INSIDE - Health Care Compliance Association

Volume Five 

Number Eleven 

November 2003 

Published Monthly 

Interview 

with 

Sharon 

Hoyle 

REGISTER TODAY! 

FOR THE HCCA/AHA HIPAA FORUM, SAN DIEGO, CA – DEC 10-12, 2003 

For registration info go to the HCCA Website, www.hcca-info.org, 

or see page 35 of this issue. 

INSIDE 

2 

3 

6 

8 

10 

15 

18 

22 

25 

27 

28 

29 

30 

31 

Leadership letter 

On the calendar 

Inter-rater validity 

Outpatient outlier payments 

under scrutiny 

Payor/Managed Care 

CFG 

Meet Sharon Hoyle 

The new EMTALA: 

Part I 

Clinical quality 

2004 election results 

CEO’s letter 

FYI 

Your HCCA staff 

New members 

Websites

Dear 

Colleagues 

AL JOSEPHS 

HCCA 1st Vice President 

I want to let you know the latest information 

we have on the HCCA 2004 Business 

Plan. In the September 2003 issue of 

Compliance Today, I outlined our business planning efforts. 

We now have completed the process and have developed eight 

key priorities. These key priorities are listed below and 

include the member of the HCCA Board that is providing 

leadership for the priority. The HCCA Board and others have 

worked very hard to develop a plan that not only meets the 

mission of HCCA, but that also recognizes the ever changing 

regulatory environment. 

Now, if you have ever wanted to get involved in HCCA, these 

key priorities shape our work list of things that will be accomplished 

during the 2004 business year beginning in January 

2004. Please contact me or the chair of the key priority in 

which you would like to be involved. 

Key priority #1: Deliver services to members locally 

■ Al Josephs, Chair, al.josephs@hillcrest.net 

Definition: HCCA will provide high quality, local, inexpensive 

educational and networking opportunities for the membership. 

Key priority #2: Recruit and retain members 

■ Shawn DeGroot, Chair, shawn.degroot@med.va.gov 

Definition: HCCA will broaden the current health care membership 

base and minimize attrition. 

Key priority #3: Establish 

and enhance compliance as 

a profession 

■ Debbie Troklus, Chair, 

debbie.troklus@louisville.edu 

Definition: HCCA will position 

the profession as a 

unique, valuable, and 

respected component of senior management. 

Key priority #4: Develop resources for members 

proactively 

■ Rory Jaffe, Chair, rsjaffe@ucdavis.edu 

Definition: HCCA will broaden the menu of learning 

resources for both experienced and new compliance staff (e.g. 

web-based learning, regulatory updates, training tools, journal, 

industry trends, and best practices). 

Key priority #5: Diversify and grow revenue 

■ Lisa Murtha, Chair, lmurtha@ptd.net 

Definition: HCCA will develop new sources of revenue to 

reduce reliance on conferences and membership dues. 

Key priority #6: Explore broadening the HCCA vision 

■ Dan Roach, Chair, droach@chw.edu 

Definition: HCCA will explore the wisdom and feasibility of 

expanding its mission beyond health care. 

Key priority #7: Broaden and enhance external 

relationships 

■ Greg Warner, Chair, gwarner@mayo.edu 

■ Roy Snell, Executive Committee, Roy.snell@hcca-info.org 

Definition: HCCA will establish and maintain strong working 

relationships with all government and non-government 

enforcement entities. 

HCCA’S 

HCCA exists to champion ethical 

practice and compliance standards 

MISSION in the health care community and 

to provide the necessary resources for compliance professionals and 

others who share these principles. 

November 2003 

2 

HCCA • 5780 LINCOLN DRIVE, SUITE 120 • MINNEAPOLIS, MN 55436 

Health Care Compliance Association • 888-580-8373 • www.hcca-info.org

Key priority #8: Develop partnerships and strategic 

alliances 

■ Roy Snell, Chair, Roy.snell@hcca-info.org 

■ Alan Yuspeh, Chair, alan.yuspeh@hcahealthcare.com 

Definition: HCCA will identify, explore, and create partnerships 

that support achievement of the other organizational 

priorities. 

Planning Work Group: 

■ Julene Brown 

■ Britt Crewse 

■ Gary DeVaan 

■ Suzie Draper 

■ Wilma Eisenman 

■ Odell Guyton 

■ Tracy Hlavacek 

■ Al Josephs 

■ Allison Maney 

■ Erin O’Donnell 

■ Dan Roach 

■ Debbie Troklus 

■ Steve Vincze 

■ Jerry Bryant, 

Planning Facilitator ■ 

■ Tony Burke 

■ Shawn DeGroot 

■ Margaret Dragon 

■ Darin Dvorak 

■ Georgette Gustin 

■ Keith Halleland 

■ Glenna Jackson 

■ April Kraft 

■ Vickie McCormick 

■ Steve Ortquist 

■ Roy Snell 

■ Sheryl Vacca 

■ Greg Warner 

NEWS FLASH: 2004 OIG Work Plan Is 

Now Available 

On October 1, 2003, the Department of Health and 

Human Services Office of Inspector General (OIG) 

posted on its Website its FY 2004 Work Plan at the 

following link: http://oig.hhs.gov/publications/ 

workplan.html#1 

AUDIO 

CONFERENCES 

All are at 12 Noon CST 

■ OCT 15, Exclusions/ 

Sanctions 

■ OCT 29 & 30, Top Ten Tips 

for Avoiding AntiKickback 

Liability and Waiting for 

Phase II: Principal developments 

under the Stark 

Law–Two Part Series 

■ NOV 18 & 20, Unlocking the 

Mystery of Non-physician 

Practitioner Coding and 

Billing–Two Part Series 

HCCA 

ON 

THE 

CALENDAR 

2003 CONFERENCES: 

■ NOV 19 & 25, OIG Work Plan 

2004 (Hospitals & 

Physicians)–Two Part Series 

■ DEC 2 & 5, Identity Theft–Two 

Part Series 

■ DEC 16, Responding to 

Subpoenas for PHI from Law 

Enforcement 

SAN DIEGO, CA 

■ DEC 10-12, HCCA/AHA HIPAA 

Forum 

SAN FRANCISCO, CA 

■ OCT 23-24, Physician Group 

Practice Compliance 

Conference 

ATLANTIC CITY, NJ 

■ NOV 17-18, Region II & III 

Compliance Conference 

LAS VEGAS, NV 

■ NOV 6-7, HCCA Region IX 

Compliance Conference 

DALLAS, TX 

■ NOV 3-6, Academy for Health 

Care Compliance 

2004 CONFERENCES: 

CHICAGO, IL 

■ APR 25-28, HCCA 

Compliance Institute ■ 

RESOURCES 

The 90-page Work Plan includes a brief description 

of the various projects to be addressed during the 

fiscal year by the OIG’s Office of Audit Services, 

Office of Evaluation and Inspections, Office of 

Investigations, and Office of Counsel to the 

Inspector General. The Work Plan includes projects 

focused on Hospitals, Home Health, Nursing 

Homes, Physicians and other health care professionals, 

Medical equipment and supplies, Drug reimbursement, 

other Medicare services, Managed Care, 

Medicare Contractor Operations, Investigations, and 

more. ■ 

HCCA • 888-580-8373 • www.hcca-info.org 

For more information about events 

or resources, check out the HCCA 

Website, http://www.hcca-info.org 

or call 888/580-8373. 

■ Monitoring & Auditing Practices 

for Effective Compliance 

■ HCCA’s Compliance, Conscience, 

and Conduct , a videobased 

compliance training 

program 

■ HCCA’s book, Compliance 101 

■ Individual & Small Group 

Physician Practice Compliance: 

What every physician should 

know 

■ Privacy Matters–HCCA’s videobased 

HIPAA Training Program 

HCCA’s CD Videos - 

■ Alice Gosfield-Unplugged (with 

2 HCCB CEUs) 

■ HIPAA Forum Digital Reference 

CD (with 20 HCCB CEUs) 

■ Physician Group Practices 

Compliance Conference (with 

3.6 HCCB CEUs) ■ 

November 2003 

3

Keynoter Dara Corrigan, Acting Principal Deputy Inspector General, 

poses with Elisabeth Carder- Thompson, Esq. and Al Josephs. 

Scenes from the Fraud & 

Compliance Forum 

The HCCA Member Luncheon 

November 2003 

4 


Health Care Compliance Association • 888-580-8373 • www.hcca-info.org 

November 2003 

5

By Phoebe Moore, BA, CPC, CPC-H, CHC 

Editors note; Phoebe Moore is a project which an audit accurately reflects or 

manager and senior consultant with assesses the specific concept that the 

HP3’s Coding and Audit Group. In her reviewer is attempting to measure. 

role, she conducts onsite medical record Validity is concerned with the audit’s 

reviews, mentoring, and coding training success at measuring what the reviewers 

programs. She has managed pre-billing set out to measure. Consider this 

and concurrent coding audits and conducted 

coding in-service education for example. If an audit sets out to measure 

Evaluation and Management (E/M) 

both coding staff and physicians. She may the “coding accuracy and documentation 

quality” of a particular inpatient 

be reached at 610/332-2990. 

consultation, these are some possible 

Most health care organizations findings: 

perform periodic audits of ■ No documentation found for the date 

physician documentation. of service billed 

The purpose of the exercise is often stated 

in general terms before commencing ■ Illegible note 

■ Unsigned note 

the review. An example might be the following: 

“to assess coding accuracy and ■ Incorrect level of service billed as 

■ Teaching physician rules not followed 

documentation quality.” Although this compared to documentation 

appears to be a straight-forward statement, 

it becomes a complex issue partic- 

clear indication of who requested the 

■ Criteria for consultation not met (no 

ularly when it involves rating individual consultation) 

physicians or departments based upon ■ Incorrect diagnosis code as compared 

the findings. 

to documentation 

■ Medical necessity not supported 

The outcome of an audit is often the ■ No chief complaint 

instrument by which the institution ■ Additional services or procedures provided 

at the same encounter which 

determines how its corrective action plan 

should be implemented. For example, are documented but not billed 

which physicians or other staff will be ■ Additional services or procedures provided 

at the same encounter which 

required to attend education sessions? 

How should the content of the education 

session be modified to focus on the ■ Incorrect use of modifiers 

are billed but not documented 

areas of exposure? Do some physicians 

or groups need one-on-one education or Clearly this is not a simple pass/fail exercise. 

Some errors are more serious than 

are group sessions and on-line training 

sufficient? At what point should an institution 

impose a pre-billing documenta- 

troublesome from a compliance perspec- 

others. For example, it would be more 

tion review as a “safety net”? 

tive to find no documentation at all than 

billed. In both cases the CPT code billed 

is incorrect, but the validity of a pass/fail 

rating system is questionable in the context 

of the initial intent of the audit. 

Additionally, an auditor might discover 

that one or more of these findings apply 

to the particular encounter. How should 

the auditor rate a case where 1.) the documentation 

does not meet the consultation 

criteria, 2.) also does not meet the 

level of service billed, and 3.) is partially 

illegible? Which error takes precedence 

or should all be reported? 

Some findings such as “incorrect diagnosis 

code” may not actually be very helpful 

in determining an appropriate corrective 

action. Is the “incorrect” diagnosis 

due to insufficient documentation or 

incorrect information on the encounter 

form? Is the diagnosis “in*correct” due 

to a lack of documentation specificity or 

because the physician documented additional 

diagnoses that did not appear on 

the claim? Does the audit process allow 

for identification of data entry errors or 

will the incorrect finding automatically 

result in requiring the physician to 

attend mandatory education sessions 

about diagnosis coding? 

to find that documentation supported 

November 2003 

Inter-rater validity refers to the degree to one level of service higher than that The challenge is to develop a valid 

6 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org 

PHOEBE MOORE

methodology by which the audit results internal policies. If one level of service 

can be accurately reported. This is critical 

if scores or “ratings” are used to might be categorized as medium risk. A 

difference is typically not refunded this 

determine how corrective actions will be low risk (or educational opportunity) 

implemented. A fair and consistent might be under-billing or missing an 

approach is also critical if findings are anatomic modifier. Some errors are categorized 

as “administrative errors” such as 

used to illustrate effectiveness of educational 

initiatives or to compare documentation 

improvement over time. charge ticket information to allow for 

data entry, coder error, or incorrect 

specific education for support staff. This 

Some institutions have developed point method allows for errors to be easily 

systems where a specific number of quantified and corrective actions may be 

points are assigned to different types of prioritized accordingly. 

errors. Typically a score of zero points 

indicates no errors; the more serious the Assessing your compliance program’s 

error, the higher the number of points. inter-rater validity offers opportunity for 

An equal number of encounters are improvement in accurately capturing 

reviewed for each physician and thresholds 

are established above which specific physician services audit. Audits are costly 

and reporting important data from your 

corrective actions are required. 

and time-consuming and it makes good 

business sense to establish a rating 

Another approach is to establish categories 

for errors such as high, medium, efficient. An additional benefit is in 

methodology that is comprehensive and 

and low risk. “No documentation allowing a fair and consistent implementation 

of your corrective action plan. A 

found” or “teaching physician rules not 

met” would be categorized as high risk. valid rating system will result in efficient 

This category would typically include use of resources to provide education 

circumstances where refunds to third where it is needed most and accurate 

party payers are necessary. A medium tracking and reporting of improvement 

risk might include different errors for in coding accuracy and documentation 

different institutions depending upon quality. ■ 

HCCA Call For Authors! 

The HCCA is seeking authors for January, February, and March issues of 

Compliance Today (CT). We welcome all members of HCCA who wish to 

propose topics and write an article. We are seeking articles focused on recently 

proposed or final health care regulations, ethics, Stark, OIG Work Plan 2004, 

Coding and Documentation, HIPAA, and compliance and compliance program 

issues. Articles, when the topic allows, should include “how to” tips. Articles in 

CT average between 1,250 and 2,500 words, but are not limited to this. All 

those interested in writing an article for CT should send your name, title, organization, 

phone, and fax number along with article title and a brief summary to 

Margaret Dragon, Fax: 781/593-4929 or email: Margaret.dragon@hcca-info.org. 

Please submit this information as soon as possible to reserve space and topic. 

Thank you for your time and attention; we look forward to hearing from you. ■ 


HCCA Compliance 

Focus Group Chairs 

Academic 

■ Marti Arvin 

marti.arvin@louisville.edu 

Behavioral Health 

■ John Ciavardone 

jciavardone@nhsonline.org 

Government 

■ Shawn DeGroot 

shawn.degroot@med.va.gov 

Home Health 

■ Chris Anderson 

chris.anderson@gentiva.com 

Large Health System 

■ Michael Hemsley 

mhemsley@che.org 

Long Term Care 

■ Chauncey Hunker 

Chauncey.Hunker@sunh.com 

■ Pat Kolling 

Patricia_Kolling@BeverlyCorp.com 

Payor/Managed Care 

■ Vickie McCormick 

vmccormick@halleland.com 

Pharmaceutical 

■ TBD 

Physician Care Practice 

■ John Steiner, Jr. 

steinej@ccf.org 

Privacy 

■ Lisa Murtha 

murtha@email.chop.edu 

Research 

■ Rory Jaffe 

rsjaffe@ucdavis.edu ■ 

November 2003 

7

By Jesse A. Witten, Esq. and Renee M. Howard, Esq. 

Editor’s note: Jesse Witten and Renee paid hospitals a fixed amount for most 

Howard are attorneys in the Washington, outpatient services, based on the ambulatory 

payment classification (APC) 

D.C. office of Jones Day. The views 

expressed herein are those of the authors group to which the service belongs. In 

and do not necessarily reflect those of Jones addition, Medicare pays an additional 

Day. Jesse Witten and Renee Howard amount for outliers; i.e., for outpatient 

may be reached at 202/879-3939. encounters that are exceptionally costly. 

JESSE A. WITTEN 

payment + outlier payment. 4 

The current government Outpatient outlier payments are calculated 

based on the costs incurred to ments have been calculated using the 

Since January 17, 2003, outlier pay- 

scrutiny of Medicare 

inpatient outlier payments provide the services on a given claim. hospital’s outpatient cost-to-charge 

has been widely publicized. 1 Less As with the calculation of outlier payments 

ratio from its most recent full-year cost 

noticed is the fact that the government 

for inpatient services, costs are reporting period, whether or not set- 

has also begun to focus on outlier payments 

derived by multiplying the hospital’s tled. 5 Previously, outpatient cost-to- 

for outpatient hospital services. charges for the service by the hospital’s charge ratios were determined based on 

The HHS Office of Inspector General relevant cost-to-charge ratio (here, the the hospital’s most recently settled cost 

(OIG) included outpatient outlier payments 

cost-to-charge ratio for outpatient serv- 

report. If the most recently submitted 

on its 2003 Work Plan. It has ices). If the hospital’s total costs for the cost report were not settled, Centers for 

also released seven audit reports for outpatient 

outpatient service exceed a certain Medicare and Medicaid Services (CMS) 

outlier claim reviews conducted threshold (currently, 2.75 times the applied a “settled-to-submitted” factor 

at hospitals in New England, California, 

outpatient payment for the service), an to estimate the cost-to-charge ratio for 

and Illinois. 2 The OIG audits outlier payment is calculated as a per- 

a settled cost report. 6 

found that systemic hospital billing centage of the amount by which the 

errors–especially overstating the number 

costs exceed the payment (currently, 45 OIG audits of outpatient outlier pay- 

of units of drugs dispensed during percent). 3 

ments 

an outpatient procedure–have caused 

Recent OIG audit reports suggest that 

Medicare to make excessive outpatient Assume the following by way of exampletient 

hospitals may be vulnerable to outpa- 

outlier payments. 

outlier overpayments due to cer- 

■ Hospital charges for a certain outpatient 

tain billing system quirks. Five of the 

Below is a brief description of 

service: $800 

OIG’s audit reports concluded that the 

Medicare’s outpatient outlier payment ■ Hospital cost-to-charge ratio: 0.56 hospitals received excessive outlier reimbursement 

methodology, the OIG’s recent scrutiny ■ Hospital’s adjusted cost: $448 = 

by not reporting the correct 

of outpatient outlier payments, and the $800 x 0.56 

number of units of drugs administered 

compliance risks presented by outpatient 

■ APC payment: $100 

to outpatients. 7 For example, one hos- 

outlier reimbursement. 

■ Threshold: $275 = $100 x 2.75 pital inadvertently applied an adjust- 

■ Outlier payment: [$448 - $275] x ment for recording operating room 

Medicare outpatient outlier payment .45 = $77.85 

services (which converted multiple OR 

methodology 

■ Total provider reimbursement: units to one unit) to all Revenue 

November 2003 

Since August 1, 2000, Medicare has $177.85 = ($100 + $77.85) =APC Center Code line items containing 

8 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org

multiple units. As a result, the billing 

system converted multiple units of passthrough 

drugs to units of one. The 

OIG explained the effect of misstating 

the number of drug units as follows: 

■ Because payments for OPPS [outpatient 

prospective payment system] 

outliers are based on a comparison of 

RENEE M. HOWARD 

the charges for OPPS services to the 

total APC payment for the claim, 

the incorrect billing of units results 

in insufficient APC payments and 

excessive or unwarranted outlier payments. 

8 

Other billing errors identified by the 

OIG that resulted in excessive outlier 

payments included (i) failing to identify 

separately each surgical procedure on a 

claim with its specific HCPCS code; 9 

(ii) incorrectly charging drugs with separate 

APC codes under RCC 250 (and 

hence not identifying the drugs as eligible 

for separate payment); 10 and (iii) 

billing for unsupported, unnecessary, or 

excessive observation charges. 11 

After exposing weaknesses in their 

billing systems, the OIG recommended 

that the hospitals (i) improve billing 

controls; (ii) conduct internal reviews of 

outpatient outlier claims and resubmit 

any claims as necessary; and (iii) initiate 

adjustments with fiscal intermediaries 

to repay overpayments found by 

the OIG or identified through the hospitals’ 

subsequent internal reviews. In 

addition, the OIG also directed hospitals 

to perform self audits to determine 

the full extent of any exclusive outlier 

payments. For example, for one hospital, 

the OIG found that each of the 

OPPS claims reviewed was billed incorrectly. 

Thus, the OIG speculated that 

there was a risk that payment errors 

were made for all other claims involving 

outpatient outlier payments, likely 

exceeding $1.3 million. 

Risk areas and recommendations 

As the OIG audits demonstrate, hospitals 

may be vulnerable to outpatient 

outlier overpayments due to billing system 

errors. These errors could stem 

from computer changes resulting from 

OPPS implementation. The OIG 

acknowledged this possibility in its 

2003 Work Plan, where it stated its 

desire to evaluate “the appropriateness 

of [outpatient] outlier payments” in 

light of the fact that “[s]ignificant overpayments 

can result if providers submit 

claims with clerical errors that result in 

overstated charges for services.” 

Hospitals should ensure that their 

billing systems appropriately capture 

charges for outpatient services, particularly 

those involving multiple units of a 

service. The key is for hospitals to 

ensure that they are billing for the correct 

number of units of drugs or other 

supplies or services. 

Hospitals that consistently err by charging 

for excessive numbers of units of 

supplies or services, and thereby receive 


excessive outpatient outlier payments, 

risk being accused of a False Claims Act 

violation. In other contexts, OIG audit 

reports have inspired hospital employees 

to bring qui tam actions under the False 

Claims Act against their employers 

based on overpayment scenarios 

described in the audit reports. 

Hospitals should thus consider auditing 

their billing systems to ensure that they 

are not making the same billing errors 

as those hospitals audited by the OIG. 

Finally, since observation billing errors 

were identified in two of the OIG audit 

reports, hospitals should consider 

reviewing their practices related to 

coding and billing for observation 

services. ■ 

1 See, e.g., Modern Healthcare, “It’s More 

Than Just Tenet” (July 14, 2003); The 

Los Angeles Times, “Tenet Gets 

Subpoena for Medicare Documents” 

(Jan. 3, 2003); CMS Program 

Memorandum No. A-02-122 (Dec. 3, 

2002) (instructing Medicare fiscal intermediaries 

to review appropriateness of 

inpatient outlier payments made to certain 

hospitals); Statement of Thomas A. 

Scully, Administrator, Centers for 

Medicare and Medicaid Services, on 

Medicare Payment for Hospital Outliers 

Before the Senate Appropriations 

Subcommittee on Labor, Health and 

Human Services, and Education (March 

11, 2003), available at http://www. 

hhs.gov/asl/testify/t030311.html; 68 Fed. 

Reg. 34494 (June 9, 2003) (CMS final 

rule revising inpatient outlier payment 

methodology). See also “Medicare 

Outlier Payments” (Jones Day Health 

Care Compliance Adviser, Nov. 2002), 

available at http://www1.jonesday.com/ 

pubs/detail.asp?language=English&pubid= 

611. 

2 See OIG, “Review of Outlier Payments 

Made to Mercy Hospital Under the 

Continued on page 10 

November 2003 

9

OUTPATIENT OUTLIER PAYMENTS... 

continued from page 9 

November 2003 

10 

Outpatient Prospective Payment System 

for the Period August 1, 2000 Through 

June 30, 2001,” No. A-01-02-00518 

(April 17, 2003) (“Mercy Audit”); OIG, 

“Review of Outlier Payments Made to 

Baystate Medical Center Under the 

Outpatient Prospective Payment 

System,” No. A-01-02-00528 (March 6, 

2003) (“Baystate Audit”); OIG, “Review 

of Outlier Payments Made to Eastern 

Main Medical Center Under the 

Outpatient Prospective Payment System 

for the Period August 1, 2000 Through 

June 30, 2001,” No. A-01-02-00507 

(Jan. 15, 2003) (“Eastern Maine Audit”); 

OIG, “Review of Outlier Payments 

Made to Rhode Island Hospital Under 

the Outpatient Prospective Payment 

System for the Period August 1, 2000 

Through June 30, 2001,” No. A-01-02- 

00521 (Dec. 5, 2002) (“Rhode Island 

Audit”); OIG, “Review of Outlier 

Payments Made to Massachusetts 

General Hospital Under the Outpatient 

Prospective Payment System for the 

Period August 1, 2000 Through June 30, 

2001,” No. A-01-02-00500 (June 20, 

2002) (“MGH Audit”); “Review of 

Outlier Payments Made to Orthopaedic 

Hospital Under the Outpatient 

Prospective Payment System for the 

Period August 1, 2000 Through June 30, 

2001,” No. A-09-03-00031 (May 29, 

2003) (“Orthopaedic Audit”); OIG, 

“Review of Medicare Outpatient 

Prospective Payment System Outlier 

Payments Made to Rush-Presbyterian-St. 

Luke’s Medical Center,” No. A-05-03- 

00033 (July 31, 2003). 

3 See 67 Fed. Reg. at 66789 (Nov. 1, 

2002). 

4 This formula is somewhat simplified in 

that a hospital’s charges for a particular 

outpatient service are adjusted to costs by 

applying both an operating and a capital 

cost-to-charge ratio. 

5 See CMS Program Memorandum No. A- 

03-004 (Jan. 17, 2003). 

6 See Eastern Maine Audit at 2–3; Mercy 

Audit at 2-3; Baystate Audit at 3; MGH 

Audit at 2–3; Orthopaedic Audit at 3. 

A HIPAA 

Privacy 

Rule 

Preemption 

Analysis of the NAIC Insurance 

Information and Privacy Protection 

Model Act 

Some Model Act provisions preempt 

or supplement Privacy Rule requirements 

By Jacqueline Moen 

COMPLIANCE 

FOCUS 

GROUP 

PAYOR/ MANAGED 

CARE 

Editor’s note: Jacqueline Moen is an 

attorney with the law firm of Halleland 

Lewis Nilan Sipkins & Johnson. She 

has been adopted in some form in each 

may be reached by email at jmoen@ 

of the following states: Arizona 2 , 

halleland.com or by telephone at 

California 3 , Connecticut 4 , Georgia 5 , 

612/204-4143. 

Illinois 6 , Maine 7 , Massachusetts 8 , 

Minnesota 9 , Montana 10 , Nevada 11 , New 

Many organizations and groups around 

Jersey, 12 North Carolina 13 , Ohio 14 , 

the country have been busily comparing 

the HIPAA Privacy Rule require- 

general preemption analysis of the IIPP 

Oregon 15 , Virginia 16 , and Wisconsin 17 . A 

ments with the privacy requirements set Model Act, therefore, is a valuable reference 

tool for health plans in those 

forth in the various state laws. They 

have been doing this because of the states that are covered by both the 

special state law preemption provision Privacy Rule and the IIPP legislation. 

in the Privacy Rule that gives the 

Privacy Rule precedence over contrary The preemption analysis 

state law provisions unless the state law The principles of Privacy Rule preemption 

are stated in detail in the Privacy 

“is more stringent than a standard, 

requirement, or implementation specification” 

adopted under the HIPAA prisideration 

of whether the state law is 

Rule. 18 The analysis first requires convacy 

regulations. 1 

contrary to any standard, requirement, 

or implementation specification set 

This article examines the preemptive forth in the Privacy Rule. 19 A law is 

effect of the Privacy Rule on an insurance 

information privacy legislation 1) A covered entity would find it 

contrary to a Privacy Rule provision if: 

that has been enacted in several states impossible to comply with both the 

based on the Insurance Information state and federal requirements; or 

and Privacy Protection (IIPP) Model 2) The provision of state law stands as 

Act proposed by the National Association 

of Insurance Commissioners 

and execution of the full purposes 

an obstacle to the accomplishment 

(NAIC). As of this writing, this NAIC and objectives of [the HIPAA 

model legislation, proposed in 1992, 

Article continues on page 14 


JACQUELINE MOEN

Model Act 

Section 

§ 2.T. 

(Definitions) 

Description 

Table 1. NAIC Insurance Information and Privacy 

Protection Model Act HIPAA Preemption Analysis 

In addition to protected health information, state law also protects “personal 

information,” defined as “any individually identifiable information gathered in 

connection with an insurance transaction from which judgments can be made 

about an individual’s character, habits, avocations, finances, occupation, general 

reputation, credit, health,” along with any other personal characteristics including 

an individual’s name and address and any health information. 

Privacy Rule 

Comparison 

Increases the amount of information 

that is subject to 

individual rights of access, 

accounting, amendment, and 

notification of privacy practices 

§ 4.A.(1) 

(Notice of 

Insurance 

Information 

Practices) 

In addition to the Privacy Rule requirements stating when a privacy notice 

must be provided, an insurer 23 must also provide a copy of its privacy notice 

not later than the time when the insurer first collects personal information on 

an applicant for insurance from a source other than the applicant or public 

records. 

Imposes additional individual 

rights to receive a copy of 

the notice of privacy practices 

§ 4.A.(2) 


must be provided, an insurer must also provide a copy of its privacy notice 

no later than the date of renewal of a policy (if the insurer collects personal 

information from sources other than the policyholder or from public 

records) unless a copy of the notice has been given within the previous 

24 months. 




§ 4.A.(3) 


must be provided, an insurer must also provide a copy of its privacy notice 

when there is a request for policy reinstatement or change in insurance benefits 

if the insurer collects personal information from sources other than the policyholder 

or from public records. 




§ 4.B. 

In addition to the Privacy Rule’s requirements for the content of the Notice of 

Privacy Practices, the notice must also state: 

1. Whether personal information may be collected from persons other than the 

individual(s) proposed for coverage; and 

2. The type of personal information that may be collected and the type of 

source and investigative technique that may be used to collect such information. 


rights to receive certain 

information in the notice of 

privacy practices 

§ 4.B. 

In addition to the Privacy Rule’s requirements for the content of the Notice of 

Privacy Practices, the notice must also state that information obtained from a 

report prepared by an insurance-support organization may be retained by the 

insurance-support organization and disclosed to other persons. 


rights to receive certain 

information in the notice of 

privacy practices 

§ 6.G.(1)(a) (Content 

of Disclosure 

Authorization 

Forms) 

An authorization to an insurer to disclose information to another insurer in Imposes outside limits for the 

connection with an application for life, health, or disability insurance coverage, expiration of authorizations 

reinstatement, or change of benefits must expire within 30 months from the 

date the authorization is signed. 



November 2003 

11

PAYOR/MANAGED CARE CFG...continued from page 11 

Model Act 

Section 

§ 6.G.(1)(b) 

Description 

An authorization to an insurer to disclose information to another insurer in 

connection with an application for property or casualty insurance coverage, 

reinstatement, or change of benefits must expire within one year from the date 

the authorization is signed. 

Privacy Rule 

Comparison 

Imposes outside limits for the 

expiration of authorizations 

§ 6.G.(2)(a) 


connection with a claim for health insurance benefits must expire within the 

term of coverage of the health insurance policy. 



§ 6.G.(2)(b) 


connection with a claim for insurance benefits other than health insurance 

benefits must expire within the duration of the claim. 



§ 8.A. (Access to 

Recorded Personal 

Information) 

An individual’s request to an insurer for access to his or her personal information 

in an insurer’s possession must be accompanied by proper identification. 

Imposes additional confidentiality 

protections 

§ 8.A. 

An insurer must respond to a written request to access recorded personal information 

within 30 business days. 

Imposes additional access 

rights by potentially shortening 

the time permitted to 

respond to the request 

§ 8.A.(1) 

In addition to the Privacy Rule’s requirements for responding to an individual’s 

request for access to health information, an insurer must also, at the same time, 

inform the individual of the nature and substance of such recorded personal 

information in writing, by telephone, or by other oral communication, which 

ever the insurer prefers. 


rights 

§ 8.A.(2) 


request for access to health information, an insurer must also permit the individual 

to see and copy, in person, such recorded personal information pertaining 

to him or her or to obtain a copy of such recorded personal information by 

mail, which ever the individual prefers, unless such recorded personal information 

is in coded form, in which case an accurate translation in plain language 

shall be provided in writing. 


rights 

§ 8.A.(3) 



identify those persons to whom the insurer has disclosed the personal information 

within the previous two years. If disclosures by the insurer to other insurance 

institutions, agents, or insurance support organizations were made but not 

recorded, the insurer must identify for the individual the names of such entities 

to which the information is normally disclosed. 

Imposes additional access and 

accounting rights 

November 2003 

12 


Model Act 

Section 

§ 8.A.(4) 

Description 



provide the individual with a summary of the procedures for requesting correction, 

amendment, or deletion of recorded personal information. 

Privacy Rule 

Comparison 

Imposes additional access and 

amendment rights 

§ 8.B. 


request for access to health information, any information the insurer provides 

to the individual in response to the individual’s request for access, shall identify 

the source of the information if the source is an institutional source. 


rights 

§ 8.C. 

To the extent an individual’s recorded personal information contains medicalrecord 

information supplied to the insurer by a medical care institution or 

medical professional, if the insurer denies the individual access to this information 

(say, for example, on grounds specified in 45 CFR § 164.524(a)(3)), the 

insurer must provide the medical-record information, along with the identity 

of the professional or institution that supplied the information, to a medical 

professional designated by the individual and licensed to provide medical care 

with respect to the condition to which the information relates. The insurer 

shall notify the individual at the time the disclosure is made that it has provided 

the information to the designated medical professional. 


rights 

§ 9.A. (Correction, 

Amendment or 

Deletion of 

Recorded Personal 

Information) 

An insurer must respond within 30 business days after a written request from 

an individual to correct, amend, or delete any recorded personal medical information 

in an insurer’s possession. 

Imposes additional amendment 

rights by reducing the time to 

respond and potentially increasing 

the amount of information 

to which the right to amend 

pertains beyond the designated 

record set 

§ 9.B.(2), (3), 

and D.(3) 

If an insurer corrects, amends, or deletes recorded personal medical information; 

or if it refuses to comply with a request for correction, amendment, deletion 

and the individual provides a statement of disagreement; the insurer must 

provide the correction, amendment, deletion, or statement to (in addition to 

those required to be notified by the Privacy Rule): 

1. Any insurance support organization (ISO) whose primary source of personal 

information is insurance institutions if the ISO has systematically received such 

information from the insurance institution within the preceding 7 years, except 

that the correction, amendment, deletion need not be furnished if the ISO no 

longer maintains information about the individual; and 

2. Any ISO that furnished the personal information that has been corrected, 

amended, or deleted. 

Imposes additional amendment 

rights by potentially 

increasing the number of 

entities who must be notified 

of an amendment or statement 

of disagreement 

§ 13.A.(2)(c) 

(Disclosure 

Limitations and 

Conditions) 

An authorization to an insurer to disclose information to someone other than Imposes outside limits for the 

another insurer must expire within one year from the date the authorization is expiration of authorizations 

signed. 



November 2003 

13

PAYOR/MANAGED CARE CFG...continued from page 13 

November 2003 

14 

Administrative Simplification legislation 

or the privacy regulations]. 

If a state law meets this definition of 

contrariness, then it is preempted by 

the Privacy Rule. If it does not meet 

this definition, then it is not preempted, 

and it must be followed. 

If, on the other hand, the state law does 

conflict with the Privacy Rule, then the 

analysis must go to the next step and 

determine whether the state law is saved 

from preemption either because it is 

more stringent than the contrary 

Privacy Rule requirement; 20 it is a state 

disease, abuse, vital statistic, or public 

health reporting requirement; 21 or it 

relates to disclosures for purposes of 

governmental oversight and regulation 

of health plans. 22 If the contrary law is 

not saved by any of these exceptions, 

then it is preempted, and it need not be 

followed. If it is saved, then it must be 

followed. 

Ultimately, all state laws that touch on 

the privacy of health care information 

will fall into one of three categories: (1) 

laws that are not preempted, and must 

be followed, because they are not contrary 

to any of the Privacy Rule standards, 

requirements, or implementation 

specifications; (2) laws that are preempted 

(that is contrary) but are saved 

from preemption, and therefore must 

also be followed; and (3) laws that are 

preempted and are not saved and therefore 

need not be followed. A useful 

result of a “preemption” analysis should 

identify all of the state laws in categories 

(1) and (2). These plus the 

Privacy Rule requirements form the 

entire book of rules and regulations 

with which covered entities in the state 

must comply. 

The IIPP Model Act 

The goal of the IIPP preemption analysis, 

then, was to determine whether it 

or any of its separate provisions supplement 

or bolster the Privacy Rule’s protection 

of individually identifiable 

health information. It was found that 

several of the IIPP provisions contain 

protections that are in addition to or 

more stringent than the Privacy Rule 

respecting individually identifiable 

health information. Those provisions 

include the following: § 2.T. (definition 

of “Personal Information”); § 4 (Notice 

of Insurance Information Practices); § 6 

(Content of Disclosure Authorization 

Forms); § 8 (Access to Recorded 

Personal Information); § 9 (Correction, 

Amendment or Deletion of Recorded 

Personal Information); and § 13 

(Disclosure Limitations and 

Conditions). 

Table 1 (on pages 11-13) lists these provisions 

in detail, describing the additional 

protections they provide and 

comparing those additional protections 

to the Privacy Rule. 

Conclusion 

Health plans in the 16 states that have 

adopted the NAIC IIPP Model Act 

need to consider these provisions when 

preparing their HIPAA Privacy Rule 

compliance plans. Note that most states 

have not adopted the model act verbatim; 

many have added protections even 

beyond these stated in the model act. A 

complete analysis will require reference 


to the specific applicable state statutes 

to confirm the analysis and ensure that 

all supplemental and more stringent 

protections are considered. ■ 

1 45 C.F.R. § 160.203(b). 

2 See Ariz. Rev. Stat. §§ 20-2101 et seq.; 

but see § 20-2122 (providing that a 

health plan in compliance with the 

HIPAA Privacy Rule is deemed to be in 

compliance with most of the IIPP legislation). 

3 See Cal. Ins. Code §§ 791 et seq. 

4 See Conn. Gen. Stat. §§ 38-975 et seq. 

5 See Ga. Code Ann. §§ 33-39-1 et seq. 

6 See 215 Ill. Comp. Stat. 5/1001 et seq. 

7 See Me. Rev. Stat. Ann. tit. 24-A, §§ 

2201 et seq. 

8 See Mass. Gen. Laws ch. 175I, §§ 1 et 

seq. 

9 See Minn. Stat. §§ 72A.01 et seq. 

10 See Mont. Code Ann. §§ 33-19-101 et 

seq. 

11 See Nev. Admin. Code §§ 679B.560 et 

seq. 

12 See N.J. Stat. Ann. §§ 17:23A-1 et seq. 

13 See N.C. Gen. Stat. §§ 58-39-1 et seq. 

14 See Ohio Rev. Code Ann. §§ 3904.01 et 

seq. 

15 See Or. Rev. Stat. §§ 746.600 et seq. 

16 See Va. Code Ann. §§ 38.2-601 et seq. 

17 See Wis. Stat. §§ 610.70 et seq. 

18 Id., Part 160, subp. B. 

19 Id. § 160.203. 

20 § 160.203(b). 

21 § 160.203(c). 

22 § 160.203(d). Note that a fourth savings 

criteria stated in the Privacy Rule 

requires the Secretary of Health and 

Human Services to make a determination 

regarding the state law. As the 

Secretary has not yet made any such 

determinations, this criteria currently 

does not apply. See § 160.203(a). 

23 All references in this analysis to the term 

“insurer” include insurance institutions, 

insurance agents, and insurance support 

organizations.

feature 

Compliance Professional in a 

Physician Group Practice 

Editor’s note: This feature interview with 

Sharon Hoyle, Compliance Coordinator, 

Medical Center Clinic, was conducted in 

August 2003 by Debbie Troklus, CHC, 

Assistant Vice President for Health Affairs 

Compliance. Sharon may be reached at 

850/474-8246 and Debbie may be 

reached at 502/852-0758. 

DT: How is the group practice structured 

(ie. how many physicians, what 

specialties, etc.)? 

SH: Medical Center Clinic (MCC) is 

a multi-specialty physician group of 75 

physicians founded in Escambia 

County, Florida in 1938. The physicians 

specialize in many areas including 

neurosurgery, pain management, infectious 

disease, ophthalmology, orthopaedics, 

urology, radiation oncology, 

and hematology/oncology just to name 

a few. The group also owns and operates 

an ambulatory surgery center, 

regional dialysis centers, clinical lab, 

retail pharmacy, outpatient chemotherapy 

clinic, and an outpatient IV antibiotic 

infusion clinic. 

DT: How long has your compliance 

program been in effect? 

SH: Some aspects of the program 

were implemented in 1998, but it wasn’t 

until 2000 when MCC purchased 

itself back from a physician practice 

management company, that the pro- 

article 

Meet Sharon Hoyle 

Compliance Coordinator, Medical 

Center Clinic, Pensacola, FL 

gram began to fall into place and 

became an inherent part of the company. 

DT: Did your practice use the OIG’s 

Physician Guidance to help you with 

compliance program implementation? 

SH: Yes we did. In fact, the program 

guidance for small physician groups, 

third party billing companies, and clinical 

labs was used to develop and implement 

the program. We felt that by 

using all three, we could identify and 

address important risk areas and create 

a program unique to our company. We 

will also use the program guidance for 

pharmaceutical companies released in 

May to enhance our existing policies 

and procedures and ensure these risk 

areas are also appropriately addressed. 

DT: What does your compliance 

structure look like? 

SH: The Compliance Department 

consists of the Chief Compliance 

Officer (CCO) and me. Our primary 

focus is to assure the Board of Directors, 

physicians, and employees at all 

levels that the health care services the 

physicians deliver and the manner in 

which they document, code, and bill 

these services exceed the requirements 

under the various federal and state 


health care laws like Stark, Anti-kickback, 

and the False Claims Act. Privacy 

and Security, Risk Management, and 

Human Resource functions are separate 

from the compliance structure, though 

from time to time, it is necessary to 

team up with one or more of these 

departments when dealing with compliance 

matters that overlap. 

DT: Being in a group practice, I 

understand that Compliance Officers 

sometime wear many hats. Does the 

Compliance Officer at your practice 

have other duties in addition to compliance? 

SH: Yes, he does. Andy Popple is our 

CCO and he also serves the organiza- 


November 2003 

15

Sharon Hoyle 

tion as Executive Director and CFO. 

November 2003 

16 

DT: What are your duties as 

Compliance Coordinator? How does 

your position interact with the 

Compliance Officer? 

SH: I am responsible for all aspects 

of program operations, which include 

everything from training and education 

to preparing and presenting reports to 

the Board. Andy provides general oversight 

and we meet regularly to discuss 

any issues that are either in the process 

of being resolved or have recently surfaced. 

DT: What external resources have 

you found to be helpful in your day-today 

compliance activities? 

SH: There are two resources that I 

rely on and find helpful. One is our 

HCCA membership. Each time I 

attend an HCCA event, read an article 

in Compliance Today or The Journal 

of Health Care Compliance, or network 

with other members, I am reminded 

that our company is not the only one 

facing the challenges that health care 

compliance can impose on an organization 

and there are other organizations 

with challenges very much like ours. 

The value of being part of this organization 

comes from the tremendous 

amount of information available 

through these resources, which makes it 

easier to conquer these challenges. 

Another resource that I rely on is 

our outside legal counsel. For about 

three years, I have engaged the same 

health law firm and find them to be 

very responsive and in tune with compliance 

issues that are common in 

physician practices. This long-time relationship 

has a lot of value to our company 

in that the attorneys are familiar 

with our corporate structure and can 

respond to our questions with sound, 

practical advice. Although they are not 

local, they are accessible and so it is 

good to know that when I have a question, 

I can easily get an answer with a 

quick phone call or email. 

DT: Do you provide annual training 

for your physicians and staff? If so, is 

the training mandatory and what topics 

are included? 

SH: Training on our Code of Ethics 

is conducted annually during the first 

quarter. Every member of the organization 

receives a copy of the Code of 

Ethics and is required to acknowledge 

in writing that they have read, understand, 

and agree to abide by our Code 

of Ethics. I also present an overview of 

our compliance program to physicians 

and employees hired throughout the 

year. During the overview, the Code of 

Ethics is discussed and the physician or 

employee must provide written 

acknowledgement of our Code of 

Ethics. 

Focused training on fraud and 

abuse, coding, local medical review 

policies, ABNs, etc. is provided 

throughout the year and anyone directly 

involved in coding and billing is 

expected to participate. The training 

environment is relaxed and informal 

and a variety of formats ranging from 

department meetings to Web casts are 

used to communicate information. I 

think the most successful format has 

been computer-based training (CBT). 

In 2001, we began using the CBT 

modules provided by the Centers for 

Medicare and Medicaid as an option 

for training. This proved to be successful 

in two ways. First, it is cost effective, 

and second, it is convenient for 


DEBBIE TROKLUS 

employees unable to leave their workstation 

for an extended period. Given a 

deadline for completing the CBT, these 

employees can work on the assigned 

modules at their own pace and remain 

in their department. Our company 

intranet is also used to communicate 

important information like new or 

revised compliance policies and procedures, 

changes in Medicare policy, and 

Medicare program exclusions. 

DT: Do you conduct compliance 

audits/reviews? If so, how many services 

are reviewed per physician? 

SH: Compliance audits are a normal 

part of operations and the physicians 

look forward to the feedback. Generally, 

when auditing E/M coding, I will 

look at 10 encounters per physician 

annually and about 30 encounters for 

new physicians to establish a benchmark. 

The number of services reviewed 

can change depending on procedure 

code utilization and previous audit 

results. 

DT: How do you determine what to 

include in your audit plan each year? 

SH: The audit plan is determined by 

a couple of things. One is the OIG’s 

Work Plan. Each year the Work Plan is

eviewed to identify areas of focus that 

apply to MCC. Procedure code utilization 

from the preceding year is also 

considered and any areas that reflect a 

noticeable change in pattern from the 

previous year or are significantly skewed 

in comparison to national averages will 

be included in the audit plan. 

DT: Does your auditing process 

include elements other than coding and 

documentation? If so, what other areas 

are addressed? 

SH: Yes, it does. The audit process 

includes other risk areas like business 

arrangements with providers outside 

the group and physician self-referrals. 

DT: Do physicians in your group 

buy-in to the program? 

SH: We do have physician buy-in and 

there is employee buy-in at all levels in 

the company. 

DT: Have you found any creative 

methods for obtaining commitment 

from the physicians? 

SH: I find that promoting our compliance 

program as a positive resource 

that not only helps to protect the 

organization, but also helps the organization 

grow by maximizing revenue 

through accurate documentation and 

correct coding and billing is more conducive 

to gaining commitment as compared 

to limiting the program and its 

potential to just policing the organization. 

Using a practical, common sense 

approach to compliance also works. 

There are probably other ideas more 

creative than this, but this approach has 

worked well for us. 

DT: What challenges do you feel 

physician practices face in implementing 

compliance programs? 

SH: The biggest challenge is probably 

finding the resources necessary for 

developing and implementing a program 

and then figuring out where and 

how to start the process. The concept, 

at first, may seem overwhelming to 

some, but there are resources that can 

help with the process and in time, 

everything begins to fall into place. 

DT: Do you have any advice for 

physician practices, which have still not 

put a compliance program in place? 

SH: Practices that do not have a program 

should give this serious consideration. 

I think a voluntary compliance 

program, stated plainly, is good business. 

I know, by now, that sounds like a 

cliché, but with the focus on corporate 

America and the public demanding corporate 

responsibility and integrity, an 

effective compliance program can send 

a powerful message to employees, business 

contacts, and most importantly, 

the community in which it serves that 

it is serious about conducting its business 

responsibly and with integrity. In 

addition, the benefits of a well-designed, 

properly implemented program can 

be seen through reduced risks of audits 

and more efficient processes in the 

organization. 

DT: What made you choose employment 

as a Compliance Coordinator and 

would you encourage others to do the 

same? 

SH: I began working at MCC 15 

years ago and have always been 


involved in the coding and billing functions. 

In 1999, I took a position in the 

Compliance Department as an auditor 

and during MCC’s transition in 2000, 

our Compliance Coordinator resigned 

and the position was passed on to me. 

Like many others who unexpectedly 

end up in this profession, I knew 

very little about developing or managing 

a compliance program and so when 

the ball fell in my court, I made the 

choice to run with it instead of passing 

it on to someone else and that turned 

out to be a good decision. I would 

encourage others to pursue opportunities 

in health care compliance because it 

can be rewarding and if you thrive on 

challenge, there is plenty of that too. I 

would also emphasize caution because I 

believe one of the most important qualities 

a compliance professional should 

have second to integrity is knowing 

when to bend and make compromises 

and when to stand firm and say “no”. 

Mix this with a sense of humor and the 

chances of being successful are good. I 

learned this early on and not long after 

my first year as Compliance Coordinator, 

I read an article published in the 

August 2001 Compliance Today that 

makes a lot of sense. The article is titled 

Just say “yes” - Everything I know about 

compliance I learned in kindergarten. It 

was written by Roy Snell. It confirmed 

for me what I think is a good approach 

for compliance professionals and is one 

that will leave you with extra “no” chits 

at the end of the year. Since reading 

that article, I have enjoyed and look 

forward to reading Mr. Snell’s articles, 

which I think offer a unique and sometimes 

humorous twist to the compliance 

profession. ■ 

November 2003 

17

By M. Steven Lipton 

Editor’s note: M. Steven Lipton, is a partner 

at Davis Wright Tremaine LLP. He 

may be reached in San Francisco, CA at 

415/276-6550 or by email, stevelipton 

@dwt.com 

department, and how and where 

EMTALA applies throughout the hospital 

in a variety of settings and circumstances. 

The final rules also codify prior 

CMS guidance on on-call obligations, 

prior authorization, and patient registration. 

On September 9, 2003, CMS 

released the long-awaited and 

eagerly anticipated final regulations 

Although it is premature to issue final ance to answer these questions and 

November 2003 

revising the EMTALA obliga- 

tions for hospitals and physicians. The 

regulations will be effective on 

November 10, 2003. 

The new regulations have attracted substantial 

attention, with prominent 

media coverage, an overdose of educational 

programs, and adulation by the 

medical community. Beyond the hype, 

however, the bottom line is that 

although the new rules alter the legal 

landscape for EMTALA compliance, 

they do not materially change how 

health care will be delivered in most 

hospitals to individuals who present 

with a medical emergency. 

This is the first of two articles on the 

new EMTALA regulations. Part I discusses 

what you need to know about 

the new rules. Next month, we will discuss 

what you need to do to get ready 

to comply with the new rules when 

they are effective on November 10th. 

Grading the new rules 

The final regulations are a noble 

attempt by CMS to delineate where 

and when, and to whom, the EMTALA 

obligations apply in the hospital. The 

new rules define what is an emergency 

grades on the new rules before they are 

effective, CMS deserves high marks for 

its effort to define the scope of EMTA- 

LA. For providers, CMS also receives 

high marks for repealing EMTALA coverage 

for most off-campus departments, 

and interpreting EMTALA that it does 

not extend to inpatient services and 

most outpatient services outside of the 

emergency department. 

However, the new rules raise a host of 

new questions and potential challenges 

that will be tested in the coming 

months. The definition of a dedicated 

emergency department expands EMTA- 

LA to services that may not have been 

previously considered to be emergency 

departments. The reaction of the medical 

community to the on-call rules may 

make it more difficult for some hospitals 

to provide call coverage. CMS also 

dangled a number of tantalizing or 

imprecise statements on medical screening, 

on-call, and other subjects. Several 

areas of continuing confusion (for 

example, the application of EMTALA 

to psychiatric hospitals and the meaning 

of “stable for transfer” and “stable 

for discharge”) were not addressed in 

the new rules. We will have to wait for 

future rule-making or new policy guidresolve 

open issues. 

The ABCs of the new rules 

1. Dedicated emergency departments 

The EMTALA obligations begin when 

an individual “comes to the emergency 

department” and makes a request for 

examination or treatment for a medical 

condition. In the most stunning development 

of the new rules, CMS created 

the concept of the “dedicated emergency 

department” (DED) in a manner 

that expands the EMTALA obligations 

beyond the traditional emergency 

room. In reading the definition of a 

DED below, keep in mind that a DED 

must meet all of the EMTALA obligations, 

including on-call coverage. 

A. Defining the DED. A DED is a hospital 

department or facility that is 

located on the hospital campus or 

off-campus, and meets at least one of 

the following requirements: 

■ The department or facility is 

licensed by the state as an emergency 

room or department. 

■ The department or facility is held 

out to the public (by name, signs, 

advertising, or other means) as a 

place that provides care for emergency 

medical conditions on an 

18 


M. STEVEN LIPTON

urgent basis without requiring a previously 

scheduled appointment; or 

■ The department or facility, based 

on a representative sample of patient 

visits within the preceding calendar 

year, that provides at least one-third 

of all of its outpatient visits for the 

treatment of emergency medical conditions 

on an urgent basis without 

requiring a previously scheduled 

appointment. CMS will issue 

instructions to surveyors on sampling 

and will post questions and 

answers on the CMS website to give 

further guidance to providers. 

B. So, What’s a DED? The definition of 

immediate medical care for patients 

on a drop-in basis. 

2. Application of EMTALA to hospital 

property outside of the DED 

CMS reaffirmed its view that EMTALA 

does not apply outside the DED unless 

an individual on hospital property 

requests examination or treatment for 

what may be an emergency medical 

condition or has such a request made 

on his/her behalf. EMTALA also 

applies if a prudent layperson observer 

would believe, based on the individual’s 

appearance or behavior, that the individual 

needs emergency examination or 

treatment. 

new Medicare condition of participation 

requiring written policies and procedures 

for appraisal of emergencies and 

referral when appropriate. 

4. Application of EMTALA to individuals 

who present to a DED CMS 

reaffirmed that a hospital has an 

EMTALA obligation with respect to 

any individual who comes to a DED 

seeking or in need of examination or 

treatment for a medical condition, even 

if the request is not for an emergency 

condition. However, the final regulations 

emphasize that that medical 

screenings are not required to be 

“equally extensive.” An individual who 

a DED intentionally goes beyond 

requests medical care that is not of an 

emergent nature may receive a medical 

the typical emergency room. As The final rules continue to define “hospital 

property” by the 250-yard test for 

screening that is appropriate for other 

described by CMS, the DED 

persons presenting in similar circumstances 

to determine the presence or 

includes other hospital departments, describing the hospital-campus (including 

parking lots, sidewalks and drive- 

including labor and delivery and 

absence of an emergency medical condition. 

CMS suggested that in some 

psychiatric units, to which labor or ways) under the provider-based rules. 

psychiatric patients may present for However, the new rules clarify that 

cases, such as suture removal, a nurse or 

emergency services. 

“hospital property” does not include 

other qualified medical person could 

private physician offices, rural health 

perform the medical screening and 

More startling, a DED may include clinics, skilled nursing facilities, other 

determine that the individual does not 

many hospital urgent care and dropin 

care centers. CMS rejected a separately from the hospital, and pri- 

entities that participate in Medicare 

have an emergency condition. 

request to exclude hospital urgent vately-owned businesses such as restaurants, 

shops, and other non-medical 

In the preamble to the final regulations, 

care centers from being a DED, stating 

that “it would be very difficult activities. 

CMS also states: 

■ EMTALA does not apply to individuals 

who request services that are not 

for any individual in need of emergency 

care to distinguish between a 3. Application of EMTALA to offcampus 

departments of a hospital 

an examination or treatment for a 

hospital department that provides 

medical condition, “such as preventive 

care services.” Preventive services 

care for an ‘urgent need’ and one Under regulations adopted in April 

that provides care for an ‘emergency 2000, CMS applied the EMTALA obligations 

medical condition’ need.” Thus, an 

urgent care center is a DED if it is 

held out to the public as a place that 

provides care for emergency medical 

conditions. This explanation could 

also include as DEDs hospital occupational 

medicine clinics and other 

ambulatory care services that offer 

to all off-campus provider-based 

outpatient departments. In the most 

notable shift of policy, CMS repealed 

the 2000 regulations, and instead limited 

the application of EMTALA to offsite 

DEDs of a hospital. Off-campus 

hospital departments and facilities 

(other than a DED) will be subject to a 

are not defined in the preamble. It is 

expected that CMS will clarify this 

exception in a forthcoming guidance. 

■ Pharmaceutical services in a DED 

may be for medical conditions and 

are therefore subject to EMTALA; 



November 2003 

19

THE NEW EMTALA...continued from page 19 

and 

■ Requests by law enforcement for 

medical clearance of persons for 

incarceration or blood alcohol or 

applies to inpatients. The federal 

courts have split on this issue, and 

CMS agreed in 1998 to issue regulations 

addressing the issue. The final 

8. On-call obligations The on-call 

obligations under EMTALA have 

sparked the biggest backlash against the 

anti-dumping law, even though the law 

rules, rejecting the proposed approach 

other tests to be used as evidence in 

itself has never required physicians to 

in the draft regulations, provide that accept call or mandated specific rules 

criminal proceedings will be reviewed 

the EMTALA obligations are terminated 

when an individual is admitted June 2002, CMS published two memo- 

on the extent of on-call coverage. In 

on a case-by-case basis as to whether 

they trigger the EMTALA obligations. 

for inpatient care. The regulations follow 

the definition of “inpatient” in attempted to dispel the misperceptions 

randa, that, among other guidance, 

the Medicare Hospital Manual as “a and myths of the coverage rules by reaffirming 

the discretion given to hospitals 


receiving outpatient services 

person who has been admitted to a 

hospital for bed occupancy for purposes 

of receiving inpatient hospital needs, including the availability of 

to establish call panels that meet patient 

Many providers have been confused as 

to whether EMTALA applies to individuals 

with scheduled non-emergency 

services.” CMS further clarified that physicians on the medical staff to take 

individuals who are “boarded” and call. 

services at the hospital outside of a 

admitted in the DED are inpatients if 

DED. In response to these concerns, 

they have been admitted in accordance 

with the Medicare rules. guidance, with slight modification, that 

The final rules adopt the June 2002 

the final rules provide that the EMTA- 

LA obligations do not apply to an individual 

who has begun to receive outpa- 

However, CMS warned that EMTA- a hospital must maintain its on-call roster 

“in a manner that best meets the 

LA will apply if a hospital does not 

tient services as part of an encounter 

admit an emergency patient in good 

needs of hospital’s patients” who are 

other than an encounter that triggers 

faith (i.e., to avoid EMTALA requirements), 

and then inappropriately 

receiving services required by EMTALA 

the EMTALA obligations. The new 

rules apply to any person who comes to 

in accordance with resources that are 

transfers or discharges the individual 

a hospital department (other than a 

available to the hospital, including the 

prior to stabilization. 

DED) for non-emergency services (such 

availability of on-call physicians. CMS 

as physical therapy or diagnostic imaging) 

and has begun to receive those 

reaffirmed that there is no national 


in hospital-owned ambu- 

requirement for full-time on-call coverage 

by any specialty (although state law 

services. If the patient develops an 

lances Under the prior regulations, 

emergency condition during the outpatient 

encounter, the hospital’s response 

“ratio” linking days of coverage to the 

may be different) or any predetermined 

EMTALA applies to an emergency 

patient in a hospital-owned ambulance. 

will be governed by the Medicare conditions 

of participation (even if the 

specialty. Rather, CMS will consider all 

number of physicians in a particular 

The final rules provide that EMTALA 

does not apply to an individual in a 

patient is moved to a DED for stabilizing 

treatment). However, EMTALA will 

of physicians on staff, other demands 

relevant factors, including the number 

hospital-owned air or ground ambulances 

if: 

apply to outpatients before and after 

on these physicians, the frequency with 

■ The ambulance is operated under 

their service encounters, as well as to 

which the hospital’s patients typically 

community-wide EMS protocols 

other persons on the hospital campus 

require services of on-call physicians, 

that direct the ambulance to another 

such as hospital employees or visitors, 

and the provisions the hospital has 

hospital (for example, the closest 

who experience what may be an emergency 

made for situations in which a physician 

November 2003 

condition. 

6. Application of EMTALA to hospital 

inpatients Another long-time area 

of confusion is whether EMTALA 

available hospital); or 

■ The ambulance is operated at the 

direction of a physician who is not 

employed or affiliated with the hospital 

that owns the ambulance. 

in the specialty is not available or 

the on-call physician is unable to 

respond. Initial reactions indicate that 

hospitals appreciate the discretion to 

structure on-call coverage, but are 

20 


apprehensive about being secondguessed 

by surveyors. Anecdotal evidence 

suggests that some physicians are 

citing the new rules in dropping or curtailing 

call coverage. 

the need to come to the hospital 

must be resolved by deferring to the 

medical judgment of the treating 

physician. 

■ Hospitals that do not maintain a 

DED are not required to maintain 

ance on prior authorization. They also 

clarify that the treating physician (or 

another qualified medical person) may 

seek advice at any time from a health 

plan or other physician as to the 

patient’s medical history and needs, so 

In addition, CMS required hospitals to 

long as the consultation does not inappropriately 

delay required emergency 

an on-call roster. 

adopt policies and procedures in two 

■ Physicians in the hospital to see their 

circumstances: 

services. 

own patients are not on-call if they 

■ To respond to circumstances when a 

are not listed on the call roster for 

In addition, hospitals may follow reasonable 

registration processes for emer- 

specialty is not available or the oncall 

physician cannot respond to due 

that time period. 

■ The practice of refusing to be listed 

gency patients, including asking for 

to circumstances beyond his/her on the on-call roster, but taking calls insurance status and information so 

control 

selectively (for example, based on the long as the inquiry does not delay the 

■ To provide that emergency services 

are available to meet the needs of 

patients with emergency conditions 

if on-call physicians are permitted to 

(i) schedule elective surgery when 

they are on call, or (ii) accept simultaneous 

on-call for two or more hospitals 

ability to pay), is a violation of 

EMTALA. 

9. Patient registration In the 1999 

Special Advisory Bulletin on EMTALA 

and Managed Care, CMS and OIG 

issued guidance that a hospital may not 

medical screening or treatment. 

However, reasonable registration 

processes may not unduly discourage 

individuals from remaining for further 

evaluation. 

10. Application of EMTALA in 

seek prior authorization (or require a national emergencies CMS adopted a 

patient to seek prior authorization) for new regulation that sanctions under 

emergency services until a patient has EMTALA for inappropriate transfers 

In the preamble to the final rules, CMS 

received a medical screening examination 

and treatment has been initiated to bioterrorist attack) do not apply to a 

during a national emergency (e.g., a 

used the opportunity to express the following 

views on the scope of on-call 

stabilize an emergency condition. The hospital with a DED located in an 

obligations: 

final regulations adopt the 1999 guid- 

emergency area. ■ 

■ Hospital services offered to the public 

should be available through oncall 

coverage of the DED; however, 

CMS declined to adopt that standard 

in the regulations, stating that 

that it may “establish an unrealistically 

Congratulations on achieving 

CHC status 

The Healthcare Compliance 

Certification Board (HCCB) 

■ Cheri Huber, CHC 

■ Robert B. Jacobs, CHC 

■ Richard H. King, CHC 

■ Kathleen M. Kinsman, CHC 

■ Sandy L. Marks, CHC 

high standard that not all hos- 

announced that the following individ- 

■ Amy M. Bailey Muckler, CHC 

pitals could meet.” 

uals recently successfully completed 

■ Bill C. Parke, CHC 

the Certified in Healthcare 

■ Physicians who practice in a narrow 

■ Cari S. Reed, CHC 

Compliance (CHC) examination thus 

subspecialty may be medically competent 

in their general specialty, and 

■ Kirk A. Ruddell, CHC 

earning the CHC designation: 

■ Meghan K. Beck, CHC 

therefore should respond to requests 

Editor’s note: This listing was provided 

■ Patricia L. Calvin, CHC 

by emergency physicians to assist 

by Tracy Hlavacek. To learn more about 

■ Margaret R. Dittrich, CHC 

emergency patients. 

CHC Certification please contact Tracy 

■ Susan E. Garrison, CHC 

Hlavacek at HCCA, 888/580-8373, 

■ Disagreements between a treating 

■ Jolynn A. Hanson, CHC 

tracy.hlavacek@hcca-info.org. ■ 

and an on-call physician regarding 


November 2003 

21

By Amy Helder, MS, CPHQ and Becky Sutherland Cornett, Ph.D., CHC 

Editor’s note: Amy Helder, MS, CPHQ Participation (QAPI CoP); 2) The 

is Director, Quality & Operations Quality Initiative: A Public Resource on 

Improvement, The Ohio State University Hospital Performance; and 3) the CMS 

Hospitals East. She may be reached by Hospital Patient Experience of Care 

email at helder-1@medctr.osu.edu. Survey (HCAHPS). 

Becky Sutherland Cornett, Ph.D., CHC, 

is Director, Compliance Coordination, The Centers for Medicare & Medicaid 

The Ohio State University Health System, Services (CMS) published requirements 

Columbus, Ohio. She may be reached at 

614/293-5937. 

in the January 24, 2003 edition of the 

Federal Register for the QAPI CoP for all 

and reflects the paradigm shift to providing 

safe care by focusing on systems and 

hospitals participating in federal health processes of care, rather than an individual 

response to an individual quality of 

The scope of issues addressed by care programs. The intent of QAPI is to 

health care compliance programs 

has expanded with the ensure provision of high quality care to all five standards: 

protect patient health and safety and care concern. The QAPI CoP addresses 

federal government’s increasing focus on patients by requiring hospitals to develop, 

clinical quality and patient safety as compliance 

issues. This focus began with the 

Department of Justice’s use of the False 

Claims Act to prosecute health care 

implement, maintain, and evaluate hospital-wide 

quality programs based on the 

complexity of the organization’s operations 

and services. The program focuses 

Standard #1: Program scope 

■ Requires ongoing program that 

demonstrates measurable improvements 

in evidence-based indicators 

organizations that were seeking Medicare on maximizing health care outcomes and that will improve health outcomes, 

or Medicaid payment for substandard the prevention and reduction of medical including identification and reduction 

care. Readers are referred to the January- errors. Effective date for the CoP was 

of errors 

February, 2001 issue of the Journal of March 25, 2003. This approach is consistent 

with the Joint Commission on 

■ Requires measurement, analysis, and 

Health Care Compliance for a thorough 

discussion of the evolution of quality as a 

tracking of quality indicators 

Accreditation of Healthcare 

compliance issue. These issues have also 

• Adverse events 

Organizations’ (JCAHO) performance 

risen to the forefront in the health care 

• Processes of care 

improvement standards which emphasizes 

industry, and in the popular press, in 

the following principles: 

• Hospital service 

large part due the Institute of Medicine’s 

■ Identification of quality-related opportunity 

for improvement 

• Hospital Operations 

(IOM) landmark report To Err Is Human 

(1999), which estimated that between 

Standard #2: Program data 

■ Design and implementation of appropriate 

action 

44,000 and 98,000 Americans die each 

■ Hospitals must incorporate quality 

year due to preventable medical errors. 

indicator data, including patient care 

■ Follow-up to determine success of 

and other relevant data into their performance 

improvement program (e.g., 

Three recent federal health care quality intervention 

and safety initiatives provide a new infrastructure 

for health care organizations to 

■ Sustained improvements 

data submitted to or received from the 

November 2003 

support delivery of high quality care and 

service to patients. These initiatives 

include: 1) Quality Assessment & 

Performance Improvement Conditions of 

QAPI replaces the Quality Assurance 

CoP published in 1986, when the health 

care industry used a reactive approach to 

evaluating and improving quality of care, 

Medicare contractor Quality 

Improvement Organization) 

■ Requires monitoring of effectiveness, 

safety of services, and quality of care 

22 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org 

AMY HELDER

■ Data must be used to identify opportunities 

for improvement and changes 

that will lead to improvement 

■ Frequency and detail of data specified 

by hospital’s governing body 

BECKY SUTHERLAND CORNETT 

Standard #3: Program activities 

■ Requires priority setting related to the 

following: 

• High risk, high volume, problem 

prone, known to affect health outcomes 

• Health outcomes, patient safety, 

quality of care 

■ Requires adverse patient event tracking 

• Analysis of causes and implementation 

of preventive actions 

• Mechanism for feedback and learning 

throughout hospital 

• Demonstration of sustained improvements 

Standard #4: Performance 

Improvement (PI) Projects 

■ The number of annual projects must 

be proportional to scope and complexity 

of services and operations of individual 

hospitals. 

■ Requires documentation of: 

• What projects are being conducted 

• Reason for projects 

• Measurable progress achieved 

■ Participation in a Quality 

Improvement Organization’s (QIO) 

cooperative project not required, but 

hospitals’ own projects must be of 

comparable effort 

■ Information Technology (IT) may be 

selected as a project 

Standard #5: Executive responsibilities 

■ Hospital’s governing body accountable 

for ensuring on-going QAPI program 

• Priority setting, implementation, 

maintenance 

• Evaluation of all improvement 

actions 

• Set expectations for patient safety 

• Annual determination of number of 

distinct projects 

• Allocation of adequate resources to 

accommodate: 

– Measuring 

– Assessing 

– Improving 

– Sustaining hospital performance 

and reducing risk to patients 

Compliance with QAPI does not currently 

require use or reporting on specific 

measures, but future rulemaking will 

require hospitals to participate in a system 

of performance measures with other hospitals. 

The quality initiative: A public resource 

on hospital performance 

The Quality Initiative is a national collaborative 

effort to collect and report hospital 

quality performance information, led 

by the American Hospital Association 

(AHA), the Federation of American 

Hospitals (FAH), and the Association of 

American Medical Colleges (AAMC). 

Supported by the resources of JCAHO, 


the National Quality Forum (NQF), 

CMS, and the Agency for Healthcare 

Research and Quality (AHRQ), the purposes 

of this initiative are to: provide 

valid information about hospital quality 

to the public; standardize data collection 

priorities and mechanisms; support 

health care clinicians in offering quality 

care to patients; and enhance hospitals’ 

efforts to improve patient care. The initial 

voluntary reporting phase measures 

hospitals’ use of specific interventions for 

three conditions (acute myocardial infarction, 

heart failure, and pneumonia). The 

quality measures, developed jointly by 

JCAHO and CMS, are: 

Condition: Acute Myocardial 

Infarction 

■ Aspirin upon arrival 

■ Aspirin upon discharge 

■ Beta blockers at arrival 

■ Beta blockers at discharge 

■ ACE inhibitor for left ventricular systolic 

dysfunction 

Condition: Heart Failure 

■ Left ventricular function assessment 

■ ACE inhibitor for left ventricular systolic 

dysfunction 

Condition: Pneumonia 

■ Initial antibiotic timing 

■ Pneumococcal vaccination 

■ Oxygenation assessment 

On July 10, 2003, HHS Secretary 

Tommy Thompson announced that 

CMS is expanding its quality reporting 

initiative by creating a three-year demonstration 

program that will pay hospitals 

for performance. Hospitals who score in 

the top 10% on quality measures related 

to myocardial infarction, heart failure, 


November 2003 

23

ABCs 

AAPCC - Adjusted Average Per Capita Cost 

ACE - Affiliated Covered Entity 

ADMC - Advance Determination of Medicare 

Coverage 

AEP - Appropriateness Evaluation Protocol 

CBO - Congressional Budget Office 

CDC - Centers for Disease Control and 

Prevention 

CHC - Certified Healthcare Compliance 

CLIA - Clinical Laboratory Improvement Act 

CMI - Case Mix Index 

CMN - Certificate of Medical Necessity 

CPI - Consumer Price Index 

CPR - Customary, Prevailing and Reasonable 

CRS - Congressional Research Service 

DME - Direct Graduate Medical Education 

(sometimes DGME) 

DRG - Diagnosis Related Group 

EMS - Emergency Medical Services 

ERISA - Employee Retirement Income 

Security Act 

FEHBP - Federal Employees Health Benefits 

Program 

HPSA - Health Professional Shortage Area 

HRSA - Health Resources and Services 

Administration 

ICF/MR - Intermediate Care Facility for the 

Mentally Retarded 

IADL - Instrumental Activity of Daily Living 

IME - Indirect (Graduate) Medical Education 

IMG - International Medical Graduate 

IPA - Independent Practice Association 

HPSA - Health Professional Shortage Area 

Other acronyms on the Internet: 

http://www.allhealth.org/sourcebook2002/acrony 

ms.html ■ 

November 2003 

24 

OF ACRONYMS 

CLINICAL QUALITY...continued from page 23 

pneumonia, coronary artery bypass graft across hospitals about care experiences 

(CABG), and hip/knee replacements will and hospital performance. Although most 

be given a 2% bonus on Medicare payments; 

hospitals who score in the second faction data, there is currently no stan- 

hospitals collect and analyze patient satis- 

10% will earn a 1% bonus. It is estimated dard tool to address either satisfaction or 

that Medicare will pay a total of $21 million 

in bonuses over three years. Premier, “such information will help consumers 

experience of care. According to CMS, 

a consortium of 500 not-for-profit hospitals, 

is CMS’ partner in the program. ing a hospital and can create incentives 

make more informed choices when select- 

Performance “report cards” for participating 

Premier hospitals will be posted on vide.” The tool has recently been pilot 

for hospitals to improve the care they pro- 

the CMS website. The DHHS’ administration’s 

goal is to develop a national per- 

York, and Arizona), and CMS requested 

tested in three states (Maryland, New 

formance-based payment system for additional HCAHPS test sites in the July 

Medicare. 

31, 2003 Federal Register. Following analysis 

of pilot results and feedback received 

The initiative will be further expanded in during the public comment period, a final 

the future to include many more quality survey tool, and instructions for implementation 

will be made available in The 

priorities and measures identified in the 

Institute of Medicine report Priority Areas Quality Initiative: A Public Resource on 

for National Action: Transforming Health Hospital Performance. More information 

Care Quality (2003, National Academies about HCAHPS and a copy of the survey 

Press). These priority areas, which include tool is found at www.cms.hhs.gov (click on 

topics such as care coordination, evidence-based 

cancer screening, end-of-life the project may be addressed to 

Quality Initiatives). Feedback about 

issues, self-management/health literacy, hospitalcahps@cms.hhs.gov. 

medication management, and obesity, 

will be drawn from measures endorsed by The new QAPI Conditions of 

the National Quality Forum, and will Participation, The Quality Initiative, and 

respond to the broad health care aims the Hospital-CAHPS demonstrate 

published in the IOM report Crossing increasing federal expectations for health 

the Quality Chasm: A New Health System care quality management and improvement 

programs, and present an opportu- 

for the 21st Century (2001). Both publications 

can be read on-line or purchased at nity for health care organizations, associations, 

and accreditation agencies to collec- 

www.nap.edu. 

tively move toward a common system of 

Hospital Patient Experience of Care performance measurement and reporting 

Survey (HCAHPS) 

of indicators for clinical and service quality, 

and patient safety. 

DHHS’ Agency for Health Care 

Research & Quality (AHRQ) and CMS 

are developing and testing a standard It is also clear that hospital compliance 

instrument to be used by hospitals to professionals must collaborate with colleagues 

who lead quality improvement 

measure patients’ experiences while hospitalized. 

The data will be publicly available, 

and used to make comparisons formance goals. ■ 

programs to achieve organizational per- 


The ballots for the HCCA 

Board of Directors have 

been counted and the election 

results are in. The HCCA membership 

elected the following individuals 

to serve on the HCCA Board of 

Directors. Congratulations to: 

Julene Brown, RN, BSN, CHC, CPC 

Billing Compliance Manager 

MeritCare Health System 

701/234-3747 

The HCCA Board, during the 

September 20, 2003 Board Meeting, 

elected the following individuals to 

serve on the Executive Committee 

along with Al Josephs in 2004: 

Odell Guyton, Esq. 


Senior Corporate Attorney, 

Director of Compliance 

Microsoft Corporation 

425/7076-8527 

Al Josephs 

Steven Ortquist 

Alan Yuspeh 

Britt Crewse, MBA, MHS 

Associate VP and Chief Compliance 

Officer 

Duke University Health System 

919/668-6250 

Daniel Roach, Esq. 

HCCA 2nd Vice President 

VP, Compliance & Audit 

Catholic Healthcare West 

415/438-5579 

Odell Guyton 




415/438-5579 

Allison Maney, CPA, CHC 

HCCA Treasurer 

Director of Claims Research and 

Resolution 

Pacificare 

Gregory Warner, CHC 

714/226-5405 

Director for Compliance 

Mayo Clinic 

507/284-9029 


HCCA Secretary 

Chief Compliance Officer 

Daniel Roach 

2004 Executive Committee 

Al Josephs, having served in 2003 as 

HCCA Vice President will automatically 

succeed Alan Yuspeh as 

HCCA President beginning in 

January 2004 in accordance with the 

Banner Health System 

602/495-4845 

Alan Yuspeh 

Immediate Past President 

Senior Vice President, Ethics, 

HCCA Bylaws. Al is Director of Compliance & Corporate 

Corporate Compliance for Hillcrest Responsibility 

Allison Maney 

Health System in Waco, TX. He 

may be reached at 254/202-8620. 

HCA, Inc. 

615/344-1005 ■ 


Julene Brown 

Britt Crewse 

Gregory Warner 

November 2003 

25

Share Compliance Documents 

With Other HCCA Members... 

And win one of 12 Dell pocket PC’s 

Courtesy of: 

Each time you add a compliance document to 

the HCCA Website you will have an additional 

chance to win a Dell pocket PC* **, 

courtesy of Sheeder & Welch. Add 30 

documents and you will have 30 

chances to win each month for 

a period of 12 months– 

November 2003*** to 

October 2004. One 

Pocket PC will 

be given away each 

month for 12 months. 

Any non-copyrighted 

compliance document will 

count such as policies, procedures, 

forms, memos, presentations, educational 

tools, government documents, articles, white 

papers, or miscellaneous documents. Just visit 

eCommunities on the HCCA Website: 

www.hcca-info.org 

November 2003 

26 

*No repeat winners. 

**HCCA staff members are not eligible. 

***First winner announced in December 2003. 


Compliance 

vs. the legal 

department 

ROY SNELL 

In a September 5 letter to Tenet 

Healthcare, Senator Grassley stated 

there was an inherent conflict with 

Tenet’s Compliance Officer and the 

General Counsel positions being held by the same person. He 

wrote “It doesn’t take a pig farmer from Iowa to smell the 

stench of conflict in that arrangement.” Given that he risked 

offending all of the pig farmers in Iowa (his constituency) he 

must feel very strongly about the issue. (please note that 

Tenet announced it had separated the General Counsel and 

Compliance Officer function in an August 4 press release 

prior to Senator Grassley’s September 5 letter.) 

Grassley is not alone on this issue. Many believe that if you 

want to get off on the wrong foot with a government investigation, 

tell them your General Counsel and Compliance 

Officer is one in the same person. If the General Counsel 

does not also perform the compliance function many believe 

the second most irritating thing is to have the Compliance 

Officer report to the General Counsel. 

For the record I have seen organizations that have combined 

the functions somewhat successfully. The Compliance Officer 

was respected enough by the enforcement community to pull 

off both jobs. Unfortunately the organization I site most frequently 

announced last week they were splitting up the function. 

I am sure there are others. The question is not, “Can it 

be done successfully?” Rather, the question should be “Is it a 

wise move?” 

What is Senator Grassley’s point? 

He feels that there is a conflict of interest. He believes it is 

difficult to defend the organization from the outside world as 

General Counsel and look out for the organization’s stakeholders 

as Compliance Officer. Investigators frequently complain 

about the conflict and the OIG guidance suggests that 

the Compliance Office should be independent from the 

General Counsel function. 

Why do organizations combine 

the functions? 

Some organizations choose to combine 

the functions because the jobs 

are similar. They both study regulations, 

investigate problems, respond 

to complaints, etc. There are similarities 

in the two functions, but the 

difference in the overarching mission 

of each function may make it difficult to perform both 

tasks. The legal department should be able to do what ever it 

takes to defend the organization from outside attack. 

The compliance department should do what ever it takes to 

ensure the organization is treating its stakeholders fairly. The 

two departments are working for two entirely different constituencies. 

To the outside world (especially Senator Grassley), 

combining the functions is akin to having a court case where 

the prosecutor and the defense counsel are one in the same 

person. 

Some organizations combine the functions because they are so 

small they can’t afford the added expense. It is true that small 

organizations can not afford to increase expenses. However, 

outsiders wonder why you would add the compliance function 

to a “conflicted individual.” Outsiders look at the organization 

and ask, “Why not add the function to the Quality Assurance 

Department or someone else who is not charged with defense 

of the organization?” 

What’s the enforcement community’s perspective? 

They often think the functions are combined (or the CO 

reports to the General Counsel) “to keep the compliance function 

in line.” Why have they come to that conclusion? 

Apparently during investigations some employees have claimed 

to have heard directly or indirectly that the functions were 

combined because management wanted to “keep a lid on the 

compliance function.” 

Senator Grassley’s letter has stirred up a controversy which has 

been going on for some time. There are different perspectives 

and most of the people involved feel very strongly. This is a 

controversy that will not be ending any time soon. ■ 


November 2003 

27

November 2003 

28 

FOR 

Medicare 

announces 

plan to 

accept HIPAA 

non-compliance 

electronic transactions after October 

16 compliance deadline 

The Centers for Medicare & Medicaid 

Services (CMS) announced September 

23 that it will implement a contingency 

plan to accept noncompliant electronic 

transactions after the October 16, 2003 

compliance deadline. This plan will 

ensure continued processing of claims 

from thousands of providers who will not 

be able to meet the deadline and otherwise 

would have had their Medicare 

claims rejected. 

The contingency plan permits CMS to 

continue to accept and process claims in 

the electronic formats now in use, giving 

providers additional time to complete the 

testing process. CMS will regularly 

reassess the readiness of its trading partners 

to determine how long the contingency 

plan will remain in effect. For 

more: http://www.cms.gov/media/press/ 

release.asp?Counter=870 

CMS update and improves its 

Medicare coverage decision process 

On September 25, the CMS announced 

an updated and improved process for 

making Medicare coverage decisions to 

ensure the highest quality of care for beneficiaries 

of the program of health care 

for the elderly and disabled. 

YOUR INFO 

“As we strive for continuous improvement, 

we are revising our procedures f 

or developing a National Coverage 

Determination to be more efficient and 

to ensure that we have access to all relevant 

information to make fully informed 

decisions,” CMS Administrator Tom 

Scully said. 

“Our goal is to make the latest advances in 

medical care available to Medicare beneficiaries 

more rapidly, while making evidence-based 

decisions that safeguard the 

health and safety of patients,” Scully said. 

A notice published in the Federal Register 

on Friday, September 26, 2003 incorporates 

lessons learned over the past three 

years and implements certain requirements 

of the Medicare, Medicaid and 

SCHIP Benefits Improvement and 

Protection act of 2000 (BIPA). It replaces 

an April 27, 1999 notice and will be 

effective on October 27, 2003. For more: 

http://www.cms.gov/media/press/release.asp? 

Counter=876 

OIG and CMS announce efforts to curb 

power wheelchair benefit abuses 

On September 9, the Health and Human 

Services Office of Inspector General and 

the Centers for Medicare and Medicaid 

Services announced a new 10-point initiative 

to substantially curb abuse of the 

Medicare program by unscrupulous 

providers of power wheelchairs and other 

power mobility products that prey on 

Medicare beneficiaries. For complete 

details: http://oig.hhs.gov/publications/docs/ 

press/2003/090903release.pdf 

Former Vertex chief patent counsel 

charged with insider trading 

On September 9, the US Attorney for 

Massachusetts Michael J. Sullivan 

announced that Andrew S. Marks, former 

Chief Patent Counsel of Vertex 

Pharmaceuticals, Inc., had been charged 

with securities fraud. For more: http:// 


www.usdoj.gov/usao/ma/presspage/Sept 

2003/Marks-Andrew-Information.htm 

Missouri PT provider settles allegations 

of overcharging Medicare 

On September 9, US Attorney for the 

Eastern District of Missouri Raymond 

W. Gruender announced that Missouri 

Bone and Joint Center, Inc. agreed to 

pay $145,208 to resolve civil allegations 

that it miscoded diagnostic charges billed 

to Medicare for physical therapy services 

resulting in a higher rate of reimbursement 

from Medicare. For more: 

http://www.usdoj.gov/usao/moe/press%20 

releases/archived%20press%20releases/ 

2003%20press%20release/september/ 

missouri_bone.html 

Griffin Hospital Settles, agrees to pay 

$180,000 

On September 8, US Attorney for 

Connecticut Kevin J. O’Connor 

announced that a civil settlement was 

reached with Griffin Health Services 

Corporation, Derby, CT, in a Drug 

Enforcement Administration civil penalty 

case. Griffin will pay the government 

$180,000. Allegedly Griffin failed to 

maintain complete and accurate receiving 

and dispensing records for eight Schedule 

II narcotic drugs; to forward the proper 

order forms to the DEA; to properly 

complete DEA order forms, and to properly 

document transfers between the hospital’s 

two pharmacies. O’Connor noted 

in a press release that “over 600 alleged 

violations had been uncovered during the 

course of the investigation. For more: 

http://www.usdoj.gov/usao/ct/Press2003/ 

20030908lhtml ■

Erin O’Donnell 

Director of Operations 

Erin.odonnell@hcca-info.org 

888/580-8373 x222 

Margaret Dragon 

Director of Communications 

Margaret.dragon@hcca-info.org 

781/593-4924 

Roy Snell 

Chief Executive Officer 

Roy.snell@hcca-info.org 

888/580-8373 

Karrie Hakenson 

Project Coordinator 

Karrie.hakenson@hcca-info.org 

888/580-8373 x233 

Gary DeVaan 

Webmaster/Graphic Designer 

Gary.devaan@hcca-info.org 

888/580-8373 x229 

Stephanie Lentsch 

Accounting Manager 

Stephanie.lentsch@hcca-info.org 

888/580-8373 x231 

Caroline Lee Bivona 

Project Coordinator 

Caroline.leebivona@hcca-info.org 

888/580-8373 x227 

Tracy Hlavacek 

Conference Planner 

Tracy.hlavacek@hcca-info.org 

888/580-8373 x223 

Wilma Eisenman 

Member Relations 

Wilma.eisenman@hcca-info.org 

888/580-8373 x221 

April Kraft 

Database Administrator 

April.kraft@hcca-info.org 

888/580-8373 x224 


Darin Dvorak 

Conference Planner 

Darin.dvorak@hcca-info.org 

888/580-8373 x232 

November 2003 

29

November 2003 

30 

HCCA welcomes the following people 

and organizations listed below (U.S. 

Sates Idaho to Pennsylvania) who 

joined HCCA between January-April 

2003. All member contact information 

is available on the Members Only section 

of the HCCA Website– http:// 

www.hcca-info .org - Please email April 

Kraft (april.kraft@hcca-info.org) with 

any questions on how to update your 

information on the Website. 

Idaho 

■ Bettina M. Ferraro, St. Alphonsus 

Regional Medical Center 

■ Kent Loosle, Magic Valley Regional 

Medical Center 

Illinois 

■ Tina Ahten, BSN, MHSA, Northwest 

Community Hospital 

■ James Bowers, Crain, Miller & 

Associates, Ltd 

■ Larry Lake, Protiviti, Inc. 

■ Carol E. Lewis, Qunicy Medical Group 

■ Robb Miller, Robb Miller Consulting, 

Inc. 

■ Sherri K. Myers, MA, Methodist 

Medical Center of Illinois 

■ Sharla J. Parker, VA Hines 

■ Alan Peterson, Tucker Alan, Inc. 

■ Robert S. Spadoni, Oak Park Hospital 

■ Stephen Weiser, Duan Morris, LLC 

Indiana 

■ Ronald Buskirk, AS, BS, MPA, St. 

Joseph Hospital 

■ Charlotte L. Howells, RN, Greater 

Lafayette Health Services, Inc. 

■ Nancy Lund, Community Foundation 

of Northwest Indiana 

■ Jan Teal, Advantage Health Solutions, 

Inc. 

Kansas 

■ Edward Barker, SCL Health System, 

Inc. 

■ Erica Bush, Shawnee Mission Medical 

Center 

■ Jan Clay, The Consotium Inc. 

■ Cindy S. Flentie, RHIT, Community 

Hospital Onaga 

Kentucky 

■ Donna D. Curry, RN, BS, CCM, 

DAHM, Center Care Health Benefits 

Programs 

■ Kevan Shaheen, Data Advantage 

Lousiana 

■ Cindy Baughman, MS, CPA, Ochsner 

Clinic Foundation 

■ Louella P. Givens-Harding, MBA, JD, 

House Call 

■ Shirin Harrell, JD, Sessions, Fishman, 

& Nathan LLP 

■ Karen Hebert, University Medical 

Center 

Maryland 

■ Victor Blanchard, Protiviti, Inc. 

■ Cheryl T. Godsey, MS, Keswick Multi 

Care Center 

■ Noreen Herbert, Mental Hygiene 

Admin. 

■ Pamela Hodges, BA, RAC, Human 

Genome Sciences, Inc. 

■ Linda Rago, CPC, LBR Assoicates, LLC 

■ Lisa Shay, Montgomey General 

Hospital 

■ Tracy Thomas, Catholic Health 

Inititatives 

■ Robert A. Wells, BA, JD, International 

Physicians Network 

Massachusetts 

■ David T. Haig, BS, Hallmark Health 

System Inc. 

■ David Rogers, Deloitte & Touche, LLP 

Michigan 

■ David L. Currin, BA, MBA, St. John 

Health 

■ Denise A. Dach, McLaren Health Care 

■ Julie Gutzman, Trinity Continuing Care 

Services 

■ Hala Helm, Spectrum Health 

■ Lena Payne, Integrated Health 

Associates 

■ Brenda Wilson, Training & Treatment 

Innovations, Inc. 

■ Kimberly Winnik, MSM, CIA, CFE, 


OCSA, Blue Cross Blue Shield of 

Michigan 

Minnesota 

■ Sean K. Bailey, DaVita 

■ Mary De Ranitz, UCare Minnesota 

■ Susan Hanstad, BA, Centerpulse Spine- 

Tech Division 

■ Andrew Labowitch, TruSource, Inc. 

Mississippi 

■ Debbie Adams, AA, CPC, Cardiology 

Associates of North MS 

■ Cathy Robinson, Rush Health Systems 

Missouri 

■ Camille D. Cohen, RehabCare Group 

■ Lynn Idle, University of Missouri Health 

System 

■ Patricia L. Weir, BN, BSN, MBA, 

Rehab Care Group, Inc 

Montana 

■ Michael Frank, Blue Cross Blue Shield 

of Montana 

■ Mary K. Nash, II 

New Hampshire 

■ Tonya Eastman, Littleton Regional 

Hospital 

■ Linda Gilmore, RN, BSN, CCRN, 

Littleton Regional Hospital 

■ Susan Sanfacon, BS, MBA, Simione 

Consultants 

New Jersey 

■ Alex Cocoziello, Dendrite International 

New York 

■ Melanie Belman-Gross, Ernst & Young 

■ Ellen Bennett, Sanofi-Synthelabo, Inc. 

■ Ann M. Curran, Medical Management 

Resources, Inc. 

■ David Ross, Protiviti, Inc. 

■ Ewa Winiarska, RN, BSN, Schervier 

Nursing C.C. 

North Carolina 

■ Pamela F. Farmer, NorthEast Medical 

Center 

■ Lea Fourkiller, JD, Cherokee Indian 

Hospital

■ Andy Hunter, MedClaim, Inc. 

■ Linda Jordan, Brody School of 

Medicine 

■ Deane E. Schweinsberg, RN, BSN, 

Duke Univ. Health System 

■ Paula Vaughn, Wake Forest University 

Oklahoma 

■ Judy M. Dunford, CMMPA, Tulsa 

Nephrology, Inc. 

■ Gwen Ford, DaVita 

■ Bill Oden, Oden Insurance Services 

■ David Stanton, Purcell Municipal 

Hospital 

Ohio 

■ Madelyn Anderson, RN, Community 

Health Partners 

■ John N. Petrus, JD,CPA, Univ. 

Hospitals Health System 

■ Pat Roam, Mount Carmel Health 

System 

■ Vicki Stubbers, Mercy Health Partners 

■ Greg A. Wessinger, Abbott Labs-Ross 

Products Division 

■ Nancy White, RHIT, Cincinnati 

Children’s Hosp. Med. Center 

Oregon 

■ Phoebe Bennett, Bay Area Hospital 

■ Bonnie Mullins, Oregon Anesthesiology 

Group, PC 

■ Marcus C. Mundy, Kaiser Permanente 

Pennsylvania 

■ Lori Biacchi, MHA, RRA 

■ Chetan Deshmukh, MS, MBAL, HP3 

■ Steve Gallerizzo, VA Medical Center 

■ Geoffrey A. Jennings, DaVita 

■ Paul Lench, BS, MS, JEVS 

■ Phoebe Moore, BA, CPC, CPC-H, 

HP3 

■ Donna Osborn, Susquehanna Health 

System 

■ Diane Posternack, JEVS 

■ Stephanie Randall, Children’s Paraclete 

■ Cyndi M. Shipman, BS, Community 

Alternatives, Inc. 

■ Andrew Stuart, Klingensmith 

Healthcare 

■ Carol Ann R. Wilcock, DaVita ■ 

WEBSITES 

OF 

■ CMS 

Unveils 

New Website 

http://www.cms.hhs.gov 

■ CMS Health Care Industry Market 

Update 

http://www.cms.hhs.gov/reports/hcimu/ 

default.asp 

CMS Program Memos 

■ Managing Medicare Appeals 

Workloads in FY 2004 

http://cms.hhs.gov/manuals/pm_trans/ 

AB03133.pdf 

■ 2004 Annual Update for Skilled 

Nursing Facility (SNF) Consolidated 

Billing for the Common Working 

File (CWF) and Medicare Carriers 


B03068.pdf 

■ Addition of Three New International 

Classification of Diseases, Ninth 

Revision, Clinical Modification 

(ICD-9-CM) Diagnosis Codes to be 

Effective as Part of the October 1, 

2003, ICD-9-CM Update 


AB03129.pdf 

■ Changes to Code List for Therapy 

Services 


B03065.pdf 

■ Instructions for Provider Credit 

Balance Reporting Activities 


A03072.pdf 

■ FY 2004 Inpatient Prospective 

Payment System (IPPS), Long Term 

Care Hospital (LTCH), and Other 

Bill Processing Changes 


A03073.pdf 

Federal Register 

■ Table of Contents 

INTEREST 

http://www.access.gpo.gov/su_docs/ 

fedreg/frcont03.html 

■ FR–CMS published in the FR on 

pages 50717-50722, Final Rule related 

to Electronic Submission of Cost 

Reports rule 

http://a257.g.akamaitech.net/7/257/ 

2422/14mar20010800/edocket.access. 

gpo.gov/2003/03-21441.htm 

GAO 

■ The Month in Review contains the 

reports, testimony, correspondence, 

legal products, and other publications 

made publicly available during 

the previous month, grouped according 

to subject categories, subscribe at 

http://www.gao.gov 

OIG 

■ Audit–Review of Outpatient Cardiac 

Rehabilitation Services– Saint Luke’s 

Medical Center, Milwaukee, 

Wisconsin 

http://oig.hhs.gov/oas/reports/region5/ 

50200084.htm 

■ Ineligible Medicare Payments to 

Skilled Nursing Facilities Under the 

Administrative Responsibility of 

Cahaba Government Benefit 

Administrators 


50300051.pdf 

■ Ineligible Medicare Payments to 

Skilled Nursing Facilities Under the 

Administrative Responsibility of 

Veritus Medicare Service 


50300035.pdf ■ 


31 

November 2003

Editor: 

Margaret R. Dragon, Director of Communications, HCCA, 781/593-4924, 

Margaret.dragon@hcca-info.org 

Publisher: 

Health Care Compliance Association, 888/580-8373 

Consulting Editors: 

Alan Yuspeh, President, HCCA, 615/344-1005 

Roy Snell, CEO, HCCA, Roy.snell@hcca-info.org 

Design & Layout: 

Robin Taliesin, Raven Creative, 781/631-4639, robint@raven2.com 

Advertising: 

Erin O’Donnell, HCCA, 888/580-8373, Erin.odonnell@hcca-info.org 

Place 

HCCA Cool Clothes 

ad here: half page 

(exact reprint from 

Oct. issue, p.27) 

HCCA Officers and Board of Directors: 

Alan Yuspeh, JD, MBA 

HCCA President 

Senior Vice President 

Ethics, Compliance & Corporate 

Responsibility 

HCA, Inc. 

Al W. Josephs, CHC 


Director of Corporate Compliance 

Hillcrest Health System 

Odell Guyton 

HCCA 2nd Vice President 

Senior Corporate Attorney, 

Director of Compliance 

Microsoft Corporation 

Allison Maney, CPA, CHC 

HCCA Treasurer 

Director of Claims Research and 

Resolution 

Pacificare 


HCCA Secretary 



Sheryl Vacca, CHC 

HCCA Imme. Past President 

Director, National Health Care Regulatory 

Practice, Deloitte & Touche 

Shawn Y. DeGroot, CHC 

VISN 23 Compliance Officer 

Department of Veterans Affairs 

Suzie Draper, BSN, RN 

Corporate Compliance Officer and Privacy 

Officer 

Intermountain Health Care 

Rory Jaffe, MD, MBA 


U.C. Davis Health System 

Vickie McCormick 

Special Counsel 

Halleland Lewis Nilan Sipkins & Johnson 

F. Lisa Murtha 

Chief Audit and Compliance Officer 

Children’s Hospital of Philadelphia 



Banner Health System 

John Steiner 


The Cleveland Clinic Health System 

Debbie Troklus, CHC 

Assistant Vice President for Health 

Affairs/Compliance 

University of Louisville, School of 

Medicine 

L. Stephan Vincze, JD, LL.M, CHC 

Ethics and Compliance Officer 

TAP Pharmaceutical Products, Inc. 

Greg Warner, CHC 

Director for Compliance 

Mayo Foundation 

CEO/Executive Director: 

Roy Snell, CHC 

Health Care Compliance Association 

Counsel: 

Keith Halleland, Esq. 

Halleland Lewis Nilan Sipkins & Johnson 

Compliance Today (CT) (ISSN 1523-8466) is published by the Health Care Compliance 

Association (HCCA), 5780 Lincoln Drive, Suite 120, Minneapolis, MN 55436. Subscription rate 

is $357 a year for non-members. Periodicals postage-paid at Minneapolis, MN 55436. Postmaster: 

Send address changes to Compliance Today, 5780 Lincoln Drive, Suite 120, Minneapolis, 

MN 55436. Copyright 2002 the Health Care Compliance Association. All rights reserved. Printed 

in the USA. Except where specifically encouraged, no part of this publication may be reproduced, 

in any form or by any means without prior written consent of the HCCA. For subscription information 

and advertising rates, call HCCA at 888/580-8373. Send press releases to M. Dragon, PO 

Box 197, Nahant, MA 01908. Opinions expressed are not those of this publication or the HCCA. 

Mention of products and services does not constitute endorsement. Neither the HCCA nor CT is 

engaged in rendering legal or other professional services. If such assistance is needed, readers should 

November 2003 consult professional counsel or other professional advisors for specific legal or ethical questions. 

32

INSIDE - Health Care Compliance Association

Create successful ePaper yourself

Delete template?

Save as template?