July/August Med Beat

MARYLAND HOSPITALS PLEDGE TO SERVE LOCAL FOOD AS PART OF STATE-WIDE BUY
LOCAL INITIATIVE

Thirteen Maryland hospitals have committed, so far, to buying and serving foods from local farmers in their
menus during the Maryland 2014 Buy Local Challenge. The annual Buy Local Challenge (BLC), an initiative
created by the Southern Maryland Agricultural Development Commission, is a personal commitment to support
farms by eating local. Maryland residents are asked to pledge to eat at least one thing from a local source every
day during Buy Local Week, July 19-27th.

The BLC has partnered again this year with the Chesapeake Food Leadership Council, an initiative of Maryland
Hospitals for a Healthy Environment (MD H2E), to invite hospitals and other large-volume purchasing
institutions to participate in the Buy Local Challenge by serving at least one local food each day during Buy Local
Week. Those that sign up to participate will be recognized on the BLC website.

The Maryland hospitals participating are: Carroll Hospital Center, Frederick Memorial Hospital, Johns Hopkins
Bayview Medical Center, Johns Hopkins Hospital, Laurel Regional Hospital, MedStar Montgomery Medical
Center, Meritus Medical Center, University of Maryland Harford Memorial Hospital, University of Maryland
Medical Center, University of Maryland Upper Chesapeake Medical Center, Union Hospital, Washington
Adventist Hospital and Western Maryland Health System. These hospitals are also encouraged to serve local,
sustainable meat and poultry produced without routine antibiotic use, as well as local certified organic foods.

Hospitals are also encouraging their employees, including their executives and surrounding community, to take
the pledge to eat local foods. “Health care providers understand the importance of providing the freshest produce
to their patients and employees while supporting local farmers, and growing our regional food system and local
economy,” said Louise Mitchell, sustainable foods program manager for MD H2E. Last year, fifty-six hospitals
and nursing homes in the Mid-Atlantic region served over $53,500 in locally produced vegetables, fruit, beef,
pork and poultry.

Jointly promoted with the Maryland Department of Agriculture, the statewide BLC initiative highlights the
environmental, health and economic benefits of buying local food. This campaign to engage health care has
catalyzed a movement towards healthier food choices at hospitals, increased support for local farmers and the
local economy, and healthier communities—not only during Buy Local Week, but throughout the year.
Any institution, organization or business participating in the BLC is encouraged to download free resource
materials including official BLC logos, fliers, press releases, and to use #buylocalchallenge to tweet the latest
BLC happenings around the state. For details and to sign up, visit the sustainable foods page at the MD H2E
website.

About MD H2E: Established in 2005, MD H2E’s vision is to advance a culture of environmental health and sustainability in Maryland’s health care community by engaging Maryland hospitals and health care providers though networking, education, technical assistance and recognition. MD H2E has established itself as the go-to organization for sustainability in healthcare in Maryland; no other program serves this role in this region.

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Revised Maryland Medical Marijuana Law Will Certify Physicians

After 2013 Maryland medical marijuana legislation failed to produce any academic medical centers that were willing to make the drug available for medical purposes, the Medical Marijuana Law Senate Bill 923 and House Bill 881 were passed in this legislative session. Signed by Gov. Martin O’Malley on April 14, 2014, the new law retains the Natalie M. LaPrade Medical Marijuana Commission that was established in 2013, and charges the Commission with promulgating regulations to implement the changes by Sept. 15, 2014.

The new legislation will allow “certified doctors” to give recommendations (not a prescription, as these are prohibited by federal law) for medical marijuana to patients that they believe would benefit.

Paul Davies, MD, chairman of the Medical Marijuana Commission, said, “After our Commission proposes the regulations, they will be reviewed by the Maryland Department of Health and Mental Hygiene, the attorney general’s office and a legislative oversight committee.”

Once final regulations have been promulgated, which is anticipated to take about four-six months, the Commission can begin taking applications from physicians and prospective growers and dispensers.

“Maryland will have one of the best programs in the country, thanks to the lessons learned from the many states
that have already legalized medical marijuana,” Dr. Davies notes. “Any physician wishing to recommend medical marijuana for his or her patients will have to undergo a training program and be credentialed by the Commission.”

The Commission chairman estimates that it will take until early in 2016 to establish the necessary network to make the drug available to qualified patients. “We are already working on an implementation plan,” he said.

While initially, the number of potential licensed growers is limited to 15, the Commission may choose to increase the number of licensed growers in future years. Licensed growers must undergo a background check. Dr. Davies anticipates strong demand from growers, and is hopeful that physicians will exhibit equally strong interest. “Studies have shown that marijuana can help ameliorate nausea and vomiting, stimulate appetite, reduce pain and lower intraocular eye pressure.”

The new legislation increased from 11 to 14 the number of Commission members, which include medical, pharmaceutical, law enforcement, and legal professionals.

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Minimally Invasive Spine Surgery: Fast Relief for Intractable Pain

A 54-year-old male presents with a four-year history of severe back pain, sciatica and difficulty walking. He has spinal stenosis and spondylolisthesis at L4-L5. The patient has loss of sensation and weakness. He is no longer able to work out or even enjoy recreational activities with his wife due to intense pain and the need for opiates. [...]

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Rappel for Kidney Health

BY TRACY M. FITZGERALD

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On June 7,  2014, approximately 100 people made their way up to the rooftop of the Baltimore Marriott Waterfront Hotel, suited up, and stepped to the edge of the 32-story building. Demonstrating not only their adventurous sides but most importantly their commitment to supporting program development and research efforts for kidney disease patients, each participant of “Rappel for Kidney Health” took the handle of a rope and slowly rappelled 28 floors down, ultimately setting foot on the hotel’s pool deck.

Sponsored by the National Kidney Foundation of Maryland, Rappel for Kidney Health gives physicians, nurses and other clinical providers, as well as the community at large, an opportunity to do something unique and exciting, all while raising awareness about kidney disease and how it can be prevented, detected early and treated. The event is chaired by David Lesser, MD, who serves as chief of Kidney and Pancreas Transplantation at the University of Maryland Medical Center.

“My professional life surrounds this issue, so I am happy to put time and energy into this event to raise awareness and funding for research,” said Dr. Lesser, who had planned to rappel himself at this year’s event, but instead was called to the operating room to perform two emergency kidney transplant cases. “And, when people can say ‘Wow, I rappelled off the Marriott Waterfront’ that’s pretty wild.”

Since Rappel for Kidney Health first launched five years ago, approximately 350 people have participated, each contributing a minimum of $1,000 toward the collective total of $525,000 that has been raised. Dollars generated through this event have benefited the National Kidney Foundation of Maryland’s emergency patient assistance program, patient education and screening programs, physician education events and ongoing research efforts though the University of Maryland Medical Center and Johns Hopkins Hospital.

“Some do this in honor or memory of a kidney disease patient and others join groups and see this is a good corporate team-building exercise,” said Katie Kessler, development coordinator for the National Kidney Foundation of Maryland. “Each year, the event grows and allows us to do more for local patients while also providing research grants that help advance our mission.”

Part of that mission emphasizes the importance of prevention and early detection of kidney disease, and includes a series of resources to help educate and screen local citizens. The National Kidney Foundation of Maryland offers KEY (Kidneys: Evaluate Yours) screenings at locations throughout its service area in Maryland, all year long.

“Kidney disease is a silent disease that often goes undetected until the advanced phases,” said Bernard Jaar, MD, chairman of the Medical Advisory Board  for the National Kidney Foundation of Maryland. “This is why awareness and early detection are so important. We are very proud of how successful the Rappel for Kidney Health event has become and how much it is helping us get out there in the community and make a difference.”

For more information on the National Kidney Foundation of Maryland, visit kidneymd.org.

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21st Century Healthcare: Value, Technology, Engagement & Integration

Almost across the board, technology is being applied to care delivery. Both patients and healthcare reform demand it. Healthcare reform is driving value, new technology, engagement and integration. Baby boomers, estimated to account for more than 40% of the country’s population by 2020, demand it. In this issue, we explore two significant clinical areas where this premise prevails: orthopaedics (Advances in Lower Extremity Care ) and diagnostic testing (Enhancing Diagnostic Accuracy).

When this issue went to print, I was spending some treasured time with my 88-year-young dad, who now suffers from dementia. He was a practicing physician well into in his 70s, and for almost 30 years, he was director of pathology and the medical lab of a community-based hospital. During our visit, I told him that one of my colleagues referred to pathologists as the future rock stars of care delivery. I wish my dad had been able to fully grasp what that meant. He was always a man of outstanding integrity who recognized the critical role each member of his staff played in the diagnosis of innumerable patients.

According to data supplied by the World Bank, healthcare accounted for almost 18% of the United States’ GDP in 2012. We’re all quite aware of claims of inefficiencies in delivery of care, and although we spend more than any other industrialized nation, metrics focused on quality of care rank very low. That will change.

With a population that both demands and requires more efficiency in care delivery, the metric of United States healthcare expenditure will most likely remain at the top of the industrialized nations, but the metric focused on quality will shift. It has to. Our article examining whether or not Patient Centered Medical Homes and/or Accountable Care Organizations (Healthcare IT) are impacting care finds that cost savings may be elusive initially, but they are improving care delivery.

Genomics also are already playing a part, and I wish my dad was able to understand where the foundations of his training and practice are going. For me, I’m extremely proud to have had it be a part of my heritage and most fortunate to be part of an industry that is indeed shaping the future.

- Jacquie Cohen Roth

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Advances in Lower Extremity Repair

BY LINDA HARDER | PHOTOGRAPHY BY TRACEY BROWN

Living longer has its advantages. But our lower extremity joints weren’t necessarily built to withstand all of the stresses placed on them. Our orthopedic  experts discuss the latest in repairing these critical joints when they suffer lifelong damage.

Robot-Assisted THA

With baby boomers increasingly seeking hip and knee replacements at a younger age, and with longer-lasting component materials, getting a good ‘fit’ is increasingly critical. Hip replacements are now expected to last for 20 years or more, both fueling and responding to this trend. Robot-assisted total hip arthroplasty (THA) is a newer option to increase the precision in component orientation, now available in Maryland.

Orthopedics, cover July/August 2014

William Cook, MD, chair of orthopedics at The University of Maryland Upper Chesapeake Health System, is among the first to employ MAKOplasty® for THA in Maryland. “MAKOplasty is a CT-guided navigation system that gives us a new level of accuracy,” he states. “It uses a software program based on a 3D model of the area that enables us to plan our surgery based on the patient’s unique anatomy. We optimally position our implants ahead of time based on the computer model. Then, when we’re performing the procedure, the robot prevents changes and minimizes bone resection.”

Since the hospital system purchased the MAKOplasty component for hips in the fall of 2013, Dr. Cook and his colleagues have performed approximately 20 procedures with robotic assistance. “The exciting thing about MAKOplasty for hips is that it can precisely align the acetabular cup in the correct inclination and the correct version, to create the most stable hip possible. We can precisely duplicate the anatomy, leading to a lower risk of dislocation and reduced leg length discrepancy. One of the main reasons for patient dissatisfaction following hip replacement is leg length discrepancy.”

He adds, “We can duplicate a patient’s hip offset, which is the distance between the socket and the leg. If the soft tissue is aligned properly, it restores the muscle tension and decreases pain and recovery time.“

A good candidate for MAKOplasty is someone who is not overly obese or muscular and has bone that is not excessively osteoporotic. Dr. Cook explains, “I currently reserve this procedure for very active patients, such as someone who is jogging or playing tennis. The difference is less critical for older, less active patients.”

After the patient decides to have MAKOplasty, he or she typically undergoes a 3D CT scan one to two weeks in advance of the procedure. The data from the scan is fed into the computer program, then the surgeon selects the appropriate sized implant and the amount of bone to be removed. Patients typically have a one-night stay in the hospital, and then are discharged to home with full weight bearing.

Depending on the patient, they may receive home or outpatient physical therapy. “Pain scores are consistently lower,” says Dr. Cook. “Most patients can recover in four to six weeks instead of three months with the robotic approach.”

Anterior Approach

Dr. Cook performs the majority of THAs using an anterior approach, which he has employed on appropriate candidates for the past 10 years (see Maryland Physician July/August 2012, “Joint Tune Ups” for more on anterior hip replacements). “An anterior approach prevents having to detach and reattach muscles, which can lead to atrophy and/or a limp,” he notes. “A posterior approach has a higher dislocation rate, and a lateral approach requires muscle detachment. However, due to the positioning of the leg in the anterior approach, it’s not appropriate for everyone, such as those with significant osteoporotic bone, which can fracture, or obese patients.”

Rethink Pain Management

Dr. Cook has seen a growing trend among referring physicians to send patients who fail physical therapy and anti-inflammatories for pain management. “There is a tendency to send patients for narcotics rather than referring them to an orthopedic surgeon. In my opinion, that’s not the ideal management of these patients. While you don’t want a patient to undergo surgery unnecessarily, physicians may not be recognizing that many of these patients have issues that won’t be satisfactorily addressed by narcotics. The infection risk in THA is less than 1% nationally, and the satisfaction rate is greater than 95%.”

Trending Younger

Dr. Cook comments, “In the 70s and 80s, the mindset was to have patients wait until they were in their 60s or 70s to get a THA. That started to change in the early 2000s. My philosophy is that we can offer these procedures to younger patients now because we can expect one implant to last up to 30 years. The more precisely it mimics the patient’s anatomy, the better the outcome and longevity. One of the reasons I love being a joint surgeon is that you give people back their lives.”

Is Cementless Knee Arthroplasty Superior?

Cover article, July/August 2014The increase over the years in the number of hip replacements is linear, but knee replacements are increasing exponentially, according to Antoni Goral, MD, medical director of the Joint Center at Holy Cross Hospital. “We’re doing about 800,000 knee replacements today, but by 2030, we expect that to grow to 3.5 million. Why? In part because we’ve been doing knee arthroscopy since the 1980s for meniscal tears and other problems, and people go back to high levels of activities. We relieved people’s symptoms, but were we setting many of them up for developing arthritis over time? For young and active patients, wear and loosening contribute to the need for revision surgery of a prior knee replacement.”

If knees were simple hinge joints, it might be easier to repair or replace them. But because they involve both rollback and pivoting, they are complex to treat. As with hips, more people are choosing to have a knee replacement while younger and more active. That also makes it crucial for knee surgeons to carefully assess and recommend the optimal approach.

Dr. Goral explains, “Most of the load on a hip joint is compressive, but with knees, many of the loads are shear. The goal of knee arthroplasty is to restore the normal kinematics of the knee.”

Evaluation and Non-Surgical Approaches

“Some physicians still focus on using anti-inflammatories even when there’s no inflammation,” complains Dr. Goral. “Analgesics, such as acetaminophen around the clock, are better in these cases. Some studies suggest that chondroitin and glucosamine supplements are protective of cartilage, but the American Academy of Orthopaedic Surgeons has graded this approach a “C,” meaning that the evidence can’t presently support that claim.”

He adds, “If there are flare-ups, injecting cortisone or a biological lubricant such as hyaluronics into the joint may help. Injectable medications, unlike pills, have to get into the joint. I tell people that you can’t put oil on the hood of a car, you have to put it in the engine.”

History of Cementless

Cementless knee arthroplasty has been available since the 1980s, when loosening of a knee replacement over time was believed to be due to ‘cement disease’ – a reaction to the cement used to adhere the replacement. During surgery, the bone is slightly compacted, contributing to the problem.

“Today, we believe that a combination of motion and minute particles that wear away lead to inflammation and enzymes that trigger osteoclasts. The osteoclasts then gradually eat away the bone,” says Dr. Goral. “There are sharp changes in loading going from bone to implant, so manufacturers have tried to design an ‘ingrowth’ approach using more porous implant surfaces into which bone could grow. In the 1980s, the implants would have layers of tiny beads or a mesh to address this, but we found that they separated and left too much space over time.

“While the vast majority of knee replacements today are still cemented, we’ve tried various cementless approaches over the years. Today, one approach uses a powdery plasma spray that increases osteo integration. However, with a cementless approach, you need to provide additional stabilization of the implant during early recovery.”

Comparable Results

To provide the necessary stabilization after a cementless approach, there are three options for fixing the tibial side – pegs, screws or stems. Dr. Goral comments, “There are advocates for each approach, though I personally prefer stems. All three hold the implant firmly for the three to four months that the bone is potentially growing up to, and into the surface.”

According to Dr. Goral, cementless and cemented knee arthroplasties have roughly the same results. “Most studies of implant longevity and patient satisfaction have found that the restoration of a neutral knee alignment is most important, not the implant technology,” he notes. “Better, more customized instrumentation and robotic guidance improve outcomes. The ideal outcome is a ‘forgotten’ joint, one that has no clicks or pain and that feels stable enough that the patient forgets it is there.”

On the Horizon

In the future, Dr. Goral believes that platelet-rich plasma, which contains growth factors, may be used to promote healing. “It’s safe, but we’re not sure yet if it’s effective. Autologous, adipose-derived stem cells may also hold promise, though there’s insufficient evidence as of now, so it’s not reimbursed by insurers.”

Healing Complex Ankle Fractures

Knees and hips get much of the attention in orthopaedics, but a strong, properly fixated ankle is critical to staying mobile. AccordingCover article, July/August 2014 to Stuart Miller, MD, MedStar Orthopaedics foot and ankle surgeon, “When you go up a set of stairs, you’re putting five times your body weight on your ankle. And ankle fractures, surprisingly, are one of the most common fractures, occurring across all age groups.”

Fortunately, a growth in dedicated foot and ankle specialists, better technology, and more flexible stabilization devices are revolutionizing care of this key joint.

Growth in Foot and Ankle Specialists

“There’s been an explosion in foot and ankle specialists recently,” Dr. Miller claims. “Some 10 years ago, there were six in the greater Baltimore area; today, there are 12 specialists, and two more are coming soon. When a fellowship-trained specialist performs a foot or ankle procedure, it may be more precise because it’s all we do.”

Dr. Miller says, “I perform many total ankle joint replacements today. More than 80% of these patients have trauma-caused arthritis. One journal recently reported that it can take 21 years from an ankle fracture to the development of arthritis. It’s why we’re seeing so much of it now. Over the years, we’ve learned that even a small amount of displacement creates a big problem over time.”

Anatomic Locking Fibular Plates

A substantial improvement in ankle fracture stabilization is the number of new anatomically locking fibular plates that are available. Designed to fit on the lateral aspect of the distal fibula, these devices maximize bone fracture stabilization and minimize soft tissue irritation.

“They are pre-contoured to fit the patient’s anatomy, and use locking screws that function somewhat like a molly bolt, to work far better in comminuted osteoporotic fractures,” explains Dr. Miller.

Fixation of Syndesmosis & Fracture Suture “Buttons” Offer Advantages Over Screws

Newer approaches to stabilizing the ligaments and bones following a complex ankle fracture have eliminated the need to use screws, which are removed in a follow-up procedure. These approaches instead use a tiny incision to insert a suture between two ‘buttons.’

“We drill across the tibia and fibula, insert a tiny oblong rod or ‘button’ that’s analogous to a rice kernel in shape,” Dr. Miller states. “We pull/twist it so that it can’t go back through the hole. Today, we’re also using this method to fix ankle syndesmotic injury and gain stability. Biomet Sports Medicine offers a ZipTight™ Fixation System and Arthrex offers a Knotless TightRope® System for syndesmosis repair. They are low-profile and knotless, to prevent soft-tissue irritation and allow more precise duplication of joint mechanics during movement.”

From Casts to ROM Splints

Newer approaches to immobilizing ankles after a fracture are putting cast technicians out of business. “We got rid of our cast tech at Union Memorial Hospital years ago,” Dr. Miller notes. “Our patients go into a splint after surgery and then to a Range of Motion (ROM) ‘boot’ at one week. We use it like a cast for the first four to six weeks post-op, then start gradually introducing weight bearing. This approach promotes faster and better rehabilitation, the skin is healthier, and patients can take the boot off to do gentle ROM and to bathe. If the fracture is stable, patients may even be able to take the boot off at night.”

The ROM boots can be non-inflated (appropriate for minor injuries), pre-inflated, or have an adjustable bladder that allows the ankle to be fixed at a given point or permits range of movement within a set angle. Dr. Miller concludes, “With the elimination of casting, patients no longer have to spend months getting back range of motion, and they are much happier.”

William Cook, MD, chair of orthopaedics at The University of Maryland Upper Chesapeake Health System

Antoni Goral, MD, medical director of the Joint Center at Holy Cross Hospital

Stuart Miller, MD, MedStar Orthopaedics foot and ankle surgeon

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Dr. Beans: The Forgotten Man in the Star-Spangled Banner Story

BY MEG FAIRFAX FIELDING Key Battle of Baltimore (1)

The Medical & Chirurgical Faculty of Maryland (MedChi) was founded in 1799, just years after the birth of our country. Many of MedChi’s early members fought in the American Revolution, and were prepared to fight again in the War of 1812 – and in the Battles of North Point and Baltimore, which took place in September of 1814.

It is one of MedChi’s founding members, William Beanes, MD, of Prince George’s County, who played a pivotal, yet largely unknown, role in the history of The Star-Spangled Banner. If not for Dr. Beanes, Francis Scott Key would not have been on a ship in Baltimore’s Harbor, and he would never have written the poem which became our National Anthem.

William Beanes was born at Brooke Ridge, in Prince George’s County on January 24, 1749. There were no medical schools when Dr. Beanes studied medicine, so he apprenticed with a local physician. Professionally, his fine reputation spread beyond the county, and in 1799 he became one of the founding members of the Medical and Chirurgical Faculty of Maryland, and a member of its first examining board.

During the summer of 1814, as the British prepared to invade Washington, General Ross selected Dr. Beanes’ home as his headquarters, and Dr. Beanes agreed not to object to his presence or harm the troops. However, when the British Army returned to Upper Marlborough (now spelled Marlboro) after burning Washington, they were jubilant, drunk and marauding. Dr. Beanes and some of his neighbors were forced to arrest some of the most badly behaved of the group. One prisoner escaped and reported this to General Ross.

General Ross returned and arrested Dr. Beanes in the middle of the night. Dr. Beanes traveled with the British Army down the Potomac River and up the Chesapeake Bay, as the British prepared to burn Baltimore as they had done in Washington.

A lawyer named Francis Scott Key was engaged to free Dr. Beanes from the British Army. Key traveled to Baltimore with letters of support from President James Madison, as well as letters from British prisoners whose injuries Dr. Beanes had treated only weeks earlier in Upper Marlborough.

Dr. Beanes was being held on a truce ship just south of Baltimore, and Key sailed out to negotiate for his release. Key secured Beanes’ release, but the as battle was beginning, the men were not allowed to leave.

For more than 25 hours the battle raged. Dr. Beanes and Key watched and waited all through the night. Toward the morning, the cannon fire slowed and then stopped, followed by an ominous silence from across the water. As the dawn broke, Key and Dr. Beanes were able to see that the flag was still there, flying above Fort McHenry. They knew that the British had not captured Baltimore.

As the men sailed back to Baltimore, Francis Scott Key penned the now famous poem on the back of an envelope. It was printed in a local paper and then set to the tune of an old drinking song, To Anacreon in Heaven.

Dr. Beanes returned to his home, Academy Hill in Upper Marlborough, and continued to practice medicine. He died at age 80 in October of 1828.

Dr. Beanes is buried in a small graveyard in Upper Marlborough, and is remembered throughout Prince George’s County, where roads, schools and parks bear his name and continue to tell his story.

Dr. Beanes is the forgotten man in the Star-Spangled story.

Meg Fairfax Fielding is director of development, Center for a Healthy Maryland, The Foundation of MedChi. For more information, visit healthymaryland.org.

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KISS-IT: Keeping It Simple with Information Technology

KISS IT and optimize the operation of your medical practice by bridging the gap between delivering superior healthcare services and utilizing technology to support your patient care and engagement initiatives.

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Avoiding Billing Pitfalls in the Age of the ACA

Tom-MorrowBY THOMAS C. MORROW

In the second decade of the 21st century, many healthcare providers are struggling to decide whether or not to accept patients who have Medicaid. A key issue is the provider’s ability to ensure compliance with its myriad reimbursement regulations.

Failure to maintain familiarity with the requirements can result in withheld reimbursement, civil lawsuits for restitution of past payments, and even federal and state criminal prosecution. As the pool of Medicaid-enrolled patients increases, a growing number of providers will need to navigate complex and confusing reimbursement procedures. Thorough knowledge of proper billing procedures is not optional. Failure to adhere to reimbursement regulations and requirements can be disastrous to individual and institutional providers.

The Patient Protection and Affordable Care Act (ACA) include provisions that Medicaid payments may be suspended as the result of an audit, even without proof of fraud. A credible allegation of fraud is the sole requirement. Section 6402(h) of the ACA requires a state to suspend payments to an individual or entity providing medical services pending investigation into such allegations. A state may decline to withhold payments only if it determines that there are good reasons not to withhold such payments, and these are limited.

Potential Sources of Fraud Allegations

Sources of allegations include the obvious, such as “whistle blowing” from a disgruntled employee or tips to a fraud hotline. Sources also may include virtually any allegations that may ultimately be deemed “credible.” Increasingly, such allegations originate from computer analyses of claims data that produce atypical, and therefore suspicious, patterns compared to similarly situated providers. An example is “up-coding,” where a provider uses a higher billing code than the norm among similar providers.

Another example involves consistent failure to provide documentation that the auditing entity requires to justify the procedure associated with a specific code. Obvious examples of fraud include billing for services not provided or multiple billings for single procedures. Outright false billing aside, allegations can arise from errors made when providers delegate the coding/billing process to persons inadequately trained in the complexities of the billing process.

Maryland Law

In Maryland, a provider may appeal a notice of suspension to the Office of Administrative Hearings (OAH). The OAH does not conduct an independent review to determine if the suspension is justified, but limits its determination to whether or not the allegation of fraud is credible. This standard is far from the “preponderance of evidence” standard used in civil trials, and demands less proof than the “probable cause” standard required to initiate a criminal charge.

The criteria to justify a suspension are probably most analogous to “reasonable belief,” which requires only that the specifics of the allegation itself be verified by a state entity and that the source has the indicia of reliability. Thus, the appellate review of a suspension in the Maryland OAH is typically limited to an inquiry into the nature of the allegation and the reliability of its source.

Once the state has “verified” an allegation of fraud, the ACA requires the allegation to be referred to the Medicaid Fraud Control Unit (MFCU), an investigation and prosecution unit of the Attorney General’s Office in most states. CMS has published standards for evaluating fraud allegations.

Know When to Seek an Attorney

Because suspension of reimbursement is usually based on a “credible allegation of fraud” that will inevitably be evaluated by MFCU, a provider notified of a pending suspension should immediately contact an attorney. Aggressive intervention by counsel familiar with reimbursement issues may have the suspension terminated through negotiated settlements and help a provider establish that the coding was justified.

Where coding practices are erroneous, an attorney can help establish that errors were not the result of intentional fraud. This may lead to settlement options ranging from reimbursing the Medicaid program for overpayments, implementing corrective action plans and educational programs, reorganizing and upgrading medical records and other remediation options. Most importantly, early resolution of such investigations can avoid the economic devastation of defending a complex false-claims suit or the professionally catastrophic impact of defending criminal charges.

Thomas C. Morrow, partner of Shaw & Morrow, P.A., represents healthcare providers in professional discipline and credentialing matters. For more information go to shaw-morrow.com.

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PCMHs and ACOs: Are They Working?

How effective are Patient Centered Medical Homes and Accountable Care Organizations? Maryland experts describe how both models are improving care and why the new Maryland Medicare waiver may provide an impetus to both.

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