Practice Beat

By Joan R. Rose, Senior Editor

Coding: "Black box" edits: HCFA throws in the towel

Beginning with physician services performed on or after Sept. 5, 2000, so-called "black box edits" will no longer be applied to Medicare claims. The Health Care Financing Administration has not renewed its contract with the software vendor McKessonHBOC (formerly HBO & Company).

The 2-year-old program was controversial from the outset, because neither the carriers nor the company would disclose the reasons for claim rejections based on those edits. The company contended that the information was proprietary, and that its contract with HCFA prohibited disclosure.

In a memo to Medicare carriers, HCFA advised them that "all commercial (HBOC) edits have been deleted from [the Correct Coding Initiative]" file that carriers use to review claims. But "carriers need not search their files either to retract payment or to retroactively pay claims for deleted CCI edits."

If, however, you believe a claim has been rejected based on the secret edits, you may be able to get an adjustment—if you can provide information indicating that the services were unrelated and separately payable.

Although HCFA hasn't explained its reasons for ending the program, it's been reported that the projected savings never materialized.

Medicare PROs: Will Uncle Sam make it easier for patients to sue you? HCFA says No

Federal law requires peer review organizations to investigate Medicare patients' complaints about quality of care and to inform complainants of the final disposition of their cases. However, PROs are prohibited from identifying physicians—unless the doctor agrees.

Recent news accounts of a case heard in US District Court of the District of Columbia suggested that the Feds plan to drop the physician consent requirement, increasing doctors' malpractice risk. Not so, says HCFA—at least, not in the immediate future.

As part of its offer to settle the lawsuit, however, HCFA will rewrite the instructions in the PRO manual to make it clear that although review agencies are required to disclose their key findings, they aren't obligated to name the doctors involved. In the case tried in the DC court, a PRO had refused to disclose its findings, citing the physician's refusal to consent.

In addition to the manual changes, HCFA says, there's a possibility that, later this year, the government will propose a rule change to drop the physician consent requirement. Before a change could take place, though, HHS would have to publish a Notice of Public Rulemaking. That move would solicit comments from all those who would be affected by the change—physicians and patients alike.

Docket Watch: Court: A doctor can't be fired for wanting the best for his patient

A California appellate court has reinstated a physician's wrongful-termination suit against his employer, noting that the state's Business and Professions Code protects physicians and surgeons from being penalized "for advocating for medically appropriate health care."

A trial court had dismissed the suit after concluding that the law applied only to advocacy in disputes with a health care payer. But the appellate court found that the language of the statute "plainly demonstrates that it protects physicians and surgeons from termination or penalty" resulting from their efforts to provide appropriate care.

The suit arose when Feather River Anesthesia Medical Group fired anesthesiologist Nosrat Khajavi, who was about five months into his one-year employment contract. According to court records, Khajavi was preparing to administer anesthesia to an elderly cataract patient when he noticed that she was in atrial fibrillation. He notified ophthalmologist Robert Del Pero, who advised him that the patient was already being treated for an irregular heartbeat.

Based on the surgeon's assurance, Khajavi administered the sedative. But before surgery began, Khajavi learned from the patient's primary physician that the woman had never been treated for an irregular heartbeat. That doctor ordered Khajavi to "cancel the case" and send the patient directly to his office. Khajavi then told Del Pero that he didn't think surgery was in the patient's best interest; Del Pero insisted otherwise. The two had a heated argument—overheard by staff and patients—and Khajavi refused to participate in the surgery.

The ophthalmologist related the incident to his brother, Richard, who was also Feather River's president. A short time later, the group's shareholders voted to terminate Khajavi's contract. Feather River members testified that concerns over the amount of work available required that they let one doctor go, and Khajavi was chosen because he was the only one with negative marks on his record. Khajavi, however, pointed to statements by shareholders suggesting that his disagreement with Del Pero was the reason for his termination.

The appellate court remanded Khajavi's wrongful termination case to trial.

The Election: Voters have their say on health care

While health care wasn't a determining factor in the presidential election, voters in several states addressed a variety of issues.

Initiatives in Massachusetts and Maine were narrowly defeated. The electorate in the Bay State rejected a referendum that would have required the state to provide health coverage for every resident by July 2002. The Massachusetts Medical Society had opposed the measure, noting that its patient-protection provisions were not as far-reaching as those in a new law already on the books.

Voters in Maine, meanwhile, quashed an effort to legalize physician-assisted suicide. The state medical, osteopathic, and psychiatric associations were part of a coalition that opposed the proposed law. The group claimed it was "dangerous, fatally flawed, and littered with loopholes."

Of the five states that considered measures to use tobacco taxes to expand health care services, Oregon rejected the idea, while Arizona, Arkansas, Montana, and Oklahoma approved it. And two states—Colorado and Nevada—voted in favor of legalizing marijuana for medical purposes.

 

Joan Rose. Practice Beat. Medical Economics 2001;2:19.