False Claim Act

At Hospitals, Lessons in Detection of Fraud | NYT | 12.24.06

WASHINGTON, Dec. 23 — Most of the nation’s hospitals and nursing homes will have to teach their employees how to ferret out fraud and report it to the government under a federal law that takes effect next month.

…

Starting Jan. 1, companies that do at least $5 million a year in Medicaid business must educate all employees and officers on how to detect fraud, waste and abuse. Moreover, health care providers must tell employees that if they report fraud, they will be protected against retaliation and may be entitled to a share of money recovered by the government.

…

The new requirement will also apply to many pharmacies, health maintenance organizations, home care agencies, suppliers of medical equipment, physician groups and drug manufacturers.

…

Frank E. Sheeder III, a health care lawyer with the firm Jones Day in Dallas, said the new requirement, just a few paragraphs in a lengthy law, had huge implications.

“Health care providers are putting all their Medicaid money at risk if they do not comply,” Mr. Sheeder said. “Compliance is a prerequisite to receiving Medicaid reimbursement.”

The 1863 False Claims Act comes to healthcare big-time in 2007. I see more mandatory continuing education coming…

31 USC § 3729

a. Liability for Certain Acts.— Any person who—

1. knowingly presents, or causes to be presented, to an officer or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval;
2. knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government;
3. conspires to defraud the Government by getting a false or fraudulent claim allowed or paid;
4. has possession, custody, or control of property or money used, or to be used, by the Government and, intending to defraud the Government or willfully to conceal the property, delivers, or causes to be delivered, less property than the amount for which the person receives a certificate or receipt;
5. authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and, intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the receipt is true;
6. knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the Government, or a member of the Armed Forces, who lawfully may not sell or pledge the property; or
7. knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government, is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person, except that if the court finds that—
   1. the person committing the violation of this subsection furnished officials of the United States responsible for investigating false claims violations with all information known to such person about the violation within 30 days after the date on which the defendant first obtained the information;
   2. such person fully cooperated with any Government investigation of such violation; and
   3. at the time such person furnished the United States with the information about the violation, no criminal prosecution, civil action, or administrative action had commenced under this title with respect to such violation, and the person did not have actual knowledge of the existence of an investigation into such violation;

   the court may assess not less than 2 times the amount of damages which the Government sustains because of the act of the person. A person violating this subsection shall also be liable to the United States Government for the costs of a civil action brought to recover any such penalty or damages.

b. Knowing and Knowingly Defined.— For purposes of this section, the terms “knowing” and “knowingly” mean that a person, with respect to information

1. has actual knowledge of the information;
2. acts in deliberate ignorance of the truth or falsity of the information; or
3. acts in reckless disregard of the truth or falsity of the information,

and no proof of specific intent to defraud is required.

A rose by any other name . . .

JCAHO Plans Familiar Name Change | Health Decisions | 12.15.06

A December 11 memo from JCAHO President Dennis O’Leary, MD, to all JCAHO employees reveals the name change plans. “This change is simply intended make our name more memorable than the current 18-syllable Joint Commission on Accreditation of Healthcare Organizations,” reads O’Leary’s memo, which was obtained by Briefings on JCAHO, a newsletter published by HCPro Inc., which also publishes HealthLeaders.

1951: JCAH, the Joint Commission on Accreditation of Hospitals

1987: JCAHO, the Joint Commission on Accreditation of
Hospitals Healthcare Organizations

2007: JC, the Joint Commission on Accreditation of Healthcare Organizations

2011: TH, Tthey’re Joint Commission Here

† history

Asymptotic Nonsense

1200-year-old problem ‘easy’ | 12.6.06

Dr James Anderson, from the University of Reading’s computer science department, says his new theorem solves an extremely important problem - the problem of nothing.

…

But Dr Anderson has come up with a theory that proposes a new number - ‘nullity’ - which sits outside the conventional number line (stretching from negative infinity, through zero, to positive infinity).

Funny that Dr. Anderson should use the term “nullity.” I guess he is probably asymptotically correct. No doubt he believe that c is achievable despite the equation to the contrary… Perhaps he needs to review L’Hôpital’s Rule.

Hat tip Seann.

Expectations Trumps Exam

Study: Doctors call in more antibiotics without exams | USA Today | 12.6.06

Prescribing antibiotics has become so common that many doctors literally are just phoning it in, a new analysis of insurance claims suggests.

Patients who received at least one antibiotic
prescription without visiting a doctor.

Age	%
0-5	25.1
6-12	23
13-17	34.5
18-24	42.2
25-64	45.8

Of course the implication is that antibiotics are given indiscriminately because there was no exam. How many are given indiscriminately with an exam? I’ll bet there isn’t much difference; which begs the question—are antibiotics given based upon need or upon expectation? Patient satisfaction? JCAHO satisfaction? Press Ganey satisfaction? Litigation avoidance? The exam is much overrated when you consider all the eyes and all the ways physicians are scrutinized. Antibiotic overprescribing is a symptom of an underlying complex condition that plagues healthcare. Trivializing the problem to whether or not an exam was conducted is truly an ostrich in the sand approach.

Estranged Bedfellows

Hospital-Physician Relations: Cooperation, Competition, Or Separation? | Health Affairs | 12.5.06

Because many services performed in hospitals can safely and conveniently be performed in ambulatory settings, physicians have become owners of entities directly competing with hospitals for patients in a new medical arms race. Hospitals and medical staff physicians face growing tensions as a result of physicians’ growing reluctance to take emergency department call and the consequences of hospitalists replacing physicians in the care of inpatients. Although there are increasing expectations that health system challenges will lead hospitals and physicians to collaborate, in many markets the willingness and ability for hospitals and physicians to work together is actually eroding.

More incentivized behavior and more fractioning of physician services:

• Hospital Associated:
  • Emergency Medicine
  • Hospitalists
  • Intensivists (↑ eICUs)
  • Radiology (teleradiology, nighthawking)
  • Pathology
  • Specialists (all kinds ↓ )
  • Primary Care (↓, hospitalist impact)
• Hospital Non-Associated
  • Specialists (all kinds ↑ )
  • Primary Care (↓, hosptialist impact?)
  • Radiology

Is the time coming that all “on-call” services will be paid for by hospitals, all the time? Seems the only way to stave off further movement of physicians to hospital non-associated venues. There are only two ways to incentivize the reverse trend: make hospital non-associated venues unattractive (regulated to the same degree as hospitals; EMTALA?) or make hospitals more attractive (which means money).

Health Hurdles

Health Hazard: Computers Spilling Your History | NYT | 12.3.06

Powerful forces are lobbying hard for government and private programs that could push the nation’s costly and inefficient health care system into the computer age. President Bush strongly favors more use of health information technology. Health insurance and medical device companies are eager supporters, not to mention technology companies like I.B.M. and Google. Furthermore, Intel and Wal-Mart Stores have both said they intend to announce plans this week to embrace electronic health records for their employees.

…

Technology experts have many explanations for the slow adoption of the technology in the United States, including the high initial cost of the equipment, difficulties in communicating among competing systems and fear of lawsuits against hospitals and doctors that share data.

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But the toughest challenge may be a human one: acute public concern about security breaches and identity theft. Even when employers pay workers to set up computerized personal health records, many bridle, fearing private information will fall into the wrong hands and be used against them.

…

No small hurdles: access, adoption, control, cost privacy, security, etc..

“E” is for emergency

E really is for emergency, more hospitals say | Florida Times-Union | 11.30.06

In mid-November, Orange Park Medical Center became the second Northeast Florida emergency room in recent months to ask the least sick of its patients to turn elsewhere for care or face a $100 fee.

…

“There really is a national push to get ERs back to their original intent[.]“

Where does your problem fall?

• Category 1: the patient needs to be seen immediately; e.g., a heart attack or profound injuries from an accident.
• Category 2: strong potential for emergency; doctors need to fully examine the patient; e.g., could be serious abdominal or chest pain.
• Category 3: potential emergency; the situation could develop into a full-fledged emergency; e.g., could be abdominal or chest pain, high fever or a major cut.
• Category 4: not an emergency; these patients have satisfactory temperatures and blood pressure;they don’t immediately need any tests or labs and don’t need an X-ray; e.g., include dental problems, colds and minor injuries.
• Category 5: referred elsewhere for treatment.

10 Reasons

1. Emergency Medicine has been a willing victim of its own success.
2. Emergency Medicine has been all too willing to cover for the deficiencies in the availability of primary care (in terms of numbers and time).
3. Emergency Medicine is not an essential service, but a convenient service.
4. Emergency Medicine should be no more a marketing tool for a hospital then a police or fire department is for a city.
5. Emergency Medicine is a primary specialty, not primary care.
6. Triage is really about meeting needs, not the toll booth on the way to the pharmacy.
7. The internet is only a little bit better then tea leaves in its ability to diagnosis health problem, only because you don’t have to boil the water.
8. “Next” is not a guarantee.
9. We want a safety net, not a circus tent.
10. “Just go to the ER” is not a national health policy.

More teeth for e-discovery

New Rules Compel Firms to Track E-Mails | WP | 12.1.06

U.S. companies will need to keep track of all the e-mails, instant messages and other electronic documents generated by their employees thanks to new federal rules that go into effect Friday, legal experts say.

The rules, approved by the Supreme Court in April, require companies and other entities involved in federal litigation to produce “electronically stored information” as part of the discovery process, when evidence is shared by both sides before a trial.

FRCP Rule 26. General Provisions Governing Discovery; Duty of Disclosure

FRCP 26(a)(1)(B) Pre–December 1^st

a copy of, or a description by category and location of, all documents, data
compilations, and tangible things that are in the possession, custody, or control of
the party and that the disclosing party may use to support its claims or defenses,
unless solely for impeachment;

FRCP 26(a)(1)(B) Post–December 1^st

a copy of, or a description by category and location of, all documents, electronically stored information, and tangible things that are in the possession, custody, or control of the party and that the disclosing party may use to support its claims or defenses, unless solely for impeachment;

† e–discovery

Microsoft Firefox

Microsoft Firefox

Old Friend

Civil Defense Logo Dies at 67, and Some Mourn Its Passing | NYT | 12.1.06

The stark insignia of civil defense — a C and D forming a red circle in a white triangle on a blue disk — died yesterday after a long eclipse. It was 67 years old and lived in the mind’s eye of anyone who remembers air–raid drills, fallout shelters and metal drums filled with what had to be the stalest biscuits in the world.

Its demise was announced by the National Emergency Management Association, the group that represents state emergency managers.

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