September 2014
HealthTrust Joins Mission Nac to Make a Huge Impact in Nacogdoches
The house on 1907 Timberlake Street looked like another home on the rough side of town. The embodiment of
have-nots, this leaky wooden residence occupies the corner of its street, almost giving by-passers a preview of what could be expected if they dare venture down the neighborhood. Moms may jester it as a warning – “take the long way around if you see one of those houses.” What you don’t see is the 64-year-old disabled mother of two who resided here. “My family has lived here for 65 years,” she said. “We live on the corner of this street so we’re what people see when they first pull down this road.” This summer, a Mission Nac team was sent to her home, spending four long days in the summer humidity repainting
the house, fixing leaks and cutting off large tree limbs that hung dangerously above the roof of the residence. Within four days, the house was transformed and looked like it belonged in a real estate catalog. The white paint jumped from the walls, contrasting neatly with the freshly-painted dark
blue porch step, shutters and window seals. The trees were trimmed, and the windows were fixed. But nothing shined brighter than the woman who stood at the front door. She was the recently retired mother of two, ecstatic about the opportunity to newcomers around her renovated home. “They built the porch step to make sure I wouldn’t fall when I stepped outside the house. It’s a real pretty blue.” Leading to
the back porch, she said they fixed the window seals so water would no longer leak on the inside. “It used to flood real bad back there," she said. Finally, she got down to the best part. “It took me three years to get approved for disability. My house was falling apart. I couldn’t afford to pay anybody to help me out when I’m getting by on government aid. Thank God I received help from Mission Nac. The volunteers were so amazing and kind. They’re coming by later to put the finishing touches on the house.”
It was obvious that something else had been repaired. Her peace of mind. Ten homes were given the same treatment in this year’s Mission Nac, an annual op-
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Can Insurance Carriers Perform Audits The Same Way Medicare Does?
By Edward Vishnevetsky
Within the last year, I have seen a significant increase in the number of insurance carriers (“insurers”) that perform prepayment and post payment audits on providers’ claims. Moreover, many of these insurers have taken a page out of Medicare’s book by performing statistical extrapolations which results in astronomical overpayments. For example, a provider may receive an overpayment request from United or Humana for $5,000,000 based on a 80% claims denial rate on $20,000 worth of claims with dates of service in 2013, extrapolated to the universe of the provider’s claims between 2011 and 2014. Auditors for the insurers apply many of the same rules as Medicare auditing contractors; and many providers respond to these audits in the same way they would if the audit was conducted by a Medicare auditing contractor. This may not be the best strategy! Insurers are subject to different statutes and regulations than Medicare (or its contractors) when performing audits. Specifically, insurers are subject to both state and federal law, unlike Medicare contractors, which are only subject to federal law. Additionally, since many plans offered by insurers are provided to workers by their employers, auditing claims under these plans is subject to ERISA law. ERISA requires insurers to ad-
here to numerous requirements when auditing claims, such as giving the provider adequate notice of adverse benefit determinations. Many insurers do not follow these notice requirements. Providers may be able to use insurers’ failure to follow ERISA notice requirements as a partial or complete defense to an audit. Under the Employment Retirement Income Security Act of 1974 (“ERISA”), every employee
reasons for such denial [including ] reference to the specific plan provisions on which the determination is based.” The notice must also include a “description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under [ERISA] following an adverse benefit determination on review.” With respect to the appeal process, the plan administrator must give the claimant at least sixty (60) days to lodge the appeal and allow him/ her to submit written comments, documents, and records relating to the claim. Full and fair review also requires the plan administrator to give written or electronic notice of its decision. In Penn. Chiropractic Ass’n v. Blue Cross Blue Shield Ass’n, an Illinois district court determined that members of the association of network providers were considered “beneficiaries” for ERISA purposes. Based on this finding, in-network providers may be able to stand in the shoes of beneficiaries when responding to an audit that is subject to ERISA law. Cont. on page 11
"Providers may be able to use insurers’ failure to follow ERISA notice requirements as a partial or complete defense to an audit."
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benefit plan must “maintain reasonable procedures governing . . . notification of benefit determinations, and appeal of adverse benefit determinations.” If an insurer makes an adverse benefit determination under an ERISA plan, ERISA entitles a beneficiary (which, depending on state law, includes the provider) to sufficient notice of an adverse benefit determination, an opportunity to appeal it, and a full and fair review of the appeal. The definition of “sufficient notice” is extensive. Moreover, ERISA specifically states that a notice of denial of benefits is adequate only if it is in writing and includes “specific
Honesty
"It is discouraging how many people are shocked by honesty and how few by deceit." Noel Coward "With people of limited ability, modesty is merely honesty. But with those who possess great talent, it is hypocrisy." Arthur Schopenhauer I am a hypocrite. I admit it. I didn't realize it until this morning when I read that quote by Mr. Schopenhauer. I thought I was a very honest person, but I'm not. I lie to myself every day. I've been reflecting today on how much daydreaming I do. Maybe I should be more professional and call it "visualizing." That's what great leaders do, right? I visualize, not daydream! Either way, it is a fake reality. It is a lie. I daydream about our company running smoothly, customers singing our praises, and innovations being churned out of our lab like items on an assembly line. I daydream about patients getting better, never worse. I visualize our software and tools being used to connect families, caregivers, knowledge, and resources so that no one has to experience the pain so often associated with our healthcare system today. I even daydream about personal goals, like having happy kids who run smoothly, sing my praises, and churn out accomplishments like an assembly line. Then someone like Arthur Schopenhauer comes along to slap me back into reality, proving to me in one quote that I am a hyp-
ocrite. I'm a hypocrite because my daydreams are an escape from the realities of life - those realities that I am too afraid to face, too confused to confront, too weak to battle, too exhausted to overcome. Instead, I am too self-absorbed to even admit they exist. I try to hide in books, lectures, learning, and daydreams. For a CEO who is trying to push a company past it's limits or a dad trying to push his kids into successful adulthood, embracing a new buzzword is easier than embracing reality. Reality is hard. Motivation, passion, innovation, culture, all of the buzzwords we use to describe elite companies, all express a temporary state of being. Motivation, the "Big Mo", is present at good and bad companies, at different times and to varying degrees. Same with passion. Innovation happens chaotically. Culture grows, develops, and changes over time. All of those buzzwords are like the wind; we hope to feel them, ride their energy, and soar to new heights. But, like the wind, they are fickle. They change direction. They lose intensity. They disappear. Buzzwords don't build businesses because
Jonathon Kovar buzzwords don't build people. People, for better or worse, are everyone's business. And people, for better or worse, are in the business of living. Unfortunately, life doesn't accept buzzwords as a form of payment. Life requires absolute honesty. Life punches us in the face with absolute honesty. My lesson here is simple: if you are tired of fighting life, then stop fighting life. Embrace honesty. If your first reaction to that statement was, "I am honest. I don't lie to people.", then good. You have a leg up on quite a few people (provided you were being honest!). Honesty in our words is important, vitally important if you own a business that is going to survive long term. More important though, is honesty in your actions. Is your life honest? Or, like me, is your life more of a daydream? Honesty in action begins with an honest assessment of yourself. Are you living up to your full potential? Are you running scared from the very purpose God gave you? Do you sit at home and daydream about a better life? Are you truly living as the best version of yourself? Anything less, as Arthur Schopenhauer said, is hypocrisy. Jonathon Kovar is CEO of HealthTrust Software, an author, speaker, and healthcare attorney.
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“Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don’t settle.” Steve Jobs "Choose a job you love, and you will never have to work a day in your life.” Confucius She originally planned on becoming a high school teacher, but she wouldn’t have loved it. Thankfully, Lacey Broussard followed Confucius’ advice and hasn’t “worked” since her senior year in high school when she joined the staff of Nurses Specialties. In the ensuing 11 years she has never worked anywhere else. Her job taught her that she was made for the field of nursing and so instead of interning at her local high school, she went to nursing school while learning the business side of home health. To this day she doesn’t want any other job. “It’s such a big part of my life. I don’t ever want to leave. Ever.” Working at Nursing Specialties has become very much, well, family.
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Lacey served as project manager when the company began to transition from paper to electronic files. In fact, before the first HealthTrust Software trainer came on site, Lacey spent three months diving into the software, testing it and becoming familiar enough with it that she was able to write booklets of her own with quick tips for every type of person who would use the software from
field staff to administrative nurses. “I didn’t want to just throw the nurses into it…and we wanted an in-house expert who knew the software well so that the transition would be smooth." It was a four month project for only one of their four branches, and when it was complete, she would go to the next branch. “It was a yearlong process but it went
branches. Lacey said that since she has done just about every job in home health, she understands its challenges. Their top priority of patient care has never wavered. “Home health is super rewarding. We are a progressive company and are always developing new protocols. We have seen some amazing outcomes and seen great improvements in patient satisfaction.
Lacey Broussard DON - Nursing Specialties very well.” Company CEO, Stacy Mollet says they couldn’t have had anyone better do the job. “She is dedicated, loyal, ethical, morally sound, and a very strong leader. Taking our company from paper to electronic records was a very big deal for me. I am older, and I liked my paper!” But with Lacey, the process was smooth. Now, her job as Director of Nurses has her overseeing clinical operations from day to day for all four
HTS has really helped. We have used a lot of trending and have gotten a lot of statistics out to physicians.” Trust, the intimacy of treating patients in their own home, and the longevity of the relationship between the nurse and patient are the aspects of working in home health that Lacey loves the most. “We get to know their emotional status, their physical wellbeing, and even their family relationships, and therefore have more comprehensive personal ownership in their health. All of these components result in better outCont. right
“If I could choose any super power, it would be to duplicate myself!” As a single mom of three, ages 10, 8, and 6, and CSR for HealthTrust, her super power wish is understandable. Michele Morton came to work for HTS six months ago and has been an invaluable resource for numerous users who call in needing software help. “I enjoy working with computers and helping people with their problems.” Put the
Michele Morton CSR for HTS two together and you have a great HTS customer service representative. “I love the family atmosphere at HTS. It is very casual.” But she hates when she cannot solve problems for those calling in. “Sometimes the problem is on their end, like a computer issue and I try to give them a way to get the issue fixed, even if I can’t fix it.” Like all of the CSR’s at HealthTrust, Michele has a very strong urge to find answers. After receiving a degree in computer information systems and psychology, Michele worked at a localphone company as their first CSR. Five years later she was laid off so she tried her hand at teaching in a public school. But since computers don’t talk back and students do, after two years of teaching she decided to get back into the technology field. She has not regretted it and has taken on extra duties at HTS like cleaning up and organizing the ticketing system.
exceptionally calm and kind when she is on the phone with customers. “Michele’s deepest desire is to help in any way she can, and to never leave her callers without answers to their problems.” Other workers notice her ready smile and sweet disposition. But there are even more colorful things that draw her fellow workers to her desk! Michele has a couple of very cute M&M dispensers that sit right by her computer. She fills them and her peers empty them! Michele has collected M&M paraphernalia for years because all three of her names begin with an “M”. When she was a kid she fully believed the candies were made just for her! Hanging out with the kids is Michele’s preferable past time. And even though she is not into sports, her two boys are, and her daughter is a gymnast, “which means I am a runner!” Michelle says. Which gets us back to her super power wish: to duplicate herself. At HTS, we would love for her to be doubled! After all, the only thing that would be better than one Michele is two!
Michele is is known by all her co-workers as being Cont. from left comes.” One example of this was a patient who called her at 3am. Because Lacey had treated her and knew her well, she knew it was a real emergency. An ambulance was called, and to this day that patient calls Lacey her “little Angel” and credits her with saving her life.
Lacey’s source of inspiration is Stacy who she has worked intimately with over the years and always has an open door policy. “She is a wealth of knowledge. She has 30 years’ experience in the home health industry and is also a RN. That makes a big difference.”
Her advice to those starting out in the field is no big surprise if you know Lacey. Besides encouraging newbies to give it at least three months to get used to it, she says “be passionate about what you do. And then you will never work another day in your life.” 5
It's in the software....
ARE YOU USING IT? Medical Records
The medical records module is available for you to quickly access a patient’s chart!
Help! A surveyor just walked in and wants a patient’s entire chart, how can I print it out? Go to Patients > Medical Records: 1. Change the first option to All Records 2. The second option defaults to all documents. If you want a specific type of record you can choose it from the dropdown. 3. Select the patient whose record you need to view 4. Click Go to pull that patient's chart 5. Check the box beside each record you want to print 6. Click Print at the bottom to print all selected records 6. Hand chart to surveyor.
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I ask you this month, for the next thirty days, to embrace the pain of reality, enjoy the good and bad times, and work very hard to make reality better for all of us. I read a quote today about our soldiers that basically said they don't go home at 5:00; they go home when the job is done. Anything less sacrifices our freedom. Their sacrifice is real, every day. It would be a shame
for them to give so much for us to live, and then have us spend our lives in a daydream. Embrace reality. Fight through the struggles and make the world a better place. The old Army slogan was right when it told us to "be all that you can be." That is honesty. Embrace it.
SOFTWARE TIPS From Your Customer Service Reps
1. Company Notice Alert System: Did you know we have a Company Notice alert system that you can use to alert your staff? It also allows them to sign up for the activity! Company Notices can be set up by going to Administration > Company Notices > New. After the Company Notice has been added, users will see the Company Notice under the Dashboard > Alerts > Company Notices.
files for the filters you selected. Check the boxes on every Oasis that you want to include in the batch file. After you have selected the Oasis to include, click SUBMIT. The file will be created with an option to download and save the file to your desktop or to a specific place you want to save it to. Once you have the file saved, you are ready to send the file to the State.
6. Ready Episode Status: What does a ready episode status mean? Ready = 1st billable date has been entered and the Rap should be in potential claims.
7. Setting user access times: Can I set times for when a user can access HealthTrust Software? Yes! Administration > Users: 1. Select the user to edit 2. Edit the Allowed Days in/out fields & Allowed Time in/out fields (note 4. Pulling patients back into an this is military time). 3. Click Subunsent OASIS transmission file: mit to save. I created the OASIS transmission 2. Adding a User: How do I add file but I accidently deleted it be- 8. Printing a patient's chart: a user? Go to Administration > fore I was able to send it, how can A surveyor just walked in and wants a patient’s entire chart, Users > Add User: 1. Assign the I pull those patients back? PPS > how can I print it out? Patients > user a unique username that is Create OASIS Transmission File: Medical Records: 1. Change the at least 6 characters in length 2. Since the system believes that Assign the user a temporary pass- you have already transmitted the first option to All Records 2. Select the patient whose record you word that is at least 6 characters OASIS, you will need to uncheck need to view 3. Click Go to pull in length (the user will have the the box marked 'Only Show option to change their password Assessments That Have Not Been that patient's chart 4. Check the once they sign into HealthTrust Transmitted'. If you have transmit- box beside each record you want to print 5. Click Print at the botSoftware) 3. Select which Group ted OASIS files you need to filter the user will be a part of 4. Set by the Created, Locked, or M0090 tom to print all selected records their allowed days and times in/ date to get the correct date range 6. Hand chart to surveyor. out of the system 5. Fill in any so you do not resubmit OASIS 9. Accessing HTS User Manual: other required or necessary infiles that you have transmitted HealthTrust Software released formation 6. Click Submit to save before. Click Submit to bring up an updated User Manual at the the user into the system. a list of all OASIS from that date beginning of 2014. To view or range, select the ones you want download the User Manual click 3. Oasis File to State: How do I to transmit, click submit and on the Alerts button in the top get the Oasis file that we send to download the file presented. right hand corner of your screen the State? You will need to create an Oasis Transmission File to send 5. Relocating a pending check: and then click on the alert “New to the state. Go to PPS > Create I was working in a pending check User Manual”. Oasis Transmission File. This and went to another page and 10. Missed Visits Report: What screen allows you to group the now I cannot find my check. If for report can I run that will show me Oasis by Agency ID or Provider. some reason you close the pend- all of my missed visits? Charges There is also a created date and ing check, you can locate it under report. Filter by charge status and locked date that you can search Ledger > Check Menu. Under the then enter your date range in the by. Select the filters you need search criteria > Check type > schedule date filter. and click SUBMIT. You will then click the radio button for pending be taken to a page with the Oasis and search. 7
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Cont. from page 1 portunity for local residents to help the less fortunate with real estate repairs. The event extended over four days with hundreds of volunteers from local churches, including a few businesses like HealthTrust and HealthTrust client Bethany
Home Health Services. Restaurants supplied dozens of trays of free food. Most of those served through Mission Nac were elderly, disabled and widowed. The event has become a powerful avenue for Christians to spread the love of Christ
throughout the community. In the roughest parts of town, athletes from nearby colleges were seen painting houses with their cellphones pedaling Christian worship music in the background. Nurses paired themselves with former patients to bring an encouraging word
of prayer. Youth volunteers came inside to mingle with the children of those being served. When the job was done and the volunteers said their final goodbyes, it was obvious that strangers had become neighbors through a common faith. The rough side of town seemed
like a great place to be because these acts of service brought the community together. One of the volunteers, Audrey Hepburn summed it up best. "As you grow older, you will discover that you have two hands, one for helping yourself, the other for helping others."
HealthTrust Software plans to continue its support of Mission Nac and hopes to attract more home health industry players to the worthy cause. The next event will be held in June of next summer. 9
SOFTWARE UPDATES COMPLIANCE DIVISION PATIENT MANAGEMENT: INTAKE - When adding DX Codes in the Referral and Patient Menu, you now have the option to add DX codes and Physicians under the Referral Services tab. This allows you to keep track of discipline specific DX codes and Physicians associated with the discipline. - The following Point of Care visits will now update the Patient Menu > Referral Services tab once the visit is passed in Care Validation: Pedi PT Eval, Pedi OT Eval, Pedi ST Eval, Pedi SN Assess, and the Office Pedi ST Eval. When any of these visits are passed the Referral Services tab will update the following fields: Ordered, DX Code, and Physician. - The Patient Menu DX tab now allows you to move the DX codes up and down with arrows to change the order of the DX codes. - The Patient Menu DX codes will now auto-populate in Point of Care for the following visit types: Pedi PT Eval, Pedi OT Eval, Pedi ST Eval, Pedi SN Assess, and the Office Pedi ST Eval. - When selecting Face to Face forms under Process Orders (Review Orders, Send Orders and Receive Orders), the Edit Patient screen will now open at the Referral Tab > F2F sub-tab. ORDERS - The primary care physician will default when creating Physician Orders. There will be an option to select from the list of physicians that are assigned to the patient. There will also be an option to select other that
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will allow you to select a physician that is not assigned to the patient. - Several additions have been made to the h-Faxing module located under the Orders tab > h-Faxes. - To ensure a quicker load time, each tab will display the first 100 faxes available. - In the upper right hand corner of each tab, below the ‘Refresh List’ button, users will see the number of faxes displayed on the page in comparison to the total number of faxes available based on the search criteria. - Filter options have been added to the ‘Archived’ sub-tabs under both the Sent and Received tabs. - All filter options have been enhanced to include a ‘THRU’ date filter to allow users to search for faxes sent or received in a specific date range in all tabs. - All filter options have been enhanced to include a ‘LIMIT TO’ option to allow users to specify how many faxes will pull based on the search criteria. (Note: by default 100 items will pull to each tab) - The filter options in the Received tabs have been enhanced to include a blank status filter option to allow users to pull both processed and unprocessed faxes simultaneously
OUTCOMES MANAGEMENT: CARE VALIDATION - The "Show all confirmed visits" is no longer part of the search criteria in Care Validation. EMPLOYEE MANAGEMENT: POLICIES AND PROCEDURES
- A new ‘User Classification’ field has been added to the Add User screen under the Administration tab > Users Menu. This is a required field when adding a new user account or editing an existing user account. GROWTH DIVISION BILLING - A payer setting has been added to allow the option to only pull the discipline's primary DX code on the claim. This setting can be turned on by going to the Reference Menu > Payers > select the Payer > click on the CLAIMS tab > USE SERVICE SPECIFIC PRIMARY DX CODE > Check the box to (Only pull primary DX code to claim). Submit to save the changes. REPORTS - Report templates can now be deleted. To use this feature go to Reports > Report Center > Select Report > Select Report Template > Select ‘Delete Template’ (new option located beside ‘Update Template’). Note: Once deleted, report templates cannot be retrieved. PHYSICIANS PORTAL - The Physician Portal now allows physicians to view and print previously signed orders. MENUS - Note fields that allow for itemized, categorized note entries now have validation to ensure that the Title, Note Category and Notes sections have all been filled out. These note fields are present in the Referral and Patient accounts, Applicant and Agent accounts, Physician ac
Cont. from left counts and on Tasks BUG FIXES AND RESOLUTIONS - Additional physicians can now be added in the Patient Menu > PHYSICIAN tab. - The Process Orders > Receive Orders date filter now functions properly. - Only active pharmacies will default when selecting a pharmacy in online or offline Point of Care. You must do an advanced search to see inactivated pharmacies. - The MAR within PDN visits now only reflects medications with a start date on or before the visit's DOS. - The charge menu advanced search now filters by DOS, patient, and agent correctly. - The previous wound documentation within Skilled Nursing visits is now listed in date order. - When advanced searching for a patient in the Patient Menu, the DOB field now displays.’ - Resolved the problem that prevented users from signing Ventilator Flow Sheets and Seizure Logs while completing visits in Point of Care. - Resolved the issues where you
could not open messages that were system generated. - Inactive attributes will no longer show as selections for the Applicant Status field in Agent and Applicant accounts. This field is located under the HR tab > Applicant or Agent Menu > Select account > Application Information field > Applicant Status field. - Information entered into the ‘Requires Physician Tax ID’ field under the Reference tab > Payers Menu > Select Payer > Claims tab > Requirements Section will now save properly. - Restored functionality of the ‘Show Plan of Care defaults on the Patient Screen’ company setting. This is located under the Administration tab > Company Settings > Components Tab > Check box Selection besides ‘Plans of Care’ setting. - Resolved the problem that caused a delay in selecting Patients when using the Advanced Search in several menus - Resolved the problem that caused users to receive ‘File Not Found’ when attempting to download reports in the Report Center - Removed the green back arrow from the Charge List screen
Cont. from page 2. Footnotes: 1 29 C.F.R. § 2560.503–1(b). 2 Id. at § 2560.503–1(g)–(h); see Premier Health Ctr., P.C. v. UnitedHealth Grp., 292 F.R.D. 204, 222 (D.N.J. 2013). 3 Id. at § 2560.503–1(g)(i)-(ii). 4 Id. at § 2560.503–1(g)(1)(iv). 5 Id. at § 2560.503–1(h)(2)(i)-(ii). 6 Id. at § 2560.503–1( j). 7 Penn. Chiropractic Ass’n v. Blue Cross Blue Shield Ass’n, No. 09 C 5619 at 25 (N.D. Ill. Mar. 28, 2014).
when accessed through the Episode Calendar. This resolved the problem of receiving ‘Webpage has Expired’ when clicking this button. (Go to Schedule > Episode Schedule > Click Here to Confirm Episode) - Resolved a bug preventing the patient name from populating properly when adding an authorization from Episode Schedule > Auths > Add Authorization - Fixed the Edit Authorization screen to open in a new window instead of overriding the main window when accessing Authorizations from the patient account (Insurance tab > Auths button) and the Episode Schedule (Episode Schedules > Auths button) - Resolved error stating that signature must be fewer than 65 characters when e-signing a medication review and other documents. - Resolved error requiring that users ‘Please Select the Patient’ when adding Ventilator Flowsheets and Seizure Logs. - Resolved problem with Previous Answers not populating into the fields correctly in Point of Care.
Providers need to be aware that insurers must follow certain statutes and regulations under ERISA, including providing sufficient notice of an adverse benefit determination. In my experience, many insurers fail to follow these notice requirements, thereby giving providers an additional argument to partially or completely defend against an audit. HTS guest writer Edward Vishnevetsky is an associate at Munsch Hardt Kopf & Harr. His focus is on health law and commercial litigation. Edward is the recipient of the "Legal Leaders on the rise award provided by "Texas Lawyer Magazine," recognized him as one of the top 25 lawyers in Texas under 40.
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