Thursday, February 16, 2017

UTILIZATION REVIEW HYPOCRISY REVISITED -- One Doctor's Answer to Arbitrary Utilization Review Denials


UTILIZATION REVIEW HYPOCRISY IN VELVET GLOVES,
originally published in this blog, 03-18-2014, has met its match in the psych practice of Richard Dorsey, MD. With Doctor Dorsey's permission, we publish his method of dealing with Utilization Review minions.


Doctor Dorsey uses an 866 number going to a 24/7 answering service. This number is used for all UR doctor calls as listed on his RFAs. What this method means is that every UR call gets a live answer, no voicemails. All of his UR calls will be logged in as to date and time. This method allows Dorsey to claim accurately that UR personnel who say they couldn't reach his office are likely lying.

Should odd-hour calls come in, said calls are noticed to Dr. Dorsey by e-mail and are then answered during normal business hours. Dorsey keeps a log for dates and times of the UR doctor calls he actually returns. Dorsey says he'll do two such calls per case. For UR calls that come in during regular business hours, Dorsey's answering service e-mails notification of same upon receipt. Far from creating hostility, this method allows Dorsey to develop his own rapport with the UR doctors such that his rate of  "cases approved" has reached a high level. 

For more about Dorsey's technique, go to dorseypsych.com 

References

Utilization Review: Hypocrisy in Velvet Gloves, politicsofhealthcare.com (The Weinmann Report), 3/18/14, & workcompcentral, 3/26/14

Out-of-State v. In-State Utilization Review, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 01/10/13

Malpractice by Utilization Review? politicsofhealthcare.com (The Weinmann Report), 12/13/14, & workcompcentral, 12/19/14

Malpractice Reform Reaches California Supreme court, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 4 Jan 2017

SB 863 Benefits Employers, Harms Injured Workers, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 7/26/16

Getting to Yes with UR and IMR, Dr. Steven Feinberg, workcompcentral, 02/07/17 (more on this topic in subsequent issues)







Friday, January 20, 2017

WHEN PATIENT CARE INTERFERES WITH REQUIRED DATA INPUT, IT'S THE PATIENT WHO LOSES


First, a word of congratulations to the CEO of the American Academy of Neurology whose reportable compensation from the organization (W-2/1099-MISC) in 2014 was listed as $596,190 and whose estimated amount of other compensation from the organization and related organizations was reported at $35,338 (total of $631,5280).

In 2015 the respective amounts in these two categories grew to $657,503 and $36,142, respectively, an overall increase of  $61, 313 in reportable compensation and an overall increase in both categories of $62,117 (for 2015 the total was $693,645).

Next,  look at the American College of Cardiology (ACC) where the Chairman/president's reportable compensation from the organization was $258,551 and whose "other compensation" was listed as $70,000 (total = $328,551).

Why is ACC financially outstripped by AAN when it reports about 49,000 members to AAN's 30,000?

Neither organization has committed to full scale opposition to MOC or EHR with its attendant penalties for non-compliance. 

AAN, meanwhile, in its December 2016 issue of AAN News, proudly announced that "AAN Lobbying Helps Ease Impact of MACRA Changes on Neurologists" -- a "new program involves a two-track system for Medicare reimbursement"-- actually, what members really want is a Zero Track System -- THAT is what AAN and ACC should be using its net assets to acccomplish.


Both organizations in the opinion of this writer are applying their assets to greasing through MOC, EHR, and similar programs desired by government and/or insurance companies. Both organizations give pricey seminars, continuing educational course, and examinations to members. The need for enhanced organizational income is real.

Dues alone will not pay for the high level of staff and CEO remuneration that have now replaced clinical devotion as the hallmark of the medical profession. This writer's opinion is that the boards and their financial allies can derive mutual income benefit if they can dominate CME (Continuing Medical Education) by making their courses and programs mandatory.  


The net result is less time spent with patients, more time spent doing computer input for EHR to avoid financial penalties for non-compliance, and time actually taken away from true Continuing Medical Education (CME) which produces real benefits for patient and physician alike. 

Patients may not see these issues straight away: what they see are doctors whose focus is on a near-by computer screen during what they thought was going to be a personal medical visit

References

AAN News (American Academy of Neurology), V. 30, # 12, December 2016

ACC website (American College of Cardiology, Official site, www.acc.org)

"Maintenance of Certifcation (MOC): a rising business opportunity," 15 May 2015, The Weinmann Report (www.politicsofhealthcare.com) 

IRS Form 990 for 2014 & 2015, AAN, and 2015, ACC

"Medical Staff Votes Against Mandatory MOC (Maintenance of Certification Requirements)," 16 January 2016, The Weinmann Report (www.politicsofhealthcare.com) 

"Medical staff votes against Mandatory MOC, Workcompcentral. 22 Jan 2016




Monday, January 2, 2017

MALPRACTICE REFORM MAKES IT TO CALIFORNIA SUPREME COURT


The late and illustrious David J. DePaolo was on target in "Out of State UR" published on 4 January 2013 when he wondered why it should make any difference whether or not Utilization Review (UR) physicians were in-state residents or not. He summarized my own argument at the time by quoting the following: "Because reviewing doctors out of state can't be controlled by California licensing authorities, insurance companies are then free to 'scour the country' for doctors who are willing to to give favorable reviews to insurers." My conclusion at the time, and still is my conclusion, is that "in-state licensure should be required, not in-state residency."

The entire issue has now hit the proverbial fan. UR is now before the California Supreme Court. Fourteen and counting organizations have asked to file amicus curiae briefs. All of of them focus on a combination of clinical matters and legal issues over which looms the spectre of money.

The case at issue is  King v. CompPartners. In January of 2016 the 4th District Court of Appeal issued a ruling that UR physicians have an obligation to apply ordinary care and diligence in their provision of medical opinions with reference to the reasonableness of treatment for injured workers. The clinical issue had to do with the sudden discontinuation of klonopin without having taken due regard of risks, namely, that abrupt discontinuation of this medication is associated with epileptic seizures. This unfortunate situation befell Kirk King when the UR physician reviewing his treatment recommendation in turn advised discontinuation of the medication. The clinical argument is that the UR physician assumed responsibility for the patient when he made a recommendation that directly contradicted the treating doctor's treatment plan and thereby harmed the patient.

One of the organizations filing an amicus curiae brief is the California Applicants' Attorneys Association (CAAA). Their argument is that King is simply asserting his "common-law right to bring a lawsuit against someone ... who may have caused injury." In this writer's opinion, that is precisely what the UR physician did when the insurance company adopted his fallacious opinion and discontinued an indicated and necessary medication.

Not surprisingly, organizations that provide UR physicians are up to their necks in legal riposte. Coventry and Examworks provide UR physicians. These two organizations, among others, argue that UR doctors play only limited roles and as such should not be exposed to malpractice liability. They have the effrontery to argue that UR doctors do not interview or examine the patients so shouldn't be held to the same clinical standard as treating physicians.

They don't remind us about the corporate interests that supported SB 863 which established the misguided public policy allowing legal largesse to UR physicians and their Independent Medical Review (IMR) counterparts -- UR and IMR physicians are not required by law to be licensed in California although both are allowed under SB 863 to provide treatment directives such as the one that discontinued Kirk King's medication and brought the current case to the California Supreme Court.


There is history on this matter that turns out to  have been prescient, maybe even predictive:

In "Malpractice by Utilization Review?" (The Weinmann Report, www.politicsofhealthcare.com, 13 December 2014), this author described a case wherein lyrica was improperly suspended from an injured worker who had had a three-level cervical fusion (the medication was eventually restored by a California licensed physician). This case and the King case have in common that the UR physicians asserted clinical opinions that harmed the lives of patients dependent upon them for good faith judgments. I understand this argument to be the crux of the case being brought by Attorneys Law, Falcioni, and Lockwood on behalf of King.

In "Utilization Review Hypocrisy in Velvet Gloves" (workcompcentral.com, 26 March 2014), we pointed out more reason why the defective UR program should be replaced.

Finally, we mention again that former Medical Board of California (MBC) president Dr. Frantozzi long ago submitted opinion that UR is an aspect of medical practice and that UR physicians should be licensed in California. The underlying fault is inherent in SB 863 which provides the legal basis that allowed for the wrongful discontinuation of lyrica in the case of the patient with the the three-level cervical fusion and klonopin in the case of Kirk King.  

King's case should be sustained by the California Supreme Court. SB 863 should be repealed. The two situations are analogous: without SB 863 the cavalier determinations by  the UR doctors vis-a-vis one patient's lyrica and another patient's klonopin would not have taken place. 

References


"Supreme Court Gets Additional Amicus Briefs for UR Doctor Malpractice Dispute," workcompcentral, 2016-12-29;

"Supreme Court Gets Amicus Briefs in UR Doctor Malpractice Dispute," workcompcentral, 2016-12-16;

"Malpractice by Utilization Review?" The Weinmann Report, www.politicsofhealthcare.com, 2014-12-13

"Utilization Review Hypocrisy in Velvet Gloves," workcompcentral, 2014-03-26;

"Medical Board Asserts Jurisdiction over Utilization Review," workcompcentral, 2013-06-12;

"Out-of-State v. In-State Utilization Review," workcompcentral, 2013-01-10.


Monday, December 5, 2016

The R & R Ride for SB 1160 (Mendoza)

Now that Governor Brown signed SB 1160 (Mendoza) into law, it's time for the bill to enter the "rulemaking" phase. That's when legislation either gets its teeth or gets its teeth kicked in. The Rules and Regulations (R&R) Ride for SB 1160 (Mendoza) starts at the Hiram Johnson State Office Building at 455 Golden Gate Avenue, San Francisco, 10 AM, 4 January 2017. Public testimony is supposedly limited to 10 minutes per speaker. The subject will be Title 8, CCRs, Section 10770 (amended) and 10770.7 (newly adopted).

Here is our opinion: implementation of SB 1160 (Mendoza) needs to be far more friendly to injured workers than it currently is. The Rules and Regulations (R & Rs) as proposed will implement a lien process that may be expanded in the sense that it will apply not only to doctors who accept liens but also to any physician or other provider who runs into snags with payment so that the only way remaining to proceed with an unpaid claim is through the lien process. That means if the lien process becomes the only viable option for a delayed or denied payment for medical or other service it will be necessary to file a lien under new R & Rs. That means increased crunch and grind especially for small offices. In turn that means progressive reduction in access to care for injured workers.  

We also believe that a hint of hypocrisy persists in the process. Here's how: supposedly, treating doctors will get the first 30 days of treatment unimpeded by Utilization Review. Not quite. Not all procedures will be removed from the UR Cauldron of Dismissal: MRI scanning will remain off limits. So will non-formulary medications and durable medical equipment costing over $250. Psychological treatment will remain on the proscribed list (remember in 2015 that Neuropsych QME was unilaterally and arbitrarily canceled by the Director). 

Surgery will still require prior authorization by UR. 

For these reasons, we urge participants with a stake in this process to file statements:

By mail, Workers Comp Appeals Board, Annette Gabrielli, Regional Coordinator, P.O. Box 429459, San Francisco, CA. 94142-9459

By delivery service or personal delivery, WCAB, Annette Gabrielli, Regional Coordinator, 455 Golden Gate Avenue, 9th floor, San Francisco.

By Fax, 1-415-703-4549.

Have fun over the New Year's Holiday but keep your fingers crossed. We give you two references, see below.

References

"Weinmann: Now Comes SB 1160: Unreasonable Denials," www.workcompcentral.com, 2016-08-23;

"SB 1160 (Mendoza): anti-fraud legislation aimed at physicians permits MPN fraud," www.politicsofhealthcare.com, 2016-08-06.




Monday, October 17, 2016

UNIONIZING PHYSICIANS IN WASHINGTON STATE -- Taking on MultiCare


In a historic development for professional unions, Stuart Bussey, MD, JD, president of the Union of American Physicians and Dentists (UAPD), stated on 15 October 2016 that the private practice physicians at Auburn Medical Center (AMC) in Tacoma, Washington, voted to join the UAPD -- the occasion is historic because it is the first time that the UAPD has formally organized a hospital medical staff outside of California. Although the UAPD has had non-California membership throughout its history, this effort marks the first successful organizational campaign outside of California. This step means that the UAPD and its AMC members can now negotiate legally with MultiCare which had opposed the formation of a doctors' union but which also indicated its intent to work with the physicians' elected union representative.

Local leadership was provided by Virginia Stowell, MD, general surgeon, whose concerns included winning more autonomy for physicians in the disposition of patient care, developing more clout in the negotiation of compensation and working conditions, and preventing the arbitrary outsourcing of professional work by hospital administration. Stowell's history includes having worked at MultiCare since 2012. Before that she was in private practice for 16 years. At the present time, MultiCare reviews physician compensation and makes its own decisions. From now on the UAPD will be enabled to participate in these decisions. In leading up to this historic vote, Stowell won two cases with NLRB that prevented MultiCare from foisting its will upon their physicians. In a nutshell, NLRB ruled that efforts by MultiCare  to prevent its doctors from discussing wages and working conditions violated the National Labor Relations Act which protects this activity.

It was pointed out during the voting process that hospitals have many committees staffed by physicians but that in the final analysis such committees have minimal ability to oppose administrative decisions decided upon by management. Stowell and others, including Neil Partain, a hospitalist at AMC, agreed that it would be better for the physicians and their patients if the doctors had a union to represent their views before the hospital and MultiCare.

Representing the UAPD in this effort was Theodore Gashaw, Lead Organizer, 916-796-3124, tgashaw@uapd.com.  Gashaw said that members of other systems have also called him although at this time MultiCare is where the UAPD has received the most interest.

Meanwhile in California, expanded interest in private practice organization is anticipated especially since Governor Brown signed AB 72 (Bonta) into law. This bill slashes "surprise billing" (see our previous editorial about "surprise billing" and AB 72, 6 October 2016) but leaves "network contraction" intact. Critics point out to what extent this legislation, under the guise of patient protection, actually promotes corporate compensation at the expense of patient care.

Thursday, October 6, 2016

SB 1160 (Mendoza): anti-fraud legislation aimed at physicians permits MPN fraud


Governor Brown signed SB 1160 (Mendoza) supposedly to combat fraud in the form of abusive lien practices by physicians. The trouble is that injured workers in disputed claims often rely on physicians to risk non-payment by accepting liens, hopefully eventually to be paid. SB 1160 shoots an arrow into the heart of this largess because its language is such that it discourages physicians from getting involved in any liens at all. The net result is that many injured workers will no longer have access to medical care.


In exchange for this slap-in-the-face the bill supposedly eases up on Utilization Review for the first 30 days following injury. The idea, or so said the press releases, was to facilitate treatment. The trouble in this part of the bill is that it actually specifically prevents physicians even in this 30 day period from getting certain crucial but specific diagnostic studies because they're deemed too expensive. Access to profit trumps patient care in SB 1160. 

So much for easing up on Utilization Review. It appears that once again injured workers get the short end of the stick if in fact they get any part of it at all. 

GOVERNOR BROWN SLASHES CARE TO INJURED WORKERS -- AGAIN!


Governor Brown vetoed AB 2086 (Cooley), by and large for the same wobbly reasons that he vetoed AB 1542 last year, namely, that the bill "would create a unique lower standard" even though this specialty had already served the state and its injured workers well for 22 years before it was dissolved for undisclosed political reasons. The bill had no significant opposition in the legislature. This bill would have required the Division of Workers Comp to appoint qualified clinical neuropsychologists as QMEs (Qualified Medical Evaluators) to evaluate injured workers who sustained cerebral concussion and/or traumatic brain injury (TBI) for return to work placement. Impartial non-medical organizations supported the bill, for instance, organizations not representing either physicians or psychologists such as the California Alliance of Retired Americans (CARA) which told the governor in written communication that "TBI patients need all the help they can get." What is clear from the veto is that none of this help is going to be provided by Governor Brown.