Two of the 10 Miami-Dade home-health agencies facing Medicare suspensions for suspicion of fraud intend to fight Uncle Sam in court. Yema Home Health Care and Alliance Home Health filed lawsuits in U.S. District Court against Michael Leavitt, secretary of the Department of Health and Human Services.
“This is grossly unfair,” the agencies’ attorney, Anthony Vitale, said of the suspensions. “They can suspend payment with little or no evidence. My clients have no right to a hearing. It’s absolutely draconian.”
The Centers for Medicare & Medicaid Services (CMS) suspended payments to the 10 agencies in October as part of a campaign to crack down on fraud in the home-health industry. Local providers drew the attention of CMS auditors when their Medicare billing surged 1,300 percent in the last five years. Eight percent of all Medicare payments for home care go to Miami-Dade, even though the county has less than 1 percent of Medicare beneficiaries. The increase comes mostly from payments for outliers, patients who command higher rates because they’re treated at home for more than 60 days. Nationwide, 6 percent of Medicare home-care payments are for outliers. In Miami-Dade, outlier payments average 60 percent, and at some agencies, are as high as 80 percent.
The 10 providers with the highest outlier payments are the ones facing suspension. They’ll soon have more company, predicts CMS spokesman Peter Ashkenaz.
“We will suspend additional agencies as we expand the audits,” Aashkenaz said.
He said payments would be withheld “as long as it takes to complete the audits.”
That could drive his clients out of business, according to Vitale. “They can’t afford to stay in business very long,” he said. “Ninety percent of their reimbursement comes from Medicare.”
“Drastic Action Had to be Taken”

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Florida doctors, hospitals and HMOs may have to confront yet another set of damaging budget cuts in the next few months as the state’s economic woes continue to push the state deeper and deeper into the red.
But a political showdown is looming between Democrats and Republicans over how to respond to the grim economic news, which is expected to get worse when state economists meet in late November to come up with a new set of formal revenue estimates.
“There are just going to be some things that we cannot do and we don’t have money for and it’s going to be a huge problem,” said State Sen. Dan Gelber, a Miami Beach Democrat and former House minority leader.
On Nov. 21, economists will decide how much money they expect the state will collect for the main state account that pays for expenses such as education and the state’s share of Medicaid. The general revenue account as it is known comes primarily from the state’s 6 percent sales tax. Preliminary estimates suggest the state’s overall budget deficit for this fiscal year alone could be as much as $2.5 billion.
The ramifications from the continued economic slowdown could jeopardize many health-care programs, including Medically Needy or the Medicaid Aged and Disabled program. Both programs will automatically be eliminated in 2009 unless lawmakers can find the $700 million needed to keep them intact.
Chief Financial Officer Alex Sink, a Democrat, has already called on legislators to hold a special session later this year in order to grapple with the ongoing financial problems, while Gelber has suggested that the legislature should be ready to respond if Congress moves ahead with an economic stimulus package. President-elect Barack Obama has made the package a top priority and said he wants state and local governments to get help so that they are not forced to cut jobs while the nation’s economy continues to struggle.

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A board-certified internist was disciplined based on allegations he aided in the unlicensed practice of medicine and improperly delegated responsibilities to his wife by allowing her to take pap smear specimens on two patients. The doctor’s wife was not licensed in the United States in any capacity, but was a physician in another country, so the doctor testified that he felt comfortable allowing her to take these specimens as a medical assistant in the doctor’s office. The doctor’s wife was charged criminally for engaging in the unlicensed practice of medicine, and did not contest the facts alleged. The doctor was fined $20,000, given a letter of concern, required to undergo a risk management review of his practice, and to complete 100 hours of community service and five hours of CME.
Physician settles over
failure to order tests
An emergency room physician from Tampa was before the Board of Medicine after entering into a settlement agreement based on an allegation that he fell below the standard of care by failing to follow-up on an elevated D-dimer level, and failing to order other tests to rule out pulmonary embolism and deep venous thrombosis. The doctor offered additional facts at the hearing that he was not aware that a D-dimer test was ordered.
The board found that the records showed that attempts were made to admit the patient to the hospital, but that request was refused, so arrangements were made to transfer the patient to another hospital. The board also found that the patient was hemodynamically stable after being treated in the emergency room, and that the doctor did everything expected of him, so the case was dismissed.

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Q: Our group practice is seeing more patients than ever, our staff is happy and we are reporting a profit. So why don’t we have the cash available to add equipment or expand the practice?
A: Could time be your enemy?
Managing working capital can be one of the thorniest problems a medical practice faces. As your patient load increases, so do your expenses. But third-party payors may take as long as 120 days to reimburse you -- longer if there are coding errors and billing disputes.
Because you can’t wait that long to pay your bills, you may find that cash is flowing out faster than you can bring it in. In such cases, you may need to turn to your local bank to tide you over with a line of credit. But before you take on debt, be sure you’re doing everything possible to improve your cash flow by thoroughly analyzing the effectiveness of the practice’s billing and collection cycle.

* For the complete story, call our Circulation Department at 800-327-3736 ext. 127
Determining patients’ primary insurance
BENJAMIN FROSCH
Q: I have a very large Medicare practice that continues to grow. I am starting to have some billing issues where Medicare turns out to be my patient’s secondary insurance. How do I determine if Medicare is primary or secondary?
Office Manager,
Delray Beach
A: In the majority of cases Medicare is primary; however, there are certain situations where Medicare can be the secondary payor. The following are some examples where Medicare can pay as the secondary:
The individual in question is Medicare entitled due to End Stage Renal Disease (ESRD). Medicare would be the secondary payor to a group health plan until a 30-month coordination period has ended.
The individual or his/her spouse is currently employed/working and is covered under an employer group health plan as a result of current employment.

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Hoping to streamline nurse scheduling and give employees more choice, Health First in Melbourne implemented a Web-based shift-management technology, which has more than delivered—saving the three-hospital health system about $1.8 million.
“It has simplified a cumbersome process, primarily from the staff side,” said Jan McCoy, RN, vice president of patient care services at Cape Canaveral Hospital. “It has improved efficiency of staffing and saved significant money in the process.”
Nurses from Cape Canaveral, Holmes Regional Medical Center and Palm Bay Community Hospital can sign up in CAREshift for shifts they are eligible, by training and experience, to work anywhere in the system.
“Nurses, as a rule, don’t like to float,” McCoy said. “However, through CAREshift, they are able to go in and schedule themselves on other units. Forty-six percent of the shifts scheduled through CAREshift were outside their own unit. It’s called self-directed scheduling. It’s wonderful. … We didn’t know nurses would be willing to do that.”
Shands at the University of Florida in Gainesville, which uses a similar online system, also has found nurses more willing to work on different units.
“Because nurses have control, we will see nurses float,” said Dave Hudson, manager of Central Staffing. “We have seen 15 percent to 20 percent cross pollination. It has helped us cut some of the travelers.”
At Shands, online staffing has spread to the pharmacy department. And the hospital has started using the software to let clinical staff sign up for nursing education classes.
St. Vincent’s Medical Center in Jacksonville began using an online nurse-scheduling program in April. However, nurse manager Melissa Scott, RN, has not noted an increase in nurses willing to float, but St. Vincent’s has decreased use of agency nurses. And there have been other benefits.
“It’s freed up time for the managers, who would have spent time calling people to get their shifts covered,” Scott said. “The nurses are happy, because they get to see more shifts. If they want to work, nine times out of 10, they will find a place to work.”
Giving nurses that freedom to choose means more shifts are covered by employees, who know the health system. Every nurse has the same opportunity to sign up for a shift, eliminating the variance that occurs when a paper schedule was posted on a day that nurse might not be working.

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As an attorney practicing in the wills, trusts and estates area for quite a number of years, I have had my fair share of physicians as clients. In many cases, physicians are no different than any other potential client with estate planning issues, such as trying to minimize federal estate taxes, avoiding probate, etc. However, classically, physicians have always had one issue that separated them from most of the rest of the clients who walk through my door. Physicians are potentially subject to lawsuits, which in some cases are negligent errors, but in other situations are merely based on bad results. For this reason, I have developed a specialty in estate planning/credit protection planning. Again, most of the clients interested in estate and credit protection planning have been physicians; however, in recent years real estate developers, businessmen, etc. have asked the same types of questions and have wanted the same protections.
The first thing that everyone needs to know is that Florida is one of the best states to reside in in order to maximize your estate/creditor protection planning results. Florida’s exemptions are superior to most other states. However, I first want to touch upon an issue that overlays this entire area of planning. It is the concept of a “fraudulent conveyance.” A fraudulent conveyance is a transfer at a time when a creditor exists or is known to likely exist, which tends to either defraud or hinder that creditor from collecting its debt. There are thousands of cases in the fraudulent conveyance area, and there are many issues the courts consider in determining whether to rule in favor of the debtor or the creditor.
There is one fundamental concept that runs through all the cases in this area, and that is timing. If people were to plan their affairs at a time when they have no known creditors, or none are likely to exist, and in such a way as to protect their assets, then that would not be a fraudulent conveyance. However, if a client waits too long, then a fraudulent conveyance claim can be made by the creditor. I therefore encourage anybody who is thinking of doing this type of planning to act swiftly and not wait until the last minute.
The first place to start is the Florida Statutes and the Florida Constitution. Please note that this article is not meant to be a primer in the Federal Bankruptcy area. Bankruptcy is handled through the federal courts, which have a different set of rules. I do have discussions with my clients so as to minimize the chance that a creditor can involuntarily place my client into bankruptcy because they like the playing field in the federal system better than the playing field in the Florida state courts. I will not discuss these issues in this article.

* For the complete story, call our Circulation Department at 800-327-3736 ext. 127