medical billing transcription supplier information

MedLink International, Inc. (OTCBB:MLKNA.OB, BCN: WM6) announced today that it has entered into a letter of intent to acquire CNI Medical Coding & Recovery, Inc.("CNI").

Ray Vuono, CEO of MedLink International stated "The economies of scale in this venture are apparent to us. We believe that we will now be able to refer our physicians internally for their billing and recovery needs. In addition, we will also have access to provide CNI clients with the MedLink EHR and its suite of services. We believe this presents MedLink International the opportunity to realize revenues on the practice management end as well as the billing side and enables us to offer solutions to the medical community for every aspect of their practice."

The principals of CNI have nearly twenty years of experience in the medical billing and recovery arena. CNI specializes in re-gaining the revenue and subsequent profits its clients practices are entitled to, utilizing electronic claims and personalized reimbursement strategies. With its experience in assigning proper coding to diagnoses and procedures, CNI receives the financial reimbursement correctly from insurance companies and government agencies that approximately 25% of medical practices across America are only receiving 70% on due to under coding, missed charges, and un-reimbursed claims.

MedLink's acquisition of CNI is subject to MedLink's continued due diligence and there can be no assurance that its acquisition of CNI will be completed, or if completed, whether it will be completed on a timely basis.

About MedLink International, Inc.:

MedLink International is a holding company for its suite of subsidiaries that support the MedLink VPN (collectively "MedLink"). Utilized in conjunction with the security platforms of the MedLink VPN which allows subscribing doctors and others to securely communicate and to remotely access and retrieve patient records, lab results, X-Rays, CAT Scans and other pertinent patient information. The Company's flagship product the MedLink EHR provides patient-centric data. The primary care doctor utilizes MedLink EHR to gather and update the data on his or her patients. The MedLink EHR is used as a practice management system, it provides for the consolidation of data among the disparate networks, whereby it goes out like a powerful search engine within a doctor's own private network and collects and organizes the data into an application that provides for all of a doctor's records to be stored on their local database while keeping connected to all the networks their practice is affiliated with. Additional information about MedLink International and the MedLink VPN may be found at http://www.medlinkus.com.

Note on Forward-Looking Statements:

Statements contained in this press release, which are not historical facts, are forward-looking statements as that term is defined in the Private Securities Litigation Reform Act of 1995. These forward-looking statements are based largely on current expectations and are subject to a number of known and unknown risks, uncertainties and other factors beyond our control that could cause actual events and results to differ materially from these statements. These statements are not guarantees of future performance, and readers are cautioned not to place undue reliance on these forward-looking statements, which speak only as of the date of this release. MedLink International, Inc. undertakes no obligation to update publicly any forward-looking statements.

Maybe the Medicare "giveback" legislation will be the final word on whether reimbursement is adequate to ensure quality care. Or maybe it won't, given the passel of regulations--in healthcare dealing with work-site ergonomics and medical record keeping/Privacy--fired off in the final weeks of the Clinton administration.

Despite the uncertain future in the new Bush administration over such regulations, providers were nonetheless ecstatic as 2000 came to a close (and this column went to press) over enactment of the Medicare law formally known as the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. The new law is estimated to provide $1.6 billion over five years for skilled care, in the process hopefully undoing the havoc wrought by the 1997 Balanced Budget Act.

Among the changes affecting the Prospective Payment System, providers would get the full market-basket adjustment in fiscal 2001 and the market-basket increase minus 0.5% in fiscal 2002 and 2003. These amounts would be on top of the temporary increases under the 1999 balanced budget restoration law. Also, the 2000 law limits the SNF consolidated billing requirement to stays covered by Medicare Part A and Part B therapies and extends the moratorium on the physical therapy and occupational therapy caps through 2002.

Clearly the question of adequate staffing will emerge in the years ahead. One provision in the new law increases the nursing component of each RUG by 16.66% over previous law, for SNF care furnished after April 1, 2001, and before October 1, 2002. The congressional General Accounting Office (GAO) would be required to conduct an audit of nurse staffing ratios in a sample of SNFs and to report results to Congress by August 1, 2002, and recommend whether the additional 16.66% payment should be continued.

More heat will be generated by the staffing issue when some industry officials try to get Congress to undo the following provision in the new law: Medicare and Medicaid nursing facilities will be required to post nurse staffing information daily for each shift in the facility, effective January 1, 2003.

Nursing home providers fought this provision on the grounds that a number is an unfair way for consumers to compare facilities, because it fails to take case mix into account. Although they were unable to scuttle the provision when it went through Congress, providers were able to obtain an effective date that allows for a congressional revisit long before implementation.

Another provision would permit the Department of Health and Human Services (HHS) to establish a process for geographic reclassification of SNFs based upon the method used for inpatient hospitals, which incorporates local labor costs in calculations of Medicare payments. HHS might implement the process upon completion of the data collection necessary to calculate an area wage index for SNF workers. Meanwhile, it looks as though the days are numbered for the RUG system used to calculate Medicare prospective payments. By July 1, 2002, the GAO would be required to submit a report to Congress on the adequacy of Medicare payments, taking into account the role of private payers, Medicaid and case mix on the financial performance of SNFs and including an analysis, by RUG classification, characterizing the performance of such facilities. The law would also require HHS, by January 1, 2005, to submit a report to Congress on possible alternatives to RUG classification.

Abstract: The consolidated

billing requirement of the Balanced Budget Act of 1997, which becomes effective on July 1, 1998, has catapulted postacute care providers into the arena of vulnerability for possible fraud and abuse. With this in mind, the postacute care providers must identify the implications and develop and implement a compliance program to prevent fraud, abuse and waste. [Nurs Manage 1998:29(5):16-18]

The Federal Bureau of Investigation (FBI) has made health care fraud its number two directive. According to Nancy Bradford of the National Association of Certified Fraud Examiners, efforts to combat fraud will continue to grow. Experts offer con servative estimates indicating that 3% of the $1 trillion health care costs ($30 billion) was lost to fraud in 1997. 1 Last year, the Department of Justice expected to recover more than $1 billion in fines and settlements, just from fraud against government health care programs.2

In the private sector, a survey done by the Health Insurance Association of America revealed that nine out of ten private insurers had launched antifraud programs since 1995. The savings enured from these private insurers' antifraud programs totaled $260 million; an average $2.3 million per insurer, and $7.50 savings for each dollar spent on fraud detection.3

Fraud and abuse trends

According to the FBI, the shift of illegal drug distributors to health care fraud is due to more money and less risk of injury, detection and prosecution. Total health care expenditure in the United States is expected to reach $1.2 trillion in 1998. This amount of money is very attractive to illegal drug dealers and others. As a case in point: a South Florida grand jury indicted two men on charges that they submitted more than $50 million in fraudulent health claims to private insurers and self-insured companies. One man has a prior federal conviction and the other has been previously convicted for narcotics trafficking. Today, both men remain fugitives.4

The "qui-tam" provisions of the False Claims Act (FCA) authorize private individuals to bring FCA actions on behalf of the government and share in any recovery, thereby giving even employees incentive to report any case of fraud and abuse. Per the Department of Justice figures in 1997, 5% of quitam cases involved the Department of Health and Human Services (DHHS).

A recent review done by the DHHS' Office of Inspector General (OIG), found that portable chest X-rays done in long-term-care facilities cost up to nine times more than nonportable chest X-rays. Moreover, the OIG also found after reviewing medical records in California, New York, Florida, Texas and Illinois, that there was "no indication in more than 50% of the beneficiaries' medical records that they would be unable to be transported outside of the nursing home for medical services." Consequently, OIG recommended that the Health Care Financing Administration (HCFA) enforce the Medicare requirement that a physician must justify the need for portable services. The result of such enforcement, according to the HCFA, would be [a savings on as much as $63.7 million per year and $371.9 million over 5 years.5

Recently, the Cambridge Information Services (CIS), a Massachusettsbased health care information research company, used data obtained from the HCFA and determined that U.S. hospitals may have overbilled Medicare for as much as $482 million for laboratory tests performed between 1990 and 1997. Consequently, CIS estimated that nationally the Department of Justice could potentially recover at least $750 million in overbillings and penalties.6

In the private sector, provider fraud falls into one of two categories: billing for services not rendered and upcoding. Examples of billing for services not rendered include a physician who spends just a moment with the patient but bills for a full evaluation; a podiatrist billing for foot surgery when he/she only trimmed toenails; or a therapist who bills for an hour of therapy with a patient, when in fact, it was for 15 minutes. In terms of upcoding fraud, a different code is used to maximize reimbursement for a service or procedure done instead of the specific code for such service or procedure. According to Greg Anderson, director of corporate finance investigations for Blue Cross-Blue Shield of Michigan, these types of fraud constitute 100% of the provider fraud in fee-for-service plans.7

In managed care, the incidence of fraud has been in terms of embezzling capitation funds, falsifying new enrollee registrations, falsely increasing encounter rates to increase future capitated payments, illegally balance-billing patients and overcharging for copayments. On the provider side in managed care, some physicians have under charged copayments in order to attract more patients, thereby increasing their capitated collection from the managed care company; have taken kickbacks in exchange for increased referrals to particular specialist or facilities; and have routinely admitted patients at 11:55 p.m. instead of 12:05 a.m., thus collecting for an extra day's stay.8

The debate surrounding the appropriate and ethical use of individual medical records has crescendoed.[1-15] Like many medical dilemmas, this one requires a balance between individual rights and societal benefit. Individual rights advocates argue that medical record studies are not intended to benefit any one person, but they may put an individual at risk.[16-23] But even those people most concerned about the individual's right to privacy acknowledge the societal benefits that medical research has to offer.[16] To provide those benefits, the information used must be complete and unbiased. Complete access to existing data can help to ensure unbiased research results.[1]

In 1996, Minnesota translated this debate into a statute that went into effect on January 1, 1997 (Minnesota Statute 144.335: "Patient Consent to Release of Records," available by visiting the Journal's Web site at www.jfp.denver.co.us). This law requires each patient to sign a general authorization form (not informed consent) to release records for medical or scientific research.

The research community has speculated about the impact of the Minnesota statute and similar statutes on medical records research, but no data have been published.[24] Our study presents the rate of authorization refusal for a primary care multispecialty medical group and characterizes some of the differences between the people who refuse authorization and those who grant it.

METHOD

The Olmsted Medical Center (OMC) is a 75-clinician primary care multispecialty medical group in southeastern Minnesota, consisting of a large ambulatory care office in Rochester, Minnesota, and 12 branch offices in small communities throughout seven counties. The medical center includes a 65-bed acute care community hospital with an active obstetrical service, an outpatient surgery suite, an emergency department, and a full-time research department. For the past 35 years, the OMC has contributed data on all patient encounters to the Rochester Epidemiology Project, a population-based diagnostic index[25,26] housed in the Mayo Clinic and supported by funding from the National Institutes of Health.

SAMPLE

The study sample consisted of all new and established patients seen at the OMC for their first 1997 visit, during January or February, including scheduled office visits, emergency department visits, and admissions to the hospital and the outpatient surgery center. Since each ambulatory office keeps its own records, separate from those at the hospital, authorization is required at every site.

STUDY DESIGN

Each patient was asked by a department receptionist or hospital registration clerk to read and sign a general authorization form as a part of the normal registration procedure.(*) Patients who asked for additional information were given brochures. The authorization form was mailed to those patients who were unable to complete it during their emergency department visit or hospital stay. If a patient died before becoming stable enough to grant or refuse authorization, the next of kin was asked to sign the form. A parent or guardian was asked to sign the authorization form for children aged 16 years or younger and for adults legally unable to grant authorization.

The patient's authorization decision (granted, refused, or undecided) was entered into the electronic registration database of the clinic or hospital and was electronically linked to patient demographic data and the patient's stated reason for the first 1997 appointment. Patients who had a service or billing code but no corresponding authorization code were identified as not having been

asked about authorization.

ANALYSES

Simple descriptive statistics were used to estimate the proportion of patients granting authorization, refusing authorization, and remaining undecided (or not asked). The characteristics of patients refusing or granting authorization, and those either not asked or undecided, were assessed separately. Mantel-Haenszel tests were used to compare the proportions of patients granting authorization, refusing authorization, and undecided or not asked, across subgroups stratified by age, sex, and reason for appointment. Additional analyses were done to compare the two main groups, those patients granting and refusing authorization. Multivariate logistic regression analysis was used to describe the relationship between patients' characteristics and the decision to refuse authorization, after taking other characteristics into account.

Abstract: On February 11, 7998, the Department of Health and Human Services Office of Inspector General (OIG) released guidelines to assist hospitals and their agents and subproviders to comply with Medicare and Medicaid regulations. While adopting and implementing a compliance program is voluntary, the OIG believes that such a program prevents fraud, abuse, and waste while simultaneously furthering providers' fundamental mission-to provide quality care.

[Nurs Manage 1998:29(6):12-15]

Before developing a compliance program, it is necessary to understand its core elements. According to the Department of Health and Human Services Office of Inspector General (OIG), the program's fundamental purpose is to establish a culture with the facility that prevents, detects, and resolves conduct that does not conform to federal and state law, private payer health care requirements, and the facility's ethical and business policies. In effect, everyone is an integral part. Internal control is critical: the claims and billing operations are often the source of fraud and abuse.

Program benefits

In its guidance release, the OIG cites many benefits of a compliance program. Its benefits include:

* Ensures that accurate claims will be submitted to government and private payers

Enables the hospital/facility to fulfill its caregiving mission

* Assists hospital/facility in identifying any weaknesses in internal systems and management

* Demonstrates a strong commitment to honest, responsible provider and corporate conduct

* Provides a more accurate view of employee and contractor behavior relating to fraud and abuse

* Identifies and prevents criminal and unethical conduct

* Improves quality of care

* Creates a centralized source for information distribution on health care statutes, regulations, and other program directives related to fraud, abuse, and other issues

* Develops a mechanism for employees to report potential problems

* Develops a procedure that allows for prompt, thorough investigation of alleged misconduct by corporate officers, managers, employees, independent contractors, physicians, other health care professionals, and consultants

* Initiates immediate and appropriate corrective action

* Minimizes the loss to the government from false claims, and thereby reduces the hospital's/facility's exposure to civil damages and penalties, criminal sanctions and administrative remedies.

There is no single "best" compliance program. Nevertheless, there are seven core elements that can be used:

1. written policies and procedures

2. designation of a compliance officer and a compliance committee

3. effective training and education effective lines of communication

5. auditing and monitoring

6. well-publicized disciplinary guidelines

7. detected offenses and corrective action initiatives.

...policies and procedures

Written policies define the standards of conduct; risk areas; claims processing and submission; reasonable and medically necessary service parameters; antikickback and self-referral concerns; bad debts; credit balances; retention of records; and compliance in performance evaluations.

The standards of conduct should indicate that the facility's governing body, management, employees, and others who provide services on-site comply with all federal and state standards to prevent fraud and abuse. Standards could be articulated in the organization's mission, goals, and ethical requirements. The standards of conduct must be communicated to everyone (e.g., in the handbook) and updated in accord with statute changes. Disciplinary action could range from oral or written warnings, suspension, termination of admitting privileges for physicians, and financial penalties.

Risk areas should zero in on OIG concerns, i.e., billing for items or services not actually rendered; providing medically unnecessary services; upcoding; "DRG creep"; outpatient services rendered in conjunction with inpatient stays; duplicate billing; false cost reports; unbundling of services; billing for discharge in lieu of transfer; failure to refund credit balances; and knowing failure to provide covered services or necessary care to members of a health maintenance organization (HMO). "DRG creep" entails billing using a Diagnosis-Related Group (DRG) code that provides a higher payment rate than the DRG code that accurately reflects the service provided to the patient. A similar "RUGS III creep" can occur when the patient classification is done based on higher categories.

When processing and submitting claims, policies and procedures should: 1. Provide for proper and timely documentation of all physician and other health care professional services that substantiate billed services.

Pittsburgh based Acusis(R), a leading provider of medical transcription services to hospitals, clinics and physician practices was recognized for outstanding excellence after placing as a runner-up for the 2005 MTIA Billing Method Principles (BMP) Beacon Award. The Medical Transcription Industry Alliance (MTIA) along with other industry affiliates evaluated outsourced medical transcription service organizations and selected finalists based upon those that employed the following billing and pricing principles: verifiability, definability, measurability, consistency, and integrity.

Leading healthcare associations from the American Association of Medical Transcription (AAMT), American Healthcare Information Management Association (AHIMA), Modern Healthcare magazine and Medical Group Management Association (MGMA) were chosen to assess semi-finalists from leading medical transcription service organizations in the industry. Evaluation of 24 applicants resulted in six selected as semi-finalists based on their ability to demonstrate clarity in pricing methodologies and billing practices and support this transparency with actual client experiences. "Receiving recognition for first place was CyMed, Inc. who was very closely followed by Acusis. By placing high, our panel of judges can attest that Acusis maintains a high standard of integrity in the relationship with their clients," assessed Scott Faulkner, MTIA Board Member and BMP Beacon Award committee chair.

"We are constantly seeking ways to improve the service we offer to our customers. We've recently added new billing features, pricing options as well as participated in an independent audit to verify to our customers that we maintain the highest integrity when it comes to customer billing," commented David Iwinski Jr., chief executive officer of Acusis. In August, 2005, AcuSuite(R), Acusis' web-based software application has been enhanced with a new feature, AcuBilling, available for use this fall. AcuBilling provides customers with the means to access billing information electronically at their convenience.

In order to further validate and verify our processes and controls, Acusis commissioned an independent accounting firm to conduct an evaluation of their line-count pricing methodology, billing processes, system and controls. According to a report released in June, 2005 by Grossman, Yanak & Ford, LLP, "Acusis maintained internal control over customer billing based on published pricing methodologies."

"We could not be more pleased to make these improvements for our customers and receive recognition from leading industry affiliates when our industry is plagued with many companies having questionable billing practices that cast a shadow on all legitimately run operations. At Acusis, we have always placed a tremendous amount of effort into the relationship we share with our customers, pledging to them integrity and service excellence in all that we do," commented Iwinski. "We pride ourselves on being open with billing practices and ensuring that all transactions are done with the highest integrity and honesty. Being recognized by MTIA certainly places credibility on our message to provide the Highest Standards(SM) of medical transcription service in the industry."

Acusis, a leading provider of outsourced medical transcription services with Higher Standards(SM), specializes in superior performance, integrity and world class service. Headquartered in Pittsburgh, PA, Acusis delivers an integrated solution to hospitals, clinics and physician practices. AcuSuite(R), its web-based software application uses a secure method to manage the entire transcription process. Acusis delivers accurate reports within a 24 hour or less turnaround time. A global team of more than 600 highly trained Acusis associates provides an unparalleled higher standard of excellence and customer satisfaction at the most competitive prices, evidence of why you should expect more from your transcription service provider.

THE TSUNAMI HAS BEEN used as an apt metaphor to describe the coming impact of changes in American health care. (1) Those of us in health care are walkers on a beach unaware of the danger and destruction that is bearing down upon us. One might well object that most of us are anything but "unaware" about changes in health care these days. but our knowledge is not the same as foresight. Do we really see what dangers lurk on the horizon?

Even the most knowledgeable person can be surprised when cataclysmic events occur suddenly and seemingly without warning. Journalist Hedrick Smith, a long time Moscow correspondent for The New York Times, admitted that he did not foresee the sudden collapse of the USSR, despite his many years of living in and reporting on that country. (2) If such a historical and cultural "tsunami" can catch even the most knowledgeable and astute observer by surprise, how comfortable can we be about our future?

Today's events in medicine suggest that a tsunami-like catastrophe could catch us unaware at any time. Our health care system may be teetering toward the brink of its own implosion; yet who among us is considering this possibility--let alone preparing for it? It is human nature to believe that things will eventually work out for the best; often this is so. But we need to consider the bleaker picture as well. This article will describe some reasons why an apocalypse of American medicine could occur and discuss some actions we might take to prepare for such an event.

Five trends that threaten medicine

Let us consider five readily identifiable trends that threaten American medicine. None of these trends is a secret; they will seem all too familiar. We live with these realities every day, but do we consider their long-term consequences? Any one of them ought to be enough for serious concern, but taken together their meaning may be much more ominous.

The five dangerous trends are:

1. The practice of providing medical care is becoming too complex from both a business and a legal perspective.

2. Less money is being spent on medical care without any corresponding reduction in services provided, creating long-term operating deficits.

3. Investor-owned, for-profit corporations are changing the focus of medicine by putting shareholder concerns ahead of patient care.

4. Employment-linked health care insurance creates a growing uninsured population. adding extra financial stress to our hospitals.

5. Providers are losing faith in their future and are becoming increasingly demoralized about practicing the healing arts.

Let us consider each one of the trends in more detail before thinking about their cumulative impact on our future.

1. Business and legal camplexity

The growth of complexity is insidious. Each day we adjust a little more to living with increasing complexity in doing the business of medicine. Keeping up with the science of medicine ought to be enough, but it Is not. Laws are passed that turn normal referral patterns and innocent billing errors into "crimes" punishable by fines and jail. HMOs and insurance companies develop new and ever more complex rules for the care of their "covered lives," making navigation of any particular health plan difficult even for knowledgeable patients and their doctors. We all grumble about how difficult the practice of medicine has become, but we strive to cope and carry on.

Any given doctor's office, clinic, or hospital will have at least a dozen separate contracts for providing health care services. Each contract has its own special requirements and restrictions. Billing requirements vary, the referral forms for each health plan are unique, and the panel of referral specialists is different for each plan and changes from day to day. Thus, layer upon layer of complexity is added to practicing medicine--this slows us down, needlessly increases overhead, and diverts us from attending to patient needs. We seem to never experience a day when these sources of complexity are reduced, streamlined, or eliminated. Worse, as soon as we learn to play the game. the rules change once again.

If business complexity were the only problem, things would be bad enough, but it gets worse. Practicing medicine is becoming a legally dangerous activity. We have all learned to live with the ever-present threat of a malpractice action, but who among us is ready to face the full fury of the government in a criminal case?

The Health Care Financing Administration tries to reassure us that it only wants to catch the "bad apples." but who believes this? HCFA's new emphasis on documented medical services (i.e.. E & M bullet points) and aggressive discovery of what the agency considers "fraud and abuse" now includes a request for deputizing private contractors to investigate individual doctors. Moreover, HCFA specifically wants these agents-for-hire to have blanket permission to issue search warrants, make arrests, and carry firearms. (3) How will it play in your office or clinic when the C-men arrive with guns and warrants to search your patient records for fraud and abuse? Why are we not reassured?

Background. Despite emerging interest in computer-based patient records (CPRs), less than 1% of medical records in the United States are stored electronically. Some physicians may be reluctant to implement CPR system because of fear that the physician-patient relationship would be adversely affected. This study ascertained the attitudes of patients regarding the use of CPR systems.

Methods. This study was an in-depth interview survey of 16 patients concerning the CPR system used at the family medicine department at the Medical University of South Carolina. Interview topics included patient knowledge, perceived advantages and disadvantages, and the impact of the CPR system on their relationship with their physician.

Results. Most patients were informed about the nature of the CPR system and had positive attitudes toward it. Common perceptions were that CPR provides physicians with easy access to information, facilitates clinical encounters, and improves physician-patient relationship and the quality of care delivered. Although confidentiality was the major concern expressed about the CPR system, only one respondent indicated that this factor limited his interaction with his physician.

Conclusions. This study demonstrated patient acceptance and support for the CPR system in use at the study site. These findings should encourage physicians to use CPRs.

Key words. Medical records systems, computerized; physician-patient relations; patient satisfaction. (J Fam Pract 1994; 38:606-610)

Despite emerging interest in computer-based patient records (CPRs),(1)(2)(3)(4) less than 1% of medical records in the United States are stored electronically. There are numerous barriers to wider dissemination of CPR systems, one of which is physician reluctance. This barrier to the implementation of CPR systems may stem from physicians' fear that their relationships with their patients would be adversely affected. In view of this concern, it is necessary to ascertain the attitudes of patients toward the use of CPR systems.

The available literature on patient perspectives about CPR systems(5)(6)(7)(8)(9)(10)(11)(12)(13) is limited, inconsistent, and may represent societal attitudes toward computers in general. There seems to be a tendency toward greater patient acceptance of CPRs in recent years, a trend anticipated by Cruickshank(8) in 1984. The increase in personal and occupational use of computers over time may have played a large role in this attitude change. Another major theme present in this body of reserch is that patients actually exposed to CPR systems have more favorable attitudes toward them(6)(7) than do those who are asked for their theoretical opinion about CPRs.(8) Confidentiality is another aspect of CPR systems that affects patient attitudes about them. This concern is shared by patients contemplating CPR use by their physicians(9)(10) and those who have actual experience with the systems.(7)

There are several limitations to the studies published to date. Only three have reported on the perspectives of patients who have had actual experience with comprehensive CPR systems.(6)(7)(11) With one exception,(11) which reported the opinions of patients of only one American physician, the published studies are all from Europe. In addition, all published studies to date have used traditional quantitative survey techniques, which may have limited the scope of the findings.

This study expands on the CPR systems research base by reporting the results of an in-depth interview survey among patients at a medical university family medicine department. The site chosen for this study is ideal for studying patient perspectives in CPR systems because a computerized patient record system has been in place for more than 20 years and computers have been located in each examination room for more than 2 years. The CPR system used at the study site is a fully automated, paperless patient record, which has been described extensively elsewhere.(3)(14)

Methods

This study included an in-depth interview survey of 16 patients of the 8 faculty physicians at the medical university where the study took place. Purposeful random sampling was used in the recruitment process to ensure participation by patients of all 8 faculty physicians. Eligible patients included those 18 to 65 years of age whose appointments with their primary physician took place between April 1, 1993, and July 7, 1993, and were coded "medical exam." Patients of faculty physicians were chosent to minimize the effect of clinical and computer inexperience among residents that might have influenced responses to the survey. The code "medical exam" was chosen because this type of visit would give physicians an opportunity to use many features of the CPR system. Only patients with recent vists were eligible, so that the experience would be relatively fresh in their minds. Random sampling of every 5th eligible patient was employed to derive a final sample of 16 patients. Patients were excluded if they were an employee of the medical university, if they could not be contacted, if they refused to be interviewed, or if two of their physician's patients had already been interviewed.

The practice of medicine is becoming increasingly business-like and the business of medicine is becoming increasingly complex. Third-party and government organizations are imposing more regulations. Insurance companies and managed care firms are requiring more stringent utilization and quality controls, resulting in a blizzard of paperwork. The costs of practice inputs continue to rise, while physician revenues are stagnating. The availability of experienced support staff is limited, and turnover is frequent.

The need to investigate organizational alternatives to the traditional practice of medicine is becoming even more urgent with the expectation that the next few years will see a revolution in the way health care is organized and paid for. "Managed competition, "guaranteed access, "community capitated health plans, and "global price controls" are but a few of the new concepts that are being discussed at the national level and that may dramatically affect the delivery of physician services. Physicians, and the hospitals they relate to, must position themselves to respond quickly to these changes.

Objectives of Practice Integration

In order to compare the advantages and disadvantages of alternative models, it is important to identify key operational, financial, and legal objectives of medical practice integration. Does the model enable physicians to: * Enhance (or preserve) take home pay by:

* Raising practice revenue through improved collections and higher productivity.

* Benefiting from profits from group-owned ancillary services. * Reduce practice costs (lower prices for supplies and services, greater practice efficiencies). * Share profits from high-income specialties to low-income specialists. * Increase their influence in dealing with managed care and other payers. * Improve practice "life-style" by reducing hours spent in nonpatient care, permitting the physician to focus on the practice of medicine and leaving administrative, financial, and management issues to others. * Avoid, or deal more effectively with, burdensome government regulations. * Retain a large measure of autonomy and control over practice management and operations. * Participate in the strategic and operational decision making of the organization. * Avoid potential political problems with nonparticipating medical staff colleagues. * Expend a minimal amount in personal funds and time. * Avoid the risk of antitrust and/or fraud and abuse prosecution. * Involve the hospital in assisting financially in development and operations.

The table below provides a "score card" of how well the various models achieve these objectives.

Group Practice without Walls (GPWW)

A GPWW can be formed jointly by a hospital and physicians, referred to in this article as an affiliated medical practice corporation (AMPC), or it can be formed independently by community physicians, an independent group practice without walls (IGWW). The two models have much in common but are different in some very important ways.

Features in Common:

A GPWW is formed by physicians in established practices coming together to develop and control a professional corporation. (If this is an AMPC, the hospital is also involved and may take the lead, but the established physicians must have a major input). Physicians become employees of the group practice, merging their existing practices. Support staff members become employees of the group practice or of a separate management company that contracts with the professional corporation for management services. This management company may be owned 100 percent by the physicians, jointly by the physicians and the hospital, or by a third-party management firm.

Regardless of the arrangement, the physicians maintain their separate office locations and operational control over their support staffs, equipment, medical records, and clinical relationships with patients--the without walls aspect of the model. Practice income and expenses are tracked through the group practice's central financial books to each physicians' "profit center" so that the individual's productivity and cost-effective management are rewarded.

Other than common elements of a single fee schedule, flow of at least 75 percent of business through the group, a standard fringe benefits plan, central payables and payroll system, and risk sharing on managed care, physicians in a GPWW may operate their practices quite autonomously.

The employer/employee relationship of the GPWW provides very powerful advantages of this model over the other models in figure 1. As a single legal entity, the group practice can act on behalf of its physician/employees without fear of violating antitrust, safe harbors and other regulations that limit solo physicians from planning and working together. This enables the participants to enjoy the following benefits that can be achieved from the operation of a GPWW: * Collective operational and financial leverage in negotiations and program development with hospitals, HMOs, and third parties. (See sidebar, page 21, for a discussion of why group practices are attractive to HMOs. * Opportunity to share overhead costs and even revenue among physicians. In some GPWWs, specialty physicians "tax" their earnings in order to increase the income and ensure the survival of primary care physicians who are their referral base. * Opportunities to refer to and enjoy profits from group-owned ancillaries and other medically related businesses. Group practice ownership of ancillaries is one of the few remaining "safe harbors." * Efficiencies and professionalism of centralized billing, accounts receivable management, accounting, and financial reporting generate higher revenue. * Collegiality and support, financial and moral, of others who share common values, objectives, and strength in confronting common problems and external threats. * Enhanced ability to recruit new physicians to the area to assume the practice of a retiring physician or to expand services. * Economies of scale in buying supplies, services, equipment, and fringe benefits. * Centralized human resource functions providing wage and salary management, personnel policies, recruiting, orientation, training, and performance appraisals and advancement opportunities for support staff. * Ability, through cooperative marketing, to better withstand erosion of patient base to established groups that are expanding aggressively. * Delegation of administrative burdens to a central administrator, returning the physician's time to the delivery of medical services.

University Mednet is a 120-physician, multispecialty group practice located in the northeastern part of the Greater Cleveland area. In 1966, when I joined the clinic as a general and vascular surgeon, there were 25 physicians and dentists. The governance consisted of a board of trustees with an internally elected president who practiced medicine full-time and who was not involved in day-to-day management. The administrator was not a physician. The physicians practiced under the same roof, utilized the same billing services, and covered each other on nights off and vacations.

During the ensuing years the clinic grew and prospered, as did my career. I gradually became interested in participating in the governance of the clinic and, in 1971, succeeded in getting elected to the board. I served in that capacity for 14 years. Although relations between clinic and nonclinic physicians at our local hospital were never very good, particularly after we started our HMO, I managed to get myself elected chief of surgery and eventually chief of staff, the first clinic physician to serve in that capacity.

Two events were pivotal in shaping the clinic prior to the 1980s. The first was our decision to build a clinic facility in Mentor, a community 20 miles from the main clinic building. Subsequent growth has confirmed the correctness of that decision. The second major event was the formation of our HMO, which occurred in 1978 as a joint venture with the local Blue Cross/Blue Shield organization. This also was a fortuitous move, and, on more than one occasion, it saved the day for the clinic financially.

In the early 1980s, the clinic was run by an administrator who did not have the abilities of the prior one. He could not deal well with physicians, his management abilities were questioned, and he failed to develop the trust of both his staff and physicians. The CEO and president of the board was a physician who had been elected to the board in the late `60s. Initially, he practiced medicine full-time, but, as time went on, he gradually worked part-time in medicine and part-time in administration. He had no real experience or formal training in administration but learned on the job, as the rest of us did, with help from various ACPE courses that we all took.

During this time, the clinic seemed to be doing fairly well, in spite of a lack of capable administration. The executive director finally left and, for one-and-one-half years, we had no executive director. Yet we dramatically improved our pension plan, instituted profit-sharing plans, started a car and gasoline allowance, and instituted better insurance plans. Our auditors were beginning to tell us that. we needed to make significant improvements in the way that we ran the business, but in the face of healthy profits, we saw no need to make any drastic changes. However, we did hire a new executive director in 1984.

Starting in 1983, we began to show operating losses. In spite of these losses, we continued to give physicians increases in their pay. Finally, in the summer of 1985, we recognized that we were in trouble. Many were not happy with our executive director, and many were not happy with the job that the CEO was doing. A physician pay cut was looming on the horizon and our bankers were telling us that we were tapped out.

In June 1985, an off-campus meeting was held by the board, without the CEO or administration present, and it was decided we should meet with the CEO and inform him of our concern with the way things were going. We had doubts about the capabilities of the executive director, were troubled about the financial position of the clinic, and sensed a lack of confidence in the leadership of the CEO.

Another off-campus meeting was held with the CEO present, and he was informed of our concerns. We agreed to his request for full-time status in administration, with the understanding that he would become more involved in the day-to-day running of the clinic. We gave him a one-year contract to do just that. Unfortunately, a few months later he developed some cardiac difficulties requiring hospitalization and some time off. Upon his return, things did not improve, and we felt that he was no longer an effective administrator. He had been CEO for many years and had accomplished a lot during that time, but we felt that a change was in order. We were not sure about the executive director, but we felt that change had to start at the top.

A third off campus-meeting was held in early December at which we decided to dismiss the CEO. After volunteering, I was elected to fill that position. We met, once again off-campus, with the CEO present, and he was relieved of his duties. I read a prepared statement to him, explaining why we thought a change was necessary and telling him I was taking his place. He asked if there shouldn't be a transition period, but we felt the change should occur immediately.

I think that, when such events occur in physician organizations, the initial reaction is to have an internal person assume the position. That person is a known quantity, is a physician (in this case), and is one of us. If the person also seems to have some leadership ability and, most important, the respect of physicians, it would seem logical to have him step up and take charge. Of course, that person must want to do the job.

"I love what I do for a living," says Gerry Kelly, who runs All Type, a medical-transcription business, from her home in East Brunswick, New Jersey. Kelly is one of approximately 9,100 members of the American Association of Medical Transcription (AAMT), many of whom are home based. No matter what happesn to the health-care system, the field of medical transcription appears to be headed for strong growth in the 1990s.

At an AAMT conference last year, Robert Love, a Houston attorney specializing in the health-care industry, cited his projection that the industry will expand by 100 percent by the year 2000. In his opinion, barely one-third of the hospital market is being tapped. In addition, health-care facilities don't always have the space or the budget to keep all their transcription work on-site. The money you can earn as a medical transcriptionist, depending on the time you devote, your client base, and your location, ranges from $25,000 to $40,000 a year, according to most reports. Kelly herself made $43,000 last year.

Doctors dictate audiotapes describing patient care, operations, autopsies, and lab reports. Transcriptionists use a transcribing machine to listen to the tapes through headphones; they input the information to a computer. Doctors and hospitals need the records both to ensure consistent patient care and to protect themselves against malpractice suits. The transcribed documents become permanent records of patient care.

Typing skills are important for medical transcribing, but competence is not measured only in words per minute. "Medical transcription is a language specialty, not a keyboard specialty," says Pat Forbis, a certified medical transcriptionist and director of member services at AAMT. "Your speed and accuracy are determined by how well you know the language doctors use."

The main drawback to medical transcription is that it demands intense mental and physical concentration. Transcriptionists are hooked to headphones listening to doctors' hastily dictated notes for hours on end; when hospitals require quick turnaround, they may work well into the night. And after years of intensive typing, they run the risk of suffering a repetitive motion disorder.

LEARNING THE LINGO

How can you break into this specialized industry? Kelly, who has a bachelor's degree in biology and has worked as a pharmaceutical sales representative, attended night classes at a local technical institute for one semester, then got a job at a family-practice center. One month later the office manager agreed to give Kelly a set of keys so she could work flexible hours. (Since she had a two-year-old son at home, she preferred to work at night.) As she gained experience, Kelly researched computers and transcription equipment; she finally started her own business in December 1990. Now, she has contracts with two hospitals, works regularly for a third on a freelance basis, and has two subcontractors working for her.

There are various ways to learn medical transcription. There are two-year junior-college programs and two-semester courses at technical institutes, as well as on-the-job training. Kelly's knowledge of biochemistry enabled her to bypass the study of medical terminology and begin studying transcription immediately.

RUNNING THE BUSINESS

Once Kelly was confident of her technical skills, she called other transcriptions to determine pricing in her area. She now charges 15 cents a line; others charge by the typed page. Kelly bought a 286 computer with two floppy-disk drives, a laser printer, a modem, and a $650 transcriber unit. She uses WordPerfect software.

Kelly knows she needs an aggressive marketing approach. She keeps a prospect file and introduces herself by letter to individuals in charge of medical records, stating the benefits of using her services. She follows up by phone to ask about the prospects' current and future needs, and doesn't hesitate to ask about other departments that might be able to use her servides. "Even if they say they already have a complete staff of people on-site, I am quick to ask how they handle backlogs, overflow, vacations, and sick days." She tries to devote at least one morning a week to prospecting, including making sales calls.

Once you sell a client on using your services, you may wish to draw up a contract. Attorney Love says it's important to be as specific as you can. State what you will do; outline your work schedule and turnaround time; how the work will be delivered; and any on-site arrangements. You should also include your fees for services and your billing schedule.

Love says that anyone who has the technical expertise as well as the interpersonal skills to establish and maintain a working relationship can start a medical-transcription service today. "Medical transcription is a classic opportunity without walls," says Love.

Nursing home care is guaranteed to challenge your optometric and creative skills.

The primary goal for those involved in nursing home care should always be to provide the highest quality of care. It should be no different than what we strive for in our private or commerrcial setting practices. When I'm working at a facility, I often hear staff say to the residents, "The eye doctor is here. Do you want to get glasses?" This idea is far from what actually occurs at these exams. I see many more patients who have eye health concerns than who just need glasses.

They have problems

In most private practices, the majority of patients are refractive cases (unless you're in a more specialized setting). While a refraction is a part of every eye exam in a nursing home, the majority of patients exhibit one or more ocular pathologies. People commonly use the term "nursing home" instead of the more accurate name, long-term care center.

Residents are people who are unable to live on their own secondary to health issues or who need 24-hour care. Typically these are the elderly, in which the common ocular conditions are macular degeneration, cataracts, glaucoma and diabetic retinopathy.

Yet it isn't unusual to see residents in these homes who are under the age of 65. These are people commonly suffering from multiple sclerosis, long-standing, uncontrolled type-I diabetes mellitus, traumatic brain injuries, incapacitating health issues and psychiatric conditions. All of these people need your training in ocular disease, geriatrics, special populations and general optometry.

The patients are often challenging and just taking a case history can prove difficult, especially from those who have advanced dementia or Alzheimer's disease. You must often base exam findings entirely on objective testing, which is often difficult with poor head position and marginal cooperation. Patients suffering from Tardive dyskinesia, for example, have jerking motions that won't allow them to remain stationary for more than a few seconds.

Here's what you'll need

Nursing home care is probably one of the most challenging modes of optometry - one that requires all of your technical and creative skills. The following are skills and characteristics that are helpful in this practice setting.

* Background requirements. Because of the breadth of knowledge needed, eye care in a long-term care facility requires a strong optometric background. Although there aren't any training requirements, ocular disease residency training is recommended and beneficial. Being confident and comfortable in managing and treating ocular disease is required because this is a routine part of the patient care. This also includes being certified to treat therapeutically at the highest level allowed. Knowledge of low vision and experience with special populations is also beneficial.

* Equipment. In a regular practice setting, all of the equipment is fairly large and for the most part stationary. When working in a nursing home, however, the equipment needs to be portable yet adequate to provide a complete and thorough examination.

Probably the largest piece of equipment needed is the lensometer; everything else should be hand held. A retinoscope is an essential piece because objective data is most reliable.

Additional refractive instruments include a trial lens set and skiascopy bars, which will enable an adequate refraction. Optionally, a hand held autorefractor may be of use, but the retinoscope can generally give as good data, especially in most of the more challenging patients.

Equipment needed for the ocular health assessment includes a slit lamp instrument for the anterior segment, a direct ophthalmoscope and a binocular indirect ophthalmoscope for the posterior segment. As glaucoma is common, you should include either a tonopen or a Perkins tonometer. To perform comprehensive examinations, a supply of diagnostic pharmaceuticals, such as those used in a conventional practice, is needed.

As for therapeutic pharmaceuticals, these are generally available in the nursing home facilities. I do, however, recommend an acute angle closure kit. If you provide glasses to the residents, then you should include an inventory of frames for them to choose from.

Nurses are your friends

Generally, the point of contact in the facility is the social services department. In most instances, social services will coordinate all in-house ancillary health specialties such as eye care, podiatry, dental and audiology. The department will assign a room for the exams unless a patient is unable to leave his room.

Clinix Medical Information System (ClinixMIS) today announced that it has been contracted by Brentwood, CA-based Diablo Medical Billing, Inc. to handle the company's billing technology needs. Clinix also announced that it has extended a 3-year contract to Apollo Information Services of Fort Myers, FL to provide ClinixMIS' ASP-based practice management system. Apollo Information Services is one of the largest emergency billing companies in the country and has clients in 12 states.

Diablo Medical Billing, Inc is a full service medical billing company providing services to physician groups, individual practices and clinics throughout California. The company serves over 200 physicians. "ClinixMIS ASP medical billing software has proven itself to be the most superior in features, reporting and technical support in the physician marketplace. We can now focus 100% of our attention on our current physicians and the growth of our company," said Allen Bellinghausen, president of Diablo Medical Billing.

"Over the last seven years ClinixMIS has been there to provide us with the technology to handle our explosive growth while keeping headcount down," said Phyllis Whitney, Vice President of Apollo Information Systems. "Through their custom programming support we have been able to significantly improve the efficiency of our operation."

ClinixMIS also announced that the company has expanded its data center and invested in hardware enhancements that will significantly increase the capacity of its security and storage capabilities. "At ClinixMIS, we take protecting our client's data, providing a HIPAA-compliant environment and patient safety very seriously, ensuring that we have the latest solutions for our clients," said Jerry Killough, president of ClinixMIS.

MedCom USA (Nasdaq:EMED), a leader in the health-care information technology field, announced that Kingsbrook Jewish Medical Center (KJMC) has selected the company's MedCard Division for the administration of all of its hospitalwide physician, part-B billing (Part-B billing covers services rendered by physicians within a hospital, as compared with part-A billing, which is for the hospital's services).

MedCom is currently responsible for all aspects of the billing process for a portion of KJMC's acute care outpatients, including retrieving patient demographic, financial and insurance information. Under the expanded association, MedCom will process the part-B claims for all of KJMC's outpatient physician services, covering a total of 10 departments, as well as KJMC's skilled nursing facility.

MedCom's current run rate computes to the processing of approximately 50,000 claims on an annual basis, representing several million dollars in gross patient hospital billing. Once MedCom assumes complete responsibility for all outpatient part-B billing functions, claims volume is expected to increase by more than 300%.

"KJMC has been a longtime MedCard System user and we believe that this expanded responsibility illustrates their trust in our capabilities and the effectiveness of the MedCard System," said Mark E. Bennett, president and chief executive officer for MedCom USA.

"This is a tremendous opportunity for us. We currently average about $10,000 a month in revenue and this new arrangement with KJMC is expected to increase our revenue several fold. However, more importantly is that we now have another proven service that we can market to other large health-care providers based upon the expansion of this relationship," added Bennett.

"We have been using the MedCard System for years and have not only been delighted with the customer service we receive, but have also experienced a significant improvement in billing and collections. By outsourcing this function, we have been able to reduce our overhead while simultaneously improve our cash inflow.

"We anticipate that we will receive the same results as MedCom assumes the remainder of our outpatient part-B billings," said Mohamed Hebela, chief financial officer for KJMC.

About Kingsbrook Jewish Medical Center

Kingsbrook is an 864-bed multi-specialty teaching medical center housing a full range of diagnostic and medical treatment services including Rutland Nursing Home, a nursing facility offering skilled nursing, rehabilitation and post acute services. Kingsbrook and Rutland are voluntary, not-for-profit health-care institutions that are notable for their rehabilitation and geriatric psychiatry care.

New Medicare 2006 Outpatient Coding and Reimbursement Changes, Live Audio-Conference on CD-ROM to their offering.

The Centers for Medicare & Medicaid Services (CMS) has just announced dramatic changes to the rules for billing and coding hospital outpatient services in 2006. More than 500 codes will be deleted and new ones created with no grace period for compliance. And there will be over 230 code changes that directly affect the chargemaster.

Join the reimbursement experts of BESLER Consulting, a leading advisory firm in healthcare financial management and operations, to get a better understanding of the new Medicare coding and reimbursement changes for OPPS and how it will impact your organization in this special 90-minute audio conference, "Management Briefing: New Medicare 2006 Outpatient Coding & Reimbursement Changes." Get the CD-ROM of the conference proceedings which is scheduled for Thursday, December 8th.

Be prepared! The final rule will be effective for hospital outpatient services furnished on or after January 1, 2006. "There's a lot of work to be done with this year's changes almost doubling last year's... and still no grace period!"

According to CMS, the changes to the payment rates and increased volume of services will contribute to an overall increase in projected payments to over 4,200 hospitals for Medicare outpatient services of $27.6 billion in 2006 compared to projected payments of $26.2 billion in 2005, an increase of 5.4 percent. But this doesn't necessarily mean that payments will increase to your organization. Attend this conference and bring your staff members to evaluate the changes to determine if this will mean an increase or decrease in payments to your organization!"

Presenters:

--Tina Ford, Senior Manager, Reimbursement, BESLER Consulting

--Vickie McElarney, Senior Manager, Chargemaster, BESLER Consulting

Agenda:

--Review the new 2006 Medicare code deletions and additions

--How to prioritize over 700 code changes to get them in on time

--Learn the reimbursement impact of the changes

--The new infusion therapy and chemotherapy infusion code changes

--Observation code changes and regulations -- what does it mean for reporting these codes?

--Contrast media code changes -- what are they and how do you bill them?

--New "Status Indicators" and what they mean to you

--Multiple pharmacy code changes plus say good by to generic versus brand name drugs

--Multiple radiopharmaceutical code changes

--What's going on with 3 D reconstruction?

--Live question and answer session

Who Will Benefit From This Audio Conference?

CEOs, COOs, CFOs, vice president of finance, director of reimbursement, controller, vice president of operations, strategic and implementation consultants, operations executives, executive directors, team leaders, planners, product managers, knowledge managers, department heads, medical directors, director of managed care, director of contracting, network development and provider services directors, strategic planners, healthcare management, TPAs, network managers, company executives, medical management directors, analysts, implementer consultants, account services and administration executives.

How The Audio Conference Works:

"Attend" this program right in your office and enjoy significant savings no travel time or hassle; no hotel expenses. It's so convenient!