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The Health Law Advisor - Spring 2007

DETROIT MEDICAL CENTER - WAYNE STATE UNIVERSITY
JOINT RESIDENCY PROGRAMS: PROGRESS MADE, BUT WORK REMAINS

Andrew B. Wachler, Esq.
Jessica L. Gustafson, Esq.
Paul Bozyk, M.D.

On November 22, 2006, the Detroit Medical Center ("DMC") and Wayne State University ("WSU") announced a temporizing resolution to a long-standing contractual dispute. This dispute threatened both the future of the DMC/WSU jointly sponsored residency programs and patient access to quality care in Michigan. The resolution, in the form of a legally binding "Memorandum of Understanding," provided basic provisions to serve as the framework for a final, definitive agreement between the parties in the future. This article will address the dispute between DMC and WSU from the perspective of resident training (also known as "graduate medical education"); the current status of the DMC/WSU jointly-sponsored residency programs as defined by the Memorandum of Understanding; and the residents' role in effectuating a resolution of the dispute between DMC and WSU.

DMC and WSU, working in partnership, have enjoyed a rich tradition of providing physician training for decades. Roughly 1000 residents in nearly 70 accredited specialty and subspecialty-training programs have the opportunity to receive university-centered residency training from the renowned faculty of WSU, while providing clinical services to meet the challenging medical needs of the patient community seen in the Detroit DMC hospitals. This DMC/WSU resident workforce provides a significant contribution to primary healthcare within Detroit and plays a vital role in the health care safety net for the uninsured and underinsured.

While partnership has clear benefits for medical education and clinical service, disputes between DMC and WSU arose surrounding multiple issues. Areas of disagreement included the payment structure for medical training and clinical care provided by WSU physicians, the ability of the parties to work together under non-exclusive arrangements, and control of various resident training programs which have historically been co-sponsored between the institutions.

Casualties of this conflict were first announced in April 2006, when inability to achieve contractual agreement at that time resulted in a nine month contract extension. This extension was unable to rectify core differences between the parties, which led to the discontinuation of the orthopedic surgery residency program. This program was the second largest orthopedic residency in the Midwest and had received national recognition for their contribution to trauma surgical care. At the DMC's discretion, the state and federal funding paid to them for resident training was not released to follow these residents to new programs, despite Michigan State Medical Society and the American Medical Association positions urging such temporary transfer of funds upon residency program closure. As a result, twenty-four DMC/WSU orthopedic residents were forced to seek other accredited programs that would be also willing to incur the cost of their training, and relocate by July 2006. These residents, who initially chose to pursue their medical training in Detroit in good faith, were ultimately dispersed throughout the state and country.

Several months later, it became clear that there was little progress in contract negotiations, jeopardizing the remaining residents who relied on both sponsors for their continued resident training. This was recognized by the accrediting body for graduate medical education, the Accreditation Council for Graduate Medical Education ("ACGME"), which mandates that all residency programs demonstrate adequate institutional support for resident training in an environment conducive to medical education and clinical care.

Throughout months of interaction, the ACGME requested documentation detailing how resident education and well-being was to be preserved, and held an onsite review of the institution to evaluate the long term stability of the institutional agreements to date. If these conditions were not satisfactory, the ACGME was empowered to withdrawal accreditation at special meeting held in the end of November 2006. Had the DMC/WSU institution lost ACGME accreditation, all DMC/WSU residency programs likely would have been discontinued, resulting in the mass relocation of nearly 20 percent of Michigan's resident workforce out of a single health system. This relocation would have been at the personal, professional, and financial expense of each individual resident. However, there would have been a higher cost to the community, which is comprised of many who are already medically underserved and depend on the DMC for provision of care.

The fear of the termination of DMC/WSU partnership and their cosponsored residency programs invoked active involvement from numerous parties, including the Wayne State University Board of Governors, the Detroit Medical Center Board of Trustees, DMC/WSU residents, WSU School of Medicine students, medical societies representing both Wayne County and the State of Michigan, Detroit Mayor Kwame Kilpatrick, and Michigan Governor Jennifer Granholm, among others. David Fink was appointed by Governor Granholm to mediate the negotiations in early November.

The outcome of this concerted effort was realized at a press conference called by Governor Granholm on November 22, 2006, where DMC and WSU announced that they finally had reached agreement in the form of a binding Memorandum of Understanding, which became effective January 1, 2007. This document provided an outline of the main provisions that the parties would finalize at a later date in an executed final contract.

Pursuant to the Memorandum of Understanding, which addresses the teaching, clinical, and administrative arrangements between DMC and WSU, the initial term of the agreement between DMC and WSU is for 3-1/2 years. Following this 3-1/2 year initial term, the contract will be automatically extended for an additional year, unless either party gives 18 months' notice of intent not to renew. Other key provisions of the agreement include the following:

• DMC will allocate and pay to WSU $76 million per year for clinical, teaching and administrative services.
• All of the 68 current graduate medical residency programs will be continued until at least 2009. Notably, however, not all of these residency programs will remain jointly sponsored by both DMC and WSU. A small number of the residency programs will be solely sponsored by either DMC or WSU, provided the new solely sponsored programs are able to obtain ACGME accreditation. Additionally, after June 30, 2008, either DMC or WSU may apply for sole sponsorship of a number of residency programs not strictly tied to the Hospital sites.
• DMC will pay WSU up to $8.8 million in performance bonuses and recruitment support.
• DMC and WSU agree to focus on their partnership for 18 months, and not "pursue new competitive activities that would disrupt the partnership." However, the WSU Physician Group is permitted to partner with Oakwood Health System to open an ambulatory care center in Troy, Michigan. See Memorandum of Understanding, DMC/WSU 2006.

The Memorandum of Understanding was a critical step, which was recognized by the ACGME, which subsequently granted a two-year institutional re-accreditation. While this secures some degree of stability for the DMC/WSU residency programs, it should be noted that the typical renewal of accreditation occurs every four to five years. Also, the ACGME issued several citations and identified issues that needed to be addressed in a progress report by DMC/WSU, including a statement of institutional commitment to the residency programs. This report has been submitted and will be evaluated in April 2007. If the progress report is inadequate, or if other additional areas of concern evolve, the DMC/WSU residency programs may be subject to an additional ACGME review before the scheduled timeframe, with accreditation again placed in jeopardy.

While the Memorandum of Understanding does demonstrate progress, it does have noticeable shortcomings. This document, which is thirteen pages (including signatures and attachments), does not articulate many of the details of the anticipated final contract. As in the interpretation of any contract, DMC and WSU could interpret its provisions differently, which may impede negotiations as the parties make efforts to enter into a formal final agreement. As of this writing, no finalized contract between DMC and WSU exists.

As noted above, achieving the temporizing agreement in the Memorandum of Understanding was the result of influence from multiple parties. The DMC/WSU residents played a particularly important role in effectuating a resolution to the dispute between their co-sponsors.

Early in the process the DMC/WSU residents realized that they were very important stakeholders in the outcome of the negotiations, as apparent from the potential jeopardy placed on their continued training in an ACGME accredited program. Notably, the completion of an ACGME-accredited residency program is a condition for medical board eligibility. However, loss of institutional accreditation would have likely resulted in the discontinuation of DMC/WSU residency programs altogether. With their training in jeopardy, residents felt that they should be afforded an opportunity for input in the negotiation process.

Once it appeared that contract negotiations between DMC and WSU had stalled, residents employed several means to communicate their positions to DMC and WSU. This began with formal letters to institutional leadership defining the resident role as a neutral third party in contract negotiations, with support for the continuation of their current co-sponsored graduate medical education. These correspondences continually emphasized the threat to their own training, as well as to those patients who required their medical services. They involved the media, had a press release, and held rallies attended by an estimated 400 residents and medical students, to articulate the need for a DMC and WSU agreement to the institution as well as the public.

Additionally, the residents obtained independent legal counsel of Wachler & Associates, P.C. The residents and their legal counsel provided the Governor's appointed mediator, Mr. Fink, position papers and additional information regarding the residents' legal rights afforded to the residents through the resident contract with the DMC/WSU. Notably, all residents are afforded rights pursuant to their individual residency agreements. Pursuant to the standard DMC/WSU residency agreement for the 2006-07 academic year, the DMC/WSU institution has a contractual obligation to provide all co-sponsored residents with a jointly sponsored, ACGME-accredited training program. Breach of the DMC/WSU residency agreements would have resulted in substantial damages to the DMC/WSU residents, potentially including lost wages (both current and future earnings), relocation costs, emotional damages, etc. As a result of their communications with the negotiation mediator, the DMC/WSU residents were able to lend their insight and concerns to the negotiation process.

Further, the residents' communications with DMC and WSU leadership ultimately led to the institutional recognition of the residents' rights. For example, during and subsequent to the contract negotiations between DMC and WSU, the DMC/WSU residency programs worked to substantially revise the standard residency agreement that the DMC/WSU residency programs routinely entered into with residents. Although several changes to the standard residency agreement were enacted for the 2007-08 academic year, DMC/WSU reaffirmed their support for residents by expressly including that the institutional responsibilities included providing ACGME-accredited educational training programs. Thus, DMC/WSU is contractually obligated to the DMC/WSU residents to provide medical education and clinical exposure in substantial compliance with ACGME requirements.

In summary, though the intermediate solution to the dispute between DMC and WSU may be imperfect, the Memorandum of Understanding as adopted by the parties provides a framework for the future relationship between the DMC and WSU. However, it is essential that the DMC/WSU institution take the necessary steps to provide adequate support to the existing DMC/WSU residency programs, as defined by the ACGME. To achieve this end, and meet the contractual obligation to its residents, it is imperative that DMC and WSU enter into a final written agreement enacting the terms of the Memorandum of Understanding.

Paul Bozyk, M.D. graduated from the Wayne State University School of Medicine in 2003 and completed his residency in internal medicine from the cosponsored DMC/WSU program in 2006. During residency, Dr. Bozyk was trained by academic physicians from the Wayne State University Department of Internal Medicine within the hospitals of the Detroit Medical Center. He currently serves as Chief Medical Resident in Detroit Receiving Hospital, and is the President of the DMC/WSU Resident Council. Dr. Bozyk can be reached at pbozyk@med.wayne.edu.

NATIONAL PROVIDER IDENTIFIER DEADLINE FAST-APPROACHING

The compliance deadline for providers to obtain and use a National Provider Identifier (NPI) is May 23, 2007. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard unique identifier for health care providers, called the NPI. After the compliance deadline, the NPI will be the only health care provider identifier that can be used for identification purposes in standard transactions carried out by covered entities. More information on the NPI can be found on the CMS website: http://www.cms.hhs.gov/NationalProvIdentStand/.

CASH CARE AND RETAIL MEDICINE OPPORTUNITIES ENHANCE YOUR
PRACTICE: LEGAL ISSUES EVERY DOCTOR SHOULD KNOW

Susan H. Patton, Esq.
Adrienne Dresevic, Esq.

Retail and cash care medical practices increasingly appeal to physicians and patients for a wide variety of reasons. Mass media is witness to the surge in consumer demand for health related life-style services that help healthy people look good and feel good about themselves. Weight loss clinics, wellness centers, personal nutrition and fitness services, laser hair removal clinics, massage therapy, acupuncture, smoke stopping programs, medical spas, cosmetic surgery and dentistry, Lasik, hair transplants, age-defying skin care, dental whitening and veneers, skin whitening or tanning, are examples of life-style driven services. "Worried well" consumers are concerned with the prevention and early detection of health care problems. They demand health related services that provide peace of mind. Open access clinical and sleep laboratories and whole body CT or MRI scans help the "worried well" detect substance abuse, sleep problems, latent cancer, gallstones, or clogged arteries. Blood pressure testing, bone density screening, elective endocopies and health education programs provide the "worried well" with needed reassurance about their health status. Elective ultrasounds can reassure anxious parents about "the delightful reality" of their unborn babies.

Both physicians and consumers alike are drawn toward concierge or retainer medical practice models in pursuit of a more personal and private physician patient relationship, greater patient and professional satisfaction, larger blocks of times to interact with one another and no intrusive third party involvement. Concierge or retainer practices harken back to the pre-Medicare days when physicians made house calls and patients had 24/7 access to personal physicians.

Physician needs are also behind the dramatic expansion of retail and cash care practices and sidelines. A traditional medical practice can benefit from retail or cash care sidelines that compliment a practice or allow a physician to pursue a personal professional interest. Retail or cash care sidelines can diversify and buttress traditional medical practice revenues from third party payors and make a physician office a convenient destination for "one stop shopping" for all medical or dental needs.

Some of these opportunities have been around a long time and include national, turnkey brand name franchises like Lenscrafters, Medical Weight Loss Centers and Dermacare Laser & Skin Care Clinics. There are lots of medical franchises on the Internet. New ideas become new franchise realities every day. The rigid structure of a franchise, with its required adherence to trade and brand standardization, will not be right for everyone. Some physicians with an interest in adding a retail side line to a traditional medical practice will custom build their own niche side line from the ground up to serve a personal interest or meet a consumer demand.

Some physicians with traditional medical practices are saying "goodbye" to third party insurers and "hello" to cash. National provider networks, such as SimpleCare, are targeting the growing numbers of patients in need of traditional medical services who have private health care spending accounts ("HSA"), high deductible major medical insurance plans, are high income uninsured, or who have an interest in consumer driven health care. This category of health care consumers will increase as traditional employer insurance benefits shrink and individuals are forced to assume more responsibility for their health care choices. HSA accounts, in particular, are a boon to retail medical practices targeted toward the "worried well" and people with a healthy lifestyle because they enable patients to prefund and pay for elective health care services with pre-tax dollars. Self-funded or high deductible patient populations tend to be consumer savvy in their purchase of health care services because they have a more direct personal stake in how their health dollars are spent because a significant portion comes out of their own pockets. Patients with significant first dollar costs tend to be receptive to advertising messages relevant to cost and comparison-shopping alternatives. Empowered patient-consumers are educated to look for physicians who will reward their cash payments with discounts.

Finally, physicians are drawn toward retail or cash care practices because they are fed up with the hassle associated with traditional medicine and its declining reimbursements, criminalization of mistakes, increasing patient loads, and enormous administrative costs of dealing with claims processing, billing and collection. Some of these physicians will continue in traditional practice but go "Non-Par" with third party payors altogether or severely limit the number of payors with whom they choose to do business. In a pure cash payment practice, no third party payors are involved. A result may be significantly lower overhead expenses because claims processing, patient billing and collection related activities are eliminated, as are contractual allowances, co-payments and deductibles and the threat of bad debt. Cash is not discounted, has no collection expense, and there is no wait for funds. With less overhead expense, a cash care practice can pass on the paperwork savings to cash paying patients by charging them less. Even Rep. Pete Stark is interested. On April 28, 2004, the Congressional Joint Economic Committee heard testimony on cash care practices with Rep. Stark saying "he had no problem with what he had heard here today."

Business consultants and advisors can help physicians make informed decisions as to whether retail or cash care activities are right for them or feasible in their community. Ethicists can help with questions about two tier medicine and equity in access issues. From a lawyer's perspective, there are some very important things every physician must know in order to do this right. The goal of this article is to briefly address some of the more important legal issues in retail and cash care practices. The answers to some common questions may vary with state law or by third party contract.

State licensing laws regulate the scope of the practice of medicine. What is permitted or prohibited may vary by state. What some states permit, others prohibit. Some retail and cash sidelines fall within the practice of medicine and are regulated. For example, a recent Michigan attorney general opinion has opined that the use of lasers is within the practice of medicine and laser hair removal centers may not be owned by laypersons. Some retail sidelines fall outside of the practice of medicine and are unregulated, such as smoke stopping programs. A threshold matter is to identify how the contemplated activity fits with state licensing laws.

Every state has its own regulatory idiosyncrasies. Some states are very old fashioned about who can provide medical services. Michigan is a "corporate practice of medicine" state that prohibits corporations, limited liability companies and other types of for profit business entities from employing physicians to provide professional services. Retail and cash care practices that provide services within the scope of the practice of medicine are restricted to physicians or separate legal entities that are wholly owned by physicians, such as professional service corporations and professional limited liability companies, or not for profit corporations. Corporations such as Wal-Mart or Target, that want to offer in-store health clinics for routine health care problems, must carefully structure these clinics in states such as Michigan. Legal ramifications from improperly structured clinics might range from threats to revoke corporate charters to threats to take actions against licensed professionals. State corporation laws can also keep professionals holding different types of licenses from doing business together. This prevents synergies between different classifications of licensees that have proved beneficial in other states, such as Ohio which permits chiropractors and physicians to own businesses together and which offer an array of orthopedic and chiropractic options under one roof. In Michigan, chiropractors cannot be shareholders in a professional services corporation with physicians. Michigan laws also prohibit physicians from splitting fees with non-physicians, although payments can be made to non-physicians for bona fide goods, items and services. Michigan is also a "certificate of need" state, which requires advance approval from the state before certain types of equipment can be acquired, such as CT and MRI scanners, or certain types of facilities can be opened, such as ambulatory surgery facilities. For ASCs, a state health care facility license is also required. These state laws can stifle innovation, limit competition and even outright prohibit some health related activities that are popular and perfectly legal in other states, to the detriment of Michigan health care consumers. They can also keep multi-state chain organizations out of a state. Because each state has different regulations, a knowledge of state law is essential to the successful structure of retail and cash care medical practices, especially where a franchise is involved.

Third party payors are the customary source of traditional practice revenues. The "mother" of all third party payor decisions is what to do about Medicare! Medicare and other third party payor rules and regulations are only relevant if the retail or cash care item or service is, or could be, a medically necessary covered service. If there is no chance that the item or services is a covered service, then the Medicare dilemma is removed. There are few situations where this determination is clear-cut. For example, Medicare does not cover weight loss services unless they are incorporated into the treatment of an underlying covered service such as diabetes, in which case they may be covered. Extreme care should be taken with Medicare in dealing with coverage questions. Medicare has recently undertaken a complete overhaul of the Advance Beneficiary Notice (ABN) billing rules, which permit physicians and other Part B providers to bill beneficiaries directly when Medicare will not cover services for lack of medical necessity or lack of coverage status. These rules are highly technical and heavily favor beneficiaries. Getting Medicare "right" is of critical importance in light of the potential for running afoul of the False Claims Act, Civil Monetary Penalties Act, the fraud and abuse laws and Stark anti-referral laws.

There are three ways to deal with Medicare. First, a physician can refuse to take Medicare beneficiaries as patients. This can be done informally by declining to establish a physician/ patient relationship with any Medicare beneficiaries.

Second, a physician can accept Medicare patients but refuse Medicare assignment. However, if a practice does not accept Medicare assignment and the service is a medically necessary covered service, the physician may only collect 115% of the 95% Medicare allowable amount. If a physician will see Medicare beneficiaries as patients in a retail or cash care practice, or if the practice will help patients obtain reimbursement from third party payors for any services which may be medically necessary covered services, a physician will still need to obtain a Medicare National Provider Identifier (NPI) and enroll as a Medicare provider. A physician must have an NPI to help patients get reimbursed from their third party payor where the physician requires cash and does not accept assignment. However, if a retail practice or sideline is all cash, and patients do not include Medicare beneficiaries or ask that the physician help them submit claims to a third party payor, the NPI could be avoided. If a physician is going to provide services to Medicare beneficiaries but not accept assignment, the physician will still need to complete a Medicare provider enrollment application but should NOT complete a participating provider application. As a result, the physician will be Non Par. However, Medicare still requires that a bill be submitted to Medicare for information purposes. As a result of not accepting assignment, a physician will receive payments directly from patients and patients will receive payment directly from Medicare. An operational business decision faced by physicians that do not accept assignment is whether the medical practice will provide insured patients with blank or completed CMS-1500 Forms.

Third, a physician may choose not to participate in the Medicare program completely for ALL practice locations and employers, which makes the physician's relationship to the patient one of a "private contractor." Medicare wants physicians to stay in the Medicare program. There are incentives to stay in and regulatory barriers to get out. A physician has to file an affidavit with Medicare and tell patients in writing that he or she has chosen to no longer participate with Medicare and that none of the services the patient receives will be covered by Medicare, even if the patient later changes their mind and tries to file a claim with Medicare without the help or knowledge of the physician. When this is done, even only once with one patient, a physician is compelled to stay out of the Medicare program for a minimum period of two years. Medicare's mandatory two-year exile period requires careful consideration before a physician chooses not to participate with Medicare completely. Physicians who fail to re-file affidavits every two years, reaffirming their intention not to participate in the Medicare program, will have their private patient contracts voided and must file Medicare claims for every voided contract. Physicians in a group may make individual elections not to participate in Medicare. When a group physician makes this choice, it does not affect the ability of the rest of the group to furnish and bill for services they furnish to Medicare beneficiaries. However, the group may not bill in its name for the services provided by the physician who has chosen not to participate in Medicare. There are certain exceptions to the prohibition on billing Medicare by physicians who have chosen not to participate in the Medicare program. For example, a non-participating physician can bill Medicare for emergency and urgent care services under certain circumstances. Further, patients who agree to a private contract with a non-participating physician are still eligible for covered services and the non-participating physicians may order, certify or refer a patient for Medicare covered items or services, provided the physician is not paid directly or indirectly for such services.

Many physician offices have two fee schedules: one for Medicare and one for private pay patients. It is permissible for physicians to have two or more fee schedules so long as a physician never charges Medicare patients substantially in excess of the physician's usual charge, which generally is considered the amount the physician charges to his or her private pay patients. Physicians who charge Medicare substantially in excess of their charge to private pay patients may be excluded from participation in the Medicare program, which is a penalty that is not relevant to physicians who have chosen not to participate in the Medicare program. This limitation remains for physicians who accept assignment, even if only occasionally.

Medicare is only one possible third party payor. Each governmental and private third party payor program has its own rules and regulations. Physicians may choose not to participate with certain third party payors and may choose not to accept certain patients. A review of each third party payor contract with whom the physician participates is also necessary to determine coverage issues under Medicaid, Blue Cross Blue Shield Plans, health care insurers, HMOs, PPOs and self-insured employer plans. Most governmental and many private third party payors prohibit physicians from balance billing. However, if a service is a non-covered service, then direct patient cash payment practices should be permitted. A careful audit of all third party payors is necessary to ensure compliance with all payor requirements.

What better way to make consumers aware of new retail or cash care medicine options than by advertising and offering special promotions? Media opportunities abound. Never use eyeglasses again. Lose weight while you sleep. Health care demands a high level of public trust. Health related advertising is regulated at both the state and federal level. The Federal Trade Commission and state watchdogs, including state physician licensing boards, protect consumers from advertising claims about health related goods, items and services that may be false, misleading or deceptive. Weight loss programs and nutritional supplements are chronically scrutinized for overstatements or misstatements in their advertising trade practices. Common retail marketing practices may be prohibited or fraught with peril when health care services are involved. Some states prohibit providing exams at no cost. The federal fraud and abuse anti-kickback laws prohibit physicians from offering or soliciting remuneration or anything of value to induce referrals for items, goods and services paid for with federal dollars.

With many of the hard legal and regulatory issues out of the way, physicians interested in retail and cash care side lines can consider operational issues, such as what does "cash" mean? Cash can mean dollars, checks, credit or debt card payments. Credit and debit card payments are ubiquitous in retail businesses. Physicians should be forewarned, however, that credit and debit card programs are subject to consumer protection procedures for disputing charges on a wide variety of reasons, including that a service was never provided or was not provided to the quality or satisfaction expected by the patient. Credit and debit card dispute procedures, coupled with merchant fees and transaction fees, can reduce overall return and constitute a type of contractual allowance as compared to a true cash care practice. Whatever "cash" means to a physician, payments can be required in advance, at the time of service, or upon receipt of invoice. However, care must be taken with retainer and concierge medicine. The Insurance Commissioners of some states have taken interest in advance payment arrangements which promise coverage for defined services as potentially falling within the definition of an insurance company. Check with your state Insurance Commissioner for the status of this issue if concierge or retainer services will be offered in exchange for a fixed monthly or annual fee.

Finally, as with any business, retail medicine or cash care side lines are subject to all state and federal laws and regulations governing business organizations, taxation, real estate, zoning, leases, contracts, collection practices, employment and insurance, among others. All of these general business issues must also be kept in mind.

Consumers are exposed to an explosion of non-traditional heath innovations in surfing the web, watching extreme makeover reality shows, listening to the radio, taking with friends and researching solutions to their own health challenges. With increased consumer demand for life-style and "worried well" health related services, needs of physicians to diversify their revenue base, a desire for more customized care by cost conscious health care consumers, and increased empowerment by consumers in how and where they spend their health care dollars, retail medicine and cash care side lines have gone mainstream, as a replacement or compliment to traditional medical practice. While retail medicine and cash care side lines are not as easy to design and implement as a non-health retail business, it is possible to thread the labyrinth of laws and regulations: to do it right and do it well.

This article is intended only as a brief summary of some the legal issues raised by adding retail and cash care services to a practice. This article does not address all of the potential issues associated with cash care and retail medicine practices. For questions about this or other health law related matters, please contact Susan Patton or Adrienne Dresevic of Wachler & Associates, P.C. at (248) 544-0888.

RECENT AND UPCOMING EVENTS AT WACHLER & ASSOCIATES, P.C.

• Abby Pendleton spoke on a number of healthcare topics at the Society of Pain Practice Management in March 2007 in Arizona.
• Abby Pendleton spoke on the Medicare appeals process at the Annual Meeting of the American Society of Addiction Medicine in April 2007.
• Andrew Wachler spoke on the Medicare appeals process at the Annual Meeting of the Michigan Hospice and Palliative Care Organization in April 2007.
• Andrew Wachler spoke on the topic of New Developments in Third Party Payor Audits at the 2007 Radiology Summit of Radiology Business Management Association (RBMA) in May 2007.
• Andrew Wachler will speak on the topic of Healthcare Legal Issues Impacting Radiology Providers at the 2007 Annual Meeting of the American Healthcare Radiology Administrators in July 2007.
• Andrew Wachler will speak on compliance issues facing hospice providers at the Annual Meeting of NAHC in October 2007.

For questions regarding any of the information contained in this newsletter, or if we can assist you with any of your legal needs, please contact the attorneys at Wachler & Associates, P.C. at (248) 544-0888:

For more information, please visit our website at www.wachler.com.