Archive for June, 2013

Providers Beware of Suspect Joint Ventures

As the Healthcare Reform initiatives drive providers to think outside the box and evaluate new sources of revenue or integration models, the Office of Inspector General (“OIG”) last week shut down one potential proposal that many providers may have considered. Specifically, the OIG found in an Advisory Opinion that a management company assisting a provider in establishing a new service line could potentially violate the Anti-Kickback Statute and that the government could enforce penalties for such violation. The Anti-Kickback Statute generally prohibits anyone from knowingly or willfully providing any form of remuneration to another individual to induce the purchasing, ordering or referral of services that are billed to state and federal healthcare programs. Interestingly enough, in this proposal, the parties attempted to exclude state and federal beneficiaries to avoid any such violation, but the OIG took a broad approach when examining the proposed arrangement.

The facts …

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Signs Point to Yes

The preliminary numbers look like the Affordable Care Act (ACA) is going to work as intended. Insurers were required to declare if they were going to and what plans and premiums they would offer in the individual exchanges by early May. In Georgia, seven insurers are participating in all or parts of the state. The premiums and plans they are offering resemble those currently offered by large employers.

A central question is whether the private insurance market as reconfigured by the ACA will be sustainable. A sustainable private insurance market is possible only if adverse risk selection is managed. Adverse risk selection is the fact that individuals with the highest demand for health insurance are those with the greatest health care needs. No insurance market can be sustained if the only people purchasing insurance are those about to file a claim.

Currently almost 95 percent of those with private health insurance coverage purchased that coverage through an employment-based …

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Does the General Public get it?

What is” it” you ask? Healthcare Reform

The picture in Georgia appears to be pretty bleak. The State has chosen not to expand Medicaid. Early estimates predict the cost of Health Insurance on the exchanges may be 45% higher, than the ridiculously high cost Georgians are already paying for Health Insurance. Any chance of an affordable plan will likely come with a deductible of $5,000 or more. Employers are dropping coverage left and right in favor of the penalty, which in reality is not really a penalty because it is cheaper. Employers, who are opting to keep their group plans, are facing substantial premium and deductible increases, as well. It is not looking good for anyone, especially those who most need it, from a cost perspective.

However, the average member of society- the one who does not work in the industry- does not understand, and they are not ready for what lies ahead. My question to you as a Healthcare Leader is what are we doing about it? Our patients, clients, …

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Defensive Medicine: More Than Just Another Extra X-Ray

med mal 4Defensive medicine occurs when physicians order tests, procedures or consultations of doubtful clinical value in order to protect themselves from costly and frivolous malpractice suits. Doctors detest the very thought of being sued so they find every means possible to avoid litigation.

And that includes ordering numerous unnecessary and expensive tests and procedures.

While not all Georgia physicians practice defensive medicine, the overwhelming majority do. According to a recent survey conducted by Oppenheim Research, 82 percent of Georgia doctors say they perform unnecessary tests, procedures and referral consultations exclusively to avoid a medical malpractice claim.

A 2010 Gallup Poll of physicians found that one-in-four healthcare dollars is spent on defensive medicine. A great deal of money is “wasted” on the practice of defensive medicine. Last year, Georgians were subjected to $14 billion of unnecessary tests, procedures or consultations with little or no clinical or …

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