Payers & Providers California Edition – Issue of May 3, 2012

8/2/2019 Payers & Providers California Edition Issue of May 3, 2012

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Calendar

3 May 2012

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the details of your event, or call(877) 248-2360, ext. 3. It will be

published in the Calendar section,space permitting.

California Edition

Californias hospitals and a leading laborunion struck an agreement to kill twocontentious voter initiatives that were well ontheir way to placement on the November

ballot.In what they are calling a visionaryagreement, the SEIU-United HealthcareWorkers West and the California HospitalAssociation announced Wednesday theywould collaborate on issues affectinghealthcare costs and quality, although the two-page pact they released was short on specics.

But in lieu of the agreement, the SEIU-UHW abandoned its effort to put before votersthis fall initiatives that would have impactedhospital charges and charity care if approved.

The union had already spent millions ofdollars to gather signatures for the initiatives,

which would have placed a minimum

oor onhospital charity care spending and a ceiling onhow much facilities could charge forproviding services. The CHA had pledged anequally expensive ght to make sure neitherpassed voter muster.

We made clear we would mount a veryaggressive opposition campaign, said JanEmerson-Shea, the CHAs vice president ofexternal communications.

Although the debate aboutuncompensated and charity care has reached

a national level after numerous reports offacilities providing community benets atlevels far below the value of their taxexemptions, the ballot initiatives had drawnre from the hospital sector for selectivelyexempting either for-prot facilities or those

with long-term union contracts in place. Areport by the states Legislative Analyst alsopredicted the passage of both initiatives couldlead to hospital closures.

The SEIU-UHW had gathered about850,000 signatures apiece for the initiatives.They were in the process of being veried bycounty clerks throughout California when thetwo parties said they had reached theagreement.

We had enough signatures to get thisqualied, said SEIU-UHW Communications

Director Steven Trossman, who added thatabout 550,000 signatures apiece wererequired to do so. But this gives us anopportunity to work on a much, much broaderange of problems. Ultimately, (the signaturegathering) ended up being a better investmentby many times over.

Both the SEIU and the CHA said theywould enter into discussions to replace or

May 23-25

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In Brief

KFF Projects $1.3 BillionIn Insurance Rebates

The Menlo Park-based Kaiser FamilyFoundation has estimated thatconsumers and businesses will

receive about $1.3 billion in rebateslater this year from health insurersthat spent more on administrativeexpenses than permitted under thePatient Protection and AffordableCare Act.

The large group market isexpected to reap the most money:$541 million. The individual marketwill receive $426 million, and thesmall group market will receive $377million.

Altogether, about 31% of thoseconsumers who purchased individualpolicies will receive a rebate,followed by 28% of the small groupmarket and 19% of the large group

market.Texas is expected to rebate thelargest amount, $186 million,followed by Florida, at $148 million.Data for California was unavailable.

This study shows that askinginsurance companies to put more oftheir premium dollar towards patientcare rather than administration andprots is not only popular but alsoeffective," said KFF President andCEO Drew Altman. There aretangible benets for consumers andemployers.

L.A. Care Health PlanWins EPA Asthma

Award

L.A. Care Health Plan, the Medi-Calmanaged care insurer for Los AngelesCounty, has won an award from theU.S. Environmental ProtectionAgency for its asthma care programs.

The L.A. Care program, knownas L.A. Cares About Asthma, buildson collaborations with community-

Continued on Page 3

NEWS

improve the current hospital pricing systemand protect the neediest patients by

addressing uncompensated care in hospitalsin a manner that accounts for low Medicareand Medi-Cal payments, a joint statementsaid. And according to Emerson-Shea, theCHA would try and open up communicationsbetween the SEIU and its member hospitalsthat were not unionized. The SEIU has thegoal of allowing up to 100,000 hospitalemployees statewide to vote on union

Federal prosecutors unsealed on Wednesdaysweeping indictments of more than 100 clinicoperators, durable medical equipmentbusiness owners and physicians nationwide aspart of an ongoing crackdown on Medicarefraud.

Altogether, 107 individuals are facingprosecution, accused of bilking Medicare ofmore than $452 million. Eight are facingcharges in the Los Angeles area. Indictmentswere also brought against suspects in Miami,Tampa, Chicago, Houston, Detroit and BatonRouge.

These indictments remind us thatMedicare is an attractive target for criminals.But it should also remind those criminals thatthey risk prosecution and prison time everytime they submit a false claim, said AssistantAttorney General Lanny A. Breuer. Ofcials said claims analysis led to mostof the prosecutions.

Those indicted in Southern California areaccused of bilking Medicare of more than $20million.

One of the indictments involves twophysicians, August Ohemeng, M.D. of BuenaPark and George Tarryk, M.D. of Long BeachBoth work at the Pacic Clinic in Long BeachThey are accused of conspiring with the clinimanager and owners of two durable medicalequipment companies of prescribing nearly400 enteral feeding regimens for Medicareenrollees that did not need them, leading toclaims payments totaling about $3 million.

Tarryk had his medical license revoked bthe California Medical Board in 2005 foroverprescribing medications, but therevocation was stayed after he adhered to twoyears of probation.

In three other cases, the suspects wereaccused of submitting false claims forwheelchairs, taking kickbacks for patientreferrals and billing for home health servicesin lieu of providing massages.

In addition to the indictments, theCenters for Medicare and Medicaid Servicesis moving to suspend payments to 52 differencontractors nationwide.

representation by 2015.The CHA would also assist in the unions

Lets Get Healthy California campaign to cuthe states incidences of chronic diseases suchas diabetes.

Both parties had been in preliminarydiscussions for months about some form ofjoint venture, although the inexorable move the initiatives onto the November ballot hadintensied the conversation, Emerson-Sheasaid.

SEIU (Continued from Page One)

Eight Indicted For Medicare FraudL.A.-Area Clinics, DME Businesses Are Implicated

FOLLOW THE MONEY]

CALIFORNIAS HEALTHCARE INDUSTRY ANDPOLTICAL FINANCE

CALL (877) 248-2360, ext. 2 to orderOR CLICK HERE
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Page 3Payers & Providers

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In Brief

based organizations to identifyenvironmental triggers and otherasthma management skills.

L.A. Care was one of fourorganizations to receive the EPAsNational Environmental LeadershipAward in Asthma, and the only healthplan.

The program has been tailoredto be culturally sensitive andresponsive to the needs of the diversepatient population we serve,especially in the most ethnicallydiverse county in the nation, saidElaine Batchlor, M.D., L.A. Careschief medical ofcer.

Health Net ExpandsNarrow Network Health

Plan Into Orange County

Woodland Hills-based insurer HealthNet has expanded its SmartCare

narrow network product into OrangeCounty.

SmartCare, which offers about a25% discount on premiums comparedto a full network, debuted in LosAngeles, San Bernardino and SanDiego Counties last March. Itsattracted more than 200 medium-sized employer groups to date.

It has proven to be popular withemployers seeking aneasy to use plan that delivers moreaffordable value, said Steve Sell,president of Health Nets westernregion.

Altogether, Health Net hascontracted with nine medical groupsin Orange County to provide care. Ithas contracted with 40 medicalgroups in the four counties where itoffers the product.

We believe thatSmartCares strategic alliances andfocus on promoting healthy habits willhelp improve the patient experienceand help keep costs affordable formembers, said Dan Frank, chiefexecutive ofcer ofProspect MedicalGroup, one of Health Nets contractedproviders.

NEWS

Prime Stent Care Under ScrutinyReport Suggests Desert Valley Pushed Procedure

Ontario-based hospital operator PrimeHealthcare Services has drawn scrutiny forcardiac stent procedures performed at 83-

bed Desert Valley Hospital in Victorville.According to the investigativejournalism website California Watch, DesertValley performed four times as many heartstent implants as the typical hospital inCalifornia with a limited heart care license.Desert Valley was fully licensed by stateregulators last March. The CaliforniaDepartment of Public Health said in astatement that the hospital passed twoinspections prior to its granting of fulllicensure.

Under a limited license, Desert Valleywas only able to perform stent procedures

during emergencies. California Watch

uncovered four incidents of stents beinginserted in non-emergency situations that ledto patient death or injury. Two patients died,

and one injured patient was in need of a hearttransplant.State health inspectors have cited Desert

Valley four times for cardiac care lapses since2007, including a 2008 incident involving thedeath of a relatively healthy 72-year-oldpatient. Regulators uncovered at least 18incidents where stents were implanted at thehospital outside of the purview for a facilitywith a limited license.

However, data analyzed by CaliforniaWatch also reported that patient deaths at thehospital for stents are within the statewideaverage mortality rates. A Prime spokesman

said stent procedures can be unpredictable.

HEALTHCARES BEST ADVERTISING VALU]

PAYERS & PROVIDERS reaches 5,000 hospital, health plan and noprot executives statewide. There is no better venue for marketin

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CALL (877) 248-2360, ext. 2OR CLICK HERE

Molina Reports Improved EarningsModest Gains In Income, Big Boost in Revenue

Long Beach-based Medicaid managed careinsurer Molina Healthcare reported slightlyhigher earnings and signicantly morerevenue for the rst quarter of 2012,attributable in part to growth of newprograms in California.

Molina reported net income of $18.1million for the rst quarter of 2012, upabout 4% from the $17.4 million reportedduring the rst quarter of 2011. Revenuewas $1.37 billion, up about 23% from the$1.11 billion during the year-ago quarter.

Molina Chief Executive Ofcer J. MarioMolina, M.D. attributed the revenue growth

to the movement of Seniors and PersonsWith Disabilities in California to managedcare. Enrollment in that program more than

doubled, from 14,000 at the end of March2011 to 37,000 at the end of March 2012.That overall population for Molina in ninestates grew more than 60%, from 155,600 inMarch 2011 to 246,000 in March 2012.

California health plan revenue has grownnearly 20% since the rst quarter of 2011,Molina said. Our revenue growth in Texas iseven more dramatic. With the regional andbenet expansions that were effective March1, 2012, our Texas health plan added nearly125,000 members and $900 million inannualized revenue. Enrollment in the LoneStar State grew from 128,000 in March 2011

to 280,000 in March 2012.The company reiterated its 2012 earnings

guidance of $1.75 per share.
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Payers & Providers PageOPINION

Keeping Score On Patient RatingsDespite Provider Misgivings, They Carry More Weigh

Robert Wachter, M.D, is the associate

chairman of the department of medicine a

the UC San Francisco.

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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

!

local physician members. I t is the network providing healthcare and administering benef its for HMO members in Marinmedicaland administrat ivestaff dedicated to ensuring that youreceive the highest quality health careavailable.

UTILIZATION REVIEW NURSE SUPERVISOR

Novato, CA

Job Summary: Th is pos i t ion sup e rv ise s U/R and Case Management act ivit ies for commerc ia l and Medicare enroll-ees. Candida te must be know ledgeable about Nurse Pract iceAct, JCAHO, NCQA, HMO and Medicare rules, pert inent sta te/federal regula t ions, and hold a current , unrestr icted CaliforniaRegistered Nurselicense .

Principal Accountabilities: Plans, organizes , and overseesUR Nurses to provide day-to-day oversight for UR act ivit ies .Evaluatesaccuracy, productivity, timelinessand ensurescustomersa t isfact ion. Demonstra tes a comprehensive understanding ofcontracts, including division of financial responsibili ty regardingmaking UR determinations. Possessesability to research medicalnecessity criteriaand maintain current knowledge of UR, Medicaland Risk Management Policies. Ensures collabora t ion betweenBenefits Coordinatorsand URRNs. Ensures organizationaladher-ence to ICE, NCQA and health plan regulatory requirements,andmaintainsclinicalskilland knowledge necessary to set standards.Assists w ith ident ifying pat terns and trends, and develops andimplementscorrectiveactions when necessary. Reviews referral/service requests on assigned pat ients in accordance with NCQAtimelinessstandardsand health plan benefit structure. Educatesand supports members in accessing care using their HMO ben-efits. Ident ifies and refers pat ients to disease management andWellness Programs when relevant . Assesses members physical,psychological,social, environmental, financialand funct ionalsta-tus, and informs treating physician of clinically relevant findings.Provides complex case management to pat ients consistent withMarin IPA Case Management Policy 029.

Qualifications:Current CaliforniaRN License. Bachelor ScienceDegree , Nursing. Minimum 5 years of superv isory and 7 yearsof clinical experience. Experience required in one or more ofthe follow ing: Ut iliza t ion Management , Health plan, Medicare,

Case

Manage

me

nt.

Ce

r tifica t

ion

in Ca

se

Manage

me

nt,

pre-ferred. Bilingual, Spanish, preferred. Knowledge of health care

and medical procedures. In terpersonal/human rela t ions sk ills.A t tent iveness to de ta il . Superv isory sk il ls inc lud ing t ime lyfeedback. Ab ili ty to priorit ize dut ies and delegate responsibili-t ies. Good clinicaljudgment and crit ical thinking sk ills. Ab ili ty toorganizeand priorit ize workload. Computer li teracy.

To apply, please send your resume in text, .doc or .pdfformat to [email protected]

Please reference job posting: IPA2012-5

Please visit www.LaSalleMedical.com forfurther details and to submit resume

LaSalle Medical Associates is one of the largeIndependent Pract ice Associat ion (IPA ) groups in tIn land Empireand opera tes four (4) pr imary careclics. We are hiring three (3) compassiona te, missiooriented, board eligible physicians in Family MedicinInternal Medicine,and Pedia tr ics. Candida tes must commit ted to serv ing a diverse popula t ion w ith coutesy and respect. Our clinicsare posit ive workenviroments w ith a fully staffed support team. Join usshare your passion for pa t ient careand diversity .

Job Location for positions: San Bernardino, CA andor Hesperia CA.

Our benefit package includes:

Compet it ive Base Salary

Malpract icecoverage(provided by CAP-Coopera t ive of American Physicians)

9 Paid Holidays

Medical/Dental/L ifecoverage

401(k)Ret irement Plan

Interested candidatesmay fax their CV to (909)380-802or [email protected]

PRIMARY CARE PHYSICIAN

INLAND EMPIRE


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

It costs up to $27,000 to fill a healthcare job*

will do it for a lot less.

Employment listings begin at just $1.65 a word

Call (877) 248-2360, ext. 2Or e-mail: [email protected]

Or visit: www.payersandproviders.com

*New England Journal of Medicine, 2004.

SEEKING A NEW POSITION?

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Documents

Payers & Providers California Edition – Issue of May 3, 2012