Leadership

I once heard someone describe a true leader as one “who is the first to take the blame and the last to take the credit.”  What a stark contrast too many of our modern politicians who seek out “plausible deniability,” who seek credit for all manner of positives, and point fingers at others for all manner of negatives.  To listen to our political parties is to listen almost to children pointing fingers at the other when the glass breaks.

Leadership, to state it simply, is decisiveness.  Leadership is being sure and confident.  It is knowing, with clarity what you believe, and conveying that belief with the same clarity to others.  Most people are not entirely sure what they believe, mainly because developing a confident and deeply felt belief system requires a great deal of time and thought.  Most people look to leaders to tell them what to believe.  There is nothing wrong with this.  It is completely natural.  When we were children, we looked to our parents and teachers, perhaps an older sibling for this.  As adults, we do the same with politicians, historical heroes, spiritual guides, or more experienced adults.

Positive leadership is decisiveness that moves people forward to a better place—morally, emotionally, spiritually, physically, financially.  Negative leadership, of course, does the opposite.  Sometimes, however, these opposites might not be so easily distinguishable, or might be easily distinguishable only in hindsight.  It obviously sounded appealing to Germans in the 1930’s to make the Jewish population the scapegoats of all of their economic woes, but that scapegoating somehow led first to the confiscation of their property, then their internment in ghettos, then their extermination in death camps.  How?  Because the Nazi leaders were so confident in their beliefs—horrific as they were—they managed to convince millions of the correctness of their views.  There was no question, no doubt, no equivocation in the Nazi psyche as to whether they were right or wrong.  Well, they were wrong, as were the millions who followed them.

Today, we see the same unequivocation with Islamist extremism.  They are so confident in their calling, so sure of their world view, they are able to commit horrifying acts of violence against innocent men, women and children, and still thousands of people from all over the world flock to their cause.  The decisiveness of it all is where the appeal lies, because so many do not take the time or energy to think about what they believe and why.

The obligation on all of us followers—and we all are followers to one extent or another—is to weigh seriously and objectively all of the ideas we hear from all sorts of leaders in all sorts of places and come to our own conclusions as to what we believe and should believe.  We need to engage, in the words of John Stuart Mill, in the “marketplace of ideas.”  It is our responsibility to choose wisely among the leaders we see and hear, and to choose those who will move us forward.  It takes time to shop effectively and rationally in this market, to see clearly who is taking us to a better place, and who is marching us backward, who is “right” in the sense of advancing humanity in one way or another and who is “wrong.”

This begs the question, how do we know who or what is right?  When we watch, and we listen, and we learn, we will know.  We might disagree, but we will know.  False prophets—the real false prophets—the Adolph Hitler’s and the Osama bin Laden’s—“you will know them by their fruits,” in the words of Jesus.

So, amidst all the noise about what is wrong with the world and how to improve it, the myriad of views we see on TV, and all around us about how things should be and how they need to be fixed and by whom, be the follower who listens, watches, learns, and knows, and be the leader who, when you do know, moves those around you forward to a better place.

Leadership

PPO’s and Their Overarching Effect

Preferred Provider Organization (PPO) Agreements—what are they exactly?  You, hospital or surgery center, are a preferred provider, meaning the insurance carrier, the one who desperately wants you signing such an agreement, affords you preferential treatment when you sign up.  Well, for the most part, the most significant aspect of these agreements is lower reimbursement to the medical provider.  Some preference!

Let’s examine a bit more closely the effects of these contracts.

The overarching effect of these agreements is to create fee schedules, where they otherwise would not exist.  In the normal course, a medical provider would be reimbursed at the rates established by a government-created fee schedule, such as the federal Medicare fee schedules or the New Jersey No-Fault fee schedules, or, in the absence of an applicable fee schedule, at the provider’s usual and customary rate (UCR).  Insurance carriers welcome government-imposed fee schedules, because they tend to reimburse medical providers at rates lower than the provider’s UCR, in effect cutting the carrier’s costs.

Carriers also realize they could benefit even more by creating their own fee schedules, where there were no government fee schedules, as long as they could get providers to agree to accept the lower reimbursements.  Hence, the creation of networks.  Carriers like to promise patient referrals in exchange for signing up to the lower reimbursement rates; they also like to promise quicker payments.  It is impossible for anyone other than the provider itself to determine whether these promised benefits exceed the detriment of lower reimbursements, or even whether the promised benefits exist.  And, of course, some PPO agreements are better than others.  But, it is possible–perhaps very possible–the reality of the PPO the medical provider is committed to is not nearly as beneficial to the medical provider as the carrier promised.

This would seem to be especially true in areas where patient referrals do not even come into play, such as hospital emergency room (ER) claims.  ER patients usually have no choice as to the hospital they will go to for treatment.  They head, in most instances, whether by ambulance or other means, to the nearest ER facility.  They do not choose a facility based on whether or not the facility is part of their insurance carrier’s network.  Accordingly, commercial insurance ER claims should not even be subjected to a PPO arrangement.  These claims should be paid at UCR by commercial carriers.  The same is true of Workers Compensation ER claims, since there is no government-imposed Workers Compensation fee schedule in New Jersey.  Likewise, the rules and regulations governing No-Fault exempt ER treatment from the relevant fee schedules, maintaining a history of hospital ER claims being paid at UCR.  The only thing enabling reimbursement to hospitals at rates lower than UCR in all three of these circumstances is the existence of PPO’s.

Understand, too, why these agreements are so important to carriers.  Regardless of how effective or ineffective you think government action can be, we can all agree at least that when a government entity promulgates fee schedules, it does so in order to keep down the related insurance rates.  For example, the no-fault fee schedules were created in an attempt to reduce auto insurance premiums for the consumer.  Whether they did so or not is another question, but, at least this was the intent.  When carriers create their PPO fee schedules and rates, they do so to improve their bottom lines.  There is nothing wrong with profit, but I state things this way, so that medical providers make informed choices when deciding whether or not to become a “preferred” provider.

PPO’s and Their Overarching Effect

The Standard of Reimbursement for Medical Providers Under the New Jersey PIP Laws

The following is a summary of reimbursement standards for medical treatment provided to a patient who was injured in a motor vehicle accident in New Jersey.  Let’s say you are an orthopedic surgeon who practices in north New Jersey, and a patient’s primary doctor has requested an orthopedic consultation for an assessment as to whether surgery may be needed for a knee injured in a motor vehicle accident.  The patient presents to you, and you conduct a comprehensive evaluation and examination, and make your recommendation.  You billed for the consultation under CPT Code 99245, but the PIP insurer reimbursed you only $252.93, which is less than the amount you billed.  You contact the insurer and they insist the amount is proper. As it turns out, the insurer is correct.  The New Jersey Department of Banking and Insurance (“DOBI”) has enacted various medical fee schedules, and indeed a fee schedule exists for Physicians and the amount for the CPT Code at issue is what the insurer paid.

 

What if a medical provider renders a service, but there is no corresponding amount on a medical fee schedule?  For example, what if a physician provides treatment and the applicable CPT Code does not appear on the physician fee schedule?  In this instance, the physician is entitled to reimbursement at the “usual, customary and reasonable” amount.  But how is this amount, often coined the “UCR amount” determined?

 

The current regulations governing New Jersey PIP provide the standard for analysis to determine this amount.  N.J.A.C. 11:3-29.4 (e)(1) provides,

 

“For the purposes of this subchapter, determination of the usual, reasonable and customary fee means that the provider submits to the insurer his or her usual and customary fee by means of explanations of benefits from payors showing the provider’s billed and paid fee(s).  The insurer determines the reasonableness of the provider’s fee by comparison of its experience with that provider and with other providers in the region. National databases of fees, such as those published by FAIR Health (www.fairhealthus.org) or Wasserman (http://www.medfees.com/), for example, are evidence of the reasonableness of fees for the provider’s geographic region or ZIP code. The use of national databases of fees is not limited to the above examples. When using a database as evidence of the reasonableness of a fee, the insurer shall identify the database used, the edition date, the geozip and the percentile.”

 

It is important to recognize the provider has the initial burden of proof that is, the provider must prove the “usual and customary” fee.  Here, you should be able to prove you bill the consistent amount to different insurers.  You should also organize the explanations of benefits you receive from different insurers, to be able to show what insurers have paid you for the treatment.  The insurer is then permitted to introduce data as to the “reasonableness” of the rates.  You can do this by showing your experiences with payments from other carriers, as well as introducing data from national databases.

The Standard of Reimbursement for Medical Providers Under the New Jersey PIP Laws

The number of electronic transaction is growing everyday in the modern world where technology is embraced and people are looking for alternative ways of doing business. One major factor that most online companies consider is the safety of the data transmitted daily, all the data stored in clouds or other locations are prone to hacking. Major companies such as yahoo, drop box, and LinkedIn have all in the past experienced data breach and this has prompted many other firms to look for security of the information in the form of cyber liability insurance. This is a new type of liability coverage that is geared towards protecting the companies financially in cases of electronic data breach security.

How It Works

Cyber liability insurance covers any kind of liability that arises out of unauthorized use of electronic data, unauthorized access to data or software, which is operated by a company. In basic terms, it covers data theft and the spreading of viruses to the company website. It is imperative to understand that it coves error or omission and negligence associated with data and use of the software as well. For example, if an employee sends personal information of a client to another clients email accidentally, the company will be liable to cover and the insurance works will cover such instances. Many may wonder about the difference between the traditional liability cover and cyber liability cover; however, the main difference is that traditional liability insurance covers only tangible objects; however, cyber covers non-tangible objects.

The Main Features

The main item covered by the insurance policy is network privacy; it protects you in case a client or member of the public suffers damage or loss because of your inability to protect sensitive information or data that is stored on your network. This issue often arises when there is data theft of security leaks, the data breach could cause inaccessibility to access the data which they entitled to. Moreover, modern polices are customized to cater for electronic media cover, this is vital in covering libel, defamation, invasion of copyright, privacy, slander of any kind of infringement that arises from online publication of electronic data.

In summary, cyber liability cover is important in keeping electronic data and software safe from hackers and there are numerous polices depending on the company taste and preference.

Test Post from Callagy Law Blog

Test Post from Callagy Law Blog http://callagylawblog.com