NOTE: While the posts on this blog should generally be concerned with healthcare related issues, the current political situation in Washington along with pending healthcare reform render politics and healthcare inextricably bound. When looking at the current logjam relating to healthcare reform, I think that there are a number of inescapable facts. Although I am far from a political expert, it is possible that the inexperienced person may be able to suggest workable and proper solutions specifically because they are not constrained by the minutia of the political process.

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What do you think?

Posted in You Decide on February 23rd, 2010

I recently heard a news report describing how medical patients in Colorado were complaining that their doctors had a new policy that required lodging a credit card and signing an authorization for any payments that were not made by the insurance carriers.

The patients felt that they were being unfairly taken advantage of and “blackmailed.” Furthermore, they felt that this new conduct on the part of the doctors was a breach of trust as they had been long-standing patients and had always fulfilled their obligations.

On the other hand, the doctors claimed that it was a move to streamline their office protocols in an effort to be more efficient. In addition, they felt that this policy did not violate their contracts with the insurance carriers or any other state or federal regulations. The doctors saw this as a way to become more efficient and ostensibly lower their operating costs.

As an outsider, I can understand that the doctors have to optimize their operations and do not want to go to the trouble of billing the patients for any shortfall.

On the other hand, I understand that the patients feel they should be trusted.

I question what the medical practices do with those patients who do not have a valid credit card and, even if they were willing to, could not provide one. Would the doctor, under those circumstances, treat the patient?

The report went on to say that AETNA, one of the insurance carriers, suggested that under these circumstances the patients could find a new doctor. In my opinion, it was an insurance carrier’s way of not entering into the debate. It was essentially saying that if the doctor was within his/her rights and the patient did not like the treatment, it was his/her option to go elsewhere.

What do you think?

As you articulate your thoughts, are you a doctor, a member of a medical office staff, do you have any affiliation with a medical billing company, or are you looking at this from the perspective of the patient?

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Posted in News on February 17th, 2010

While the Democrats and the Republicans are busy squabbling over health care reform, a recent article in the journal Health Affairs has shed light on the new reality regarding United States healthcare.

The report sets forth that sometime in 2012 or 2011 federal and state programs will pay slightly more than 50% of the healthcare purchased in the United States. Projections by Medicare are consistent with this finding.

I believe that the reason for this shift is the aging of the baby boomers in conjunction with increased eligibility for Medicaid-due at least in part to the United States economic downturn.

To the extent that government pays for the majority of healthcare in the United States, they get an increased “say” in the provision of healthcare.

From a medical billing perspective, increased government funding of healthcare will probably lead to lower reimbursement on a per procedure basis. Accordingly, doctors will either be earning less or will have to work harder to maintain their current revenue levels. In either case, logically, doctors will be looking for ways to optimize their medical practices and cut costs without compromising the quality of their medical care.

Medical billing companies that work for a percentage of recovery, may see their revenue decline and also have to contend with doctors seeking lower percentage deals for medical billing services. This will require medical billing companies to reevaluate their cost structure so that they can remain competitive.

The recent HIPPA and HITECH legislation will (at least initially) increase the operational costs of both medical practices and medical billing companies. However, I believe that medical billing companies will be able to absorb these new increased costs more efficiently than individual medical practices.

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The HITECH Breach Notification Rules

Posted in News on February 17th, 2010

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Posted in News on February 16th, 2010

The American Psychiatric Association is in the process of revamping its diagnostic and statistical manual of mental disorders. While the new manual (DSM-5) will not be published until 2013, a draft was released on February 10, 2010 and will be displayed for public comment until April 20, 2010 on

A brief review of the site reveals a vast array of conditions, including mood, sexual, personality and your garden-variety personality and psychiatric conditions.

What apparently has labor lawyers in a tizzy is the possibility that these disorders may provide new found freedom for employees and their attorneys, and place unprecedented restrictions on employers-because employees may demand special accommodations because of their disorders-also known as disabilities-which would render them subject to the ADA.

Some of the examples cited by the concerned attorneys are binge eating and excess gambling. However, in reviewing the site it appears that there are many other conditions contemplated as psychiatric disorders that might give labor lawyers pause.

The real fear is that inclusion in the DSM-5 will give attorneys the opportunity to test newly formulated disorders, increasing potential liability for employers in defending these claims with the added risk of a ruling that would open the floodgates for numerous claims.

While the ADA is truly important and protects many people whose rights might otherwise be trampled, the fear is that the proposed disorders will lead to significant abuse of the ADA.

From a medical billing perspective, these disorders coupled with recent legislation that broadens insurance coverage for mental health disorders, causes one to wonder the future conditions that medical billing operators will be keying into their computers.

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Fax Machines – The New Enemy

Posted in News on February 16th, 2010

Over the years, fax machines have become a fixture in virtually every office – including doctors’ offices. With the advent of HIPAA regulations and their HITECH overlay, however, doctors may begin to look at their fax machines in a totally new light.

Let’s face it; if you have sent enough faxes, chances are that you or a member of your staff has sent a fax to the wrong number. Because of this, virtually every fax cover sheet gives instructions as to what to do if the wrong recipient gets the fax.

What happens when protected health information (PHI) is sent to the wrong recipient?

While technically this may not be covered by the new HITECH rules, it would be covered by the general HIPAA regulations and, therefore, depending on the number of patients affected, HHS would either have to be notified immediately or at the end of the year.

This is especially troubling in light of the fact that many doctors’ offices still send their encounter forms or superbills to medical billing companies by fax. In a recent interview, Susan McAndrew, the Deputy Director for Health Information Privacy for OCR (the new sheriff in town to police HIPAA and HITECH violations), reported that the breach numbers for the month of January 2010 are as follows:
      • As of January 2010, there have been 35 reports of breaches affecting 500+ individuals resulting in 712,000 notices, and
    • Most of the reports were E-PHI and contained lost or stolen unencrypted media or portable devices, and
      • There were more than 300 reports of smaller breaches, and
   • Most of the paper records were sent to wrong fax numbers, wrong addresses, and wrong individuals.

It is frightening to think that a misdialed number on a fax machine can begin the process of risk assessments, notifications and fines simply because of an oversight in your medical practice. There has been very little if any proactive enforcement of HIPAA on the part of the government, and because the enforcement and assessment of penalties for HIPAA violations has been virtually non-existent, many holders of protected health information (PHI) have, at some level, grown accustomed to certain practices that have never been questioned or tested. They have, therefore, convinced themselves that they are in compliance with the law.

The rules of the game, however, are rapidly changing and many people are not aware that the government is mandated to and, in fact, intends to police the medical profession and enforce its laws and regulations through “periodic audits.”

Based on a statement from Susan McAndrew, the calendar for when these periodic audits will take place has not yet been established. Essentially, she said that OCR is considering its budgetary means and the most effective methodologies as there are many ways to accomplish these periodic audits.

In future posts to this blog and submissions to our website, we will have various materials available to keep medical professionals abreast of developments and to point out some of the issues and challenges they may face regarding compliance with HIPAA HITECH.

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Should We Learn How to Act on HIPAA and HITECH Security Breaches From the Government?

Posted in News on February 16th, 2010

On February 1, 2010, 49,352 Medi-Cal beneficiaries were mailed information and their social security numbers were on the address mailing labels.

The first question this raises is why the mailing house or mail room had the recipients’ social security numbers in the first place? Assuming we can get past that, should we assess how the government deals with these types of security breaches and act accordingly?

As a curative notion, Medi-Cal advises that it has sent notification letters to the 49,352 beneficiaries alerting them to the security breach. The letter also advised beneficiaries how to protect themselves from identity theft by contacting the three credit reporting agencies and placing a fraud alert on their files.

We can contrast this with the security breach that occurred with HealthNet who offered its beneficiaries two years of credit bureau monitoring for free. In light of the government’s position, was this move by HealthNet excessive?

In fact, HealthNet is not the only organization that has gone to that length when there were breaches of PHI.

Considering that Medi-Cal is a senior program, one can only wonder what benefit the letter containing information as to how to contact the credit reporting agencies is really worth.

At this point, one might think that the breach at HealthNet was more troublesome than the breach at Medi-Cal. I leave it to the readers of this article to decide.

In the case of HealthNet, an optical drive was missing, and while the information was not encrypted, special software would be needed to be able to view it. One might argue that the likelihood of the drive ending up in a landfill and/or in the hands of someone who neither knew what it contained nor had the ability to extract the information was most likely.

In the case of Medi-Cal, the information was apparently front and center on every envelope. Of course Medi-Cal’s position is that because the numbers were not separated by hyphens they were not clearly identifiable as a social security number. I think that the press coverage of this incident may auger in favor of the fact that the masses know what those nine digits represent.

On the other hand, in the case of HealthNet, a single person having possession of the optical drive would have access to many different health records whereas in the case of the Medi-Cal situation, the almost 50,000 letters are spread throughout the state – unless you have access to the mailbox at senior citizens communities.

Should the Medi-Cal mishap serve as guidance to the private sector?

Considering that the government has allowed the covered entities to do their own risk assessments in the case of unauthorized dissemination of PHI, the Medi-Cal case would apparently give a lot of latitude in the risk assessment process.

Which brings us to the basic question; will the government be held to the same standard as the private sector, and on the other hand, should the private sector learn from how the government deals with HIPAA and HITECH breaches?

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The End Game

Posted in News on February 9th, 2010

As we enter 2010, it is clear that the government seeks to move medicine from paper- based practices to digital format. In fact, the HITECH legislation is merely the government addressing security issues expected as a result of the move to digital medical records before the actual transition takes place.

The big question, though, is “why?”  Why should the government be so interested in transitioning from paper to computer/digital-based medicine and creating incentives for electronic health records (EHR).  The reasons that are given most frequently are that it will bring down the cost of providing medicine, will prevent mix-ups in various medications, will afford patients the freedom to visit a doctor and have their complete medical histories available to them in a painless manner, and will, hopefully, preclude people in hospitals from having to repeat their medical histories half-a-dozen times before a procedure, etc., etc.

I suggest that irrespective of the above mentioned benefits, there is one overriding benefit that is not regularly discussed but is of epic proportions.

The larger the pool of data that can be assessed regarding a disease, its diagnosis, its treatment, and the effects of various drugs, the better and more efficient the provision of care will be, thus taking a lot of the guess work out of the process. Medical care will no longer rely on a doctor’s gut instincts and will be based on more comprehensive and accurate empirical data.

One example of the efficiencies that can be reached relates to Medco Health Solutions which currently boasts service to 62 million members across the United States. As such, Medco has a very large database and has conducted a study using data from 17,000 patients. Half the group used Plavix and the other half used Plavix plus a proton pump inhibitor. The finding was that the latter group using Plavix with the proton pump inhibitor (heartburn medicine) experienced a 50 percent increase in cardiovascular events and a 70 percent increase in heart attacks. Subsequently, the FDA issued a warning to doctors and patients. This is but one example of what can be accomplished if medical data is assembled and various statistical calculations are performed so that a new body of empirical data is derived that can guide the provision of medical care in our country.

While the overall cost benefit of electronic health records is yet to be proven, logic dictates that if enough statistical information can be assembled, it will yield important information that will save lives.

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