Dr. Lyn Olsen’s presentation on The Good, Bad and Ugly in Leadership, June 2016.
Feds Announce Largest Ever Criminal Medical Fraud Takedown
The government claimed that those involved billed Medicare and Medicaid for medically unnecessary treatments, or treatments never provided. A total of 243 individuals were charged including 46 doctors, nurses and other licensed medical professionals for a total of $712 million in fraudulent billing.
Over 44 of the defendants were charged with fraud related to the Medicare prescription drug benefit program, also known as Part D.
An Indiana court has awarded a plaintiff $1.44 million in a Professional Liability case she brought against a pharmacist, according to Reports from Mondaq. The case highlights how HIPAA requirements affect the day-to-day work required of pharmacists and other allied health professionals, as well as the potentially stratospheric cost of violating those requirements.
Here’s a look at what happened in the Indiana case and how you can ensure that your Allied Health practice maintains HIPAA compliance and avoids costly fines and judgments.
HIPAA Privacy Violation: Improper Disclosure of Client Information
According to sources, the million-plus-dollar judgment resulted from the following events:
- A Walgreens pharmacist improperly accessed one patient’s information and shared it with her husband.
- Upon gaining access to the patient’s information, the husband harassed and intimidated her.
- The alleged reason for the harassment and intimidation was that the patient had a prior relationship with the pharmacist’s husband that resulted in the birth of a child. The husband apparently used information from the patient’s file to deny child support payments the patient requested.
The Indiana Superior Court found in favor of the patient, noting that accessing and sharing her information violated standards of care outlined by HIPAA. In its decision, the court noted that the pharmacist was negligent and guilty of privacy invasion and publication of negligent facts (a Professional Liability / Malpractice matter). It also found that Walgreens had liability for failing to terminate the pharmacist after it learned about the behavior.
What’s perhaps most interesting for other pharmacists and allied health professionals, however, is the potential decision of higher courts.
HIPAA Violations, Standards of Care, and Causes of Action
This case made news in part because it marks the first time a court has awarded a plaintiff such a large judgment for a defendant’s violation of standards of care defined by HIPAA. Here’s why that matters for allied health professionals:
- Standards of care as causes for action: In law, a “cause of action” is a legal reason why a plaintiff seeks damages from a defendant. In this case, the patient cited the pharmacist’s violation of HIPAA’s standards of care as cause for action. Because the court ruled in the patient’s favor, it set a precedent for allowing other patients to sue allied health professionals (and receive financial awards) over HIPAA violations.
- Variations in state law: The Indiana court’s ruling, however, could be vastly different from rulings in similar cases in other states. That’s because state law determines the extent to which HIPAA violations can be considered causes of action, and whether those violations can result in more than monetary (civil) damage awards. In other words, some states might come down even harder on HIPAA violators.
- Establishment of legal precedents: There are still relatively few legal precedents for how HIPAA violations are handled. Specifically, it’s possible that, depending on state laws, HIPAA violations could lead to criminal as well as civil penalties. The Indiana Walgreens case led only to civil penalties (a monetary fine). For this reason, allied health professionals need to be prepared to defend themselves and their practice if and when they’re charged with professional liability for HIPAA violations.
How to Protect Yourself and Your Practice
So what can pharmacists and other allied health professionals do to ensure that they’re protected from lawsuits over HIPAA violations? Obviously, the most important thing is to make sure you are aware of HIPAA care standards (especially as they relate to disclosure of patient information) and that you establish protocol to ensure your employees adhere to those standards.
It’s also important to remember that, even if you don’t think you violated HIPAA guidelines, a dissatisfied patient could bring a lawsuit against you. If your state doesn’t have clear legal precedents outlining how such a lawsuit should be handled, you’ll need solid legal representation to help you argue your case. A solid Malpractice / Professional Liability Insurance policy can pay for the costs of mounting such a defense, which is crucial given the high cost of legal fees.
Finally, keep lines of communication open among yourself, your patients, and your employees. Many legal actions can be avoided by addressing small problems before they grow into big ones.
Congress is still debating whether ICD-10 should be implemented this fall or not. One of the main reasons is the possible explosive costs to practitioners including hospitals and small practices which some have estimated to be as high as a quarter of a million for small practices to implement. Besides Obamacare also having to be institutionalized, it is probable that the costs for small practices, and even bigger ones including hospitals, could be numbing at the least.
ICD-10 Debated on Capitol Hill;
Most in Favor of 2015 Implementation
Feb 23, 2015
The House of Representatives’ Energy and Commerce Committee’s Subcommittee on Health held a hearing on the transition to ICD-10 this week that ended up being lopsided in favor of moving forward with the transition.
The panel included stakeholders from the healthcare industry, including practitioners, advocacy groups, and vendors. Most members of the panel were in support of keeping Oct. 1, 2015 as the official deadline for ICD-10 implementation. Only one, William Jefferson Terry, M.D. from the Mobile, Ala. Urology Group, represented an anti-ICD-10 voice. Although a few doctors in Congress, most prominently, Rep. Larry Buschon, M.D. (R-Ind), spoke out against the ICD-10 transition.
Some medical groups, such as the Medical Group Management Association (MGMA) and the American Medical Association, are pushing for a third delay of the compliance deadline for the code-set. Neither group had official representatives on the panel, although Dr. Terry has been associated with the AMA in the past. He was speaking on behalf of the American Urological Association at the hearing.
The debate centered on the cost and benefits of the ICD-10 transition. John Hughes, M.D. Professor of Medicine at the Yale School of Medicine, said that ICD-10 will accurately describe information on procedures that will ultimately lead to new discoveries and treatments. Sue Bowman, the senior director of coding policy and compliance for the American Health Information Management Association (AHIMA), listed the many improvements that will come from ICD-10 including analysis, ability to measure outcomes, public health measures, and much more.
Cost became a hot topic. Those like Dr. Terry said the transition to ICD-10 was costing physicians. Many, he said, were opting to retire early than face ICD-10. He recommended an implementation that should be carried out over 2-3 years. Buschon said that in his own life, the administrative costs of ICD-10 led to his practice being sold to a hospital.
Having cited a study that said the cost of transition would be up to $250,000 for small practices, some disputed his claim it would be this overwhelming. Rich Averill, director of public policy at 3M Health Information Systems, said that another study had shown the cost for small practices to on average about $8,000.
Many derided the ICD-9 code-set as out of date. Bowman said it doesn’t fit with a 21st century health system. Averill noted that when ICD-9 was implemented, you could still smoke in a room with the patient. “The reality is with ICD-9 we often don’t know what really is wrong with the patient or what procedures were performed. ICD-9 codes like a repair of an unspecified artery by an unspecified technique are virtually useless for establishing fair payment levels or evaluating outcomes,” he said.
Hughes at Yale Medicine testified on his own frustrations with using ICD-9. “I have been frustrated many times at ICD-0’s inability to specify the exact nature of a complication, its extent, its location, and how it was treated,” he said. He said it doesn’t have the capacity to describe new technologies. Also speaking in favor of the transition was Kristi Matus, chief financial and administrative officer of Watertown, Mass.-based vendor athenahealth, Edwin Burke, M.D. a practicing physician, and Carmella Bocchino, of the America’s Health Insurance Plans (AHIP) group.
- Executive Vice President of Clinical Affairs and Strategic Planning
- Executive Vice President of Clinical Affairs and Strategic Planning
On the specificity of the code-set, Terry said that the ICD-10 was too granular. He noted that there were more than 200 codes for diabetes alone. He said this increased granularity would lead to reduced production from physicians. He said the codes were statistics and not for people who want to practice.
After initial testimony, Rep. Joe Pitts (R-PA) took a vote asking panelists if the health industry was ready to implement ICD-10. Everyone, except Terry, said yes. When he asked if another delay should be opposed, everyone again said yes except Terry
One thing I always tell my new students is that when you are done with my courses you should have a whole new perspective of healthcare. Our healthcare has changed drastically from one centered on patient-doctor to one that involves a whole myriad of employees, administrators, and a multitude of various agencies including government.
Despite how much we have changed healthcare administratively, the core of healthcare has remained the same. An integral part of this core is that it is vast yet simple meaning that while the common purpose of the body to maintain its well-being is simple it is overshadowed by a complexity that exceeds anyone’s understanding of even a small minutiae of the human body which leads to one conclusion only – that life is the greatest miracle ever.
We see testimonies of this constantly and the following story is one of those miracles that exceeds any human understanding.
Sarah Scantlin was unable to speak after an automobile accident in which a drunk driver crashed into her, leaving her in a coma. Though doctors believed her brain was injured so badly in the accident that should would never be able to talk again and spend her life in a vegetative state, Scantlin began speaking a week ago.
Sarah’s friends and family gathered Saturday at the health care center where she lives to celebrate.
“She’s 100 percent Sarah again. The family is back together, and it’s just simply a joyous situation,” her father, Jim Scantlin, told CNN.
Scantlin was 18 when she was injured and, until last month, she was aware of her surroundings but unable to speak. Suddenly, she began talking to workers at the health care center.
“It just happened one day and nobody really knows why,” said Sharon Kuepker, administrator for the Golden Plains Health Care Center.
Now, Scantlin is forming words, counting, and remembering people and places.
“You condition yourself to be able to try to deal with something like this, and then all of the sudden, the world instantly changed from despair to joy because it’s amazing how important communication is between human beings,” her father told the Associated Press.
Members of the British parliament today voted to make Britain the first country in the world to allow scientists to create three-parent genetically-engineered embryos, sometimes called “designer babies.”
In the process, the babies the babies, born from genetically modified embryos, would have DNA from a mother, a father and from a female donor. The British parliament voted 382 to 128 in favor of the technique and Prime Minister David Cameron allowed a free vote on the issue and voted for it.
Conservative lawmaker Fiona Bruce said the measure would lead to “designer babies.”
Medical coding has become a critical component of quality healthcare, so it is critical that coders are well-educated and highly knowledgeable withim a wide variety of healthcare administrative areas. Dr. Olsen’s new medical coding textbook is comprehensive in order to provide top quality instruction in medical coding, not only in preparation for the national coding exams, but also to ensure that coders are highly qualified. With more than 15 years experience and five national certifications in healthcare administration, Dr. Olsen combines her many years working with thousands of highly successful students and her own extensive experience and education to bring the same high level of educational quality to everyone as she has done for her students, so enjoy the great quality at a great price in her newest publication, Comprehensive Medical Coding Study Guide and prepare for a new great future!