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Vol. 6 No. 5

South o Dakota gets a

Physical Then & Now

Father/Son Plastic Surgeons

Stay out of Trouble Your Guide to the 60-Day Rule





Contents VOLUME 6, NO. 5 ■ J U LY / AUGUS T 2015


South Dakota Gets A Physical By Peter Carrels

4 | From Us to You A groundbreaking new public health report provides a comprehensive look at the state of healthcare in South Dakota. In this month’s cover story, we summarize the major findings and what they could mean for the future of medicine in the region.

5 |  MED on the Web Articles and Information available exclusively on the MED Website

10 | News & Notes New doctors & facilities, awards, renovations, and other news from around the region

35 |  Learning Opportunities Conferences, Events, and CME Courses

IN THIS ISSUE 6 |  Healthcare Hurdles

■ By Patrice Hirning, MD Improving care by overcoming the barriers between doctors and patients.

21 |  Sanford Launches Pharmacogenetics Service Technology integrates pharmacogenetic testing, clinical decision support

23 |  Children’s Expands Anesthesiology Services

to Improve Outcomes Children’s Hospital & Medical Center has expanded its pediatric anesthesiology team to meet growing demand.

24 |  AveraNow: Healthcare in the palm of your hand 25 |  UnityPoint Clinic Now Offering Virtual Care 26 |  Great Western Bank’s Healthcare Receivables Management Product HRM increases administration efficiency by minimizing paper claim handling.

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30 |  Heart Disease Still a Top Threat

■ Kelly Steffen, DO An up-to-date look at the American Heart Association’s (AHA) “Life’s Simple 7” steps to controlling heart disease risk.

31 |  Preserving Your Fine Jewelry: Seven Actions to Avoid

■ By Riddle’s Jewelry

32 |  Hospice ‘A Godsend’ for Siouxland Family 34 |  New Grad Says MBA Allowed Her to ‘Grow with the Company’



9 | Then and Now Father and son join professional forces in Sioux Falls plastic surgery practice

18 |  Medicare/Medicaid Overpayments —Return to Sender

■ By Scott Leuning What is 60 days in length, not yet fully defined, and could result in criminal prosecution? Understanding the “60-Day Rule”

20 | Addressing Hospital Workplace Violence

■ By Jill Heyden Violence in healthcare settings is very real, and hospitals are especially vulnerable.

On the


From Us to You Staying in Touch with MED


ELCOME TO THE SUMMER ISSUE of MED Magazine, the premier business publication for healthcare professionals across the upper Midwest. We are excited to bring you a full lineup of timely local news and advice from area experts. In this issue, you’ll find tips for overcoming barriers between patients and providers, an explanation of the “60-Day Rule” from the legal experts at Goosmann Law, and some disturbing facts about violence in hospitals. On the business side, Great Western Bank brings you a sponsored feature that could transform how you handle your receivables. As always, MED also brings you all of the very latest regional healthcare community news and a roster of upcoming events and CME opportunities inside our back cover. It is always free to submit your own news and events, both in print and online, so take advantage of MED’s wide reach to spread your message. If you’re a part of the South Dakota regional medical community, we’re committed to being your go-to communication resource. Visit us at www. to sign up for advance notice of the digital edition and previews of upcoming articles. Best wishes for a fun-filled and productive summer! —Steff and Alex

PUBLISHER MED Magazine, LLC Sioux Falls, South Dakota Steffanie Liston-Holtrop






PHOTOGRAPHER studiofotografie


DIRECTOR Jillian Lemons CONTRIBUTING Alex Strauss

MED was proud to once again sponsor the annual South Dakota Lions Eye and Tissue Bank “Gifts of Sight & Health Golf Tournament”, now in its 17th year. Our own Steffanie Liston-Holtrop braved the elements on a chilly day along with 71 other golfers to raise more than $25,000 for public education and outreach.

WRITERS Lizabeth Brott

Peter Carrels Patrice Hirning Scott Leuning Kelly Steffen Vince Weber

STAFF WRITERS Liz Boyd Caroline Chenault John Knies

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©2011 Midwest Medical Edition, LLC Midwest Medical Edition (MED Magazine) is committed to bringing our readership of 5000 South Dakota area physicians and healthcare professionals the very latest in regional medical news and information to enhance their lives and practices. MED is published 8 times a year by MED Magazine, LLC and strives to publish only accurate information, however Midwest Medical Edition, LLC cannot be held responsible for consequences resulting from errors or omissions. All material in this magazine is the property of MED Magazine, LLC and cannot be reproduced without permission of the publisher. We welcome article proposals, story suggestions and unsolicited articles and will consider all submissions for publication. Please send your thoughts, ideas and submissions to alex@midwestmedicaledition. com. Magazine feedback and advertising and marketing inquiries, subscription requests and address changes can be sent to MED is produced eight times a year by MED Magazine, LLC which owns the rights to all content.


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Healthcare Hurdles Improving care by overcoming the barriers between doctors and patients By Patrice F. Hirning, MD


ROVIDERS TODAY FACE unique barriers to the care of patients. Managed care adds layers of administrative work that can take time away from patient care. Technology adds another potential layer of interference in the physician-patient relationship Decreasing reimbursements often lead providers to see more patients per day, further decreasing the time spent on each encounter. Finally, changes in reimbursement methods and financial pressures often lead physicians to become employed by hospital corporations, which can add yet another layer between physician and patient.

Chaos Medicine has always been chaotic with many unknowns. You can schedule a day of patient visits but cannot prepare for unexpected phone calls or emergencies or for unanticipated complications that emerge during a visit. However, you can control the timing of appointments and leave spaces to accommodate the unexpected. This simple precaution can relieve pressure and improve your job satisfaction. A morning huddle to review the schedule for the day with your assistant and to prepare for potential problems also helps to avoid chaos. A little foresight can help make your day easier, whether it’s planning for patients who need more time, obtaining results of tests, finding summaries from an ER visit or hospital stay, or identifying a patient that might need another reminder to arrive on time.



Overcoming barriers

Technology can improve patient care if it adds to patient safety. Technology can interfere with the physician-patient relationship if the provider faces the computer more than the patient. A few minutes in the exam room face to face with the patient without the computer can improve patient engagement and satisfaction. Likewise, the patient experience and the physician-patient relationship can be improved by explaining to the patient what information is being entered into the computer or turning the screen so the patient can see what is being done.

Providers can counteract some of these effects by increasing patient engagement. Engaged patients will call for their results and be sure that their results do not fall through the cracks. Engaged patients will be willing to ask questions about when to return if a treatment is not effective or if the response is not as predicted, and therefore the provider will have an opportunity to reassess the patient and avoid diagnostic errors. Physicians enter medicine to care for patients. In the current challenging healthcare environment, a few safeguards can be put in place to improve patient safety and also enhance the physician-patient relationship. An improved physician-patient relationship can increase both provider and patient satisfaction. â–

Financial pressures When a provider searches for ways to increase revenue, the priority should always remain patient safety. Adding more patients to the schedule often decreases time per visit, which can impact patient satisfaction. More patients in a given day with decreased time per patient can lead to more opportunities for errors, both diagnostic errors and missed results. Employment by a hospital corporation can eliminate provider autonomy. This can impact the physician-patient relationship as processes may change in a clinic owned by a large corporation as compared to the provider’s former patient care in private practice.

This article originally appeared in the Winter 2015 issue of Brink, a quarterly risk solutions magazine published by MMIC.

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Beckenhauer Construction has been providing high quality construction service to its clients for 137 years and counting. Beckenhauer Construction is a family owned general contracting firm specializing in healthcare construction and is now being directed by the fifth generation of family ownership. Safety of the staff, the patients, visitors, and crews is always at the top of our list to control. We do so by continual training, monitoring, providing the best of equipment to assist us, and constant communication with the client so they are awary of our every move. We go above and beyond the industry standard requirements when it comes to protecting employees, client staff, patients, and visitors. If you are not already one of Beckenhauer Construction’s clients we urge you to visit with any of our past or current clients to see what they have to say about doing business “The Beckenhauer Way”.

July / August 2015



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Then and Now

Father and son in the “T-Ball” days

For Drs. Richard and Tom Howard,

Plastic Surgery is a Family Affair Dr. Tom Howard and his father, Dr. Richard Howard

By Alex Strauss


IOUX FALLS PLASTIC surgeon Richard Howard, MD, says it was T-Ball that originally prompted him to establish his practice in Sioux Falls in 1992. Specifically, his son Tommy’s T-Ball. “We were living in Kansas City at the time and we had one son. It was T-Ball season and, if I wanted to catch a game, it was a 45 minute drive there and then another 45 minutes back to the office to finish up,” says Dr. Howard. “An hour and a half to watch one game. Living in the big city had pros and cons but, at that point, the cons were outweighing the pros by a long shot.” Leaning on advice from his father that “a man who fails his family fails his life”, Dr. Howard moved his family and surgical practice to Sioux Falls, enjoyed as much T-Ball as he could, and never looked back. Twenty-three years later, that emphasis on family appears to be paying off in spades. Not only did Thomas Howard, MD, decide to follow his father into medicine, but he has recently decided – after some considerable debate – to follow him into his Sioux Falls practice. “Tom told me years ago that he was absolutely not going to go into plastic surgery,” recalls Dr. Howard with a laugh. “He got into medical school at USD and arranged

July / August 2015

most of his rotations outside of Sioux Falls. He decided that he wanted to do cardiovascular surgery.” But things changed for Dr. Tom Howard when he realized how the cardiovascular landscape had changed in recent years. “Interventional cardiologists have become so proficient that the surgeons tend to get the very sickest patients. That means more challenges, longer recovery, more problems,” says the younger Dr. Howard, who completed his Plastic & Reconstructive Surgery residency at the University of Oklahoma in June. “With plastics, everyone seemed really happy and excited to go to work. Their patients tend to be happier, too. It all seemed much more attractive.” After discussions with his dad and evaluation of the local medical landscape, the idea of coming home to Sioux Falls with his wife Katie (also a Sioux Falls native) and young son seemed more attractive, too. “My dad and I get along great,” says Tom. “He’s a wonderful teacher, a talented surgeon, and great with people. I would be missing a great opportunity if I went anywhere else.” “I’m confident knowing Tom’s personality, his high standards, and how he approaches taking care of people, that he will do very well here,” says Dr. Richard,

who is hoping to cut back his own workload by 25 to 30 percent. “I think it will be a lot of fun. And the timing for me right now couldn’t be better.” Like his father, Dr. Tom Howard says he enjoys the personal nature of plastic surgery and the opportunity to get to know patients over time, such as over the course of a breast reconstruction. As much as he knows he stands to learn from his dad, he’s also hoping to be able to teach some, too. “I am hoping that he will show me some of the old tried-and-true things that always work and I’ll be able to show him some things that are on the forefront of the specialty,” says Tom, who will be studying for his board exam in the fall. For his part, Dr. Richard Howard, whose Sioux Falls Center for Plastic and Reconstructive Surgery has been primarily a solo practice, is glad to be gaining not only a partner he likes and trusts, but also a closer relationship with his three-and-a-half year old grandson, Benjamin. “He’s my only grandson and now I am going to get to go to his T-Ball games,” says Dr. Howard. ■ NOTE: Dr. Tom will join Dr. Richard in practice at the Sioux Falls Center for Plastic and Reconstructive Surgery in August.


Happenings around the region

South Dakota Southwest Minnesota Northwest Iowa Northeast Nebraska

News & Notes AVERA

Avera is inviting cancer patients, families and other stakeholders to serve on a Cancer Care Services and Research Advisory Committee.

Jim Woster, a South Dakotan who is well known in the state’s agriculture industry, and Kris Gaster, Assistant Vice President for Outpatient Cancer Clinics at Avera Cancer Institute Sioux Falls will chair the committee whose work will be funded by a $5 million Community Innovation grant from the Bush Foundation. Avera St. Anthony’s Hospital in O’Neill is one of only eight hospitals in Nebraska to get a five-star rating from CMS.

CMS recently introduced the star ratings to make it easier for consumers to choose a hospital. The star ratings appear on the “survey of patients’ experience” section of On average, hospitals scored highest in Maine, Minnesota, Nebraska, South Dakota and Wisconsin. Avera Medical Group Worthington is now a Federally Qualified Health Center. Created in 1991

under federal law, FQHCs are “safety net” healthcare providers that charge for services on a sliding-fee scale based on family income and size, and provide services to all regardless of their ability to pay or health insurance status.



Mark Schmidt has been selected as the new President of Lead-Deadwood Regional Hospital and the LeadDeadwood Market. Schmidt was most recently the Executive Director of Avera Maryhouse Long-Term Care in Pierre, SD. He also served as Executive Director of Avera Gettysburg Hospital in Gettysburg, SD. Schmidt holds an MBA from USD. Louis H. Hogrefe, MD, has been selected Regional Health’s Vice President of Physician Services responsible for physician recruitment, provider relations,

wellness and population health, practice management standards, clinical practice standards and clinic finance. Dr. Hogrefe earned his MD at Brown University and his MBA at the University of California. He had been the Regional Health Medical Director for Managed Care and Population Health.

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Three Regional Health caregivers were recognized in June as part of the year-long ‘I Am Regional Health’ campaign.

They are Jolene Deveraux, EMR Specialist in Newcastle, Wyoming, Jason Knudson, MD, a family physician in Spearfish, SD, and Concepcion Hendricks, Patient Care Technician in Rapid City, SD. Each month, the organization showcases three exceptional individuals from across the region who represent Regional Health’s mission.

SANFORD Micah Aberson has assumed duties is the new president of the Sanford Health Foundation.

Aberson was most recently vice president of client services and business development at Lawrence & Schiller, a Sioux Falls-based advertising and marketing agency. A Sioux Falls native and graduate of Augustana College, Aberson holds an MBA from the University of Sioux Falls.

Sanford Health is among the first sites to offer the EXTEND trial, a clinical trial that will test the ability of the drug tocilizumab to slow disease progression and help maintain natural insulin production in individuals with newly diagnosed type 1 diabetes.

Tocilizumab is FDA-approved for treatment of rheumatoid arthritis and juvenile idiopathic arthritis, other autoimmune diseases, as young as 2 years of age. Sanford Heart is now using the CardioMEMS Heart Failure Management System to help reduce heart failure hospitalizations and improve quality of life for heart failure patients. The system uses a

small sensor implanted in the pulmonary artery (PA). The patient can take and send readings from home using a special electronic pillow. Studies show that patients whose physicians used the CardioMEMS HF System had fewer hospitalizations than patients who did not.

SIOUXLAND The June E. Nylen Cancer Center celebrated the 28th annual National Cancer Survivors Day in June with an “Old Fashioned Pie & Ice Cream Social” for cancer survivors and their families. This celebration

took place outside on the riverfront area at the Lewis & Clark Interpretive Center and featured musical entertainment by Mike Langley.

Midwest Medical Edition

Devon Gurnett and Hilary Overby have been appointed wellness specialists at Mercy Business Health Services.

Gurnett earned a BS in Athletic Training from Upper Iowa University in Fayette, Iowa and an MS in Recreation Management from Wayne State College. He is also a NATA BOC Certified Athletic Trainer. Overby obtained her BS in Exercise Science from SDSU and a Master’s Degree in Nutrition, Exercise and Food Sciences. She is a SCSM Health Fitness Specialist, and AFAA Certified in Group Exercise and Personal Training. Douglas W. Martin, MD, FAADEP, FACOEM, FAAFP, Medical Director of UnityPoint Clinic Occupational Medicine, was the lead editor of a new textbook entitled “Complex Regional Pain Syndrome – What is the Evidence?” Martin chaired a

committee of six nationally recognized experts who recommend doing away with CRPS terminology. Instead, Martin and his coauthors created a tool for clinicians, insurance carriers, attorneys and others dealing with patients who have been labeled with CRPS. Martin received his MD from the University of Nebraska Medical Center in Omaha and is certified in family medicine.

July / August 2015

Mercy Medical Center-Sioux City has earned The Joint Commission’s Gold Seal of Approval and the American Heart Association/American Stroke Association’s HeartCheck mark for Advanced Certification for Primary Stroke Centers. Mercy

underwent a rigorous onsite review in February of stroke-related standards and requirements, including program management, the delivery of clinical care and performance improvement. Sue Thompson, Chief Executive Officer of UnityPoint Health–Fort Dodge and Senior Vice President of Integration and Optimization for UnityPoint Health, was recently appointed to the Medicare Payment Advisory Commission (MedPAC) by the US Government Accountability Office. She was the only new

commission member selected and the only Iowan ever appointed to MedPAC. Thompson earned her BSN and her MS in Health Services Management from Clarkson College in Omaha. Cardiologist Frank Addo, MD, has joined the staff of Mercy Cardiology. Dr. Addo is triple-board certified in Cardiovascular Disease, Echocardiography and Nuclear Radiology. He

earned his medical degree from the University of Ghana Medical School and did his Internal Medicine residency and fellowship at the University of Illinois College of Medicine. Dr. Addo comes to Mercy from the Heart and Vascular Institute at Mercy North Iowa in Mason City.

Lynn Wold has been appointed the new President and Chief Executive Officer of UnityPoint Health–St. Luke’s. Wold replaces current President and CEO Peter Thoreen who has led St. Luke’s for the last 12 years and will retire at the end of 2015. Wold most recently served as Chief Operating Officer for St. Luke’s, a position he has held since 2008. A native of North Dakota, Wold will soon complete an MS in Health Services Administration at USD in Vermillion. April Leigh is the new Director of Surgical Services at Mercy Medical Center. Leigh has been with Mercy for 8 years. Leigh holds a

Bachelor’s Degree in Nursing from Briar Cliff University and is pursuing a master’s degree in nursing from Walden University. She will oversee all surgery operations and Central Processing. Mercy Medical Center recently partnered with Stryker Medical, a leading manufacturer of patient care equipment, to outfit their facility with the most advanced technology in wheelchairs.

Mercy is the only medical facility in the region to offer the new state-of-the-art ergonomic wheelchairs which alleviate common issues and feature flip-up footrests, one-touch central brakes, backsmart push handles, and big wheel maneuverability for easier steering and turning. The chair also has the ability to accommodate a weight capacity of 500 lbs.

OTHER Ophthalmologist Vance Thompson, MD, is celebrating his 25th year of practice in Sioux Falls.

Dr. Thompson is an internationally recognized specialist in Laser Vision Correction and Advanced Cataract Surgery and Director of Refractive Surgery for Vance Thompson Vision. He is an assistant professor of ophthalmology at the Sanford USD School of Medicine, has performed more than 70,000 procedures, and has served as the medical monitor lead or principal investigator in over 40 FDA monitored clinical trials. Sioux Falls surgeon and Chair of the University of South Dakota Sanford School of Medicine’s Department of Surgery Dr. Gary Timmerman was a guest presenter at a special, two-day symposium hosted by the National Institutes of Health in Bethesda, Maryland in May.

Dr.Timmerman represented the American College of Surgeons’ Committee on Optimal Access, and explained that group’s research objectives investigating disparities of surgical care impacting various demographics across the United States. Jacklyn Karli, CNP, has joined the Prairie Lakes Cardiology Clinic. Karli will see patients along with Interventional Cardiologists Dr. Garcia, Dr. Maaliki, and Dr. Jones in the clinic and hospital settings. Employed at Prairie

Lakes Healthcare System since 2006, Karli first started as a nurse in the Emergency Department then transitioned to Cardiac Catheterization Lab when it opened in 2007. Karli holds an MS in nursing and is a member of the American Academy of Nurse Practitioners.


. . . continued

News & Notes

Dr. Jerome Freeman, Professor and Chair of the Department of Neurosciences at the USD Sanford School of Medicine, has been named the recipient the inaugural John C. Sall, MD, Professorship in Medicine.

The three-year appointment recognized Dr. Freeman’s leadership and service to the medical school as well as his distinguished career as a physician. A graduate of Augustana and the University of Utah School of Medicine, Freeman joined USDSM in 1980 and has served as professor and chair for the Neurosciences Department since 1991. In April, the FDA announced final approval for the clinical use of an implantable device that can improve near vision in certain patients. AcuFocus

KAMRA corneal inlay is intended for patients with presbyopia who have not had cataract surgery. When it is implanted just beneath the surface of a person’s cornea, it increases their depth-of-focus, improving near vision without compromising distance vision. Vance Thompson Vision was part of the five-year clinical trial that led to the FDA approval.

When you need it.

Mary Nettleman, MD, dean of the USD Sanford School of Medicine and Vice President of Health Affairs

at USD has been elected to the national Council of Dean’s top administrative board overseeing the Association of American Medical Colleges. The Council of Deans helps develop strategies guiding service and advocacy functions, including research, patient care, and student performance and preparation for the nation’s medical schools and related institutions. Dr. Nettleman will serve a one-year term. LifeScape Rehabilitation Medical Supply (RMS) of Sioux Falls welcomes Certified Orthotist, Bob J. Johansen to its team. He joins current

orthotic and prosthetic practitioners Todd Jensen, Mark Wegleitner and Michael Watt in providing comprehensive orthotic and prosthetic services to the Sioux Falls region. Johansen takes pride in providing individualized care to help each person reach their highest level of mobility with the least amount of discomfort. He is a Fargo, ND native and received his BOCO Certification in 2006.

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July / August 2015


South Dakota Gets a Physical A Groundbreaking public health report provides comprehensive look at the state of healthcare in South Dakota By Peter Carrels


Midwest Medical Edition


THE EXECUTIVE SUMMARY of the report titled “Focus on South Dakota, A Picture of Health” the following statement summarizes the scale and importance of this newly-released statewide analysis.

“South Dakota and other largely rural states face many challenges in meeting the healthcare needs of rural and underserved communities, in part because data to guide improvement is often limited or unavailable. The South Dakota Health Survey provides unprecedented statewide survey data on regional patterns of behavioral health prevalence and access to care.”

The sponsor of the report, The Leona M. and Harry B. Helmsley Charitable Trust, declared that the report’s findings can serve as a catalyst to start conversations between city, county and state governments, organizations, and individuals who strive to improve access to care, including mental health and substance abuse care. The Leona M. and Harry B. Helmsley Charitable Trust is a charity that contributes to nonprofits and other organizations in the fields of health, place-based initiatives, and education and human services. Since 2008, when the Trust began issuing grants, it has committed more than $1 billion. The Helmsley fortune behind the Trust came mostly from hotels and real estate in several states, including the Park Lane Hotel and Empire State Building in New York City. “Unprecedented” is an ambitious word, but it is indeed likely that South Dakotans have never before been the

July / August 2015

beneficiaries of such a comprehensive analysis of their health and their access to healthcare. The ‘Picture of Health’ report includes graphs, charts, maps, and concise narrative throughout. The report’s scale is immediately impressive, even to the layperson. Trained public health officials will find limitless applications and usefulness from the data and information. “The Helmsley South Dakota Health Survey is rich in detail,” says Mary Nettleman, MD, Dean of the University of South Dakota Sanford School of Medicine and Vice-president of Health Affairs at the university. “It provides a comprehensive picture of South Dakotan’s healthcare needs, highlighting the need for access to mental health services and underscoring geographic disparities.” Included in the report is a county-bycounty assessment covering dozens of health-related categories. Information is

broken out that profiles the incidence of numerous maladies such as diabetes, asthma, depression, addictions, cancers, heart disease, and high cholesterol, among others. County by county comparisons – made easy by the report – reveal interesting disparities and worrisome hotspots. Statewide data is compared to the county data, adding additional comparative usefulness. Subpopulation reports focus on the state’s two largest cities, Sioux Falls and Rapid City, as well as on the state’s American Indian population. Issues related to health, including homelessness, ethnicity, gender, age, and immigrant and refugee status are covered and described and are accompanied by valuable statistics. To conduct this health needs assessment, 7,675 randomly-selected households from across the state were surveyed by phone, mail and in-person.

We view this report as an investment in improving healthcare for South Dakota. —Shelley Stingley

An additional 519 surveys focusing on homeless, immigrant/refugee, and “housing insecure” populations were completed. Data was collected between November 2013 and October 2014. According to the report, uninsured respondents were more likely to perceive a need for mental health care, more than 50% of responders must travel more than 20 miles to receive mental healthcare, and 62.5% of responders must travel more than 20 miles to receive substance abuse treatment. Adverse childhood experiences


Noteworthy Stats


of respondents screened positive for alcohol misuse


of respondents screened positive for symptoms of depression


of respondents perceived a need for medical care during the previous year


perceived a need for prescription medications


perceived a need for mental

health care

Dr. Michael Lawler


Mary Nettleman, MD

(ACEs), a term that includes conditions such as abuse, neglect and household dysfunction, affected 53% of respondents. ACEs are linked to many adverse short-term and long-term behavioral consequences, including depression, anxiety, and chronic health conditions. Incidentally, survey results indicate that Buffalo, Lake, Lyman, Union and Yankton counties are the healthiest counties in the state. At the same time, surveys suggest that McPherson, Potter, Harding, Clay, and Fall River counties are among the state’s least healthy counties. Report readers will also be able to study issues that impact health such as access to daycare and substance abuse treatment, and the relationship of such access issues and the prevalence of alcohol use, depression, anxiety and drug use are noted. A large collection of data related to American Indian health issues is a critical aspect of the report. Dr. Michael Lawler is dean of the University of South Dakota’s School of Health Sciences, overseeing ten health-related programs ranging from addiction studies, social services, nursing and various therapies. Lawler says he is impressed with the report’s focus on specifics. “Not only does this report affirm the need for reliable access to healthcare in rural communities,” he explained. “It also points out needs for serious conditions such as mental health and addictions.”

Shelley Stingley

Shelley Stingley serves as the program director for the Rural Healthcare Program of The Helmsley

It provides a comprehensive picture… highlighting the need for access to mental health services. —Mary Nettleman, MD

Charitable Trust. From an office in Sioux Falls, the program identifies and aids healthcare needs in seven Northern Plains states, including Montana, Wyoming, Nebraska, Minnesota, Iowa, North Dakota, and South Dakota. Though the program has only been serving public needs in the region for six years, the office has already awarded 220 grants totaling more than $260 million dollars. Much of that money has been directed at improving emergency services, telemedicine, and other technology needs in the region. Stingley says the research and information in the report addresses an unmet need for South Dakota. “We determined that there was inadequate health data on a county or statewide basis in South Dakota,” said Stingley. “We view this report as an investment in improving healthcare for South Dakota. Good decision-making requires sound data, and this report furnishes policymakers and decision makers with excellent references and information for them to make better decisions for South Dakota.” The report also gives local citizens and officials the opportunity to assess local issues and conditions. This unique

Midwest Medical Edition

set of information can help shape strategies and encourage appropriate emphasis in various communities. “The report provides data that local people can review to determine what is needed in their specific area,” explained Stingley. But Stingley says even such a comprehensive report cannot be called successful unless it prompts others to find solutions for the problems that it highlights. It appears, based on the reactions from statewide health leaders, that this will be the case with the Helmsley research. “The report shows that a number of communities have a high prevalence of mental illness and addictions with low access to services,” says Dr. Lawler. “To help these communities, we must develop practitioners who can work in interprofessional teams and address both behavioral and physical health.”

South Dakota’s Secretary of Health, Kim Malsam-Rysdon, agrees that the report is not just a collection of data, but also a call to action. “The Department of Health appreciates the considerable work done by The Leona M. and Harry B. Helmsley Charitable Trust in producing ‘Focus on South Dakota – A Picture of Health,’ says Secretary Malsam-Rysdon. “We expect it will be very helpful as we collaborate with the Trust and other key stakeholders in ongoing efforts to address the health needs of South Dakotans, especially in our most rural areas.” ■

“key” findings South Dakota may have rates of alcohol misuse, anxiety, and post-traumatic stress disorder that are higher than national rates. Hospitalization use for mental health issues is high. Individuals utilizing hospital emergency rooms present high rates of mental health concerns. There are pockets of high rates of depression, heavy alcohol misuse, unmet medical needs, and adverse childhood experiences.

Log On! For a link to the full report.

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July / August 2015




What Is the Impact of the 60-Day Rule? By Scott Leuning

Question: What is 60 days in length, not yet fully defined,

healthcare programs for failure to report and return overpayments. Physicians and hospitals may already be on the hook if they do not promptly identify and refund Medicare overpayments even with the one-year delay in finalizing CMS’s regulations implementing the 60-day Rule.

and could result in criminal prosecution, civil monetary penalties and possible exclusion from federal healthcare programs?

Answer: Section 1128J(d)(2) of the Patient Protection and Affordable Care Act (ACA), known as the 60-day Rule.


HIS PROVISION of the ACA may adversely affect many healthcare providers with its 10-year look back period. Under the 60-day Rule, when a person or entity receives a Medicare overpayment, it must be “reported and returned” within 60 days after the overpayment is “identified.” Any payment that is not returned within the 60-day window is an obligation under the False Claims Act (FCA) and may subject the person or entity that retained the overpayment to criminal prosecution, civil monetary penalties, and possible exclusion from federal healthcare programs.

Delays to Final Rule Do Not Mean a Free Pass Until 2016.

Step 1:

Presently, there is no final regulation regarding the 60-day Rule. The deadline for the final implementation of the 60-day Rule has been pushed back to 2016 due to the volume of public comments and internal stakeholder feedback received. CMS has noted that even without a final regulation in place. Physicians and hospitals are still subject to the statutory requirements of the ACA and could still face penalties, including exclusion from Federal

The threshold issue behind the 60-day Rule is whether you have received an “overpayment” from Medicare. The 60-day Rule defines an “overpayment” as any funds received by a healthcare entity that are in excess of the amounts to be paid under Medicare statutes and regulations. Overpayments may occur from operational or payment errors, including non-covered services, duplicated services,

Defining What Constitutes an Overpayment


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Midwest Medical Edition

“I am so glad my family physician recommended “I am so glad Hospice my family physician of Siouxland for myrecommended mom.” “I am so glad

or ineligible services. CMS recognizes that in certain situations Medicare makes estimated payments for services with the acknowledgement that a reconciliation of those payments to actual costs will be done at a later date. Under the proposed CMS rules an overpayment does not exist until after an applicable reconciliation takes place. But any excess funds retained after payment reconciliation place the physician or entity in violation of the 60-day Rule.

Step 2 : Identifying Overpayments —Maintain Due Diligence

Hospice my family “I am so glad my family of Siouxland physician The 60-day Rule places an affirmative duty on providers and physician recommended suppliers to identify overpayments. The proposed CMS regulations for myrecommended mom.” Hospice of Siouxland state that “a person has identified an overpayment if the person has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment.” According to CMS, this definition gives providers and suppliers “an incentive to exercise reasonable diligence to determine whether an overpayment exists.” In other words, CMS expects that physicians and hospitals will conduct compliance checks, self-audits, and other research to discover overpayments, because turning a blind eye to potential overpayments will not excuse physicians and hospitals from liability and penalties.

Hospice for my mom.” of Siouxland for my mom.”

• Serving Siouxland for over 30 years • Serving Siouxland for over 30 years • Community based non-profit.

An Ounce of Prevention

• Community non-profit. • Servingbased Siouxland for over 30 years

• Locally owned by: • Serving Siouxland for over 30 years

The 60-day Rule has significant ramifications for healthcare providers. Even an inadvertent violation of this rule could expose an individual or organization to unacceptable risks. As CMS has noted, you cannot avoid penalties by turning a blind eye to the situation. A proactive compliance and audit program should be the cornerstone of any medical practice moving forward. If you or your organization has not yet prepared for the 60-day Rule, now is the time to act proactively. Contact a health law attorney to help you navigate the requirements of the 60-day Rule so that you are not caught off guard by this ACA provision. ■

• Community • Locally owned by:based non-profit.

Mercy Medical Centerbased Sioux City and • Community non-profit. • Locally owned by: Sioux City and Mercy Medical Center • Locally owned UnityPoint Health -’s.

UnityPoint Health St. Luke’s. Mercy Medical Sioux City Mercy Medical-Center Center Sioux City and and UnityPointHealth Health --St. UnityPoint St.Luke’s. Luke’s.

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Log on! To read Leuning’s advice for reporting overpayments including the all the information needed to ensure compliance.

July / August 2015


Addressing Hospital

WorkPlace Violence


Lizabeth Brott, JD

IOLENCE IN HEALTHCARE settings is very real, and hospitals are especially vulnerable. According to a study by the Emergency Nurses Association, the overall frequency of physical violence and verbal abuse for an ED nurse working 36.9 hours in a seven-day period is 54 percent.1 Nurses affected were most often involved in triaging a patient, performing an invasive procedure, or restraining/subduing a patient; patients were the main perpetrators in all incidents. The study also found physical violence rates increase as population density increases (9.1% rural vs. 14.1% large urban areas). The following tactics were found to decrease the odds of violence and verbal abuse:

• Use of panic buttons/silent alarms •  Enclosed nursing stations •  Locked or coded ED entries •  Security signs • Well-lit areas It’s also important to have a system-wide program in place to address workplace violence. The Joint Commission requires accredited hospitals to assess their risk of violence, develop written plans, and implement security measures.2 Risks may vary by facility and department, underscoring the importance of individualized analysis. A whitepaper on workplace violence in healthcare, published by ASIS International (an organization of security professionals with 35,000 members worldwide), recommends workplace violence teams adopt a multidisciplinary approach that includes: security, first responders, clinical staff, risk management, legal, human resources, administration, and other key stakeholders.3 They cite the following


five components of an effective workplace violence program:

Management commitment and employee involvement

• Worksite analysis (including

evaluating the physical environment)

• Hazard reduction and response • Training • Recordkeeping and program

may be necessary for employees in high-risk areas. These areas typically include emergency departments, ICUs, behavioral health, and operating rooms. ■ Lizabeth Brott, JD, is Regional Vice President, Risk Resource with ProAssurance, a national provider of medical professional liability insurance and risk resource services. This article is not intended to provide legal advice.


The ASIS white paper also includes a sample threat assessment checklist, a workplace violence policy, a list of common warning signs, and an assessment outline. Staff training may be one of your most effective tools in reducing violent incidents. New employees should receive violence prevention training as part of their orientation. Training should be ongoing and include supervisors and staff. Additional training

1 Emergency department violence surveillance study. Emergency Nurses Association Institute for Emergency Nursing Research. / Documents/ENAEDVSReportNovember2011.pdf. November 2011. Accessed May 21, 2013. 2 Preventing violence in the health care setting. The Joint Commission website. assets/1/18/SEA_45.pdf. June 3, 2010. Accessed May 15, 2013. 3 Managing disruptive behavior and workplace violence in healthcare. ASIS International Healthcare Security Council website. pdf-articles/hospitals and healthcare/council_healthcare_workplaceviolence.ashx December 2010. Accessed May 21, 2013.

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Midwest Medical Edition

Sanford launches pharmacogenetics service Technology integrates pharmacogenetic testing, clinical decision support SANFORD HEALTH HAS announced the first enterprise-wide availability of real-time drug dosing and order modification alerts tailored to a patient’s genetic profile within a commercial EHR system. To provide these services, Sanford’s clinical molecular genetics laboratory analyzes a custom panel of genes involved in drug metabolism. The Syapse Precision Medicine Platform delivers clinically actionable drug metabolizer status information to the EHR, where real-time alerts suggest dosage changes or alternative drugs, as appropriate. “Pharmacogenetic data are most useful when actionable decision support is

July / August 2015

provided in the EHR right when a clinician orders a drug,” says Gene Hoyme, MD, Sanford’s chief of genetic and genomic medicine. Sanford’s integrated health plan will pay for the service, subject to deductibles and copays, which combines genetic testing and EHR-based therapeutic decision support to help clinicians safely prescribe and dose common drugs, including statins, blood thinners, anti-cancer drugs and painkillers. Pharmacogenetic testing is available for all Sanford patients and can be ordered by any Sanford physician, including primary care providers. “We couldn’t even think of rolling out

pharmacogenetic testing at this scale without automation and integration,” said Megan Landsverk, PhD, director of Sanford’s clinical molecular genetics laboratory. “Running the test is straightforward, but mapping the genetic data to metabolizer status and providing decision support at the point of care is a highly complex process. It can take hours to do manually for a single patient, but we can now do it in seconds.” Sanford Imagenetics is a first-of-its-kind program that integrates genetic testing and counseling into adult primary care with patient-specific information. ■


Socioeconomic Status

May Affect Early Development Study co-authored by Sanford researchers published in national journal SOCIOECONOMIC STATUS could have an effect on language and memory development at as early as 21 months, according to a study co-authored by investigators from the Center for Health Outcomes and Prevention at Sanford Research. “Socioeconomic disparities in neurocognitive development in the first two years of life” was published ahead of print by Developmental Psychobiology. Senior author Amy Elliott, PhD, Jyoti Angal, MPH, and Luke Mack, MA, of the Center for Health Outcomes and Prevention contributed to the study. It was conducted in collaboration with colleagues from Columbia University and the PASS Network, a


National Institutes of Health initiative designed to explore the role of prenatal exposure to sudden infant death syndrome (SIDS) and adverse pregnancy outcomes. A total of 179 infants from socioeconomically diverse families living in Sanford Health’s Sioux Falls region were recruited and tested for competency in memory and language. Half were tested at nine and 15 months, and half were tested at 15 and 21 months. Researchers also noted various factors related to the infant’s home life, like education level and life experiences of parents, literary environment and parental affection towards the child known as “parental warmth.”

At 21 months, children of highly educated parents scored higher in language and memory than those of less-educated parents. Additionally, data indicated a more robust literacy environment and more parental warmth corresponded with the differences in language development. “This study reveals just how early in life children can become developmentally at risk,” said Elliott, who serves as director and senior scientist for the Center for Health Outcomes and Prevention. “Both clinicians and caregivers can use this research as a guide to ensure earlier intervention efforts for infants and increase attention to home environments.” ■

Midwest Medical Edition

Children’s Expands Anesthesiology Services to Improve Outcomes CHILDREN’S HOSPITAL & MEDICAL Center has expanded its pediatric anesthesiology team to meet growing demand. In the past year, Children’s has added five new pediatric anesthesiologists for a total of 20 board certified pediatric anesthesiologists. Outcomes indicate that having specialized pediatric anesthesiologists as part of the operating room team decreases complications and mortality from anesthesia. Outside of Children’s, there are few other pediatric anesthesiologists in Nebraska, and no other pediatric cardiac anesthesiologists. “We now have six pediatric cardiac anesthesiologists,” says Mohanad Shukry, MD, PhD, clinical service chief of Anesthesiology at Children’s. “That is especially important

Refractive Laser Assisted Cataract Surgery Now Available in Sioux Falls VANCE THOMPSON VISION in Sioux Falls is now offering new technology for performing the most common surgery in the US – cataract surgery. ReLACS (Refractive Laser Assisted Cataract Surgery) is a custom, blade-free, laser assisted cataract removal option that allows surgeons to plan and perform cataract surgeries to exacting, individualized specifications unattainable with standard cataract surgery. “We’re excited because the same technology that we offer in our bladeless LASIK program is now available to folks who suffer from cloudy vision due to cataracts.” says Vance Thompson, MD. “There are no two eyes that are exactly the same, so our ability to use a laser to bladelessly treat the growing cataract population is really exciting.” Since cataract surgery using ReLACS uses the laser to perform the most critical

steps of cataract surgery, which used to be done by hand, patients not only receive the highest precision in surgical incision but can also reduce their dependence on glasses after their surgery. “We see firsthand that just because someone needs eye surgery, doesn’t mean they want to be dependent on their spectacles or reading glasses,” says Dr. John Berdahl. “For years we have offered advanced intraocular lenses that replace the cloudy lens we remove in cataract surgery,” says Dr. Thompson. “These lenses, when used in conjunction with ReLACS may mean a lot more freedom from glasses after cataract surgery for this group of people who remain very active for decades after their retirement.” Vance Thompson Vision was the first center in the world to offer the technology. ■

to our heart transplantation program, which brings the most complicated pediatric cardiac cases to Children’s for treatment and surgery.” Anesthesiology care at Children’s now also includes a new sedation service and an expanded pain management service. The Non-Operating Room Anesthesia (NORA) service is available to children who undergo procedures outside of the operating room. Children’s also now has eight pediatric anesthesiologists experienced in treating post-operative pain. These anesthesiologists lead a multidisciplinary pain management team that includes intensive care physicians and nurses, pediatric pain management nurse practitioners, pharmacists, physical therapists and child care specialists. The pain manage-

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July / August 2015

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AveraNow Healthcare in the palm of your hand THROUGH THE LATEST Internet and mobile technology, Avera patients can access health care from the palm of their hand. AveraNow lets patients connect to an Avera provider anytime, from anywhere, through their smartphone, tablet, laptop or personal computer. AveraNow will have a free app offered through the iTunes App Store as well as Google Play and other Android-based app distributors. Or, patients can connect by logging onto a special web page. Payment is a $49 flat fee with a credit card, without insurance and reimbursement steps. “Our goal was to maximize technology for the best possible video visit,” said Jason Knutson, DO, Family Practitioner with Avera Medical Group McGreevy

69th and Western, and member of the Avera’s Primary Care Innovation Council. Avera, recently recognized as a national leader in telehealth, is working with American Well, which developed the number-one rated telehealth app of 2014, to provide AveraNow. Tractica, a market intelligence firm that focuses on human interaction with technology, reports that health technologies like AveraNow will increase from 14.3 million worldwide in 2014 to 78.5 million by 2020. Data show that telemedicine, like video visits, can deliver quality outcomes comparable to in-person clinic visits. And on average, patients report a 96 percent satisfaction rate with this mode of health care delivery. ■

64% of patients are willing to participate in a video visit

61% said convenience was a factor in this decision.

7% of respondents who had been with their doctor for less than a year said they would switch doctors to get online video visits. 10% of respondents who had been with their doctor for two to four years said they would switch. Younger people were more likely to switch to a physician that offered video visits. Source: Harris Poll survey

South Dakota Medical Group Management Association

Fall Conference August 26-28, 2015

Cedar Shore Resort – Oacoma, SD


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Midwest Medical Edition

FARM Expands THE HIGHLY SUCCESSFUL University of South Dakota Sanford School of Medicine’s FARM (Frontier and Rural Medicine) program has been expanded, adding students and locations.

The program’s original host communities included Milbank, Mobridge, Parkston, Platte and Winner. Those communities will continue to host FARM students. New FARM communities hosting FA R M Providing South Dakota with physicians who will students practice medicine in in our smaller communities is in the future an important mission of the medical school are VerFARM was launched in summer, 2014, million, starting in February 2016, and with six third-year medical students Pierre and Spearfish, beginning in working in five rural locations. The Class February 2017. of 2018 FARM students –starting their Students selected to participate in the work with FARM in February, 2016- will FARM program receive nine months of include seven students. intense, hands-on clinical training in a

single, rural location that helps them understand the opportunities and rewards of practicing medicine in a small-town setting. All FARM students are in their third year of medical training. “Providing South Dakota with physicians who will practice medicine in in our smaller communities is an important mission of the medical school,” says Dr. Susan Anderson, MD, director of the FARM program. “The FARM program is a useful tool to help us accomplish that.” FARM students are supervised by practicing physicians in clinical, hospital and other healthcare environments in host communities. ■

UnityPoint Clinic Now Offering Virtual Care UNITYPOINT CLINIC IS NOW offering people the option of receiving care for minor health conditions virtually – by phone or secure video via computer, tablet or smartphone. “Technology has made it possible to do many things faster and more conveniently, and now it presents an opportunity to expand access to healthcare services to more people in real time,” says Dr. Alan Kaplan, president and chief executive officer at UnityPoint Clinic. UnityPoint Clinic is partnering with MDLIVE, a national network of boardcertified telehealth doctors, to make virtual care available to anyone in areas served by UnityPoint Health including the state of Iowa, in Illinois, and expanding to the Madison, Wisconsin area early in 2016. Virtual

July / August 2015

visits are provided by UnityPoint Clinic and MDLIVE providers and cost $49 or less depending on insurance coverage. Virtual care is available 24/7. Dr. Bill Chase, a UnityPoint Clinic family medicine physician who is directing the virtual care service, says virtual care is not a replacement for primary care, but is a convenient option for treating common ailments such as allergies, cold and flu, sinus infections, ear aches, rashes and urinary tract infections. “Our virtual care providers have had extensive training and follow clinical protocols for telehealth consulting to ensure that people will experience the same quality of care they would in our clinics,” he says. UnityPoint Clinic and MDLIVE virtual care providers are U.S. board-certified in family medicine, internal medicine,

emergency medicine and pediatrics. UnityPoint Clinic providers will staff consultations during daytime hours while MDLIVE will provide care during overnight hours and additional coverage as needed. To use the virtual care service, people must complete a brief registration process that includes providing general information about their medical history, reason for requesting an appointment, and credit card information for payment. If the condition qualifies for virtual care, a phone or video appointment is scheduled with a UnityPoint Clinic or MDLIVE provider. Anyone who has a virtual visit will receive a completed form to submit to their insurance company for reimbursement if virtual care is covered by their health plan. ■




MAGINE walking into your office in the morning and not having to deal with the mounds of billing paperwork. If you’re like many medical groups, you house a bustling doctors’ office. On any given day, dozens of patients will visit for trusted advice and expertise in specialty medical care. That’s good. A busy office means a steady flow of loyal customers. But good business can also equal a steady and often complicated flow of claims and payment postings. This is where Great Western Bank’s Healthcare Receivables Management (HRM) comes into play to manage a fully automated revenue cycle. Not just denial management, not just a clearing house, but the full cycle. The results can be remarkable.


What can take 5-7 days to post cash now is finished by the time you get to the office in the morning. The processing of denials can be completed in a fraction of the time. Great Western Bank’s HRM product can just make life easier! What’s more, a tool like Great Western’s

Making life great is the mission of Great Western Bank and the financial institution’s new HRM product is case in point. Great Western saw the increase need for such a service. HRM increases administration efficiency by minimizing paper claim handling. With real-time electronic exchange with payers, providers and other key trading partners, Great Western’s HRM helps accel– Ryan Boschee erate payments and lowers transaction costs. In addition, HRM has become a necessity as the new reguHRM provides the ability to increase timely lations associated with ICD-10 are rolled out processing of critical information, effecon October 1st, 2015. Requirements for extra tively shortening delays and minimizing coding will make it imperative to efficiently lost cash revenue. HRM analyzes all areas monitor and understand denials. The absence of the revenue cycle to ensure the shortest of this will cost companies time and money. turn around possible.

In short, it’s a life saver.

Midwest Medical Edition

We want to make staffing easy and increase the bottom line for our customers. HRM does just that. – Machelle Moen,

“Our Healthcare Receivables Management product improves customer service, increases total dollars collected and shortens the time spent collecting revenue. In short, it’s a life saver,” said Ryan Boschee, Group President, Great Western Bank. The main features of Great Western Bank’s HRM product solve five of the top issues seen in revenue collection. What sets Great Western Bank apart from the crowd of providers is its comprehensive approach. They include manual procedures, unapplied cash, recoupment, underpayments and denials.

Features of Great Western Bank’s HRM product include: ● N  o more manual keying

of paper EOBs ● 1  00% auto-posting paper

EOB/ERAs/Self Pays

Other services available with Great Western’s HRM include: Direct Connection to Payer

● P aper2ERA Fast Forward program ● Reduction  of write-offs ● R  eduction of posting rejects

with business rule analyzer  U ●  napplied cash/re-association module Great Western Bank’s Healthcare Receivables Management product simplifies the complex world of revenue cycle management. “Great Western’s Healthcare Receivables Management streamlines backend operations making it easy to focus not on paperwork but what’s most important—the patient,” said Machelle Moen, Sr. Cash Management Consultant for Great Western Bank. “We want to make staffing easy and increase the bottom line for our customers. HRM does just that.”■

● S  ame day denial processing

and trend module ● S  ame day secondary processing

24-Hour Processing Transactions are processed in one day and include Paper EOBs, ERAs, ACHs, Patient Pays, Secondary, Denials and Re-Association.

Application of Business Rules Apply business rules by payer to improve accuracy of the information posted, reducing rejects which delay processing.

Denial Management A total denial management system with an integrated workflow allows employees to manage and route denials. Denial code translation technology allows for all payer denial codes to be translated into the provider denial code set, allowing for quick recognition of denial type.

Re-Association This fully automated service provides a posting file of the deposit date without any need for manual keying. The re-association may include ERA/Paper Check, ERA/ACH, Paper EOB/ACH, etc.

Digital Auto Posting

●  S ame day self-pay processing

This service provides a billing system that automatically posts files by 10 a.m. each day allowing for same day patient pay billing.

● O  nline patient portal ●  ne call customer service  O

close methodology ● Same  day ERA processing

This service analyzes the provider payer list and recommends which payers can be converted from paper to electronic. Complete management of the conversion from preparing paperwork to working with the payer and obtaining necessary approval.

Machelle Moen

Ryan Boschee

For more information on Great Western Bank’s Healthcare Receivables Management, visit or contact Machelle Moen, Sr. Cash Management Consultant at Great Western Bank at or 605-336-4451

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Midwest Medical Edition


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Midwest Medical Edition

Occupational Hearing Loss in the Healthcare Setting By Vince Weber


CCUPATIONAL HEARING loss is something that employers need to take seriously. There are a number of factors that must be taken into consideration when evaluating hearing loss. Given that the average employee is only exposed to their working environment for about 25% of their daily activities, a careful review of work and lifestyle sound exposures should be a part of any evaluation. Workplace sound exposures, for general industry, fall under OSHA regulation 29CFR1910.95. This regulation sets maximum sound levels and durations. (See MED on the Web below). When an employee is exposed to noise levels in excess of these permissible exposure limits (PELs), the employer is required to implement and enforce mandatory hearing protection practices. Employers are also subject to additional requirements when noise exposures equal or exceed an 8-hour time weighted average (TWA) of 85 decibels. These requirements include monitoring of the workplace to identify specific operations or activities that may exceed PELs. Employers are also required to establish and maintain an audiometric testing program for all employees whose exposures reach or exceed the TWA of 85 decibels. This audiometric testing is to be conducted at, or shortly after, the beginning of employment, in order to establish a baseline reading. From this point, the employer is required to conduct annual audiometric testing, to monitor for significant changes or “threshold shifts,” as an indicator of possible injury. Full details of an audiometric testing program can be found in OSHA regulations 29CFR1910.95 (g) & (h). The need to monitor the work environment is necessary for the employer to fully evaluate any potential exposures to harmful

July / August 2015

noise. A simple screening of the workplace can be accomplished through the use of hand held “decibel” or sound level meters. It is important to take readings from specific work stations or operator positions that are suspect. Readings should be conducted during various phases of operations or activities. These ambient readings are only a screening method to determine if further monitoring or evaluation is necessary. A true determination of the employee’s 8-hour TWA can only be accomplished through the use of a personal noise dosimeter. Many small and compact dosimeters are now available for purchase or lease from major scientific equipment vendors. These dosimeters are worn by employees during their normal shift and collect noise exposure data points at specific intervals (usually every 30 – 60 seconds). The final readings will then take into account all noise exposures throughout the employees work shift, including breaks; interruption of process; and changes in operations, activities, or equipment. The findings are then downloaded or taken directly from the unit, and a full report is generated. The report will usually indicate high level “impact” type sounds as well as long duration sounds, to yield a more accurate TWA of the employee’s actual exposures. Of course other factors, including lifestyle, recreational activities, and the employee’s personal health must also be considered when evaluating hearing loss. It is not unusual for the employee, who routinely wears hearing protection at work, to operate noisy equipment such as lawn mowers, snow blowers, or chainsaws without this protection when working at home. Recreational activities, including loud music, participation in motorized sports, and attendance at many sports venues can also be sources of high

noise exposure. Finally, a wide variety of personal health conditions, medical history, and medications are all factors that should be evaluated. With few exceptions, occupational hearing loss is the result of a lifetime of exposures, both on and off duty. A thorough understanding and evaluation of all of the employee’s exposures is necessary in making a final determination of “occupational” hearing loss. ■ Vince Weber has over 30 years of experience in the health, safety, and loss control field. He is an authorized trainer for a variety of OSHA training courses. Weber is a Loss Control Specialist with RAS.

To see an illustration of OSHA’s thresholds for workplace noise exposure, see the full version of this article on our website.


HEART DISEASE Still a Top Threat


By Kelly Steffen, DO

EART DISEASE continues to be the No. 1 killer of both American men and women today, and the latest statistics are staggering. Approximately 2,150 people die from heart disease each day, an average of one death every 40 seconds. While rates declined 30.8 percent from 2001 to 2011, cardiovascular disease still accounted for 31.3 percent of deaths in 2011. Here is an up-to-date look at the American Heart Association’s (AHA) “Life’s Simple 7” steps to controlling heart disease risk. Although tobacco use has declined substantially, it remains the second-leading cause of total deaths in the United States. And e-cigarette products threaten these declines. The economic impact of smoking every year in the United States, including direct medical costs and lost productivity, is estimated at more than $289 billion. The leading risk factor for death in the U.S. is an unhealthy diet. Major contributors were insufficient amounts of fruits, nuts/ seeds, whole grains, vegetables and seafood, as well as excess amounts of sodium. When comparing healthy and unhealthy diets, the AHA found the unhealthy option cost an average of was $1.50 more per day.

In the same study, snack food was found to cost 31 cents for fruit and vegetables, containing only 57 calories per portion, compared to 33 cents and 183 calories per portion of a less healthy snack. Only 75.7 percent of children and 46.6 percent of adults have ideal cholesterol. Prevalence of ideal levels has improved over the past decade in children, but unfortunately has remained the same in adults. Blood pressure. According to the AHA, one-third of Americans have hypertension. The National Health and Nutrition Examination Survey (NHANES) released data from 2009 to 2012 revealing that among U.S. adults with hypertension, 54.1 percent were controlled, 76.5 percent were currently treated, 82.7 percent were aware they had hypertension and 17.3 percent were undiagnosed. Diabetes mellitus affects one in 10 US adults, 90 percent of cases being type 2 diabetes mellitus. The prevalence of type 2 diabetes mellitus in children or adolescents now constitutes 50 percent of all childhood diabetes mellitus. According to the National Health Interview Survey, only 20.9 percent of Americans met the guidelines for both aerobic and


strengthening activity. In a study completed by the NHANES, men engaged in 35 minutes of activity per day, whereas women engage in 21 minutes per day. In the same survey, reviewing self-reported versus actual measured physical activity, 60 percent of respondents self-reported higher values of activity than what was measured by use of direct methods; men self-reported data was 44 percent greater and women self-reported 138 percent greater than actual physical activity.  According to NHANES data, there have been no overall changes in obesity rates in adults between 2003 to 2004 and 2011 to 2012.  If current trends in the growth of obesity continue, total health care costs related to obesity could reach nearly $900 billion by 2030, accounting for 16 to 18 percent of U.S. health expenditures.  By doing just four things – eating right, being physically active, not smoking and keeping a healthy weight –the risk of heart disease can be lowered by as much as 82 percent. As healthcare providers, we can work together to help our patients get heart healthy with just a few simple steps, and eliminate heart disease as our nation’s leading cause of death, once and for all. ■

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Midwest Medical Edition

Midwest Medical Edition

ewelry J

Preserving Your

F ine By Riddle’s Jewelry

Wearing Your Jewelry All the Time


Seven Actions to Avoid



Submerging Your Jewelry in Cleaner for Too Long


Showering or Swimming in Your Jewelry


We’re usually so sentimental about

Your Jewelry in an Ultrasonic Machine

our jewelry that we are tempted to

Ultrasonic machines are great

Those little containers with jewelry

jewelry all the time, you should

wear it all the time, whether it is a

because they thoroughly clean your

cleaner and a brush that you dunk

most definitely never wear your

necklace you received as a child or

jewelry. However, they are not suit-

your jewelry in to clean are great,

jewelry when swimming or shower-

your engagement ring. Engagement

able for all jewelry! Avoid putting

but it’s important not to submerge

ing. Chlorine in swimming pools

rings are most commonly worn every

pearls, cameos, emeralds, opals,

your ring in the solution too long.

can be quite corrosive to gold or

day. Even though they are worn

coral, and other soft stones in an

Prolonged exposure in a tarnish

silver, causing damage that can

every day, but it doesn’t mean you

ultrasonic machine. These stones can

remover can actually make silver

require costly repairs or even result

have to wear them ALL the time.

be severely damaged by the vibra-

jewelry tarnish almost to a black

in loss of valuable stones. Soaps,

Don’t wear your jewelry while

tions or the cleaning chemical.

color. Prolonged exposure with gold

shampoos, hair conditioners and

sleeping, washing dishes, painting,

Instead, use a soft toothbrush and

can discolor the gold as well as wear

cleaning solutions can dull dia-

working with your hands or wearing

a mild soap. Pearls and opals should

the gold down over time. A few

monds and metals, or corrode

latex gloves. Not wearing a necklace

be cleaned only with a soft cloth and

moments, a brief swish, and a gentle

jewelry. Jewelry should be “last on

while sleeping is especially important

water. You can always bring your

brush with a soft brush will make

and first off” when applying

since the chain is prone to tangling

jewelry in to your favorite jewelers

your precious jewelry look like new.

makeup or hair-care products.

or breaking. Use your best judgment,

for professional cleaning and care.

but if in doubt, take your jewelry off.

Keeping Your Jewelry Out in the Open


Storing Your Jewelry in Different Places


Not only shouldn’t you wear your

Taking Rings off by Pressing on the Stones


In an ideal world, having fine jewelry sitting on

So where should you store your beautiful jewelry

There is a right and a wrong way to take on and

your kitchen counter in a jewelry dish shouldn’t

when you’re not wearing it? Just like people have

off a ring. It is so important that when you put

be a big deal. However, it is smart to store your

a designated spot for their car keys, you should

on or take off your rings that you pull from the

jewelry in an inconspicuous and safe location so

always have a consistent spot for jewelry that

sides of the shank. So many people, especially

that it is not visible to visitors or others who come

you wear often. A crystal ring holder can keep

when the ring is too tight, have the tendency to

to your home. It is important to make sure jewelry

your rings from slipping off the dresser, and a

remove the ring by pressing with one finger on

has adequate insurance coverage in case of theft

jewelry case or tray will

top of the stone and the other on the bottom

or loss. Check with your insurance agent to

organize your other

of the ring. Over time this will loosen your

ensure you’re properly protected.

jewelry in an easy

stone and make it susceptible to falling

to find place that will protect it from

out. If it is difficult to get off, a little soap can help make the ring slide off

being lost or misplaced.


Hospice ‘A Godsend’ for Siouxland Family By Alex Strauss


MY MACFARLANE’S mother, who was in her 80s at the time, began having trouble not long after Macfarlane’s father died. Like many people who eventually end up turning to hospice for help, Macfarlane did not even realize how much she had been doing for her mother – and the toll it was taking on her – until after hospice stepped in. “My mother was living alone at the time and had been diagnosed with colorectal cancer,” recalls Macfarlane. “My dad had had the physical issues and we did not realize before he died that my mom had a lot of dementia.” Macfarlane, a wife and mother, was working as Community Relations Director at a senior community in the Sioux City area. Between duties at home and at work, she was stopping by her mother’s independent living apartment at another nearby senior community every day to do things like ensure she was taking her medicine and remind her to go eat. After her mother got a colostomy bag, things got even harder. “That is the point at which caregiving really got difficult for me because you’re no longer really acting like a daughter,” says Macfarlane. Enter Hospice of Siouxland. Family physician, Carol Roge, MD, who also happens to be Macfarlane’s own doctor, neighbor, and friend, made the referral. “By the time I refer them to hospice, patients have already come through a long period of being told what to do, where to go, what test to take, what treatment to have,” says Dr. Roge. “Hospice is a way to give control back to the patient. It also allows family members to stop being caregivers and just be family members again.” As Macfarlane found, it can also give a


Macfarlane and her mother in happier, healthier times

great deal of stress relief and peace of mind. “You can feel very alone and not even realize it until hospice steps in,” she says. After a hospice nurse began stopping by three times a week to help with various daily tasks, Macfarlane was able to breathe a sigh of relief and even travel occasionally – something she hadn’t done for years. “The thing that was so great is that they let you stay in the driver’s seat,” she says. “They asked me about everything that I was doing for my mother. And then Renee would call me after she visited. She would say her blood pressure is good, we had her take her meds, changed the bad, etc. She really became my ‘significant other’.” “Every time I refer someone to hospice and the family comes to see me later they say ‘Oh my gosh, I wish we had done that earlier!’” says Dr. Roge. Unfortunately, she says, too many physicians may be reluctant to have what she calls ‘The Big Conversation’ that can open the door for hospice. “I think a lot of physicians are not comfortable saying ‘You’re nearing the end of

your life. Nothing we are going to do is going to extend your life by very much. Do you really want to go through this or do you want to have comfort and be with your family and enjoy your remaining weeks or months?’” she says. Medicare will pay for hospice care, whether at home, or in a long-term care facility, but it is reserved for patients who are believed to have less than six months to live and are no longer having curative treatment. Patients are reassessed every three months and can be taken off hospice if their prognosis improves. In the case of Macfarlane’s mother, her hospice nurse continued to visit her even after she fell and was moved from the independent unit to the hospice wing of her care facility. “It was a godsend and I would not have even known that this was available if it hadn’t been for Dr. Roge,” says Macfarlane, who now, several years after her mother’s death, sits on the Hospice of Siouxland board. “Hospice helped make something that was so sad a little more bittersweet.” ■

Midwest Medical Edition

goodbye gut ache. hello belly laugh. > personalized Gi expertise > acceptinG referrals and new patients > flexible schedulinG > outreach clinics in huron and Mitchell

Are your patients missing out on the fun due to digestive health issues? At Midwest Family Care Digestive Health, we can diagnose a wide range of gastrointestinal disorders to ensure that you have the accurate information you need to provide the individualized care they deserve. Our team works with you to determine an effective, personalized course of treatment to get them laughing again.

(605) 444-8665

July / August 2015

Dr. Mark Milone

716 E 19th St | Sioux FAllS, SD

Gastroenterologist & Hepatologist > Specializing in fecal incontinence

Proud to be Physician Owned and Operated


New Grad Says MBA Allowed Her to

‘Grow with the Company’

Dziedzic and classmate Naren Narendranath were two of three MBA students recognized from this year’s graduating class with the MBA Excellence in Academics award. .

SOME PEOPLE ENTER an MBA program as a stepping stone to new opportunities and new places. Marla Dziedzic, Director of Staff Development for Avera Health, saw the MBA program at the University of Sioux Falls as a way to progress along with the organization she loves.

“Before I went into the program, I was an education consultant at Avera working with things like onboarding,” says Dziedzic. “When I started my master’s program, my ultimate goal was to develop my own skills so that I could one day grow with the company. “ And that’s exactly what happened. Dziedzic, who holds a business degree in Marketing and Management from Creighton, was encouraged to pursue her MBA by Avera higher-ups. “Here at Avera, they really want to develop their employees and they thought this would be a good step for me. I’m not sure I would have jumped into it if I hadn’t had a little bit of a push,” says Dziedzic. As she considered her options, Dziedzic says USF’s cohort learning model seemed like a better fit than online-only MBA programs. “Online programs can be convenient but I didn’t feel like a strict online program was for me at the time. I liked the cohort model, which has you working with a range of people from different backgrounds. It was one of the things that prompted me to choose the USF program over other programs.” She started her MBA program in 2012

and finished this summer. Partway into her studies, Dziedzic was promoted to her current position with Avera Health, where she says she is already applying what she’s learned every day. “I moved from working with one region at Avera McKennan to working with the entire system and one of the things that it has really helped me do is to take a more strategic approach.,” says Dziedzic. “The MBA program has helped me learn to apply a more visionary focus, which has been very important for my team. I have also found some of the communication and finance aspects to be very valuable. I look at numbers very differently than I did before.” USF offers both a standard MBA and a healthcare track. Dziedzic close to go the traditional route since her background was in business rather than medicine. “Particularly if you are managing people, I feel like the program provides you with the platform you need to grow and understand the challenges and complexities of the healthcare environment,” she says. “Having these tools is going to help me grow both personally and professionally.” ■

Prairie Lakes was one of the first facilities in South Dakota to perform a new heart failure monitoring procedure. The CardioMEMS HF System is the first and only FDA-approved heart failure monitoring device that has been proven to significantly reduce hospital admissions. Now symptoms for heart failure patients can be discovered up to 20 days earlier. The new system allows patients to transmit daily sensor readings from their homes to Prairie Lakes Healthcare System, allowing for personalized and proactive management for Watertown area patients.



Midwest Medical Edition

Learning Opportunities July – October July 22 Avera Infection Prevention Day of Sharing 9:15 am – 4 pm Location: Sr. Colman Room, Prairie Center, Avera McKennan Information:, 605-322-8987 Registration: August 10–12 Digital Marketing for Medical Devices 8:30 am -3:45 pm Location: Hyatt Regency, Minneapolis Information and Registration: August 20–22 2015 Fall SDMGMA Conference 8:00 am – 6:30 pm Location: Cedar Shore Resort, Chamberlain, SD Information and September 23–25

SDAHO 89th Annual Convention

8:00 am - 5:00 pm Location: Sioux Falls Convention Center Information: 605-361-2281, Registration: September 24–25 16th Annual Avera Oncology Symposium Location: Avera Cancer Institute, Prairie Center, Avera McKennan Information:, 605-322-8987 Registration: October 2 6th Annual Avera Women’s Conference for the Primary Care Provider 9:00 am – 4:15 pm Location: Sr. Colman Room, Prairie Center, Avera McKennan Information:, 605-322-8987 Registration: October 2 15th Annual Community Response to Child Abuse Conference 8:00 am – 5:00 pm Location: Sioux Falls Convention Center Registration: Registration open July 1 Information: Elizabeth Groff at 605-333-2200 October 20 Avera McKennan Social Work Conference 11:00 am – 5:30 pm Location: Sr. Colman Room, Prairie Center, Avera McKennan Information:, 605-322-8987 Registration:

Save the Date: October 30, 2015 16th Annual Sanford Health Ministry Conference

July / August 2015

Do you or your organization have an event for the MED Calendar? Post it online for free through the calendar link on our home page.

MED reaches more than 5000 doctors and other healthcare professionals across our region 8 times a year. If you know of an upcoming class, seminar, webinar, or other educational event in the region in which these clinicians may want to participate, help us share it in MED. Send your submissions for the Learning Opportunities calendar to the editor at 35

Superior 3D Team Advanced 3D Technology. Read by the region’s largest and most experienced breast radiologist team. A 3D mammogram produces the most detailed images of your breast. And in order to give you the most accurate picture of your breast health, you need an expert reading the results. At Edith Sanford Breast Center, our team: • Performed more than 50,000 3D mammograms • Participated in a national study focused on the benefits of 3D mammography • Began offering 3D mammograms in 2012 • Is led by the region’s only fellowshiptrained breast radiologists

Call 855-35EDITH to schedule your 3D mammogram today. Breast cancer has no place to hide.

Melinda Talley, MD

011004-00174 06/15

Andrea Lamphiear, MD

Thomas Cink, MD

MED-Midwest Medical Edition-July/August 2015  
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