- group project class work 35min - hc youtube - practice test - hospital privileges - stark...
TRANSCRIPT
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HCM 302
Financial Management
in the Healthcare Industry
Week V
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WEEK V OUTLINE
- Group Project Class work 35min
- HC Youtube - Practice Test - Hospital Privileges - Stark versus Antikickback - Break-Even Analysis
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HCM 302
Group Project02/16/2012
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GROUP A
1- Dana 3- Deja 2-Theresa
4- Nancy Medical Practice Name: Women’s Specialty Care
Details : Specialty: OB-GYN # Of Employees: 10 # Of Physicians: 6 # Of PA's :2 # Of MW‘s: 2 # Of Offices: 3 # Org Type: C-Corp
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GROUP B
1- Diana 3- Hana 2- Devon
4- Cailin Medical Practice Name: Community Care of New Castle County Details : Specialty: Family Medicine # Of Employees: 14 # Of Physicians: 9 # Of PA's :3 # Of NP‘s: 3 # Of Offices: 2 # Org Type: LLC
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GROUP C
1- Natalia 3- Irene 2-Norberto
4- Alyssa Medical Practice Name: Pediatric Physician Care Details : Specialty: Pediatric # Of Employees: 10 # Of Physicians: 6 # Of PA's :2 # Of MW‘s: 2 # Of Offices: 3 # Org Type: C-Corp
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WEEK IV & V 1) Mission statement 2) Sample contracts for physicians 3) Hiring of other office staff – LPNs/medical assistant/accountants/receptionist 4) Contracts with hospitals 5) Hospital privileges 6) Insurance Credentialing 7) Cell phones/pagers for physicians
8) Contract with office space (rent/buy) 9) Scheduling 10) Plan for how to grow patient base/how to receive more patients from local PCPs
Uninsured/unassigned/PCPs PCPs in Southern Delaware that still do not utilize hospitalists to the extent of
Christiana area 11) Retention strategy 12) Flow charts for structure of organization 13) Use specific dates for process; especially with hospital privileges and/or
credentialing 14) Website
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HCM 302
Hospital Privileges 02/16/2012
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FULL PRIVILEGES:
Physicians are allowed to admit unlimited number of patients to the hospital. Physicians are usually given all the privileges needed to perform ‘core procedures’ of their medical specialty. Physicians are also required to attend a required number of medical staff meeting regularly.
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COURTESY PRIVILEGES
Courtesy hospital privileges limit the physician to admitting only a nominal number of patients to the hospital.
It still satisfies most medical insurance companies requirement for physicians to hold hospital privileges.
Physicians are usually exempt from attending medical staff meetings. Such privilege is used by physicians who do not expect to admit patients to the hospital or do procedures there.
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PRIVILEGES STEPS
- Call the ‘medical staff office’ of the hospital and get a privilege application.
- Fill and Submit it back to the medical staff office.
- Follow up with your references to make sure they mailed the recommendations back to the hospital.
- Make sure medical office has everything they need on your file, prior to the next credentialing committee meeting.
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HCM 302
Stark versus Antikickback02/16/2012
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UNDERSTANDING THE DIFFERENCE BETWEEN THE FEDERAL ANTIKICKBACK AND STARK LAW)
-both laws cover similar ground, -an arrangement that is acceptable under one of these statutes could violate
the other.
-Both the antikickback statute and the Stark law were enacted to prevent healthcare providers from inappropriately profiting from referrals.
- These laws are intended to ensure physician’ medical judgments are not compromised by improper financial incentives and are based solely on the best interests of the patients
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UNDERSTANDING THE DIFFERENCE BETWEEN THE FEDERAL ANTIKICKBACK AND STARK LAW)
-the antikickback statute is a criminal statute.
-the statute prohibits any knowing or willful solicitation or acceptance of any type of remuneration to induce referrals for health services that are reimbursable by the Federal government.
-Example, -a provider may not routinely waive a
patient's co-payment or deductible.
-the Stark law is a civil statute -the Stark law essentially provides that a
physician may not refer a patient to an entity with which the physician has an ownership interest or compensation arrangement if payments for the services furnished under the referral are to be made by the Medicare or Medicaid programs.
-Unlike the antikickback statute, the Stark law prohibits referrals for specific "designated health services
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DESIGNATED HEALTH SERVICES
- Clinical laboratory services - Physical therapy - Occupational therapy - Radiology services including magnetic resonance imaging, computerized axial tomography scans,
and ultrasound services - Radiation therapy services and supplies - Durable medical equipment and supplies - Parenteral and enteral nutrients, equipment, and supplies - Prosthetics, orthotics, and prosthetic devices and supplies - Home health services - Outpatient prescription drugs - Inpatient and outpatient hospital services
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EXAMPLES
Healthcare finance professionals need to ensure that all business transactions comply with the antikickback statute and the Stark law Sometimes, it is relatively easy to discern whether a transaction is a violation.
For example, a vendor offering free tickets to the Super Bowl to a provider in anticipation of future product referrals is in blatant violation of the antikickback statute, whereas a hospital offering free compliance training to physicians with privileges at the hospital probably would not be in violation of the statute, depending upon how the training is structured.
A clear Stark violation would be a physician referring patients for treatment to his or her spouse.
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2010 FRAUD ALLEGATIONS AGAINST CHRISTIANA CARE HEALTH SYSTEMCASE STUDY
UNITED STATES EX REL. V. NEUROLOGY ASSOCIATES, P.A. AND CHRISTIANA CARE HEALTH SYSTEM
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EVENTS LEADING UP TO LAWSUIT
In February of 1989 Christiana Care entered into an “evergreen” contract
with Neurology Associates Neurology Associates, P.A. was paid by
CCHS for providing, on an exclusive basis, interpretations of EEGs
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EVENTS LEADING UP TO LAWSUIT
In 2002, other practices competed with Neurology Associates to be the
exclusive provider of EEG interpretations for CCHS
CCHS decided to stay with Neurology Associates, and entered a contract that
significantly lowered the fees CCHS paid for the EEG interpretations
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LAWSUIT In April of 2005 a “qui tam” action was
filed by a competing neurology group, Wilmington Neurology Consultants
In qui tam lawsuits, private individuals who assist a prosecution can receive all or part of any penalty imposed
They had inside information that CCHS was violating the federal and state False Claims Act, the Physician Self-Referral Law, and the federal and state Anti-
Kickback Statute
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FALSE CLAIMS ACT
Law that allows people who are not affiliated with the government to file actions against federal contractors they accuse of committing claims fraud against the government Act of filing such actions is called “whistleblowing” and
person typically receives a portion of recovered damages
CCHS allegedly violated the False Claims Act by overpaying physicians at Neurology Associates for in-hospital readings of EEG as a “reward” for referring patients to the hospital
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PHYSICIAN SELF-REFERRAL LAW
Also known as the Stark Statue; prohibits a hospital from profiting from
referrals of patients made by a physician with whom the hospital has
an improper financial relationship
Contract was given to Neurology Associates and in return physicians were referring patients to
Christiana Care
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ANTI-KICKBACK STATUTE
Very similar to the Stark Statute; prohibits a hospital from paying a physician to induce
the physician to make referrals to the hospital
Christiana Care receives reimbursements from Medicare and Medicaid for services rendered in their
facilities CCHS paid Neurology Associates P.A. significantly more
(in some cases multiples) than the amount Medicare & Medicaid was paying CCHS for those services
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RESPONSE FROM CHRISTIANA CARE
Never admitted to any wrongdoing in this case
The case alleged that Christiana Care overpaid a medical group for services Never any allegation that CCHS was billing for
services that it did not provide or that it was billing for services that were not medically necessary
Patient care was not compromised in any way
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RAMIFICATIONS
Out of court settlement of 3.3 million dollars to the United States & the state of Delaware Whistleblowers were awarded $190,000 in
settlement
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RAMIFICATIONS
Christiana Care entered into a Corporate Integrity Agreement that is monitored by: Office of Inspector General of the US
Department of Health and Human Services United States Attorney for the District of
Delaware, David Weiss Delaware Attorney General, Beau Biden
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HCM 302
Break-Even Analysis02/16/2012
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WHAT IS BREAK-EVEN?
The break-even point (BEP) is the point at which cost or expenses and revenue are equal: there is no net loss or gain, and one has "broken even".
Break-even analysis calculates what is known as a margin of safety, the amount that revenues exceed the break-even point.
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FIXED COST
These are costs that are the same regardless of how many items you sell.
All start-up costs, such as rent, insurance and computers, are considered fixed costs.
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VARIABLE COST
These are recurring costs that you absorb with each unit/service you produce.
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BREAK-EVEN
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HCM 302
EMR ROI02/16/2012
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RETURN ON INVESTMENT SUMMARY
Standardizing Coding 1,897,063Elimination of Dictation 80,345No Show Reduction 300,000FTE Savings 60,000Subtotal 2,337,408
EMR Annual CostHardware * 57,528Software and Hosting 200,000Maintenance and Support 60,000Connectivity 33,600Subtotal 351,128
Annual Total Return $1,986,280
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PAPER VERSUS EMR
EMR = With Standardized Coding X EfficiencyPaper = Prior to EMR
Differential = EMR - Paper
PHYSICIAN TYPES EMR PAPER DIFFERENTIALSkipper 92% 449,922 392,133 57,789Halftime 88% 440,549 392,133 48,416
Steady Eddy 88% 440,549 392,133 48,416Speedball 100% 468,669 392,133 76,536
Slider 75% 410,085 392,133 17,952Tortoise 60% 374,935 392,133 -17,198