The Patient Advocate deciphers medical billing

Just a few years after launching a company to help doctors run the business side of their practices, Springfield businessman Don Tucker saw an opportunity to start a second venture aimed at helping patients.

Tucker launched Focused Physicians Inc. in 2006, helping physician practices with scheduling, medical record coding, billing, claims, collections and accounts receivable.

In August, he opened The Patient Advocate LLC after his Focused Physician work shed light on a widespread need among patients for help navigating the billing maze.

"A lot of elderly people struggle with their medical bills, sorting things out," said Tucker, who has been in health care administration for more than three decades. "If you have a hospital stay, you'll get a bill from the hospital (and) a bill from every specialty physician you see. So you're inundated with medical bills."

The Tuckers are in the process of relocating both ventures to leased space in Butler, Rosenbury & Partners Inc.'s 319 N. Main Ave. building in downtown Springfield, from 1135 E. Lakewood St.

Breaking down bills

Six contracted case managers at The Patient Advocate, led by Tucker and his son, Michael, vice president of operations, make sure clients understand what their insurance is responsible for covering and how much they need to pay out-of-pocket.

"(Clients) come and bring their shoebox with all of their bills ... and we'll go through and sort those by providers, by dates of service to get a clear understanding of what is involved," said Michael Tucker, who has worked in medical billing for nearly 20 years. "Then ... we'll come up with a summation to the client of what we see to go forward." And if there are questions that need to be answered, he said case managers will call and get the information.

Advocacy is not new in health care, Don Tucker said, noting that doctors, hospitals and insurance companies sometimes answer patients' questions.

For example, Springfield-based Employee Benefit Design LLC offers its clients access to assistance through an independent company, Health Advocate. The fee-based service is available with favored pricing because EBD is a member of United Benefit Advisors, said Alecia André, EBD account manager.

"It will handle any type of medically related service," she said, pointing to finding providers, making appointments and answering benefits, billing or medical questions. "When the doctor talks real fast and shuffles you out of the office and you don't understand what's going on, you can call Health Advocate, and they'll help piece together the information that you need to make informed decisions," she said.

Dr. Thomas Brooks, a pain management specialist with CoxHealth and former client of Focused Physicians, often fields patients' billing questions - sometimes even related to other providers - and has referred patients to The Patient Advocate.

"I'm not a billing expert by any means," Brooks said, adding that it's important to find help from somebody who can look at the whole scope of a patient's insurance package and address questions. It's essential that patients understand what's covered - or not - by their insurance, he said.

"Physicians' offices are overwhelmed with different policies," Brooks added. "Having somebody who has an expertise in that area to guide the patient, I think, is a fabulous idea."

Access to assistance

Right now, The Patient Advocate operates on a fee structure that starts at $50 for physicians' bills and ranges up to $100 for bills related to a hospital stay, Don Tucker added. He declined to say how many clients have been assisted since opening in August, but he said the plan now is to convert The Patient Advocate into a not-for-profit entity. Doing so, he said, would open the door for financial assistance for patients.

"I have visited with (Congressman) Roy Blunt's office (which has) an advocate for Medicare. They ... offered us all kinds of information about government programs, if we wanted to apply for a grant to help fund this service, rather than do it on the backs of the people who need it," Tucker said.

Sometimes, in the process of examining client bills, case managers are able to alleviate the burden of medical bills, by uncovering instances of over-billing or double billing, or by matching patients with available government assistance.

But reductions aren't a given.

"There are times when we'll go through (the process) and say, 'You know what? You've got a $2,000 bill, and you owe it," Michael Tucker said.

While turning a new business into a nonprofit might be unusual, Don Tucker said, it benefits several parties, including Focused Physicians, as it helps its eight client practices streamline billing and claims.

"If you don't understand a bill, you're not going to pay it, so we're everybody's friend," Tucker said. "We want the hospitals to get their just due. We want the doctors to get their just due, and we want the patient to be treated fairly."

Kaplan College's Denver Campus Launches New Medical Billing and Coding Diploma Program

Kaplan College in Denver has opened enrollment for the new medical billing and coding diploma program. The campus will begin classes Jan. 20.

The 36-week program prepares students with the knowledge, technical skills and work habits to pursue an entry-level position in the medical billing and coding field or related area.

Duties may include a variety of functions such as
accounting, preparing and filing insurance claim forms, Medicare and Medicaid billing, reimbursements, collections, coding procedures, benefits, coverage, and limitations. The students will develop the understanding of insurance co-pays, deductibles and out-of-pocket expenses, along with collection procedures.

'We are proud to offer our new medical billing and coding program in response to the growing demands of the field and our community,' said Todd Smith, executive director of the Kaplan College Denver campus.

Debbie Lundy, medical program director for the Kaplan College Denver campus, will oversee the program. She has worked in the medical field for 10 years. During this time, her role included administrative work, coding and billing and assisting with minor surgeries at local pediatric and family practice offices. Lundy began teaching at Kaplan in 2005 as a medical office specialist instructor.

Individuals interested in learning more about the program can contact an admissions representative at 303.295.0550.

The Kaplan College Denver campus is accredited by the Accrediting Commission for Career Schools and Colleges of Technology (ACCSCT). ACCSCT is listed as a nationally recognized accrediting agency by the United States Department of Education.

About Kaplan College
Kaplan College is part of Kaplan Higher Education, which serves 100,000 students through more than 70 campus-based schools across the United States and in Europe. It also has online programs through Kaplan Virtual Education, Kaplan University and Concord Law School of Kaplan University. Kaplan Higher Education schools offer a spectrum of academic opportunities, from high school diplomas to graduate and professional degrees, including a Juris Doctor degree. Kaplan Higher Education is part of Kaplan, Inc., a subsidiary of The Washington Post Company (NYSE: WPO). For more information, visit portal.kaplancollege.com.

NY AG accuses hospitals of kickbacks, fraud

ALBANY, N.Y. (AP) — Seven New York state hospitals are facing lawsuits accusing them, in some cases, of rounding up the homeless or paying kickbacks to get more inpatient detox patients into their drug treatment beds, and lacking certification for detox services.

In one of the cases — Parkway Hospital in Queens, which closed in November — is accused of paying people to search homeless shelters and other places for patients to enter a three-day stay in detox in exchange for cigarettes, beer, food, and other items, according to a suit filed by Attorney General Andrew Cuomo. His office hasn't charged the now-defunct hospital with kickbacks.

In civil lawsuits filed by Cuomo and U.S. Eastern District Attorney Benton Campbell, the hospitals are accused of fraudulently billing Medicaid for more than $50 million in more than 14,000 different claims.Both attorneys' offices declined to say why they didn't pursue criminal charges. In both investigations, former hospital employees notified federal and state authorities of the issues, dating back to 2002.

The hospitals named in the suit are Columbia Memorial Physicians Hospital Organization Inc., in Hudson; Long Beach Medical Center; New York Downtown Hospital; St. Joseph's Medical Center in Yonkers; the former Our Lady of Mercy in The Bronx; Benedictine Hospital in Kingston, and Parkway.

The suits also name Missouri-based SpecialCare Hospital Management Corp., as a defendant. The company faced a similar suit in Illinois, when a former hospital employee accused the company and an Illinois hospital of admitting patients into detox who did not meet criteria because of the lucrative Medicaid reimbursements. That case was dismissed, but more detailed claims have since been filed.

Spokesmen for St. Joseph's, Benedictine, Downtown Hospital, Columbia Memorial and Long Beach denied the allegations. Parkway closed and officials couldn't be reached. Our Lady of Mercy is now run by Montefiore Medical Center and didn't return calls. SpecialCare didn't return a call for comment.

"Despite years of investigation, neither the Office of the Attorney General of the state of New York, nor the United State's Attorney's Office has articulated any viable claims," said Gary Schulz, an attorney representing St. Joseph's.

Cuomo said all the hospitals operated detox services claiming they were part of a government treatment program, but they didn't have the required state license for the treatment. The suits also accuse the hospitals of billing Medicaid for inpatient detox services that weren't medically necessary, or didn't meet standards.

Separately, the suits accuse four of the hospitals of engaging in a kickback scheme with SpecialCare to illegally refer patients to the hospitals' detox units.

The suit claims the company entered into agreements with Columbia Memorial; Long Beach Medical Center; New York Downtown Hospital, and St. Joseph's Medical Center in Yonkers. The agreements were supposed to have SpecialCare provide management and administrative services for the detox program, but the lawsuit accuses the company and hospitals of illegally referring patients to the hospitals for a fee.

Cuomo asserts that violates New York's anti-kickback laws.

"SpecialCare at times literally picked up strangers on the street, shuttled them to hospitals where they received treatment that was either inadequate or unnecessary, and then billed the state," Cuomo said in a written statement.

The state settled for $4.5 million with Our Lady of Mercy, which denied all wrongdoing.

The lawsuits were first reported by The New York Post.

athenahealth: Don't Curb Your Enthusiasm Just Yet

When it comes to diagnostic imaging, drug eluting stents, and hip replacements, healthcare technology in America is without a doubt the best in the world. Sadly, it’s a recurring nightmare when it comes to information technology within hospitals and small physician practice, where everything from ballooning bad debt expense to illegible prescriptions and 200,000 preventable deaths a year are bleeding our healthcare budget dry, scarring the people who pay too much for too little, and overworking providers of care.

IT investment per worker in the healthcare industry is roughly half of what private industry in America pays and only 1 in 6 physicians have a fully working healthcare technology platform. The US spends $2.2 trillion, or 16% of GDP, on healthcare, yet we rank #46 and #42 when it comes to life expectancy and infant mortality, respectively. Without adjustment, healthcare spending will double to over $4 trillion by 2016.

City to Pay Doctors to Contribute to Database

For Dr. Harvey Benovitz, who graduated from medical school in 1962, it is as profound a shift in the way he treats patients as advances in diabetes drugs. Instead of jotting down notes on charts and filling out prescriptions in his small, meticulous handwriting, Dr. Benovitz, whose patients have always thought of him as a reassuringly old-fashioned internist, tapped a patient’s blood pressure and other vitals into a laptop next to the examining table during a checkup the other day.

Not only will this new electronic record-keeping system eliminate the rows upon rows of bursting manila folders stuffed into what could be another examination room in the back of Dr. Benovitz’s cramped office on the Upper West Side. It allows him to compare the patient’s blood pressure management with all his other patients’ — and with those in hundreds of private medical practices across New York City.

Dr. Benovitz is among about 1,000 primary-care physicians who have given up their doctor’s pens over the past year to collect the smallest details of their patients’ lives in a database as part of a $60 million city health department project.

Experts say it is the most ambitious government effort nationwide to harness electronic data for public-health goals like monitoring disease frequency, cancer screening and substance abuse. It follows the Bloomberg administration’s aggressive focus on everyday health concerns — which has included startling anti-smoking advertisements in subways and requirements that chain restaurants post calorie counts — and frequent use of statistics to drive public policy on crime, homelessness and other issues.

And echoing the city’s cash-incentive experiments in the school system, the health department will soon start offering doctors bonuses of perhaps $100 for each patient who hits specified targets like controlling blood pressure or cholesterol, up to $20,000 for each doctor.

In April, the city will begin sending participating doctors report cards on how their preventive efforts compare to their peers’ (only the individual doctor being rated will be named, and the rankings will not be public). A prototype was used in 2007 to send electronic messages warning physicians in the Bronx of an outbreak of Legionnaires’ disease. And the city is currently using the system to track the spread of flu infection in New York City in real time — a much more accurate gauge, doctors say, than a Web tool being developed by Google.

Health maintenance organizations, clinics and hospitals here and elsewhere already use electronic records to communicate; Kaiser Permanente, the giant California H.M.O., has a system much like New York’s. Perhaps the one most similar to New York’s initiative is a demonstration project of the Massachusetts eHealth Collaborative that links doctors in three small suburban and rural communities.

But New York is trying to connect the vast majority of medical practices, which have 10 or fewer doctors, particularly in poorer neighborhoods, in hopes that providing them access to a broader base of patient information — and ranking their performance against their peers — will help them make strides in preventive medicine. The health department is providing subsidies for doctors to subscribe to the system and teams of trainers to support the transition; so far, more than 1 in 10 of the city’s estimated 10,000 primary-care doctors have started using the system, and an additional 500 are in the pipeline.

“We know that at these fancy schmancy systems, they can do these things. But here in New York, we’re trying to do this for the storefront in Harlem,” said Dr. Farzad Mostashari, a health department epidemiologist who is spearheading the New York effort. “As of now, about 2 percent of solo and small practices have electronic health records. This is really hard stuff to do. We have boots on the ground.”

Dr. Mostashari said New York’s system had already attracted interest from President-elect Barack Obama’s transition team; Mr. Obama pledged during his campaign to spend $50 billion over five years on electronic health records.

The system, custom-designed for New York by a Massachusetts company, eClinicalWorks, would cost a typical doctor’s office $45,000 to implement, but city subsidies reduce that to $24,000 for practices with at least 10 percent of their patients on Medicaid or uninsured; those in neighborhoods with the highest poverty rate pay $10,000. The health department is also putting together groups of doctors to share services like calling or sending text messages to patients to remind them of follow-up visits.

The health department has marketed the program most aggressively in three of the city’s poorest areas — Harlem, the South Bronx and central Brooklyn — sending employees to visit every doctor’s office in an effort to enroll them.

Particularly for less experienced doctors, the system provides what Dr. Jesse Singer, a health department records expert, described as CliffsNotes-style advice on how to handle medical problems based on a patient’s age, sex, ethnic background and medical history. It prompts doctors to provide routine tests and vaccinations, advises them on appropriate treatment and medication for certain conditions, and warns of potentially dangerous drug interactions.

To demonstrate, Dr. Singer created a fictional case of a 66-year-old woman with diabetes and a blood pressure of 145/90. The system flagged her blood pressure as too high and offered a pop-up box recommending treatment options. Dr. Singer could then fill out an electronic prescription, which could be printed or transmitted automatically to participating pharmacies.

Two or three weeks later, the data system would prompt the doctor to check whether the patient had filled the prescription, providing boxes to record “compliant” or “noncompliant.” Later, at a glance, doctors can look at how their overall patient base or certain groups are doing on measures like filling prescriptions — studies show that up to 50 percent of all prescriptions are not filled.

The system of tracking issues like diet and medication can be overridden if, for instance, a diabetic patient’s husband is sick and the doctor gives her permission to eat ice cream with him. The software designers found that doctors get annoyed by too many pop-up boxes, and has tried to give them the ability to suppress features they do not like. But, Dr. Singer said, “We can tell if the doctor clicks ‘never mind’ for every patient.”

Last week, Vicky Gianoukakis pored over billing records at Twilight Medical in Washington Heights, the practice that her husband, Nicholas Gianoukakis — Dr. Nick to his patients — started earlier this year. Two employees from the health department were on hand to troubleshoot.

Medicare steps up fight against medical-equipment fraud

Medicare has canceled the billing privileges of 1,139 suppliers of durable medical equipment in the Miami and Los Angeles areas after the companies failed to resubmit necessary documents. The CMS on Monday also issued a rule requiring suppliers to secure a $50,000 surety bond. The rule "is another tool in our toolbox to help us fight Medicare fraud," said Kimberly Brandt, the agency's director of program integrity. Bloomberg (12/29) Wall Street Journal (free content), The (12/29)

Allscripts Sells Physicians Interactive Business Unit to Investment Firm

CHICAGO -- Allscripts Healthcare Solutions, Inc., the leading provider of clinical software, connectivity and information solutions that physicians use to improve healthcare, announced today it has signed a definitive agreement to sell its Physicians Interactive(R) business unit to a fund managed by Perseus, L.L.C., a merchant bank and private equity fund management company.

The transaction is scheduled to close on or about October 3, 2008, subject to customary closing conditions.

Physicians Interactive develops online clinical education programs that enable life sciences companies to reach physicians. The company's free, online solutions for healthcare providers deliver timely clinical information and educational programs while building an electronic dialogue between physicians and life sciences companies.

The acquisition by Perseus Acquisitions Holdings LLC will allow Physicians Interactive to continue to grow its business and more aggressively invest in new opportunities that expand and build upon its current product portfolio. The transaction will allow Allscripts to focus on its core business of providing information and connectivity solutions to physicians and hospitals, which continues to grow. The pending merger of Allscripts with Misys Healthcare would create a new company with a client base of nearly one-third of the practicing physicians in America.

"This is a win-win for Allscripts and Physicians Interactive," said Glen Tullman, Chief Executive Officer of Allscripts. "The sale of Physicians Interactive is an important step that will enable Allscripts to concentrate our resources on achieving our goals, while providing Physicians Interactive the right opportunity to continue to develop its set of solutions."

"We are very excited to acquire Physicians Interactive," said Norman Selby, Senior Managing Director of Perseus, LLC. "We plan to build on the strengths that Physicians Interactive already has and invest aggressively to increase the value it provides to physicians, nurses and other healthcare providers, and the pharmaceutical, biotech and medical device companies that want to reach them. Our goal is to create a company that has the leading suite of alternative channel marketing and sales products and programs to serve pharmaceutical, biotech and device customers, including direct mail, eDetailing, video detailing, eCME, market research, surveys, eSampling, eNewsletters, blogs and social networking."

As part of the transaction, Allscripts President Lee Shapiro will assume a seat on the board of directors of Perseus Acquisitions Holdings LLC.

Additionally, Allscripts and Perseus/Physicians Interactive have signed an agreement to explore innovative and unique offerings that leverage Allscripts strengths as the leading provider of Electronic Health Records and ePrescribing solutions for physicians, and Physicians Interactive's strengths in communicating with and educating providers.

About Perseus

Perseus, L.L.C. is a merchant bank and private equity fund management company with offices in Washington, D.C., New York and Munich. Since its inception in 1995, Perseus has invested in numerous buyout and growth equity transactions in the United States, Canada, and Western Europe. Perseus manages seven investment funds with capital commitments totaling approximately $2.0 billion.

About Physicians Interactive

Physicians Interactive builds an electronic dialogue with healthcare professionals by utilizing technology platforms and online interactive programs to deliver valuable education and promotion about medical products and disease states. Since 1996, Physicians Interactive has developed over 950 online programs for more than 150 brands throughout every stage of the product life cycle. Physicians Interactive's client list includes nearly 75 pharmaceutical, biotech, and medical device companies, including nine of the top 10 worldwide pharmaceutical corporations. For more information, visit www.physiciansinteractive.com.

About Allscripts

Allscripts (NASDAQ:MDRX) is the leading provider of clinical software, connectivity and information solutions that physicians use to improve healthcare. The company's unique solutions inform, connect and transform healthcare, delivering improved care at lower cost. More than 40,000 physicians and thousands of other healthcare professionals in clinics, hospitals and extended care facilities nationwide utilize Allscripts to automate everyday tasks such as writing prescriptions, documenting patient care, managing billing and scheduling, and safely discharging patients, as well as to connect with key information and stakeholders in the healthcare system. To learn more, visit Allscripts at www.allscripts.com.