OnCall 2014 Quarter 1 by Palm Beach County Medical Society

The Official Publication of the Palm Beach County Medical Society

The Advocacy Issue

YOUR VOICE MATTERS

Quarter One 2014

Find out why we are the only agency endorsed by the Palm Beach County Medical Society. We make it our practice to genuinely care about yours. As a long-time supporter of the Palm Beach County Medical Society, we do much more than just negotiate the best med mal rates available. We are financially and actively involved, both locally and statewide, in seeking solutions to some of healthcare’s most pressing issues. Call us today to see what we can do for you.

The Providers’ Insurance Specialists ��Healthcare ��

Delray Beach • Jacksonville • Miami • Orlando • Pensacola 800.966.2120 • info@dannagracey.com • www.dannagracey.com

Did you receive money back on your premium last year? Many doctors have through the Palm Beach County Medical Society Workers’ Compensation Program. The rates for all physicians throughout the state are set by the State of Florida. Your practice will pay the same price no matter where you choose to secure coverage. However, under the OptaComp program, you may be eligible for a potential dividend of up to 24.8%. Your membership with the PBCMS can provide savings that can be paid back in dividends. OptaComp has returned a dividend for 12 straight years, with over $4 million over the past six years to Florida medical societies’ members: $600,000 of that went to PBCMS members. The OptaComp (rated “A” by A.M. Best) program is endorsed by the PBCMS and is offered by Danna-Gracey, Inc. For more information, please call Tom Murphy at 800.966.2120.

The Providers’ Insurance Specialists ��Healthcare ��

President’s Report Ronald Zelnick, MD

Quarter Three 2013

President, Palm Beach County Medical Society

An Honor and a Pleasure It is an honor and pleasure to be the President of the Palm Beach County Medical Society. Tonight’s theme of the gala is the ‘70s, a time I am very familiar with. I can tell you my desire to be a physician was positively influenced by physicians who practiced in that decade. One of them is in the audience tonight, Dr. Ernest Zimmerman, a professor of Ophthalmology at George Washington University where I attended college. His inspiration and guidance clearly influenced my career! During the ‘70s, the Vietnam War came to an end. Mark Spitz won seven gold medals at the Olympics, the Supreme Court ruled on abortion. President Nixon resigned after Watergate, and we had the Iranian Hostage Crisis. We had some great music in the ‘70s. In 1972, a song by Don McLean reached number one nationally, American Pie. Over 40 years later it remains one of the most discussed, dissected and debated song that popular music ever produced. It was voted number five in top songs of the century by the Recording Industry of America. Rolling Stone listed Karen Carpenter, ‘70s singer and a drummer among the 100 greatest singers of all time. As she said, “We have only just begun!” In 1977, the movie Saturday Night Fever significantly popularized disco music around the world. The

soundtrack by the Bee Gees is one of the best selling soundtracks of all time. Remember, we all tried to disco back then! Donna Summer, referred to as the Queen of Disco, was one of the defining voices of the ‘70s. Her Rock and Roll Hall of Fame page listed her as the ”first true diva of the Modern Pop Era.” Medical TV shows of the ‘70s had an influence on the public perception of physicians. There was the medical drama of Marcus Welby and his young associate Steven Kiley who were in general practice together in southern California. The comical surgeons of MASH entertained us! There were many advancements in medicine in the ‘70s. Vaccines were developed for rubella, chicken pox, pneumonia and meningitis. Gene splicing, the CT scan, the glucose meter, in vitro fertilization were all introduced. With the growth of new medical technology there was a marked increase in the amount that was spent per average American on health care in the 70’s. However, it was nowhere near what we are spending today. In 1970, the US Healthcare spending was $312 per person compared to $8,000 per person in 2013. The number of actively practicing physicians grew in the ‘70s primarily due to an increase in the number enrolled in medical schools.

To quote William Shakespeare, “what is past is prologue.”This famous quote is on a statue in front of the National Archives in Washington DC and certainly pertains to Health Care Policy in the US. In 1971, a subcommittee on Health of the US Senate summarized five major problems in health care as mass distribution and shortage of health manpower, inequality of access and financing, rising costs, too little attention to keeping people well, lack of coordination resulting in waste and duplication of services. Numerous health care bills were submitted to Congress in the ‘70s. There was the Kennedy plan for universal national health insurance and the more limited Nixon plan, a private health insurance employer mandate with federalization of Medicaid. In 1974, representatives of President Nixon, Senator Kennedy, and Wilbur Mills, the chairman of the Ways and Means Committee, met at a secret meeting at St Mark’s church in Washington DC to format a National health plan. They tried to work out a comprise, but Nixon got caught up with the Watergate scandal and Wilbur Mills with the Fannie Fox scandal . Thus, no health care legislation progressed in Congress. When asked about his greatest regret as a legislator Ted Kennedy would usually cite his refusal to cut a deal with Nixon on health care. ( Continued on Page 20 )

QUARTER ONE 2014

ON CALL MAGAZINE

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FEATURES

09 15

Avoid Being Put on the RAC: Be Prepared for a Recovery Audit Contractor Audit

12 Palliative and Hospice Medicine

15 16

Workers’ Compensation Update American Medical Association Reclassifies “Obesity”

Experiencing Trends of Growth Advocacy in Action

A Time to Die: Making End of Life Decisions

Thank You to our Circle of Friends

ARTICLES

03 President's Report 07 Directors Desk 19 Med Memo 26 Med Society News

12 23 About the Cover: 2014 PBCMS President Ronald Zelnick, MD PBCMS STAFF Tenna Wiles

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DIRECTORâ&#x20AC;&#x2122;S DESK

PBCMS Board of Directors

CEO, Palm Beach County Medical Society

James Goldenberg, MD

Ronald Zelnick, MD President

Stephen Babic, MD

Tenna Wiles, CEO

President-Elect

First Vice-President & Chair, Innovation & Strategic Direction Committee

Shawn Baca, MD Secretary & Chair, Council on Communication & Technology

Who Cares - Advocacy Matters

Brandon Luskin, MD Treasurer & Chair, Council on Finance & Administration

K. Andrew Larson, MD As physicians struggle with the challenges of running a practice and caring for their patients, it is very understandable that there is limited time to deal with the legislative issues facing medicine. I want to remind you that advocacy matters to every physician. The 2014 Florida Legislature will convene on March 4 and will consider proposed legislation that may have a significant impact on your practice and your patients. The Palm Beach County Medical Society Council on Advocacy & Legislation and MEDPAC play a very important role in representing the interests of physicians and patients.

and the impact their decisions have on the medical profession and the delivery of quality medical care. When our physicians speak, our representatives listen. When we our quiet our opponents win.

Immediate Past President

Marc Hirsh, MD Chair, Council on Advocacy & Legislation

Vijay B. Harpalani, MD Member at Large

H. Daniel Adams Yes, we have great physician leaders but we need your support. Effective advocacy requires a chorus of physicians speaking with a united voice. We need your membership, we need your contributions to MEDPAC, and we need your involvement. Check out our new website at www.pbcms.org . There you will find a detailed listing of the 2014 Legislative Agenda and legislator contact information.

Medical Student

Vincent Apicella, DO Member at Large

Michael Dennis, MD PBCMS Services Liaison

Roger Duncan, MD Chair, Ethical & Judicial Affairs Committee

Brad Feuer, DO Chair, Medical Legal Committee

James Howell, MD Chair, Council on Medical Education

Tulisa Hanflink LaRocca, MD Advocacy results often take years to reveal themselves. Did you know that Palm Beach candidates for state and national legislative office are interviewed, educated and informed so that they can understand physician issues? They may not always agree with every position but we can help them understand the issues

Please contact me anytime at tennaw@pbcms.org or 561 433-3940 to discuss how you can become engaged.

Resident

Beth-Ann Lesnikoski, MD Chair, Council on Member Services

Alan Pillersdorf, MD FMA/AMA Liaison

Jack Zeltzer, MD

Tenna Wiles

Chair, By-Laws Committee

CEO

Sandra Blair Alliance Representative

PBCMS Board of Trustees Brent Schillinger, MD Jack Zeltzer, MD Lawrence Gorfine, MD Alan Pillersdorf, MD Jose F. Arrascue, MD Malcolm Dorman, MD K. Andrew Larson, MD Ronald Zelnick, MD Steven Babic, MD James Goldenberg, MD

QUARTER ONE 2014

ON CALL MAGAZINE

Workers’ Compensation Update American Medical Association Reclassifies “Obesity” The American Medical Association (AMA) has approved a resolution reclassifying obesity as a “Disease state.” This AMA resolution is the equivalent of declaring that almost one third of all Americans suffer from a medical condition that requires treatment. A recent report conducted by the California Workers’ Compensation Institute (CWCI) attempts to quantify the potential impact of this reclassification on future workers’ compensation costs. The study was based upon 1.2 million workers’ compensation claims in California from 2005 to 2010. The conclusion of the study is that paid losses on claims with obesity as a co-morbidity averaged $116,437, or 81.3% more than those without obesity as a co-morbidity. The claims involving obesity averaged about 35 weeks of lost time, or 80% more than the 19-week average for claims without obesity.

In the past, obesity has been classified as a condition that occurs at the same time of an injury or illness, but has always been considered independent and not the actual cause of the claim. The reclassification of obesity as a “disease state” will likely lead to an increase in claims involving obesity and a rise in costs for employers. Tom Murphy is a workers’ compensation and medical malpractice insurance specialist agent with Danna-Gracey. He can be reached at or (800) 966-2120 or Murphy@dannagracey.com.

Many workers’ compensation experts believe that this new classification will open the “floodgates” for claims that include obesity as a co-morbidity and increase the claims in which the injured worker claims that obesity was a result of the injury and should be compensable. Additionally, medical providers will have a greater responsibility to treat obese patients and they will be much more likely to treat them knowing the potential for being paid for this treatment, as indicated in the report.

QUARTER ONE 2014

ON CALL MAGAZINE

Avoid Being Put on the RAC: Be Prepared for a Recovery Audit Contractor Audit By Kathleen Stillwell, MPA/HSA, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company

What is a RAC Audit?

Who is the RAC Auditor?

Any medical practice submitting claims to a government program, such as Medicare, may contend with a Recovery Audit Contractor (RAC). RAC audits are not one-time or intermittent reviews; they are a systematic and concurrent operating process for ensuring compliance with Medicare’s clinical payment criteria, documentation, and billing requirements.

CMS has contracted with RAC auditors for each region in the United States. It is important to know who the RAC auditor is in your region. Never ignore a letter from one of these organizations. The United States is divided into four regions. Each region has a designated recovery audit contractor. Florida, Georgia, and South Carolina are in Region C. • Region A RAC Auditors: Performant Recovery, Inc., and subcontractor, PRG-Schultz USA, Inc. • Region B RAC Auditors: CGI Technologies and Solutions, Inc., and subcontractor, PRG-Schultz USA, Inc. • Region C RAC Auditors: Connolly Consulting Associates, Inc., and subcontractor, Viant Payment Systems, Inc. • Region D RAC Auditors: HealthDataInsights, Inc. Las Vegas, Nevada, and subcontractor, PRG- Schultz USA, Inc.

The RAC program was signed into law by the Medicare Prescription Drug Improvement and Modernization Act of 2003 and made permanent by the Tax Relief and Health Care Act of 2006. Its purpose is to identify improper Medicare payments—both overpayments and underpayments. The RACs use proprietary software programs to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries’ mistakes, medical necessity, and coding. RACs also conduct medical record reviews. In fiscal years 2010 and 2011, RACs identified half of all claims they reviewed as having resulted in improper payments. The program’s mission is to detect and correct past improper payments so that the Center for Medicare and Medicaid Services (CMS) can implement actions that will prevent future improper payments: • Providers can avoid submitting claims that do not comply with Medicare rules. • CMA can lower its error rate. • Taxpayers and future Medicare beneficiaries are protected.

Who Is Subject to a RAC Audit? • Hospitals. • Physician practice. • Nursing homes. • Home health agencies. • Durable medical equipment suppliers. • Any provider or supplier that submits claims to Medicare.

What Does the RAC Review? The recovery audit looks back three years from the date the clam was paid. RACs are required to employ a staff consisting of nurses, therapists, certified coders, and a physician. The RAC reviews claims on a postpayment basis. There are three types of review: • Automated—no medical record needed. • Semi-automated—claims review using data and potential human review of a medical record or other documentation. • Complex—medical record required.

What Can You Do to Prepare for a RAC Audit? Assess your risk for billing issues by performing a risk analysis of your billing practices. Assign a knowledgeable member of your staff to review your

billing processes and to develop a billing compliance plan. Consider hiring a contractor for this task. Identify billing issues, keep track of denied claims, and look for patterns and determine what corrective actions you need to take to avoid improper payments. Common billing errors include: • Inadequately trained staff. • Lack of time. • Did not follow recommendations in Federal Register bulletins. • Did not consult Health and Human Service bulletins. • Misinterpretation of rules. • New staff/New billing company. The person responsible for implementing the billing compliance plan should regularly monitor RAC progress in your region. Each RAC must maintain a website with information on new audit focus areas and the status of a provider’s audits. Areas to include in your assessment and monitoring plan include: • Review denied claims categories by RAC audit. • Keep abreast of notifications on CMS website. • Review annual Office of Inspector General (OIG) work plan to identify audit areas. ( Continued on Page 20 )

Palliative and Hospice Medicine Experiencing Trends of Growth by Faustino Gonzalez MD, FACP, FAAHPM Hospice and Palliative Care are often said in the same breath. While related, they are two separate disciplines. Each one is experiencing a trend of growth, as healthcare develops initiatives to frame medical care in terms of the whole person rather than treating each diagnosis separately. Palliative medicine dovetails nicely into this initiative, offering medical support to patients suffering from a serious illness. Offered in conjunction to curative care, palliative serves patients with chronic illness at any stage. Common referrals are for addressing pain, shortness of breath, fatigue, constipation, nausea, appetite loss, difficulty sleeping, and depression. As a subset of palliative care, Hospice is reserved for those patients who the primary physician and hospice physician identify as having a prognosis of 6 months or less. Along the continuum of care, hospice is a support system for a family and their primary physician, allowing physicians to continue to see their patients, prescribe medications, and direct the plan of care both under the hospice diagnosis and under related diagnoses. It is not the transition from the primary physician to hospice care, but rather a team approach for the patient. Most hospices provide extensive support for the primary care physician as well, such as providing assistance in continuing to bill and copies of RN visit notes.

Palliative Service model trends Once associated more with end of life 12

ON CALL MAGAZINE

care, palliative medicine is increasingly being utilized from the time of diagnosis. Hospitals throughout the country are increasingly opting to add palliative medicine programs. More than two-thirds of hospitals with more than 50 beds now offer palliative care, up from 25 percent in 2000, according to the Center to Advance Palliative Care at Mount Sinai School of Medicine. Washington leads the trend, with more than 80 percent of hospitals designating palliative programs. In Palm Beach County, there are several independent institutions that partner with hospitals to offer palliative medicine, such as Harbor Palliative Care and South Florida Palliative Medicine Specialists.

Hospice Service model trends In the last decade, the clinical community has demonstrated a greater acceptance of alternative forms of care including hospice. According to peer review literature through the American Academy of Hospice and Palliative Medicine, adding hospice to the patient’s physician team 6 months prior to death (compared to weeks before death) greatly improves quality of life for both the patient and family. For hospices, perhaps one of the largest changes is a paradigm shift from requiring patients to stop all aggressive treatments. Today, 4% of hospices nationwide allow patients to continue treatments that are considered aggressive, as long as they are providing comfort and quality of life without changing the prognosis. The concept addresses patients for whom treatments affect quality of life, such as a patient with a large brain lesion receiving radiation to reduce pain. Hospice of Palm Beach County and Broward County has been a local pioneer in this “open access” effort, and continues to be unique in not only offering full services,

QUARTER ONE 2014

but funding treatments for some cases thanks to the generosity of donations from the community.

Public awareness trends for end-of-life care Programs that assist families in discussing their end-of-life wishes are emerging. One example is the Conversation Project (www.theconversationproject.org), which notes that when surveyed, “60 percent of people say that making sure their family is not burdened by tough decisions is ‘extremely important.’” In contrast, 56 percent have not communicated their end-of-life wishes. The program is taking part in a national campaign called “Let’s have dinner and talk about death,” a campaign that encourages and assists families to “transform the seemingly difficult conversation about death into an intimate shared experience.” From my viewpoint over the last 40 years, it’s been fascinating to witness the paradigm shift. Where palliative medicine was unheard of at the time of diagnosis, today it is common. Where hospice was strictly defined by ceasing treatments, today’s view addresses the medical needs of the whole person. Where the senior community once saw hospice as “giving up on your life,” they are increasingly seizing the opportunity to shape and control their medical care—not just at the very end of life, but in the years ahead of time. Faustino Gonzalez MD, FACP, FAAHPM serves as Vice President of Medical Affairs for Hospice of Palm Beach County and Broward County. He is board certified in Internal Medicine and Hospice and Palliative Medicine, both by the American Board of Internal Medicine.

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Advocacy in Action

PBCMS Council on Legislation Members This year The Palm Beach County Council on Legislation and Advocacy is being led by Mark Hirsh, MD.

PBCMS Council on Legislation

MEDPAC MEDPAC is the bipartisan political action committee of the Palm Beach County Medical Society. Its goal is to support and elect pro-medicine candidates at the state and local level. Every year there are critical votes that have a major impact on the practice of medicine. MEDPAC has proven to be a valuable asset in educating legislators about the concerns of medicine.

What Does MEDPAC Do? • MECDPAC makes direct contributions to candidates seeking election to the Florida House of Representatives and Senate. • MEDPAC offers political education programs • MEDPAC may also conduct independent surveys, or distribute direct mail or produce media support of a particular candidate.

How to Join MEDPAC: MEDPAC dues are $100. You can join online at www.pbcms.org or call Mindi Tingler561 433-3940 ext 12.

The Palm Beach County Medical Society Council on Legislation works with the Florida Medical Society, representing Florida physicians at the Capitol and fighting for legislation that protects patients and safeguards physicians’ ability to practice medicine. The Council and the FMA are dedicated to the passage of laws that improve Florida's practice landscape, and we are equally committed to defeating proposals that would harm patients or undermine physicians’ authority as leaders of the medical care delivery team. Over the years, our efforts have secured many victories for physicians including historic medical liability and expert witness reform, legislation requiring insurance companies to honor patients’ assignment of benefits, and much more.

Mark Hirsh, MD

Vincent Apicella, DO Steve Babic, MD Shawn Baca, MD Monroe Benaim, MD- Co-Chair Jeffrey Berman, MD Kelly Bryant Malcolm Dorman, MD James Howell, MD Emily Kelly Norman Henry Pevsner, MD Mark Rubenstein, MD Brent Schillinger, MD Maureen Whelihan, MD Kenneth Woliner, MD Jack Zeltzer, MD

MEDPAC Board Members

The responsibilities of the Council include coordinating legislative activities with the FMA, maintaining and promoting close relationships with elected officials, and keeping our members informed with regard to legislation which may or possibly will affect the practice of medicine.

The 2014 MEDPAC is being chaired by; Brent Schillinger, MD.

Brent Schillinger, MD

The 2014 Legislative Session runs from March 5 - May 30. During this 60-day session a wide range of legislation affecting medicine will be considered. For a complete listing of the 2014 Legislative Agenda and a contact listing of the Legislative Delegation visit www.pbcms. org. The role of PBCMS members is crucial. We will be sending a delegation to Tallahassee to meet with our Legislative Delegation. It is also important for our members to communicate with their representatives. Legislative alerts will be issued throughout the Session.

Jeffrey Berman, MD (Co-Chair) Jose Arrascue, MD Stephen Babic, MD Shawn Baca, MD Malcolm Dorman, MD Marc Hirsh, MD Stuart B. Himmelstein, MD James Howell, MD Beth-Ann Lesnikoski, MD Norman Henry Pevsner, MD Alan Pillersdorf, MD Mark Rubenstein, MD Ronald Zelnick, MD

QUARTER ONE 2014

ON CALL MAGAZINE

A Time to Die: Making End of Life Decisions By Sheila Berkowitz

Ecclesiastes 3:1 To everything there is a season, and a time to every purpose under heaven: a time to be born and a time to die... Already, you are thinking, "This is too depressing, never mind!" Talking about death always stirs our deepest emotions. I understand, but please keep reading. At some time in your life, you are going to have to make decisions concerning your own death or perhaps someone else's. It is less difficult when we make decisions concerning our own death. But It is agonizing to have to make this decision for someone else - your parent, your spouse, sibling, child, or perhaps your best friend. Having worked in a hospital as a respiratory therapist for over 30 years, I have witnessed this agony firsthand thousands of times. I have found that It is oftentimes a lack of understanding in many areas which causes the greatest anguish in those making the decision. It is my desire to help you understand and help you make an informed decision when you are faced with your own end of life decision or someone else's. Perhaps you are reading this as you sit in a your doctor's office: Primary Care, Cardiac, Pulmonary, Bariatric, Kidney, Infectious Disease. Whether you are 30 years old or 80 years old, the most pertinent question you could ask your doctor today is, "What, in your professional opinion, knowing my past and present medical history, is the likelihood that I would survive if placed on life support?" Whatever the answer is, it requires end of life decisions which only you should make while you are able. Now 16

ON CALL MAGAZINE

is the best time to make that decision. We don't know what the next moment may bring. Tragically, you might be a family member reading this as you sit in the Intensive Care or LTACH (Long Term Acute Care Hospital) waiting room. You have been left with making the agonizing end of life decision for your mother, father, sibling, or spouse. This can be the most difficult decision you will ever have to make. You are wrought with so many emotions guilt, sadness, loss, loneliness. This is perhaps the reason why so many people procrastinate when making the end of life decision because the reality of living without this person is not imaginable. How do you make your (or someone else's) end of life decisions?

IMPORTANT CONSIDERATIONS: 1) Past medical history: As much as we wish we had not made poor choices in life, unfortunately those poor choices creep up on us exponentially as we age (smoking, drinking, drug abuse, poor eating habits, etc). Additionally, we may be laden with hereditary illness, i.e, congenital heart disease, kidney disease, diabetes, blood disorders, addiction, cancer, etc. We may become the victims of work related diseases and injuries (asbestosis, pulmonary fibrosis, mesothelioma). Finally, there are those diseases that attack us from nowhere (Lou Gehrig's disease, muscular dystrophy). Not to mention automobile accidents, head injuries, the list is endless and age often does not matter. These diagnoses alone may not bring us to the brink of death, but when you add more insults to the

QUARTER ONE 2014

initial one (aspiration pneumonia, end stage renal failure, congestive heart failure, stroke, hemorrhage, anemia, blood pressure issues, cardiac arrest, respiratory failure, sepsis, wounds, etc, etc), things get frustratingly more and more complicated and difficult to treat and almost impossible to cure. 2) Oftentimes, end of life decisions must be made in the Critical Care/Intensive Care Unit or LTACH: The Intensive Care Unit is the area where a patient receives care for the original diagnosis. The length of time in intensive care becomes a problem when there are additional insults which were mentioned above. If the patient qualifies (insurance coverage), after so many days/weeks in intensive care, he/she will be discharged to a "Long Term Acute Care Hospital" or LTACH. Patients discharged to an LTACH are in an extremely fragile medical state. It is by no means a rehabilitation facility where a great deal of attention is focused on getting the patient out of bed and walking. The majority of patients in an LTACH are much too sick for extensive physical therapy, at least initially. These patients have added insults to their original injury; now you have a 79 year old obese patient, for example, who has smoked 3 packs of cigarettes a day for 60 years, with pneumonia on a ventilator, in kidney failure on dialysis, with deepening wounds. This patient is being kept alive by life sustaining machines. The patient is literally teetering between life and death. In other words, an irregular heartbeat, blood clot, infection, hypertension, hypotension, etc, could occur at any moment and be life threatening. Today, with amazing technology, with medications, dialysis and ventilators, we

can literally keep someone in a vegetative state for months and even years! You might be asking yourself, "Why would well educated medical professionals do this?" It is simply because end of life decisions were never made, or made without a clearer understanding.

CHOOSING YOUR "CODE STATUS" PERTAINING TO END OF LIFE DECISIONS The most important information you provide when you enter a hospital is your "advance directives" which is a legal document (specific for each state) which clearly states your end of life wishes. If you do not have a living will, you should fill out an "Advance Directives" document. You can find this form online, at your Doctor's office or in the hospital. You must be alert and of sound mind when you sign it for this document to be valid. If you choose to appoint a healthcare surrogate/power of attorney to be in charge of your end of life decisions, you MUST make your wishes clearly known to this person beforehand. End of life is an emotional time for those having to make these decisions on your behalf. Too many times we see these wishes completely disregarded, even when they are discussed beforehand. This extremely important information will be kept in your medical record. In the hospital it is translated as your CODE STATUS. This status informs hospital staff TO WHAT EXTENT you wish to be resuscitated in the event of cardiac arrest and/or respiratory arrest.

FULL CODE STATUS: Every means possible will be attempted to resuscitate the patient in the event of cardiac arrest/respiratory arrest.

1) Cardiac Compressions: the resuscitation team must place both hands, one on top of the other, in the center of the chest and compress 2 inches at least 100 times/minute. Ribs are broken more often than not. Compressions may continue for more than 30 minutes. Few patients survive CPR. 2) Endotracheal intubation: involves using a metal blade to open the mouth (often teeth are broken) in order to insert a tube into the lungs to provide an airway for breathing. Many attempts may cause trauma to the airway. The patient is then placed on a ventilator indefinitely (when or IF they are able to be weaned). 3) I.V. Medications: requires insertion of intravenous line (if not already available) and if not able to place intravenously, must be performed intra-oseously, by forcing catheter into the bone of the lower leg (largest bone, bone of choice). If the patient survives CPR, they will be placed on life support. Statistics reveal that a very small number of patients survive CPR; being placed on life support has no guarantees of survival, in fact, oftentimes being placed on life support prolongs the inevitable, which could be days, weeks, months and even years. When the patient is in the midst of the original insult we mentioned above, and has possibly had minor setbacks, the decision of FULL CODE is reasonable. However, you must also consider if the patient has had numerous additional complications. These complications take a constant toll on an already compromised body, causing extreme weakness, loss of will to live, multisystem failure and finally a state of unresponsiveness. As hard as the medical teams (numerous doctors, nurses, and

respiratory therapists) work to wean patients from life support, it is a constant day to day battle of one step forward, two steps back. It is possible to wean some patients from mechanical ventilation, which is a challenge considering that the patient is constantly at risk for infection/ sepsis, aspiration pneumonia, feeding tube issues, organ failure, etc. Statistics show that it is highly unlikely that this person will survive a full cardiac arrest. It is a very difficult decision, one that you will struggle with, especially when you are making the decision on behalf someone else. Let me say now, that it is a decision you must make for yourself. This is not a decision for someone else to make for you. If you have ever witnessed the sheer agony a person goes through, the guilt, the heartache, the very real anguish, when they are left with this decision for a loved one, you would make your end of life wishes known to your family and physician today. It is your life and your death and your decision. It is your right and your responsibility!

LIMITED CODE STATUS: 1) Resuscitation Medications only, without endotracheal intubation or cardiac compressions, OR 2) Medications and Intubation, without Cardiac Compressions. This might be indicated for a patient who has severely compromised lungs but a strong heart. Non-invasive (BIPAP) ventilation rather than endotracheal intubation is an alternative means for ventilation. ( Continued on Page 22 )

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SAVE THE DATES March 29, 2014

Family / Doctors Day South Florida Science Center and Aquarium. (6 p.m - 9 p.m.)

April 13, 2014

Proceeds from this event benefit Project Access, providing health care for low income, uninsured residents of Palm Beach County; and the Medical Society’s medical scholarship fund. The awards will be presented at the Heroes in Medicine luncheon at the Kravis Center Cohen Pavilion on Thursday, May 8, 2014.

PBCMS Services Annual Dinner

Thank You!

Presentation: "Leading and Living: The Impact of Work and Life" by Michael F. Gervasi, DO. (6 p.m.) www.pbcms.org

Two Wheels One Cause and Ilene Mercier for the generous donation of over $3500 to assist in the care of Project Access patients. To date Ilene Mercier and Two Wheels One Cause have raised over $10,000 for support of Project Access patients.

May 8, 2014

Heroes in Medicine Awards The Kravis Center, Cohen Pavilion. (11 a.m. - 1 p.m.) www.pbcms.org/heroes

Escape Fire: The Flight to Rescue American Healthcare Palm Beach Drama Works presents FILMS TO THINK ABOUT. The Fledgling Fund is driven by the passionate belief that films can inspire a better world. They believe that films can raise awareness about key social issues, engage audiences, strengthen social movements, and create change. You will not want to miss - Escape Fire: The Flight to Rescue American Healthcare tackles one of the most pressing issues we face: how to improve our healthcare system presented on March 4, 2014 - 2:00pm and 7:00pm. www.palmbeachdramaworks.com

Heroes in Medicine Palm Beach County Medical Society Services, a non-profit organization, is hosting the 11th Annual Heroes in Medicine Awards Ceremony. These prestigious awards honor individuals and organizations throughout Palm Beach County that use their skills and resources in the field of health care to provide outstanding services for the people of our local, national, and global communities.

PBCMS Triple Aim Diabetes Initiative is launching its pilot program with help from generous donations from Quantum foundation, Palm Healthcare Foundation and PBC HealthCare Stuart Miro, MD District. UM/JFK Residency program and FAU Diabetes program will be providing services. The program will provide coordinated care for type 2 Diabetes patients. The goal for the program is to improve health outcome and quality of care while lowering costs. Jose Arrrascue, MD will Chair the program with Stuart Miro, MD serving as Lead Care Coordinator. For additional information please contact Stuart Miro, MD by email at stuartm@pbcms.org or by calling 561-433-3940.

Health Care Sonnection Educational Series

Palm Beach County Medical Society and Palm Beach Medical Group Management Association are proud to announce our 2013-2014 Health Care Connection Educational Series. Luncheons are held on the 1st Wednesday of the month from 11:30 – 1:00 March 5 “Don’t be a Doer be a Leader” at the Palm Beach Gardens Doubletree Hotel April 2 Protecting and Keeping What’s Yours – “Watching Out for Your Assets” at the Delray Beach Golf Club May 7 “Practice Management Tools Budget, Expenses, Staffing and More” at the Atlantis Country Club June 4 Regulatory Update – CMS at the West Palm Beach Marriott – The Bistro To enroll please register online at www. pbcms.org call (561) 433-3940.

ATTENTION PHYSICIAN SPOUSES: THE ALLIANCE NEEDS YOU! The Palm Beach County Medical Society Alliance is a grassroots volunteer organization comprised of physician spouses who represent the family of medicine in our community. Not only does the Alliance promote and support the well-being of our physicians and their families, they advance health-related endeavors which enrich our community through patient education. ( Continued from Page 24 )

QUARTER ONE 2014

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( Continued from Page 3 ) There were many similarities between the Nixon health care plan and the Obama health care plan of today. They both provide for universal coverage, are based on private insurance, have an employer mandate, expand Medicaid and ban pre-existing conditions. Who would have thought the Affordable Care Act would be modeled after Nixon. We have just taken a look back into the past. Many of the health care issues of the ‘70s are still with us today. Our Palm Beach County Medical Society will continue to advocate for accessible, cost effective, quality health care for our community. We have some wonderful physicians in Palm Beach County and as a physician leader, I will strive to support that they be treated like professionals. Which they are!

Establish compliance and practice standards and conduct internal monitoring and auditing to evaluate compliance. Conduct appropriate training and education for staff and respond to deficiencies identified during internal audits. Establish corrective action plans and enforce disciplinary standards when necessary. Medical billing is complex. Billers and coders must be knowledgeable about many areas pertaining to billing/ reimbursement. Be sure your billing staff understands local medical review policies and is knowledgeable of practice jurisdictions. Billing personnel must staff stay current on coding requirements and keep up with industry changes, understand denial and appeal processes, and be able to identify resources for support.

extended payment plan. If a recoupment demand is issued, you may pay by check within 30 days with no appeal, allow recoupment from future payments, or request or apply for an extended payment plan. There is an appeal process if you do not agree with the audit findings. Do not confuse the RAC Discussion Period with the appeals process. If you disagree with the RAC determination, do not stop with sending the discussion letter detailing why you disagree with the findings. File an appeal before the 120th day after the demand letter. Send correspondence to RAC via certified mail. It is recommended you have legal representation to advise you in the response to a recoupment demand, to determine if you should appeal, and to ensure you meet the required regulatory requirements of the appeal process.

What to Do if You Are Audited In 1977 we lost one of the greatest, Elvis, the King of Rock and Roll. As he said “we can't go on together with suspicious minds.” Thank you, Ronald Zelnick MD,FACS,FASCRS Installation Address November, 23rd 2013

( Continued from Page 11 ) • Monitor RAC progress at regional RAC (their web postings). • Perform audit of your billing practices.

Potential Issues with Electronic Medical Records The OIG is studying the link between electronic medical record (EMR) systems and coding for billing. There is a concern that some EMR systems may upcode billing through automatically generated detailed patient histories, cloning (when you cut and paste the same examination findings), and templates filled in to reflect a more thorough or complex examination/visit. Review these issues with your EMR company and determine if your EMR program has the potential to automatically upcode billing based on EMR documentation.

Fundamentals for Compliance 20

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Do not ignore a letter from the RAC auditor. It is recommended you have an attorney assist you with your response to a RAC audit. Check with your insurance company to determine if you can get help with the audit. The Doctors Company, for example, provides RAC audit legal assistance for all members as part of its MediGuard® coverage. Before you send records to the auditor, be sure to review them in a “self-review.” Are there common themes? Are you coding with the correct documentation? Make copies of everything you send to the RAC auditor and be sure to keep a copy of all documentation. Send medical records via certified mail.

Where to Get More Information on Government Audits More information on the growing risk of government investigations and audits can be obtained through five short videos featuring tips from Kevin R. Warren, Esq., of Michelman & Robinson LLP's Healthcare Practice at http://ow.ly/rP02n. The videos address how to create an effective compliance program, why it's important to train staff to avoid improper and exaggerated coding, what steps to take if your practice receives a subpoena, and how to properly protect electronically stored information. Medicare Recovery Audit Contractors and CMS's Actions To Address Improper Payments, Referrals of Potential Fraud, and

Staying on top of the RAC audit process is important as there are multiple policies and procedures governing RAC audits. The RAC can request a maximum of 10 medical records from a provider in a 45day period. The time period that may be reviewed has changed from four years to three years.

Performance. Office of Inspector General. U.S. Department of Health and Human Service. August 2013. https://oig.hhs.gov/ oei/reports/oei-04-11-00680.asp. Accessed Dec. 16, 2013.

The Recovery Audit Program and Medicare: The Who, What, When, Where, How and Why? Centers for Medicare & Medicaid Services. May 13, 2013. http://www.cms.gov/Research-Statistics-Data-and-Systems/ Monitoring-Programs/Recovery-Audit-Program/Downloads/

Responses are time-sensitive, and significant penalties may result if they are not handled properly. RACs are paid on a contingency basis for overpayments and underpayments. If you agree with the RAC demand letter you have the choice of paying by check or recoupment from future payments, or you may request an

QUARTER ONE 2014

The-Recovery-Audit-Program-and-Medicare-Slides-051313. pdf. Accessed Dec. 16, 2013.

The latest news & information on PBCMS

YOUR AD IN Reach your Palm Beach County doctors and medical community when you advertise here. Other advertising and sponsorship opportunities are also available.

Call 561-433-3840 for details!

THE HCA PALM BEACH HOSPITALS are proud to serve the people of Palm Beach County. We are committed to staying at the forefront of medical excellence and quality patient care. YOU BELONG HERE: HCA Hospitals of Palm Beach County

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( Continued from Page 17 )

DO NOT RESUSCITATE (DNR) STATUS: 1) Cardiac compressions will not be given 2) Resuscitation medications will not be given 3) No Intubation, however, non-invasive ventilation may or may not be administered. When you choose not to be resuscitated (DNR), it does not mean you will die in pain and agony, struggling for each breath. It essentially means you are simply allowing nature take it's course without intervention. Comfort measures continue to be a priority in the hospital setting. Most hospitals offer consultation in easing pain and suffering such as Hospice Care, palliative care and termination of life support . This must be requested by the patient or person making the end of life decisions and ordered by the primary care physician.

week after week, the person you have left to make your end of life decision sits at your bedside, holding your hand, hoping and praying for a miracle that you will regain your strength, and return to the person you once were; that person who just a few weeks ago was so full of life and energy. Sickness robs the body of all those things. It is very difficult for those who love you to come to terms with this. Spouses become angry with their husband/wife because they can't just 'snap out of it.' A pregnant daughter leaves her comatose mother on life support for months so she could deliver her baby before having her mother removed from life support. Families who are at odds with each other, perhaps not speaking, leave their loved one on life support unable to make the decision day after agonizing day, while the patient suffers in pain with a feeding tube, breathing tube, fecal management tube, and IV's, with their hands restrained for fear they might pull one of these tubes out.

They have employees who are looking for a paycheck. It is not ethical for them to tell you when it is time to let go. On the other hand, you may have a doctor telling you it is time to make a decision. In either case, you must face the reality that a decision must be made. Be informed; don't leave this decision for a time when your mind is not clear, your body is weak and you are emotionally overwhelmed. It is the right thing for you to do. Don't wait any longer!

Various organizations make advance directive forms

available. One such document is “Five Wishes” that includes a living will and a health care surrogate designation. “Five Wishes” gives you the opportunity to specify if you want tube feeding, assistance with breathing, pain medication, and other details that might bring you comfort such as what kind of music you might like to hear, among other things. You can find out more at:  Aging with Dignity www.AgingWithDignity. org (888) 594-7437  Other resources include:  American Association of Retired Persons (AARP) www.aarp.org (Type “advance directives” in the website’s search engine)  Your local hospital, nursing home, hospice, home health agency, and your attorney or health care provider may be able to assist you with forms or further information.  Brochure: End of Life

CONCLUSION Imagine the unthinkable: day after day,

Easily overlooked is the fact that hospitals are a business... they have a bottom line.

Issues www.FloridaHealthFinder.gov (888) 419-3456

Mental and Behavioral Health Symposium (6th Annual) Saturday, March 8, 2014 n Baptist Hospital of Miami (4.0 CME/CE) MentalandBehavioralHealth.BaptistHealth.net

Pediatric Symposium: A Multispecialty Approach to Pediatric Care (13th Annual) Saturday, April 5, 2014 n Marriott Miami Dadeland Hotel, Miami (6 CME/CE) MiamiPediatrics.BaptistHealth.net

Nephrology Symposium (Fourth Annual)

Saturday, April 12, 2014 n Baptist Hospital of Miami, BCVI Conference Room (4 CME/CE) NephrologySymposium.BaptistHealth.net

Miami Robotics Symposium (Third Biennial)

Friday and Saturday, April 25-26, 2014 n Eden Roc Hotel, Miami Beach, Florida MiamiRobotics.BaptistHealth.net

Head and Neck Cancer Symposium (Third Annual) Saturday, April 26, 2014 n Baptist Hospital of Miami, Auditorium (4.5 CME/CE) HNCancerSymposium.BaptistHealth.net More CME opportunities at BaptistHealth.net/CME

Connect with us BaptistCME

Thank You to Our Circle of Friends

Accounting BDO Tammy Clarke (561) 689-7888 Accounting and consulting services with deep industry knowledge and proactive guidance

Billing and Coding Acevedo Consulting Jean Acevedo (561) 278-9328 A firm focusing on the compliance needs of a medical practice

Business Coach Proffitt Management Solutions Nancy Proffitt (561) 582-6060 Certified business coaching-enhancing management and business skills for healthcare professionals.

Education Keiser University Elizabeth Houlihan (561) 471-6000 Florida’s second largest independent University

Financial Services Comerica Bank Kerri Burke (561) 804-1420 Specializing in lending to large Medical Practices and Medical lock box services 1st United Bank Rayma Buckles (561) 575-7860 We offer lending and depository services, tailored to the Healthcare industry First Citizens Bank Michelle Tierney (772) 221-7050 Local bankers specializing in Health Care, business banking you can count on Morgan Stanley Wealth Management Patricia Corbett, CFP (561) 393-1535 Helping individuals and groups realize and build their financial potential

PNC Healthcare Business Banking Mary Helen Johnson (561) 803-9238 Dedicated healthcare banker for medical professionals providing innovative banking solutions

The Doctors Company Shelley Hakes (800) 741-3742 We are the nation’s largest physicianowned medical malpractice insurer

Legal Services Rockefeller & Associates Jeffrey J. Rockefeller, CFP (561) 575-6363 Financial Planning, Fee-Based Wealth Management and Insurance for Medical Professionals

Broad & Cassel Heather Siegel Miller, Esq. (305) 373-9406 Providing timely health law advice to physicians, hospitals and health care organizations

SunTrust Bank Medical Specialty Group Ashlea Ayer (954) 765-7380 Serving the complex financial needs of physicians and their practices

The Florida Healthcare Law Firm Jeff Cohen, Esq. (561) 455-7700 Legal help on regulatory and business matters and their practices

United Capital Peter Anderson (561) 314-4711 Providing independent, comprehensive wealth management strategies for physicians

Medical Defense Solutions Tom Murphy (800) 601-8979 If you have to self-insure don’t do it alone

Human Resources Tri-Net Marc Petroski (561) 741-1845 Delivering HR services including benefits, payroll and worker’s compensation insurance

Insurance Danna-Gracey Matt Gracey (561) 276-6906 An independent agency dedicated solely to insurance coverage for Florida’s physicians & healthcare providers. Opt Comp Tom Murphy (561) 276-6906 You could be eligible for a dividend of up to 24% on your Workers Comp insurance premium

Practice Management ProMD Practice Management Juan Kouri (786) 419-7973 Billing & Collections, Practice Assessments and more Palm Beach Accountable Care Organization Kelly Conroy (561) 429-2680 Physician-owned and operated organization dedicated to providing quality coordinated care

Technology DocbookMD Heather Wray (512) 383-5822 Send fast, secure HIPAA-compliant messages and images For more information on our Circle of Friends please visit our website at www. pbcms.org

QUARTER ONE 2014

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( Continued from Page 19 ) Here is just a sampling of some of their activities.

"Stop America's Violence Everywhere" (SAVE) Program Teaching children kindergarten through fourth grade about bullying and resolving conflict, the Alliance presents "Hand are Not for Hitting" video.

Susan G. Komen South Florida Race for the Cure Each year, the Alliance sponsors a team for the Race, which attracts more than 18,000 participants and raises money to fund breast cancer research and health efforts in our community. The Alliance is proud to join this celebration of life honoring those who have survived the dreaded disease and in memory of those who've lost their battles.

Palm Beach County Science Fair Alliance members were honored to serve as judges for the competition at the South Florida Fairgrounds in December. They interviewed finalists in the medicine and health categories and awarded a monetary prize to the top performer.

AMA Foundation Holiday Sharing Card Program Members of the Alliance raised money to support medical school programs and needed financial aid to medical students in our county pursuing a health related career. All who contributed were featured in the Holiday Sharing Card that went to all Alliance members.

National Doctors Day March 30th has been designated National Doctors Day and is observed across the country to pay tribute to members of the medical profession. To recognize the unique sacrifices, dedication and special challenges our local physicians face as they better the health of our citizens, the Alliance places bookmarks of appreciation on patient food trays in all the area hospitals.

Legislative Advocacy It's important for Alliance members along with their physician spouses to support advocacy efforts in Tallahassee

and Washington. Their involvement helps give legislators a more accurate picture of how healthcare legislation is affecting patients, families and the practice of medicine. Interaction with fellow members is one of the greatest benefits of Alliance membership. The Alliance provides social networking opportunities and participation in programs and community events. The Alliance collaborates with the Palm Beach County Medical Society on fundraising events such as the 'Heroes in Medicine' luncheon and the annual gala. Every member or potential member is invited to our General Membership meetings which include lots of socializing, food and fun! County Alliance dues are only $30.00/year and even just the financial support will help us continue our community programs and scholarships. There are benefits for everyone's varied interests Working together as a team (county, state and national) the Alliance makes a difference and has greater impact! Thank you so much for your support!

BDO IS PROUD TO SUPPORT

PALM BEACH COUNTY MEDICAL SOCIETY

MED SOCIETY NEWS Quarter One 2014

A Warm Welcome To Our Newest Members David Alboukrek, MD Boca Raton Specialty: Rheumatology

Michelle Kaplan, MD Boca Raton Specialty: Psychiatry

Nana Amiridze, MD Atlantis Specialty: Radiology

Alan L. Melotek, MD Boca Raton Specialty: Internal Medicine

Noa Beck, MD Atlantis Specialty: Radiology

Margaret Wilkes, MD Boca Raton Specialty: Rheumatology

Iqbal Z. Hamid, MD Atlantis Specialty: Anesthesiology

The latest news & information on PBCMS

2014 State of Medicine Dinner, James Howell, MD, Stephen Babic, MD , John Armstrong, MD, Surgeon General State of Florida & Michael Dennis, MD

2014 State of Medicine Dinner, Katie Ballard, Dr and Mrs Ralph Nobo FMA PAC President

CLASSIFIEDS FOR SALE OR LEASE 5,300 SF Class A Medical Condo all equipment & furniture Included Located at 2320 Seacrest Blvd, Boynton Beach Two short blocks from Bethesda East Hospital Contact Bob Locke for details 561 488-8872 or Rlocke@atlanticCG.com

Prime Medical Professional Office Space Adjacent to JFK Medical Hospital 109 JFK Drive, Atlantis, FL 33462 1,375 SF, $17/SF/YR, NNN, 36 months Five rooms/ offices, waiting/conference room, central filing area, kitchen, two baths. Private rear access. Last space available. Rental rate & improvement costs negotiable. Contact Leonora or Victor Zabik 561-966-9082

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ON CALL is a quarterly publication, advertising rates and deadlines can be found at: www.pbcms.org/advertise

Care is about more than being comfortable. It’s about having all the comforts of home. For more than 25 years, Vi has been providing quality environments, services and care to enrich the lives of older adults. At our beautifully appointed on-site care center, our commitment to hospitality shines through daily. We offer assisted living, Alzheimer’s/memory support and skilled nursing care—with dedicated nurses and caregivers on staff 24 hours a day. Whether it’s short-term care while recovering from surgery or illness or long-term nursing care, we can provide your patient or loved one with the individual attention they need.

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