California Edition - Payers _ Providers by wuzhenguang

VIEWS: 13 PAGES: 7

									                                                                    2 August 2012




                                               California Edition

      Calendar                                        IPA Used Non-Docs For Reviews
                                                   DMHC Says CEO’s Son Made Decisions on Care

                                               The Department of Managed Health Care                               The younger Jayatilaka appears to hold a
          August 1-3                           issued an unusual cease and desist order                       medical degree from an unknown institution,
                                               against a Signal Hill medial group, claiming                   records suggest. In 2009, he led suit against
                                               the son of its chief executive ofcer had been                 the National Board of Medical Examiners in
 ;8%025"<%428!%2!72$=4%.6!>.8.#/>/8%?!@%?!
   A2$/=7!B2$=4%.6'!C0.8#/?!D5"<.%428.6!       illegally reviewing cases and making medical                   an attempt to receive extra time to complete a
  $/$$428$!0/#.0548#!%7/!>.8.#/>/8%!2E!        necessity decisions for insurers.                              licensing exam due to a disability. He lost the
6.0#/!$<.6/!7/.6%7<.0/!=02F/<%$?!@=28$20/5!         George Jayatilaka, M.D., is the CEO of                    case in federal court last year and was ordered
  +,!%7/!B2$=4%.6!!$$2<4.%428!2E!@2"%7/08!     the Accountable Health Care IPA. The DMHC                      to pay more than $6,100 in costs, records
             :.64E2084.?!GHI(?                 alleges in his complaint that his son, Druvi                   show. He could not be reached for comment.
                      !
                                               Jayatilaka, the group’s vice president, and                    George Jayatilaka did not return phone calls
     :64<J!B/0/!E20!K20/!;8E20>.%428           another employee, Ambarish Pathak, had                         seeking comment.
                                               engaged in utilization reviews on behalf of                         Pathak’s LinkedIn prole says he is a
                                               nine health plans. Neither is a licensed                       medical management consultant. He referred
        August 13-15                           physician, a requirement under state law to                    a telephone inquiry to his attorney, Douglas
                                               engage in prospective medical reviews, which                   Stuart of Santa Monica, who declined
                                               could lead to the modication or even denial                   comment.
                                               of specic kinds of care to patients.                               The DMHC accused the pair of engaging
 L7405!!88".6!K/54<.6!K.8.#/>/8%!48!                Altogether, Accountable provides care to                  in medical reviews since December 2008
K/54<.0/!!53.8%.#/!@">>4%?!M2"+6/%0//!         more than 148,000 patients from nine                           until the cease and desist order was led on
B46%28'!@.8!M4/#2?!!!54$<"$$428!2E!8/N%!
#/8/0.%428!>/54<.6!>.8.#/>/8%!%.<%4<$?!        different health plans in a risk-bearing                       July 16. The agency was tipped to the alleged
             GOOIPG)'QOI?                      arrangement. It includes Medicaid insurer L.A.                 practices at Accountable through a
                                               Care Health Plan, Anthem Blue Cross of                         condential complaint, according to agency
                                               California, Aetna and Blue Shield of                           spokesperson Marta Green.
     :64<J!B/0/!E20!K20/!;8E20>.%428
                                               California.                                                         Green said the cease and desist order also
                                                    A DMHC spokesperson could not say                         applies to the health plans because they
                                               whether the decisions rendered by Pathak and                   referred their patients over to Accountable.
                                               Druvi Jayatilaka had a material impact on care                 “Under the Knox-Keene Act, everyone
        August 19-21                           outcomes, adding that the case was still under                 involved has to comply with the law,” she
                                               investigation.                                                 said.

 R/$%/08!:6.4>!:28E/0/8</?!S/8.4$$.8</!
  D$>/0/65.!S/$20%'!-.6>!@=048#$?!T/U!
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       %7/!<6.4>$!0/.6>?!:2$%!T!?


     :64<J!B/0/!E20!K20/!;8E20>.%428                  WEBINAR                        Wednesday, August 15, 2012                          10 A.M., PDT
                                                   CALIFORNIA HEALTH BENEFIT EXCHANGE: A PROGRESS REPORT
                                                  Please join David Panush, director of government relations, the California Health Benefits
                 E-Mail                           Exchange, Anthony Wright, executive director, Health Access, and Jon Gabel, senior fellow,
info@payersandproviders.com with                  NORC/University of Chicago, to discuss the next major step in the implementation of the Affordable
   the details of your event, or call             Care Act in California.
  (877) 248-2360, ext. 3. It will be                            http://www.healthwebsummit.com/pp081512.htm
 published in the Calendar section,
          space permitting.                         a HealthcareWebSummit Event                            co-sponsored by    PAYERS & PROVIDERS


                                                      !"#"$%!&'!&()&!*!&()&!+,!-.,/0$!1!-02345/0$!-"+64$748#'!99:
   Payers & Providers                                              NEWS                                                                     Page 2


    Top Placement...                       Litigious Doctor Sues Patient Again
   Bottomless Potential
                                             Kentucky Suit Filed After Treatment in California
     Advertise Here
  (877) 248-2360, ext. 2                  The only individual physician in California                      insurer paid Martello about $2,500, she
                                          ever to be the subject of an enforcement                         returned the money to Anthem and sought full
                                          action by the Department of Managed Health                       payment from the Bucks, ling a lawsuit in Los
                                          Care has sued another one of her California                      Angeles Superior Court seeking more than
         In Brief                         patients again – this time in Kentucky.                          $15,000.
                                               Jeannette Y. Martello, M.D., led the suit                        Martello received a default judgment
                                          against Bill Buck, a Duarte cabinetmaker, on                     against Jae Buck as the result of the way the
                                          July 20 in mostly rural Johnson County in the                    Bucks led their response. Martello later led
  L.A. Care To Sponsor                    eastern portion of the state, records show.                      a lien against the Bucks’ South Pasadena
  Free Clinic At Sports                        Martello, who claimed in her lawsuit that                   condominium, claiming in her motion that Jae
         Arena                            she worked as a locum tenens physician at                        Buck had been abusive to her and that the
                                          Paul B. Hall Regional Medical Center until                       couple fought often.
L.A. Care Health Plan, the Medicaid       2010, accused Buck in the lawsuit of                                  A Payers & Providers investigation
managed care health plan, will again      contacting hospital management in July of that                   published last May determined Martello, who
sponsor a free medical clinic at the      year in an attempt to discourage her                             in addition to her medical training holds a law
Los Angeles Sports Arena next month.
      The clinic, which will be staffed   continued employment at the facility. It                         degree from UC Berkeley, had sued at least 70
by volunteer physician and dentists,      contends that Martello’s employment at the                       of her patients in California after treating them
drew an overwhelming response last        hospital was terminated as a result.                             at Huntington and other hosptial ERs in the
year, with tens of thousands of people         The lawsuit accuses Buck of defamation                      San Fernando and San Gabriel Valleys.
seeking care.
      This year’s clinic, which will be   and tortious interference and seeks a                                  In 2010, the DMHC ordered Martello to
held Sept. 27 through Sept. 30, will      minimum of $5,000 in damages.                                    stop balance billing her patients who had
feature a 20% larger capacity for              Hospital spokesperson Donna Waddell                         insurance, and led suit against her last year
dental and vision care, including the     noted that Martello’s work at the hospital                       when she did not heed the order. The DMHC
on-site manufacturing of crowns and
                                          ended not because it terminated her, but                         has also gotten many of Martello’s lawsuits
denture repair. About 1,000 medical
staff will be volunteering. Their         because her license to practice medicine in                      against her patients dismissed.
services are being coordinated by the     Kentucky had expired.                                                  In May, the DMHC successfully sought a
not-for-prot group Care Harbor.               Records indicate Martello’s license lapsed                  preliminary injunction against Martello that
      “Care Harbor may be more            in Kentucky last February.                                       prohibits her from ling further suits against
important this year than ever before,”
said L.A. Care Chief Executive Ofcer          Although Martello is a Southern                             her insured patients.
Howard Kahn. “Now is the time to          California native and attended medical school                          Bill Buck has been one of the most vocal
begin transitioning the uninsured into    at UCLA, she underwent a surgical fellowship                     critics of Martello’s conduct, posting several
care and to start the process of          at the University of Kentucky Medical Center                     notices of the DMHC cease-and-desist order
informing, educating and orienting
                                          early in her career as a physician, and had                      on review websites such as Yelp.
people about what's to come with the
implementation of federal healthcare      been licensed to practice in Kentucky since                           The California Medical Board is also
reform. The opportunities for access      1991.                                                            attempting to revoke Martello’s license to
to quality health services will be             Waddell also noted that Martello’s                          practice medicine in this state, in part because
tremendous, and Care Harbor will be       employment contract was with a locum                             of her balance billing of patients and suing
uniquely positioned to raise public
awareness and eliminate hurdles for       tenens rm, Houston-based Whitaker                               them. A licensure hearing is scheduled for
those seeking long term health            Medical, and not directly with the hospital.                     October.
solutions.”                                    Martello treated Buck at Huntington                              The allegations against Martello in
                                          Memorial Hospital in Pasadena in April 2010                      California have no bearing on the case in
Women’s Preventative                      after he had severed part of a nger in a                        Kentucky, according to her attorney, Jeremy
Services Expand Under                     workplace accident. Although he had                              Rogers of Louisville.
         ACA                              insurance with Anthem Blue Cross, and the                              “The case speaks for itself,” Rogers said.

Insurers are now required to
provide specific preventative care                                                     MEET YOUR FELLOW READERS
services as part of the Affordable
Care Act.                                                                     Need to promote a conference? Your brand? Payers &
     On Aug. 1, insurers were
required to provide free of charge
                                                                              Provider!s e-mail list for all editions is available for your
eight services to women free of                                               marketing needs. Reach out to more than 12,000
charge. They include well visits,                                             healthcare professionals who read our publications. Call
                                                                              Claire Thayer at (877) 248-2360, ext. 3 or e-mail her at
      Continued on Page 3                                                     clairet@mcol.com.



                                             !"#"$%!&'!&()&!*!&()&!+,!-.,/0$!1!-02345/0$!-"+64$748#'!99:
Payers & Providers                                                        NEWS                                                           Page 3

       Longer ALOS!*                          Kacic Resigns From CalOptima
     Advertise Here                       Former Chairman Steps Down After Grant Issues
 (877) 248-2360, ext. 2
   *For our ads, not your hospital      Edward B. Kacic has resigned from the board                         Kacic also co-chaired another
                                        of CalOptima, little more than ve months                      organization, the Managed System of Care,
                                        after accusations of self-dealing involving a                  that was in line to receive as much as $12.7

         In Brief                       non-for-prot foundation he heads had
                                        surfaced.
                                                                                                       million in funding from CalOptima.
                                                                                                           Kacic and other ofcials have said that
                                              Kacic submitted his letter of resignation to             the Managed System of Care would have
                                        the Orange County Board of Supervisors on                      submitted the application for the federal
gestational diabetes screening,         July 30. He had served on the board since                      grant itself, but had not been properly
breastfeeding support, FDA-             2009, and although appointed its chairman in                   incorporated to do so.
approved contraception methods          August 2011, he had temporarily been                               Although Kacic has strenuously denied
and counseling, and HIV                 removed from the post earlier this year.                       any conicts and the California Fair Political
screening, among others. Certain
religious organizations are             Moreover, his reappointment to the board had                   Practices Commission declined to provide
exempted from paying for the            been delayed, and it appeared increasingly                     advice on the matter at the request of
provisions of the contraceptive         unlikely he would receive one before his term                  Orange County Counsel Chris Chrisos,
services.                               expired on Sept. 30.                                           fellow CalOptima board member and
      “The Obama administration
                                              CalOptima, which provides managed                        County Supervisor Janet Nguyen termed it a
will continue to work with all
employers to give them the              care coverage to about 400,000 of the                          conict of interest.
flexibility and resources they need     county’s Medi-Cal recipients, have been                            Nguyen, who received an appointment to
to implement the healthcare law in      rocked by allegations of mismanagement for                     the CalOptima board last year after lobbying
a way that protects women’s health      months now. Published reports indicate that as                 by the region’s hospitals, has been at odds
while making common-sense
accommodations for values like          many as 14 top and middle management                           with Kacic and other board members.
religious liberty,” the U.S.            executives have left the organization in the                       In March, the Supervisors voted to delay
Department of Health and Human          past year. It is currently lacking both a chief                Kacic’s reappointment. In May, the
Services said in a statement.           executive and chief operating ofcer.                          CalOptima board voted to remove Kacic as
      Altogether, the expansion of
                                              Kacic’s conict with CalOptima began in                  chairman on the same day it also voted to
services is being made to about 47
million women nationwide,               February, when an anonymous letter surfaced                    beef up its compliance practices.
including about 5 million in            that accused him of self-dealing.                                  Soures have also suggested that an
California.                                   Payers & Providers reported on Feb. 23                   investigation is continuing into the possible
                                        that the Irvine Health Foundation, of which                    use of CalOptima employees to prepare the
 Kaiser Enrollees More                  Kacic is the executive director, had submitted                 Irvine Health Foundation’s bid for the grant.
  Likely To Stay After                  an application to receive a $9.3 million                           In his letter of resignation, Kacic said that
   Using EHR System                     federal grant that would be used to provide                    it was inappropriate for CalOptima to be
                                        medical homes and other services to                            investigating such matters internally, and that
Kaiser Permanente enrollees who         CalOptima members.                                             an outside entity, such as a law rm, would
use the system’s electronic health           The foundation itself would not have                      have been more appropriate for an inquiry.
records and associated patient          received funds for its own use, but would                          “The inquiry seems to have been taken
portal are more likely to remain        supervise the employees engaged in the                         inside the organization, with the internal
enrolled compared to non-users.
      According to a survey of          initiative.                                                    counsel playing a signicant role…since I
nearly 400,000 Kaiser enrollees,             The Center for Medicare and Medicaid                      don’t believe in the propriety of asking
those who use the My Health             Innovation – an afliate of the Centers for                    individuals to investigate those to whom they
Manager are 2.6 times more likely       Medicare and Medicaid Services – ultimately                    ultimately report, I nd this situation odd, at
to stay with the organization than
                                        turned down the grant application.                             best,” he wrote.
those who do not use the system.
      “We have always known that
our members find these online
tools convenient and empowering,
but now we have proof that these
offerings actually increase member
loyalty and can improve the
                                           STORIES OF ONE HIGHLY LITIGIOUS PHYSICIAN
relationships between
patients and their physicians,” said
Christine Paige, senior vice
                                                                       $149
president for marketing and
Internet services.                                      Call (877) 248-2360, ext. 2 to order
     The results of the study will be
published in the latest issue of the
American Journal of Managed
Care.                                                                           OR CLICK HERE

                                             !"#"$%!&'!&()&!*!&()&!+,!-.,/0$!1!-02345/0$!-"+64$748#'!99:
Payers & Providers                                                OPINION                                                               Page 4

 ;2#"<.!='!>00".!%?                        A New View Of America’s Physicians
                                           Predictive Analytics, Link Analysis Playing Larger Roles
      ,-$./0!1!,/2345./0!40!
   @"+#406.5!.3./$!A6"/05-$!+$!
  ,-$./0!1!,/2345./0!,"+#406478'!        I am not a doctor and I don’t play one on TV.             his considered opinion.
    99:B!C7!-77"-#!4754345"-#!           I am, however, an occasional patient. So                       “You have gout!”
    0"+0D/4@E427!40!F??!-!$.-/!          while I am not qualied to write about                    To say that I was astonished would be an
     GF)=?!47!+"#H!"@!E2!)(!             airway management or anesthesia carts or                  understatement.
  0"+0D/4+./0IB!>E!40!5.#43./.5!+$!      the pros and cons of scrub laundering                          “Gout? How do you work that out?”
   .J<-4#!-0!-!,KL!-EE-D6<.7E'!          services, I am ideally suited to ponticating                  “Well, you are English and the English
  2/!-0!-7!.#.DE/274D!7.M0#.EE./B        about physicians, their foibles and fortés.               drink a lot of port wine and too much port
                                              My rst encounter with an American                   wine often leads to gout.”
   C##!-53./E40478'!0"+0D/4+./!-75!
         .54E2/4-#!47N"4/4.0O            physician was a memorable one. I had been                      I suddenly had an urge to take to the
                                         in the US only a few months after arriving                bottle, possibly copious quantities of port wine.
           GPQQI!%=PJ%R&(                from England.                                                            But instead I sought a second
     47S2T@-$./0-75@/2345./0BD2<              I was directed to an                                                   opinion.
                                         examination room where I                                                       With every yin, however,
         U-4#478!-55/.00O                waited patiently, and patient-                                              there is a yang. Since then I
   P)P!VB!W2##$M225!X-$'!Y"4E.!Z         like, for the physician.                                                    have been innitely more
        Z"/+-7H'!:C!?)[([                After a while, a long while, I                                              fortunate in my visits to
                                         heard footsteps in the corridor                                             physicians. I have undergone
              X.+04E.                    outside, some activity, rustling                                            knee surgery, watching the
     MMMB@-$./0-75@/2345./0BD2<          of papers, and a loud voice                                                 specialist clean out fragments
             L-D.+22H                    saying: “What’s this guy’s                                                  from my patella on a monitor
                                         name?” followed by the nurse’s                                              while being genuinely
  MMMBS-D.+22HBD2<\@-$./0@/2345./0
                                         whispered response: “Geoffrey                                               entertained by a fascinating and
               AM4EE./
                                         Charlton-Perrin.” The door                                                  informative commentary from
   MMMBEM4EE./BD2<\@-$./0@/2345./0
                                         ew open. In walked a                                                       the physician as he explained
                                         physician I had never met in                                                what he was doing and why.
         ]54E2/4-#!Z2-/5                 my entire life, arms                                                       And eventually I had surgery on
   YE.3.7!AB!;-#.7E47.'!,/.045.7E'!      outstretched, a beaming smile on his                  By           my shoulder - yes, that shoulder -to
        A6.!:-<5.7!^/2"@                 face, as he bellowed, “Geffy, baby!”              Geoffrey repair my rotator cuff at the hands of a
   _200!^2#5+./8'!><<.54-E.!,-0E!
                                         and hugged me like I was his long-lost                                                     assistant who
                                                                                          Charlton- surgeon and surgeonat their craft but
                                                                                                            were not only artists
                                         chum from childhood.
    ,/.045.7E'!920!_2+#.0!W20@4E-#!           Friendliness, accessibility,                    Perrin        friendly, helpful, informative and
         -75!U.54D-#!:.7E./              unpretentiousness – these are                                      down-to-earth.
                                         welcome qualities in a man of medicine. But                    And the reason I can say with some
     U-/H!L47"D-7.'!U-7-8478!
                                         there is such a thing as too much                         authority that they were artists? I was
     K4/.DE2/'!C#3-/.`!1!U-/0-#
                                         friendliness, accessibility and                           producing a video on ambulatory surgery
    W.7/$!92"+.E'!:64.S!YE/-E.8$!        unpretentiousness!                                        center accreditation at the time and had the
          aSS4D./'!b..7-7                I remember another encounter some years                   entire procedure lmed so I could include
                                         later when I was experiencing extreme                     parts of it in the video.
     C7E627$!X/486E'!]c.D"E43.!          discomfort in my right shoulder. Every time I                  Afterward in the editing room, I marveled
  K4/.DE2/'!W.-#E6!CDD.00!:-#4S2/74-     raised my arm to pitch to one of my young                 at the skill, the deftness, the sure hands of both
                                         sons, I felt a erce, stabbing pain that                  physicians. And thanked my lucky stars that I
         ,"+#406./\]54E2/                prevented me from completing the                          wasn’t witness at the time to what they were
                                         movement. I went to a physician who                       doing to my body with what looked
          _27!Y647H<-7                   enjoyed great renown as “ofcial orthopedic               suspiciously like a hammer! For a patient,
                                         surgeon” to the city’s hockey team. Hockey                some things are best left a mystery.
  @"+#406./T@-$./0-75@/2345./0BD2<       players must often have shoulder problems,
                                         right? How could I go wrong?, I reasoned.
       :27E/4+"E478!]54E2/                                                                          Geoffrey Charlton-Perrin is the director of
                                              He examined me carefully, put me
                                                                                                    marketing and communications for the
                                         through several tests, but failed to come up
                                                                                                    Accreditation Association for Ambulatory
        b-E6$!U4##./!b.##.$              with an answer. More examinations. More
                                                                                                    Health Care.
                                         tests. Still no answer. At the third visit, as I sat
  >S!$2"!52!72E!/.D.43.!$2"/!400".!2S!   on the exam table being poked and prodded
   ,-$./0!1!,/2345./0!+$!)!,BUB!27!                                                                     Op-ed submissions of up to 600 words are
 A6"/05-$'!@#.-0.!D-##!GPQQI%=PJ%R&(B    for a third time, he straightened up and
                                                                                                         welcomed. Please e-mail proposals to
                                         delivered – with some fanfare, I might add -
                                                                                                               editor@payersandproviders.com




                                                  !"#$!%&'!%()%!*!%()%!+$!,-$./0!1!,/2345./0!,"+#406478'!99:
Payers & Providers                     MARKETPLACE/EMPLOYMENT                                                                       Page 6



                                                                                                                   CONTROLLER/
                                                                                                               DIRECTOR OF FINANCE


                                                                            Casa Colina Centers for Rehabilitation, a nationally recognized
                                                                            leader in the field of medical rehabilitation located in Pomona, is
                                                                            seeking to fill the vital role of Controller to oversee the Finance
                                                                            and Accounting functions for the entire rehabilitation continuum
                                                                            with a total bed complement of 178 beds, and consisting of a
 HEALTH PLAN/HOSPITAL CONTRACTING CONSULTANT                                hospital, brain injury program, 3 long term care facilities, an Adult
                 (flexible hours)                                           Day Health Center and outpatient children’s program.
A dynamic and growing medical group in the Los Angeles                      The selected candidate will be responsible for all financial, payroll
County area is currently seeking a highly experienced con-                  and A/P activities. Oversees internal controls to ensure revenue
tracting consultant for the purpose of leading and success-                 cycle effectiveness, expenditure management and safeguarding
fully negotiating and renegotiating health plan and hospital                of assets. Prepares financial statements in a timely, accurate
contracts.    The ideal candidate will have an understanding                and efficient manner. Supervises all accounting and payroll staff.
of all product lines within the managed care industry, be                   Responsible for tax returns and regulatory filings. Requirements
well-versed in contractual language, excel at maintaining                   include a Bachelors degree in Accounting or Business related
positive working relationships internally and externally, and               field, two (2) years of supervisory experience, prior hospital/
demonstrate an understanding of legal, financial and opera-                 healthcare accounting experience, and a working knowledge of
tional processes that meet company objectives.  Flexible                    accounting software programs. CPA background is strongly pre-
hours and telecommuting are available.                                      ferred. Excellent work ethic and motivation required.

                                                                                 Competitive compensation and excellent benefit options
        If interested, please email your cover letter                            available. To apply, visit us at www.casacolina.org/jobs.
           and resume to: ssabanal@ahcipa.com                                                   Principals only at this time.




                      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. 2
                   Or e-mail: advertise@payersandproviders.com

                           Or visit: www.payersandproviders.com
                                    *New England Journal of Medicine, 2004.




                                           !"#$!%&'!%()%!*!%()%!+$!,-$./0!1!,/2345./0!,"+#406478'!99:
Payers & Providers      MARKETPLACE/EMPLOYMENT                                       Page 7


                     SEEKING A NEW POSITION?
                                                                       CAN HELP.
           We publish advertisements for those seeking
                          new career
                opportunities for just $1.25 a word.

               If you prefer discretion, we’ll handle all
                        responses to your ad.
                 Call (877) 248-2360, ext. 2, or e-mail
                advertise@payersandproviders.com.




                        !"#$!%&'!%()%!*!%()%!+$!,-$./0!1!,/2345./0!,"+#406478'!99:

								
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