As EAMC’s sole in-house attorney, what day-to-day issues are the most pressing for you?
Roben Nutter: Compliance and regulatory issues take up most of my time. There are a lot of regulatory pressures in the healthcare environment right now. There’s a lot of regulatory focus by the government and RAC auditors who are looking for various ways to recoup payments. I serve as compliance officer for the whole organization.
There are also, of course, general legal issues. I’m spending time providing guidance, researching, and working with outside counsel, as well as on contract reviews and transactional issues.
What are the advantages of working for a small, regional healthcare system?
RN: We have about 3,000 employees in our system. I’m located in the main hospital facility, and I’m very accessible. People know who I am. They see my face and the faces of other administrators, including our CEO, who is walking the halls every day. That probably translates into a comfort level in discussing issues, raising issues. There may be a little bit more of a family feel as compared to much larger organizations. People are free to come by, talk to me, and raise questions. So I feel like I have a lot of access and knowledge about what’s happening in the organization.
Yesterday I received calls from our security department. A person came in [claiming] that she was pregnant. When she was taken to our delivery unit and staff began examining her, they found that she was not pregnant. When the staff realized that, it raised a lot of alarms and potential issues. They had questions for me about how far we can go in our questioning of her. Can we call law enforcement officials? What is our responsibility here? What can we do given the constraints around HIPAA?
“I think we have an advantage being a small organization to get on top of issues quickly and to intervene sometimes.”
I think we have an advantage being a small organization to get on top of issues like that quickly and to intervene sometimes; whereas if I wasn’t readily available, then maybe people would make certain decisions that I would have advised against them making.
What about the disadvantages?
RN: Some disadvantages are balancing available resources, being the only attorney, and juggling many different duties and responsibilities. And it’s a challenge in the healthcare environment generally—not just at EAMC. I’ve got a great team of people, and I rely on them heavily. I also rely on outside counsel fairly extensively, and I couldn’t do my job without them.
Outside counsel was essential to one of your key accomplishments—guiding the legal process of a major acquisition. What were your major challenges in EAMC’s acquisition of Lanier Memorial Hospital?
RN: That was a huge transaction from a legal perspective. It’s biggest thing that I’ve worked on over the past few years. We weren’t looking to acquire anybody; we were approached by representatives of that hospital in October 2013. We closed the deal in a relatively short time frame. It was completed on February 1, 2014.
Our CEO had talked about this abstractly. If the opportunity ever came up, he’d be interested in an acquisition. We talked through some of the issues around that and whether we thought that would be good for our organization. So when the opportunity came up, we were able to move quickly.
The financial state of that hospital was one of the biggest issues for EAMC to consider. Did we think we could turn it around? From a legal perspective, the biggest issue was assuming the liabilities of that facility. The due diligence period was so important, to make sure that we tried to uncover everything that we could that might be out there. We used a firm—Maynard Cooper & Gale, out of Birmingham—that we had a long-term relationship with. They were essential to the success of the deal.
How has the Affordable Care Act impacted your work?
RN: One of the ways it impacts me the most involves increased auditing and the government’s attempts to recover funds for things that they might consider fraudulent or in error. Across the country, we’re seeing increased pressure for billing compliance. There are so many regulations surrounding billing for Medicare, Medicaid, and commercial insurance carriers, and it’s hard to stay on top of all the new rules and regulations that seem to surface daily. The Recovery Audit Contractors are making sweeping record requests, looking for opportunities to see if something was billed incorrectly so they can recover those funds.
The system became so backlogged with appeals that the administrative law judges who worked for the Centers for Medicare & Medicaid Services (CMS) got so far behind that it was taking years to get appeals resolved. CMS is making changes that we all hope will improve the process. There’s been a moratorium, especially as it relates to medical necessity of inpatient stays—that’s the real big one—where they were denying payment for visits to the hospital when the physician said an inpatient stay was necessary. Before the moratorium, a lot of my time and my staff’s time was spent on hearings before administrative-law judges, defending with the attending physician or physician reviewers that a denied payment was appropriate.