President's Report
Important Dates
From the Legal Counsel
President's Report...Gregory Borah, MD
Health care reform has been the "hot button" issue all summer,
as forces on the right and left spin off a series of draconian
scenarios that have little to do with the vast majority of the
issues that matter to the average person, or to the average
plastic surgeon. Instead of focusing on transformation or
reformation of the "health care system," a more realistic
approach is reform of the 'health insurance system."
In the recession, this health insurance muddle has become even
more poignant, as evidenced by two recent patients. One
middle-aged man with a master's degree in electrical engineering
was laid off shortly after his first stage nasal reconstruction,
with a forehead flap for a large basal cell defect. He wanted to
rush his subsequent procedure before his COBRA coverage ran out,
and said he'd just have to live with the pedicle deformity in
his eyebrow area if he couldn't. But when his wife reminded him
it would be hard to find a new job with an unusual facial
appearance, he seemed even more deflated. Happily, we scheduled
his procedure within the proscribed time limit, but he is still
left without insurance for whatever comes next.
The second patient that comes to mind is a twenty-five year
woman who sustained an acid burn to her face in an domestic
dispute several years ago. She had numerous skin grafts and lost
her job when a major manufacturer moved out of state.
Predictably, she developed scar contractures. Even though her
skills enabled her to find a new job with a company that
provided health insurance, this carrier denied any coverage of
her 'pre-existing' condition. We are still working on her behalf
to convince the insurer that this is a functional problem that
limits her activity and is not cosmetic.
Conservative commentators insist that any changes to the present
construct in America will ruin the world's best health care.
But, as we all know when we try to schedule our post-op indigent
ER patients for follow-up care in the community, there are real
limits to what is available for optimum care.
If the goal were to design the best health care system for our
patients and reduce hassles and frustrations for plastic
surgeons, the current structure would not be what we would
construct.
The left advocates a 'public option' or ' Medicare for
Everyone.' But this would not be an attractive plan from our
standpoint, because while it is relatively straightforward to
deal with, it is encumbered with vastly unrealistic
reimbursement assumptions. It has a stated goal of zero-sum
spending, in an era with a growing elderly population and
escalating fixed practice costs that are not being considered
seriously by the CMS. The 'public option' seems to be less
palatable to both sides of the debate, and my prediction is that
it will fail to be included in any federal overhaul bill because
of lack of support.
The issues that seem to have most traction, I believe, will be
those focused on mandated changes to current health care
insurance environment. Changing insurance laws to be
administered on a national scope instead of on individual
state-to-state basis will make it harder for such wide
variations in coverage. The idea of preventing pre-existing
disease coverage exclusion is a popular one across all political
ideologies. The ability for everyone to get 'group rates' when
one is part of a group or is simply an individual is also widely
popular. In many ways, I think that the Massachusetts experience
is a valuable one for a nation wide plan of insurance reform.
As surgeons, we have seen that CMS and Medicare are not our
friends, but neither are the insurance companies. What will be
best for our patients' freedom of choice and access is a reform
in how the insurers are allowed to manipulate the system for
their profitability at the expense of adequate reimbursement and
patient coverage. The next few months will surely be exciting
and challenging. Because the system is in flux, we surgeons have
an unusual opportunity to influence the legislators on how this
plan will evolve.
We need to ready to mobilize to effect the change we seek.
Important Dates
2010 Annual
Meeting
April 17, 2010
The Westin Princeton
2011 Annual
Meeting
April 16, 2011
The Westin Princeton
More details to
come!
Legal Report...Kern
Augustine Conroy & Schoppmann, P.C.
Appellate Court Rejects Challenge to PIP Fee Schedule
Not surprisingly, the Appellate Division recently rejected the
challenge of a number of medical professional societies and
trade organizations to the New Jersey PIP fee schedule
promulgated by the Dept of Banking & Insurance (DOBI). The Court
found that the fee schedule was not arbitrary, even though the
Ingenix database that DOBI relied upon might have been flawed.
The unsuccessful challengers' attorneys (who are not members of
Kern Augustine Conroy & Schoppmann) have announced that they
will be seeking relief from the NJ Supreme Court, and possibly
the legislature. Considering the fact that the appellate panel
which issued the decision was composed of three of this state's
most well-respected jurists, a Supreme Court reversal might
prove to be a long shot. As for a legislative remedy in this
election year, with the legislature focused on a hotly-contested
gubernatorial race and the on-going debate over health care
reform and ever-rising insurance costs, little should be
expected.
Deadline for Establishing a New Surgical Practice or
Licensed ASC Approaches
Senate Bill 787, enacted by the New Jersey legislature on March
21, 2009, among other things, established September 17, 2009, as
the deadline for new surgical practices and new licensed ASCs to
file plans as required by the new law. Although regulations or
other guidance have not been published to date, the Dept of
Health & Senior Services (DOHSS) has advised that one-operating
room surgical facilities may seek ASC licensure, but requires
that the applicant entity have at least one owner who is not a
licensed health care professional (to avoid DOHSS regulating the
practice of medicine). Physicians wishing to meet the September
17th deadline must act immediately to make the necessary
filings. See www.drlaw.com
for more information.
Healthcare Prosecutions on the Rise
The Obama Administration is set to dramatically increase the
number of healthcare fraud prosecutions to "add muscle to back
up its rhetoric about cracking down on health care and corporate
fraud." According to the National Law Journal, Attorney General
Eric Holder, Jr. is adding ten trial attorneys to the fraud
section and looking for a new chief for the section. The Fraud
Section is already the largest litigation unit within the
Justice Department's Criminal Division and Holder has now named
prosecution of health care fraud a "top priority." For the full
story, and tips on how to protect your practice, go to
www.drlaw.com, click on
Publications and then "The Heat's Getting Hotter."
NJ Receives Federal Stimulus Funds to Inspect ASCs
New Jersey's DOHSS has received $125,000 in federal funds to
increase on-site surveys of ASCs, specifically focusing on
infection control practices. DOHSS expects to have conducted 31
federal inspections of ASCs by the end of September. Additional
monies will soon be received to increase federal inspection of
ASCs from every seven years to every three years, using the more
intensive survey process developed in conjunction with the U.S.
Centers for Disease Control & Prevention. DOHSS expects to
conduct about 30 federal inspections annually.
Office for Civil Rights Takes Over Enforcement of HIPAA
Security Rule
The Centers for Medicare & Medicaid Services has announced that
it will no longer be handling the enforcement of the HIPAA
Security Rule. The Office for Civil Rights (OCR) will be taking
over that role and will now have the administrative and
enforcement authority for both the HIPAA Privacy and HIPAA
Security Rules, in addition to those provisions of the American
Recovery and Reinvestment Act of 2009 governing the security of
electronic health records. Physicians facing investigation by
the OCR are encouraged to contact Kern Augustine Conroy &
Schoppmann.
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