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The following are articles, links, web page content and other information we find interesting to the healthcare professional. They are listed below in the order shown. Click on the title or scroll down and read them all. Please comment if you like.

Check back often, we update this page whenever we find new articles and information.

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List of Articles

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Choline During Pregnancy Boosts Memory

By Jennifer Warner

Oct. 6 (CBSHealthWatch)--Getting enough of the little-known nutrient choline during pregnancy may play a vital role in the formation of your baby's brain and memory function, according to a new survey of research in animals.

"There is a critical time during pregnancy when making this nutrient choline available changes the structure and rate of formation of one of the memory centers in the brain," says Steven Zeisel, MD, PhD, of the department of nutrition at the University of North Carolina at Chapel Hill. "This is the memory center that stores our short-term memories and how to find things like the car in the airport after a long trip--spatial memories."

Choline is a naturally occurring amino acid found in egg yolks, milk, nuts, liver and soybeans as well as human breast milk. It's an essential building block for a memory forming brain chemical called acetylcholine, and it plays a major role in the formation of cell membranes throughout the body.

Zeisel says based on studies in laboratory rats, that critical time in which choline is needed would seem to be in the last trimester of pregnancy for humans. If the rats were not given enough choline at that time, the babies suffered memory problems throughout their lives and were more likely to become senile.

"In addition, if that mother, during pregnancy, is offered extra choline--about three times what she'd normally take in from her food--her babies were born with enhanced memory, and it would last their entire lives," says Zeisel.

Other experts say this study adds to growing body of research that has demonstrated the importance of choline sufficiency in the development of the brain and cell function.

"It's critical in a whole host of biochemical processes in the body," says Donald Mattison, MD, medical director of the March of Dimes.

Mattison says this and other studies suggest that choline, like folate, may be vital to the healthy development of the fetus. "This, like other things, as we learn about them indicate that nutrition prior to pregnancy and early in pregnancy can be very important in the development of diseases in the adult and in the normal formation and development of the child and newborn," says Mattison.

Zeisel's study is published in the October issue of the Journal of the American College of Nutrition.

© 2000 by Medscape Inc. All rights


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August 17, 2000

 No Significant Link Proven Between Strokes and Chiropractic

CHANDLER, Ariz., Aug. 17 /PRNewswire/ - Almost since it was founded as a separate profession in 1895, chiropractic has been under attack by many in the medical profession. As was proven in federal court, most of the criticism has been totally unfounded, an attempt to destroy a competing health care field which threatens the medical monopoly in this country.

In their latest attempt to discredit chiropractic and discourage people from seeking care from chiropractors, some proponents of allopathic medicine continue to disseminate misleading information about a possible link between cervical adjustments and strokes.

According to the World Chiropractic Alliance (WCA), an international advocacy organization representing chiropractors worldwide, such misinformation is a deliberate and unethical scare tactic which does not stand up to critical analysis.

"Even if we restrict our investigation to cervical adjustments - which have been the focus of many of the media and medical attacks - the only reasonable conclusion which can be drawn is that chiropractic adjustments do not pose any significant risk of stroke and are remarkably safe," stated Terry A. Rondberg, D.C., president of the WCA and author of "Chiropractic First," a consumer guide to chiropractic.

A stroke occurs when a blood clot blocks a blood vessel or artery, or when a blood vessel breaks, interrupting blood flow to an area of the brain. The lack of blood causes brain cells to die. There are nearly 750,000 first ever or recurrent strokes each year in the U.S. and more than 150,000 deaths are directly stroke-related.

Numerous published scientific and medical studies indicate that the incidence of a cerebrovascular accident (CVA) or stroke is estimated at between one and three per million adjustments. One study covered a period of 28 years, while another involved reviewing about 110 million chiropractic visits. The results of these studies show conclusively that the risk of stroke from a chiropractic adjustment is so small as to be statistically insignificant.

It has been estimated to be even less than that of "beauty parlor stroke syndrome" - a rare occurrence triggered when a customer leans her head back on a sink to get her hair washed. In reality, even the one to three incidents per million adjustments figure may be overestimated. In some cases, spinal manipulation was blamed even if the stroke occurred days or weeks afterwards. According to researcher Christopher Kent, D.C., "The fact that a temporal relationship exists between two events does not mean that one caused the other."

Additionally, medical researchers frequently misunderstand the critical differences between specific chiropractic adjustments and cervical manipulation. Doctors of chiropractic are highly trained in the use of the adjustment, which is the specific application of force to help correct nerve interference. Manipulation is the forceful passive movement of a joint beyond its active limit of motion. Since it doesn't imply the use of precision, specificity or the correction of nerve interference, it is not synonymous with chiropractic adjustment.

Finally, many of the cases cited by medical researchers as being "chiropractic treatments" were actually spinal manipulations rendered by non-chiropractic practitioners.

According to a 1995 research report in the Journal of Manipulative and Physiological Therapeutics, "Misuse of the literature by medical authors in discussing spinal manipulative therapy injury," manipulations administered by a Kung Fu practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had been incorrectly attributed to chiropractors.

The report explained that, "The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non-chiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors."

Even medical researchers have had to admit that chiropractic care carries far less of a stroke risk than medical treatment. "Indeed, most interventions by allopathic physicians have a higher complication rate than chiropractic interventions," said Philip Lee, M.D., a co-investigator of a research survey presented at the American Heart Association's 19th International Joint Conference on Stroke and Cerebral Circulation. Because of this inaccurate reporting to the media, the World Chiropractic Alliance is calling upon the medical establishment to provide factual data to the public and restrain from using scare tactics in a blatant attempt to continue its long-standing history of opposition to chiropractic and other disciplines which threaten its monopoly on the health care system.

The WCA posted its complete position paper on strokes, including abstracts of numerous scientific studies, on its website, http://www.worldchiropracticalliance.org/positions/stroke.htm The World Chiropractic Alliance is an international organization representing doctors of chiropractic and promoting the traditional, drug-free and non-invasive form of chiropractic as a means to correct vertebral subluxations which cause nerve interference. The WCA is an NGO (Non-Governmental Organization) associated with the United Nations Department of Public Information and publisher of the peer-reviewed chiropractic research journal, "Journal of Vertebral Subluxation Research." For more information, contact the WCA at 800-347-1011 or http://www.worldchiropracticalliance.org.

SOURCE: World Chiropractic Alliance


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July 11, 2000

SB 1508 or The Florida Prompt Pay Act takes effect on Oct 1st

SB 1508, more familiarly known as the "Prompt Pay Bill" takes effect on Oct 1st. The bill has important implications for physicians and other health care providers. It provides detailed specifications to more accurately define acceptable billing practices for providers, HMOs and patients. The following are some highlights of the bill:

A "Clean Claim" must be paid within 35 days. Clean claims are defined as (for physicians) a claim submitted on a HCFA 1500 form which has no defect or impropriety, including lack of required substantiating documentation.

If a claim is contested, the HMO must pay the uncontested portion of the claim within 35 days, or request additional information. After the receipt of the request for more information, the provider has 35 days to submit the additional information. The HMO then has 45 days to make a final payment or denial determination.

The HMO must pay or deny a claim within 120 days, or face an uncontestable obligation to pay the claim.

Interest of 10 percent on an overdue clean claim or any uncontested portion begins to accrue on the 36th day after the claim is received. The interest is payable with the payment of the claim.

Claims are considered to be "received" when verified electronically or by return receipt for mailed claims. Electronic verification of the receipt of a claim is to be made within 72 hours.

HMOs must provide treatment authorization 24 hours a day, 7 days a week. Requests cannot be pended without a provider's approval.

Providers (regardless of whether they are under contract with the HMO) cannot attempt to collect money from an HMO subscriber when the provider knows or should know that the HMO is liable for payment. Similarly, providers may not file legal action or report to a credit agency an HMO subscriber under these circumstances. Providers may be fined by ACHA for balance billing.

HMOs now must submit written claims to providers to recover overpayments. HMOs may no longer reduce current payments to providers based on alleged overpayments unless the provider agrees to the reduction or fails to respond to the HMO's claim for repayment.

If a provider does not contest or deny an HMO's claim for repayment, then he/she must pay the claim within 35 days of receipt. If the provider wishes to contest or deny the claim, he/she must: Notify the HMO in writing within the 35-day period; and if denied, identify a reason why; and if contested, request additional information.

The HMO has 35 days after the receipt of the information request to submit the additional information. The provider then has 45 days to make a final payment or denial determination. The provider must pay or deny a claim within 120 days, or face an uncontestable obligation to pay the claim plus interest.

Providers must wait 45 days following an HMO's receipt of a claim before submitting a duplicate claim. Similarly, HMOs may not resubmit a claim for provider repayment until 45 days after the original claim was received.

Systematic downcoding with the intent to deny reimbursement otherwise due is now listed as an unfair claim settlement practice. HMOs are subject to fines for systematic downcoding; providers are subject to fines for systematic upcoding.

There are more facets of this new law and should be discussed with your consultant, your FCA contact or an attorney. Information is presented in summary form and should not be construed as accounting or consulting advice.

©Rachlin Cohen & Holtz LLP



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Tuesday July 18, 1:30 pm Eastern Time

Washington State Insurance Commissioner Senn Orders Targeted Investigation Into Allegations of Improper Denial of Auto Injury Claims

OLYMPIA, Wash., July 18 /PRNewswire/ -- State Insurance Commissioner Deborah Senn said today she has ordered her staff to investigate national allegations that auto insurers rely on "medical reviews" performed by laypersons to deny insurance benefits to policyholders injured in auto accidents.

"This is an issue that we looked at in 1996, making sure auto insurers used the right type of health-care providers to review auto-injury claims," Commissioner Senn said. She also invited Washington consumers to report any firsthand trouble they had experienced with "medical reviews" and auto claims.

Commissioner Senn said Washington state has consumer protections in place that should prevent improper denials. She noted that "Dateline NBC," which reported the allegations in June, also acknowledged that Washington is one of four states that has reacted to the problem.

"There are serious allegations about companies who do business in the state of Washington, and we want to be sure that the industry is adhering to the rules we have spelled out," Commissioner Senn said.

In 1997, Commissioner Senn adopted regulations that require insurers to use "like licensure" providers. This means that, if the patient sees a chiropractor, the insurance company cannot have the treatment reviewed by an orthopedic surgeon who is not trained in chiropractic.

Commissioner Senn said she had ordered six of the largest carriers doing business in Washington state to submit claims data so her investigators can be certain that Washington consumers are getting the benefits they pay for in their auto insurance policies.

The new allegations were raised in a "Dateline NBC" program in late June. The program said auto insurers today rely upon "medical opinions" from non-professionals to deny valid claims.

Commissioner Senn said the six companies targeted by the investigation are: State Farm Mutual Insurance Co., Safeco Insurance Co., Farmers Insurance Co. of Washington, Pemco Insurance Co., Mutual of Enumclaw, and Allstate Property & Casualty Co. Together, the six account for approximately half of the auto insurance sold in the state annually.

Commissioner Senn said she wants the investigation to proceed as quickly as possible so faulty insurance company practices do not deprive Washington policyholders of legitimate benefits.

Commissioner Senn said the Dateline report raises questions about the so-called "paper reviews" in which a medical reviewer simply looks over the paperwork involved in treatment but never interviews the patient. The Dateline report said it found many "paper reviews" were not even conducted by licensed health-care providers.

That should not be true in Washington state if companies are following state law, Commissioner Senn said, noting that carriers conducting such reviews are obligated under "like licensure" to use health-care providers, not laypersons.

SOURCE: Washington State Office of the Insurance Commissioner

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Thursday June 22, 7:09 pm Eastern Time

Allstate New Jersey Files Fraud Suit Under New Jersey Civil Rico Statues Essex/Union Chiropractor at Center of Fraud Conspiracy
MORRIS COUNTY, N.J., June 22 /PRNewswire/ -- Citing violations of the New Jersey civil RICO Statute and the New Jersey Insurance Fraud Prevention Act, Allstate New Jersey Insurance Company (ANJ) and Continental Insurance Company of New Jersey (CNA-PI) filed suit today against 14 defendants allegedly engaged in an elaborate fraud conspiracy netting millions in fraudulent auto insurance claim payments. The companies filed the 14-count suit in Morris County Superior Court. This is Allstate New Jersey's and CNA-PI's first case alleging RICO conspiracy violations.

"This case is unique. Our Special Investigative Unit uncovered evidence of a money laundering scheme fueling this fraud operation," said Joseph L. Scrimo, Jr., Manager, Allstate New Jersey Special Investigative Unit. "This allows us to seek additional penalties under the New Jersey RICO laws."

The suit alleges that Essex/Union chiropractor Richard C. Nardone set up a variety of medical companies in the names of other individuals in order to disguise his personal ownership interests in the facilities. The defendant corporations include Camino Rehabilitation, Inc.; Hermosa Medical Services, Inc.; Professional Medical Technologies, Inc.; ZNS Billing Service; Advanced Diagnostics, Inc.; and Medical Diagnostic Systems, P.A.

By disguising his ownership interests, Nardone attempted to skirt provisions of New Jersey's Codey Law which prohibits a doctor from referring patients from his practice to another in which he or a family member has a financial interest.

The suit alleges Nardone created the appearance Camino Rehabilitation was a medical facility operating at a location distinct from his chiropractic office to allow him to bill insurers at a higher rate. The suit charges that patients Nardone referred for rehabilitation were actually treated at his office by, or under the supervision of, his chiropractic office staff. The address given for the alleged Camino Rehabilitation facility was nothing more than a Mail Boxes, Etc. location. In addition, Allstate New Jersey and CNA-PI have never received a claim for a patient of Camino who was not already a patient of Nardone's practice.

By hiding his ownership interests in Camino, Nardone avoided reimbursement reductions mandated under the state's No-Fault medical fee schedule, enabling him to significantly increase the amount billed to the insurance companies for a patient visit. For a typical patient requiring therapeutic care, billing increased from $87.50 to $131.00, or 49 percent, per visit. Allstate New Jersey and CNA-PI have identified 732 individual claimants involved in the suit.

The majority of Nardone's patients were also allegedly prescribed an Electromuscular Stimulation Device (ESD), often without any medical need. The ESDs were supplied by Hermosa Medical Services, Inc., a company also believed to be controlled by Nardone, though registered in the named of another party. The suit contends the insurers were billed $780 for each EDS device, significantly more than the estimated actual cost per unit of $80.

Allstate New Jersey alleges that Nardone was aided in controlling Camino and Hermosa by his sister and co-defendant, Donna Januik, who handled the billing and finances for those defendant entities, as well as for Nardone's chiropractic offices.

The suit also alleges the defendants engaged in a money-laundering scheme to enrich the defendants and perpetuate the scam. Allstate New Jersey and CNA-PI were able to obtain copies of checks cashed by unlicensed Essex County check cashing facilities. These checks were issued by the defendant facilities to fictitious individuals and to alleged runners, who solicited claimants for the ring. The suit further contends that the proceeds of the checks were used to illegally pay referral fees and kickbacks for the solicitation of patients and/or for the staging of accidents.

Through its investigation, Allstate New Jersey was also able to obtain copies of hundreds of thousands of dollars in checks made payable to Nardone and drawn from the attorney trust accounts and the business accounts of dozens of New Jersey law firms. Allstate New Jersey alleges that the cash proceeds of those checks were also used by the defendants to make unlawful payment of referral fees for the solicitation of patients and for the staging of accidents. The defendants allegedly waived all co-payments and deductibles for claimants to encourage excessive and expensive treatments.

Allstate New Jersey and CNA-PI are seeking restitution of $2.4 million in paid PIP claims, plus treble damages and expenses. They are also seeking to deny payment of all pending and future bills submitted by the defendants and to block and recoup any payments pending or already made to the defendants in PIP arbitration proceedings.

This action is the result of a year's investigation by Allstate New Jersey's Special Investigative Unit (SIU) in cooperation with the New Jersey Office of Insurance Fraud Prosecutor. In 1999, the work of Allstate's SIU resulted in legal action against 388 suspected defrauders totaling $54 million. In 1998, the company also established a front-end Fraud Prevention Unit, to help identify and eliminate potential fraud at the time of application.
SOURCE: Allstate

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Friday June 23 10:45 AM ET

Hospitals Embrace Alternative Care
By PHIL GALEWITZ, AP Business Writer

NEW YORK (AP) - Beth Israel Medical Center, a large New York teaching hospital, this month opened a funky looking facility - complete with pastel-colored walls and a waiting room with fluffy couches and a redwood bench - where physicians work along side chiropractors and practitioners who specialize in homeopathy and clinical imagery.

At Cedars-Sinai Medical Center, one of the most prestigious hospitals in Los Angeles, cardiac patients are given the option of receiving acupuncture or massage therapy after coronary bypass surgery.

At the University of Pittsburgh Medical Center, known for its ground-breaking organ transplants, psychiatrists prescribe herbal medicines to help patients overcome depression.

Hospitals, the bastions of Western medicine and high-tech gadgetry, are increasingly using procedures such as aromatherapy and Tai Chi to try to attract patients by tapping into one of the hottest trends in health care.

Though the medical profession remains skeptical about the effectiveness of alternative therapies, hospital administrators say they can no longer escape the reality that millions of Americans routinely use them to complement - or even take the place of - traditional medicine.

About 83 million Americans are spending some $27 billion a year on alternative care, according to a recent study published in the Journal of the American Medical Association.

With these patients and dollars in mind, about 13 percent of U.S. hospitals provide alternative therapies, according to a survey of about 1,000 hospitals by the consulting firm Deloitte & Touche. The figure rises to 25 percent for inner city hospitals and 32 percent for hospitals with at least 500 beds.

A decade ago, it would have been almost unheard of for hospitals to offer such services, industry analysts say. That's changing fast.

``It would be silly for doctors and hospitals to ignore something that will be a large part of health care for years to come,'' said Dr. Matthew Fink, a neurologist who is president and chief executive of Beth Israel Medical Center.

But doctors and the practitioners of alternative care don't always mix well.

Many doctors still are suspicious of alternative therapies and consider chiropractors and acupuncturists to be quacks. And health insurers are reluctant to pay for most alternative procedures.

At the State University of New York at Stony Brook, a move to affiliate with a group of alternative care practitioners prompted a firestorm of criticism from faculty members before the program got off the ground.

Despite occasional setbacks, alternative care providers and medical practitioners are increasingly seeking to find common ground to help their businesses prosper.

That's what's happening at Beth Israel's Center for Health and Healing, located on the second floor of a nondescript office building in downtown Manhattan. The $5 million center, with 17 treatment rooms, has pastel-colored walls. The waiting room is light and airy with fluffy couches, and there's a bench made from recycled redwood in the reception area.

``We are providing a wide range of therapeutic options of remedies that have stood the test of time and/or scientific scrutiny, and preferably both,'' said Dr. Woodson Merrell, the center's executive director who is a physician and an acupuncturist. ``I see integrative medicine as the future of medicine.''

The center, opened in June, includes medical doctors, registered nurses, nurse practitioners, psychotherapists and practitioners of acupuncture, chiropractic procedures, mind-body therapy and massage therapy.

Beth Israel officials opened the center not only to tap into the growing interest among consumers for alternative care but also to conduct research to try to determine if these therapies - some practiced for thousands of years- really do work, Merrell said.

Merrell said some Beth Israel doctors were suspicious of the center, especially orthopedic surgeons who are leery of chiropractors. To win the specialists' support, the center has agreed that after a patient sees a chiropractor three times, the case must be reviewed by a physician.

``We tried to get both sides to come to the table to work together,'' Merrell said. ``It was like putting together disparate worlds.''

Experts say alternative care providers gain credibility by working with physicians and hospitals. And the doctors and medical institutions are viewed as cutting edge for facilitating alternative care.

Financial barriers remain, however, because there is limited insurance coverage for alternative procedures. Beth Israel's center so far has been unsuccessful in attracting an insurer for a pilot project to test whether alternative therapies can save money and provide good care, Merrell said.

Still, support among physicians is growing.

Dr. Gregory Fontana, a cardiothoracic surgeon at Cedars-Sinai, uses acupuncture to relieve the neck pain he develops from surgery.

Seeing first hand how the therapy works for him - and concerned that his own patients were not receiving effective treatment for pain - Fontana recently led a group of physicians to start a pilot program to test acupuncture, massage therapy and guided-imagery relaxation techniques on cardiac bypass patients. Early results on about 100 patients show that nearly all reported some relief from the services, he said.

``As my practice evolved, I saw the frustrations of my patients and came to the realization that Western medicine does not have all the answers,'' Fontana said.

Fontana's study is just one area at Cedars-Sinai where there is alternative care.

The hospital last year launched its Integrative Medicine group, which offers such services as acupuncture and meditation as well as physician services. Doctors are becoming involved because their patients are asking about such procedures, officials say.

``Doctors fear they will lose patients if they do not know how to talk to patients about alternative therapies,'' said Dr. Mary Hardy, the group's medical director who is an internist and specialist in herbal medicines.

Beyond New York and Los Angeles, hospitals in more conservative areas of the country also are introducing alternative care.

Central Iowa Health Systems last year opened the Center for Health and Well Being in West Des Moines, Iowa. The center, which treats allergies with Chinese herbs and back pain with acupuncture, hopes the hospital name and logo will attract patients who are hesitant to give these alternative services a try.

"We give patients more of a comfort level because they know we've checked out these practitioners," said Sheila Gregan, the center's director.


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GENERAL INFORMATION
May/June 2000 Edition Medicare B Update

Office of Inspector General Special Fraud Alert

This Special Fraud Alert focuses on the rental of space in physicians' offices by persons or entities that provide health care items or services. The Office of Inspector General (OIG) was established at the Department of Health and Human Services by Congress in 1976 to identify and eliminate fraud, abuse, and waste in the Department's programs and to promote efficiency and economy in departmental operations.

The OIG carries out this mission through a nationwide program of audits, investigations and inspections. To reduce fraud and abuse in the federal health care programs, including Medicare and Medicaid, the OIG actively investigates fraudulent schemes that are used to obtain money from these programs and, when appropriate, issues Special Fraud Alerts that identify practices in the health care industry that are particularly vulnerable to abuse. (suppliers)(1) to patients that are referred either directly or indirectly by their physician-landlords. In this Special Fraud Alert, we describe some of the potentially illegal practices the OIG has identified in such rental relationships.


Questionable Rental Arrangements for Space in Physician Offices - A number of suppliers that provide health care items or services rent space in the offices of physicians or other practitioners. Typically, most of the items or services provided in the rented space are for patients, referred or sent, either directly or indirectly, to the supplier by the physician-landlord. In particular, we are aware of rental arrangements between physician-landlords and:


* Comprehensive outpatient rehabilitation facilities (CORFs) that provide physical and occupational therapy and speech-language pathology services in physicians' and other practitioners' offices;

* Mobile diagnostic equipment suppliers that perform diagnostic related tests in physicians' offices; and

* Suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) that set up consignment closets for their supplies in physicians offices.

The OIG is concerned that in such arrangements, the rental payments may be disguised kickbacks to the physician-landlords to induce referrals. We have received numerous credible reports that in many cases, suppliers, whose businesses depend on physicians' referrals, offer and pay "rents" - either voluntarily or in response to physicians' requests - that are either unnecessary or in excess of the fair market value for the space to access the physicians' potential referrals.

The Anti-Kickback Law Prohibits Any Payments to Induce Referrals - Kickbacks can distort medical decision-making, cause over-utilization, increase costs and result in unfair competition by freezing out competitors who are unwilling to pay kickbacks. Kickbacks can also adversely affect the quality of patient care by encouraging physicians to order services or recommend supplies based on profit rather than the patients' best medical interests.

Section 1128B(b) of the Social Security Act (the Act) prohibits knowingly and willfully soliciting, receiving, offering or paying anything of value to induce referrals of items or services payable by a Federal health care program. Both parties to an impermissible kickback transaction are liable. Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to five years, or both. The OIG may also initiate administrative proceedings to exclude persons from Federal health care programs or to impose civil money penalties for fraud, kickbacks and other prohibited activities under sections 1128(b)(7) and 1128A(a)(7) of the Act.(2)

Suspect Rental Arrangements for Space in Physician Offices - The questionable features of suspect rental arrangements for space in physicians' offices may be reflected in three areas:

* The appropriateness of rental agreements;
* The rental amounts; and
* Time and space considerations

Below, we examine these suspect areas, which separately or together may result in an arrangement that violates the anti-kickback statute, in order to help identify questionable rental arrangements between physicians and the suppliers to which they refer patients. This list is not exhaustive, but rather gives examples of indicators of potentially unlawful activity.

Appropriateness of Rental Agreements. The threshold inquiry when examining rental payments is whether payment for rent is appropriate at all. Payments of "rent" for space that traditionally has been provided for free or for a nominal charge as an accommodation between the parties for the benefit of the physicians' patients, such as consignment closets for DMEPOS, may be disguised kickbacks. In general, payments for rent of consignment closets in physicians' offices are suspect.

Rental Amounts. Rental amounts should be at fair market value, be fixed in advance and not take into account, directly or indirectly, the volume or value of referrals or other business generated between the parties. Fair market value rental payments should not exceed the amount paid for comparable property. Moreover, where a physician rents space, the rate paid by the supplier should not exceed the rate paid by the physicians in the primary lease for their office space, except in rare circumstances.

Examples of suspect arrangements include:

* Rental amounts in excess of amounts paid for comparable property rented in arms-length transactions between persons not in a position to refer business;

* Rental amounts for subleases that exceed the rental amounts per square foot in the primary lease;

* Rental amounts that are subject to modification more often than annually;

* Rental amounts that vary with the number of patients or referrals;

* Rental arrangements that set a fixed rental fee per hour, but do not fix the number of hours or the schedule of usage in advance (i.e.,"as needed" arrangements);

* Rental amounts that are only paid if there are a certain number of Federal health care program beneficiaries referred each month;

* Rental amounts that are conditioned upon the supplier's receipt of payments from a Federal health care program.

Time and Space Considerations. Suppliers should only rent premises of a size and for a time that is reasonable and necessary for a commercially reasonable business purpose of the supplier. Rental of space that is in excess of suppliers' needs creates a presumption that the payments may be a pretext for giving money to physicians for their referrals. Examples of suspect arrangements include:

* Rental amounts for space that is unnecessary or not used. For instance, a CORF requires one examination room and rents physician office space one afternoon a week when the physician is not in the office. The CORF calculates its rental payment on the square footage for the entire office, since it is the only occupant during that time, even though the CORF only needs one examination room;

* Rental amounts for time when the rented space is not in use by the supplier. For example, an ultrasound supplier has enough business to support the use of one examination room for four hours each week, but rents the space for an amount equivalent to eight hours per week;

* Non-exclusive occupancy of the rented portion of space. For example, a physical therapist does not rent space in a physician's office, but rather moves from examination room to examination room treating patients after the physician has seen them. Since no particular space is rented, we will closely scrutinize the pro-ration of time and space used to calculate the therapist's "rent."

In addition, rental amount calculations should prorate rent based on the amount of space and duration of time the premises are used. The basis for any proration should be documented and updated as necessary. Depending on the circumstances, the supplier's rent can consist of three components: (1) exclusive office space; (2) interior office common space; and (3) building common space.

1. Apportionment of exclusive office space - The supplier's rent should be calculated based on the ratio of the time the space is in use by the supplier to the total amount of time the physician's office is in use. In addition, the rent should be calculated based on the ratio of the amount of space that is used exclusively by the supplier to the total amount of space in the physician's office.

2. Apportionment of interior office common space - When permitted by applicable regulations, rental payments may also cover the interior office common space in physicians' offices that are shared by the physicians and any subtenants, such as waiting rooms. If suppliers use such common areas for their patients, it may be appropriate for the suppliers to pay a prorated portion of the charge for such space. The charge for the common space must be apportioned among all physicians and subtenants that use the interior office common space based on the amount of non-common space they occupy and the duration of such occupation. Payment for the use of office common space should not exceed the supplier's pro rata share of the charge for such space based upon the ratio of the space used exclusively by the supplier to the total amount of space (other than common space) occupied by all persons using such common space.

3. Apportionment of building common space - Where the physician pays a separate charge for areas of a building that are shared by all tenants, such as building lobbies, it may be appropriate for the supplier to pay a prorated portion of such charge. As with interior office common space, the cost of the building common space must be apportioned among all physicians and subtenants based on the amount of non-common space they occupy and the duration of such occupation. For instance, in the example in number one above, the supplier's share of the additional levy for building common space could not be split 50/50.

The Space Rental Safe Harbor Can Protect Legitimate Arrangements - We strongly recommend that parties to rental agreements between physicians and suppliers to whom the physicians refer or for which physicians otherwise generate business make every effort to comply with the space rental safe harbor to the anti-kickback statute. (See 42 CFR1001.952(b), as amended by 64 FR 63518 [November 19, 1999]). When an arrangement meets all of the criteria of a safe harbor, the arrangement is immune from prosecution under the anti-kickback statute. The following are the safe harbor criteria, all of which must be met:

*The agreement is set out in writing and signed by the parties.

*The agreement covers all of the premises rented by the parties for the term of the agreement and specifies the premises covered by the agreement. If the agreement is intended to provide the lessee with access to the premises for periodic intervals of time rather than on a full-time basis for the term of the rental agreement, the rental agreement specifies exactly the schedule of such intervals, their precise length, and the exact rent for such intervals.

*The term of the rental agreement is for not less than one year.

*The aggregate rental charge is set in advance, is consistent with fair market value in arms-length transactions, and is not determined in a manner that takes into account the volume or value of any referrals or business otherwise generated between the parties for which payment may be made in whole or in part under Medicare or a State health care program.

* The aggregate space rented does not exceed that which is reasonably necessary to accomplish the commercially reasonable business purpose of the rental.

Arrangements for office equipment or personal services of physicians' office staff can also be structured to comply with the equipment rental safe harbor and personal services and management contracts safe harbor. (See 42 CFR 1001.952(c) and (d), as amended by 64 FR 63518[November 19,1999]). Specific equipment used should be identified and documented and payment limited to the prorated portion of its use. Similarly, any services provided should be documented and payment should be limited to the time actually spent performing such services.

(1.)Persons or entities may be either suppliers or providers. For purposes of this Special Fraud Alert, we will refer to such persons as suppliers. (2.) Some of the arrangements identified as suspect in this Special Fraud Alert may also implicate the Ethics in Patient Referrals Act, also known as the Stark law (section 1877 of the Act). The interpretation of the Stark law is under the jurisdiction of the Health Care Financing Administration (HCFA). (3.)This Special Fraud Alert does not address the appropriateness of consignment closet arrangements under HCFA DMEPOS supplier standards.

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Respect the Net's Power
6/12/00

(inc.com) The Internet might be the cornerstone of your company's marketing strategy, or it might facilitate communications among employees spread across the country. It also might get you sued. According to Barry D. Weiss, a partner at the Chicago law firm of Gordon & Glickson, if you give employees access to the Internet, give them specific guidelines, too. Traditional corporate communication policy, says Weiss, can't account for a medium in which a libelous letter can reach a million people in a matter of minutes. He advises companies to take the following precautions:

• Implement authorization codes. Identify employees who are allowed to use the Internet, and give them passwords to get online.

• Control participation on bulletin boards. To reduce the risk of defamation claims, restrict participation in chat channels and bulletin boards to employees who have specific business to conduct in those forums.

• Put your rules in writing. Employees should sign agreements stating that they understand that unauthorized use of the Internet could be grounds for dismissal.

• Give advanced notice of monitoring. To avoid being cited for invasion of privacy, be sure to inform employees clearly and in advance if you plan to monitor their E-mail or Internet use.

• Limit downloading of information. To protect against copyright-infringement liability, allow employees to download or distribute only those Internet materials that include a copyright notice and specifically permit such dissemination.

• Pass by legal. Have your lawyer review your formal Internet policy.


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Company Press Release

Workout.com Launches Program Pro - A Free, Online Workout Program Editor

MILPITAS, Calif., May 16 /PRNewswire/ -- Workout.com, the Internet's first and largest library of graphical exercise and workout programs, has launched Program Pro as part of their Professional's Corner. Deployed on Microsoft Windows 2000 platform, this ``smart tool'' empowers fitness, rehabilitation and healthcare professionals with an application for dynamically building, customizing and printing graphical workout routines for diverse client bases. ``Our online program editor will be the new standard in the healthcare industry for anyone building exercise, rehabilitation or workout programs,'' states Joe Gigantino, Workout.com's Founder and President.

``Prior to incorporating Program Pro, my clients received written (text) instructions for their rehabilitation prescription. This information was then translated from either one of my certified trainers or myself to the client. While this process did work, I noticed it created a dependency that often hindered progress. Program Pro has not only allowed me to increase the number of clients, but also have the client become fully educated and interested in the entire rehabilitation process. Believe it or not, this interest alone has created a confidence within my clients that is so important to the healing and building process,'' states Chiropractor, Dave Conner, DC.

Workout.com's programs uniquely offer graphics for visual instruction. Workout.com is offering their online program editor free to the first 2,500 registered professionals. There is no software to download and no charge for technical support. By also offering biography pages and email accounts, Workout.com meets the needs of healthcare and fitness professionals that want to bring their business and knowledge to the Internet.

Workout.com is the leader in providing graphical fitness, rehabilitation and workout programs on the Internet. Workout.com equips consumers of all fitness levels and interests with targeted workout programs and information. Workout.com is rapidly becoming the standard in online preventative care.

SOURCE: Workout.com
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