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Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society KERN COUNTY Kern County Medical Society KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society TULARE COUNTY Tulare County Medical Society

June 2009 • Vol. 31 No. 6

Vital Signs

Pudding Creek, White Heron Fort Bragg, California


J U N E 2 0 0 9 / V I TA L S I G N S

Vital Signs Official Publication of

Contents EDITORIAL ..................................................................................................................................5

Fresno-Madera Medical Society Kings County Medical Society

CMA NEWS.................................................................................................................................7

Kern County Medical Society Tulare County Medical Society June 2009 Vol. 31 – Number 6 Editor, David Slater, MD Managing Editor, Carol Rau

NEWS PRACTICE MANAGEMENT: Medicare Update ...............................................................................9 PRACTICE MANAGEMENT: Excerpts from Medical Society Community News ...............................10 PHYSICIAN PROFILING: What You Don’t Know Can Hurt You ......................................................11 AIR QUALITY: “Environmental Sustainability” ............................................................................13

Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD John T. Bonner, MD David N. Hadden, MD Steven J. Hager, DO Prahalad Jajodia, MD Abbas Mehdi, MD Robb Smith, MD Roydon Steinke, MD Kings Representative, Sheldon R. Minkin, MD Kern Representative, John L. Digges, MD Tulare Representative, Gail Locke

Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medical Society, PO Box 28337, Fresno, CA 93729-8337. Advertising Contact: Display: Annette Paxton, 559-454-9331 Classified: Carol Rau, 559-224-4224, ext. 118

CLASSIFIEDS ............................................................................................................................22 FRESNO-MADERA MEDICAL SOCIETY .........................................................................................14 • President’s Message • Medical Managers Forum • Medical clinic in Afghanistan • Alliance News • Visit FMMS’ new website • Membership News KERN COUNTY MEDICAL SOCIETY .............................................................................................18 • Sweet news for Medicare recipients and their providers • Employment Practices Lawsuits: Are You at Risk? • KCMS Member Recognition • Membership News TULARE COUNTY MEDICAL SOCIETY ..........................................................................................20 • President’s Message • Medicare Recovery Audit Contractors (RAC ) – Here to Stay • EPrescribing • Membership News

Cover photography by Newton Seiden, MD

Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. V I TA L S I G N S / J U N E 2 0 0 9

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J U N E 2 0 0 9 / V I TA L S I G N S

EDITORIAL The 2009 Physicians’ Advocacy Pilgrimage to DC by David Slater, MD, Editor, Vital Signs

I recently returned from Washington, DC where I participated in the College of American Pathologists’ 2009 Advocacy School. In what other speciality can you learn, while going around the room doing self-introductions, that a guy from Montana has done one Grizzly bear mauling autopsies and one from Florida has done four alligator mauling autopsies? Maybe political advocacy just brings out the characters. Speaking of characters: As I entered Congressman Nunes’ office, out walked FMMS’s Dr. Linda Hertzberg, who is active in state and national Anesthesiology organizations. This repeated itself in Congressman Radanovich’s office an hour later. As I left there, FMMS’s Dr. Mark Alson was waiting with his Radiologists’ advocacy folder in hand. A year ago in Sacramento at CMA Legislative Day, we were shadowed by “Raw Milk” advocates in their bovine T-shirts and Optometrists wearing fashionable frames. At least in DC, I was seeing some familiar faces. So, what were the Pathologists doing in DC? Some of that is top secret of course, but issue #1 was the 21.5% Medicare cut scheduled for 2010 under the sustainable growth rate (SGR) formula. Like the Fresno colleagues shadowing me and the Tulare and MercedMariposa colleagues who reported in May’s Vital Signs on their AMA DC Advocacy Conference in March, CAP is working hard on this issue. Our CMA is also busy, aiming to terminate SGR and provide physicians a 10% Medicare pay increase. Remember that 2008 average Medicare physician rates were about what they were in 2001 (meaning there has been nearly no capture of the interim large cost increases to provide physician care and office services). SGR is like the Alternative Minimum Tax – everyone knows it is highly flawed, and everyone agrees in principle it should go away. But like the AMT, it is dreadfully expensive to bury. Medicine’s hope is that this year might be different – not because Washington is rolling in money (though I hear they are printing a bit of it), but because it has become clear that SGR simply will not be abolished as a stand-alone Congressional action. Indications are that enough pieces of the federal government’s involvement in US health care will be in play this year that a permanent SGR fix may be possible. However, as Congressman Nunes wryly noted, be careful what you ask for because the quid pro quos are likely to be major. Physicians know that and are watching closely. By the time you read this in early June, there will be more information about what both the Democrats, who control all major committees such as Senate Finance and the Republicans have in mind. The Congressional Budget Office just issued an updated analysis of SGR and the fiscal implications of some actions being considered in Congress and by physician leaders. The Senate Finance Committee published an initial framework in late April. I will close with a few highlights of those. An aside: Is anyone else worried about how inured we’ve become to huge dollar totals over the past 6 months? What would Senator Everett Dirksen, famed for the 1960’s line, “A billion here, a billion there, pretty soon you’re talking about real money,” say in 2009?

from Congressional Quarterly (May, 2009): Providing physicians with a zero percent update annually from 2010 to 2019 would increase Medicare spending $285 billion, while giving doctors a 1 percent increase per year would hike program payments nearly $333 billion over the same time period. Doctors’ Medicare reimbursement will be reduced 21 percent in 2010 unless Congress intervenes, which it is expected to again do this year. Due to the cost involved with replacing the current system or providing a long-term fix of the current one, it appears Congress this year will once again enact a short-term fix for the system. Reforming the system also would cost hundreds of billions of dollars. CBO scored several proposals to again pay for a physician payment increase in then next few years by reducing doctors’ future payments. For example, CBO said providing doctors a zero percent pay update for 2010, but then allowing a 25 percent cut in 2011, would increase Medicare spending $9.4 billion over 10 years, while providing a zero percent update in 2010 and 2011, then allowing a 29% reduction in 2012, would cost $24.5 billion over 10 years. CBO also said providing physicians with a pay hike based on the Medicare Economic Index would cost $344 billion over 10 years (Editor’s Note: this is in line with what CMA is advocating). In a health reform policy options paper released April 28, Senate Finance Committee Chairman Max Baucus (D-Mont.) and ranking minority member Chuck Grassley (R-Iowa) said they were considering two ways to cancel the 21 percent cut in 2010. The first option would update the fee schedule by 1 percentage point in 2010 and 2011 and freeze it in 2012, the document said. The calculations under the SGR to determine updates would then revert to the current law for 2013, it added. (Editor’s Note: This means all the pent-up reductions from prior years would continue to hang over our heads and hit in 2013). The second option would have the same schedule of updates for 2010-2012 as under option 1[;] however, once the update calculation reverted to current law SGR for 2012, a floor of [minus] 3% would be in effect. (Editor’s Note: This would soften the reductions, but would make it more palatable for Congress to let them happen, in “modest” annual minus 3% steps.) Beginning in 2014, the fee schedule update for localities with 2-year average fee-for-service growth rates at or greater than 110 percent of the national average would have a [minus] 6% floor,” the document stated. (Editor’s Note: We talked about the Dartmouth data last month on variations in cost of care around the US – Congress is going to reign in high spending regions one way or the other.) Based on the estimated cost of these two options, the committee is continuing to explore other options for physician payment updates,” the document said. (Editor’s Note: I guess the good news, with our tax-payer hats on, is that $300 billion is still considered “real money” in DC.) V I TA L S I G N S / J U N E 2 0 0 9

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CMA NEWS What CMA is doing on your behalf: FTC “RED FLAGS” RULES: DON’T DELAY DURING THE DELAY Failure to comply could mean penalties or fines of up to $2,500 per violation

Despite a second postponement of enforcement of the red flags rules until Aug. 1, experts recommend that physicians take steps now to become compliant with new Federal Trade Commission rules requiring the development of a formal identity theft prevention policy. Once enforcement kicks in, failure to comply with the red flags rules could mean administrative penalties or fines of up to $2,500 per violation. Resources CMA Toolkit. CMA Legal Center has prepared a toolkit to assist CMA members and their staff with the scope of the Red Flag Rule and how to comply with its requirements. The toolkit also compares and contrasts the requirements of HIPAA. Although there is significant overlap, complying with HIPAA alone will not guarantee compliance with the Red Flag Rule. This toolkit is available under the CMA Spotlight section on CMA’s home page website: For assistance members can call CMA’s Member Hotline at 800-786-4262. FTC guide. On April 2, the FTC launched a guide to help businesses understand and comply with the red flags rules. The FTC also is developing a more detailed template for a formal identity theft prevention policy that will be available on the agency’s Web site ( AMA guide. The AMA prepared sample policies and guidance to help physicians comply with the new requirements and build off of existing HIPAA policies. Meanwhile, the AMA continues to challenge the FTC’s view that physicians are covered by the rules as creditors ( World Privacy Forum report. The World Privacy Forum issued a report on the red flags rules and medical identity theft with suggestions for the health care field (www.worldprivacy

PHYSICIANS COULD FACE A 21% MEDICARE RATE CUT IN 2010 At the beginning of 2009, it appeared as though the annual kabuki theater of threatened Medicare cuts might not materialize this year. The Obama administration became the first presidential administration to release a budget that would eliminate the SGR, at a cost of $380 billion. Also, the House Budget Committee agreed in March to waive congressional payas-you-go rules (which require new federal spending to be offset by budgetary cuts or tax hikes) for the SGR, further clearing the path toward a permanent Medicare fix. However, the House recently reversed itself, and voted to uphold the pay-as-you-go rules for all programs, effectively requiring an additional $285 billion. Therefore, Congressional leaders may scale back their plans to completely eliminate the SGR and only reverse the cuts for a few years at a time. If no changes are made, physicians face a 21 percent cut in Medicare

rates in 2010. The Senate Finance Committee released a paper on Medicare payment reform. It is the first of three papers they will be releasing in May on health reform. In brief, because of the enormous cost to eliminate the SGR ($380 billion), the finance committee’s plan stops the SGR cuts for three years and gives physicians a one percent payment increase in the first two years. Physicians who provide 60 percent of their services in ambulatory settings would receive five percent bonus payments for five years for E & M services for new and established patients. General surgeons practicing in designated rural areas would also receive five percent bonus payments. With Medicare reform discussions in Congress providing the backdrop, CMA’s Board of Trustees adopted new policy dealing with the issue. The new policy is designed to reflect different modes of practice and to ensure that doctors have a choice in determining how and whether they participate in Medicare - and should they do so, receive a fair compensation. CMA will also advocate for physicians to be granted anti-trust relief to collectively negotiate contract terms with the private health plan.

Legislative Update CMA KILLS BILLS TO EXPAND NONPHYSICIANS’ SCOPE OF PRACTICE CMA killed two bills that would have significantly expanded the scope of practice of pharmacists and physical therapists. AB 977 would have allowed pharmacists to independently initiate and provide immunizations to children and adults, and AB 721 would have allowed physical therapists to evaluate and treat patients without a previous diagnosis or referral from a licensed physician.

CMA OPPOSING BILLS THAT ERODE THE BAR ON CORPORATE PRACTICE OF MEDICINE CMA is vigorously opposing multiple legislative efforts (AB 646, AB 648 and SB 726) to erode the ban on the corporate practice of medicine in California by allowing certain hospitals to hire physicians. Under current law, hospitals are barred from hiring physicians as employees, in the effort to prevent corporations or other entities from unduly influencing the professional judgment and practice of medicine by licensed physicians. Complicating CMA’s efforts are the facts that the bills have bipartison authors, and at least one of the bills (AB 646) is backed by the powerful labor union AFSCME.

CMA OFFERS ASSISTANCE WITH SIGNING CONTRACTS Physicians are reminded that before they sign a health plan contract, it is important to know what value that relationship will bring to their practice. Physicians do not have to accept contracts that are not mutually beneficial. To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting tool kit, “Taking Charge: Steps to Contracting.” The tool kit is available free to members at the members only website: member (click on “Reimbursement Advocacy” under “Physician Advocacy” in the main menu. V I TA L S I G N S / J U N E 2 0 0 9

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June 1, 2009, the responsibility for certain charges denied with message code PR-B7 (“this provider was not certified/eligible to be paid for this procedure/service on the date of service”) will change from patient responsibility (PR) to contractual obligation (CO) as specified on Medicare remittance notices. These services will be denied with message code CO170 (“payment is denied when performed/ billed by this type of provider”). You may not bill the patient for services that are denied as contractual obligations. If you believe that the services submitted are within the scope of practice of the billing provider based on Medicare guidelines and applicable state laws, you may file a written request for Redetermination (first level of appeal). • The Redetermination Request must be filed within 120 days of the claim decision (the date on the initial remittance notice). Note: if claims are submitted and denied multiple times, the 120-day timeframe begins with the date of the first claim determination. • Although a specific form is not required, we strongly recommend that you use the Redetermination Form on the Palmetto GBA Web site: • Jurisdiction 1 Redetermination Form: www.PalmettoGBA. com/J1B/forms (PDF, 216 KB) • State the reason you disagree with the initial determination • Attach supporting documentation

MANDATORY CLAIMS SUBMISSION AND ITS ENFORCEMENT The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries, and the requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment. Compliance to mandatory claim filing requirements is monitored by CMS, and violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation, a 10% reduction of a physician’s/supplier’s payment once the physician/supplier is eventually brought back into compliance, and/or Medicare program exclusion. Medicare beneficiaries may not be charged for preparing or filing a Medicare claim. For the official requirements, see the following: • Social Security Act (Section 1848(g)(4)(A); “Physician Submission of Claims”) at ssact/title18/1848.htm on the Internet. • Requirement to file claims – The Medicare Claims Processing Manual, Chapter 1, Section 70.8.8: http://www.cms. on the CMS website.

EXCEPTIONS TO MANDATORY FILING • Physicians and suppliers are not required to file claims on behalf of Medicare beneficiaries for: • Used Durable Medical Equipment (DME) purchased from a private source; • Medicare Secondary Payer (MSP) claims when you do not possess all the information necessary to file a claim; • Foreign claims (except in certain limited situations); • Services furnished by opt out physicians or practitioners (except in emergency or urgent care situations when the opt out physician or practitioner has not previously entered into a private contract with the beneficiary); • Services that are furnished for free; or • Services paid under the indirect payment procedure. For further details, see the Medicare Claims Processing Manual (Chapter 1, Section at http://www.cms.hhs. gov/manuals/downloads/clm104c01.pdf on the CMS website.

E-PRESCRIBING INCENTIVE PROGRAM As of January 1, 2009, eligible professionals can participate in the E-Prescribing Incentive Program by reporting on their adoption and use of an e-prescribing system by submitting information on one e-prescribing measure on their Medicare Part B claims. For the 2009 e-prescribing reporting year, to be a successful e-prescriber and to qualify to receive an incentive payment, an eligible professional must report one e-prescribing measure in at least 50% of the cases in which the measure is reportable by the eligible professional during 2009. There is no sign-up or pre-registration to participate in the E-Prescribing Incentive Program. For more information, visit Incentive/ on the CMS website.

CMS NOTICE OF NEW INTEREST RATE FOR MEDICARE OVERPAYMENTS AND UNDERPAYMENTS Medicare Regulation 42 CFR §405.378 provides for the assessment of interest at the higher of the current value of funds rate (3% for calendar year 2009) or the private consumer rate as fixed by the Department of the Treasury. The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 11%. Medicare contractors implemented an interest rate of 11%, effective April 16, 2009, for Medicare overpayments and underpayments.

PART B MEDICAL RECORDS: SIGNATURE REQUIREMENTS, ACCEPTABLE AND UNACCEPTABLE PRACTICES While CMS guidelines mandate the presence of signatures specifically for all ‘medical review’ purposes, modifiers, etc., records pertaining to any procedures billed to Medicare Part B are potentially subject to review by not only Palmetto GBA, but Please see Medicare Update on page 12 V I TA L S I G N S / J U N E 2 0 0 9

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Excerpts from Medical Society Community News, NORCAL Mutual Insurance Company, Spring 2009 Issue


As a condition of coverage of a medical practice, for over 30 years NORCAL has generally required that all physicians who practice in a formal association be insured by NORCAL. By formal association, NORCAL meant a partnership, corporation or employer-employee relationship. NORCAL originally implemented this “all or none rule” to help protect policyholders from the imputation of liability for acts or omissions of nonNORCAL-covered practitioners through such legal theories as vicarious liability, joint and several liability and ostensible agency. Although these issues remain a serious concern, the practice of medicine has evolved and practice situations have changed tremendously since NORCAL first implemented the rule. Therefore, NORCAL established an inter-departmental team with representatives from Claims, Risk Management, Sales and Underwriting to review the rule. To be more flexible in meeting the needs of customers, NORCAL is modifying the all or none rule. Effective April 1, 2009, the rule was changed as described below. It will now be generally acceptable for NORCAL insureds to employ, be employed by or independently contract with nonNORCAL-insureds. The non-NORCAL entity or employing physician must maintain medical professional liability insurance acceptable to NORCAL. If NORCAL insures the entity, NORCAL will require that more than 50 percent of the entity’s physicians and more than 50 percent of its health care extenders be insured by NORCAL. The non-NORCAL-insured physicians and health care extenders must maintain medical professional liability insurance acceptable to NORCAL. In addition, NORCAL will not apply the rule to physicians who practice in a situation that may create the appearance of an ostensible agency. However, NORCAL generally will continue to apply the all or none rule to physicians who are partners or shareholders, or who otherwise maintain an ownership interest, in a medical practice. Maintaining underwriting integrity To maintain underwriting integrity and protect all NORCAL policyholders, requests for NORCAL to insure some but not all of the physicians in a medical practice will continue to be subject to underwriting review and approval, and NORCAL underwriters will charge additional premium, if necessary, for added exposure. Furthermore, a representative from NORCAL’s Risk Management Department will be involved in evaluating such practices by conducting practice audits for those applying for coverage and risk assessments for existing policyholders. If you have any suggestions regarding other steps that NORCAL can take to enhance its products, without compromising its financial strength, we encourage you to discuss those suggestions with your Underwriter or Jeanne Zosky.


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the enactment of the Medical Injury Compensation J U N E 2 0 0 9 / V I TA L S I G N S

Reform Act (MICRA) in California in 1975, organized attacks on MICRA by the personal injury lawyer lobby have fallen into two general categories: legislation designed to repeal or weaken MICRA and judicial challenges to MICRA. The last personal injury lawyer-sponsored bill was introduced in the 1999-2000 legislative session. AB 250 would have raised and indexed the cap on non-economic damages. The bill never made it out of the Assembly due to concerns raised by moderate Democrats that the proposed legislation would raise a physician’s medical liability costs by an estimated 35-50 percent. Because of California’s budget crisis, NORCAL does not expect the personal injury lawyer lobby to sponsor legislation to repeal or weaken MICRA this year. Instead, the lobby is pursuing judicial challenges to MICRA. Van Buren vs. Evans, MD, is currently pending before the California Court of Appeals. Van Buren is the first significant challenge to the cap on noneconomic damages since the 1980s, when the California Supreme Court considered and rejected several constitutional challenges to MICRA. Plaintiff in Van Buren argues the cap violates the right to jury trial, separation of powers and equal protection. These arguments echo the claims made in previous court challenges. Briefs have been filed by Dr. Evans, Californians Allied for Patient Protection (CAPP), the Civil Justice Association of California (CJAC), and the California Medical Association-California Healthcare Association-California Dental Association (CMACHA-CDA) Amicus Committee, arguing that the reasons for supporting the cap are as strong today as they were in the 1970s. A decision is expected by next summer. Given the tough economic times, any state legislation to increase healthcare costs is likely to run into stiff opposition. NORCAL believes that modification or repeal of MICRA would increase health care costs in California by several billion dollars. At the federal level, a bill sponsored by the personal injury lawyer lobby that would limit the right to arbitration in lieu of court trial has been introduced. The bill will test the new Congress and President Obama’s position on medical liability reform issues. NORCAL’s message to Sacramento remains the same as in the last battle – MICRA is not broken and does not need fixing. – Phil Hinderberger; Jan Keiser



good news for NORCAL policyholders who use a Macintosh computer at home or office. Mac users can access MyCME by adding the Firefox browser to their Macintosh computers Once you have installed Firefox on your Mac, you’re ready to go. Just open Firefox and go to Log on to your MyNORCAL Log-In account to access and enjoy all the convenience of online CME. If you’re a Mac user and don’t yet have a MyNORCAL LogIn account, you must first call NORCAL Policyholders Services at (877) 443-7232. A staff member will create an account for you and give you your username and password. The Please see NORCAL on page 12


What You Don’t Know Can Hurt You Written by AMA Private Sector Advocacy staff

Big news related to physician profiling came out of New York last year, when Attorney General Cuomo announced his landmark settlements with insurers operating in his state. Resulting from these settlements, the insurers are now required to submit the rating criteria they use to place physicians in tiered networks, in which members pay lower co-pays or otherwise receive discounts for seeing favored physicians. In addition, these insurers must abide by a set of standards for their physician profiling programs and hire an independent Ratings Examiner to report to the Attorney General every six months or incur penalties. Shortly after the insurers signed agreements with Mr. Cuomo, members of the Consumer-Purchaser Disclosure Project adopted The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs. Under this voluntary agreement, health insurers will follow a set of standards, hire an independent entity to audit their programs to ensure they use valid measures to rate physicians, and work toward pooling their data. Although neither the New York settlements nor the Patient Charter is a panacea for the problems associated with physician profiling, they represent important steps forward. However, the AMA contends that all physicianprofiling programs must follow standards that require the use of valid methodologies, promote transparency at all levels, and assure accurate results. In order to encourage legislation on physician profiling programs, the AMA developed a model bill, which mandates profiling programs adhere to a set of standards, use valid quality standards, properly adjust for risk, use sufficient sample sizes, and correctly attribute episodes of care. Additionally, insurers must fully disclose the methodology used to profile physicians and disclose the limitations of the methodology, profile physicians at the group level, establish a reconsideration or appeal process, and hire an independent third party to oversee the program. Recently, Colorado Gov. Bill Ritter signed legislation aimed at regulating the physician rating systems used by many of the state’s health insurers. The Colorado law requires health insurers to make their processes for profiling, rating or characterizing physicians more transparent, and ensure greater accuracy in the results. The law also provides for an appeal mechanism so physicians can challenge the validity of their rankings prior to their release or use by health insurers. Regulations like those adopted in New York and now Colorado, and documents such as the Patient Charter are essential to help ensure that the physician performance information that health insurers provide patients is both reliable and meaningful. They establish processes that temper some of the inherent risks that can result from physician profiling. While the AMA neither supports nor opposes physician profiling per se, when it is done, patients and physicians have the right to understand how the profiles are developed as well as an expectation that the results accurately reflect the realities of the physician practice. Some health insurers have unfairly evaluated physicians? individual work. Not only can incorrect and misleading information tarnish a physician’s reputation, it is unfair to patients who may consider it when choosing a physician. Erroneous information can erode patient confidence, trust in physicians, and disrupt patients? longstanding relationships with doctors who know them and have cared for them for years.

In an effort to assist physicians engaged in programs that use physician data, the AMA Private Sector Advocacy (PSA) unit created an entire series of informational pieces designed to help physician practices understand and effectively deal with such programs: • Physician Pay for Performance Initiatives is a white paper detailing all facets of the pay for performance movement. • How physician incentives are used to impact medical practice describes the various incentive models in use and provides examples of these models in practice. • Tiered and narrow physician networks explains how these networks are constructed and gives numerous examples of programs in place. • Pay for performance: A physician’s guide to evaluating incentive plans provides physicians with a roadmap to evaluating pay for performance programs. • Optimizing outcomes and pay for performance: Can patient registries help? describes how patient registries may be used to enhance pay for performance opportunities. • Economic profiling of physicians: What is it? How is it done? What are the issues? is another white paper that explains how cost of care measurement is performed and what its abilities and limitations are in providing accurate results. • How to Challenge Your “Profile” or Placement in a Tiered or Narrow Network is a one-page document that gives physicians a systematic process to follow for challenging their profile ratings. • Physician Profiling: How to prepare your practice provides physician practices with steps to take to be well prepared for profiling programs. • TO OUR PATIENTS is a poster designed for physicians? offices to educate their patients on the problems with physician rating systems. • A Comparison of 4 Physician Profiling Programs is a chart comparing key components of The AMA model bill, the Colorado law, the Patient Charter and Mr. Cuomo’s settlement with CIGNA.

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Medicare Update Continued from page 9 other CMS contractors. Because of this, we are alerting you to the importance of these signature requirements and if changes are needed, we suggest you take immediate action.

SIGNATURE’S PURPOSE Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend you include your applicable credentials, e.g., PA, DO, or MD. The purpose of a rendering/treating/ ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc. is to demonstrate the Part B services have been accurately and fully documented, reviewed and authenticated. Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration. Visit the Palmetto GBA website for more information.

NORCAL Continued from page 10 following day you will be able to log on to your MyNORCAL Log-In account and access MyCME. With MyCME, you can: • Review and download courses, publications and other resources. • Register for and complete a CME course online – and download your Certificate of Completion or transcript without delay! • Submit Evaluation and CME Attestation forms. • Track your CME activities and credits – past and present. For a free download of Firefox, go to and follow the easy instructions.


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“Environmental Sustainability” by Michelle Garcia, Fresno-Madera Medical Society Air Quality Director

More demand for energy, water and materials puts more strain on the state’s infrastructure and land resources, as well as increasing pollution, air emissions and waste. Being environmentally sustainable is being smarter about how to use resources, rather than doing without/ Learn how we can protect human health and environmental well being while at the same time learning how one person’s efforts going “green” can make a difference. Don’t miss this opportunity to learn California’s and Fresno County’s strategies, programs and resources for building a greener state and sustaining the environment. On May 6, 2009 the Society’s General Membership Meeting focused on the very BIG issue of “Environmental Sustainability.” Presenters included Allison Rodriguez who is the co-developer for the Go-Green Policy in Fresno County, Bob Gedert who is a co-chair for the Fresno Green Team for the City of Fresno and Michael DeLollis, M.D., who is the Chair of the Community Health and Relations Committee for the Fresno-Madera Medical Society.

• Water resources are limited • Necessity • State and Federal grants require “Green” policies • Our residents are asking us to be “Green” • Green Policies tied to Implementation of City’s 2025 General Plan For more information on this program contact Robert Gedert at 593-5298 or

WHAT IS GO GREEN FRESNO COUNTY? Go Green Fresno County is an environmental policy package that encourages superior environmental stewardship for Fresno County and its operations. Go Green Fresno County Components: Energy efficiency, Exceed State building code energy standards, Attain Leadership in Energy & Environmental Design Certification for all new County facilities, Require the use of energy-conserving landscaping on County-owned properties. Why Go Green Fresno County? • Cannot ignore poor air quality. • The world has a fixed amount of natural resources. • Create a new mindset among employees and residents alike. AB 32 requires the State’s global warming emissions be reduced to 1990 levels by 2020. For more information about this program contact Allison Rodriguez at 488-3663 or

WHAT IS FRESNO GREEN? Fresno Green’s mission is to be nationally recognized for the innovative integration of buildings within their neighborhood context, good urban design, and for giving priority to public health, open spaces, public art, historic preservation, urban forests and the protection of natural habitats. Why Fresno Green? • Economics • Cost of energy and fuel is on a steady incline • Environmental • Climate change from greenhouse gases is impacting our state • Poor air quality caused by criteria pollutants continues as a major problem in our region

Michael DeLollis, MD, shows at FMMS’ May General Membership meeting the solar panels he used on his house.

WHAT IS SOLAR POWER? Solar power is by far the Earth’s most available energy source, easily capable of providing many times the total current energy demand. Sunlight can be converted into electricity using photovoltaic’s (PV), concentrating solar power (CSP), and various experimental technologies. PV has mainly been used to power small and medium-sized applications, from the calculator powered by a single solar cell to off-grid homes powered by a photovoltaic array. Why go Solar? Solar power is not only the cleanest form of energy available to us, but it is also a renewable energy source. Solar energy is abundant unlike other sources. The use of solar power emits no pollution and uses a renewable resource. If we substitute fossil fuel burning with solar power, we could reduce the amount of CO2 in our atmosphere which would help clean up our air. CO2 is known as the main contributor to global warming. For more information about the benefits of going solar contact Michael DeLollis, MD at 559-224-4224 ext. 119 or

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Post Office Box 28337 Fresno, CA 93729-8337 559-224-4224 Fax 559-224-0276 website:

FMMS Officers Cynthia Bergmann, MD President Harcharn Chann, MD President-elect Krista Kaups, MD Vice President Oscar Sablan, MD Secretary/Treasurer David Slater, MD Past President Board of Governors Sergio Ilic, MD Margaret Hadcock, MD David Hadden, MD Linda Hertzberg, MD Soo Y. Kim, MD Abbas Mehdi, MD Ranjit Rajpal, MD Krishnakumar Rajani, MD Daniel Stobbe, MD Philip Tran, MD Tanya Warwick, MD Paul Yun, MD

President’s Message In every established organization there comes a time when a routine becomes established. Everyone knows their position within the organization. Everyone knows exactly how things are done, how meetings will run and what the outcomes will be. The organization seems to conduct itself in what appears to the onlooker to be an effortless manner. How easy it is to be a member of an organization like that – one that is in perfect stasis. However, static organisms have a tendency to become extinct when the world around them changes. Being an endangered species is not a healthy position for either organisms or organizations. The ability to adapt to a changing environment helps both survive and thrive into the future. The FMMS Board is currently undergoing goal setting to help assure our relevance and viability now and on into the future. We are facing budget shortages on both the state and federal levels. Our president has vowed to have health insurance coverage for all while setting no restrictions on health insurance profits. The same health insurance companies are vowing to trim over a trillion dollars ($1,000,000,000,000) from health care costs. The same president has vowed to have health care cost less for the patients and their families. It should come as no surprise that the dollars are expected to come from those who provide the services and products that keep America healthy. In spite of these serious issues over 80% of CMA members never even open the emailed CMA Alerts to find out what is being done to physicians and what the CMA is doing to protect our ability to practice medicine. If you have never been actively involved before, now is the time to start. Contact us about our “Adopt a Legislator” program where we make direct contacts with our legislators on an on-going basis. Tell us your goals for the FMMS. Join a committee, attend a meeting, donate to the Foundations, write an article. Help us adapt to the swiftly evolving environment we now face. If we are not active participants, we will surely have the future done to us, not created by us.

CMA Delegates: FMMS President John Bonner, MD Denise Greene, MD Clarke Harding, MD Kevin Luu, MD Abbas Mehdi, MD Salma Simjee, MD Robb Smith, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates: FMMS President-elect Adam Brant, MD Pervaiz Chaudhry, MD Shahla Durrani, MD Glenn Hananouchi, MD Sergio Ilic, MD Peter T. Nassar, MD Kanwal Jeet Singh, MD Rajiv Verma, MD


Doug Larsen, Esq. Fishman, Larsen, Goldring & Zeitler

WEDNESDAY, JUNE 10, 2009 • 12:00-2:00 p.m. LUNCH $15/person prepaid by credit, check or cash with reservation Limited to 50 people – 2 per FMMS doctor’s office RESERVATIONS must be made by June 5, 2009 Sheryl Tatarian • • 224-4224x112

CMA YPS Delegate: Kevin Luu, MD CMA Trustee District VI: Virgil Airola, MD Staff: Sandi Palumbo Executive Director


The Medical Manager's Forum meets monthly in the board room of the Fresno-Madera Medical Society. The purpose of this forum is to provide a platform for medical managers and medical office staff to share specific needs their office experiences as well as providing solution resources through seminars, workshops, training, special speakers, open discussions and more. Membership is open to staff members of FMMS-member doctor's offices and facilities. For more information,contact Sheryl Tatarian at the FMMS office via email at or 559/224-4224x112.

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Medical Clinic in Afghanistan by Mohammad Arain, MD


the war in Afghanistan continues, the sufferings of the people increase. The country, which was already devastated with decades of war, has lost its infrastructure. People are dying due to lack of basic medical needs. Due to the law and order situation, international communities have failed to implement any effective health care system. Mohammad The average life expectancy of an Afghan is Arain, MD under 50 years (lowest in world). Mothers and children suffer the largest casualties – 33% of mothers die during pregnancy, and less than 50% of the children live beyond age five. FMMS member Dr. Sohaila Mojadaddi and her husband, with the help of many local friends, started a NGO “Help the needy.” Dr. Mojadaddi has been singlehandedly providing medical aid to the suffering people. In August 2008, Dr. Mojadaddi decided to open a clinic near Kabul, Afghanistan. At the fundraiser our own President of FMMS Dr. Bergmann and Dr. Noel were the largest donors. The land for the building has been purchased. A clinic building in Shakardara (about 25 miles from Kabul), has been leased, and two doctors with needed staff are being recruited. Total estimated daily expense will be $481, which will provide health needs for over 30,000 people. If we can have sponsors for just one day a year we can have this clinic running without any difficulty. Anyone who wants to volunteer their time will be provided with needed assistance and a place to stay in

Afghanistan. Below is the list of needed supplies. For donations you may contact Dr. Mojadaddi, 559-661-1100; fax: 559-6611107; Tax ID: 30-0069054; or the supplies may be delivered to her office at 550 E. Almond Avenue, Suite B, Madera CA 93637.


4 2

3 2 1 4 10 1 1 1 1 2 2 4 1

Wall-mounted blood pressure monitor Portable blood pressure monitor (one child size; one adult size) Ear thermometor Nebulizer PFT Mayo Sstands Basins Pulse oximeter Utility cord Crash cart Defribrilator Wheelchair (one regular; one large) Transport gerny Examining table (adult sizes) Pediatric examining table

1 1 4 2 1 2 3 1 2 100 20

100 • • • •

Microscope Centrifuge Doctor’s stool Procedure light Obstetric ultra sound Scale (one pediatric; one adult) Computer X-Ray unit Opthalmoscope/ Otoscope Otoscope spatula each (large, medium, small) Stainless steel vaginal speculums Linen patient gowns Staff uniforms Disposable surgical cap Surgical instruments Medical supplies

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Fresno-Madera Alliance News by Sharon De St. Jeor, FMMS Alliance President “T he Fresno-Madera Medical Association Alliance is an organization of physician families, dedicated to the health and well-being of our community through education, health programs, and legislative advocacy.” It is with this mission statement in mind that the alliance strives to make a positive health difference in the lives of others. This year, our project: (Before) Stroke Happens… FMMSA HAS A Every Minutes Counts: Stroke WEBSITE – VISIT Awareness Bookmark came IT! about after reading in Vital 1. The latest FMMSA Signs the shocking fact that events “Stroke kills twice as many 2. Continuing informawomen as breast cancer”. We tion on current proinvited the local neurologist jects who wrote the article to attend 3. And – coming soon: our September 2009 general A page for local nonmeeting. We learned the profit organization symptoms to recognize when Send in information someone is experiencing a regarding projects you’d stroke, the importance of like to promote. We’re calling 911 and getting to a also reviewing possihospital within three hours. It bilities for a BLOG. was interesting to learn that the Fresno area has a large Hispanic population, as well as many African-Americans, and these groups are especially vulnerable to having a stroke because of their tendency toward obesity and high blood pressure. Our members asked: “What can we do to help spread the word?” From this group, a committee was formed consisting of Marian, Chair, Jan Goza, Patty Witmer, Cindy Terrell, Beverly Achki, Barbara Barman, Brenda Joseph, Sharon De St. Jeor. It was determined that designing and distributing bookmarks printed with the necessary Stroke information would be the most effective way to reach the largest amount of people. Our plan is to put the bookmarks in clinics, doctors’ offices, hospitals, libraries, pharmacies, health fairs, etc. Our goal is to distribute


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this valuable information in Fresno and Madera counties, including the outlying areas. We have printed a total of 20,000 bookmarks, 10,000 in each English and Spanish. The FMMSA Stroke committee began distributing the “Stroke Happens” bookmark in May, “National Stroke Awareness Month.” Anyone wishing to have these bookmarks available in their offices, clinics, etc., please contact the FMMS office at 559224-4224 to schedule your bookmark pickup. We give special thanks to the CMA Alliance Foundation for their grant, and to the Community Regional Medical Center (CRMC) for funding the Spanish version of the bookmark. It has been a honor to serve as FMMS Alliance president during the 2008-2009 term. The alliance will continue to participate in our ongoing favorite projects. They include the ‘Susan G. Komen Race for the cancer cure’ in October at Fresno State University, Fresno; giving gifts to the children at Craycroft Youth Center, during the holidays, and participating at the Girl Scout World Thinking Day by distributing AMAA health booklets. I have seen the benefits of what our Alliance offers to our community and my hope that both the Alliance and the Fresno Madera Medical Society continues to be leaders in promoting health care and legislative action within our community.

Fresno-Madera MEMBERSHIP NEWS New Members The following physicians are applicants for membership in the Fresno-Madera Medical Society. The Medical Society welcomes your comments, pro or con, if you have knowledge of these physicians.

Uzair Chaudhary, MD IM *HEM *ON 445 S. Cedar Fresno 93702 AGA Khan Med Col ’92 Loren Alving, MD *N 445 S. Cedar Fresno, 93702 UC San Diego ’88


Visit FMMS’ New Website FMMS’s new website is up and running. Thanks to a grant awarded by the Hewlett Foundation, FMMS was able to hire a website designer to design a site that improves communications with its members and the public with timely news alerts and response mechanisms. This new site will also have members’-only items, such as practice management materials, members’ calendar of events and meetings and FMMS reports. Calling for all FMMS members’ E-mails The members’-only sites can only be accessed with a password and email address. To begin the process, a temporary password will be e-mailed to each member. Members will then have the capability to determine their own permanent password. Please send your email address to FMMS at or at

Committee Meetings

Membership Recap

All meetings are held at the FMMS offices unless otherwise noted.

APRIL 2009

JUNE 2 4 9 10 15 16

Well Being...............................6 pm Finance .............................12:30 pm Membership.............................6 pm CME .................................12:30 pm Medical Managers .................12 pm Board of Governors .................6 pm MRAC.....................................6 pm

Active ..................................................703 Leave of Absence.....................................1 Retired..................................................200 Residents ..............................................218 TOTAL ...........................................1,122 Applicants................................................2


Hoffman, MD, a retired cardiac surgeon, passed away on April 19, 2009 at the age of 88. Dr. Hoffman was born in Idaho in 1920. After completing his Bachelor of Arts degree from Fresno State College in 1942, he received his medical degree from George Washington Univ. Medical School in 1946 and completed his internship at the Fresno County Hospital. Dr. Hoffman served in the U.S. Navy for 3 three years, then returned to the Fresno County Hospital for his general surgery residency. After additional training in cardiac surgery at USC, he entered private practice in Fresno and subsequently started the cardiac surgery programs at Valley Children’s Hospital and St. Agnes Medical Center. He retired in 1987, but continued as an surgical assistant in Fresno and San Francisco until 2000. Dr. Hoffman is survived by his wife, Dr. Catherine Hoffman, five children and five grandchildren.

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Kern Sweet News for Medicare Recipients and Their Providers submitted by Portia S. Choi, MD, Director, Kern County Health Department 2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website:

KCMS Officers Bradford A. Anderson, MD President Mark L. Nystrom, MD President-elect Portia S. Choi, MD Secretary Ronald L. Morton, MD Treasurer John L. Digges, MD Immediate Past President Board of Directors Joel Cohen, MD Larry Cosner, MD Noel Del Mundo, MD Mathilda Klupsteen, MD Hemmal Kothary, MD Calvin Kubo, MD Peter McCauley, MD Anil Mehta, MD Philipp Melendez, MD Tonny Tanus, MD

Diabetes statistics are staggering. 1-in-4 seniors has diabetes. Their grandchildren have a 1-in-3 risk of diabetes in their lifetimes; risk is 1-in-2 for families of color. What can the profession do with these sad numbers? It takes time during office visits to work with patients with diabetes. Is there help? Yes, Medicare Part B covers visits with the registered dietitian (RD) for 3 (*) hours the first referral year; two hours each calendar year thereafter. Medical Nutrition Therapy (MNT) is the individualized nutritional assessment, development of treatment plan the person WILL really EAT, eating out, and follow-up to adjust meal plans to meet AACE and ADA goals. Diabetes Self-Management Training (DSMT) is also covered. This Head-to-Toe training includes glucose monitoring, ketone testing, glucagon, how medications work including injectables, devices, sick day management, high and low blood glucose, foot/skin care, vacationing, dental hygiene and coping skills. The first year includes 10 hours; subsequent years – two hours. (*after deductible, copays). Programs are held in group unless justification is documented. Each year write two prescriptions – one for MNT; another for DSMT. Medicare requires a signed referral to the RD and diabetes education programs. Referrals must include 5-digit ICD-9 code, signature of the treating MD/DO, and lab work. (CMP, urine microalbumin to creatinine, Lipids, EGFR, CBC). State law requires most insurers to cover diabetes supplies, education and nutrition therapy, however, how these services are covered varies among health plans. To locate Registered Dietitians (RDs) who accept Medicare Part B: 1-800-877-1600 or or 1-800-Medicare. Accredited Diabetes Education Programs 1-800-Medicare or 1-800-Diabetes or American Association of Diabetes Educators 1-800-TeamUp4. Kern County Association of Diabetes Educators assists with names of local RDs, Certified Diabetes Educators and education programs. Email

CMA Delegates: Jennifer Abraham, MD Lawrence Cosner, Jr., MD John Digges, MD Ronald L. Morton, MD CMA Alternate Delegates: Deepak Arora, MD Philipp Melendez, MD Patrick Leung, MD Staff: Sandi Palumbo, Executive Director Mary Dee Cruse Adminstrative Assistant Kathy L. Hughes Membership Secretary


Employment Practices Lawsuits: Are You at Risk? submitted by MARSH

Open any newspaper or look on any news Web site and you’re bound to notice an article about another business being sued by an employee or former employee alleging discrimination or wrongful termination. These stories always make headlines. But are businesses truly being sued more often? Is your practice at risk? If it is, how much could you be forced to pay in such a situation? When an employee brings a complaint against a business, or a suit involves misadventure by a key employee, the trend is unmistakable: the businesses pays more. The number of resolved lawsuits alleging breach of the Fair Labor Standards Act more than doubled in 2005 (the last year that statistics are available) to almost 3,600 compared with the 1,596 cases in 2000.1 A survey found that complaints from disgruntled employees in 2007 cost businesses an average $63,114, including judgments, settlements, fines and legal fees.2 The survey also reported that two out of three U.S. private companies experienced some type of event related to management liability within the past five years, costing an average $393,017. The number of incidents ballooned more than 25 percent from 2005.3 The survey results mirrored government statistics. The total number of charges filed with the U.S Equal Employment Opportunities Commission (EEOC) rose 26 percent from fiscal years 2006–2008.4 And the total amount of money awarded in those complaints during that span nearly tripled, from $44.3 million to $102.2 million.5 Even if a case goes to EEOC mediation, the average period it takes for it to be settled is 84 days – almost four business months.6 The question a responsible business owner should ask is: Am I covered for this increasing eventuality? Workers’ compensation, general and professional liability insurance policies generally do not cover Please see EPLI on page 22

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MEMBERSHIP NEWS KCMS Member Recognition KCMS is pleased to announce a new addition to our website – – “Recognizing Our Members.” In this section, we will pay tribute to KCMS Member Physicians by recognizing their contributions to the community, to their patients, etc., the day-to-day activities that some of us take for granite. But, we need your help. Attention All Office Managers, Staff, etc. – if your Doctor has done something you think deserves recognition and/or if your Doctor is reluctant to be noticed for a “Good Deed” or he/she just feels as if the things they do are “no big deal – just part of their daily routine” – we want to hear about it. Contact the Society office via Fax 661-328-9372, or Email We value your input!

PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581 KCMS Officers John E. Weisenberger, MD President Jeffrey W. Csiszar, MD President elect Theresa P. Poindexter, MD Secretary Treasurer Sheldon R. Minkin, DO Past President

New Members The following physicians’ names, etc. are being published in compliance with the KCMS Constitution & Bylaws. Board Certification will be listed only if the physician has been certified by a Specialty Board recognized by the American Board of Medical Specialists, as approved by the American Medical Association.

Melissa E. Larsen, MD (Obstetrics/Gynecology) Kern Medical Center 1700 Mt. Vernon, Ave., 93306-4018 661-326-2236 / FAX: 326-2235 Email: Medical Degree: Cornell Med. Clg., NY 1981 Internship: Medical U, S. Carolina 1981-1984 Residency: G. Washington U, DC 1984-1988 Board Certified OBG 1990 Farhan A. Shah, MD (Internal Medicine) San Joaquin Valley Pulmonary Medical Group 3551 Q St. #100, 93301-1658 661-327-3747 / FAX: 327-2725 Email: Medical Degree: Khyber Med. Clg., Pakistan 2001 Internship/Residency: SUNY Upstate Medical U, NY 2004-2007 Board Certified Internal Medicine 2007

Mallik Rao Thatipelli, MD (CardioVascular Disease) Central Cardiology Medical Group 2901 Sillect Ave. #100, 93308-6372 661-323-8384 / FAX: 323-9326 Email: Medical Degree: Kakatiya Med. Clg., India 1988 Internship: Bronx Lebanon Hospital Center, NY 1993-1994 Residency: Howard University Hospital, DC 1994-1996 Riverside Methodist Hospital, OH 2001-2004. Fellowship: Mayo Clinic, MN 2004-2007. Board Certified Internal Medicine 2004; Vascular Medicine 2005 and Endovascular Medicine 2008 Hobbies: Travel, World History movies and golf

Board of Directors F.T. Buchanan, MD James E. Dean, MD Ying-Chien Lee, MD Uriel Limjoco, MD Daniel Urrutia, MD CMA Delegates: James E. Dean, MD Uriel Romel Limjoco, MD CMA Alternate Delegates: Mario Deguchi, MD Sheldon R. Minkin, DO Staff: Marilyn Rush Executive Secretary

Membership Recap APRIL 2009 Active ...........................................................286 Resident Active Members................................0 Active/65+/1-20hr ...........................................6 Active/Hship/1/2 Hship ...................................1 Government Employed ..................................11 Multiple memberships......................................2

Retired ............................................................62 Total .............................................................368 New members, pending dues............................2 New members, pending application ................2 Total Members.............................................372

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3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website:

TCMS Officers Mark Tetz, MD President Ralph Kingsford, MD President-Elect Steve Carstens, DO Secretary/Treasurer Timothy Spade, MD Immediate Past President Board of Directors Thomas Daglish, MD Karen Haught, MD Mark Reader, DO Ahmad Shahroz, MD Gaurang Pandya, MD CMA Delegates: Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates: Amber Chatwin, MD Ralph Kingsford, MD Mark Tetz, MD Sixth District CMA Trustee James Foxe, MD Staff: Steve M. Beargeon, Executive Director Francine Hipskind Provider Relations Gail Locke Physician Advocate Maui Thatcher Executive Assistant


President’s Message Ahh, spring time at Disneyland. The crowds, the families, the youth groups, the school groups, well, you get the idea. Although we didn’t get the treat of waiting 90 minutes for just one ride, we were lucky enough to be at the Disneyland Hotel for the 12th Annual California Healthcare Leadership Academy. This year’s academy featured many well-known speakers and discussed compelling topics on the politics of medicine. The most interesting topic was the subsidies for medical records. A High Tech Stimulus Plan is currently being finalized within the Obama Administration. Under this plan, doctors would receive substantial money for adopting Electronic Medical Record Systems. The target payment time would be 2011 and run until 2015. The requirements to receive the federal subsidies for Electronic Medical Records are currently unknown, but TCMS will keep you updated. CMA has a tool to help decide which EMR system would be best for your practice. They have set up a website that looks at each of the systems. Please visit Be sure to decide though, by 2015, as this is the year that penalties for NOT using EMR would begin. Conversely, Medicare will be paying bonuses for e-prescribing and will also continue to pay out bonuses for the PQRI program. There’s also discussion regarding the “Medical Home” model which the federal government is trying to promote as a way of reducing medical expenditures by improving continuity of care. There is talk of providing bonuses to participating Primary Care practices. These practices would be in a better position to get paid out with an EMR system in place. Howard Dean, former Governor of Vermont and Immediate Past Chair of the Democratic National Committee, made a keynote speech regarding current government policies and talked specifically about Obama’s plan to offer alternative health insurance that would be federally funded and be available to people who cannot obtain health insurance or are unhappy with their current coverage. We will update you as details become available. SGR, the flawed Medicare payment system, is still under debate within the Congress. The House and the Senate cannot agree to terms that would effectively fix the SGR formula used to determine physician payments. Senate leaders have taken the position that they cannot come up with enough funding – $285 billion – to eliminate the SGR but House leader and the CMA are dedicated to eliminating it. The CMA is also urging a 10% increase in payments to physicians. There has been a lot of buzz about reforming health care in the state of California over the last two years. This has now ground to a halt due to the overwhelming state budget deficits. However, CMA continues to sponsor legislation and lobby politicians in Sacramento to promote physicianfriendly legislation and action. Unfortunately, the Medical Board of California ceased to provide its Diversion Program last year. This program allowed physicians to seek help and/or rehab without fear of losing their license. As a result, there is now a void in physician mental-health assistance; no network or avenue of help they can turn to. The Foundation for Medical Care and the Tulare County Medical Society are working to provide a confidential, complimentary and non-retaliatory physician access program for mental health counseling and/or rehab. Among the issues that can be helped are depression, marital strife, and substance abuse. There is currently a wellness community working out the details and contracts. TCMS will continue to provide updates on these programs as information becomes available. Have a great spring and summer. TCMS is always there to answer your questions and help out. Please be sure to come enjoy our events. I look forward to seeing you and providing an update in the fall. Be Well.

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Tulare Medicare Recovery Audit Contractors (RAC ) – Here to Stay by Judy Cotta, Compliance and Privacy Officer Kaweah Delta Health Care District


2005, the Centers for Medicare and Medicaid Services (“CMS”) established a three year demonstration program used to identify and recapture Medicare underpayments and overpayments. RACs were paid on a contingency fee basis, receiving a percentage of the improper overpayments they collected from providers. The RAC demonstration covered all providers in Florida, California and New York. RACs reviewed four years of provider claims for hospital inpatient and outpatient, skilled nursing facility, physician, ambulance and laboratory services. The only claims that were excluded were those services billed with Evaluation and Management level CPT codes. Software programs were used to identify potential payment errors in such areas that include duplicate payments, fiscal intermediary mistakes, coding and medical necessity. RACs also conducted medical record reviews. In July 2008, CMS reported that the RACs had succeeded in correcting more than $1.03 billion in improper payments. Approximately 96% were overpayments while the remaining four percent were underpayments to providers. In October 2008, the federal government made the program permanent and has expanded the program to include all fifty (50) states. Nationwide rollout of the program is underway with all states scheduled to be on board by January 2010. CMS has awarded contracts to four RACs. With the permanent program, RAC’s will be reviewing claims from October 1, 2007 forward. Those states that are part of the first phase (including California) may begin to receive requests soon. Initially the RACs focused their review on acute care hospitals. However, it is important to note that along with hospitals the permanent program will focus on physician practices, nursing homes, home health agencies and other providers that bill Medicare. To prepare for the start of the permanent program, CMS recommends that providers take the following steps: • Implementing procedures to promptly respond to RAC requests for medical records • Develop a tracking mechanism of records requests • Review each record requested • If you disagree with a RAC determination, you should file an appeal before the 120-day deadline following the normal Medicare denial process • Keep track of denied claims and identify any patterns to avoid a repeat issue If you have any further questions regarding the Medicare RAC program, please contact Judy Cotta, District Compliance and Privacy Officer at 559-624-2154.

MEMBERSHIP NEWS New Members The following physicians are applicants for membership in the Tulare County Medical Society. The Medical Society welcomes your comments, pro or con, if you have knowledge of these physicians.

Meda Billys, MD Dermatology Duke Univ School of Med ’82 5530 Avenida de los Robles Visalia 93291

Ernesto Jimenez, MD Anesthesiology Univ of Santo Tomas ’66 869 Cherry St. Tulare 93274

Bankim Dalal, MD Gastroenterology GOA Med College ’75 1827 S. Court St., Ste. B Visalia 93277

Owen Kim, MD Radiation Oncology UCLA ’81 465 W. Putnam Ave. Porterville 93257

Antonio Durazo, MD Family Practice Univ of CA San Francisco ’81 841 W. Morton Ave. Porterville 93257

Parmod Kumar, MD Gastroenterolgy Government Medical College, Petiala ’78 858 N. Cherry St., Ste. B Tulare 93274

Parul Gupta, MD OB/GYN Indira Gandhi Medical College ’98 591 E. Merritt Ave. Tulare 93274

Cristina Valero, MD Internal Medicine Univ of Southern CA School of Med ’04 12586 Avenue 408 Orosi 93647

E-Prescribing On March 26, over 100 physicians, nurses, staff and pharmacists met at the Visalia Convention Center to discuss electronic prescribing – a topic of great interest with the recent announcement of the federal stimulus package. The Tulare County Medical Society hosted lunch and dinner meetings for its members and those of the Foundation for Medical Care of Tulare and Kings counties. Consultants to the California HealthCare Foundation led discussion of e-prescribing basics, physician incentive opportunities, the importance of community-wide involvement, and resources available for stakeholders including providers, pharmacies and health plans. In addition, specific questions arose around vendor e-prescribing offerings and functionality which may be addressed at Visit the TCMS web site,, to hear a recording of the presentation or to download meeting resources. For more information, contact Gail Locke at

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CLASSIFIEDS MEMBERS: 3 months/3 lines* free; thereafter $20 for 30 words. NON-MEMBERS: First month/3 lines* $50; Second month/3 lines* $40; Third month/3 lines* $30. *Three lines are approximately 40 to 45 characters per line. Additional words are $1 per word. Please contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.





Exceptional opportunity for qualified FP or ER dept. services. Stable group with excellent reputation seeks Board Certified or Eligible provider for FT position. Previous ER experience or training helpful but not required. Physicians are independent contractors with excellent compensation. Contact Terry Hilliand, 661-323-5918 or fax CV to Emergency Medical Services Group at 661323-4703 email:

Drs. Naeem M Akhtar and Shahla Durrani and Mikhail Alper, PA-C are pleased to announce the association of Dr. Ambreen Khurshid to the practice of gastroenterology at California Gastroenterology Associates at 1382 E. Herndon #104, Fresno. Dr. Khurshid is Board Certified and is accepting new patients. Call 559-4380017. Fresno Women’s Medical Group announces the opening of its Downtown Fresno’s office in a beautiful historic Victorian at 1125 “T” St. Accepting new OB-GYN patients. 559-322-2900. Fresno Women’s Medical Group welcomes Dr. Sharon Kopacz back home to Fresno. Now accepting patients. 559-322-2900. University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am - 5 pm. Call 559320-0580. Fresno City College’s library is in need of medical journals: Journal of the AMA, New England Journal of Medicine, Consult, American Family Physician, The Cleveland Journal, The Mayo Clinic Journal, The Cortlundt Forum, Women’s Primary Health, Emergency Medicine, American Journal of Orthopedics, Nurse Weekly. For pick up, call Carolyn at 559-439-7123.

FOR RENT / LEASE Madera office space; 1,650 sf on West Yosemite Ave. Call Dr. Nassar at 674-0917. 1,550 sf office space at 7565 N. Cedar. For more information, call 559-473-6789. Office space for sale or lease at Cedar & Alluvial, 2,280-4,506 sf. 6 parking spaces per 1,000/sf. Ample allowances. Call 559-259-3077 or 559355-8416. Premium medical office, 5,500 sf shell at Maple/Herndon, easy access to Herndon/Hwys 41 & 168, next to MRI specialists & St. Agnes. Build to suit. TI’s $35-$45 sf, $1.60 sf. Fax 559433-9496 or call 559-681-6390.

FOR SALE Office space (shell) for sale or lease at Cedar & Alluvial, 2,280-4,506 sf. 6 parking spaces per 1,000 sf. Ample allowances. Call 559-259-3077 or 559-355-8416.

PHYSICIAN AVAILABLE Available at this time for a locum tenens position in Fresno. Family medicine and general medicine specialty. Call 559-999-7678.

STAFF WANTED Multi-Specialty Group seeks office manager with 3+yrs exp in a physician office or similar healthcare setting. Email or fax: 559-453-5233.


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EPLI Continued from page 18 the vast majority of complaints filed against employers. For this reason, Employment Practices Liability insurance (EPLI) has grown in popularity. “Generally, purchasing EPLI insurance is a wise investment,” write lawyers Robert Hoffer and Kelly Schoening in the Business Courier of Cincinnati, “but not all plans are created equal.” When considering EPLI insurance, they recommend asking the same questions as you would about any insurance: • what is covered; • what is the deductible; • which attorneys can you engage; and • how are claims settled. The Fresno-Madera, Kern and Tulare County medical societies offers its members EPLI insurance. This coverage also includes riskmanagement tools that can lower your risk, as well as access to a legal information hotline staffed by employment practices attorneys. And if you never had coverage before, ask about the simplified First Time Buyers program. You can contact a Marsh client service representative toll-free at 800-842-3761 today for more details and a no obligation premium indication. Kris Maher, “Workers Are Filing More Lawsuits Against Employers Over Wages,” The Wall Street Journal, Monday June 5th, 2006. page A2. 2 Chubb Private Company Risk Survey, 3 Chubb Private Company Risk Survey, 4 5 6 1

CA License #SL0633005 d/b/a in CA Seabury & Smith Insurance Program Management 42534 (5/09) ©Seabury & Smith Insurance Program Management 2009

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We go way beyond dividends. We reward years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company. You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our medical professional liability program, including the Tribute Plan, call (800) 352-0320 or visit us at

V I TA L S I G N S / J U N E 2 0 0 9

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VITAL SIGNS Post Office Box 28337 Fresno, California 93729-8337 HAVE YOU MOVED? Please notify your medical society of your new address and phone number.

PRSRT STD U.S. Postage PAID Fresno, CA Permit No. 30

2009 June  
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