Volume Six Number Three March 2004 Published Monthly INSIDE Leadership letter Sites & scenes On the calendar A little Medicare relief Special Report: Revis- iting an omnipresent framework Special Report: Proposed Guidelines signal future directions Steve Ortquist on the Compliance Institute CEO’s letter Auditing physical rehabilitation services HIPAA security Overcrowding crisis CT 2003 index New members Steve Ortquist discusses HCCA’s upcoming Compliance Institute 2 3 3 4 6 9 16 18 20 27 30 33 35 REGISTER TODAY! FOR THE HCCA COMPLIANCE INSTITUTE, CHICAGO, IL–APR 25-28, 2004 - For registration info go to the HCCA Website, www.hcca- info.org, or see page 39 of this issue. INSIDE
36
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INSIDE · 2012. 4. 18. · 2 HCCB CEUs) HIPAA Forum Digital Reference CD (with 20 HCCB CEUs) Physician Group Practices Compliance Conference (with 3.6 HCCB CEUs) HCCA • 888-580-8373
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Transcript
Volume SixNumber T h r e e
March 2004Published Monthly
INSIDELeadership letterSites & scenesOn the calendarA little Medicare reliefSpecial Report: Revis-iting an omnipresentf r a m e w o r kSpecial Report:Proposed Guidelinessignal future directionsSteve Ortquist on theCompliance InstituteCEO’s letterAuditing physicalrehabilitation servicesHIPAA securityOvercrowding crisisCT 2003 indexNew members
Steve Ortquistd i s c u s s e sH C C A’s u p c o m i n gC o m p l i a n c eI n s t i t u t e
23346
9
16
1820
27303335
REGISTER TODAY!FOR THE HCCA COMPLIANCE INSTITUTE, CHICAGO, IL–APR 25-28,2 0 0 4 - For registration info go to the HCCA Website, www.hcca-info.org, or see page 39 of this issue.
INSIDE
HCCA exists to champion ethicalpractice and compliance standards in the health care community and
to provide the necessary resources for compliance professionals and others who share these principles.
DearColleagues:
“What have we done for you lately?” is a
good daily motivational question for those
of us in a leadership role of HCCA. Often
times the efforts of individual HCCA
Sheryl Vacca assumed the
office of President in 2002,
she found herself immersed
in the management of the
transition. She, along with
Greg spent countless hours
working with Roy Snell and
Dan Roach to set up an
AL JOSEPHSHCCA President
HCCA’SM I S S I O N
2March 2004
board members, staff, or members go without notice, because
they quietly go about the business of getting things done. As I
began this year, I found the responsibilities of the President
include the assignment of projects and responsibilities to vari-
ous board members. I quickly discovered that HCCA has a
“gold mine” of resources in our board, membership, and staff.
We all work together as an effective team, and it is always
difficult to single out any individual for his or her contribu-
tion without first recognizing the support of the team.
During my short tenure as President I have been asked
numerous times, “how can I become a member of the HCCA
Board?” or “How can I become a Board Officer?” My answer
has been and will always be, “Become involved, work hard,
and it will happen”.
At the risk of leaving someone out, I want to share with you
what I think is the “behind the scenes” story of the efforts of
several members of HCCA. As we all know, we each find our-
selves where we are today, in a large part, as the result of what
we did yesterday. If we reflect back on HCCA’s yesterdays to a
board meeting in 2001, the topic of self-management (hiring
a CEO and our own staff to run the association, as opposed
to an association management company) was raised by then
President Greg Warner. The plans were laid that day for a
project that would take a full three years to complete. As
office in Minnesota. There is not space in this newsletter to
recount the details of contract negotiations, equipment pur-
chases, records transfers, and on and on and on…….. Then
Alan Yuspeh’s leadership brought us through the first full year
of operations. In addition, if you were to review the many
other efforts these individuals made during those years, your
first question would have to be; “Where did they find the
time?” One other individual that has worked tirelessly since
the beginning of the Association and, in fact was the recipi-
ent of the HCCA Pinnacle Award, is Debbie Troklus. She did
not retire after receiving that award for her tremendous con-
tributions to HCCA. Since her year as President, Debbie
continues to be the “go to” person for education and training
and has been instrumental in the development of many of
the HCCA educational products and publications. And
simply stated, the HCCB would not exist today without
Debbie’s leadership.
This provides a highlight of only a few of the leaders of
HCCA. Trust me, there are many more. If you want to know
how to become involved and work hard, ask Greg, Sheryl,
Dan, Alan, Roy, Debbie, or any other member of the HCCA
Board. Odell Guyton shared a quote with me the other day
which is fitting here: “We are standing on the shoulders of
giants”. I’ll close by again answering the questions of “How
can I become a member of the HCCA Board?” and “How
can I become a Board Officer?” by simply saying “Become
involved, work hard and it will happen!” ■
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
HCCA • 5780 LINCOLN DRIVE, SUITE 120 • MINNEAPOLIS, MN 55436
3March 2004
R E S O U R C E S
T H E C A L E N D A RONON
HCCAHCCA
2004
CONFER-
ENCES:
(See page 5 for upcoming
audioconferences)
ANCHORAGE, AK■ JUL 22-23, Alaska Area
Meeting
LOS ANGELES, CA■ JUL 16, (Date Changed)
Southwest Area Meeting
WASHINGTON, DC■ MAY 21, Northeast Area
Meeting
ORLANDO, FL■ OCT 22, Southeast Area
Meeting
ATLANTA, GA■ MAR 26, Southeast Area
Meeting
CHICAGO, IL■ APR 25-28, HCCA
Compliance Institute ■ SEPT 17, North Central Area
Meeting
BOSTON, MA■ SEPT 10, New England Area
Meeting
BALTIMORE, MD■ MAR 1-4, Advanced
Compliance Academy
MINNEAPOLIS, MN■ MAY 24, Upper Midwest Area
Meeting
KANSAS CITY, MO■ AUG 6, Midwest Area
Meeting
LAS VEGAS, NV■ NOV 5, Southwest Area
Meeting
NEW YORK, NY■ NOV 15, Mid Atlantic Area
Meeting
PHILADELPHIA, PA■ OCT 15, Northeast Area
Meeting
SALT LAKE CITY, UT■ SEPT 13, Mountain Area
Meeting
SEATTLE, WA■ JUN 4, Pacific Area
Meeting ■
For more information about eventsor resources, check out the HCCAWebsite, h t t p : / / w w w. h c c a - i n f o . o r gor call 888/580-8373.■ Monitoring & Auditing Prac-
tices for Effective Compliance■ H C C A’s Compliance, Consci-
ence, and Conduct™, a video-based compliance training p r o g r a m
■ HCCA’s book, Compliance 101■ Individual & Small Group
Physician Practice Compliance:
What every physician shouldknow
■ Privacy Matters–HCCA’s video-based HIPAA Training Program
HCCA’s CD Videos - ■ Alice Gosfield-Unplugged (with
2 HCCB CEUs)■ HIPAA Forum Digital Reference
CD (with 20 HCCB CEUs)■ Physician Group Practices
Compliance Conference (with3.6 HCCB CEUs) ■
HCCA • 888-580-8373 • www.hcca-info.org
& S C E N E SSITESSITES from the january board meeting
N E W S F L A S H: Compliance among Top 10 hot executive jobsThe ranking, according to a December 3, 2003 press release fro m
Christian & Timbers, says the 10 Hot Exe c u t i ve Jobs in 2004 are :1. Board director at public company2. Human resource director: tech or health care3. Executive VP of sales4. Executive at medical devices company5. Campaign managers6. Chief nursing officer7. Chief ethics officer8. Chief compliance officer9. VP data mining10. EVP at national security/DOD consulting companyFor more information, go to:http://www.ctnet.com/pr/releaseDetails.asp?prid=256<http://eccn.c.tep1.com/maabUeyaa325ja8YhGVe/> andhttp://wwwctnet.com/pr/studies/hotjobs2004/pfversion.html<http://twcc.c.tep1.com/maabUtlaa34T2a78pgie/> ■
4March 2004
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
s e rvices? Since such providers are not
e m p l oyees, how is the medical group to
re c e i ve payment from Me d i c a re dire c t l y,
rather than have the funds paid to the
physician? Essentially, the answer is that
the group cannot have the benefits re a s-
signed and paid directly from Me d i c a re .
In practice, the medical group seeks to
collect the Me d i c a re re i m b u r s e m e n t s
f rom the independent contractor physi-
cian directly; not always an efficient and
e f f e c t i ve pro c e d u re .
A l t e r n a t i ve l y, the Me d i c a re Ca r r i e r’s
Ma n u a l p rovides, in Section 3060.11,
that payments can be made to the physi-
cian via a bank account, so long as only
the physician has control over the bank
account and the bank is not otherw i s e
p roviding financing to the physician.
Again, this is not an error free pro c e-
d u re. The physician still has control ove r
the funds in the bank account and can
abscond with the funds at any time
without turning them over to the med-
ical gro u p. As a pro t e c t i ve measure ,
medical groups can establish the bank
account as a “ze ro balance” account,
meaning that the contents of the bank
account will be transferred daily to the
medical gro u p’s account. The medical
g roup can further protect itself by hav-
ing a contract with the physician where-
by the physician agrees to assign all
accounts re c e i vable for his services, and
set up and transfer the contents of the
ze ro balance account. This is a complicat-
ed process, and is often misunderstood
by Me d i c a re re p re s e n t a t i ves, the medical
g roups, and the physician.
Howe ver the new Me d i c a re legislation
amends 42 U.S.C. §1395u(b)(6)(A) by
revising the entities entitled to re c e i ve
reassigned Me d i c a re benefits. The
reassignment exception to the facility is
amended to state that payment can be
made to the entity “when the service was
p rovided under a contractual arrange-
m e n t” between the physician and anoth-
er entity, if under the contractual
arrangement, the entity bills for the
p rov i d e r’s services. The addition of the
“contractual arrangement” language is
c rucial. It is what now allows an inde-
pendent contractor to directly re a s s i g n
Me d i c a re benefits to the medical gro u p.
T h e re f o re, if a physician contracts with a
medical group to provide services, the
Me d i c a re benefits for those services can
n ow be reassigned to the medical gro u p
as the entity entitled to bill for the
s e rvices. This is a huge relief for medical
g roups across the country trying to hire
p roviders in a market where only inde-
pendent contractors are available. Now,
the expense and inconvenience of finan-
cially collecting Me d i c a re accounts
re c e i vable paid to an independent
c o n t r a c t o r, or setting up ze ro balance
bank accounts, is obviated. All Me d i c a re
benefits can be reassigned directly to the
medical gro u p.
Also, this particular provision of H.R. 1
is effective upon enactment. However,
it is subject to the Secretary of Health
maintaining “program integrity and
other safeguards.” Naturally these latter
terms have yet to be defined by either
Congress or Medicare. ■
Ed i t o r’s note: Clare Stebbing is staff attor-
ney for Team Health Anesthesia Ma n a g e -
ment Se rvices, Inc. in San Diego, CA. Sh e
may be reached at 858/277-4767.
he recent Medicare reform
legislation, the Medicare
Prescription Drug and
Modernization Act of 2003 (H.R. 1),
signed on December 8, 2003, by
President Bush, does much more than
establish a prescription drug benefit
under the current Me d i c a re laws and
guidelines. The Act includes an amend-
ment that could dramatically affect how
physicians and medical groups are paid
by Me d i c a re for their services. Prior to
the enactment of H.R. 1, Me d i c a re
would only reassign Me d i c a re benefits
d i rectly to the physician’s employer (as a
condition of employment) or to the facil-
ity when a facility contracted dire c t l y
with the physician. Other exceptions to
the general prohibition on re a s s i g n m e n t
of Me d i c a re benefits included payments
to an organized health care delive ry sys-
tem and payments to a physician for pur-
chased diagnostic tests. Thus physicians
e m p l oyed by a medical group could re a s-
sign Me d i c a re benefits directly to their
e m p l oyer medical group if it was a condi-
tion of employment.
But what about physicians hired by the
medical group as independent contrac-
tors and paid on a per diem basis for their
By Clare Stebbing
T
5March 2004
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Get the latest “ how to” information–tools you can imple-ment–without even leaving your office! Register on theHCCA Website–www.hcca- info.org. Once payment isreceived you are registered and will receive an email a fewdays before the conference with any conference handoutsand contact phone number and instructions.
➤ ➤ Anatomy of a Fraud InvestigationSpeakers: Gabe Imperato and Dan SmallFebruary 25 and 26
➤ ➤ HIPAA Secur itySpeakers: Frank Bresz, Michael McDermand and Nancy ScottMarch 10 and 12
➤ ➤ Pr ivacy LitigationSpeakers: Edward Shay and Ronald LevineMarch 23 and 24
➤ ➤ HIPAA Research Repositor iesSpeakers: Linda Malek and Marti ArvinApr il 6
➤ ➤ JCAHO and Pr ivacySpeakers: John Knapp and Joette HannaApr il 8 and 9
Be on the lookout for :
➤ ➤ Stark Final RulesSpeakers: Lisa Murtha, Dan Roach, John Knapp, and Roy Jaffe
➤ ➤ Coding and Documentation: Anesthesiology and Cr itical Care
➤ ➤ Surgical Documenting and Coding
March 2004
6 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
By Becky Sutherland Cornett, Ph.D., CHC
P
Text continued on page 27
21Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
EXHIBIT A: Audit Template for Inpatient Rehabilitation Services
Source Documents: CMS Publication 100-2, Medicare Benefit Policy and Draft LCD for Inpatient Rehabilitation (Draft PMR-1-003),Adminastar Federal, Inc.
Patient’s Name: MRN: Physician: Service: Reviewer’s Name: Date of Review:
Rehabilitation hospital care criteriaPatients needing inpatient rehabilitation services must require a hospital level of care. Rehabilitation care in a hospital is reasonable andnecessary for a patient who requires a more coordinated, intensive program of multiple services than is ordinarily available outside of ahospital. To qualify for a Medicare inpatient rehabilitation admission, the patient must meet two basic requirements: 1. The services must be reasonable and necessary (in terms of efficacy, duration, frequency, and amount) for the treatment of the patient’s
condition; and2. It must be reasonable and necessary to furnish the care on an inpatient hospital basis, rather than in a less intensive facility such as a
SNF, or on an outpatient basis.
Inpatient rehabilitation in a hospital setting will be considered medically reasonable and necessary if: ■ there is a reasonable expectation of measurable improvement that will be of practical value to the patient within a predictable and rea-
sonable period of time, and ■ the patient requires the active and ongoing therapeutic interventions of at least two disciplines (physical therapy [PT], rehabilitation
nursing, occupational therapy [OT], speech-language pathology services (also referred to as “speech therapy” in some Medicare docu-ments), psychology, social work, and prosthetics/orthotics, one of which must be a therapy, acting in a coordination fashion, and
■ the patient requires and can tolerate a least three hours per day of skilled therapy at least five days per week, or, in the instance of amedical condition that limits participation, an equivalent amount of combined therapy, medical, and nursing care, and
■ the therapy cannot be provided in a less intensive setting due to the need for 24-hour per day access to a registered nurse (RN) withspecialized training in rehabilitation or a need for frequent physician assessment or intervention due to a significant risk of rapid dete-rioration of physical or mental status, or the need for specialized equipment at such a frequency and duration so that it is impracticalfor the patient to use the equipment in an outpatient facility.
The patient meets criteria to qualify for a hospital-level-of-care. ❏ Yes ❏ No Comments:_____
Patients for whom admission was for evaluation Inpatient assessment of individual’s status and potential for rehabilitation (for cases in which hospitalization was focused on intensiveassessment):a) There is evidence in the record of extensive assessment by multiple professionals. ❏ Yes ❏ Nob) If the patient’s stay is longer than 10 days, the record contains evidence that very careful review was conducted to ensure that addition-
al time was necessary for evaluation. ❏ Yes ❏ Noc) If the patient received therapy prior to admission to this hospital for the same condition, it is documented that this evaluation admis-
sion was necessary because: ■ some intervening circumstance rendered such an assessment reasonable and necessary; or■ this hospital uses techniques or technology not previously available in the first hospital.
Close medical supervision, monitoring, and oversight by a physician with specialized training or experience in rehabilitation Patient’s condition must require the 24-hour availability of a physician with special training in rehabilitation. The documentation reflectsfrequent and direct, medically-necessary physician involvement in the patient’s care (at least every 2-3 days during the patient’s stay.) ❏ Yes ❏ No
In order to support the medical necessity of the services, the plan of care must contain the following elements:
March 2004Continued on page 22
EXHIBIT A: continued ■ diagnosis being treated and specific functional problem areas identified■ specific functional goals in measurable terms■ specific treatment modalities or procedures being used for each specific problem to attain the stated goals ■ amount, frequency, and duration of each therapeutic modality■ documentation at initiation of treatment that there is reasonable expectation the patient possesses the rehabilitation potential to meet
the treatment goals
The plan of care documents the required elements. ❏ Yes ❏ NoPhysician progress notes reflect the need for active and ongoing medical management. ❏ Yes ❏ No Comments:_____
The patient requires rehabilitation nursing care on a twenty-four hour basis The patient requires the 24-hour availability of a registered nurse with specialized training in rehabilitation.
Examples of nursing documentation reflecting specialized nursing care: ■ Progress in bowel and bladder continence or regulation following an injury that impacts such functions■ Skin integrity issues, including positioning techniques and weight shifting to prevent pressure areas in relatively immobile patients, and
care for any wounds or areas of already-compromised skin integrity■ Ongoing assessment of nutritional and hydration status in patients who are no longer able to eat and/or drink in the manner to which
they were accustomed■ Ongoing assessment of safety concerns, including not only physical limitations, but also such cognitive functions as memory, judg-
ment, pathfinding skills, and problem-solving abilities■ Educational interventions with the patient and/or family members/caregivers in how to maintain optimal health despite changes in the
way the patient’s body functions. Such interventions may include: training in medical techniques (e.g., tube feedings, tracheostomycare, catheterization), medication administration, bowel and bladder programs, prevention of complications, and planning for follow-up care
■ The patient’s proficiency on the nursing unit with techniques learned in therapy sessions ■ Discharge planning - assisting in the identification of the patient’s special medical needs for after-care
The documentation reflects the patient’s need for 24-hour RN care. ❏ Yes ❏ No Comments:_____
The patient requires a relatively intense level of rehabilitation therapy services The general threshold for establishing the need for inpatient hospital services is 3 hours a day of PT and/or OT, 5 days per week.However, other combinations of therapies, such as speech-language pathology services, or prosthetic/orthotic services, depending uponthe patient’s condition and individual needs, can qualify the patient for the inpatient stay. An inpatient stay can also be covered eventhough the patient has a secondary diagnosis or medical complication that prevents him/her from participating in a program consisting of3 hours of therapy per day. Inpatient hospital care may be the only reasonable means by which even a low intensity rehabilitation pro-gram can be carried out.
Note: the “three hour rule” should not be considered an inflexible “rule of thumb,” but a patient receiving a less intensive schedule oftherapy will require additional documentation to explain why he or she requires an inpatient rehabilitation facility level of care.
The medical record justifies an inpatient rehabilitation level of care, either by demonstrating at least 3 hours per day of therapies (PT, OT,or other combination), or by explaining why a low-level intensity is needed due to complicating factors. ❏ Yes ❏ NoComments:_____
The patient requires a coordinated, multidisciplinary team approach to rehabilitation Documentation should reflect not only the active involvement of multiple clinical disciplines, but also the interdisciplinary nature of theirtreatment. A multidisciplinary team usually includes a physician, rehabilitation nurse, social worker and/or psychologist, and those thera-pists involved in the patient’s care.
Auditing...continued from page 21
March 2004
22
EXHIBIT A: continued Example of interdisciplinary care: a long-term goal of independent bathing may require physical therapy to work on transfer techniques,occupational therapy to work on adaptive mechanisms for washing all body parts, and nursing to assess how well the patient remembersand follows through with these skills outside of therapy sessions.
Documentation demonstrates the team used an interdisciplinary approach to rehabilitation care. ❏ Yes ❏ No Comments:_____
Team conferences Team conferences are held at least every two weeks* to: assess the individual’s progress or problems impeding progress; consider possibleresolutions to problems; and reassess the validity of the rehabilitation goals initially established. Decisions made during such conferences,such as those concerning discharge planning and the need for any adjustment in goals or in the treatment program are recorded in theclinical record. ❏ Yes ❏ No
Note: Although CMS requires the frequency of team conferences to be “at least every two weeks,” more frequent (i.e. weekly)team conferences may be required to effectively demonstrate that the requisite interdisciplinary intensive rehabilitation is beingprovided and the patient is making measurable progress. Comments:_____
The patient demonstrates the potential for significant practical improvement“Practical improvement” is evaluated in the context of individual patient’s physical impairment. For example, practical improvement in apatient with paraplegia might include learning to manage a wheelchair, transfer back and forth from the wheelchair to bed, toilet, etc.,and dress, bathe, and toilet himself independently. For a patient with quadriplegia, however, practical improvement may include learninghow to direct others in his day-to-day care needs, achieve independent mobility with a customized electric wheelchair, and use adaptivedevices such as a mouth-stick or remote control unit to increase independence in controlling the environment.
There must be a reasonable expectation of improvement that will be of practical value to the patient, measured against his condition atthe start of the rehabilitation program. “Significant, practical improvement” in the patient’s condition is evident in the clinical record. ❏ Yes ❏ No Comments:_____
The patient has realistic goals requiring inpatient rehabilitation The most realistic rehabilitation goal for most Medicare beneficiaries is self-care or independence in the activities of daily living; i.e., self-sufficiency in bathing, ambulation, eating, dressing, homemaking, etc., or sufficient improvement to allow a patient to live at home withfamily assistance rather than in an institution. The aim of treatment is achieving the maximum level of function possible within a realistictimeframe.
Goals should be measurable and stated in terms of their functional impact. A goal of ambulating only 2-3 feet without assistance mayappear to be of little functional use to a patient unless it is also noted that he or she lives in a home with no accessible bathroom, thusrequiring the person to leave the wheelchair at the bathroom doorway and ambulate a few steps to the toilet or shower chair.
Both short-term and long-term goals should be documented. If the patient has not made the projected amount of progress between teamconferences, documentation should include the reasons and the plan for changes in the goals or treatment program.
Realistic goals are evident in the clinical record. ❏ Yes ❏ No Comments:_____
Length of rehabilitation program Coverage stops when further progress toward the established rehabilitation goal is unlikely or it can be achieved in a less intensive setting.There is evidence in the clinical record that the team considered all factors when planning discharge, and that the patient’s stay in theintensive rehabilitation setting was appropriate for the patient’s condition, progress made, and suitability of placement in a less-intensivedischarge setting. ❏ Yes ❏ No Comments:_____
Prepared by Becky Sutherland Cornett, Ph.D., CHC, The Ohio State University Medical Center, 1/04
23March 2004
Continued on page 24
March 2004
24 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Auditing...continued from page 23
EXHIBIT B: Outpatient Rehabilitation Services Audit Template INDIVIDUAL RECORD WORKSHEET
Patient Name: MRN: Acct.:Referring Physician: DOS: Today’s Date:Rehabilitation services are designed to improve or restore physical and cognitive functioning following disease, injury, or loss of a bodypart. Impairments, functional limitations, and disabilities are assessed and addressed by the design and implementation of a therapeuticintervention tailored to the specific needs of the individual patient.
Therapy staff Qualified staff members provide PT, OT, and SLP services. ❏ Yes ❏ NoThe services provided are of such a level of complexity and sophistication that such services can be provided safely and effectively only byor under the supervision of a therapist. ❏ Yes ❏ No
Physician certification/approval/supervision All therapy services must be ordered, certified, and supervised by a physician. The physician order (prescription) alone does not consti-tute approval. The physician must certify approval of the plan of care/treatment by reviewing and signing the plan.
All records for Medicare beneficiaries contain the required physician certification. ❏ Yes ❏ NoIf applicable, the physician recertifies the plan of treatment every 30 days. ❏ Yes ❏ No
The written plan of treatment contains the following information: A plan of treatment for each therapy service is established by the physician, or the qualified therapist (PT, SLP, or OT). The physicianmust review and approve the plan and certify the need for treatment as soon as possible after the initial evaluation. ❏ Yes ❏ NoPrimary diagnosis resulting in the therapy disorder. ❏ Yes ❏ NoTreatment diagnosis for which services are rendered. ❏ Yes ❏ No
Initial assessment information - current relevant history; major functional limitations; prior hospitalization and therapy for the samecondition; pertinent baseline tests and measurements from which to judge future progress or lack of progress. Functional limitations aredocumented in terms that are objective and measurable. ❏ Yes ❏ No
Re-evaluations are completed only when a significant change in condition necessitates a revision of the current plan of treatment (re-evaluations are not routine, and are not indicated for all patients). ❏ Yes ❏ No
Long-term treatment goals focus on functional gain geared toward “significant, practical improvement within a reasonable and generallypredictable period of time;” short-term goals state objectives for the monthly billing period. Goals reflect the level of independence thepatient is expected to achieve in the discharge environment. Activities are designed to have a positive effect on the quality of the patient’severyday life. ❏ Yes ❏ No
Specific treatment modalities, activities, or interventions to be used to treat each specific problem are identified. ❏ Yes ❏ No
Type, amount, frequency, and duration of treatment are documented (e.g., PT, 3 times per week for 4 weeks). ❏ Yes ❏ No
Documentation of discharge planning is indicated early in the treatment plan. ❏ Yes ❏ No
The plan is sufficiently detailed to permit an independent evaluation of the patient’s specific need for the indicated services and of thelikelihood that he/she will derive meaningful benefit from the services. ❏ Yes ❏ No
Progress reports Progress notes may be written daily or weekly (however, each session must be documented) and reflect specific progress toward long-termdischarge goals.
25March 2004
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
EXHIBIT B: continued Documentation in the medical record is descriptive, clearly related to functionality, and reflects interaction among the professionalsinvolved. ❏ Yes ❏ No
Timelines are established for short-term goals (2-4 weeks), and reasons for not achieving short-term goals are documented in the record.❏ Yes ❏ No
Documentation includes information about the patient’s prior and current level of function, progress made (or lack thereof) for thisbilling/reporting period; techniques used to achieve goals; the patient’s continued potential to make “significant, practical improvement,”and changes in the plan of treatment. ❏ Yes ❏ No
All adaptive equipment and supplies used (billed) are documented. ❏ Yes ❏ No
Group therapy Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. If the ther-apist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to twoor more patients at the same time, it is appropriate to bill each patient one unit of group therapy - 97150 (untimed code).
When direct one-to-one contact is provided, the therapist bills individual therapy and counts the minutes of therapy provided to eachpatient in order to determine how many units of therapy to bill each patient for timed codes. These direct one-on-one minutes may becontinuous (15 minutes straight) or in notable episodes ( 10 minutes now, 5 minutes later). Each direct one-on-one episode should be ofsufficient length of time to provide the appropriate treatment in accordance with each patient’s plan of care. The manner of practiceshould clearly distinguish from care provided simultaneously to two or more patients.
No more than four (4) patients may participate in a group therapy session conducted by one therapist; 6 patients may participate ifa therapist and one assistant (PT assistant) conducts the session (according to PT LMRP, Adminastar Federal).
Therapy sessions must be conducted by either a qualified therapist or therapist assistant, with appropriate supervision. Medicare will notpay for therapy conducted by therapy aides, regardless of the amount or type of supervision provided.
The -59 modifier is used to bill for both a group therapy session and an individual therapy session in the same day (CCI edit require-ment). The -59 modifier signifies that distinct, separately identifiable services were provided on the same day. CCI edit rules must befollowed (e.g., CPT codes may not be billed together if both codes require one-to-one patient contact or “constant attendance.” Grouptherapy codes may not be billed with individual codes that require constant attendance, etc.).
In a hospital setting, group therapy codes may be billed more than once per day, but sufficient documentation must be provided to deter-mine medical necessity and clinical appropriateness.
Billing issues Specific minutes of therapy provided are recorded in the record (no less than 8 minutes can be provided to bill for one unit - 8 to 22min.= 1 unit; 23-37 minutes = 2 units, etc.). ❏ Yes ❏ NoThe number of minutes recorded is correct and correlates with units of therapy billed. ❏ Yes ❏ NoTherapy codes billed are supported in the clinical record. ❏ Yes ❏ NoPhysician involvement in therapy intervention is evident in the clinical record. ❏ Yes ❏ NoDocumentation is legible, and is authenticated and dated promptly by the person (identified by name and profession), who is responsiblefor ordering, providing, or evaluating the service furnished. ❏ Yes ❏ No
Source documents•Medicare Coverage Guidelines for Medical Review of Hospital Therapy Services, AdminaStar Federal Part A Customer Service Center,9/15/00. •Outpatient Therapy Services Coverage Guidelines, AdminaStar Federal Medical Review Seminar, 6/02.
Continued on page 26
26March 2004
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
the initial evaluation. The initial
evaluation should document the rea-
son therapy has been ordered,
including the history of the injury or
illness. We also need to see that the
services rendered are physician-
approved and the service is reason-
able for the condition being treated.
We look for reduction in pain,
increases in joint movement, ADL
(activities of daily living) ability or
performance, and any other objective
and measurable data.
■ Medicare law requires that the physi-
cian be involved in the beneficiary's
care. An order for therapy does not
necessarily indicate that the physi-
cian is aware of the services you are
providing. The physician's signature
on the plan of treatment indicates
the physician is involved in the bene-
ficiary's treatment and endorses the
plan of treatment and services pro-
vided under that plan. A certification
form alone is insufficient for services
to be covered; there must also be an
associated plan of treatment.
Documentation of treatment goals is
another area of contention. Therapists
often seem to focus on short- and long-
term goals that address impairments,
but struggle to write goals that reflect
the patient's functional improvement
(ability to function in practical, every-
day situations and environments). For
example, an impairment-focused goal
is: "patient will maintain single-leg
stance greater than 5 seconds" or
"patient will be able to match pictures
with printed names with 80%
accuracy." Functional goals include
statements such as "patient will be able
to toilet independently;" "patient will
be able to reach left upper extremity to
shoulder height to comb his hair with-
out assistance" "patient will be able to
take all nutrition and hydration by
mouth."
The following statements have been
found in actual documentation, and
will likely result in denial of services:
"Patient making slow progress, weather
fluctuations affect her." "Saturday was a
good day." "Balance is improving"
(from what to what? No measures
included). "Speech somewhat slurred
today." The World Health
Organization's publication
International Classification of
Functioning, Disability, and Health
(2001) is an excellent source of infor-
mation about treatment goals and activ-
ities that focus on functionality, activi-
ties, and participation in society. Note
particularly the "ICF Checklist" (which
can be downloaded at www.who.int/
classification/icf/checklist/icf-checklist.pdf).
The checklist provides a complete
overview of impairments of body struc-
tures and functions, activity limitations
and participation restrictions, and envi-
ronmental factors that influence the
individual's participation in society.
Checklist items can be easily translated
into a hierarchy of therapy goals and
activities that would "pass" any CMS or
FI audit.
The two audit templates (see Exhibits A
and B) provided with this article are
intended to be both audit tools and
instructional guides because they incor-
porate a synopsis of CMS' rules for
delivery of inpatient (distinct rehabilita-
tion units and freestanding rehabilita-
tion hospitals) and outpatient rehabili-
tation services. Compliance profession-
als, most of whom are not experts in
rehabilitation, can use these tools to
assess rehabilitation departments' com-
pliance with the regulations, while also
providing rehabilitation managers with
easy-to-use guides to improve docu-
mentation and quality of services. ■
Auditing...continued from page 25
EXHIBIT B: continued •Guidelines for Medicare Coverage of Speech-Language Pathology Services, American Speech-Language-Hearing Association, 10/01. •11 FAQs - Post 9/13/02 Open Door on Group Therapy - Centers for Medicare & Medicaid Services (cms.gov website, 9/02). •LMRP - Outpatient Physical Therapy. AdminaStar Federal, Part A News, 6/02. •LMRP - Speech Pathology Services. AdminaStar Federal, 1/01. •Outpatient Physical Therapy - Speech Pathology Survey Report. (CMS Form 1893) 10/99•Plan of Treatment for Outpatient Rehabilitation. CMS Form-700-(11/91). •Outpatient Therapy Services, Frequently Asked Questions. AdminaStar Federal, 1/03. ■
Prepared by: Becky Sutherland.Cornett, Ph.D., CHC, The Ohio State University Medical Center, Rev. 1/04
27March 2004
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Editors note: Eric W. Klavetter, JD, works for the Office for Compliance at
the Mayo Foundation. He may be
reached at 507/266-0195.
ntroductionIn less than 16 months, the
1996 Health Insurance
Portability and Accountability Act
(HIPAA) Security Regulations will be
effective. As institutions recover from
Privacy or continue to work on
Transaction and Code Sets, they are
faced with another question: How do
we deal with HIPAA Security?
As we are all well aware, there are mul-
tiple stages to implementing a regula-
tion: Denial, Anger, Blame, Helpless-
ness, Hopelessness, and then Imple-
mentation. Seriously, there are multiple
approaches with one goal in mind:
Ensuring patient trust by having an
effective and efficient Privacy andSecurity Program.
With numerous implementation
approaches available, the opportunity to
better integrate Privacy and Security is
readily at hand and essential. Frequent-
ly, privacy will set the policy and securi-
ty will enforce it. For example, "mini-
mum necessary" is a privacy standard
and security enforces it through numer-
ous access and authorization schemes,
whereby the users are only able to
access the information they have been
authorized to review or manipulate.
Importance of semanticsAs institutions begin to tackle HIPAA
Security, it is essential to define terms as
quickly and succinctly as possible. For
this article, security is the protection of
people, property, and data. Data securi-
ty's primary components are:
1) Confidentiality through appropriate
access and authorization controls
2) Integrity which ensures data consis-
tency with the source
3) Availability that certifies proper net-
work monitoring, firewall, and a
virus strategy, to name a few
Privacy is ensuring patients can exert
their rights, such as:
1) Requesting an amendment to their
record
2) Requesting alternative communica-
tions
3) Requesting a copy of their protected
health information
4) Right to accounting of disclosures
5) Right to a copy of Notice of Privacy
Practices
6) Right to complain, to name a few
Additionally, privacy implements vari-
ous policies and process for proper use
and disclosure of information, which
ensures patient autonomy.
Institutional integrity is the ethics and
the code of conduct of the institution.
This has been in place since the mid-
90s when most institutions formalized
the standards of honesty, integrity, and
ethical and moral behavior for their
respective institutions. Institutional
Integrity is designed to educate staff
about the current health care environ-
ment, to raise staff awareness of the
Icomplexities of regulatory requirements,
and to provide resources to assist staff
in complying with those requirements.
As such, confidentiality is defined as,
"trust that personal information will be
secure, private, and managed ethically."
Depending on what expert is speaking,
each one of these artful terms can be a
leading component for any institutional
infrastructure. No matter, each institu-
tion's goal is to ensure patient trust;
therefore confidentiality is the leading
component. See Figure 1.
Confidentiality as a serviceConfidentiality is a service that patients
come to expect, which HIPAA has
re-emphasized through various stan-
dards. One unique attribute of this
service is that the patient sets the expec-
tation. We've all interacted with
patients and realize how unique each
one is. At the same time, we can forget
how vulnerable and/or desperate our
patients can be and that it can be or
"is" our fiduciary duty to protect them.
By labeling confidentiality as a service,
it can be incorporated into every aspect
of the institution.
Continued on page 28
By Eric W. Klavetter
28March 2004
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
The confidentiality programBy establishing definitions, defining a
virtual infrastructure as illustrated above
and labeling it as a "service", a confi-
dentiality program begins to take shape.
A confidentiality program can coordi-
nate the various issues, while ensuring
compliance with numerous regulations
and standards. The program can ensure
a consistent strategy that patients can
embrace, employees can promote, and
that leadership can utilize as a resource
when assessing new services, like
Telemedicine and Telecommuting. This
is where the value of the program can
be easily illustrated to leadership, as it
comes in the form of Risk Manage-
ment.
By implementing a clear strategy,
employees and work areas are able to
validate which practices and processes
need to be adjusted, eliminated, or sup-
ported. Often times, simple adjust-
ments can reduce the greatest amount
of risk. For example, assessing the need
for a department name on a return
label can subtly communicate to
employees that every detail is important
and often goes unnoticed by patients.
Necessity of a confidentiality programIn 1999, the California HealthCare
Foundation conducted a survey where-
by they found that computerization of
medical records is seen as the most seri-
ous threat to medical privacy. More
than half of all U.S. adults (54%)... say
the shift from paper record keeping sys-
tems to electronic or computer-based
systems makes it more difficult to keep
personal medical information private
and confidential. Most people consider
electronic piracy–not disclosure of per-
sonal information by medical person-
nel, health plan officials, or other
authorized users–as the bigger threat to
privacy. Nationally, 55% say they worry
more about computer hackers breaking
into a system, while only 30% worry
more about authorized users leaking
information.1
When institutions implement elements
of an electronic medical record (EMR)
or as the field of Genomics evolves, the
questions surrounding confidentiality
arise and can be effectively addressed
through a successful confidentiality pro-
gram. Once patients begin to under-
stand the societal benefits of Genomics
HIPAA Security...continued from page 27
Administrative Safeguards
StandardNumber Standard Implementation Specifications
(R)=Required ( A ) = Ad d re s s a b l eHospital A'sEnvironment
ComplianceGAP
1Security
ManagementProcess
Re: InformationSecurity Policies andStandards:
Other groups thatemploy risk analysis:• Internal Audit
Services• IT• Physical Security • Risk Office
(R)Risk Analysis
FIGURE 2
CONFIDENTIALITY
INTEGRITY/ETHICS PRIVACY SECURITY
Relationshipwith industry
Fraud & Abuse
Code of Conduct
Use of confidentialinformation
Disclosure of confi-dential information
Patient rights
Protection ofpersons
Protection ofdata
Availability
Integrity
Confidentiality
Authorizationcontrols
Access controls
Network
Database
Application
Data consistency
FIGURE 1
29March 2004
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
or the improvements of care through
EMRs, patients will participate with lit-
tle reservation.
Security dashboardOne way to begin is by constructing a
Causes of ED crowdingThe causes of ED crowding are many
and interrelated. Key contributing fac-
tors include the following:
D
■ Over recent years, many of the
nation’s general acute care hospitals
have closed, resulting in fewer beds
available to accommodate admissions
from the ED
■ The national nursing shortage has
forced many hospitals to reduce their
number of staffed beds, further
reducing inpatient capacity
■ The aging population has brought
with it more complex diseases and a
requirement for specialized medical
services. As a result, patients present-
ing in the ED are “sicker” and
require a higher level of care
■ The numbers of middle class
Americans who now find themselves
without health care insurance cover-
age are seeking primary health care
in the ED. The rise of non-urgent
patients visiting EDs adds stress to
an already capacity constrained
system
■ Facility downsizing and decreased
capital investment in hospitals over
the past several years has led to out-
dated, inadequate, and misaligned
space to efficiently handle current
and future needs
■ The ability of hospitals to manage
current capacity is often impacted by
a lack of information and communi-
cation technologies, which often
times are inconsistently deployed,
cumbersome, and may not provide
real time information on bed avail-
ability status
Implications of ED crowdingAn even more severe downstream effect
of ED crowding is ambulance diver-
sion. According to a March 2003,
report by the U.S. General Accounting
Office (GAO), two-thirds of EDs
diverted ambulances to other hospitals
during 2001. ED diversions have the
potential for significant impacts on
quality of patient care, patient safety,
and patient, physician, and staff satis-
faction and retention. Care must be
taken to work collaboratively with city
and county EMS services to create
diversion policies and protocols that
decrease risk of EMTALA violations
and promote the health of the popula-
tion.
Potential solutionsHospitals can meet the ED crowding
challenge by employing a series of
strategies to optimize hospital capacity
while driving top down growth and
positioning themselves competitively in
their market. Benefit can be achieved
from turning around current opera-
tional problems by knowing where beds
are, ensuring appropriate utilization of
beds, matching staff resources to
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Continued on page 32
31Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
March 2004
Each time you add a compliance docu-ment to the HCCA Website you will have
an additional chance to win a Dellpocket PC* **, courtesy of Sheeder &
Welch. Add 30 documents and you will have 30 chances to win each month for a period of 12
months–November 2003 to October 2004. One Pocket PC will be given away each month for 12 months. Any non-copyrighted compliance document will count, such as policies, procedures, forms, memos, presentations, educationaltools, government documents, articles, whitepapers, or miscellaneous documents. Just visiteCommunities on the HCCA Website:
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Share Compliance Documents With Other HCCA Members...
And win one of 12 Dell pocket PC’sCourtesy of:
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32 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Revisiting...continued from page 8Overcrowding...continued from page 30
demand, investigating bottlenecks, and
aggressively working toward improving
patient flow processes.
As ED crowding becomes more preva-
lent, hospitals will continue to look for
new and creative ways to respond to
demands. A few hospitals have utilized
areas such as ED parking lots, auditori-
ums, and other locations for treating
patients when EDs are saturated and
ambulance diversions have a high prob-
ability of occurrence.
Automated patient tracking systems
offer dynamic workflow solutions
aimed toward improving patient flow
and maximizing capacity. The newer
and more innovative systems on the
market take capacity management to
the next level by allowing “real time”
monitoring of patients throughout the
entire spectrum of care.
Although crowding is most prominent
in large metropolitan areas, it is a wide-
spread problem affecting EDs in all
areas of the country. It is important to
note that ED crowding is not a prob-
lem in and of itself, but rather a symp-
tom of multiple, system-wide factors
that act together to create bottlenecks
that impede access to timely and high
quality emergency care. Although long-
term solutions will likely require timely
and significant policy changes, hospitals
can benefit from implementing one or
more short-term capacity management
solutions to help ease the problem of
crowding in the nation’s EDs. ■March 2004
not at all. The Commission can also
choose to defer action until a later time.
It is worth noting that the pro p o s e d
changes add significantly greater strin-
gency to the present day criteria and
raise the bar in defining what is re q u i re d
for an ‘e f f e c t i ve’ program. T h e re f o re ,
organizations should continue to moni-
tor the U.S. Sentencing Commission
revision process, and be ready to make
p reparations to adjust its compliance
p rogram as warranted.
C o l l e c t i ve l y, the legal environment is
saying that having a compliance pro-
gram matters–in fixing liability, setting
fines, and even determining whether an
entity may continue to do business at all.
But more than just having a compliance
p rogram, management must have a basis
for knowing–and must be able to
demonstrate–that its compliance pro-
gram is effective. In sum, the ove r a l l
t rends suggest that dynamic demands
will continue to be placed on the deve l-
opment of organizational compliance
p ro g r a m s . ■
1 698 A.2d 959 (Ct. Chanc. Del. 1996). Anoverview of the duty of care owed by Boards ofDirectors, including discussion on the implica-tions of Caremark can be found in CorporateResponsibility and Corporate Compliance: AResource for Health Care Board of Directors, aguide developed jointly by the AmericanHealth Lawyers Association and the OIG.
2 118 S.Ct. 2275 (1998).3 Most companies in meeting this requirement,
will likely adopt the internal control modeldeveloped by the Committee of SponsoringOrganizations (COSO, also known as theTreadway Commission), which consists of fivecomponents: control environment, risk assess-ment, control activities, information and com-munication, and monitoring.
4 An executive summary and the full report canbe obtained from the U.S. SentencingCommission website located athttp://www.ussc.gov
33Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
March 2004
June, p. 12
■ Outpatient outlier payments are also
coming under government scrutiny,
J. Witten, R. Howard, Nov., p. 8
■ Provider alert: Watchdogs are
increasing scope and expertise, C.
Sreckovich, P. Calvin, Sept., p. 6
■ Top ten Part B errors, T. Gilbert,
Mar., p. 12
Compliance Focus Group (CFG)CFG: Academic
■ Data to information: Getting the
best value for your investment,
N. Tarnuzzer, July, p. 7
CFG: Academic
■ Private and public health care:
Regulation application, S. DeGroot,
Sept., p. 25
CFG: Home Care
■ CMS certification on homebound
criteria for home care industry
remains unclear, L. Silveria, July, p. 9
■ New hospice regulations include
many changes, D. Randall, Esq.,
C. Raffa, Esq., Feb., p. 11
■ Do bad surveys make bad claims,
D. Randall, Esq., Mar., p. 9
■ Maintaining profitability for DME-
POS in an environment of
compliance, K. Scamperle, Sept.,
p.22
■ OIG targets overpayments made to
home health agencies for OASIS
answer M0175, L. Silveria, Oct., p.
24
■ Surveys, compliance, and home
health OASIS reports, C. Hughes,
May, p. 25
CFG: Large Health System
Back to basics
■ Hotlines: More than a basic element
of a compliance program, A. Quinn,
Aug., p. 18
■ Measuring the effectiveness of your
compliance program, S. Ortquist,
May, p. 15
■ Strategies for Effective Compliance
Training, R. Frank, S. Ortquist,
Feb., p. 21
CEO's Letter
■ R. Snell, Jan., p. 15; Feb., p. 20;
Mar., p. 16; Apr., p. 18; May, p. 22;
June, p. 20; July, p. 23; Aug., p. 23;
Sept., p. 26; Oct., p. 23; Nov., p. 27;
Dec., p. 25
Compliance
■ Are you ready to deal with what
squirms up when you turn over the
rock?, D. Sheets, Feb., p. 6
■ Blending corporate compliance into
the collegial environment, M.
Walker, Aug., p. 11
■ Cataract surgery comanagement, B.
Peters, Dec., p. 10
■ Clinical quality as a compliance
issue: An update, A. Helder, B.
Cornett, Nov., p. 22
■ Compliance and quality combined,
K. Jenkins, June, p. 18
■ Compliance professionals and
administration: Living in perfect
harmony, B. Crewse, May, p. 23
■ Continuous regulatory compliance
improvement, C. Sreckovich, P.
Calvin, Oct., p.10
■ Corporate responsibility and the
compliance officer, F. L. Murtha,
Apr., p. 18
■ Corporate responsibility and corpo-
rate compliance, M. Hemsley, June,
p. 4
■ Corporate responsibility reflected in
hospital criminal conviction, G.
Imperato, July, p. 4
■ Compliance monitoring of the
research enterprise, F. L. Murtha,
Jan., p. 9
■ Developing a research audit plan,
F. L. Murtha, Oct., p. 6
■ Economic value of compliance,
T. Gregory, Mar., p. 6
■ Ever changing observation billing,
D. Sheets, May, p. 8
■ Fifteen new opportunities for com-
pliance professionals, F. Sheeder, July,
p. 17
■ Health care compliance professionals
faced with a unique opportunity, S.
Ortquist, Oct., p. 4
■ How CCOs enhance quality patient
care, K. Catalano, Oct., p. 25
■ Identifying elements and process for
conducting internal auditing and
monitoring, G. Gustin, Sept., p. 4
■ Inter-rater validity and the physician
audit, P. Moore, Nov., p. 6
■ Legal audit compliance check list,
J. Johnson, Dec., p. 18
■ Liability issues related to illegible
physician documentation, J. Russo,
July, p. 21
■ New risks of physician recruitment,
J. Krave, Sept., p. 12
■ No show: To bill or not to bill,
P. Moore, July, p. 20
■ Outpatient reimbursement: Based on
the setting, not the service, S. Steed, Continued on page 34
Compliance Today (CT) (ISSN 1523-8466) is published by the Health Care ComplianceAssociation (HCCA), 5780 Lincoln Drive, Suite 120, Minneapolis, MN 55436. Subscription rateis $357 a year for non-members. Periodicals postage-paid at Minneapolis, MN 55436. Postmaster:Send address changes to Compliance Today, 5780 Lincoln Drive, Suite 120, Minneapolis,MN 55436. Copyright 2004 the Health Care Compliance Association. All rights reserved. Printedin the USA. Except where specifically encouraged, no part of this publication may be reproduced,in any form or by any means without prior written consent of the HCCA. For subscription infor-mation and advertising rates, call HCCA at 888/580-8373. Send press releases to M. Dragon, POBox 197, Nahant, MA 01908. Opinions expressed are not those of this publication or the HCCA.Mention of products and services does not constitute endorsement. Neither the HCCA nor CT isengaged in rendering legal or other professional services. If such assistance is needed, readers shouldconsult professional counsel or other professional advisors for specific legal or ethical questions.
Al W. Josephs, CHCHCCA PresidentDi rector of Corporate ComplianceHi l l c rest Health Sy s t e m