CANS NEWSLETTER—July 2006

1.  CANS Board Pow-Wow
2.  President’s Message
3.  Report from Executive Secretary
4.  News Briefs  

1.  Board Lowers Dues; Future Focus on Economics
The CANS Board of Directors held a special meeting on 7/22/06 to consider the organization’s future.  Rejected out of hand was dissolution since CANS constitutes the only voice for California neurosurgery and going quietly into the night would leave a state with one tenth of the nation’s population with no neurosurgical organization to interact with insurance carrier committees, the Division of Worker’s Compensation, the non-surgeon dominated CMA and our national neurosurgical organizations.  It was recognized that CANS cannot wag the aforementioned dogs but silence can be a devastating message with those groups. Even more pertinent, without CANS, who will look out for neurosurgeons and their patients and keep a watchful eye on those who would try to legislate and mandate our specialty into subservience at best and inconsequence at worst?

The Board then took the following actions:

1.Annual dues were reduced to $300 from the present $500 level beginning in 2007.  The higher number was instituted in 2005 so CANS could employ a lobbyist but that maneuver wasn’t successful (even with the higher dues, we could not put more than 25K a year toward lobbying which in the lobbying game gets you a bleacher seat) so the $300 level was felt to be fiscally reasonable since we have 175 active dues paying members and it takes almost 60K to run CANS each year.  The shortfall will be made up by an aggressive member recruitment campaign involving all Board members and which will include half-price first year dues for those who have not been CANS members for 5 years or longer.

2.The annual meeting will continue but will be structured to address economic issues almost exclusively in a one day Saturday program held at a fly-in fly-out airport hotel so an attendee need be away from practice no more than 12-16 hours and needn’t incur meal/lodging costs.  A Friday evening reception, a Saturday evening banquet and a Sunday 4-6 hour program (either scientific or clinical/Work Comp educational) will be provided for those who want to come early and stay over but will be ancillary.  Topics on Saturday will be geared toward practice survival and will include such items as How to Negotiate, Electronic Medical Records, Use of Practice Extenders, Avoidance of Employee Lawsuits, State and National Legislative Updates, Retirement issues and a free-for-all Town Hall Meeting for attendees to have their say.

3.The Board voted to oppose the Tobacco-Tax initiative which will be on the November ballot.  This initiative will add $2.60 to the cost of each package of cigarettes with the money raised to go to the Mom and apple pie areas of cancer, heart and emergency care.  CANS does not support smoking but the initiative includes language, inserted by our friends in the Hospital Association, setting up a mechanism for determining the level of stipends paid for ED coverage.  It involves the hospital and medical staff agreeing on an independent market expert who will assay the landscape and determine what is a fair and reasonable stipend which the docs then have to accept.  It would not be impossible for such a process to arrive at a truly fair stipend for neurosurgical coverage but the initiative language is less than clear and having it replace the neurosurgeon’s ability to directly negotiate for his/her services is a hobbling the Board felt should be resisted.  The CMA Board of Trustees voted to not oppose the bill as they, along with the soon to be former CMA CEO Jack Lewin, felt there is just too much apple pie for opposition and that the market expert path to stipend level will be OK for us.  The CANS Board was not convinced so took its stand and will consider joining a coalition of ED back-up docs led by Jim Hinsdale, vice-chair of the Board of Trustees of CMA, who wanted CMA to oppose but was outvoted.  In the meantime, CANS, as it has done multiple times in the past, will update its database of ED coverage neurosurgical stipend levels throughout all of California .  If the initiative passes, such information should be useful if the “market expert” process results in less than truly independent or accurate numbers. 

2.  President’s message for July
I intend to use the ‘dog days of summer’ excuse to write a shorter editorial.  With our recent nationwide heat wave, very noticeable in most of California , we in Fresno had two 113 degree days; so it is easy to see how the phrase originated.  Our two German Shorthaired Pointers now spend as little time in the backyard as possible, preferring the indoor air conditioned environment, especially plopping down on the cooler aggregate of the hallway, (becoming obstacles to getting to other areas of the house).  For this, I don’t blame them.

Randy gave a good summary of our July 22 special meeting.  This Special Meeting at Harris Ranch in mid-California along Highway 5 demonstrated a very dedicated Board by very good Board and Consultant attendance, despite time of year, location and multiple individual conflicts.  I believe the meeting was very productive and hopefully will revitalize our organization.  Again we exist to serve and represent the neurosurgeons of California , and would appreciate your input.  [To that end, you will note the survey enclosed in this Newsletter regarding preferences for speaker topics and/or speakers for our Annual January Meeting.  This is your chance to help CANS provide as productive a meeting as possible for the membership.  Please take the time to e-mail or use regular mail to return your choices.]

Recruitment of additional neurosurgeons to California remains a difficulty, and this applies as well, but perhaps less so, to many specialty areas and physicians in general.  This is not a situation confined to just our state, as six internists left this year from my Montana hometown, an area not blessed with an adequate physician supply (part of the problem) leaving many patients unable to obtain care as most practices are closed to new patients.  At our Annual Meeting this year we plan to bring a practice recruitment specialist to help educate us in this endeavor.

  HIPAA continues to raise its ugly head.  Enforcement regulations: the proposed regulations extend the investigation and enforcement rules to additional items, creating a single enforcement policy for all HIPAA provisions.  Many provisions are onerous, such as making the identity of violators public, and assessing very significant possible fines.  Entities that are affiliated in any way are subject to joint and several liability in penalties (which may all be maximal), and an entity is responsible for any violation committed by its work force, including volunteers and certain independent contractors.  HIPAA appears to be becoming more enveloping and complicated.  It might be worthwhile to review the Final Enforcement Rule published in the Federal Register and always remember to pay attention to all office and practice details.  (A copy of the first page of the enforcement regulations published in the Federal Register is attached.  The cite is 71 Fed. Reg. 8390 ( Feb. 16, 2006 ).*
- John Bonner

*For internet access:  www.gpoaccess.gov; click on Federal Register (it is under the Executive Resources category); once the Federal Register option opens, in the Quick Search type:  page 8390 HIPAA and click on submit.  The HIPAA Enforcement Rules should be the first option to select.  The information is also attached to this message.

3.  Report from the Executive Office
a.         MEMBERSHIP DUES
Subsequent to last month's newsletter, 11 members have remitted dues, lowering the number of members who were dropped this year to 59.

b.         CMA YOUNG PHYSICIANS
If you are a member of CANS, a member of CMA and a practicing physician under age 40 or within the first five years of practice, you may apply to request nomination to CMA's Young Physician Assembly to represent neurosurgery either as a delegate or an alternate delegate. The assembly provides a valuable forum for physicians to discuss problems and solutions and to develop leadership capacity.

You must be able to attend the assembly that will meet in Sacramento on October 27 for a one-day seminar; CANS will reimburse your travel expenses to this meeting.  Please submit your name as soon as possible for consideration and approval by the CANS Board of Directors. 

Please contact me at janinetash@sbcglobal.net with your input on any of the above items.

4.  Work Comp Treatment Guidelines; 
    The Governor Strikes; Blackmail; Fraud Alert  

a.         GUIDELINES.  The Administrative Director (AD) of the Division of Worker’s Compensation (DWC) has determined that the American College of Occupational and Environmental Medicine (ACOEM) treatment guidelines will continue to be used to determine appropriate treatment for injured workers.  She rejected other guidelines, particularly those promulgated by orthopedic organizations.  There will be a committee created to evaluate additional guidelines.  The makeup of that committee includes the usual suspects such as chiropractors and acupuncturists along with an orthopedic surgeon but presently does not include a neurosurgeon.  CANS has requested that a neurosurgeon be put on that committee which hopefully will bring some increased surgical sense to the ACOEM guidelines.  These guidelines are used by utilization review organizations and their physicians to approve or deny treatment recommendations made by consulting surgeons.  One would hope that the guidelines for lumbar fusion published in the Journal of Neurosurgery: Spine, in its June 2005 issue, (Volume 2, No. 6) might get a fair hearing.

b.         GOVERNOR
In an executive order issued last week, Governor Schwarzenegger told the state agency that oversees managed health care to issue regulations barring the practice of so-called “balance billing” of patients when an HMO refuses to pay for emergency care provided to its insured.  As previously discussed in the CANS newsletters of  September and October of 2005 and archived on our Web site (cans1.org—newsletters), we do have the right to a reasonable fee when we provide emergency care to a patient  insured  by an HMO with which we do not have a contract. The Gov’s edict banns our ability to bill the patient directly when the HMO refuses our “reasonable fee” request and forces us to negotiate or even litigate with the HMO as the sole source of payment.  One commiserates with the patient whose HMO doesn’t budget for out-of-plan emergencies, but forcing us to make their profitable operation even more profitable is certainly another attack on our ability to conduct a fiscally prudent medical practice.  If you are offered a pittance for your emergency care and are stone-walled by the HMO, go to small claims court with the Medicode book in hand and you should prevail—and maybe get the HMO’s attention that it is more reasonable to pay reasonably than it is to lose court cases.

c.         BLACKMAIL
Los Angeles attorney Lawrence Stern recently sent letters to agreed medical evaluators and qualified medical evaluators stating that California Applicants' Attorneys Association (CAAA) members had made a "pact" not to use the services of any doctor who has not contributed at least $2,500 to the upcoming elections and urging the defeat of Gov. Arnold Schwarzenegger. The President of the CAAA has repudiated the letter and reprimanded Stern who sits on the CAAA Board.  That repudiation didn’t do much to quell the subsequent hue and cry mostly raised by the DWC and the Republicans.  There doesn’t appear to be any doc organization commenting one way or another.  Well, let’s change that:  CANS strongly opposes such blackmailing tactics which amount to a kickback for getting cases.  We who do AME’s and QME’s are happy to get cases based upon our merits as fair evaluators.  Let us resist this new twist on the concept of pay for performance.

d.         FRAUD FIRM CHOSEN
The California Fraud Assessment Commission recently approved a contract which may be worth as much as $965,000 with Chicago-based Navigant Consulting to measure the extent of fraud by medical providers within the workers' compensation industry.  This commission, which doles out more than $30 million annually in fraud-fighting grants to the Department of Insurance and county district attorneys' offices, is funded by an assessment on employers.  Navigant will determine the extent of workers' compensation medical overpayments and underpayments of all types in order to detect and evaluate suspected medical provider fraud in California .  Why is this item in our newsletter?  First, innocent billing mistakes are termed fraud when the Feds do Medicare audits and we see no likelihood this audit will be doc friendly.  Second, companies that are hired to look for fraud will always find some, particularly since fraud can be in the eyes of the beholder.  The beholders in this case will include district attorneys whose agenda is often as political as legal.  Third, what may make sense to us can be considered part of a conspiracy by docs to defraud and once you are accused, the accusers have many more staff and attorneys than you do.  A couple of suggestions: Don’t exaggerate.  These fraud fighters have subpoena power so if you bill for 6 complex evaluations on a given day and your office log shows you didn’t have enough time to actually do 6 complex evals it can be considered fraud and not efficiency.  Also, your creative surgical billing can be their fraud.  For instance, billing for two partial corpectomies of C5 and C6 while doing a routine ACD&F at C5-6 with limited removal of the vertebral endplates may not be prohibited by the CPT Code Book but should not be billed according to the AANS Coding Book unless you remove 50% or more of each vertebral body.  Who’s to say what these fraud police will use as a standard?  If you embellish, you place yourself at some risk.  As we said last month, be careful out there!

Randy Smith, M.D., Editor

The newsletter is a mix of fact, rumor and opinion.  The facts are hopefully clearly stated.  The rest is open to interpretation.  The opinion is mine.  R.S.

The assistance of Janine Tash and Jack Bonner in the preparation of this newsletter is acknowledged and appreciated.If you do not wish to receive this newsletter in the future, please E-mail or fax Janine Tash ( janinetash@sbcglobal.net, 916-457-8202) with the word “unsubscribe” in the subject line.