Relocating or expanding your medical office space is a complex process. That is why you need to start the planning process at least one year in advance, according to Evan Tarbis, senior advisor with Duncan Commercial Real Estate, and an expert in medical office leasing and acquisition. “You don’t want to rush such an important decision,” Evan says.

Allowing adequate time gives you the flexibility you need to acquire or lease the right space at the right time and at the right price.

Office Relocation Tips

To attain optimum results, you should follow these proven steps in your medical office selection and acquisition process.

- Make sure you are aware of your lease expiration date so that you can start planning well in advance. Month-to-month or holdover lease extensions after the initial lease expires can be expensive – often increasing your rent by 100 to 200 percent.

- Consider the size, location, patient flow, functionality, equipment and infrastructure requirements, parking and accessibility needs, and so on – anything that affects the objectives you have for your new office space.

- Using the information you provide, an experienced commercial real estate broker can help you survey the marketplace to identify the available properties that meet your specifications. In addition, the broker may even be able to identify opportunities that you may not have considered previously, such as new construction.

- Once the list of possible properties has been narrowed down, key office staff should gather first-hand knowledge by touring the preferred properties.

- After you have selected the location, the broker can work with your office liaison to prepare the property for occupancy. This may include interviewing, hiring and coordinating with architects, developers, property owners, financial advisors, attorneys and other professionals. Be aware that this process can take can take as much as nine to 12 months.

- Thoroughly review and approve all documentation associated with the move, including proposals, letters of intent and lease documents.

- Make sure you begin notifying your patients of the relocation as soon as possible, so they can get acclimated to the change.

Follow these guidelines to ensure that you are making an informed decision about your medical office relocation – and making the complex medical office selection process go smoothly.

For more information, or advice about medical office relocation, contact Will Duncan at 502-292-5464 or wduncan@duncancre.com.

On a chilly afternoon at a community clinic in Southeast Washington, D.C., three young doctors are busily laying the foundation for the health care law’s success.

Jacob Edwards flips through a manual on skin conditions, diagnosing a rash that looks like chicken pox. Jessica O’Babatunde consults her supervisor on treating an adolescent’s obesity, which is literally off the charts. And Julie Krueger peppers 3-year-old Daphauni with questions at her physical: How do you spell your name? What did you eat for breakfast? What’s your favorite vegetable? (Cheese.)

They are primary-care residents at Children’s National Medical Center. A third of their class has more than $200,000 each in student loan debt. At the end of residency, they can stay in primary care and earn $29.58 an hour. Or they can specialize and make $74.45. Over a lifetime, a medical student who specializes can expect to earn $3.5 million more.

The Obama administration — and, arguably, the American health care system — desperately needs them to choose primary care.

Decades of research have confirmed that more specialists leads to more specialty care, which leads to a more expensive system. Now, with the passage of the Affordable Care Act, tens of millions of previously uninsured Americans will be looking for a primary-care doctor. It is no exaggeration to say that the success of the health care law rests on young doctors choosing to do something that is not in their economic self-interest.

The surprise of the health care overhaul, at least thus far, is that so many young doctors are cooperating. The number of American medical students matching into primary-care residencies jumped 20 percent between 2009 and 2011, according to the Association of American Medical Colleges.

“Regardless of what people think about the health reform legislation, or what side of the aisle people are on, the debate shone a significant light on the importance of primary care,” says Glen Stream, president of the American Academy of Family Physicians. “There was more attention paid to the importance of primary care, the cost-effectiveness of it and that we’re facing a worsening shortage.”

That worsening shortage, he says, has to do with the economics, with nearly every incentive working against going into primary care.

“No matter what specialty you’re going into, your medical education costs the same,” Stream says. “Think about a medical student who is sort of interested in primary care and has got $250,000 in debt. People are often driven by financial incentives, and you basically get the outcome that you incent. The health care workforce is not different from any other sector in that regard.”

As with specialty doctors, specialty residents bring a hospital more lucrative business. A radiologist will earn a hospital $193 in Medicare reimbursements every hour, while a primary-care doctor brings in $101, according to an analysis done for a congressional watchdog agency.

“What hospitals build, in terms of their residency training, has a lot to do with what business they’ll bring in,” says Robert Phillips, director of the Robert Graham Center, which studies health care workforce issues. “If they have a choice between funding a primary-care residency or one in cardiology, the cardiology residency will make them a lot more money. It’s a perfect storm that aligns the incentives against everything other than primary care.”

Huge Projected Shortfall
The greatest threat to the health care overhaul might not be the Supreme Court, which is scheduled to hear challenges to the law next month, or the shifting alliances of an election year. In the end, it’s more likely to be a lack of medical providers. If the law succeeds in extending health insurance to 32 million more Americans, there won’t be enough doctors to see them. In fact, the anticipated shortfall of primary-care providers by 2015 is staggering: 29,800.

The Obama administration’s options to address that threat are limited. It does have Medicare, which covers the lion’s share of the cost of training medical residents: in 2009, it spent $9.5 billion on residents’ stipends, teaching physicians’ salaries and related expenses. But when Congress passed the balanced budget amendment in 1996, it capped the number of residencies that Medicare can fund. Since then, hospitals’ slots have been tethered to 1996 levels.

The health overhaul, some hoped, would address that issue. But with the health insurance expansion’s $971 billion price tag — and the Obama administration’s goal to keep the law’s cost under $1 trillion — funds for more slots didn’t turn up.

In the context of a $1 trillion overhaul, the White House’s main effort on this front seems modest: a $167 million sliver of the $15 billion Prevention and Public Health Fund created as part of the health care law.

“It’s good,” Stream says, “but it’s also a drop in the bucket.”

Last summer the White House launched the Primary Care Residency Expansion at 82 hospitals across the country, with two strings attached: the programs must train residents dedicated to primary care, and the residents must work in underserved areas.

Medical students see good reasons not to sign up, as primary-care doctors often find themselves at the bottom of the pecking order. Research published last month in the journal Family Medicine found that medical students, even those planning to pursue careers in primary care, viewed the work lives of primary-care doctors more negatively than those of other doctors.

“The income gap that stratifies much of society often stratifies the physician community as well,” a 2009 report on primary care from the Robert Graham Center concluded. “The ‘heart hospital’ side of a medical campus may have fountains and artwork, while the mental image of the primary-care offices is a necessarily full waiting room of a practice where physicians see 40 or more patients a day.”

Those differences help explain the country’s primary-care doctor shortage. They also make an impression on medical students like Reem Nubani, a 30-year-old student at Southern Illinois University interviewing for residency slots.

“It has this connotation that you don’t make much money or you’re not as smart,” says Nubani, who is considering primary care.

“Sometimes I feel like it may be even harder in primary care because you still have to know a little bit about everything.”

When the White House launched its residency program, it wasn’t sure medical students would show up. In fact, they snapped up all 172 slots funded in its first year. “The thing we were really thrilled about is that all the positions were filled,” said Kathleen Klink of the Health Resources and Services Administration.

Children’s National Medical Center in D.C. is among 82 hospitals that were funded. Children’s grant is among the largest, at $3.8 million, and doubled the hospital’s community health residency to 24 students. Some of those new doctors are assigned to the Children’s community clinic on Martin Luther King Jr. Avenue SE, about two miles from the Capitol, where Congress passed the health care overhaul in 2010.

The clinic’s patients are arguably among those who will benefit most from the law’s primary-care expansion. In 1993, the federal government declared the surrounding neighborhood, east of the Anacostia River, a health professional shortage area and, to this day, it has too few doctors to serve its residents.

The doctor shortage correlates with striking disparities between the health of its residents and those who live across the river. Ward 8 residents are eight times more likely to die of heart disease than residents of Washington’s tony upper northwest neighborhoods in Ward 3, according to a 2008 Rand Corp. analysis. In Ward 8, 33.3 percent of adults are obese, compared with 9.3 percent in Ward 3.

The primary-care focus of the Children’s community clinic has attracted students such as Jacob Edwards, 34, who grew up in a low-income, predominantly African American neighborhood in Atlanta. Health care specialists were hard to come by, he said. Edwards had asthma as a child and remembers his mother driving him 20 miles to see his doctor. “Especially in larger cities, you have higher rates of asthma and an inequality of medicine based on what community you come from,” he says. “I wanted to help bridge that gap.”

At Children’s, the care Edwards provides goes well behind medicine. “You end up referring patients to get assistance with basic needs, housing and basic bill paying,” Edwards says.

The health care law bolstered Edwards’s confidence in his decision to join the front line of public health.

For “pediatricians,” he says, “I think there will definitely be a demand and a need for an increasing workforce.”

Familiar Hopes
Atul Grover entertained such hopes nearly two decades ago as a young medical student who had watched President Bill Clinton and lawmakers battle over national health care legislation.

Health management organizations — which emphasized primary care as a way to limit the use of expensive specialists — were booming. So were primary-care residencies: 40 percent of medical students pursued them in 1997, an all-time high.

“There was a very clear signal,” says Grover, who completed a primary-care residency at the University of California at San Francisco. “If you want to be employed, you need to go into primary care. If you want to drive a cab, take something in anesthesiology.”

Phillips, of the Robert Graham Center, graduated around the same time and remembers the era similarly. “There was this groundswell of energy that primary care would be the centerpiece for an effective health care system,” he said. “We were obviously a bit naive and optimistic.”

The Clinton health care plan failed. Consumers revolted against HMOs’ limited networks, and the insurance plans rapidly lost market share. As for family doctors? They now earn $150,000 less, on average, than anesthesiologists, according to the American Medical Group Association.

“In the early 1990s, there was a lot of potential,” Phillips says. “By time I was in residency, that was already waning.”

These days, Phillips, Grover and others say the current primary-care craze could end much the same way. The Prevention Fund’s residency financing runs out in 2015, and administration officials say there are no plans to extend the program.

“What I worry about is young physicians being told for a couple of years that this is totally worth it, and then it doesn’t pan out and then they get discouraged,” Grover says. “Unfortunately, I think we are moving in that direction.”

Healthcare as we know it is definitely going to change over the next several years.  One of the biggest changes may be how much choice is afforded to patients.   An area that offers patients the ability to be more proactive in their healthcare is concierge medicine.   The dynamics of the system seem to prove that concierge medicine will be a viable option of the future.

PHYSICIAN SHORTAGE

As a recent Valeo article pointed out, the American Medical Association (AMA) predicts a 90,000 physician shortage by the year 2020.   In a March 28^th article, The Courier-Journal says locally that would mean approximately 455 more primary care physicians (which is approximately the number that currently exists in the area).   This is only 8 years away.

The other side to this dilemma is the decreasing number of medical students choosing not to go into primary care.  A 2010 survey from the American Academy of Family Physicians (AAFP)  showed  that less than 50% of the of the open Family Medicine residency slots were filled by physicians.   In essence, less medical students are choosing to go into Primary Care which makes the shortage even more a problem.

MORE PEOPLE SEEING PHYSICIANS

If healthcare reform stays in place, over 30 million people look to gain insurance by 2014.   In addition, according to a Business First article in July of 2011, 10,000 people a day for the next 19 years become eligible for Medicare.   This staggering number amounts to over 69 Million people in that time frame.   As a result, between these two facets alone almost 100 Million people will increase the utilization of healthcare, and primary care physicians will be where it starts.

DOCTORS KNOW REFORM CAN CAUSE MORE PROBLEMS

Perhaps the most concerning factor of all regarding the future of healthcare, is the opinion of the physicians themselves.    In November of 2010, a survey by the American Medical Association (AMA), shows that many doctors feel reform is simply going to make things more difficult for their practices.   54% of the MD’s surveyed know their volume will increase due to reform.    68% said the changes will diminish the financial viability of their practice, and even more alarming…69% said they do not have the resources to treat traditional patients while maintaining quality of care.

SO WHAT DOES ALL THIS MEAN?

When you consider all of the factors above, one has to conclude that healthcare as we know it, is going to have to change.   When more people start utilizing a system that is already short in meeting the current demand, and the physicians working in the system know the proposed changes hamper their ability to provide quality healthcare….it is all a recipe for disaster.

As a result, physicians and patients need to find a program that benefits both of them.   Concierge Medicine is one of those programs.  It allows physicians to stay financially independent, while providing quality care to their patients, and ultimately enhancing the physician-patient relationship.   Physicians no longer have to worry about the factors that are stacking up against them, or how to provide good healthcare to more and more people with less and less resources.

To learn more about the author, call 502-777-1333 or send an email to Jason@guardianmd.com, or visit www.guardianmd.com.

Drs. Larry and Emily Kelly’s shared devotion to family and athletic competition recently culminated in a thrilling family trip to Kona, Hawaii, in October, 2011, where Emily competed in the Ironman World Championship. As Emily says, “We took the whole family including, all of the kids and my mom and dad to Kona for the week leading up to the race.”

Emily finished the competition, which consists of a 2.4 mile swim, a 112 mile cycling event and a 26.2 mile run, in 10 hours 15 minutes.

Family

Four children: Eliza (10), Will (8), Samuel (6) and Vera (4)

Medical Specialties

Larry is an interventional radiologist with Diagnostic Imaging Alliance of Louisville. Emily is an endodontist and owns her practice, Endodontic Associates of Louisville, with one partner, Leslie Malueg.

On the Run

Emily started running in marathons two years ago, then jumped into triathlons in June, 2011. She qualified for a spot in the Ironman World Championship after finishing fourth in her age group in the Ironman Louisville competition in August, 2011.

Since returning from Kona, she has scaled back her training and tried to get back to “normal” life. She recently joined the racing team at VO2 Multisport and plans to keep running and doing shorter triathlons.  As she says,”I will probably try the full ironman distance again, but maybe not for a few years.”

Larry runs for fun but does not compete right now. He expects to participate in this year’s Triple Crown road races.

Family History

Larry and Emily met on the swim team at Georgetown University in 1995, and were married in 1999.

Larry graduated from UL medical school in 2002, then specialized in interventional radiology. Emily graduated from UL dental school in 2003, then specialized in endodontics.

What are the challenges faced by family members working together?

As Emily says, “We have two minivans, so that whoever finishes work first is able to pick up all of the kids.  All of our kids are involved in a lot of athletics, so we spend a lot of time driving them around and watching them compete and play.

“It is tough to be a busy two career family, with four kids, but we do get a lot of help from Larry’s mom, Ruth Kelly, who lives in town. I work three days a week, so my job is fairly flexible. Plus, Larry is an amazing husband and very ‘hands on’ dad. He and the kids have been to almost all of my races and keep me going during the long hours.”

Advantages

We are both good time managers. We both swam in college, so we are pretty good at balancing athletics and academics.

Defining moment - What made you want to become a doctor or enter the field of healthcare?

We are both science people. We knew we didn’t want a desk job.

2011 is in the books.  It is time to implement changes for 2012 to help grow your bottom line.  Here are some tips for real changes you can make in 2012.

Financial

1. Plan for slow growth in 2012. Dentists across the country have been greatly affected by the recession with 2009 being one of the most difficult financial years the profession has seen in decades. While 2010 and 2011 saw modest gains, don’t expect much from 2012. Most economists are predicting flat line or limited growth in national GDP, an increasing public debt and a ‘do-nothing congress’ that will do even less in an election year. Still, most dentists are optimistic about their personal and local economic conditions. Plan and manage for slow growth in 2012 with an eye on the future.

2. Continue to upgrade your Practice. It never ends. Just when you have replaced your last old piece of equipment, you now need to replace the carpeting. How frustrating. But it doesn’t have to be. Most high achieving and financially successful practices understand that consistent reinvestment is not only necessary but essential. Therefore, budget about 10% of your economic investment in the practice (about $20,000 per year for an average practice) for general improvements and new purchases every year.

3. Continue to upgrade your Practice, with people. If you have a stable team that works well together and is able to produce top 25^th percentile revenues and earnings, fantastic, you are in the top tier of dental practices today. For everybody else, we need to seriously look at our staffing models and individual components and make changes where necessary. Today, there are many talented individuals looking for work and we can’t recall a time when it has been more cost-effective to hire hygienists.

4. Don’t forget to increase your fees. Many dentists have refrained from increasing their fees during this recessionary period. We understand. However, your costs continue to rise and your profit margins continue to erode. 2012 represents a great year to implement across the board fee increases that are both necessary and appropriate. When raising fees, most practices are focusing on restorative and cosmetic procedures, and are more careful with fee increases on the preventive side.

Operational

5. Assess your social media/social marketing/social networking. The social movement is upon us. Much like ten years ago when dental practices were trying to assess their internet webpage options, practices are now considering their presence in social media. With Facebook, Twitter, YouTube and Blogging, a strategic approach is warranted. No need for panic and no need to implement wide sweeping program that are random and disconnected. Instead, if you have not begun utilizing these social media options, use 2012 to research and explore, and plan for implementation in 2013.

6. Work your recall/re-care list. No surprises here. Your re-care and follow-up list is and continues to be the lifeblood of your practice. Now more than ever, a renewed focus on this one process will be essential for success in 2012

7. New patients are more important than ever. In the past, 20 new patients per month per FTE dentist may have been a reasonable and acceptable goal for most mature dental practices. Due to the slow economy increased demand for dental services, consistent shifts in patient demographics and ever increasing competition between dental practices, an average of 20 new patients per month is not enough. The new target needs to be between 25 and 30 new patients per month if not more.

8. Begin tracking your internal referral rate. Of the top ten financial and marketing performance metrics, a practice’s internally generated referral ratio is one of the most important but least tracked statistics for dentists. When watching overall expenditures, gaining new patients through existing patient referrals or diagnosing new treatment options for existing patients is the number one marketing tool in your arsenal.

To learn more about how we can help your dental practice in 2012 and beyond, contact Marcia Lewis, a director with Blue & Co., LLC, at 502 584-1101 or mlewis@lbueandco.com.

by Kristen Holt, Esq., Wyatt, Tarrant & Combs, LLP   

On February 16, 2012, the Centers for Medicare and Medicaid Services (CMS) published a “Proposed Rule” addressing the statutory requirement that Medicare overpayments must be reported and repaid within 60 days after the date the overpayment is “identified,” or else such overpayments would be re-characterized as false claims.

While still subject to a comment period, the Proposed Rule creates a burdensome standard for providers in an already highly regulated industry by applying a 10 year “lookback” period, a short and unclear 60 day repayment timeframe, and additional reporting requirements. We recommend that all interested parties submit comments to CMS.  Comments are due by April 16^th, 2012.

Overview

Section 6402(a) of the Patient Protection and Affordable Care Act (PPACA) requires a person who has received an overpayment to report and return the overpayment to the proper government entity or contractor and to provide written notice of the reason for the overpayment.  According to PPACA, such overpayments must be reported and returned within 60 days after the overpayment is “identified,” or (only if applicable) the date any corresponding cost report is due, whichever is later.  If a provider retains an overpayment after the deadline, then that overpayment is considered an “obligation” under the False Claims Act, and may trigger False Claims Act liability.  A false claim may result in a civil penalty between $5,500 and $11,000 per unlawful claim, three times the overpayment amount, plus the government’s costs to bring the action.

The Proposed Rule applies only to Medicare Part A and Part B providers and suppliers.  Other providers, including Medicare Advantage Organizations, Prescription Drug Plans, and Medicaid MCOs will be addressed at a later date.  However, CMS reminds us that others are still subject to the repayment and reporting requirements under PPACA and “could face potential False Claims Act liability, Civil Monetary Penalties Law liability, and exclusion from Federal health care programs for failure to report and return an overpayment.”

Lookback Period

The Proposed Rule identifies a considerable lookback period of ten years, whereby overpayments would have to be reported and repaid if a person identifies an overpayment within ten years of the date the overpayment was received.  CMS explains that the ten year lookback period was selected because it is the “outer limit” under the statute of limitations for the False Claims Act.   However, a ten year lookback period seems overly aggressive.  The current reopening period for cases that do not involve false claims is four years, which would seem to be a more reasonable, and expected, timeframe.  Moreover, the government could still bring false claims actions under the ten year statute of limitations in cases where a provider knowingly filed a false claim or acted in reckless disregard or deliberate ignorance under existing laws, so it is unnecessary to extend the same statute of limitations to overpayments, many of which could simply be clerical or otherwise unintentional errors, not intentional fraudulent acts.

Clearly, the ten year “lookback” period could create major problems for providers.  Many providers may not even retain records for ten years, making calculation of an overpayment quite difficult to determine.  Even if a provider does retain its records for that long, the old records are likely to be offsite or filed away, adding to the administrative burden of the Proposed Rule.  Moreover, many providers are likely to tweak their billing practices and systems over time, which could make it difficult to calculate the repayment amount.

Additionally, it remains unclear exactly how providers would calculate the ten year lookback period.  From what point does the ten year lookback start?  Is this a retroactive lookback period, meaning any repayment obligation that is identified by the provider triggers a requirement to lookback into the providers records for ten years from the date of the overpayment?  Or is this a prospective calculation, whereby the ten years starts in 2012 and will build out each year?

Finally, this kind of additional administrative burden is bound to be time consuming and expensive.  According to the Economic Impact Statement for the Proposed Rule, CMS estimates that the ten year lookback period will cost providers $58 million in reporting-related expenses each year.  While CMS states that this is an “insignificant” expense, it is an expense that will continue to incur year upon year.  We assert that the time and money required to comply with the Proposed Rule may not seem so “insignificant” for small physician practices and other providers.

Repayment Period

The Proposed Rule confirms the same repayment periods established under PPACA, clarifying that some overpayments must be repaid within 60 days, and others may be repaid on the date the cost report is due.  For example, claims involving upcoding must be repaid within 60 days of their identification, while overpayments related to graduate medical education payments, which are reconciled as a part of the cost report, must be repaid either 60 days after identification of the overpayment or on the date the cost report is due, whichever is later.  The Proposed Rule warns that providers and suppliers should not improperly delay returning identified overpayments when they have no effect on the cost report, stating, “We do not believe that Congress intended to create a loophole that would allow providers to delay reporting and returning an identified overpayment until a cost report is due if the overpayment would not ordinarily be reconciled on the cost report.”

Identification of an Overpayment

The Proposed Rule provides guidance as to when an overpayment is considered to be “identified” by a provider.  Under the Proposed Rule, a person has “identified” an overpayment if the person has “actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment.”  CMS lists several examples of overpayment situations, such as where a claim was made for services or items for a person who was deceased at the time, for services or items rendered by an unlicensed or excluded individual, or when the provider performs an internal audit and discovers an overpayment exists.  CMS reasons that defining “identified” in this manner “gives providers and suppliers an incentive to exercise reasonable diligence to determine whether an overpayment exists,” and to keep providers and suppliers from avoiding “self-audits, compliance checks, and other additional research.”

However, it remains unclear when exactly the payment is “identified.”  Does the clock start running the day an employee believes there may have been a billing error?  Or, does the 60 day period begin after a practice completes an internal audit and confirms the amount of the repayment after a comprehensive examination of its books and records?  If it is the former, the 60 day time period is hardly enough time for providers to complete an investigation of their own records, let alone enlist assistance from a CPA or legal counsel.  Moreover, what is the scope of the potential overpayment investigation that is required under the Proposed Rule?  If your practice determines, for example, that it erroneously billed for the dosage of one drug, does that identification attach only to that drug or to any other drug that is administered using the same type of dosing methodology?

The Proposed Rule does not offer much flexibility with respect to the period for self reporting and repayment.  While CMS acknowledges that 60 days may be a challenging timeframe, especially for those providers and suppliers with limited financial means, CMS provides only the existing Extended Repayment Schedule (ERS) process created under Publication 100-06, Chapter 4 of the Financial Management Manual as the procedure for obtaining an extension.  CMS notes that any extension requests will not be automatically granted and providers may be required to submit “significant documentation” to demonstrate their hardship to CMS.  Moreover, an ERS extension may only be granted for financial hardship and does not cover other types of hardship such as loss of a key employee during the 60 day timeframe.

Reporting Requirements

The Proposed Rule proposes to implement the overpayment reporting requirements through the existing voluntary refund process described in Publication 100-06, Chapter 4 of the Medicare Financial Management Manual.  Under this process, providers report overpayments using a form from their applicable Medicare contractor’s website.  The form requires information to allow CMS to identify affected claims, including health insurance claim numbers; the provider’s or supplier’s name, number and tax identification number; and date of service.  In addition to a refund in the amount of the overpayment, providers will also be required to summarize why a refund is being made, including: (1) how the error was discovered; (2) a description of the corrective action plan implemented to ensure the error does not occur again; (3) the reason for the refund; (4) whether the provider or supplier has a corporate integrity agreement with OIG or is under the OIG Self-Disclosure Protocol; (5) the timeframe and the total amount of  the refund for the period during which the problem existed; (6) the Medicare claim control number, if appropriate; (7) the Medicare NPI number; and (8) if a statistical sample was used to determine the overpayment amount, a description of the statistically valid methodology used to determine the overpayment.

The Proposed Rule clarifies that reporting and repaying an overpayment under the Self-Referral Disclosure Protocol (SRDP) does not relieve a provider or supplier from its obligation to also report and repay the overpayment as required by PPACA and the Proposed Rule.  With respect to obligations to report self-discovered evidence of potential fraud to OIG through the OIG Self-Disclosure Protocol (OIG SDP), the Proposed Rule would suspend the obligation to return overpayments under PPACA and the Proposed Rule when OIG acknowledges receipt of a submission to the OIG SDP.  Any obligation to return an overpayment under the Proposed Rule would be suspended until a settlement is entered or until the provider or supplier withdraws or is removed from the OIG SDP.  The Proposed Rule warns that reporting and returning overpayments through the OIG SDP “cannot resolve any potential False Claims Act or OIG administrative liability associated with the overpayment.”  Equally concerning is CMS’ statement that “[p]roviders and suppliers should be aware that the contractors will scrutinize overpayments received through [the Proposed Rule] and may make referrals to OIG whenever the contractors believe circumstances warrant such a referral.”

The Proposed Rule is not yet law.  Interested parties have the opportunity to submit comments to CMS until April 16, 2012.   We encourage providers to comment on this overly burdensome rule.  For a copy of the Proposed Rule and information about the comment period, see the publication in the Federal Register, which can be found at  http://www.gpo.gov/fdsys/pkg/FR-2012-02-16/pdf/2012-3642.pdf.

To learn more about the author or Wyatt Tarrant & Combs, visit www.wyattfirm.com.

As a small boy in his native Argentina, Sergio Cardinali shared the dream of children around the world – a gleaming new bicycle. After his family moved to Louisville’s Fern Creek area when Sergio was 12, he continued to settle for riding on other kids’ bikes until, finally, he recalls, “I scraped together $10 and bought a pile of rust from a guy in the neighborhood. I took it apart, re-packed all the bearings with fresh grease, sanded it all down, and spray painted it gold. It wasn’t much, but it was mine and I loved it.”

The bike of his fantasies in those days was a Schwinn Orange Krate, designed to mimic the chopper-style motorcycles of the early 1970s. Today at age 50, Dr. Cardinali, who practices internal medicine with Norton Inpatient Care Specialists, is proud to own an Orange Krate, along with some 30 other select and even rare bicycles. His collection, like art, is kept in a gallery-like display in the home he shares with his wife Brandi, who enjoys cycling with her husband – sometimes on a bicycle built for two.

Dr. Cardinali’s Collection

As Dr. Cardinali says, “I was inspired to collect bikes because of the elegant design of the bicycle and because it’s such a pure form of transportation that requires no energy. Cars on the other hand spend most of their energy moving the vehicle not the package.

“With the bike, the passenger is the engine. It’s the most efficient vehicle on the planet. It incorporates beautifully artistic designs, It’s light yet strong enough to hold the engine, the passenger. Bikes require Low power from human engines. It’s one of the strongest shapes, the double diamond bicycle frame. I want to find the most beautiful examples.

“It’s not a brand or vintage I look for, but the design. And Italians have a flair for the most wonderful bicycle designs and designers. Artistically, my favorite – and my latest addition – is a Carrera Phibra carbon fiber.  It’s made of black carbon fiber clear coated with white accents.

As Dr. Cardinali says, it is hard to pick a single favorite. “I love em all. To pick a single favorite would be like deciding between ice cream and steak.”

He says he has favorites in three categories: Steel traditional road racing, old cruisers and modern carbon fiber.

In the traditional road racing category, Dr. Cardinali’s first choice is a De Rosa Neo Primato, also Italian. It’s made of steel painted in honor of Eddie Merckx Faema team world championship – mainly red, with white on the seat tube and head tube. It features world championship rainbow stripes. The De Rosa features a classic Brooks leather saddle with Brooks Leather tape on the handlebar.

One of Dr. Cardinali’s favorites in the cruiser category is a Felt Scythe. “It’s kind of a bad boy bike that mimics a motorcycle chopper with long front fork and matte black. It has a meanness about it.”

Another favorite was manufactured for Harley Davidson. “They only made 1,000 of them. Most were pre-sold. Lance Armstrong has one.”

Among his favorites constructed of modern carbon fiber are the Colnago C-40, one of the breakthrough models made of carbon fiber, and the single piece Kestrel, designed by NASA engineers. “The Kestrel 500 SCI - solid white, no seat tube. Gorgeous.”

At 50 years of age, Dr. Cardinali tries to ride as often as his work will allow – at least two or three days a week. “I always loved cycling and bikes are beautiful; on the other hand soccer and running caused swelling and hurt. With bicycling, I get the cardiovascular benefit without the pain that running caused.

“It’s amazing. The beauty of the bike brings you to moments of bliss and suffering.  Another attraction for me is the pursuit those moments of perfection on the bike.”

Dr. Cardinali’s passion for cycling is shared by a new wave of enthusiasts, which is greater now than at any time since the early 1970s. It’s a trend that has the approval of physicians, who recommend cycling as moderate exercise that can help keep their patients fit at practically any age. And some of those doctors are taking the therapy they prescribe.

Dr. Kirk Grynwald

Dr. Kirk Grynwald is now racing – and winning – in three different competitive circuits. The latest of his many triumphs was in this summer’s national championship cross country event at Sun Valley, Idaho.

Dr. Grynwald says, “I never dreamed I’d be racing in three different circuits.” He’s won his share of cycling medals in recent years. Here are a few of the highlights:

-He won national championship, 40+ Category 3 in Sun Valley, ID this summer

-He was third in Category 2 age group, DINO (Indiana) mountain bike series

-He won Category 3 age group in the DINO mountain bike series in 2010

-He won Category 4 cyclocross age group in OVCX in 2010

-He had eight class wins last year in cyclocross, including one at USGP here in Louisville in 2010

On cycling for recreation and transportation

Aside from racing, Dr. Grynwald, an arm and hand surgeon with Norton Orthopaedic Care, enjoys mixing cycling with travel to destinations where he and his family can enjoy the sport.

“I like the idea of trips centered around great mountain biking. I’ve taken the bike with me to New Zealand twice, to Australia, to Idaho. I’ve ridden in the Mt. Tamalpais area north of San Francisco, one of the homes of mountain biking.”

A goal now is to see if we can reduce miles in cars as we increase the cycling miles.

“There needs to be some consistency of philosophy among doctors. If you’re an overweight person in a white coat you’re saying some contradictory things if you tell your patient to take Crestor to lower cholesterol.

“Honestly, if we’re really into health, we should back it up with our own behavior. Every doctor’s office should have cycling parking, especially if you’re serving the underprivileged. Why should we expect that everyone is driving to our office? There ought to be a way to get there by bike. It’s a practical consideration. We should help facilitate people using active transportation.”

Dr. Grynwald, has powerful encouragement for others who are considering getting into cycling. “Give it a chance. The bicycle is the most elegant and efficient machine ever created. One of the things I like is that it gets me outside to exercise. The change of scenery is stimulating for the mind. And there are many styles of cycling to fit your needs.”

If you don’t like the traffic, Dr. Grynwald suggests getting out in Louisville’s parks. “If you’re nervous about being around cars, there’s off-road mountain biking on trails. There’s cyclocross and the closed circuit. And if you’re worried about being away from your kids, the bike clubs are wonderful. In short track and cyclocross racing, my whole family gets involved.”

Worried about wearing spandex? Dr. Grynwald suggests the mountain bike scene, where it’s all about baggy shorts and tools in the hip pocket. “And there’s always commuting to work, which means wearing the clothes you wear all the time,” he said.

Dr. Grynwald’s prescription: “Buy a high-end bike and for a tenth of the cost of a car and you can reduce your cholesterol, lose weight, own a cool machine, and look better. And as gas costs go up it’s only going to become more attractive.”

Dr. Larson

Dr. John Larson isn’t earning medals on the race circuits, but he’s earned a rare distinction of his own recently. At age 60, he was recently recognized by the Louisville Bicycle Club for a lifetime achievement - recording 50,000 miles by bicycle.

Dr. Larson, a pediatrician of 33 years with Larson, Brough and Brockman Pediatrics, first joined the Louisville Bicycle Club back in 1989. “I was into it for about 10 years and really enjoyed it. I went for the yellow jersey and rode about 6,000 miles in one year in 1998.” He credits his rides with the bike club rides with enhancing his knowledge of his hometown.

“That’s the neat thing about the bike club. I’ve lived here all my life, but you don’t get to know the city until you get on a bike. I know the city and the surroundings better than I ever did before because of all these bike rides. We do them everywhere. We ride out in Oldham County and Bullitt County.”

Dr. Larson says he drifted away from cycling in favor of running for a decade or so. But when an injury stopped him he got back into cycling. “I had forgotten how much I loved it,” he said. “Unlike running, that made me feel good afterwards, cycling makes me feel good while I’m doing it”.

“I’ll preach to my patients about aerobic exercise. I tell them that it’s great that they participate in team sports like football and basketball, but they won’t be doing that when they’re 50 years old. So I encourage them to do something like biking, running or swimming that they can do for the rest of their lives.”

To me at the end of a workday it’s relaxing to exercise. Instead of watching a TV show, I like to get exercise.

Essentially, I practice what I preach. It’s not hard to do when you love it as I do.”

Demand for medical and care is increasing dramatically. The question is, can the supply of doctors keep up with the increased demand, both now and in the future?

Increasing Demand for Medical Services

Increasing demand for medical care is being driven by a number of factors, including a growing and aging population, and rising rates of obesity and related chronic illnesses such as diabetes, hypertension, arthritis and heart disease.

The oldest members of the huge Baby Boom population (those born between 1946 and 1964) turn 66 this year, and these days people are living longer thanks to advances in public health and in health care.

As a result, the growth and aging of the population is expected to contribute to a 22 percent increase in demand for physician services between 2005 and 2020, according to a 2008 analysis of the physician workforce by the Health Resources Services Administration (HRSA).

Adding to the burgeoning population of potential medical care consumers is the major expansion of insurance coverage and access to the medical system for 30 million individuals nationwide via the Patient Protection and Affordable Care Act (PPACA). In Kentucky alone, it is estimated that 500,000+ currently uninsured individuals will have access to medical coverage via the PPACA, according to Dr. Dan Varga, Chief Medical Officer of KyOne Health. “And if you give someone insurance, they will use it,” he adds.

Supply Shortages

In light of the growing demand, many healthcare industry spokesmen predict widespread shortages of doctors in the near future. As an example, the American Medical Association projects a nationwide shortage of 90,000 doctors by 2020.

In addition, The physician workforce is aging, average hours worked are falling compared to historical levels, and a large number of physicians are nearing retirement, according to the HRSA Physician Workforce Study.

“The average age of practicing physicians has increased – to 56 or 57 years old,” says Tim Leigh, president of Select Professional, a physician recruitment company. “Many doctors are slowing down. The numbers of those leaving medicine versus those entering the field of medicine don’t match up. We can’t even keep up with where we are now. We have a mess on our hands,” he says.

In addition, many younger physicians are seeking greater life-work balance, and are working fewer hours. Estimates indicate that the average number of hours physicians are willing to work is falling by10 to12 percent. So there will be a need for even more physicians to replace those who are retiring.

Maldistribution

Of greater concern to many in the healthcare field is the maldistribution of healthcare professionals, both by location and by specialty. Regional shortages are expected to be especially acute in rural areas, including many in Kentucky. Mike Rust, president and CEO of the Kentucky Hospital Association, notes that of 120 Kentucky counties, only 15 meet the Federal recommended standard for primary care doctor-to-patient ratios.

As Mr. Leigh says, “The greatest need, both now and in the future is in the rural areas. But most physicians practice in urban areas.”

“There is significant maldistribution,” Dr. Varga says. “Currently two-thirds of physicians practice in urban areas, and one-third in rural areas, while the population distribution is a mirror image – two-thirds of the population lives in rural areas, and one-third in urban.”

For many people, our whole region is considered rural. “Kentucky is in competition with the rest of the country for trained medical practitioners – Louisville and Lexington are competing with San Diego and Kansas City for trained physicians. Doctors who have trained in New York and New Jersey don’t see Louisville and Lexington as urban,” Mr. Leigh notes.

In addition, there are often pockets of underserved areas even within otherwise well-served urban communities. Not surprisingly these underserved segments tend to occur in already distressed areas where residents are less likely to have access to transportation and healthcare insurance.

Unfortunately, at present there is not enough market incentive to direct people to practice in certain areas, notes Dr. Edward Halperin, Dean of the University School of Medicine.

Maldistribution by Specialty

Dr. Halperin forecasts that there will be shortages in primary care - internal medicine, pediatrics, and OB-GYN - plus general surgery.

These shortages will result primarily from a high level of demand. But there are other factors that exacerbate the shortages of primary care providers, including lower reimbursement rates, complex administrative burdens and the added responsibility for coordination of patient care.

Moreover, according to a 2011 Study commissioned by the Louisville Primary Care Association and conducted by REACH of Louisville, “Payment structures also fail to incentivize two of the most important roles of the primary care practitioner: preventive care and care coordination. Unlike the services of other specialties, preventive services are not well-reimbursed.”

Other specialties associated with an aging patient population, such as cardiology, neurology and rheumatology are expected to see shortages of practitioners. “The battle of gerontology is lost already,” Dr. Halperin says.

On the other hand, many new physicians are seeking to attain greater balance between their professional and personal activities, and they are attracted to “controllable” specialties, such as diagnostic radiology, dermatology, ophthalmology, emergency medicine and psychology, Dr. Halperin says.

“Certain specialties offer more manageable practices,” notes Kim Dees, Vice President of Health Professions, Kentucky Hospital Association.

As a result, shortages are not as likely among these specialties.

Addressing the Challenges

While it would be tempting to assume the doctor shortage issue could be remedied by simply training more physicians, in reality the problem, and the solution, are more complicated than that.

“Building more medical schools, and graduating more MDs won’t solve the problem.” Dr. Halperin says.

Medical Schools, Residencies and Student Debt

“Medical School training is not quick – four years of undergraduate, four years of medical school and maybe seven years of residency,” notes Dr. Steven Hester, Chief Medical Officer of Norton Healthcare.

But a challenge even greater than the length of medical school training is the shortage of residency slots. After doctors graduate from medical school they must train at teaching hospitals, which get about $3 billion a year through Medicare for doctor training and related expenses, or about 23 percent of the total cost, according to the Association of American Medical Colleges.

Unfortunately, healthcare reform did not address the shortage of funded residency slots, Dr. Hester notes. “The academic institutions continue to fund residency slots,” he says.

As a result there are significant gaps between the number of medical school graduates and the number of residency slots available. “You have unemployed medical school grads,” observes Dr. Halperin.

In addition to the lengthy training involved, doctors are likely to complete their medical education with $130,000 To $200,000 in student loan debt, a major consideration for most undergraduates.

Given that scenario, it is not surprising that some talented students might think twice about choosing medicine as a career path.

“In many cases young people who might have become doctors, are becoming investment bankers,” Mr. Leigh observes.

For those students who do choose the field of medicine, the heavy loan burden discourages many from pursuing a career in the comparatively lower paying field of primary care.

“It’s a big investment. A student could go to pharmacy school, graduate in five years and make a nice living,” Dr. Varga says.

Solutions

Healthcare industry spokesmen offer a range of solutions to address anticipated physician shortages.

Many agree that an important first step would be to expand the availability of residency slots; however in this day of government cutbacks, a realistic solution to that issue has yet to be proposed.

Other issues are being addressed, with varying degrees of success.

Many small communities and some hospital systems are offering incentives for doctors to practice in rural areas and designated shortage areas.

Incentives often take the form of partial medical school student loan repayment in exchange for a specified period of practice within the community. Hospital systems may kick in additional incentives such as attractive relocation packages, assistance in becoming a part of the new community and links to urban medical groups.

Healthcare systems are also introducing new models for healthcare delivery, such as KyOne Health’s community-based virtual care clinic model.

In addition universities in the state are doing a good job of rural-based training, Mr. Leigh says.

All three medical schools in Kentucky – University of Louisville, University of Kentucky and Pikeville College - offer programs to train and encourage medical professionals to practice in rural areas.

To address the problem of underserved areas within the urban Louisville community, and encourage medical students to practice in these areas, U of L Medical School has established clinics in the west end and other underserved areas.

Advancing Primary Care

To encourage medical students to pursue a career in primary care, U of L offers a residency program in primary care.

In addition, many spokesmen support reimbursement reform in the private and public sectors that would increase reimbursement for primary care relative to specialty care payments. According to the REACH study, “Preventive services should be as readily and adequately reimbursed as the disease-related procedures that they are intended to prevent; and reimbursement systems should adjust their payment structures to recognize and reimburse for care coordination and continuity of care.”

Physician Extenders

Another solution to the physician shortage is an increased reliance on physician extenders, including physician assistants, nurse practitioners and mental health workers such as social workers and counselors.

“Increasingly healthcare is delivered by people other than doctors. As an example, in Japan colonoscopies are administered by sigmoid technicians,” Dr. Halperin says.

Yet there are still many issues with reliance on physician assistants and nurse practitioners. “The demand for them is growing; but the programs are not expanding. There are not enough faculty to teach them. We need more training programs for extenders,” Mr. Leigh says.

Local Recruiting Efforts

Locally hospital executives perform regular evaluations to determine areas of need prior to recruiting new staff doctors.

“We conduct an evaluation process every two years; we analyze population and physician trends, and make sure we have the right information to orchestrate recruiting,” says Ginger Figg, president of Norton Healthcare Inc’s Physician Services.

As Dr. Hester says, “We look at historical trends, and the economy, not only specific to healthcare. We evaluate how healthcare functions – how and where we provide care. We make projections, taking into consideration factors such as: How many MDs do we have? How many are 60+ years old? How many will we need; from outside the community? And the doctors are being a bigger part of the planning process now as well.”

Area hospitals recruit both locally and nationally. “We definitely turn to UL, then we reach out to other medical schools where we have had relationships over the years,” Ms Figg says.

Kathy Newton-Troutman, director of physician alignment at Baptist Hospital East says that BHE has beefed up its recruitment efforts lately out of necessity. “We advertise in national magazines, utilize online recruitment services and attend out-of-state recruitment fairs, along with other hospitals from all over the country,” she says.

And there are factors that give our community a recruiting edge as compared with other communities.

“We are very fortunate in our community. The size; the lifestyle we can create, all of this appeals to outsiders, and it plays a big role in recruiting doctors,” Dr. Hester says.

“Then there are the quality of life considerations like the 21^st Century Parks. There are clear benefits that allow our community to compete with other communities. As long as we can maintain vibrant lifestyle, and a low cost of living, that will help us to recruit,” he says.

Thinking Globally

One sure way to address the shortage of doctors is to place a greater emphasis on public health.

“We need to get people to stop smoking, lose weight, get vaccinations and lead a healthy lifestyle, and reduce teenage pregnancy. It is a lot cheaper to get people to quit smoking than it is to treat lung cancer,” Dr. Halperin says.

In addition, Dr. Halperin says we need to reassess our priorities as a nation. “There is a finite pool of money that needs to be divvied up. We can shift from one priority to another. We can spend money on a nuclear aircraft carrier or on child vaccinations,” he adds.

Shortage of Dentists

Many experts expect shortages and maldistribution of dentists to be a problem in the future as well.

As stated in the www.staffcare.com white paper, “America is facing a dental shortage crisis. As the baby-boomer generation gets older, access to dental care will be paramount. Trends in dental school graduation rates and demographics suggest that the number of dental graduates will be insufficient to replace a departing dentist. Geographic supply trends show a major maldistribution of dentists limiting access to the poor and/or rural American. Insurance is another limiting factor in oral health and currently over a third of Americans don’t have dental insurance.”

Many physician groups, including the American Medical Association, have declared that ICD-10 will be an “onerous burden” to the industry and will cost thousands of dollars to implement during a time when physicians are facing reimbursement cuts and other changes. To the contrary, ICD-10 has many advantages for the healthcare industry and the first step in realizing these advantages is to begin the transition.

The ICD-10 mandate was finalized January 1, 2009 which gives organizations until October 1, 2013 to transition.

It is imperative that this transition begin in 2012 to have all of the necessary documentation and training in place to submit claims under the new system beginning October 1, 2013.

The most significant challenge in moving to ICD-10 is the specificity in the new codes which will require significantly more documentation than is used currently. Many physicians are under the assumption they are paid solely based on the CPT codes (procedures and services) along with the associated RVU’s.  Physicians are paid based on the CPT/HCPCS codes which is driven by RVU, however, CMS cites medical necessity as the “overarching criterion” for selection of any type of medical service.  Most insurance carriers agree with CMS.  In essence, the diagnosis code is the key driver for reimbursement.

To become familiar with ICD-10 implementation, start with “ICD-10 Basics for Medical Practices” and “Talking to Your Vendors about ICD-10. Tips for Medical Practices,” both available at: www.cms.gov/ICD10/05a_ProviderResources.asp.

Other important steps to take now include the following:

1. Appoint a person to be responsible for successful implementation.  That person should learn what is needed to comply with the new coding system and develop the implementation plan.
2. Conduct an impact assessment to understand how the new coding system will affect the practice.  This entails looking at what consumer systems use ICD-9 codes, what forms, and what processes involve coding.  Perform a complete analysis of all workflow and processes that could be affected by ICD-10.
3. Contact computer vendors to start planning for ICD-10.
4. Perform quarterly ICD-10 documentation readiness coding reviews to analyze documentation deficiencies with the new codes.
5. Create a budget for converting to the new coding system. Depending on the maintenance agreement, a computer vendor may be responsible for the software updates. On the other hand, some computer hardware may not be robust enough to handle the new software, which could mean an additional expense. Don’t forget expenses such as education and training, and documentation readiness coding reviews.
6. Identify the staff members who will need to be trained, and budget for their training and lost productivity. Highly experienced coders will be able to learn the new system more quickly than new coders.
7. Physicians will need to be trained, even if they do not do their own coding, because they will have to document with the level of detail needed to support the new codes. Make sure physician training is tailored to their specific needs.
8. Create a solutions analysis which will identify the current state of the organization, where the practice needs to be in 2013 with ICD-10, and the steps the practice will take to get there. Creating a solutions analysis with a timeline will keep the practice on track with ICD-10.
9. Utilize a consultant to assist with ICD-10 implementation and education for providers and staff if internal expertise is not available. To receive guidance or assistance with ICD-10 implementation, contact dgrider@blueandco.com.

Deborah Grider, a senior manager with Blue & Co., LLC, is one of the top leading industry experts on ICD-10 Implementation and Training.  She has been in the healthcare industry for over 30 years and an author of many coding books for the American Medical Association including “ICD-10 Implementation Guide; Make The Transition Manageable”, “Principles of ICD-10-CM, and the ICD-10-CM workbook.  She had developed education and training on ICD-10 Implementation for hospitals, payers, and physicians for various organizations and in 2009 testified at the National Committee for Healthcare Vital Statistics meeting on the challenges physicians face with ICD-10 implementation. She is also the author of many articles on ICD-10, is the Past National Advisory Board President for the AAPC, and an approved ICD-10 Instructor with the American Health Information Management Association.