On May 14, 2009, the Office of Inspector General (OIG) issued Advisory Opinion 09-05. The Advisory Opinion addresses a fact that speaks to our time – to obtain full physician coverage at emergency rooms, hospitals need to pay their physicians. South Florida hospitals are not immune to this problem.

The facts upon which the ruling was made were not complicated. The medical staff bylaws of the applying hospital required its active medical staff to provide emergency room call coverage. However, when the patients treated by the physicians were uninsured, the physician was not compensated for the service (the hospital itself was being compensated through a state-funded program). As a result, many staff physicians were reducing their coverage to the minimum required under the bylaws, which often left the emergency room with a shortage of on-call specialists. This frustrated the hospital, which stated that while “physicians historically performed on-call coverage out of a sense of duty to their profession, that sentiment is no longer shared by all…”

The hospital thus adopted a plan, subject to obtaining a favorable Advisory Opinion, to pay its physicians for on-call coverage. The OIG approved the plan, even though it did not meet all the elements of any Federal anti-kickback law (AKB) safe harbor. Some of the principal elements of the approved plan were:

  • All members of the medical staff (other than hospital-based physicians) are eligible.
  • The physicians are compensated through published flat fee payments, which depend upon the services rendered, and the amounts of the payments are certified to fall within the range of fair market value for services rendered.
  • Payments are only made if the patient is totally without insurance coverage (including Medicare and Medicaid).
  • Each physician electing to participate must sign a letter of agreement, agreeing to certain hospital policies and to abide by certain minimum standards of care.
  • Payments made to the physicians are made solely for services provided and without regard to hospital referrals.

Note that in OIG Advisory Opinion 07-10, the on-call issue was addressed where physicians were paid on a per diem basis, as opposed to per service rendered.

In Advisory Opinion 09-05, the OIG expressed concern that these relationships could create an avenue for payment of kickbacks, as “physicians may demand such compensation as a condition of doing business at a hospital…” Notwithstanding that concern, the OIG determined that the proposed arrangement “presented a low risk of fraud and abuse,” and approved it.

As stated above, the OIG was in fact dealing with a reality in the market place – payments to physicians by hospitals for on-call services to indigent patients has become the norm. OIG Advisory Opinion 09-05 is helpful because it sets forth written standards that will allow a hospital to provide such payments, and physicians to accept them, with low risk of being in violation of the AKB laws.



On October 1, 2013, healthcare providers will begin using ICD-10, a new diagnosis coding system replacing the previous system, ICD-9. While this date may seem far away, the fact is, providers need to start getting ready now for this extremely complex conversion.

“While it may seem a long way off, it really isn’t in terms of preparing for the education, expense, planning and administrative burden that implementing ICD-10 will require,” explained Leslie Witkin, president, Physicians First, Inc. “Providers should be in planning stages now; this is the time to get committees set up to figure out how their practices will deal with this change operationally, and to begin educating internal staff.”

The change from ICD-9 to ICD-10 requires much more than learning new codes. The new system dramatically expands the number of diagnosis codes from 17,000 codes in ICD-9 to 68,000 codes in ICD-10. “In ICD-9, the maximum number of digits in each code was five,” added Witkin. “In ICD-10, there are a maximum number of seven digits in each code, and the format now includes alphanumeric characters, which ICD-9 did not.”

In addition to adapting the ICD-10 codes, the government provided an additional mandate prior to the system’s implementation which requires providers to convert to a new electronic format for computer systems, called HIPAA 5010. This standard must be in place in all healthcare entities as of Jan. 1, 2012.

“One of biggest expenses that providers will face is in meeting this new electronic standard—no one’s software program is programmed for this,” said Witkin. “Technical contracts don’t include the waiver, “If the government sets the world on its head, we’ll pay for the upgrade.”

According to The Impact of Implementing ICD-10 on Physician Practices and Clinical Laboratories, a report to the ICD-10 Coalition by Nachimson Advisors, LLC, the cost of converting to ICD-10 and HIPAA 5010 is quite an expensive proposition. The report estimates that the potential cost to a small practice would be $83,290; the cost to a medium practice of 10 providers would be $285,195; and the cost to a large practice of 100 providers would be roughly $2.7 million.

“When you’re looking at expenses like this, you can see why it’s very important that physicians begin planning and budgeting for this conversion now,” said Witkin. “In addition to the costs of educating physicians and staff on the new codes, practices will need to update their forms and processes to capture significantly more information.” Without proper education, Witkin also warns that practices could see cash flow disruptions due to denials and delays.

“Many practices use what is called a Superbill right now, which enables them to check off the codes on a form,” she continued. “One family practice entity took their two-page Superbill and converted it for use with ICD-10. That two-page bill is now an administratively burdensome nine-page document.”

One of the reasons for the increase in code numbers is that ICD-10 is much more specific than ICD-9. “ICD-10 provides for greater specificity; instead of four diagnosis codes to cover varicose veins, there are now eight or nine codes just for varicose veins of the right lower extremity,” said Witkin. “The goal is to move into an environment where payers pay for quality and efficiency.

“ICD-10 allows for a greater determination of quality care as the government moves to a pay-for-performance requirement,” she added. “The government doesn’t want to be passive payer anymore; they want to be active purchaser of quality care.”

Despite the increased cost for physicians, Witkin doesn’t expect to see these costs passed on to patients. “With Medicare, physicians are only billing patients their deductibles and a 20 percent copay,” she explained. “The allowed amount is not going up. Contracts with managed care companies are also not changing. So while there will be an enormous expense for physicians, those costs won’t be shifting to patients.”

In order to prepare for all of the upcoming changes, the government and many health organizations have begun offering programs on the subject. The Centers for Medicare and Medicaid Services provides audio programs that healthcare providers can access for free, and they also have a specific section on their website dedicated to ICD-10. The American Academy of Procedural Coders is also offering programs to its members. “I presented my first program on July 9, and the response was overwhelming,” said Witkin. “People were saying, “Wow, I’m glad we did this now.”



University Hospital and Medical Center recently celebrated the opening of their newly renovated Orthopedic and Spine Institute with an Open House for the community and a ribbon cutting ceremony. The Orthopedic & Spine Institute at University Hospital and Medical Center will have patients and visitors feeling as though they are in a hotel. The 8-bed oversized, private suites can comfortably accommodate a family member overnight. The wing has a neutral décor that offers the peace and comforts of home. Patients have the accessibility of their own rehab gym with daily access to physical and occupational therapy. Using the latest advances in the field of Orthopedics and Spine Care, the dedicated team of professionals at University Hospital and Medical Center can attend to their patient’s needs.

The Orthopedic and Spine Institute at University Hospital and Medical Center offers comprehensive solutions for Joint Disorders, Neck pain, Sports related injuries, Fractures, Arthritis, Joint discomfort, and Back pain.



A quiet “revolution” is taking place in the field of congenital cardiac care and Memorial Healthcare System (MHS) is responding with a comprehensive program to treat adults. Since an official Adult Congenital Heart Program was created this past summer at Memorial Regional Hospital, doctors are now caring for more adults than children. This follows a national trend that is stimulating talk about a fellowship requirement for congenital heart training.

“A lot of adult cardiac physicians aren’t comfortable caring for these patients and their unique needs,” explained Dr. Richard Perryman, Chief of Cardiac Surgery, MHS. “Memorial Healthcare System is well positioned to help them because we offer a wide range of experts who understand the medical issues associated with congenital patients of any age.”

In addition to Dr. Perryman and other Memorial cardiac surgeons, the Adult Congenital Heart Program includes care from interventional cardiologists, an electrophysiologist, internists, obstetricians/gynecologists and anesthesiologists.

As recently as 20 years ago, the goal of congenital heart treatment was merely survival of the tiniest babies, according to Perryman. Now, these babies are not only surviving but thriving and living long into adulthood. However, he points out, doctors have often given their congenital patients the impression that they have been “cured” by early intervention. Often that is not the case for the long term.

“As these patients age, arrhythmias, heart failure, cyanotic episodes and challenges during pregnancy often occur,” Dr. Perryman said. “They need to be followed to prevent them from having these complications.”



“It may take a village to raise a child, but it takes that same village to care for the elders, to keep them safe and comfortable in an environment of dignity.”

With those words, Pam Dannelevitz, RN, CMC, expresses the personal philosophy that guides her as a geriatric care manager and registered nurse. Dannelevitz believes that a team effort is essential to meet the individual needs of older persons and that the aging are deserving of our reverence, care and respect.

As Director of Client Services for SeniorBridge Family in West Palm Beach, Dannelevitz practices that philosophy every single day. She is in a position to know how effective a coalition of client, family, physician, care manager and other professionals can be. “Older persons are living longer and have a right to a high quality of life, but an insurance carrier cannot meet all their needs. A doctor cannot address the social and emotional needs, beyond the medical ones. The family cannot do it alone. No single party can meet all of their needs and one of my roles is to pull it all together, to coordinate and oversee their care so that they are getting everything they need.”

Dannelevitz became a geriatric care manager after doing home care with the elderly, working as an administrator of a dementia facility and running a support group for Alzheimer’s caregivers. She developed her own practice four years ago and then joined forces last fall with SeniorBridge Family, a dynamic national eldercare company with a distinctive model of care that combines home care with care management. SeniorBridge Family provides a strong nexus of support to older clients and their families through services that ease the transitions of aging. .

With her strong clinical nursing background, Dannevitz is capable of managing clients with complex medical needs. She collaborates closely with geriatricians such as Dr. Mary Colburn, in West Palm Beach, who recognizes the value of care management.

“Dr. Colburn is an excellent, board-certified geriatrician. She understands the concept of care management and appreciates the role that I play. I add an additional dimension to her practice. The combination of a geriatrician working with a care manager is a highly effective model and we have much success with it.”

Dannelevitz feels that she can empower her clients in their relationships with physicians. She accompanies them to appointments and takes prepared documents that detail the current state of the client’s health. These include lists of all current medications, a problem list and a list of physician specialists that the client is seeing. The lists are developed with the clients input.

“The idea is to help both the client and the physician,” she says. “Doctors are not always aware of all the other doctors that a client is seeing or of all the medications that are being taken. The information on our lists is organized, up-to-date and accurate. It facilitates the doctor’s management of their problems.

“As the care manager, I am seeing the big picture. I am the doctor’s eyes and ears. I am familiar with what is going on in the client’s life. At every contact, I am conducting a re-assessment. This makes it possible for me to recognize and identify problems when they are still in the earliest stages and to take action before it gets out of hand. I can alert the doctor and we can nip it in the bud.

“As a nurse and a care manager, I can offer the clinical perspective in addition to counseling, support and navigation.”

Dannelevitz is eager to educate physicians about the role of care management in the care of aging patients. She emphasizes the enhanced quality of life and peace of mind that care management fosters, for the client and for the family. Care managers assist the doctors by arming them with more information about significant events in the client’s life, such as losses and life changes that they may not otherwise learn about.

“Many older persons tend to turn the focus of the conversation to the doctor and don’t talk about themselves. It’s due to a mixture of pride and fear. If they have a long-term relationship, they may idolize the doctor and want to please him or her. They may minimize pain or problems once they are there in the office,” she explains.

In her early career, Dannelevitz was an operating room nurse but opted for geriatrics after working with older persons in home care. She developed a passion for the people that she considers the most generous and courageous generation in American history.

“They are people who have given so much and we owe them our gratitude and our respect, and that includes helping them to age in dignity. SeniorBridge Family does exactly that.”

Pam Dannelevitz can be reached at (561) 432-3399 or (800) 431-8370.