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Health Law Firm Opens Green Bay Office

Tuesday, May 1st, 2018

Green Bay Health Care Lawyer – Opening Office in Green Bay Wisconsin

I just wanted to let readers of our health care blog know that Ruder Ware will be opening a Green Bay office and that three Green Bay attorneys will be joining our firm. This will provide us with a presence in the Green Bay/Appleton Markets that will enhance our community presence and enable us to better serve our client in eastern Wisconsin. Our health care and compliance practice with be greatly enhanced as a result of this move.

This move will provide a local platform through which we can better serve our health care clients.

Health Care Law Practice – Green Bay Health Lawyers Ruder Ware

Ruder Ware has a long history of representing health care clients.  The firm recognizes that the highly regulated and complex nature of the industry demands the attention of a team of attorneys who, as a group, monitor constantly evolving laws and regulations and their impact on our health care clients.  At Ruder Ware, we offer a full-service solution to clients as our focus team consists of health care, business, employment, and litigation attorneys with knowledge of the health care industry.   As a result, we are able to take best practices from other industries and apply them to the health care industry, thereby increasing the ability to respond promptly to the rapidly changing health care environment.

Members of the focus team have served on the governing bodies of various health care organizations.  This service has provided our attorneys with the opportunity to counsel the health care community.  

Our dedicated team of attorneys represents health care providers in various matters including:

 Health Care Business Transactions and Corporate Law

Our attorneys have substantial expertise representing various health care providers such as:

Below is the official press release:

Media Contact:
Jamie Schaefer
COO
Ruder Ware, L.L.S.C.
P: 715.845.4336
E: jschaefer@ruderware.com

For Immediate Release

Attorneys Ronald Metzler, Christopher Pahl, and Chad Levanetz to join
Ruder Ware at its new Green Bay Office

WAUSAU, WI – April 27, 2018 – Ruder Ware is pleased to announce the opening of its Green Bay office and that Attorneys Ronald Metzler, Christopher Pahl, and Chad Levanetz will be joining the firm. The new office will be located at 222 Cherry Street, Green Bay, Wisconsin, which is the current location of Metzler, Timm, Treleven, S.C.

Attorney Ron Metzler – Having practiced law for over 30 years, Ron is a well-respected and well-known commercial attorney with close ties to the banking industry.

Attorney Chris Pahl – With his strong ties to the Green Bay community, Chris has built his practice around real estate development and condominium law as well as commercial transactions and estate planning.

Attorney Chad Levanetz – A seasoned litigation attorney, Chad counsels clients in the areas of real estate, construction, and general business disputes.

Stew Etten, Ruder Ware managing partner, stated, “Ruder Ware is always looking for outstanding attorneys to join our firm. With the opportunity to add Attorneys Metzler, Pahl, and Levanetz, the time was right to open a Green Bay office. We’re very excited to have attorneys of their caliber join our team of professionals.”

About Ruder Ware
Founded in 1920, Ruder Ware is the largest law firm headquartered north of Madison. With offices in Wausau, Eau Claire, and Green Bay over 40 attorneys provide legal and business advice to clients with operations of all sizes. Areas of practice include: Employment, Benefits & Labor Relations, Litigation & Dispute Resolution, Business Transactions, Trusts & Estates, and Fiduciary Services. Ruder Ware, Business Attorneys for Business Success. www.ruderware.com

Media Contact:
Jamie Schaefer
COO
Ruder Ware, L.L.S.C.
P: 715.845.4336
E: jschaefer@ruderware.com

Verbal Orders Documentation and Authentication

Wednesday, January 24th, 2018

The Verbal Order Minefield

Authenticating Verbal OrdersPhysicians often provide orders over the telephone in cases where action must be taken immediately. For example, verbal orders must be given by a physician who is on call or off duty but an issue arises that requires staff to take immediate action. Physician orders are generally effective when they are given, subject to appropriate documentation. Verbal orders are effective when provided verbally, but must be properly recorded in the medical records and authenticated or signed by the ordering physician.

Verbal Order Policies and Procedures

Normally, the facility will have policies in place that provide guidance on how staff should handle verbal orders. Those policies will define who is authorized to receive a verbal order from a physician as well as the process for taking a verbal order. Many facilities use a “read-back” requirement that requires the provider who receives the order to read the order back to the physician and receive confirmation. The receiving provider is required to document the receipt of the verbal order in the chart.

Over-use of Verbal Orders

Medicare policy (and many state laws) clarifies that verbal orders are not to be used as common practice. Verbal orders are not to be used for the convenience of the physician, but only when the patient’s condition or status requires immediate attention and when it is impossible or impractical to enter the order without creating unacceptable delays in needed treatment. Even though verbal orders are to be used infrequently under Medicare policy, their use has become very commonplace in many facilities. Frequent use of verbal orders increases risk in a variety of ways. Verbal orders leave room for error. This can be mitigated by using a read-back process, but risk of misinterpretation or incorrect fulfillment will be enhanced when verbal orders are used. Verbal orders contribute significantly to the risk of medication error and a variety of other potential adverse patient incidents.

Another significant risk of using verbal orders relates to the need to meet authentication requirements. CMS rules direct medical reviewers to disregard orders that are not properly authenticated. All orders, including verbal orders, are required to be dated, timed, and authenticated promptly by the ordering practitioner.

Authentication of Verbal Orders by Ordering Physician

In terms of timing, Medicare guidance requires the ordering physician to sign the verbal order promptly. Some states, such as Wisconsin, require the ordering physician to sign the order within 24 hours of providing the verbal order. Medicare ties into state law requirements in this area. This is an area of significant potential risk for a facility where physician’s routinely use verbal orders during off-shift times. It can be days before the physician is back at the facility. It used to be that reviewers provided a lot of slack on the followup physician signature requirement. With the integration of electronic medical records and the use of electronic signatures, the timing requirements for physician signatures on verbal orders are enforced strictly.

CMS has gotten a bit more lenient on certain delayed medical record entries. Amendments, corrections, and delayed medical record entries are now given credit in medical review. This leniency does not apply with respect to certain types of physician orders. For example, late or corrected entries to support orders for inpatient admission or outpatient observation services are not accepted and are treated as they do not exist on medical review. Again, failure to properly and timely authenticate an “order” in contrast to an “entry,” has reimbursement implications. This makes it critical to assure that orders are completely documented. Verbal order use should be limited to appropriate cases. Verbal orders are over-used in many facilities. When verbal orders are used, prompt authentication requirements should be enforced. Strict time limitations may exist under state law. For example, Wisconsin requires verbal orders to be be signed by the ordering provider within 24 hours.

Physician Orders Legal and Regulatory Article Series

Physician Order Reimbursement Issues

Physician Orders – Why Are They So Important?

The Verbal Order Minefield

Authenticating Verbal Orders : Compliance Requirements

Third Party Authentication of Verbal Orders

Physician Order – CMS Guidelines on Texting Physician Orders

Telemedicine Credentialing By Proxy

Tuesday, February 12th, 2013

Telemedicine Credentialing By Proxy and Hospital Policies

telemedicine policies credentialing telehealthProvider Credentialing requirements raise important considerations in any telemedicine arrangement. The facility where care is received, renders a diagnosis, or otherwise provides clinical treatment to a patient, must assure that a telemedicine practitioner is appropriately credentialed and privileged in compliance with their credentialing process, CMS rules, and the requirements of applicable accreditation organizations.  The process for credentialing telemedicine providers should be addressed by the governing body and reflected in medical staff bylaws and formal credentialing policies.

Credentialing standards have been somewhat streamlined since CMS adopted new regulations that were effective in June of 2011.  CMS rules now permit “credentialing by proxy” provided that several conditions are met.  It remains the responsibility of the board to determine when or if it wishes to rely on “credentialing by proxy” or whether it should apply full credentialing requirements on remote providers of telemedicine services.  Even though the process has been simplified, credentialing of providers who perform telemedicine services to patients of a hospital is still an extremely important responsibility of the hospital board.

CMS Backpedals on Medical Staff Director Requirement

Thursday, July 5th, 2012

In May 2012, CMS issued final regulations containing new conditions of participation requirements for hospitals. One new requirement that was included in final regulations was the requirement that one or more members of the medical staff be included on a hospital’s governing body. The medical staff director requirement had not been included in previous proposed regulations and took the industry by surprise when it was included in the final regulations. The requirement was scheduled to go into place effective July 16, 2012.

 Several organizations, including the American Hospital Association, objected strongly to CMS issuing the final rule without the opportunity for stakeholders to provide any input into this new requirement.

 In a recent release from CMS, it appears that CMS may be backpedaling on this requirement. However, a June 15, 2012 memorandum from CMS to State Survey Agency Directors instructs state survey agencies not to attempt to assess compliance with this requirement or cite deficiencies without receiving further instructions from CMS. The memorandum also provides that accrediting organizations are not required to revise their standard or survey processes until CMS has addressed the issue completely.

 At least for now, the requirement that a medical staff member be included on the Board of Directors of a hospital need not be implemented. Stay tuned for further releases from CMS on this issue. It appears possible that CMS will reverse its decision on this issue in view of the regulatory deficiencies used to adopt the requirement.

Anti-kickback Statutes Safe Harbor Regulations

Thursday, December 8th, 2011

Anti-kickback Statutes and Safe Harbor Regulations

Medicare Antikickback Statute Safe HarborsOverview: On the books since 1972, the federal anti-kickback law’s main purpose is to protect patients and the federal health care programs from fraud and abuse by curtailing the corrupting influence of money on health care decisions. Straightforward but broad, the law states that anyone who knowingly and willfully receives or pays anything of value to influence the referral of federal health care program business, including Medicare and Medicaid, can be held accountable for a felony. Violations of the law are punishable by up to five years in prison, criminal fines up to $25,000, administrative civil money penalties up to $50,000, and exclusion from participation in federal health care programs.

Because the law is broad on its face, concerns arose among health care providers that some relatively innocuous — and in some cases even beneficial — commercial arrangements are prohibited by the anti-kickback law. Responding to these concerns, Congress in 1987 authorized the Department to issue regulations designating specific “safe harbors” for various payment and business practices that, while potentially prohibited by the law, would not be prosecuted.

EMTALA Transfer Policies to Specialty Hospitals

Tuesday, December 14th, 2010

EMTALA Applicability to Hospital, Critical Access Hospital Inpatients and Hospitals With Specialized Capabilities

CMS Requests Comments On Current EMTALA Transfer Policies to Specialty Hospitals

EMTALA Specialty HospitalsOn December 23, 2010, the CMS issued an advance notice of proposed rule-making regarding the creation of two new policies under the Emergency Medical Treatment and Labor Act.  The CMS is requesting comments regarding the possible need to revisit current policies relative to the applicability of EMTALA to hospital inpatients and the responsibilities of hospitals with specialized capabilities, respectively.

EMTALA imposes specific “anti-dumping” obligations on certain Medicare-participating hospitals and critical access hospitals. For example, the hospitals have certain obligations relative to individuals who come to a hospital’s “dedicated emergency department” and request examination or treatment for a medical condition.  These obligations apply to all of individuals, whether or not they are Medicare beneficiaries or whether they have health care coverage.

EMTALA requires dedicated emergency departments to perform medical screening examinations for individuals who come to the hospital and request examination or treatment for a medical condition. If an emergency medical condition is found to exist, the hospital is obligated to provide that individual with either necessary stabilizing treatment or an appropriate transfer to another medical facility where stabilization can occur.

Hospitals also have certain obligations under EMTALA to accept appropriate transfers from other hospitals. Hospitals with specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units or with respect to rural areas, regional referral centers as identified by the Secretary in regulation) are not permitted to refuse to accept an appropriate transfer of an individual who requires these types of specialized capabilities or facilities if the hospital has the capacity to treat the individual.

The current proposed rule-making notification concerns patients who have already been admitted to one hospital but after admission require the specialized care of a specialty hospital to stabilize an emergency medical condition.  The obligations regarding specialty hospitals to patients who have already been admitted to other hospitals have been in a state of flux since 1999, when the United States Supreme Court considered the case of Roberts v. Galen of Virginia, 525 U.S. 249 (1999).  That care addressed whether EMTALA applies to hospital inpatients. As a result of that case, the United States Solicitor General advised the Court that regulations would be developed clarifying HHS’s position on this issue.

CMS proposed these regulations in 2002.  The 2002 proposed rule proposed that EMTALA continued to apply to admitted individuals who were not stabilized but did not otherwise apply to inpatients. However, it was clarified that EMTALA obligations would continue to apply to individuals whose conditions go in and out of apparent stability rapidly and frequently. The 2002 proposed regulations would not have extended the EMTALA requirements to stabilized inpatients even if they subsequently become unstable.

This policy was changed in the final rule which provided that EMTALA did not apply to any patient that presents with an emergency medical condition and is stabilized or when the hospital admits the patient, even though the patient may not be completely stabilized when admitted.  The end result of the 2003 final rule is that EMTALA does not apply to any inpatient, even one who was admitted through the dedicated emergency department, for whom the hospital had initially incurred an EMTALA obligation to stabilize, even in cases where the patient remained unstabilized after admission as an inpatient.

Further information was provided as part of the 2008 IPPS proposed rule which provided additional discussion and “clarification” regarding the responsibilities of hospitals with specialized capabilities to accept appropriate transfers of hospital inpatients.  CMS stated in 2008 that the obligation of EMTALA does not end for all hospitals once an individual is admitted as an inpatient of the hospital where the patient first presented with the emergency medical condition.  CMS’ position was that the admission only affected the EMTALA obligation of the hospital where the patient first presented with the emergency medical treatment and was subsequently admitted.   Specialty hospitals were obligated to accept transfer requests of unstable patients with emergency medical conditions as long as they have treatment capacity, even in cases where the patient has already been admitted to the initial hospital to which the patient presented.  CMS reasoning was that an inpatient admission at the admitting hospital did not end the EMTALA obligations of the specialty hospital and would contradict the intent of EMTALA to assure that specialty hospitals use their available specialty treatments to stabilize patients.

After receiving voluminous comments regarding the imposition of this obligations on specialty hospitals, CMS backed down when it issued the final IPPS rule in August of 2008. The final policy in 2008 was to end the specialty hospital’s EMTALA obligation as to an individual with an emergency medical condition upon admission to the facility to which the patient initially presented.  The specialty hospital’s EMTALA obligations were ended upon the initial admission even if the patients condition remained unstable following admission. CMS cited as part of its justification for this reversal that the previously stated policy could negatively impact patient care by increasing inappropriate transfers.  CMS also stated concern that the new policy could cause some facilities to limit the care that they provide which would reduce the emergency services available in the community.  Concern was also stated that patients that were admitted for elective procedures would not have the same right to transfer if their condition subsequently required.

CMS’ current notice of rule-making results from awareness that there continues to be varying opinions on whether EMTALA obligations continue once a patient is admitted or whether EMTALA obligations continue for patients who are not stabilized and require the services of a specialty hospital.  The current notice of rule-making asks for comments that address whether the existing rules should be revisited.  CMS requests “real world examples” to demonstrate whether it would be appropriate to revisit the rules. CMS also requests information regarding situations where specialty hospitals have refused to accept the transfer of a patient in need of their care for stabilization.

Comments on this rule will be accepted until February 22, 2011.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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The Health Care Law Blog is made available by Ruder Ware for educational purposes and to provide a general understanding of some of the legal issues relating to the health care industry. This site does not provide specific legal advice and you should not use the information contained on this site to address your specific situation without consulting with legal counsel that is well versed in health care law and regulation. By using the Health Care Law Blog site you understand that there is no attorney client relationship between you and Ruder Ware or any individual attorney. Postings on this site do not represent the views of our clients. This site links to other information resources on the Internet; these sites are not endorsed or supported by Ruder Ware, and Ruder Ware does not vouch for the accuracy or reliability of any information provided therein. For further information regarding the articles on this blog, contact Ruder Ware through our primary website.