easy to report fraud

Reporting fraud and abuse?or any suspicious activity­?should be an easy process. You’ll also have to set up a system so that vendors, employees, and patients and their family members can report abuse anonymously.

Most importantly, take required action on all complaints received. By addressing issues promptly, you’ll instill confidence among your employees and patients.

 

Protect your healthcare organization today

As an honest healthcare provider, you’d certainly want your healthcare organization to be free of fraud and abuse. Having the right intentions alone won’t be able to help you achieve your goals; you’ll have to take the necessary steps too.

With the information given here, you now know what you need to do to ensure that your healthcare organization is safe. Implement these tips right away, and say goodbye to fraud and abuse!

 

What can be done about bias in peer review?

by Kym Morrissey, BA, CPHQ, CNMT, RT(N), peer review coordinator at St. Anthony Hospital in Lakewood, Colorado

A number of articles have been written about bias in peer review?what it is, how it affects the overall peer review process, and types of bias, to name a few. Bias is understandably the stumbling block to effective peer review. It is the one factor that can take a well-meaning committee that is truly focused on improvement and make it appear as if it is practicing sham peer review.

At St. Anthony Hospital, our professional review committee is a multidisciplinary committee that represents the most active specialties of the medical staff; it also has representation from internal medicine and primary care. Over the years, changes to committee scoring have been implemented to help score more fairly and with less bias.

To assess whether these changes have made an impact, we conduct a biannual survey to assess the perception of the peer review committee members. This has been done since 2009. For the past seven years, we have asked the same questions to allow for comparison across time as new members join, old members step down, and efforts toward improvement are implemented. Two questions specifically designed to assess bias have consistently been included in the survey:

  • Do you feel that the cases are reviewed in a fair and impartial manner by the committee members?
  • Do you feel that the action taken at the meeting is appropriate?

 

The results of those two questions reflect improvements that have been made and the impact of those improvements on our survey results. (See the chart at bottom-left.)

In 2010, multi-level scoring was implemented but included patient outcome, which inherently biases the case review, particularly if the outcome isn’t good. In 2012, the committee moved to a multilevel scoring system where overall practitioner care, issue identification, and documentation comprised the final case assessment. The perception of bias is slowly improving with the change to the multi-level scoring.

In 2013, one of the committee members suggested blind voting to increase members’ ability to vote with their conscience without the pressure of a show of hands. Initially this was done with a voting sheet, and the scores were tallied and reported during the meeting, but this method proved too onerous. The committee then started utilizing an audience response system to allow the members to vote privately. The voting results are displayed immediately so that the members are aware of the case level assessment.

It has been interesting to watch the voting reflect the opinions of the members. Previously a show of hands would be unanimous; it would be difficult to say that members were voting according to their conscience. Group pressure would prevail, and hands would go up as members looked around the table. With an audience response system, the results are more telling?rarely is there a unanimous vote. A simple majority determines the level assigned. In the case of a tie, the committee may discuss a few of the salient points again and then revote the question. The voting results are displayed immediately so that the members are aware of the case level assessment.

In reviewing the survey, the 2014 results marked the first time a unanimous response was registered to the question of whether the actions taken by the committee were appropriate. From a low of 41% in 2011 to 100% in 2014, we may say that anonymous voting has given the committee the freedom to vote truthfully and the peace of mind that actions are appropriate. The verbatim comments from the most recent survey of peer review committee members bear this out:

  • "The electronic voting has made final determinations more consistent and fair."
  • "I feel like I can express my opinion without risk of comment during the meeting because of electronic voting."
  • "Originally thought the voting took too long; now I appreciate the anonymity."

 

In summary, from much of the literature that exists on professional peer review, there is a general opinion that bias is one of its inherent enemies. Even small attempts to reduce bias can add value. Will we ever be able to overcome all bias? In all honesty, no, but we should not give up the battle to reduce it.

 

Legal and regulatory news roundup

Find out what’s happening in the world of federal healthcare regulations by reviewing some recent headlines from across the country.

 

Hospital’s EMTALA violations threaten its federal funding

CMS has threatened to cut Medicare and Medicaid funding for Indian Health Service’s (IHS) Sioux San Hospital in Rapid City, South Dakota, after an unannounced inspection in May found deficiencies in the emergency department.

According to the CMS report, the hospital failed to provide patients with timely medical screening examinations to determine whether they had an emergency medical condition, which is a violation of the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA). CMS based its findings on a review of medical records and interviews with patients, patient representatives, and hospital staff.

A case cited in the CMS report recounts how a mother brought her 6-month-old baby to the emergency department at Sioux San complaining of congestion, cough, runny nose, and watery eyes. The attending provider diagnosed the baby with a viral respiratory infection without taking a patient history, which would have revealed that the baby was born premature and had a history of respiratory distress. The baby later had a seizure and spent time in the ICU at another facility.

Shortly after the inspection, CMS informed IHS that it had until June 15 to address the deficiencies or risk losing Medicare and Medicaid reimbursements. IHS has submitted a 31-point correction action plan, which CMS has accepted.

The corrective plan includes:

  • A review and revision of the existing EMTALA policies and staff training on any updates.
  • 24-hour coverage of the emergency department by a MD or DO every day. During high-volume periods, a second provider will be added.
  • Pediatric assessment training for all emergency department physicians and nurses.
  • A pediatrician on call 24/7 for consultations.
  • Timely medical screening examinations provided for all patients in the emergency department.
  • FPPE performed on the last 10 pediatric patients of all emergency department providers and medical staff.
  • Daily situation reports for IHS area directors, prepared by the hospital’s CEO.

Three defendants plead guilty in $ 580 million fraud, kickback case

The U.S. government’s ongoing investigation into kickbacks paid for patient referrals and fraudulent billing at Pacific Hospital in Long Beach, California, has led to three more defendants pleading guilty to federal charges. They join six other individuals who have already pleaded guilty to charges of participating in a 15-year-long scheme that illegally referred thousands of patients to the hospital and generated hundreds of millions in fraudulent billings.

The investigation is looking into allegations that dozens of surgeons and other medical professionals participated in a scheme with Pacific Hospital in which they were paid kickbacks for referring patients to the hospital for spinal surgeries. Members of the conspiracy were paid $ 15,000 for every lumbar fusion surgery and $ 10,000 for every cervical fusion surgery referred to Pacific Hospital. During the last eight years of the scheme, Pacific Hospital submitted more than $ 580 million in bills for spinal surgeries, many of which were paid by the federal workers’ compensation system and the California workers’ compensation system.

The latest defendants to plead guilty are Michael Drobot Jr., Linda Martin, and Michael Barri.

Drobot Jr. pleaded guilty to charges of conspiracy and illegal kickback charges and faces up to 10 years in prison. He is the son of Michael Drobot Sr., the owner of Pacific Hospital who previously pleaded guilty to orchestrating the scheme in April 2014. Drobot Jr. solicited physicians and chiropractors to enter into the kickback arrangements with the hospital and served as a liaison with medical professionals.

Martin, a marketer for Pacific Hospital, also pleaded guilty to a conspiracy charge for recruiting medical professionals to refer patients to the hospital in exchange for kickbacks. She could be sentenced to up to five years in prison for her charge.

Barri, a chiropractor, pleaded guilty to a conspiracy count and admitted he received more than $ 158,000 in kickbacks during a nine-month period for referring dozens of patients to Pacific Hospital. Pacific Hospital used Barri’s referrals to bill insurance carriers $ 3.9 million for spinal surgeries. He faces up to five years in prison.

Drobot Jr., Martin, and Barri, along with the previous six defendants, have agreed to cooperate with the ongoing investigation being conducted by the FBI, the U.S. Postal Service Office of Inspector General, IRS Criminal Investigation, and the California Department of Insurance.

 

Healthcare providers responding to online reviews may violate HIPAA

A report from ProPublica has found that some healthcare providers apparently violate HIPAA when replying to reviews on the rating website Yelp. After analyzing more than 1.7 million reviews on the website, ProPublica found that some physicians, dentists, and chiropractors shared patient health information when responding to online criticism from patients.

ProPublica identified more than 3,500 one-star reviews on Yelp that mentioned privacy and HIPAA. The report further details several instances of HIPAA violations, which have resulted in warnings from the U.S. Department of Health and Human Services’ Office for Civil Rights as well as ongoing investigations after the patients filed complaints. The Office for Civil Rights, however, does not track how many complaints it has received regarding HIPAA violations on Yelp.

ProPublica was able to speak to some patients who claim their personal information was disclosed by providers on Yelp. They said the violation of their medical privacy only compounded the damage they received from poor care.

 

Physician indicted on kickback charges

A federal grand jury has indicted Hailu T. Kabtimer, MD, of Henderson, Tennessee, with five counts of violating the federal anti-kickback act.

According to the U.S. Attorney’s Office for the Middle District of Tennessee, from 2013 to 2014, Kabtimer allegedly accepted cash payments in exchange for patients to a particular medical equipment supplier.

During that time, the indictments alleged Kabtimer allegedly accepted kickback payments on eight occasions, totaling $ 3,400. Additionally, Kabtimer allegedly accepted $ 200 for every patient he referred for a continuous positive airway pressure ventilator and $ 300 for every patient he referred for an oxygen unit.

In a statement, U.S. Attorney David Rivera said, "Medical providers who break the law to enrich themselves will be caught and prosecuted … This office and our law enforcement partners will continue our vigorous efforts to enforce the anti-kickback law and to hold accountable medical professionals who accept illegal cash kickbacks."

If found guilty, Kabtimer faces up to five years in prison for each count. He would also face forfeiture of any proceeds traced back to offenses.

 

Data breach compromises 4,000 patients’ protected health information

More than 4,000 patients of Complete Chiropractic & Bodywork Therapies (CCBT) of Ann Arbor, Michigan, were recently notified of a breach that may have been exposed their treatment and billing information. This includes patients’ encrypted electronic medical record data, such as their names, dates of birth, addresses, Social Security numbers, and health/diagnosis information.

CCBT reported the breach after discovering a server infected with malware. The server was immediately secured and disconnected from the internet; all workstation and vendor passwords were changed, and additional IT security safeguards were put in place, according to a statement released by CCBT.

An investigation determined that the malware was likely scanning for login and password information and that the first unauthorized access occurred four months prior to the breach’s discovery. However, CCBT noted that there was no indication that any patient information had been taken or inappropriately used.

CCBT has offered all affected patients a free year of identity theft protection.

Patient recruiter sentenced for Medicare fraud, kickback scheme

Carlos Rodriguez Nerey, owner and president of Nerey Professional Services, Inc., a Miami-based consulting and staffing company, will spend five years in prison for his role in a $ 2.3 million Medicare fraud scheme.

In April, following a one-week jury trial, Nerey was convicted of one count of conspiracy to defraud the United States and pay and receive healthcare kickbacks, and one count of receiving healthcare kickbacks. At Nerey’s recent sentencing, U.S. District Judge Darrin P. Gayles of the Southern District of Florida imposed the prison term and ordered that Nerey pay $ 2.3 million in restitutions.

From October 2014 to September 2015, Nerey would accept kickbacks from Miami-based healthcare agencies Mercy Home Care, Inc., and D&D&D Home Health Care, Inc., in exchange for referring Medicare beneficiaries to serve as patients. Some patients didn’t actually qualify for home healthcare services based on Medicare’s rules and regulations. Nerey’s actions contributed to the submission and subsequent payment of millions of dollars in fraudulent claims to Medicare.

According to evidence presented at trial, Nerey created a shell company to accept approximately $ 250,000 in kickbacks from the two home healthcare agencies. He had also previously worked for several other fraudulent home healthcare agencies in the area.

 

HCPro.com – Credentialing and Peer Review Legal Insider