Payers & Providers California Edition – Issue of March 22, 2012

8/2/2019 Payers & Providers California Edition Issue of March 22, 2012

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Calendar

22 March 2012

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the details of your event, or call(877) 248-2360, ext. 3. It will be

published in the Calendar section,space permitting.

California Edition

A collaboration between Southern Californiashospitals and Blue Shield of California toreduce snafus in processing claimssubmissions has been successful enough that

it is migrating into facilities elsewhere in thestate.The initiative, launched in 2010 in

cooperation with the Hospital Association ofSouthern California and dubbed by BlueShield as the Partnership in OperationalExcellence and Transparency, or POET, focuseson improving communications betweenhospitals and the health plan in order toadjudicate claims more efciently.

As a result of the initiative, participantshave cut their claim cycle time from 32 daysto 28 days, with some providers claiming theyhave boosted their claims by millions of

dollars. HASC ofcials say that if extrapolatednationwide, such a system could cut

administrative costs for claims processing byabout $800 million a year.

"Hospitals have consistently felt thathealth plans withhold claims data from them.The current realities in health care tell us thata more collaborative discourse, with completedata transparency, is required, said GeorgeMack, HASCs vice president for payer andprovider relations. Mission Hospital Medical Center inMission Viejo has been able to cut claims

denials by more than 50% since it entered intthe POET collaborative.

Dan Martinez, the hospitals director ofpatient nancial services, said Blue Shield had

regularly communicated with the hospitalabout the specic basis of claims denials.Among the ndings: corrected claims

were often confused with denied claims. Thehospital was also sending claims to BlueShield that should have been sent to medicalgroups that are also risk-bearing organizationsand are responsible for the claims.

Two high-dollar claims totaling nearly $2million that had to be submitted on paperrather than electronically resulted in stacks ofpaper six inches high originally being sent inand rejected. Blue Shield required just a half-dozen pages of additional information,

according to Martinez.Altogether, Missions claims cycle wasreduced from 32 days before the start of theinitiative to 26 days in 2010.

They give us regular reports on whyclaims are denied, and they are based on allsorts of activity, said Martinez, who lateradded that POET was a great program.

The Hospital Council of Northern andCentral California announced this week that would also work with Blue Shield to improveclaims adjudications for its member hospitalswhich are mostly north of the Central Coast.

April 30-May 1

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In Brief

Martello First IndividualPhysician Subject ToDMHC Enforcement

Action

The Department of Managed HealthCare conrmed late last week thatSouth Pasadena plastic surgeonJeannette Y. Martello, M.D., is the rstindividual physician to have been thesubject of an enforcement action fromthe agency.

The DMHC issued a cease anddesist order against Martello in 2011for persistently balance billingpatients who received her services atSouthern California emergencyrooms, according to documentationobtained by Payers & Providers. Theagency later took Martello to court inLos Angeles County after sheapparently ignored the order and sued

several patients for amounts beyondwhat their insurers covered.DMHC spokesperson Marta

Bortner conrmed that Martello hadbalance billed six patients. She addedthat the agency had been successfulin getting several of those lawsuitsled by Martello against her patientsdismissed.

This is the only instance inwhich the DMHC has beencompelled to issue a cease and desistorder against an individual provider toensure compliance with the law,Bortner said in an e-mail. In all othercases, individual providers haveagreed to comply after receiving

communication from the DMHC without the department having toresort to an enforcement action.

Efforts to reach Martello lastweek had proven unsuccessful. Twotelephone numbers listed for hermedical practice had beendisconnected.

Martello contacted Payers &Providers earlier this week andsuggested she would take legal actionbecause no effort had been made to

Continued on Page 3

NEWS

The California State Auditor has issued acritical report of the management ofSalinasValley Memorial Healthcare System, citingnumerous conicts of interest in itsgovernance and lack of controls in paymentsand benets given to its top management.

The audit was triggered after the LosAngeles Times reported last year that its now-retired chief executive ofcer, SamuelDowning, received more than $3.6 million inretirement payments, on top of a $150,000annual pension, and nearly $4.9 million intotal between 2008 and last year. Downingssalary of $668,000 was also nearly triple that

of the average district hospital CEO inCalifornia.The 82-page reported concluded that

Salinas publicly elected board of directorsrepeatedly violated Californias open meetinglaws when setting executive compensation.

On several occasions since 2005, theboard discussed proposed compensation forthesystems executives in closed session,and neither the open or closed sessionagendas listed executive compensation as adiscussion topic, which the Brown Actprohibits, except in certain limitedcircumstancesthat do not apply here, the

report read.The report also concluded that somemembers of the board had been kept in thedark regarding Downings compensation.

According to two board members wespoke with, they did not clearly understand attimes what compensation the former CEO hadreceived or was entitled to because of changesin board membership during the former CEOstenure and the enactment of various

compensation agreements and retirementplans over the years, it said.The report cited 11 instances between

2006 and 2010 where it believed that theSalinas Valley board or Downing wereinvolved in conicts of interest. Among the

The system invested up to $1 million withlocal bank in which Downing had aninvestment

The system did $5.6 million worth ofbusiness with Rabobank, including thenancing of equipment leases, even thouone of its board members is a Rabobankregional president

The system disbursed more than $3.3million to medical device manufacturerMedtronic, even though a variety of thesystems executives and board membersowned stock in the company

The report also criticized the way thesystem managed community benets.

Among the recommendations made bythe report was adopting formal guidelines fosetting executive compensation and benetalong with publicly posting such discussionon the boards meeting agendas.

Although Salinas Valleys leadership sa

they would implement some of therecommendations, it insisted the audit hadexaggerated the conicts of interest.

The audit report distorts executive andboard actions, pointing out the potential forconicts in a range of circumstances withouaccurately reporting or analyzing readilyavailable details that provide a more complepicture of the realities in any of them, said Salinas Valleys board in a formal response.

Salinas Valley Conflicts DetailedIssues Chronicled at One of States Biggest Districts

HEALTHCARES BEST ADVERTISING VALU]

PAYERS & PROVIDERS reaches 5,000 hospital, health plan and noprot executives statewide. There is no better venue for marketin

your organization or conference, or recruiting new staff.

CALL (877) 248-2360, ext. 2OR CLICK HERE

Correction -- An issue converting Richard Chambers letter to the editor in the March 15 issue into

publishable format led to incorrect references to UC Irvine and intergovernmental transfers.
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Page 3Payers & Providers

Longer ALOS!*

Advertise Here

(877) 248-2360, ext. 2

*For our ads, not your hospital

In Brief

get in touch with her attorneys forcomment.

Martello has been party to morethan100 Superior Court and SmallClaims Court lawsuits in Los AngelesCounty over the past decade, most ofthem led by her personally to collectmoney from her patients.

El Camino Names NewCFO

El Camino Hospital in Mountain Viewhas appointed Michael R. King as itsnew chiefnancial ofcer.

King was previously CFO atRockingham Memorial Hospital inHarrisburg. Va. He helped lead anumber of bond renancingsconnected to $300 million in capitalconstruction and increased Medicarereimbursement. Prior to that heserved as CFO for Jupiter Medical

Center in Jupiter, Fla.Michael brings with him aproven track record of thoughtfulscal management that has resultedin more favorable cash ow for bothproprietary and non-prot healthcarefacilities, and we feel he'll be a realasset to our organization, said ElCamino CEO Tomi Ryba,

Stanford Opens TumorCenter

Stanford Hospital & Clinics hasopened a new center to treat patientswith tumor-multiplying diseases.

A multi-disciplinary team of 12specialists from the elds ofneurosurgery, epilepsy, neuro-opthalmology, neuro-oncology, neuro-otology, neuro-interventionalradiology, urology and general surgerywill comprise the programs staff.

Increasingly in neuroscience werealize we should do things in a multi-disciplinary way, said Robert Fisher,M.D., a Stanford epilepsy expert,It is a great idea for the newNeurogenetic Oncology program toform itself as a multidisciplinarystructure from inception. KATHYMILLER KELLEY

California healthcare community that Cal

eConnect is continuing to move forward withits strategy for connecting California, saidDon Crane, Cal eConnect Board co-chair anpresident and CEO of the CaliforniaAssociation of Physician Groups.

Cal eConnect is the quasi-public agencythat directs the statewide development ofhealthcare information exchanges. Laura Landry, who had been serving asCal eConnects interim chief executive ofcefor the past six months, has been appointedthe permanent CEO.

We look forward to making rapidprogress over the coming months, Crane sai

Ted Kremer has announced he has withdrawn

as the new chief executive of

cer ofCaleConnect little more than two weeks after hewas named to the post.

Kremer, who is currently executivedirector of the regional health informationorganization in Rochester, N.Y, will remain atthat job. He had been named Cal eConnectsnew CEO on March 7 following a nationalsearch, and had been scheduled to start workon April 10.

Kremer has headed the Rochester RHIOsince it was founded in 2005, and had beenlauded for its performance.

While we are disappointed with

Teds decision, we want to assure the

NEWS

Teen Births Continue Statewide DropDramatic Change in Rate From its Peak in 1991

New Cal EConnect CEO WithdrawsSurgeon Ignored Order From DMHC, Sued Patien

FOLLOW THE MONEY]

CALIFORNIAS HEALTHCARE INDUSTRY ANDPOLTICAL FINANCE

CALL (877) 248-2360, ext. 2 to orderOR CLICK HERE

Californias birth rate among teens droppedto a record low in 2010, and is now afraction of the rate it was two decades ago.

According to data from the CaliforniaDepartment of Public Health, the birth rateamong females ages 15 to 19 decreased to29 births per 1,000 in 2010 from 32.1 birthsper 1,000 in 2009 a drop of 9% in a singleyear.

The drop is dramatic compared to 1991when the teen birth rate peaked at 70.9births per 1,000, or nearly one child amongevery 15 teenage girls in California.

Teen pregnancy has been a long-

standing public health challenge associatedwith increased maternal and infantmorbidity and mortality, said CDPHDirector Ronald Chapman, M.D. Earlyteenage childbearing has been recognized

to have negative health and socialconsequences to adolescent mothers.Recent drops have been even more

dramatic among specic subgroups. Those inthe 15 to 17 age group saw a reduction in2010, to 15.2 births per 1,000 from 17.5 in2009, a 13% reduction. Birth rates amongLatinas ages 15 to 19 also saw an 11%reduction.

However, birth rates among Latinas andAfrican-American teenagers are still muchhigher than the statewide average for alladolescents.

Chapman noted that a variety of programs

focusing on preventing teen pregnancies havebeen effective. CDPH received a grant fromthe U.S. Department of Health and HumanServices last year to further bolster outreach incounties with above-average teen birth rates.
https://www.managedcarestore.com/pandp/p&pwhitepapers.htmhttps://www.managedcarestore.com/pandp/p&pwhitepapers.htm


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Payers & Providers PageOPINION

The ROI Of Reducing ReadmissionsSome Technology Investment Can Have Big Payoff

Maria Lopes, M.D., is chief medical officer

AMC Healthcare, a care coordination and

post-discharge firm with offices in San Die

and New York City.

;165


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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

SENIOR HEALTHCARE ANALYST

JOB SUMMARY: This position will support the HCC andEncounter Team in Health Care Informatics by collecting and ana-lyzing healthcare related data by performing data management,quality improvement studies and by conducting statistical analysisand generating reports for the organizations decision makers.

ESSENTIAL JOB RESULTS: Support operational needs byperforming complex analyses on a wide range of organizational

data - investigate and uncover root causes, identify trends, etc.and propose solutions. Achieve results by effectively leverag-ing expertise in healthcare/managed care data including, butnot limited to, membership, provider, claims, authorizations,pharmacy, and financial information. Commitment to customerservice achieved through timely, accurate, and supportabledeliverables. Support customer needs for what-if scenarioanalysis by developing analytical tools/models. Ensures under-standing of customer needs by proactively clarifying scope andrequirements and keeps customers apprised of project statusthrough effective communication. Achieves high-quality deliv-erables by assuring accuracy and thoroughness in executingprojects. Manages multiple (department) projects by effec-tively prioritizing work and communicating workload issues tomanagement. Develops and maintains up-to-date knowledge

of the Data Warehouse and other organizational data sources.Maintains professional and technical knowledge by attendingeducational workshops; reviewing professional publications;establishing personal networks; participating in professionalsocieties. Contributes to team effort by accomplishing relatedresults as needed.

QUALIFICATIONS: Bachelors Degree, or equivalent experiencerequired. 4+ years of proven analysis experience highly pre-ferred, or 2+ years of proven analysis experience in a Healthcare/Managed Care environment highly preferred. Ability to effec-tively interact with, and present findings to customers at all levelsof the organization including operational managers, medical direc-tors and executives required. Proficiency with MS SQL (queries)highly preferred. Clinical code knowledge related to claims/utili-zation highly preferred. Experience with managed care contractterms/analysis a plus. Experience in a Medicare Advantage envi-ronment a plus. Experience with MS BI products a plus. Expertskills in MS Office productivity software, especially MS Excel.Excellent technical, interpersonal, written and oral communica-tion skills required. Superior analytical skills required.

FT position, M-F 8 AM to 5 PM, with extended work hours andpossible travel, as needed. Apply to www.scanhealthplan.com

Job Opportunities Req. #11-540

MARKET EXPANSION PROFESSIONAL

JOB SUMMARY: Plan, design, and complete processes t

achieve business objectives for network and membershigrowth via market expansion. Manage and perform a broarange of tasks using resources effectively and efficiently tmeet identified timeframes for planned product and servicexpansions. This includes coordination of efforts and collaboration with external entities to meet all regulatory requirementand to ensure market expansion filings are fully compliant anapproved.

ESSENTIAL JOB RESULTS: Coordinate and execute completasks related to network and membership growth via markeexpansion, in order to ensure the successful completion oongoing cycles of work. Utilize detailed work lists to managthe timely completion of tasks for each phase of a particulamarket expansion process and provide necessary updates tmanagement, escalating risks as appropriate. Develop anmaintain positive relationships with internal departments anexternal entities, creating partnerships to achieve programobjectives. Effectively communicate and assign deliverableand timelines. Monitor and manage the assigned tasks tachieve timely completion. Monitor quality of tasks performed, develop and recommend process improvements foimplementation. Assure a quality market expansion procesoutcome by making sure that each finished task meets threquired level of quality. As needed, troubleshoot issues anprovide innovative solutions, focused on continuous qualitimprovement. Maintain professional and technical knowledgby attending educational workshops; reviewing professionapublications; establishing personal networks; participating i

professional societies. Contribute to team effort by accomplishing related results as needed.

QUALIFICATIONS: Bachelors Degree required. Preferred areof study: Business or Health Administration, Managemenor Process Engineering. Experience within HealthcareManaged Care, preferred. Demonstrated interpersonal skillwith the ability to compromise, persuade, and negotiatebe well-rounded and have excellent communications skillsSolid leadership skills, excellent written and verbal communications skills and ability to establish effective workinrelationships with many different people, ranging from managers, supervisors, and professionals, to administrative ansupport staff personnel. Analytical, detail-oriented, flexibleand decisive. Ability to coordinate several activities at onc

quickly analyze and resolve specific problems, and managdeadlines. Ability to work with minimal supervision, so neeto be self-motivated and disciplined. Expert skills in MOffice productivity software and strong computer skills aressential.

FT position, M-F 8 AM to 5 PM, with extended work hours andpossible travel, as needed. Must maintain valid drivers license,

automobile insurance and reliable transportation. Apply towww.scanhealthplan.com - Job Opportunities Req. #12-612


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

It costs up to $27,000 to fill a healthcare job*

will do it for a lot less.

Employment listings begin at just $1.65 a word

Call (877) 248-2360, ext. 2Or e-mail: [email protected]

Or visit: www.payersandproviders.com

*New England Journal of Medicine, 2004.

SEEKING A NEW POSITION?

CAN HELP.

We publish advertisements for those seekingnew career

opportunities for just $1.25 a word.

If you prefer discretion, well handle allresponses to your ad.

Call (877) 248-2360, ext. 2, or [email protected].


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Page 7Payers & Providers MARKETPLACE/EMPLOYMENT

Since 1959, Presbyterian Intercommunity Hospitalof Whittier has been committed to building a mutu-ally supportive health care team consisting ofpatient care givers, medical staff, volunteers and theboard of directors that have ensured our local popu-lation the highest quality of medical services in Los

Angeles County.

Our Home Health & Hospice departmentis currently seeking an

ASSISTANT DIRECTOR OF PATIENT SERVICES.

The Assistant Director of Patient Services is respon-sible and accountable for services provided topatients through Home Health and Hospice. Withdirection from the Director of Patient Services, theAssistant Director will assess and assist the Director

in all areas of operations, compliance, professionalstandards and IDS relationship.

Requirements include: Bachelors degree in Nursingor other health-related field. Valid CA RN license;BLS certification. At least 7 years of experience,5 of which must be in a home health agency. 3years of experience in a supervisory or administrativecapacity. Able to direct nursing, therapy and socialwork within the framework of regulations to care forpatients while understanding the rationale of rule-making in the industry. Must have an active interestin improving current level of skill and knowledge.

Beyond the benefits that come with working forthe areas leading community health care provider one that also recognizes the need to ensure patientsafety and comfort youll enjoy an extremely com-petitive compensation and benefits package. Plus,we use team concepts to encourage professionalgrowth and development.

Please apply online at www.pih.net,or [email protected].

Providence is calling aSENIOR FINANCIAL ANALYST OF REPORTIN

BUDGETING & PRACTICE ANALYSIS

to Providence Medical Institute, Torrance, CA.

In this position you will: Develop and maintain monfinancial reporting, prepare the annual budget, and supOperations management to identify and resolve finaopportunities in physician practices. The position willcreate, manage and track results of the annual OperaBudgets. Analyze physician compensation based on methodology.

Required qualifications for this position include:10 years of experience within a large healthcare orgation. Bachelors Degree in Accounting or Finance. Stanalytical skills with and expertise in using MicroOffice Access, Excel, PowerPoint, & Outlook. KnowledgLawson Financial Software.

Preferred qualifications for this position incluPhysician Compensation Analysis experience. MedGroup experience.

Providence Health & Services Southern California is furdeveloping its physician integration strategy. Historithe largest asset has been Providence Medical Institumedical foundation that provides administrative and osupport services to affiliated medical groups. ProvidMedical Institute is expected to grow significantly innext several years, bringing with it facilities, staff and sician growth to support that objective.

PROVIDENCE IS CALLING!

For immediate consideration, qualified candidates areencouraged to apply on-line at www.ProvidenceIsCalling.

Apply Onlinehttp://bit.ly/providence06640Healthfax

Payers & Providers California Edition – Issue of March 22, 2012

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