2 August 2012

California Edition
Calendar
August 1-3
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IPA Used Non-Docs For Reviews

DMHC Says CEOs Son Made Decisions on Care
The Department of Managed Health Care issued an unusual cease and desist order against a Signal Hill medial group, claiming the son of its chief executive ofcer had been illegally reviewing cases and making medical necessity decisions for insurers. George Jayatilaka, M.D., is the CEO of the Accountable Health Care IPA. The DMHC alleges in his complaint that his son, Druvi Jayatilaka, the groups vice president, and another employee, Ambarish Pathak, had engaged in utilization reviews on behalf of nine health plans. Neither is a licensed physician, a requirement under state law to engage in prospective medical reviews, which could lead to the modication or even denial of specic kinds of care to patients. Altogether, Accountable provides care to more than 148,000 patients from nine different health plans in a risk-bearing arrangement. It includes Medicaid insurer L.A. Care Health Plan, Anthem Blue Cross of California, Aetna and Blue Shield of California. A DMHC spokesperson could not say whether the decisions rendered by Pathak and Druvi Jayatilaka had a material impact on care outcomes, adding that the case was still under investigation. The younger Jayatilaka appears to hold a medical degree from an unknown institution, records suggest. In 2009, he led suit against the National Board of Medical Examiners in an attempt to receive extra time to complete a licensing exam due to a disability. He lost the case in federal court last year and was ordered to pay more than $6,100 in costs, records show. He could not be reached for comment. George Jayatilaka did not return phone calls seeking comment. Pathaks LinkedIn prole says he is a medical management consultant. He referred a telephone inquiry to his attorney, Douglas Stuart of Santa Monica, who declined comment. The DMHC accused the pair of engaging in medical reviews since December 2008 until the cease and desist order was led on July 16. The agency was tipped to the alleged practices at Accountable through a condential complaint, according to agency spokesperson Marta Green. Green said the cease and desist order also applies to the health plans because they referred their patients over to Accountable. Under the Knox-Keene Act, everyone involved has to comply with the law, she said.

August 13-15
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August 19-21
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WEBINAR

Wednesday, August 15, 2012

10 A.M., PDT

CALIFORNIA HEALTH BENEFIT EXCHANGE: A PROGRESS REPORT

E-Mail info@payersandproviders.com with the details of your event, or call (877) 248-2360, ext. 3. It will be published in the Calendar section, space permitting.

Please join David Panush, director of government relations, the California Health Benefits Exchange, Anthony Wright, executive director, Health Access, and Jon Gabel, senior fellow, NORC/University of Chicago, to discuss the next major step in the implementation of the Affordable Care Act in California.

http://www.healthwebsummit.com/pp081512.htm
a HealthcareWebSummit Event
co-sponsored by

PAYERS & PROVIDERS

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NEWS

Page 2

Litigious Doctor Sues Patient Again

Kentucky Suit Filed After Treatment in California
The only individual physician in California ever to be the subject of an enforcement action by the Department of Managed Health Care has sued another one of her California patients again this time in Kentucky. Jeannette Y. Martello, M.D., led the suit against Bill Buck, a Duarte cabinetmaker, on July 20 in mostly rural Johnson County in the eastern portion of the state, records show. Martello, who claimed in her lawsuit that she worked as a locum tenens physician at Paul B. Hall Regional Medical Center until 2010, accused Buck in the lawsuit of contacting hospital management in July of that year in an attempt to discourage her continued employment at the facility. It contends that Martellos employment at the hospital was terminated as a result. The lawsuit accuses Buck of defamation and tortious interference and seeks a minimum of $5,000 in damages. Hospital spokesperson Donna Waddell noted that Martellos work at the hospital ended not because it terminated her, but because her license to practice medicine in Kentucky had expired. Records indicate Martellos license lapsed in Kentucky last February. Although Martello is a Southern California native and attended medical school at UCLA, she underwent a surgical fellowship at the University of Kentucky Medical Center early in her career as a physician, and had been licensed to practice in Kentucky since 1991. Waddell also noted that Martellos employment contract was with a locum tenens rm, Houston-based Whitaker Medical, and not directly with the hospital. Martello treated Buck at Huntington Memorial Hospital in Pasadena in April 2010 after he had severed part of a nger in a workplace accident. Although he had insurance with Anthem Blue Cross, and the insurer paid Martello about $2,500, she returned the money to Anthem and sought full payment from the Bucks, ling a lawsuit in Los Angeles Superior Court seeking more than $15,000. Martello received a default judgment against Jae Buck as the result of the way the Bucks led their response. Martello later led a lien against the Bucks South Pasadena condominium, claiming in her motion that Jae Buck had been abusive to her and that the couple fought often. A Payers & Providers investigation published last May determined Martello, who in addition to her medical training holds a law degree from UC Berkeley, had sued at least 70 of her patients in California after treating them at Huntington and other hosptial ERs in the San Fernando and San Gabriel Valleys. In 2010, the DMHC ordered Martello to stop balance billing her patients who had insurance, and led suit against her last year when she did not heed the order. The DMHC has also gotten many of Martellos lawsuits against her patients dismissed. In May, the DMHC successfully sought a preliminary injunction against Martello that prohibits her from ling further suits against her insured patients. Bill Buck has been one of the most vocal critics of Martellos conduct, posting several notices of the DMHC cease-and-desist order on review websites such as Yelp. The California Medical Board is also attempting to revoke Martellos license to practice medicine in this state, in part because of her balance billing of patients and suing them. A licensure hearing is scheduled for October. The allegations against Martello in California have no bearing on the case in Kentucky, according to her attorney, Jeremy Rogers of Louisville. The case speaks for itself, Rogers said.

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In Brief
L.A. Care To Sponsor Free Clinic At Sports Arena
L.A. Care Health Plan, the Medicaid managed care health plan, will again sponsor a free medical clinic at the Los Angeles Sports Arena next month. The clinic, which will be staffed by volunteer physician and dentists, drew an overwhelming response last year, with tens of thousands of people seeking care. This years clinic, which will be held Sept. 27 through Sept. 30, will feature a 20% larger capacity for dental and vision care, including the on-site manufacturing of crowns and denture repair. About 1,000 medical staff will be volunteering. Their services are being coordinated by the not-for-prot group Care Harbor. Care Harbor may be more important this year than ever before, said L.A. Care Chief Executive Ofcer Howard Kahn. Now is the time to begin transitioning the uninsured into care and to start the process of informing, educating and orienting people about what's to come with the implementation of federal healthcare reform. The opportunities for access to quality health services will be tremendous, and Care Harbor will be uniquely positioned to raise public awareness and eliminate hurdles for those seeking long term health solutions.

Womens Preventative Services Expand Under ACA

Insurers are now required to provide specific preventative care services as part of the Affordable Care Act. On Aug. 1, insurers were required to provide free of charge eight services to women free of charge. They include well visits,

MEET YOUR FELLOW READERS

Need to promote a conference? Your brand? Payers & Provider!s e-mail list for all editions is available for your marketing needs. Reach out to more than 12,000 healthcare professionals who read our publications. Call Claire Thayer at (877) 248-2360, ext. 3 or e-mail her at clairet@mcol.com.

Continued on Page 3

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Longer ALOS!*

NEWS

Page 3

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Kacic Resigns From CalOptima

Former Chairman Steps Down After Grant Issues
Edward B. Kacic has resigned from the board of CalOptima, little more than ve months after accusations of self-dealing involving a non-for-prot foundation he heads had surfaced. Kacic submitted his letter of resignation to the Orange County Board of Supervisors on July 30. He had served on the board since 2009, and although appointed its chairman in August 2011, he had temporarily been removed from the post earlier this year. Moreover, his reappointment to the board had been delayed, and it appeared increasingly unlikely he would receive one before his term expired on Sept. 30. CalOptima, which provides managed care coverage to about 400,000 of the countys Medi-Cal recipients, have been rocked by allegations of mismanagement for months now. Published reports indicate that as many as 14 top and middle management executives have left the organization in the past year. It is currently lacking both a chief executive and chief operating ofcer. Kacics conict with CalOptima began in February, when an anonymous letter surfaced that accused him of self-dealing. Payers & Providers reported on Feb. 23 that the Irvine Health Foundation, of which Kacic is the executive director, had submitted an application to receive a $9.3 million federal grant that would be used to provide medical homes and other services to CalOptima members. The foundation itself would not have received funds for its own use, but would supervise the employees engaged in the initiative. The Center for Medicare and Medicaid Innovation an afliate of the Centers for Medicare and Medicaid Services ultimately turned down the grant application. Kacic also co-chaired another organization, the Managed System of Care, that was in line to receive as much as $12.7 million in funding from CalOptima. Kacic and other ofcials have said that the Managed System of Care would have submitted the application for the federal grant itself, but had not been properly incorporated to do so. Although Kacic has strenuously denied any conicts and the California Fair Political Practices Commission declined to provide advice on the matter at the request of Orange County Counsel Chris Chrisos, fellow CalOptima board member and County Supervisor Janet Nguyen termed it a conict of interest. Nguyen, who received an appointment to the CalOptima board last year after lobbying by the regions hospitals, has been at odds with Kacic and other board members. In March, the Supervisors voted to delay Kacics reappointment. In May, the CalOptima board voted to remove Kacic as chairman on the same day it also voted to beef up its compliance practices. Soures have also suggested that an investigation is continuing into the possible use of CalOptima employees to prepare the Irvine Health Foundations bid for the grant. In his letter of resignation, Kacic said that it was inappropriate for CalOptima to be investigating such matters internally, and that an outside entity, such as a law rm, would have been more appropriate for an inquiry. The inquiry seems to have been taken inside the organization, with the internal counsel playing a signicant rolesince I dont believe in the propriety of asking individuals to investigate those to whom they ultimately report, I nd this situation odd, at best, he wrote.

In Brief
gestational diabetes screening, breastfeeding support, FDAapproved contraception methods and counseling, and HIV screening, among others. Certain religious organizations are exempted from paying for the provisions of the contraceptive services. The Obama administration will continue to work with all employers to give them the flexibility and resources they need to implement the healthcare law in a way that protects womens health while making common-sense accommodations for values like religious liberty, the U.S. Department of Health and Human Services said in a statement. Altogether, the expansion of services is being made to about 47 million women nationwide, including about 5 million in California.

Kaiser Enrollees More Likely To Stay After Using EHR System

Kaiser Permanente enrollees who use the systems electronic health records and associated patient portal are more likely to remain enrolled compared to non-users. According to a survey of nearly 400,000 Kaiser enrollees, those who use the My Health Manager are 2.6 times more likely to stay with the organization than those who do not use the system. We have always known that our members find these online tools convenient and empowering, but now we have proof that these offerings actually increase member loyalty and can improve the relationships between patients and their physicians, said Christine Paige, senior vice president for marketing and Internet services. The results of the study will be published in the latest issue of the American Journal of Managed Care.

STORIES OF ONE HIGHLY LITIGIOUS PHYSICIAN

$149 Call (877) 248-2360, ext. 2 to order OR CLICK HERE

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Payers & Providers

OPINION

Page 4

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A New View Of Americas Physicians

Predictive Analytics, Link Analysis Playing Larger Roles
his considered opinion. I am not a doctor and I dont play one on TV. You have gout! I am, however, an occasional patient. So To say that I was astonished would be an while I am not qualied to write about understatement. airway management or anesthesia carts or Gout? How do you work that out? the pros and cons of scrub laundering Well, you are English and the English services, I am ideally suited to ponticating drink a lot of port wine and too much port about physicians, their foibles and forts. wine often leads to gout. My rst encounter with an American I suddenly had an urge to take to the physician was a memorable one. I had been bottle, possibly copious quantities of port wine. in the US only a few months after arriving But instead I sought a second from England. opinion. I was directed to an With every yin, however, examination room where I there is a yang. Since then I waited patiently, and patienthave been innitely more like, for the physician. fortunate in my visits to After a while, a long while, I physicians. I have undergone heard footsteps in the corridor knee surgery, watching the outside, some activity, rustling specialist clean out fragments of papers, and a loud voice from my patella on a monitor saying: Whats this guys while being genuinely name? followed by the nurses entertained by a fascinating and whispered response: Geoffrey informative commentary from Charlton-Perrin. The door the physician as he explained ew open. In walked a what he was doing and why. physician I had never met in And eventually I had surgery on my entire life, arms By my shoulder - yes, that shoulder -to outstretched, a beaming smile on his face, as he bellowed, Geffy, baby! Geoffrey repair my rotator cuff at the hands of a assistant who and hugged me like I was his long-lost Charlton- surgeon and surgeonat their craft but were not only artists chum from childhood. Perrin friendly, helpful, informative and Friendliness, accessibility, down-to-earth. unpretentiousness these are And the reason I can say with some welcome qualities in a man of medicine. But authority that they were artists? I was there is such a thing as too much producing a video on ambulatory surgery friendliness, accessibility and center accreditation at the time and had the unpretentiousness! entire procedure lmed so I could include I remember another encounter some years parts of it in the video. later when I was experiencing extreme Afterward in the editing room, I marveled discomfort in my right shoulder. Every time I at the skill, the deftness, the sure hands of both raised my arm to pitch to one of my young physicians. And thanked my lucky stars that I sons, I felt a erce, stabbing pain that wasnt witness at the time to what they were prevented me from completing the doing to my body with what looked movement. I went to a physician who suspiciously like a hammer! For a patient, enjoyed great renown as ofcial orthopedic some things are best left a mystery. surgeon to the citys hockey team. Hockey players must often have shoulder problems, right? How could I go wrong?, I reasoned. Geoffrey Charlton-Perrin is the director of He examined me carefully, put me marketing and communications for the through several tests, but failed to come up Accreditation Association for Ambulatory with an answer. More examinations. More Health Care. tests. Still no answer. At the third visit, as I sat on the exam table being poked and prodded Op-ed submissions of up to 600 words are for a third time, he straightened up and welcomed. Please e-mail proposals to delivered with some fanfare, I might add editor@payersandproviders.com

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MARKETPLACE/EMPLOYMENT

Page 6

CONTROLLER/ DIRECTOR OF FINANCE

Casa Colina Centers for Rehabilitation, a nationally recognized leader in the field of medical rehabilitation located in Pomona, is seeking to fill the vital role of Controller to oversee the Finance and Accounting functions for the entire rehabilitation continuum with a total bed complement of 178 beds, and consisting of a hospital, brain injury program, 3 long term care facilities, an Adult Day Health Center and outpatient childrens program. The selected candidate will be responsible for all financial, payroll and A/P activities. Oversees internal controls to ensure revenue cycle effectiveness, expenditure management and safeguarding of assets. Prepares financial statements in a timely, accurate and efficient manner. Supervises all accounting and payroll staff. Responsible for tax returns and regulatory filings. Requirements include a Bachelors degree in Accounting or Business related field, two (2) years of supervisory experience, prior hospital/ healthcare accounting experience, and a working knowledge of accounting software programs. CPA background is strongly preferred. Excellent work ethic and motivation required. Competitive compensation and excellent benefit options available. To apply, visit us at www.casacolina.org/jobs. Principals only at this time.

HEALTH PLAN/HOSPITAL CONTRACTING CONSULTANT (flexible hours) A dynamic and growing medical group in the Los Angeles County area is currently seeking a highly experienced contracting consultant for the purpose of leading and successfully negotiating and renegotiating health plan and hospital contracts. The ideal candidate will have an understanding of all product lines within the managed care industry, be well-versed in contractual language, excel at maintaining positive working relationships internally and externally, and demonstrate an understanding of legal, financial and operational processes that meet company objectives. Flexible hours and telecommuting are available. If interested, please email your cover letter and resume to: ssabanal@ahcipa.com

It costs up to $27,000 to fill a healthcare job*

will do it for a lot less.

Employment listings begin at just $1.65 a word Call (877) 248-2360, ext. 2 Or e-mail: advertise@payersandproviders.com Or visit: www.payersandproviders.com
*New England Journal of Medicine, 2004.

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MARKETPLACE/EMPLOYMENT SEEKING A NEW POSITION?

Page 7

CAN HELP.
We publish advertisements for those seeking new career opportunities for just $1.25 a word. If you prefer discretion, well handle all responses to your ad. Call (877) 248-2360, ext. 2, or e-mail advertise@payersandproviders.com.

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