Medicaid program; federal funding for Medicaid eligibility determination and enrollment activities. Final rule

This final rule will revise Medicaid regulations for Mechanized Claims Processing and Information Retrieval Systems. We are also modifying our regulations so that the enhanced Federal financial participation (FFP) is available for design, development and installation or enhancement of eligibility determination systems until December 31, 2015. This final rule also imposes certain defined standards and conditions in terms of timeliness, accuracy, efficiency, and integrity for mechanized claims processing and information retrieval systems in order to receive enhanced FFP.

Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan

BACKGROUND

Cognitive errors in the course of clinical decision-making are prevalent in many cases of medical injury. We used information on verdict's judgment from closed claims files to determine the important cognitive factors associated with cases of medical injury.

METHODS

Data were collected from claims closed between 2001 to 2005 at district courts in Tokyo and Osaka, Japan. In each case, we recorded all the contributory cognitive, systemic, and patient-related factors judged in the verdicts to be causally related to the medical injury. We also analyzed the association between cognitive factors and cases involving paid compensation using a multivariable logistic regression model.

RESULTS

Among 274 cases (mean age 49 years old; 45% women), there were 122 (45%) deaths and 67 (24%) major injuries (incomplete recovery within a year). In 103 cases (38%), the verdicts ordered hospitals to pay compensation (median; 8,000,000 Japanese Yen). An error in judgment (199/274, 73%) and failure of vigilance (177/274, 65%) were the most prevalent causative cognitive factors, and error in judgment was also significantly associated with paid compensation (odds ratio, 1.9; 95% confidence interval [CI], 1.0-3.4). Systemic causative factors including poor teamwork (11/274, 4%) and technology failure (5/274, 2%) were less common.

CONCLUSIONS

The closed claims analysis based on verdict's judgment showed that cognitive errors were common in cases of medical injury, with an error in judgment being most prevalent and closely associated with compensation payment. Reduction of this type of error is required to produce safer healthcare.

Herbicide exposure and veterans with covered service in Korea. Final rule

This document adopts as a final rule the Department of Veterans Affairs' (VA) proposal to amend VA adjudication, medical, and vocational rehabilitation and employment regulations to incorporate relevant provisions of the Veterans Benefits Act of 2003. Specifically, this document amends VA regulations regarding herbicide exposure of certain veterans who served in or near the Korean demilitarized zone and regulations regarding spina bifida in their children. It also amends VA's medical regulations by correcting the Health Administration Center's hand-delivery address.

The false claims act and the eroding scienter in healthcare fraud litigation

This article addresses the federal government's expansive methods in tackling healthcare fraud, particularly in misapplying the False Claims Act. Although tasked with the obligation to curtail the fraudulent submission of Medicare & Medicaid claims, the U.S. government must rein in the current trend to utilize the False Claims Act against smaller medical providers. As the Act's original focus has ebbed in significance, the government has increasingly applied the False Claims Act to circumstances that do not evince actual fraud. In doing so, federal courts have effectively eroded the statute's critical scienter requirement. The federal common-law doctrines of "payment by mistake" and "unjust enrichment" adequately address the payment of non-fraudulent, albeit false, Medicare & Medicaid claims. Yet the federal government pursues these appropriate remedies only rarely and in the alternative, essentially when the government fails under the False Claims Act. Thus, this article argues for reform, calling for a clearer delineation between remedial and punitive measures. In cases involving smaller medical providers, courts should strictly limit the False Claims Act to those instances where fraud is clearly manifest.

Medicaid program and Children's Health Insurance program (CHIP); revisions to the Medicaid Eligibility Quality Control and Payment Error Rate Measurement programs. Final rule

This final rule implements provisions from the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) (Pub. L. 111-3) with regard to the Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) programs. This final rule also codifies several procedural aspects of the process for estimating improper payments in Medicaid and the Children's Health Insurance Program (CHIP).

Interim final rules for group health plans and health insurance issuers relating to internal claims and appeals and external review processes under the Patient Protection and affordable Care Act. Interim final rules with request for comments

This document contains interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under the Patient Protection and Affordable Care Act. The regulations will generally affect health insurance issuers; group health plans; and participants, beneficiaries, and enrollees in health insurance coverage and in group health plans. The regulations provide plans and issuers with guidance necessary to comply with the law.

Setting the time and place for a hearing before an administrative law judge. Final rules

We are amending our rules to state that our agency is responsible for setting the time and place for a hearing before an administrative law judge (ALJ). This change creates a 3-year pilot program that will allow us to test this new authority. Our use of this authority, consistent with due process rights of claimants, may provide us with greater flexibility in scheduling both in-person and video hearings, lead to improved efficiency in our hearing process, and reduce the number of pending hearing requests. This change is a part of our broader commitment to maintaining a hearing process that results in accurate, high-quality decisions for claimants.

Extension of expiration dates for several body system listings. Final rule

We are extending the expiration dates of the following body systems in the Listing of Impairments (listings) in our regulations: Cardiovascular System, Endocrine System, Growth Impairment, Hematological Disorders, Musculoskeletal System, Mental Disorders, Neurological, and Respiratory System. We are making no other revisions to these body system listings. This extension will ensure that we continue to have in the listings the criteria we need to evaluate impairments in the affected body systems at the appropriate steps of the sequential evaluation processes for initial claims and continuing disability reviews.

Conditional rights, benefit reform, and drug users: reducing dependency?

United Kingdom government policy to increase social security claimants' entry to the labour market through conditions attached to unemployed, sickness and incapacity benefits now includes additional measures to activate particular groups such as lone parents and drug users. The latter are a prime target because of their high level of dependency on benefits and because social security rules are seen as having the potential to modify the behaviour of individuals with a lifestyle regarded as being at odds with the moral obligations of citizenship and incompatible with the government's realization of its wider economic and social goals. There are strict procedures for the identification of drug-user claimants, enabling additional conditions to be attached to their benefit rights. This article discusses the general trend in benefit reform towards increased conditionality and evaluates the reforms affecting drug users, considering human rights and other implications. It concludes by reflecting on the status of conditional rights to social security as social rights.

Medicare program: changes to the Medicare claims appeal procedures. Final rule

Under the procedures in this final rule, Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B pursuant to sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. After publication of a proposed rule implementing the section 521 changes, additional new statutory requirements for the appeals process were enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). In March 2005, we published an interim final rule with comment period to implement these statutory changes. This final rule responds to comments on the interim final rule regarding changes to these appeal procedures, makes revisions where warranted, establishes the final implementing regulations, and explains how the new procedures will be put into practice.

Medicare program; application of certain appeals provisions to the Medicare prescription drug appeals process. Final rule

This final rule will implement the procedures that the Department of Health and Human Services will follow at the Administrative Law Judge and Medicare Appeals Council levels in deciding appeals brought by individuals who have enrolled in the Medicare prescription drug benefit program. In addition, it will implement the reopening procedures that will be followed at all levels of appeal.

Revised medical criteria for evaluating malignant neoplastic diseases. Final rule

We are revising some of the criteria in the Listing of Impairments (the listings) that we use to evaluate claims involving malignant neoplastic diseases (cancer) under titles II and XVI of the Social Security Act (Act). The revisions reflect our adjudicative experience, advances in medical knowledge, diagnosis, and treatment, and public comments we received in response to a Notice of Proposed Rulemaking (NPRM).

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA): preauthorization of durable medical equipment. Final rule

This document amends the Department of Veterans Affairs (VA) medical regulations for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) preauthorization section by increasing the dollar ceiling for purchase or rental of durable medical equipment (DME) from $300 to $2,000.

Medicare program; changes to the Medicare claims appeal procedures; continuation of effectiveness and extension of timeline for publication of final rule. Interim final rule with comment period; continuation of effectiveness and extension of timeline for publication of final rule

This notice announces the continuation of effectiveness of a Medicare interim final rule with comment period and the extension of the timeline for publication of the final rule. This notice is issued in accordance with section 1871(a)(3)(C) of the Social Security Act (the Act), which allows an interim final rule to remain in effect after the expiration of the timeline specified in section 1871(a)(3)(B) of the Act (the "regular timeline") or, if applicable, at the end of each succeeding 1-year extension to the regular timeline, if prior to the expiration of the timeline, the Secretary publishes in the Federal Register a notice of continuation and explains why the regular timeline or any subsequent extension was not complied with.

Effect of delegation on standard of review. Geddes v. United Staffing, 469 F.3d 919 (10th Cir. 2006)

When an ERISA plan administrator delegates his discretionary authority to render plan benefit decisions to a third party, even one that is not a fiduciary, de novo review is not triggered when litigation arises. Rather, the standard for review is the "arbitrary and capricious"standard as set by the US. Supreme Court's 1989 decision in Firestone Tire and Rubber Co. v. Bruch.

Standard of review-effect of conflict on standard of review. Metropolitan Life Insurance Co. v. Glenn, _S. Ct._, 2008 WL 2444796 (6/19/08)

An ERISA plan administrator, whether it is an insurance company or a self-insured employer, has a conflict of interest if it both decides who receives benefits and makes benefits payments. That conflict of interest is one factor that should be taken into account in determining whether the administrator has abused its discretion in a case.

Reviews of liability claims against surgeons: what have they revealed?

Closed claims reviews are a robust source of severe surgical errors for study. Most errors are preventable. Most preventable technical errors and judgment errors occur during care provided by competent surgeons. Failure to operate within a proper scope-of-practice is the most common cause of incompetence. Patient factors and systems failures, including human factors, cause or profoundly contribute to the cause of most technical errors. Regardless of its cause or preventability, a technical error sets the stage for other errors in care that relate to systems' failures and surgeons' judgment failures. Failed judgment and poor decision-making are usually the result of cognitive errors caused by flawed behavioral practices instead of lack of knowledge. Systems of care and good behavioral practices are catalysts that maximize the power of knowledge and skill to achieve good outcomes. The uniform application of knowledge and skill in a favorable environment is as important as the possession of knowledge and skill. Identifying systems and behavioral causes of errors may help to define best practices and lead to safer patient care through improved systems of care and increased diligent attention to ordinary tasks that require more time than knowledge on the part of surgeons.

[Legal aspects of the health care institution liability for nosocomial infections]

In this paper, the basic concepts concerning the liability of health care institution for nosocomial infections are presented. The principles of ex contracto and ex delicto liabilities, as well as the concept of so-called anonymous guilt are discussed. The range of duties for both the health care institution and the employed medical personnel is indicated, the duties and the consequences of their non-fulfillment are systematized, and the obligatory jurisdiction concerning the functioning of prima facie evidence is considered. The author aimed at explaining the principles governing the civil liability of health care institutions and their employees.