PRESIDENT’S MESSAGESandy Silverman, MD

As we enter 2013, we face new challenges to our practice of medicine. This past year we witnessed the survival of the Patient Protection and A�ordable Care Act from legal challenges through the Supreme Court. The President was re-elected and his vision for health care will continue to a�ect the medical landscape.

Recent CMS rulings have signi�cantly impacted Interventional Pain Medicine (IPM). Speci�cally, the ruling allows CRNAs to independently bill Medicare for anesthesia and other related services (including interventional pain medicine), providing it is allowed by state law. In Florida, an advanced nurse practitioner must be supervised by a physician. Unless state law is changed OR our state opts out of the Medicare supervisory rule for CRNAs, this will not change the current scope of practice for CRNAs in Florida. FSIPP is closely monitoring any legislation that would change the current status, and we will keep our membership advised.

National Coverage Decisions

Local Coverage Determinations (LCDs) for various procedures in interventional pain medicine may be challenged by National Coverage Determinations (NCDs). First Coast Service Options, the Medicare Administrative Contractor (MAC) and MACs for other jurisdictions, have speci�c LCDs for facet blocks, transforaminal epidural injections, spinal cord stimulators, urine drug testing and others. Recently, epidural injections, facet blocks, and spinal cord stimulation were assessed by CMS to be items that should be managed by a National Coverage Decision. CMS invited the public's input concerning any items and services that

may be inappropriately used (i.e., underused, overused, or misused) or provide minimal bene�t in hospitals, clinics, emergency departments, doctors’ o�ces, or in other health care settings. Based on the results of this request CMS included facet joint blocks, epidural injections, and neurostimulators to be placed on the non-covered code list as a NCD, which would trump the LCD for all jurisdictions. Facet blocks were removed from this consideration, but epidurals and neurostimulators remain under consideration for non-coverage. Essentially, CMS may eliminate coverage for these procedures. This has caused great concern in the interventional pain community.

Our parent organization, ASIPP, has been working diligently to remove these items (already some success with facet blocks), or at least prevent negative determinations for these procedures. FSIPP will keep you apprised of the situation as it changes.

Annual Meeting

Our annual meeting will be held on May 17-19 at the Hilton Bonnet Creek, on the Walt Disney World® Property in Orlando, including a Controlled Substance Workshop on the 17th. This unique, comprehensive 8 hour seminar will cover topics in physiology, pharmacology, and medical risk mitigation strategies for the physician prescribing controlled substances. It will also review the status of the Florida Pain Clinic law and its e�ectiveness in stopping the illegal diversion of prescription medications. The annual meeting on May 18-19 will showcase nationally renowned speakers, and for the �rst time, we will present a mock malpractice trial, which should be very educational for everyone. The entertainment will also be fabulous, and I encourage everyone to click here and take a look at the FSIPP 2013 Annual Meeting, Schedule at a Glance and click here to register for the meeting. There is also a Disney package available for conference attendees, so bring the family!!

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Presidents Message By Sandy Silverman, MD

FSIPP Annual Meeting 2013

Changes In 2013 For Pain Management

CME Reporting Requirements

A Letter From AfarBy Andrea Trescot, MD

5 Key Elements To Survival of Physician Owned PracticesBy Lora Brown, MD

Vaughn & Associates, LLCA. Supplemental HIPPA PoliciesB. CMS Allows CRNAs to Practice Chronic PainC. $1mm ZPIC Demand: Think Twice Before

Changing Corporate Structure

Florida Doctors Insurance CompanyCase Study –EMRs, the Good, the Bad, the Undocumented

Danna-Gracey AgencyMalpractice Coverage Factors To Consider

FSIPP NEWSLETTER

FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS

Editor-in-Chief: Deborah H. Tracy, MD

WINTER 2013

FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

PRESIDENT’S MESSAGE(continued from previous page)

MembershipNo organization can survive without members. FSIPP has been very successful and instrumental in Florida’s pain legislation, particularly with pain clinic registration, which ultimately protected patients against pill mills and exempted quali�ed doctors from registration burdens. We have also been active in �ghting the unreasonable local ordinances, which supersede state law and continue to burden our members. FSIPP will continue to be active in all issues which a�ect our members.

On the national level we have supported our parent organization, ASIPP. As mentioned above, ASIPP is actively involved in the NCD challenges, as well as the CRNA scope of practice issue. We strongly encourage joining and renewing mem-bership with ASIPP. No organization has fought harder and with more success than ASIPP for the needs of IPM.

If we work together, we can survive. Your Board of Directors is working hard for both your local and national interests. Please continue to contribute generously to our e�orts.

Sincerely,

Sandy Silverman, MDPresident, FSIPP

FSIPP Proudly Acknowledges Our

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SUPPORT YOUR PROFESSION

CLICK HERE TO JOIN FSIPP

VISIT US ON THE WEBAT

FLSIPP.ORG

FSIPP’S 2013

ANNUAL MEETING, CONFERENCE & TRADESHOWMAY 17 - 19, 2013

HILTON BONNET CREEK, ORLANDO, FLORIDAON THE DISNEY PROPERTY

Don’t miss this year’s FSIPP Annual Meeting. It is expected to supersede all other meetings. The additional full day Friday Schedule will include a review of the law, best practices in prescribing controlled substances and presentations from leading authorities in prescribing. We will receive full updates on the pill mill crisis in Florida, a review of current statistics, trends in prescribing practices and addiction. The Friday Night Welcome Reception for you and your family will feature Cirque-Style Performers and a Banquet Dinner. Discounted packages for the Spectacular Disney World Kingdoms are available to all. We are proud to have lectures on Saturday and Sunday presented by nationally recognized speakers on cutting edge issues in pain management.

Go to FSIPP's homepage, http://www.�sipp.org for information on reserving your hotel room and registering for the conference. The Conference Brochure with registration materials is available online now.

Contact Executive Director Lorry Davis for further information, director@�sipp.org, 352-226-8641.

HILTON ORLANDO BONNET CREEK

A Triumph of Contemporary Designwithin this Orlando Hilton

It's all here at Hilton Orlando Bonnet Creek - a culmination of nearly nine decades of Hilton hospitality, experience and personalized service, lovingly presented in an Orlando resort that reaches above and beyond. Orlando's newest AAA 4-Diamond hotel is located near Walt Disney World® Resort and is nestled on a 482-acre nature preserve. Our resort amenities include 12 dining and lounge options, lagoon-style pool with lazy river, complimentary deluxe transportation to and from the Walt Disney World® Theme Parks, and adjacent Waldorf Astoria Spa® and championship golf club. A world-class convention center boasts 150,000 square feet of function space, providing full meeting and event services.

The 1,001 guest rooms and suites are restful, private retreats with outstanding amenities and services provided by our professional sta�. The cuisine explores new dimensions, tempting the palate with irresistible creations. An equally sublime, but entirely di�erent sort of experience awaits at the exclusive Waldorf Astoria Spa®. Or play an inspired round of golf on the beautifully serene Rees Jones-designed course. Swim in the free-form lagoon-style pool with water slide.

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Conference Program

Conference Registration

An Invitation to Sponsor & Exhibit

Make PlansTo Attend

CHANGES IN CHRONIC PAIN MANAGEMENT FOR 2013

Every year our specialty faces changes in regulation, coding, descriptions of procedures and audit threats. This year is no di�erent and following are the changes for 2013 and areas that each of us will have to change or in which we will have to invest additional attention.

VERTEBROPLASTY Bone biopsy is bundledPUMP ANALYSIS, REPROGRAM AND REFILL (62370) Broadened to include quali�ed allied professionalsBOTOX INJECTION Muscles innervated by the facial nerve, (64612 bilaterally with modi�er 50, but not for neck muscles (64613)NERVE STIMULATOR PLACEMENT (64561) Image guidance is bundledCHRONIC MIGRAINES Can only be reported once per session, added code 64615, facial, trigeminal, cervical and accessory nerves for migraine headaches. Do not report other Botox codes with this code, for example 64612-14NERVE CONDUCTION AND EMG CODES NCV done on same DOS as EMG (use 95860-95864 and 95867-95870) NCV on same DOS as EMG (use 95855-95887 add on codes) Deleted NCV codes 95900, 95903, 95904 Added new NCV codes 95907 (1-2 studies, 95907 (3-4 studies), 95909 (4-5 studies), 95910, 95911, 95912 (2 studies each), 95913 (13 or more studies)ULTRASOUND GUIDANCE CPT changed the parenthetical note for code 76942, ultrasound guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation that now includes paravertebral facet joint injections using ultrasoundDEFINED QUALIFIED HEALTH CARE PROFESSIONAL A person with proper quali�cations by education, training, licensure/regulation and facility privileging who performs a service within the scope of their practice who independently reports services distinct from clinical sta�OBSERVATION CARE CODES Now have time added, the extent of counseling and or coordination must be documented in the medical record time as “face to face time with the patient” 99234- 40 minutes 99235 – 50 minutes 99236 – 55 minutes

OIG Work Plan 20121. Unannounced on-site visits – focus on DME especially in Florida (high rate of fraud and abuse)2. Audits of Error Prone Providers and Outliers based on CERT audits3. Failure to repay overpayments4. NCVs and EMGs5. Billing in excess of allowable6. Incident to services (using percentages to determine # of hours worked)7. Point of Service errors (11 in lieu of 22 or 24)8. E&M documentation especially EMRs with same note on multiple visits9. Improper modi�ers 24, 58, GA10. O�-label drugs must be either FDA approved or identi�ed by DHSS11. RACs for potential fraud referrals12. HIPAA, to review security controls for PHI stored on laptops, devices etc

FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

FSIPP Proudly Acknowledges Our

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FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

CME REPORTING REQUIREMENTS

FLORIDA DEPARTMENT OF HEALTH

The Florida Department of Health (DOH) reports that last year only 8% of physi-cians ful�lled their requirements through CE Broker. All future licensure renewal requirements by the DOH will use CE Broker as their o�cial tracking system to verify CME credits. You can sign up for CE Broker through the FMA or direct through CE Broker (cebroker.com).

For a reasonable yearly fee they will: • Report CMEs to the DOH • Monitor your requirements • Alert you of additional hours • Provide assistance

Most CME providers, but not all, will report your CME credits to CE broker. Your requirements to complete 40 hours of credits for each licensure period of two years have not changed. Speci�c requirements, for example, Medical Errors, Domestic Violence and HIV have not changed. However, physicians practicing in registered pain management clinics must complete CMEs pursuant to rule 64B8-9.0131 of the Florida Administrative Code.

FSIPP Proudly Acknowledges Our

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August 18-21, 2013FSIPP Board Members Present Pain Medicine Session at68th Annual Workers’ Compensation Educational Conference

Drs Sanford Silverman, Orlando Florete Jr, Harold Cordner, and Je�rey Buchalter will present the Pain Session at the 2013 Workers’ Compensation Educational Confer-ence to be held August 18-21 at the Orlando World Center Marriott.

Physician attendees can earn CMEs, and more than 300 exhibitors will be on hand to present information on their products and services. Click HERE for link and details.

FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

Letter from AfarAndrea Trescot, MD

Dear fellow FSIPP members,

It has been a unique experience, practicing pain in Florida, Wash-ington State, and now Alaska. Not only was it the challenge of going from private practice to academics and then back to private prac-tice, but there is also de�nitely a di�erent mind-set of the patients and the phy-sicians on the “left coast,” especially in the Paci�c Northwest. At

the University of Washington, the sta� (doctors and support sta�) could often be seen coming into the hospital or sitting in Grand Rounds wear-ing their Spandex biking out�ts. The sta� at the clinic all called the doctors by their �rst name, even in front of patients. In Alaska, there is even less formality. Jeans are standard among doctors and sta�; I have not seen a collared shirt since I have been here. Even patients call me by my �rst name. Doctors’ waiting rooms and exam rooms are deco-rated with pictures of dead �sh and animals, proudly displayed. In the summer, the doctors and sta� are hiking, biking or �shing after work; winter sports include dog racing (the Iditarod race starts a few miles from my o�ce), skiing, and snow machining (they are o�ended by the term “snow mobile”).

The patients, too, tend to be more active. Although we have our share of obese patients, many patients ask if they can go snow machining or �shing immediately after their procedure. I have patients who have very physical jobs - one gal had been a commercial �sherman on the Bering Sea for 30 years (think “World’s Most Dan-gerous Jobs”), and many work in the oil �elds of the North Slope. And I have patients who built and live in their own cabins, often “dry” cabins without electricity or running water. One of my �bromyal-gia patients told me that she feels much better when she hauls water and chops wood.

Insurance is also di�erent. Chiropractors and Naturopaths can do injections, and there is no recognition of pain management as a separate specialty. There is no managed care in Alaska, and Workers’ Comp is currently fee for service. Since the state has a lot of oil money, Medicaid pays more than Medicare, and it has a great formulary. But there are only 750,000 people in the whole state, 300,000 of which are in Anchorage (I am in Wasilla, about 40 minutes away in good weather) and 20 pain doctors, meaning that there we are starting to see a diminishing patient pool. It has been fun adding new techniques – we have done the �rst MILD, sacroplasty, and cryoanalgesia in the state, and I have started a non-ACGME pain fellowship. We are still keeping our Florida house, and still consider Florida home, but Alaska is a fun ride, and one of the most beautiful places I have ever seen.

FSIPP Proudly Acknowledges Our

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Dr. Trescot is past president of FSIPP and ASIPP, a former professor and director of the pain fellowship at the University of Florida and University of Washington, and now she practices in Alaska.

FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

The survival of p h y s i c i a n - o w n e d practices has never been more di�cult than it is today. The healthcare marketplace is evolving. Healthcare expenditures now account for nearly 20% of the GDP in the United States, forcing the consolidation of services and providers. The future landscape of healthcare will be comprised of accountable care organi-zations composed of large provider groups that can deliver compre-hensive competitive care

to entire populations. This scenario will provide challenges to traditional independent physician owned practices. Corporate America is gradually gaining control of the reins of healthcare as it introduces technology, balance sheets, and consumer driven outcomes. Unfortunately, physicians, for the most part, are being left out of this dynamic change. Much medical care is now being provided by lower level providers. Physicians are increasingly trading their practices for a monthly paycheck and the security of being a part of a big organization. Will their loyalties shift from their patients to the organizations that control standards of care as well as pen their salaries?

How do independent pain management physician practices survive in light of these dynamic changes? Collaboration, standardization, evolving technologically, creativity and business acumen are critical to survival.

Collaboration over CompetitionNever before has it been so important for physicians to work together in collaboration. Whether we are �ghting for cover-age, sustained reimbursement, or protected scope of practice, we can no longer remain complacent. We are outnumbered and out-funded by lawyers and nurses multi-fold. Not only must we remain aware of the political battles being waged, we must each roll up our sleeves and pull out our wallets if we want our interests represented.

Our voice is far stronger when sung in unison. Like the rest of medicine, pain physicians have been constrained by fragmentation. The Florida Society of Interventional Pain Physicians continues the tireless work of staying at the forefront of issues relevant to our specialty. I encourage each of you to get more involved.

Treatment StandardizationThe specialty of pain medicine has been plagued by a lack of standardization of care. Depending on the physician seen and their interest, skill, and training, a patient may receive a varied of scope of treatments all under the guise of pain management. Never before has this been more evident than the public perception problem created for legitimate pain management practices during the recent "pill mill" crisis in Florida. The consumer driven healthcare system we are entering will demand outcomes driven comprehensive pain treatment and wellness protocols. To compete, physician owned practices will need to provide full service care while compiling outcomes data for their practices. Outcomes will be driven by economics, utilizing e�ciency, quality, e�ec-tiveness. Therefore "value" is the word of the future.

Go TechTechnology is king and it will not be dethroned. Healthcare is a late bloomer when it comes to technology but venture capital in healthcare technology has grown more than seventy percent in the last year. Seventy-one percent of consumers now say they search the internet before making any major product purchase or family spending decision. Insurance companies are now incentivizing consumers with discounted co-pays for using an e-doctor over a personal physician visit. Physicians must pull their heads out of the sand regarding technology. Electronic medical records and practice management systems and the outcomes data that can be tracked with these systems are a present day neces-sity. Physicians must educate themselves about social media, SEO (search engine optimization), digital consumer tracking and the potential that these have in driving patients to your practice.

Technology has entered the clinical arena as well. There are fabulous patient education tools now available. Pharmaco-genetic testing provides patients customized personalized medication regimens. Regenerative medicine has bloomed,

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5 Key Elements to the Survival of Physician Owned PracticesLora Brown, MD

FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

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5 Key Elements to the Survival of Physician Owned Practices(continued from previous page)

introducing stem cell therapy as one of the �rst true preven-tative therapies for our specialty. As healthcare consumers become more educated, they will demand tech driven care. Physicians who embrace these trends will thrive.

Think Outside the SpineMore and more physicians are realizing the bene�ts of a comprehensive treatment approach. Prevention and wellness are in public demand. Many of these services can be structured such that a healthy ancillary revenue stream is created. Physician owned practices possess a captive audience that craves direction and guidance in the �ourish-ing wellness industry. Provision of nutritional supplements and medical foods is one such service that has great applica-tion to the �eld of pain medicine. Clinical research supports use of conservative care including bracing, physical therapy, and chiropractic care for patients who present with pain. These services can be incorporated into a medical practice such that the patient is able to receive comprehensive coordinated care plans. For interventional based practices, there may be opportunity in the development of a level II or III procedure suite within the practice. As a greater array of procedures can be safely done in this setting, the initial investment can be recaptured relatively quickly. Ancillary revenue streams can also be captured in diagnostic testing with in-o�ce laboratory and imaging services. The introduc-tion of additional relevant diagnostic and therapeutic services such as allergy testing, sleep evaluations, massage, acupuncture, anti-aging and hormone therapies can be included in a comprehensive wellness approach.

Sharpen your Business AcumenGone are the days that physicians can chuckle that "doctors just aren't good at business." It may be time to step away from the patient for a bit and evaluate your potentially ill

practice. To survive as a physician owned practice, doctors must sharpen their business acumen. Maximizing e�cien-cies through work process �ow analytics as well as the use of extenders can increase revenue signi�cantly. The goal is to work "smarter not harder." Find ways to save money on the supply side as well. Wholesalers, buying groups, and group purchasing organizations (GPOs) can provide additional savings. For example, members of The Physicians' Group, a GPO created speci�cally for pain management, continue to save on average twenty percent on supplies and services, which translates to greater pro�tability.

Consolidation of physician practices into Independent Physician Associations (IPAs), a trend ten years ago, is seeing a resurgence as more "super groups" are formed. Another new trend emerging from the transformation in healthcare today is the use of of Management Service Organizations (MSOs). Physicians are beginning to adopt the philosophy of joining resources for survival and to improve market penetration. The core component of an MSO is a de�ned array of services made available to physicians and struc-tured in a cooperative fashion. MSOs generally provide practice management and administrative support services to individual physicians or small group practices. One purpose of MSOs is to relieve physicians of non-medical business functions so that they can concentrate on the clinical aspects of their practice. Because MSOs purchase their services as a group instead of individually, they can generally achieve economies of scale. These cost savings may be passed on to physicians, who may use this cost advantage when negotiating with health plans and health-care purchasers. The MSO skirts fraud and abuse or inure-ment problems by developing a revenue base and a customer panel which manages the services and their costs to the client base. There is actually a fee paid for the services

which are provided to the practices.

"You live and learn or you don't live long." - Robert A. Heinlein

In light of �scal cli�s, Medicare cuts, and healthcare reform, the survival of physician owned practices is in danger of extinction. The fragmented nature of physi-cian political organization threat-ens our survival even more. Now is the time to seriously consider our future course. It is time for physi-cians to embrace the inevitable changes in healthcare for the mutual bene�t of their practices and their patients. With change comes opportunity. Opportunity can be realized by physician owned practice through collabora-tion, standardization, the adoption of new technology, creativity and business acumen.

Supplemental HIPAA Policies HIPAA has become the government’s new fraud and abuse hammer. Not only have �nes increased, but we have seen several cases imposing million dollar �nes in the past year, and multiple cases imposing six �gure �nes. CMS has acknowledged that it has increased �nes in order to hire more investigators and case workers to work more HIPAA cases, which will, in turn, generate more revenue. The government wants to achieve the same results from HIPAA recoveries as it has achieved from fraud and abuse recoveries, with the latest �gures indicating that the government collects $7 for every $1 of fraud and abuse investment.

In September 2012, an ENT group in MA was �ned $1.5mm for the theft of an unencrypted laptop. A small, 4-physician group in AZ was �ned $100,000 in April 2012 for using web based email and calendaring without conducting a risk assessment and for sending emails and posting patient calendaring in an unencrypted manner. Even Alaska Medicaid was not immune, as it was required to pay DHHS $1.7mm in June 2012 when someone stole an unencrypted portable electronic storage device from a Medicaid employee's vehicle. None of these cases involve the intentional dissemination of PHI by the provider. These cases all involve theft or negligence, which can happen in any practice.

Ironically, in discussing the rationale for these large �nes, the government emphasized that the provider group failed to adopt speci�c HIPAA policies and procedures and failed to conduct risk assessments to plug security leaks. Moral: get your policies in place, conduct your risk assessments, �nd your leaks, and plug them (and document what you plugged so the government can see your e�orts to comply).

I helped many of you develop your HIPAA plans. In light of the recent cases, however, we need to supplement our policies. I have created the following new policies which I have attached hereto: (1) Removal of Paper Records Containing PHI, (2) Removal of Electronic Media, (3) Cell Phone and Tablet Policy, (4) Remote Network Access, (5) Email Security, (6) Web Based Services, (7) De-Identi�cation, and (8) Pre-anesthesia Evaluation. If you don’t get the attachment, email me and I’ll send it to you.

Make sure to tailor these proposed policies to your practice. One size does not �t all. You will probably need an IT professional to review the Electronic Media, Cell

Phone/Tablet, Remote Access, and Email Security policies because your setup may vary from those contemplated in these policies. Nevertheless, the goal is to get these policies in place, and these sample policies should get the ball rolling. I’ve defended at least 10 HIPAA infractions this year, and sooner or later, your group will probably experience a “breach” of unsecured PHI. When that happens, your �ne will be materially less if you have conducted a risk assessment, documented what holes you plugged, and adopted policies addressing the issues in the policies I’ve attached.

CMS Allows CRNAs to Practice Chronic Pain In the Final Rule pertaining to the 2012 Medicare Fee Schedule, just released this afternoon, November 1, 2012, CMS not only has rea�rmed its proposed rule this summer to allow CRNAs to practice chronic pain, but has actually extended CRNA practice and reimbursement to include whatever each state allows CRNAs to do within their scope of practice in each state.

“Therefore, we are revising §410.69(b) to de�ne the statutory bene�t category for CRNAs, which is speci�ed as ‘anesthesia and related care,’ as ‘those services that a certi�ed registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished.’ By this action, we are de�ning the Medicare bene�t category for CRNAs as including any services the CRNA is permitted to furnish under their state scope of practice. In addition, this action results in CRNAs being treated similarly to other advanced practice nurses for Medicare purposes. This policy is consistent with the Institute of Medicine’s recommendation that Medicare cover services provided by advanced practice nurses to the full extent of their state scope of practice. CMS will continue to monitor state scope of practice laws for CRNAs to ensure that they do not expand beyond the appropriate bounds of ‘anesthesia and related care’ for purposes of the Medicare program.” Final Rule, p. 374.

The Final Rule takes e�ect January 1, 2013.

To determine whether CRNAs can practice chronic pain management in any given state, you will need to know what that state's legislature has adopted as the scope of practice for CRNAs within that state.

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FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

CUTTING EDGE CLINICAL PAIN MANAGEMENT

PRESENTATIONS

FROM

NATIONALLY RECOGNIZED SPEAKERS

CIRQUE-STYLE PERFORMERS&

BANQUETAT FRIDAY NIGHT WELCOME RECEPTION!

ALL INVITED...ATTENDEES, FAMILY, EXHIBITORS!

S A V E T H E D A T E

FSIPP’S 2013 ANNUAL MEETING, CONFERENCE & TRADESHOW

MAY 17 - 19, 2013

$1mm ZPIC Demand: Think Twice Before Changing Corporate Structure

I was retained today by an interventional pain physician who changed his corporate structure from a partnership with 2 other physicians to a solo practice. In doing so, he created a new LLC for his solo practice. Thus, he ended up with 2 Medicare PIN numbers, one for the old entity, and one for the new entity.

A ZPIC contractor did an extrapolated audit of his claims. Because he had 2 di�erent legal entities during the audit period, the ZPIC performed a random statistical sampling on both tax ID's.

He received two demand letters, one demanding a refund of $348,000, and the other demanding a refund for $708,000. Had he not created a separate LLC, there would have only been one random sampling audit, not 2.

I talked to the auditor who explained that they had to do both audits because he had two separate tax ID's during the audit sampling period.

Another unusual fact is that the medical records were sent to the ZPIC back in March 2010, and the demand letters were just issued on August 30, 2012, two and one-half years later.

The moral of this story: think twice before you change your corporate structure or create a separate tax ID. If you get audited, CMS can audit and extrapolate as to both tax ID's.

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FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

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FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

As technology evolves around us, more and more medical practices are leveraging Electronic Medical Record systems as a hedge against record spoliation. Anyone who has ever been involved in medical professional negligence legal proceedings will attest to the importance of accurate and detailed medical records. How do you de�ne “medical records”? What information should be considered “part of the patient’s records”? Recently, phone records have become increasingly seminal in cases involving time sensitive diagnoses.

Consider the following example: A patient, with no known allergies, is prescribed antibiotics for an infection. That patient follows the course of medication, but develops what are thought to be symptoms of an allergic reaction. The patient phones the physician and informs the nurse practitioner of the symptoms. The physician is alerted and the patient is instructed to stop all medication and come in for evaluation. The patient does come in, but the symptoms are inconclusive and the patient is sent home with a diagnosis of HFMD and Fifth Disease. The patient develops an extremely rare and life threatening allergic reaction to the medication and is sent to ICU.

In this situation, after the patient is sent home by the physician, the patient allegedly calls back two or three days later to inform the physician of blisters and increased rash. In a history given at the hospital, the hospital documents that the patient claims “the physician informed me that this was normal when I called.” Unfortunately, there is no record of this phone call. There is no way for the defense to prove who the patient spoke to, or what was discussed. In this case, the physician would have never informed the patient of the normalcy of blisters and would have instructed the patient to come in immediately or go to the hospital.

When a patient presents at an o�ce with a complaint, that complaint is documented in their chart. Why are phone calls treated di�erently? In today’s environment, modes of communication are evolving, but that does not exempt the physician, nurse, or sta� member from documenting each and every time a patient calls. You may keep a phone log, but is that considered part of the patient’s chart? Does your system allow you to include time stamped notes for phone calls? If not, it should!

Consider the “on call” physician who receives a 2 a.m. Saturday phone call for a consult. Based on the ER physician’s description, the “on call” physician gives orders for broad spectrum antibiotics and follow up in the o�ce on Monday. However, the patient is not

discharged on any antibiotics and develops sepsis and gangrene. As a result, the patient has a number of �ngers and toes amputated. Because the phone call was neither documented by the ER physician nor the “on call” physician, the defense has little ground to defend discharging the patient without antibiotics. In this case, the patient is retired and enjoys gol�ng and playing piano, two hobbies the patient will never be able to enjoy again.

While the importance of documenting a chart is widely understood, the importance of documenting patient and physician phone calls should be considered equally as important. Simply documenting that a phone call occurred in a log is not enough. The subject of that phone call should be included in every patient’s chart as well as who spoke to the patient. A few extra steps taken at the time of the phone call could prevent tremendous headaches during litigation, or perhaps prevent them altogether.

Florida Doctors CompanyFlorida Doctors Insurance Company (FLDIC) is committed to defending and protecting Florida’s physicians. We are the 4th largest medical malpractice insurer in the state of Florida, founded on Experience and focused on Florida. We are the Preferred Partner of FSIPP, enabling members to save 10% on their malpractice premium. To learn more visit us at http://www.FLDIC.com or contact Lesa Kemp at 904-813-9284.

Case Study – EMRs, the Good, the Bad, the UndocumentedBy Michael Knox

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FLORIDA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS - NEWSLETTER WINTER 2013

Many medical professionals neglect to have a regular check-up on their malpractice insurance. This can be accomplished in a very short period of time, there is no o�ce visit required, nor should a fee be charged for the service. Malpractice insurance is often misunderstood – and many feel that “if it is not broke, then why bother �xing it.” Mistakes with your malpractice coverage could cost you in real premium dollars along with valuable time and stress over the long term. Having a malpractice insurance checkup will reveal any ailments that can harm you �nancially and

provide the necessary prescription to achieve optimum insurance health.

Nearly every licensed practitioner has experienced their malpractice premiums drop over the past six years. The insurance markets have been in a downward premium cycle and nearly every insurance expert believes that this downward trend is about to end. Physicians who have had regular insurance checkups have bene�ted the most with premium savings during this time. Those who did not bother with a checkup have missed out on the maximum savings. The bottom line is that having regular insurance checkups will help you avoid paying too much and to avoid gaps in coverage that can cause real �nancial ailments over time.

A regular checkup is also important because we often fail to recognize the small changes that tend to happen normally over time. This may include subtle changes within the medical practice like adding new employees or implementing new procedures. Maybe the practice is growing or you have actually reached a time when you are looking forward to a well-earned retirement. These changes also occur within each malpractice insurer and the overall insurance marketplace where change is constant. Below are some of the more common malpractice insurance factors that medical professionals must consider with regard to the health of their malpractice coverage.

Ability to Defend - This is arguably the most important factor to consider when purchasing your malpractice coverage. Do you know your insurance carrier’s �nancial strength, experience, and track record for defending doctors? Remember that some claims can drag on for years and cost hundreds of thousands of dollars to defend so you want to make sure your insurer is �nancially able, willing, and experienced enough to handle defending you properly.

Policy Coverage – How does your policy compare important features with other comparable companies? This can range from the policy claim trigger, any defense limitations, deductibles, tail coverage, coverage extensions for DOH complaints, HIPPA, Medicare/Medicaid, Cybercoverage, etc. How are the practice entity and employees protected under the policy? How does your premium rate compare with other comparable malpractice companies?

Limits of Coverage – Have you compared your premium cost for various levels of liability coverage? Is there an ability to “stack” liability limits of coverage and how will this bene�t you?

Discounts and Credits – Each malpractice carrier has their own interest in particular medical specialties and practice locations. They often will arrange special program credits and discounts to attract the type of practices that will suit them best. It is important to shop and compare your coverage and premium cost each year because insurance markets have a cycles that are always changing.

Having a Trusted Advisor – As you can see, there are many complex factors to consider when making such an important decision as purchasing your malpractice insurance. An “independent” malpractice insurance specialist can help you to navigate any changes within your practice, as well as the outside, and the always changing insurance markets.

Finally, have regular insurance checkups only with an experienced, independent malpractice specialist in order to keep your insurance health in top condition. A malpractice specialist will be more of an educator who is experienced with the overall marketplace. Avoid all the gimmicks and sales representatives that are simply trying to sell you an insurance product. The malpractice specialist will have many references and testimonials that they can provide to demonstrate how they have cured many real insurance ailments for their physician clients. The independent malpractice specialist will always have the physician’s interest over any company or product available in the market.

Danna-Gracey is an independent malpractice insurance agency with o�ces located in Delray Beach, Orlando, Jacksonville & Miami. Our insurance specialists can be reached anytime by contacting our toll-free number at 1-888-496-0059.

Have You Checked The Health Of YourMalpractice Coverage Lately?Malpractice Coverage Factors To Consider…By Dan RealeDanna-Gracey Agency – The Malpractice Insurance Experts