CMS should use that extra time, it adds helpfully, to conduct a much-needed cost-benefit analysis, many of which have already been done (I just read through a RAND study commissioned by HHS way back in 2004) but need to be done again.

Note that the minimum delay the AMA is seeking, until October 2015, is a two-year delay from the 2013 implementation deadline, itself a delay from the original, original deadline of October 2011. If the guns had been stuck to, the industry would be in the middle of what the RAND study and similar research predicted would be a perplexing, post-transition aftermath of up to five years, at the end of which positive benefits in the form of fewer erroneous and “exaggerated” claims, as well as better disease management and more data-driven best practices, would kick in.

Well, now that we’re back in reality, that troubling time has been punted to what is becoming an ever-more distant future. CMS has officially pushed ICD-10 back to 2014, but all dates are elastic when it comes to adopting industry standards.

While much has been written about how the AMA lacks the political muscle it used to, it’s still got something left in the tank: I’m still wiping the egg off my face for a print feature I’d written in June 2010 about the Red Flags rule going into effect, which would have required providers to have specific compliance plans implemented to safeguard consumer data commonly used for identity theft and medical identity theft. I sent that to the printer the day before the AMA and others sued the Federal Trade Commission over the rule and kept up the pressure. Eventually, President Obama signed the Red Flag Program Clarification Act of 2010 which exempted health care providers and others from having to comply with the rule.

The reason I’m mulling it over is to lay bets on whether the industry will ever be coding in ICD-10. When I read over the AMA’s concerns and questions and calls for studies about ICD-10, I come to one conclusion: The association wants all its members to pick up a shovel, together dig the deepest, darkest hole they possibly can, and throw ICD-10 into it. The stated reason for the two-year delay request, that there’s too much going on right now, what with meaningful use and the transition to HIPAA 5010 transaction sets and health reform (maybe) and accountable care and bundled payments, and, well, other stuff too, is a bit disingenuous, because there’s always going to be something going on, including a potential Stage 4 to the meaningful use program in 2018 and other regulations (maybe FDA regulation of electronic records?) that are being thought up right now in the basement of some government agency.

Mind you, the AMA and its allies in this tussle (the Medical Group Management Association and a slew of other medical societies) have their reasons to throw a wrench in the works, many of them compelling for their constituents. It’s hard to see a future where ICD-10 granularity doesn’t result in lower reimbursement rates. And as of now, it’s an unfunded mandate, and even the most optimistic advocate will concede it’s going to be hideously expensive and cause productivity losses and revenue disruptions for an indeterminate period (that perplexing post-transition aftermath I noted earlier).

But let’s just call it like it is. It would be better if the AMA issued a release saying “The AMA Calls for the Death of ICD-10” and had ended it, instead of clogging up e-mails boxes with more calls for delay, which it will inevitably do. The problem with this perpetual cycle of political jockeying is that it punishes the organizations that are inclined to take the government at its word and invest the time and resources to actually do what the government keeps saying it’s going to make them do. This is a very dangerous game being played, and unfortunately it truly feels like a game, like it did during the agony of birth for myriad HIPAA regulations.

We need some resolution. Kill ICD-10 or negotiate with the AMA and other big players to have a deadline that everyone signs on to, with their signatures written in blood. If the industry can do that, it will create a blueprint for addressing future regulations that are hugely controversial but, in the end, have to be adhered to.

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Steven Beumel of Orange Park was arrested a year ago after being indicted by a federal grand jury. He faced one count of tampering with a consumer product resulting in death, four counts of tampering with a consumer product resulting in serious injury and five counts of stealing Fentanyl by deception. The 48-year-old pleaded guilty Friday to all counts.

Beumel, who is infected with hepatitis C, worked at the Mayo Clinic from 2004 to 2010. In federal court in Jacksonville, he admitted to stealing syringes of Fentanyl during patients’ procedures and replacing them with syringes of saline contaminated with hepatitis C. The acts occurred from 2006 to 2008, according to the U.S. Attorney’s Office.

The indictment says he injected himself with the painkillers and refilled the empty syringes with saline, spreading the disease even though he put new needles on the syringes given to patients.

Mayo fired him. An arrest report said Beumel acknowledged to detectives that he was addicted to Fentanyl. His attorney said last year that Beumel did not know he had hepatitis.

Epidemiologists worked a little more than three years to solve the outbreak at Mayo. The first person discovered to have suffered an infection linked to Beumel was a liver transplant patient who received a new liver in 2006. The patient battled hepatitis C for almost four years before dying, never knowing how he got it. He was 61.

The clinic tested thousands of patients who were potentially put at risk by Beumel’s actions, the U.S. Attorney’s Office said. Two patients were linked to Beumel.

The Mayo Clinic declined, through a spokesperson, to comment Friday following Beumel’s guilty pleas.
He faces life in prison. A sentencing date has not been set, according to U.S. Attorney’s Office.

A provision in the health law will raise pay rates for primary care under Medicaid to the same level as Medicare, the federal program for retirees and the disabled. The pay change would have more effect in Florida than almost anywhere else, since Medicaid rates are among the lowest and Medicare rates among the highest in the nation.

Most primary-care doctors who treat Medicaid patients in Florida would see their pay rate almost double, according to data from a Health Affairs study published in 2009. Urban Institute health economist Stephen Zuckerman, author of the study, said more recent data show that if anything, the Medicaid-to-Medicare ratios in Florida have fallen since then.

“There’s no question that this policy change…will have a very substantial impact for primary care physicians who treat Medicaid patients in Florida,” Zuckerman said in a phone interview.

The idea behind the raise in pay is to increase Medicaid patients’ access to primary care and prevention, said officials from the U.S. Department of Health and Human Services, which released details on Wednesday. They said the difference in pay will be covered 100 percent by federal funds for two years.

Zuckerman said it’s not yet clear whether primary-care doctors who don’t take Medicaid today will be willing to start, given that the funding is assured for only two years. Some in Florida are also cautious about the long-run effects.e in Florida.

“It’s a positive step for primary care,” said Jay Millson, executive director for the Florida Academy of Family Physicians. “We think it’s wonderful; it would certainly improve access.”

But he’s afraid to count on it. “There are several potential scenarios that could derail this. It’s hard to be optimistic, politics being what they are these days.”

Assuming the proposed rule takes effect as scheduled, those who would benefit most could well be children, who account for the majority of Medicaid patients. The Florida chapter of the American Academy of Pediatrics is suing the Agency for Health Care Administration in federal court, arguing that Medicaid’s rate-setting process results in pay so low it violates federal law.

A decision in that lawsuit, which covers dentists as well as medical doctors, could come in August.

Dr. Louis St. Petery, executive vice president of the Academy of Pediatrics chapter in Florida, reviewed HHS’ proposed rule on Wednesday afternoon and called it “terrific.”

By his calculations, the pay for a typical office visit — to diagnose an upper-respiratory infection, for example, to determine whether it’s a virus that will play itself out or a serious infection that needs antibiotics or fluids  –  will jump from the current $32.56 to at least $65.

St. Petery, a pediatric cardiologist, was particularly pleased that HHS’ proposed rule will cover pediatric sub-specialists, since they have responsibility for the sickest newborns. More than half of newborns in Florida are covered by Medicaid, he said.

The rule also sets realistic pay codes for treatments that Medicare doesn’t cover, including many in pediatrics.

“It looks like they listened to us,” he said.

Florida Medical Association’s comment, sent via e-mail and attributed to VP of Government Affairs Rebecca O’Hara, was less enthusiastic: “The FMA has advocated for increased physician reimbursements for physicians serving Medicaid patients. We will continue to champion this issue until physicians are fairly compensated for their services. Unfortunately, Medicare and Medicaid payments to physicians rarely cover the cost of delivering care.”

FMA is dominated by specialists, who are not affected by the proposed pay raise for primary care.

AHCA officials didn’t comment directly, but sent some slides that the agency presented to the Social Services Estimating Conference in conference in January. One of the slides shows that after the 100-percent federal funding for primary-care pay raises expires, Florida could face a huge additional expense.

In fiscal year 2014-15, the added cost to maintain the primary-care pay raise is estimated at $188 million; for 2015-16, $383 million.

The Affordable Care Act expands the eligibility definitions for Medicaid to include those up to 133 percent of the federal poverty level beginning Jan. 1, 2014. For a family of four, that would equal an income of $29,326.

Recent estimates show that about one in four working-age adults in Florida is uninsured. Altogether about 4 million Floridians were uninsured as of the 2010 census, according to www.statehealthfacts.org.

While Medicare is a purely federal program, Medicaid is jointly operated and financed by the states and federal government. One of the reasons Florida officials claim the Affordable Care Act is unconstitutional is that the expansion of Medicaid — while federally funded at the outset — will become a state burden over time.

In leading a 26-state lawsuit against the law, Florida also argues that it is unconstitutional to force individuals to obtain health-care coverage (the “individual mandate”).

A federal judge in Pensacola declared the law unconstitutional, but courts in other regions yielded split decisions. The U.S. Supreme Court heard oral arguments in March, and is expected to render a verdict in late June.

“While we do not think physicians are being given enough time to comply with the Medicare e-prescribing program, we want to make them aware of the upcoming e-prescribing deadline so they can take steps now to prevent being hit with the 2013 penalty,” said AMA Immediate Past-President Cecil B. Wilson, M.D.

In November 2011 CMS released the final regulation on the 2013 Medicare e-prescribing penalty program. The penalty for not successfully participating in the program, or not filing for an exemption on time, is a 1.5 percent payment reduction for all Medicare claims based on the 2013 fee schedule amounts during the year.

Learn more about the e-prescribing penalty and the reporting requirements.

But the state did not take the steps required to get the money. A spokesman for the Florida House said it appears the reason was the cost involved in making changes to certain agency rules, but was unable to offer specifics Friday morning.

Children’s advocates say half a million Florida children, about one in eight, still lack health coverage.

“It’s so frustrating,” said Jodi Ray, director of Florida Covering Kids and Families at the University of South Florida. “These kids need health services.”

Ray said the state now has 2 million children covered through Medicaid or Healthy Kids, a buy-in program for uninsured working families. (Collectively, the programs are sometimes called KidCare.)

She recently received a national award for her project, which recruits and trains volunteers to find and enroll uninsured children.

It’s surprisingly hard to find the children who qualify for assistance; families often don’t know the programs exist, let alone how to sign up. That’s why the Obama administration decided to offer states a financial incentive.

The bonuses, which have been awarded for 2010 and 2011, are supposed to run through 2013. However, an effort to end the bonuses has begun in the U.S. House of Representatives, which has a Republican majority. On Monday, the House Budget Committee plans to mark up a $115 billion package of health-care cuts that includes $400 million in bonus money for children’s enrollment, Politico reported.

Those who oppose the bonus program said it could lead to fraud, tempting states to get sloppy in checking whether families are really eligible for tax-supported programs. But children’s advocates are fuming.

“Quite simply, what could be more ‘American’ than to have all children with a real and caring relationship with a medical caregiver,” said Dave Lawrence, chair of The Children’s Movement of Florida. “A country that has spent more than $500 billion dollars over the past 10 years to bring democracy to Afghanistan surely could make sure that children have the basics that would give them a fair chance to succeed in school and in life. The very future of our children depends on such issues.”

The estimate of how much Florida has given up by not seeking bonuses comes from Tricia Brooks, senior fellow at Georgetown Center for Children and Families. Brooks said she calculated the 2010 bonus that Florida would have earned at between $95 million and $100 million.

While she did not repeat the calculations for 2011, Brooks said, Florida’s enrollment increases met the targets to qualify for a similar performance bonus.

To receive the bonus, a state must adopt at least five of eight measures that make it easier for eligible children to become and stay enrolled. Brooks said Florida meets two of those: It doesn’t require a face-to-face interview, and it has no asset test – in other words, it doesn’t look at whether children’s families own a house or car.

Brooks said Florida partially meets two other measures: Creating standard forms and verification processes for Medicaid and Healthy Kids, and maintaining information from one year to the next without requiring families to start over on enrollment.

A fifth measure Florida could easily meet, Brooks said, is to make its premium-assistance program conform to one authorized by Congress. Premium-assistance programs help pay for employer coverage.

To accomplish these things, however, could require not only action by several state agencies, but also the Legislature – the same Legislature that has forbidden agencies to accept money if it comes from the Affordable Care Act.

The bonus money comes from a different funding stream, the Children’s Health Insurance Program Reauthorization Act.

To complicate things further, the Legislature will not meet again until March 2013, the last year the bonus program is supposed to operate.

Given the frustrations, child-advocacy groups are mobilizing under the banner of KidsWell Florida, part of a new national movement that wants to close gaps in public and private health insurance for children. The Florida groups will hold an organizing Webinar on May 30.

The groups involved include The Children’s Movement of Florida, Florida CHAIN, the Florida Center for Fiscal and Economic Policy, the Children’s Trust of Miami-Dade and the Florida Children’s Healthcare Coalition.

Consider these robust numbers: On Wednesday, the feds charged 107 suspects with submitting $452 million in false bills to Medicare in seven U.S. cities. In the Miami area, 59 of those defendants were accused of trying to steal $137 million from the taxpayer-funded healthcare program.

The takedown — one for the record books since the Justice Department began targeting Medicare corruption as a national crisis in 2007 — was both a surgical and symbolic strike against the still-viral crime.

Not surprisingly, “South Florida has the lion’s share of the cases,” U.S. Attorney Wifredo Ferrer told reporters after 22 indictments were unsealed in Miami federal court.

Ferrer, who held a press conference on the heels of a Justice Department media briefing in Washington, said Medicare fraud scammers have evolved from old-fashioned medical equipment suppliers to mental health, physical therapy, home care and HIV service providers.

“They all share one thing — greed,” Ferrer said, treating Medicare like an “ATM machine.”

Although Medicare has devoted hundreds of millions of dollars to fight fraud with upgraded computer software, the federal program for seniors and the disabled still pays most claims within 30 days. As a result, Medicare’s contractors pay out billions of dollars yearly on fraudulent bills because they fail to detect anything suspicious.

Miami, long-recognized as the nation’s capital for Medicare fraud, runs no risk of losing that dubious distinction.

“ Sadly, in Miami, multimillion-dollar healthcare fraud cases are no longer shocking in their magnitude or frequency,” John V. Gillies, special agent in charge of the FBI’s Miami office, said at the press conference.

Here are a handful of criminal cases unveiled Wednesday:

•  Owner Armando “Manny” Gonzalez was indicted with eight others for operating mental health clinics called Health Care Solutions Network in Cutler Bay and North Carolina that submitted $63 million in bogus bills between 2004 and 2011. The clinics billed for group therapy sessions that were either not provided or could not have benefited patients, some of whom suffered from dementia or Alzheimer’s. Gonzalez and some of the other defendants are accused of paying kickbacks to recruiters and assisted-living facility owners to supply patients.

•  Manotte Bazile, a former social worker who worked at mental health clinic in Miami Gardens, was implicated in the feds’ ongoing $57 million case against Biscayne Milieu, which was shuttered last year. Her alleged role in the fraud conspiracy: Bazile is accused of assisting patients without U.S. citizenship by completing immigration forms for them that falsely indicated they suffered from mental illnesses. In turn, that enabled the patients who did not need the therapy services to avoid taking the citizenship test, authorities said.

•  Jorge Luis Reyes and Waldo Gonzalez, owners of medical clinics that purported to treat HIV-positive patients in Miami-Dade and St. Lucie counties, filed $15.2 million in fraudulent claims for unprovided or unnecessary therapy. What made their alleged scheme different was they filed the false claims wither private insurers that operate under the Medicare umbrella. Back in the mid-2000 era, South Florida HIV-service operators billed Medicare directly for billions of dollars in purported treatments in perhaps the most costly scam ever committed against the program.

•  Owner Pablo Orama and 15 other defendants were charged with defrauding Medicare by using his Miami-Dade business, Superstar Home Health, to bill Medicare for purported skilled nursing and physical therapy services for homebound diabetic patients. The racket, which allegedly thrived by billing Medicare for costly insulin injections, revolved around kickback payments to recruiters and patients.

Wednesday’s takedown by FBI, Postal Inspection and Health and Human Services agents marked the fourth time that the Obama administration has orchestrated such massive arrests of Medicare fraud defendants. The arrests are designed to show the Justice Department’s continued crackdown in major fraud centers like Miami, deter Medicare scofflaws and promote public awareness of the widespread problem.

Despite all the doom and gloom, the FBI’s Gillies said there was some “good news” to report: Medicare’s expenditures for a variety of medical services in South Florida decreased by a half-billion dollars over the past year, largely because of stepped-up law enforcement.

The bigger surprise, however, was the firing of chairman Phil Pead, the resignation of CFO Bill Davis for another job, and the resignation of three board members who didn’t agree with the decision to terminate Pead. The now ex-chairman was CEO of Eclipsys, when it merged two years ago with Allscripts which wanted to gain entry into the hospital market.

Since then the two companies have been struggling to integrate different electronic health records, and reorganizing their salesforce and customer service teams. Clients have been waiting for Allscripts to come out with an updated version of its EHR, which is expected to be released in September.

But with so much instability in the top ranks and confusion—the company didn’t give a reason for Pead’s departure, Allscripts could fast lose credibility with investors, and more importantly with customers. Those who had adopted a wait-and-see attitude over the new product might decide to drop Allscripts altogether from consideration.

Dr. Manuel Abreu’s complaint  says he was pressured to do too much to well-insured patients and too little to those for whom insurers pay a flat fee, called capitation.

The practice “routinely provided less care, or no care at all, to capitated care patients as compared with patients covered by traditional insurance,” the complaint says.

The suit in Pinellas Circuit Court names All Care Medical Consultants. Dr. Mohammed Yamani is the director of All Care, state records show.

Abreu alleges that Yamani overrode him when he tried to refer capitated patients to specialists or admit them to the hospital. Brand-name drugs were changed to generics, he said.

Abreu was fired Feb. 24 of this year without cause, he says. He filed the suit March 29, appending his employment contract, which reinforces his claim.

It says that Abreu is to be paid:
–a base salary of $170,000.
–60 percent of what the practice collects when he sees patients in the hospital.
–$60 for an office visit for a managed-care or Medicare patient.
–50 percent for office visits for fee-for-service patients.

In addition, there was a $5,000 bonus for keeping hospital stays to an average of no more than three days.

None of that is unusual, legal experts say. But they were surprised at one bonus: He was to be paid 25 percent of the proceeds for the ultrasound tests he ordered on fee-for-service patients.

That such a “blatant” financial lure would be put in writing stuns medical-legal expert Jay Wolfson, University of South Florida associate vice president for health law, policy and safety.

“It’s highly suspicious because it provides an inducement to perform specific diagnostic procedures, giving the doctor a piece of the action,” said Wolfson, who also is a professor of health law at Stetson University. “That’s exactly what state and federal anti-fraud guidelines are designed to stop.”

(Disclosure: Wolfson serves on the board of Health News Florida.) 

Yamani, a board-certified internist, did not respond to e-mail or phone calls. A receptionist at his clinic told a reporter on Wednesday that Yamani was out of the office for several days. No one answered the door at his $1-million home in Belleair.

Todd Phillips, director of operations for All Care, declined to comment on the case. So did Abreu’s Tampa attorneys.

It’s not clear where he is practicing. While his name is still on the sign in front of the Highland Avenue clinic and that address is listed with state licensing authorities, the receptionist said he has been gone for a couple of months. She said he  didn’t leave a forwarding address.

The lawsuit draws attention to the inherent financial conflicts of medical practice: managed-care’s pressure to keep spending low, and fee-for-service’s temptation to do the opposite.

Most capitation patients are unaware of the arrangement, since contracts between insurers and doctors are typically kept secret.

State and federal statutes don’t allow payment of financial inducements, or kickbacks. If Abreu’s case led to recovery of state or federal funds, he would stand to receive a percentage of it.

St. Petersburg-based health-care attorney Mike Igel said the All Care contract appears to have sections that are ethically questionable, but he said the wording is unclear.

“It’s poorly written, at the very least,” he said.

Tampa orthopedic surgeon Michael Wasylik, the Florida Medical Association’s managed-care expert, called the contract “bizarre.” In any event, he said,  “Good doctors take care of patients regardless of compensation.”

The proposed Medicare Reporting and Returning of Overpayments rule, called for in the Patient Protection and Affordable Care Act, was released by the CMS in February. It contains provisions that the Alliance of Specialty Medicine calls “onerous and unnecessary.”

In a letter to CMS acting Administrator Marilyn Tavenner, the Alliance wrote that under the proposed 10-year “look-back period,” fee-for-service providers would have to retain documents for four years longer than Medicare currently requires them to. The alliance proposed reducing the overpayment-liability period to three years.

“In the case of criminal activity and intentional fraud, the federal government has the authority to audit for longer periods of time and a 10-year look-back for this rule is unwarranted,” the Alliance wrote in the letter. In its proposal, the CMS said a decade-long period was chosen because that is the outer limit of the federal False Claims Act.

The Alliance also states that the CMS does not clearly define when a 60-day repayment window would open. The letter argues that the window should start at the conclusion of a review confirming overpayment and not on the first day a potential overpayment is brought to the attention of a provider. “For those physicians who use external billing services,” according to the letter, “there may be considerable lag between requesting necessary documents and receiving and analyzing them.”

The American Hospital Association and the Federation of American Hospitals have also criticized the proposed rule as unreasonable.

About 200,000 physicians are represented by the Alliance, which consists of the American Academy of Facial Plastic and Reconstructive Surgery, the American Association of Neurological Surgeons, the American Gastroenterological Association, the American Society of Cataract and Refractive Surgery, the American Society of Plastic Surgeons, the American Urological Association, the Coalition of State Rheumatology Organizations, the Congress of Neurological Surgeons, the Heart Rhythm Society, the North American Spine Society and the Society for Cardiovascular Angiography and Interventions.

The CMS estimated the total “burden cost” of reporting and returning overpayments at between $34.8 million and $58 million. It did so by estimating that some 125,000 providers would have between three to five overpayments that would require about $37.10 in staff hourly wages to process.