UNIVERSITY OF VIRGINIA
BOARD OF VISITORS
MEETING OF THE
MEDICAL CENTER
OPERATING BOARD
April 2, 2009
UNIVERSITY OF VIRGINIA
MEDICAL CENTER OPERATING BOARD
Thursday, April 2, 2009
8:30 – 11:30 a.m.
Medical Center Board Room
Committee Members:
E. Darracott Vaughan, Jr., M.D.,
W. Heywood Fralin
Sam D. Graham, Jr., M.D.
William P. Kanto, Jr., M.D.
Randy J. Koporc
Vincent J. Mastracco, Jr.
Chair
The Hon. Lewis F. Payne
Randl L. Shure
Edward J. Stemmler, M.D.
John O. Wynne
Ex Officio Members:
Steven T. DeKosky, M.D.
John B. Hanks, M.D.
R. Edward Howell
Leonard W. Sandridge
AGENDA
PAGE
I.
II.
ACTION ITEM
Medical Center Policy for the Prevention,
Detection, and Mitigation of the Theft of
Patients‟ Identities
REPORTS BY THE VICE PRESIDENT AND CHIEF EXECUTIVE
OFFICER OF THE MEDICAL CENTER (Mr. Howell)
A.
Vice-President‟s Remarks
B.
Finance, Write-offs, and Operations (Mr. Howell
to introduce Mr. Larry L. Fitzgerald and Ms.
Pamela F. Cipriano; Mr. Fitzgerald to report on
Finance and Write-offs; Ms. Cipriano to report
on Operations.)
C.
Capital Projects
D.
Annual Compliance Report
E.
Health System Development (Mr. Howell to
introduce Ms. Karen Rendleman; Ms. Rendleman to
report.)
F.
III.
Continuum Home Health Annual Report
REPORT BY THE PRESIDENT OF THE CLINICAL STAFF OF THE
MEDICAL CENTER (Dr. Hanks)
1
2
3
19
22
24
27
31
IV.
EXECUTIVE SESSION
ACTION ITEMS - To consider proposed personnel actions
regarding the appointment, reappointment, resignation,
assignment, performance, and credentialing of specific
medical staff and health care professionals, as provided
for in Section 2.2-3711(A)(1) of the Code of Virginia.
The meeting of the Medical Center Operating Board is
further privileged under Section 8.01-581.17 of the Code
of Virginia.
Discussion of proprietary, business-related information
pertaining to the operations of the Medical Center, where
disclosure at this time would adversely affect the
competitive position of the Medical Center, specifically:
-
Strategic personnel, financial, market and resource
considerations and efforts regarding the Medical
Center, including Medical Center employee recruitment,
retention and compensation programs, Medical Center
subsidiaries and participation in existing and
potential joint ventures;
-
Confidential information and data related to the
adequacy and quality of professional services, patient
safety in clinical care, and patient grievances for
the purpose of improving patient care at the Medical
Center; and
-
Consultation with legal counsel regarding the Medical
Center‟s compliance with relevant federal
reimbursement regulations including Medicaid
Disproportionate Share, licensure and accreditation
standards, and negotiations concerning performance of
a contract and related litigation, all of which will
also involve proprietary business information of the
Medical Center.
The relevant exemptions to the Virginia Freedom of
Information Act authorizing the discussion and consultation
described above are provided for in Section 2.2-3711 (A)
(1), (6), (7), (8) and (22) of the Code of Virginia. The
meeting of the Medical Center Operating Board is further
privileged under Section 8.01-581.17 of the Code of
Virginia.
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 2, 2009
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
I. Medical Center Policy for the
Prevention, Detection, and Mitigation
of the Theft of Patients‟ Identities
BACKGROUND: In 2003 Congress enacted the Fair and Accurate
Credit Transactions Act. The Federal Trade Commission has
promulgated associated “Red Flag” Rules regarding identity
theft protection, which become enforceable as of May 1, 2009,
and apply to the University and the Medical Center.
DISCUSSION: As required by the Red Flag Rules, the Medical
Center Operating Board must adopt an identity theft prevention
policy for the Medical Center. The Medical Center has adopted
Medical Center Policy Number 0286, Prevention, Detection, and
Mitigation of the Theft of Patients’ Identities to apply
specifically to the Medical Center and its patient care
activities, and seeks approval of the Medical Center Operating
Board. A copy of the policy is attached.
According to the Red Flag Rules, there must also be a
University-wide identity theft prevention program. The Audit
and Compliance Committee and the full Board will consider such a
program on April 3rd.
ACTION REQUIRED:
Approval by the Medical Center Operating Board
APPROVAL OF MEDICAL CENTER POLICY FOR THE PREVENTION, DETECTION
AND MITIGATION OF THE THEFT OF PATIENTS‟ IDENTITIES
RESOLVED, the Medical Center Operating Board approves Medical
Center Policy Number 0286, Prevention, Detection, and Mitigation
of the Theft of Patients’ Identities, and authorizes the Vice
President and Chief Executive Officer of the Medical Center to
modify or amend the policy as he may deem necessary from time to
time in order to comply with law or overall University policy;
and
RESOLVED FURTHER, the Vice President and Chief Executive Officer
of the Medical Center is authorized to implement the
requirements of Medical Center Policy 0286 consistent with the
overall University program on identity theft prevention.
1
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 2, 2009
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.A.
ACTION REQUIRED:
None
Vice President‟s Remarks
DISCUSSION: The Vice President and Chief Executive Officer of
the Medical Center will inform the Medical Center Operating
Board of recent events that do not require formal action.
2
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 2, 2009
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.B.
ACTION REQUIRED:
None
Finance, Write-offs, and Operations
BACKGROUND: The Medical Center prepares a periodic financial
report, including write-offs of bad debt and indigent care, and
reviews it with the Executive Vice President and Chief Operating
Officer of the University before submitting the report to the
Medical Center Operating Board. In addition, the Medical Center
provides an update of significant operations of the Medical
Center occurring since the last Medical Center Operating Board
meeting.
FINANCE REPORT
At the end of January 2009, the operating margin was 3.6
percent, while the budgeted operating margin was 4.1 percent.
Total operating revenue was below budget by 3.2 percent, and
total operating expenses were below budget by 2.7 percent. The
University of Virginia Imaging Center and University of Virginia
Outpatient Surgery Center posted operating margins of 50.1
percent and 29.1 percent, respectively. The operating margin
for the hospital was 1.6 percent against a budgeted figure of
2.8 percent, resulting in operating income which was
approximately $7 million below budget for the hospital.
Inpatient admissions continue to track below budget. Lack
of bed capacity at peak times remains a factor contributing to
the budget shortfall. In December 2008, the Medical Center
began an inpatient unit refurbishment project designed to
improve the environment of care for both patients and employees.
The number of available beds will fluctuate as the project
progresses, but as of the end of January, thirteen fewer beds
were available for patient care than on December 1, 2008. On
January 31, 2009, the Medical Center had 578 staffed inpatient
beds in operation, compared to 580 beds in operation at the same
time last year. In addition to bed availability issues, it
appears that the current economic crisis continues to adversely
impact inpatient admissions as potential patients defer
services.
3
Inpatient admissions for Fiscal Year 2009 through January
were 6.1 percent below budget and 4.5 percent below prior year.
Admissions of adult patients were 5.7 percent below budget and
4.0 percent below prior year. Cardiology admissions remain
below the prior year, and through January of Fiscal Year 2009
are 24.2 percent below the same period last year. Pediatric
admissions were 15.2 percent below budget and have declined by
9.9 percent from the prior year. Admissions have decreased on
the acute pediatric units as well as on the Neonatal Intensive
Care and KCRC Rehabilitation units. Admissions to the
psychiatric service are 9.4 percent above budget.
Despite the 6.1 decrease in admissions, inpatient days were
only 0.5 percent below budget; this is because of a length of
stay of 6.16 days, compared to the 5.80 days budgeted. Length
of stay in the same period last year was 5.89 days. The
Neonatal Intensive Care Unit continues to experience a higher
than expected length of stay because of higher patient acuity
and some difficulty with transporting babies back to their local
hospitals. The length of stay on the Medicine service has
increased from 5.6 days in the prior year to 6.0 days in the
current year. Within Medicine, length of stay for cardiology
and gastroenterology patients has increased by 4.8 percent and
16.3 percent days, respectively. Length of stay has also
increased for surgical services, including cardiothoracic
surgery and general surgery.
Net patient service revenue for the first seven months of
Fiscal Year 2009 was 3.2 percent below budget, primarily because
of the admissions shortfall. In addition, the overall case mix
index was 1.8046, which was lower than the 1.8243 budgeted.
Total operating expenses through January were 2.7 percent
below the $572.4 million budget. Total labor expenses
(including salaries and wages, fringe benefits and contract
labor) were 0.6 percent below budget. Total supply cost was 0.6
percent below budget in total, 1.1 percent below budget on a
CMI-adjusted patient day basis, and 4.8 percent above budget on
a CMI-adjusted discharge basis. All other expense categories
(purchased services, contracts, depreciation, interest and bad
debt) were below budget as well.
4
Total paid employees with contracted employees were 13
below budget.
FY 2008
FTEs
Salary, Wage and
Benefit Cost per
FTE
Contract Labor FTEs
Total FTEs
FY 2009
2009 Budget
6,025
6,120
6,149
$66,944
$68,744
$69,342
275
237
221
6,300
6,357
6,370
OTHER FINANCIAL ISSUES
For over a year we have been working with the Virginia
Commonwealth University Health System in a collaborative effort
to lower supply costs for both organizations. The supply chain
collaborative among the University of Virginia Health System,
Virginia Commonwealth University Health System, University
HealthSystem Consortium and Novation recorded approximately $1
million in combined savings in 2008 and is projecting an
additional $2.3 million in savings in 2009. The collaborative
is currently exploring opportunities in orthopedics and
cardiology and has initiated dialogue between the physician
leaders in these areas.
We are closely following the federal Financial Stimulus
package to pursue financial opportunities for the Health System.
There is money in the package for the State of Virginia to
assist with Medicaid funding, but the Virginia Department of
Medical Assistance does not yet know the impact on the Medical
Center. There is also funding for the adoption of meaningful
electronic health records; but again, the details of how the
money will be disbursed have not been made available.
5
WRITE-OFF OF BAD DEBTS AND INDIGENT CARE
Indigent care charges totaling $107.8 million for the
period July 1, 2008, through January 31, 2009, have been written
off. Recoveries during this period totaled $25.7 million.
Bad debt charges totaling $24.8 million have been written
off in the first seven months of Fiscal Year 2009. During this
same period, $9.8 million was recovered through suits,
collection agencies, and Virginia refund set-off.
OPERATIONS REPORT
Quality and Performance Improvement
Results from the Trauma Quality Improvement Project of the
American College of Surgeons showed that Medical Center outcomes
in several categories were among the top two to three
performers. Further, our observed-to-expected mortality ratio,
based on data qualifying for the Total Quality Improvement
Project in admission year 2007, was less than 1.0, which
suggests that the patients treated at our trauma center were at
lower risk of dying than expected from their baseline
characteristics and injury severity. This is an excellent
performance by the Medical Center‟s Trauma Team.
On January 13th, we announced the winner of the 3rd Annual
Charles L. Brown Award for Patient Care Quality. Marian Lawson,
RN, BSN and Dea Mahanes, RN, MSN, CCRN, CNRN, CCNS, along with
the Critical Care Collaborative Practice Group, won the award
for their work with “The Use of a Multidisciplinary Workgroup to
Improve Care for Critically Ill Patients.”
Survey/Accreditation
On February 18th, we received the final report from the
Joint Commission survey carried out January 26-30. Findings
were issued in two categories: Direct Impact, which create an
immediate risk to patient safety or quality of care and must be
corrected within 45 days of final report; and Indirect Impact,
which increase the risk to patient safety or quality of care if
unresolved over time and must be corrected within 60 days of
final report. The hospital received 11 direct impact and 8
indirect impact findings. Continuum Home Health and Home
Infusion received 1 direct impact and 4 indirect impact
findings.
6
Clinical Operations
The Medical Center has a number of efforts underway to
facilitate patient transfers and to improve referring physician
and patient satisfaction. As reported, the length of stay has
increased in a number of areas, thereby resulting in reduced bed
availability for patient admissions. Review of patients
awaiting transfer in Fiscal Year 2008 revealed that over 500
patients were unable to be transferred to the University of
Virginia. Of these patients, approximately one-third went to
other facilities. By accommodating these transfers the Medical
Center will improve the satisfaction of referring physicians,
patients, and families by being able to say “yes” to a more
timely transfer. This will result in more favorable admissions
and financial performance.
Revision of the Registered Nurse Wage (non-benefitted)
staff compensation plan is under way. The changes are designed
to compensate wage staff for their experience and provide a
premium for serving in either a unit-based or Medical Center
wage (hourly) pool.
In conjunction with the Cancer Center project new traffic
patterns and discharge processes began at the front entrance to
the hospital on Monday, February 2nd. Arriving and discharged
patients are also being picked up or delivered to the second
floor of the Lee Street parking garage in order to provide
easier drop off and pick up from the hospital. Feedback from
patients and families has been positive.
Culpeper Regional Hospital
The affiliation between the Medical Center and Culpeper
Regional Hospital (CRH) began January 1st. The priorities for
the affiliation include establishing a basis to integrate
Quality and Performance Improvement functions, expanding CRH
facilities, clinically integrating CRH with the Medical Center,
and enhancing the financial operations of CRH. Currently the
Medical Center has a physician serving on the CRH Quality
Committee and Medical Center staff are working with CRH to
establish a quality scorecard similar to what is used at the
Medical Center. The goal is to complete this scorecard by
September 2009. On February 1st, CRH signed a contract with
Novation, the University HealthSystem Consortium's group
purchasing program. A contract also has been signed with
Chamberlin Edmonds, eligibility and reimbursement specialists,
to help improve CRH financial operations.
7
Community Service
Volunteer Services worked with 72 donors during the
December holiday season to provide 13 patients and their
families with gifts and food, provided presents for all
pediatric inpatients at the University Hospital and the Kluge
Children‟s Rehabilitation Center, and gave items for the 7 Acute
Unit (Pediatrics) and the Kluge Children‟s Hospital. The donors
were University Departments, local businesses, area families and
former patients. A total of 2,000 donated items were
distributed to children and families.
Hospital Art Work
The University of Virginia Health System Arts Committee
gave a reception on January 9th, for the artist Lois Scott
Kannenshon, whose exhibit "Historic Downtown Mall Series" was on
display in the University Hospital Lobby from January 9th,
through March 6th. The Daily Progress did a feature story on
the artist and her plans to exhibit at the Medical Center. The
Arts Committee sponsors an exhibit of original artwork by
Virginia artists approximately every 6-8 weeks.
Human Resources
An upgrade of the Peoplesoft payroll software, including
expanded Employee Self Service, was implemented in December,
2008. As part of the enhanced Employee Self Service features,
employee paycheck data is now accessible online and paper
earnings statements have been discontinued.
The Career Development Center began providing services to
staff in early January. The Center focuses on providing career
counseling and career related resources to Medical Center
employees. An intranet website which describes services and
includes career resource information was launched in February,
along with offerings of instructor-led Word, Excel and Access
training to enhance job skills. The Career Development Center
was created in response to recommendations from last year‟s
Employee Engagement Compensation and Staffing Action Teams. Its
design has been augmented by a Career Development Steering
Committee, launched in October 2008 with representatives from
key areas across the Medical Center.
Over 5,200 Total Compensation Statements were mailed at the
end of January to benefited Medical Center employees. These
8
statements inform and educate employees on the total value of
their salary and benefit packages. It also highlights the
investment that the Medical Center makes in their benefits.
Finance
Supply Chain Savings
The SCOPE (Supply Chain Optimization and Process
Excellence) project first phase is concluding. SCOPE Management
Action Teams have reported current verified savings for Fiscal
Year 2009 of $8,023,383 and are expected to reach the goal of
$8.6 million by fiscal year end. Transition planning for the
next phase is under way with new targets being developed. The
focus will shift from reducing pricing to working more closely
with individual physicians on preference items.
Revenue Management/Patient Financial Services
Effective February 2009, the Medical Center is utilizing
two new collection agencies with the goal of continued
improvement in bad debt collections. Within the clinics, the
Medical Center is beginning the roll out of an on-line journal
system for cash management at the point of care. This system
will provide accounting controls, cash receipts, and speed up
the registration process. Another new system has been put in
place to help collect payments from University of Virginia
students who use Medical Center services. Letters for
outstanding bills are now mailed both to the student‟s local
address and to their permanent address, which has eliminated
many accounts from being referred to a bad debt collection
agency.
Insurance
A number of managed care contractual efforts are underway.
Anthem has once again selected the Medical Center to participate
in their national cardiac and transplant centers of excellence.
We completed 2 year negotiations with Kaiser Permanente
Transplant, amending our existing transplant agreement to
include bilateral lung and heart transplants. We also completed
negotiations with LifeTrac Transplant Network to give the
Medical Center access to one of LifeTrac‟s largest clients, West
Virginia Public Employees. A contract is now being completed.
In an effort to more aggressively transfer out-of-state
patients back to the facilities that transferred them to us, we
have established agreements with some 15 facilities to
specifically enable such back transfers. Conversations have
9
taken place with each facility and agreements are being reviewed
for signature.
Coding & Documentation
Contract negotiations are underway with 3M to determine
final pricing and specific deliverables for the coding and
documentation enhancement project. The next step is to
coordinate with physician leadership to determine timelines and
a specific implementation strategy. Improvements in documenting
case severity and expected risk of mortality would translate to
more accurate reporting of mortality and similar quality
measures.
Electronic Medical Record
Epic Systems was selected as our new vendor to provide the
enterprise-wide electronic medical record. We have begun
organizing the teams that will design, build and validate the
EpicCare software. First, teams of physicians, nurses, and
information technologists will be sent to Epic Systems offices
in Verona, Wisconsin, the weeks of March 15th, and March 22nd, for
training. We will send hundreds of clinicians, managers and
information systems technical specialists to Epic over the next
few months as we train the teams that will create and deploy our
electronic medical record system over the next 24 months.
The Clinical Staff Retreat scheduled for March 20th and
21st will be devoted to the implementation of EpicCare.
Important decisions about the governance and the design of
EpicCare will be made during the retreat. Attendees will
include physicians, nurses, and managers involved in the
planning and implementation of EpicCare. Speakers will include
the President and Chief Executive Officer of Epic Systems, the
Chief Information Officer of the Cleveland Clinic, which uses
EpicCare extensively in all of its hospitals and clinics, a
registered nurse from Rush Medical Center, and a physician from
Geisinger Clinic who will share their lessons learned about
implementing and using the systems.
A meeting involving the Health Services Foundation, the
Medical Center, and Accenture, was held to discuss the interface
between Epic clinical systems and hospital and faculty billing
systems. It was determined that the financial function needs to
have a robust role in the initial design of Epic clinical
systems. The faculty billing system options are being reviewed
by the Health Services Foundation and a recommendation will be
made to their finance committee and Board of Directors.
10
Environment of Care/Facilities
Long Term Acute Care Hospital
The groundbreaking ceremony for the Long Term Acute Care
Hospital that will be located adjacent to our Northridge campus
took place on Friday, January 16th.
Hospital Bed Expansion
Column reinforcing for the Hospital Bed Expansion Project
is continuing, with completion expected in early Spring. The
crane for the Hospital Bed Expansion was put in place on March
8th, to begin steel erection.
Emily Couric Clinical Cancer Center
The crane for the Emily Couric Clinical Cancer Center
arrived on Saturday, January 31st. Steel erection began on
February 11th.
Smoke-Free Campaign
As the Medical Center works toward being 100% smoke-free by
October 1st, smoking cessation resources, both internal and
external, are being compiled into a format that can be placed on
our website and distributed to patients, visitors, and employees
who are trying to quit smoking. Providing information and
education is an important component of the smoke-free campaign.
11
University of Virginia Medical Center
Income Statement
(Dollars in Millions)
Most Recent Three Fiscal Years
Description
Net patient revenue
Jan-07
Jan-08
Budget/Target
Jan-09
Jan-09
$514.9
$539.0
$562.1
$580.9
12.9
14.7
15.8
16.0
$527.8
$553.7
$577.9
$596.9
472.3
502.4
521.9
533.0
27.3
29.1
30.4
33.1
3.5
4.6
4.6
6.2
Total operating expenses
$503.1
$536.1
$556.9
$572.3
Operating income (loss)
$24.7
$17.6
$20.9
$24.6
Other revenue
Total operating revenue
Operating expenses
Depreciation
Interest expense
Non-operating income (loss)
$58.2
$24.0
($76.8)
Net income (loss)
$82.9
$41.6
($55.9)
$36.6
Principal payment
$5.3
$6.2
$7.2
$4.7
12
$12.0
University of Virginia Medical Center
Balance Sheet
(Dollars in Millions)
Most Recent Three Fiscal Years
Description
Jan-07
Jan-08
Jan-09
Assets
Operating cash and investments
$202.2
$84.7
$20.6
Patient accounts receivables
62.6
51.7
57.7
Property, plant and equipment
366.2
406.3
449.2
Depreciation reserve and other investments
275.3
438.4
493.8
Endowment Funds
136.3
158.8
113.3
Other assets
117.6
121.7
144.4
$1,160.2
$1,261.6
$1,279.0
Current portion long-term debt
$12.9
$12.5
$9.1
Accounts payable & other liab
76.0
79.3
82.0
163.5
152.7
229.7
92.4
138.6
131.6
$344.8
$383.1
$452.4
$815.4
$878.5
$826.6
$1,160.2
$1,261.6
$1,279.0
Total Assets
Liabilities
Long-term debt
Accrued leave and other LT liab
Total Liabilities
Fund Balance
Total Liabilities & Fund Balance
13
University of Virginia Medical Center
Financial Ratios
Most Recent Three Fiscal Years
Description
Jan-07
Operating margin (%)
Jan-08
Budget/Target
Jan-09
Jan-09
4.7%
3.2%
3.6%
4.1%
Total margin (%)
14.1%
7.2%
-11.2%
6.0%
Current ratio (x)
3.0
1.5
0.9
2.0
206.3
214.2
174.1
190.0
Gross accounts receivable (days)
47.3
50.1
50.0
60.0
Annual debt service coverage (x)
12.9
6.9
(1.8)
7.0
Debt-to-capitalization (%)
19.4%
17.5%
24.4%
20.0%
6.1%
6.3%
6.3%
6.9%
Days cash on hand (days)
Capital expense (%)
14
Operating Statistics
Most Recent Three Fiscal Years
Description
Acute Admissions
Jan-07
Jan-08
Jan-09
Budget/Target
Jan-09
17,488
17,471
16,685
17,774
100,478
102,387
102,567
103,121
4,084
4,321
4,536
3,598
5.71
5.89
6.16
5.80
368,701
372,476
371,354
388,976
ER visits
34,248
35,733
35,392
35,893
Medicare case mix index
Occupancy %
1.9663
76.1%
1.9637
76.0%
1.9480
72.1%
1.9400
72.6%
6,115
6,300
6,357
6,370
Patient days
SS/PP Patients
Average length of stay
Clinic visits
FTE's (including contract labor)
15
University of Virginia Medical Center
SUMMARY OF OPERATING STATISTICS AND FINANCIAL PERFORMANCE MEASURES
Fiscal Year to Date with Comparative Figures for Prior Year to Date - January FY2009
OPERATING STATISTICAL MEASURES - January FY 2009
ADMISSIONS and CASE MIX - Year to Date
OTHER INSTITUTIONAL MEASURES - Year to Date
Actual
Budget
% Variance
Prior Year
Actual
Budget
% Variance Prior Year
ACUTE INPATIENTS:
ADMISSIONS:
Adult
14,186
15,050
(5.7%)
14,784 Inpatient Days
102,567
103,121
(0.5%)
102,387
Pediatrics
1,659
1,956
(15.2%)
1,841 Average Length of Stay
6.16
5.80
(6.2%)
5.89
Psychiatric
840
768
9.4%
846 Average Daily Census
477
480
(0.6%)
476
Births
1,054
1,098
(4.0%)
1084
Subtotal Acute
16,685
17,774
(6.1%)
17,471
OUTPATIENTS:
Short Stay/Post Procedure
4,536
3,598
26.1%
4,321 Clinic Visits
371,354
388,976
(4.5%)
372,476
Average Daily Visits
2,796
2,920
(4.2%)
2,768
Total Admissions
21,221
21,372
(0.7%)
21,792 Emergency Room Visits
35,392
35,893
(1.4%)
35,733
CASE MIX INDEX:
All Acute Inpatients
Medicare Inpatients
1.8046
1.9480
1.8243
1.9400
SURGICAL CASES
Main Operating Room (IP and OP)
(1.1%)
1.8043 UVA Outpatient Surgery Center
0.4%
1.9637
Total
OPERATING FINANCIAL MEASURES - January FY 2009
16
REVENUES and EXPENSES - Year to Date
($s in thousands)
Actual
Budget
% Variance
Prior Year
NET REVENUES:
Net Patient Service Revenue
562,087
580,874
(3.2%)
539,012
Other Operating Revenue
15,760
16,097
(2.1%)
14,735
Total
$ 577,847 $ 596,971
(3.2%) $
553,747
EXPENSES:
Salaries, Wages & Contract Labor
Supplies
Contracts & Purchased Services
Bad Debts
Depreciation
Interest Expense
Total
Operating Income
Operating Margin %
Non-Operating Revenue
257,703
127,905
116,231
20,030
30,446
4,611
$ 556,926
$
20,921
3.6%
$ (76,837)
Net Income
$
$
$
$
$
(55,916) $
259,321
128,719
122,853
22,152
33,080
6,229
572,354
24,617
4.1%
11,985
0.6%
0.6%
5.4%
9.6%
8.0%
26.0%
2.7% $
(15.0%) $
(741.1%) $
249,198
126,690
106,935
19,572
29,101
4,696
536,192
17,555
3.2%
23,997
36,602
(252.8%) $
41,552
10,889
4,554
15,443
11,140
4,413
15,553
(2.3%)
3.2%
(0.7%)
10,843
4,176
15,019
OTHER INSTITUTIONAL MEASURES - Year to Date
($s in thousands)
Actual
Budget
% Variance Prior Year
NET REVENUE BY PAYOR:
Medicare
$ 182,058 $ 183,457
(0.8%)
179,289
Medicaid
76,051
79,657
(4.5%)
74,340
Commercial Insurance
102,503
105,888
(3.2%)
95,246
Anthem
99,379
104,446
(4.9%)
93,993
Southern Health
28,662
29,631
(3.3%)
26,580
Other
73,434
77,795
(5.6%)
69,564
Total Paying Patient Revenue
$ 562,087 $ 580,874
(3.2%)
539,012
OTHER:
Collection % of Gross Billings
Days of Revenue in Receivables (Gross)
Cost per CMI & OP-Adj Discharge
Cost per CMI & OP-Adj Day
Cost per Outpatient Visit
Total F.T.E.'s (including Contract Labor)
F.T.E.'s Per CMI Adjusted Occupied Bed
$
$
$
41.64%
50.0
10,116 $
1,646 $
77.96 $
6,357
4.19
42.97%
60.0
9,834
1,694
70.76
6,370
4.22
(3.1%)
16.7%
(2.9%) $
2.8% $
(10.2%) $
0.2%
0.7%
44.45%
50.1
9,603
1,639
77.22
6,300
4.30
University of Virginia Medical Center
SUMMARY OF OPERATING STATISTICS AND FINANCIAL PERFORMANCE MEASURES
Fiscal Year to Date with Comparative Figures for Prior Year to Date - January 31, 2009
Assumptions - Operating Statistical Measures
Admissions and Case Mix Assumptions
Admissions include all admissions except normal newborns
Pediatric cases are those discharged from 7 West, 7 Central, NICU, PICU and KCRC
Psychiatric cases are those discharged from 5 East or Rucker 3
All other cases are reported as Adult
Short Stay Admissions include both short stay and post procedure patients
Case Mix Index for All Acute Inpatients is All Payor Case Mix Index from Stat Report
Other Institutional Measures Assumptions
Patient Days, ALOS and ADC figures include all patients except normal newborns
Surgical Cases are the number of patients/cases, regardless of the number of procedures performed on that patient
17
Assumptions - Operating Financial Measures
Revenues and Expenses Assumptions:
Medicaid out of state is included in Medicaid
Medicaid HMOs are included in Medicaid
Physician portion of DSH is included in Other
Non-recurring revenue is included
Other Institutional Measures Assumptions
Collection % of Gross Billings includes appropriations
Days of Revenue in Receivables (Gross) is the BOV definition
Cost per CMI & OP-Adj Discharge and Day uses All Payor CMI to adjust, and excludes bad debt
Costs for Cost per Outpatient Visit come from clinic income statement, and exclude bad debt
OP visits used in calculation of Cost per Outpatient Visit are provider based clinic visits only
MEDICAL CENTER
ACCOUNTS COMMITTEE REPORT
(Includes All Business Units)
(Dollars in Thousands)
Year to Date
January
2008-09
INDIGENT CARE (IC)
Net Charge Write-Off
83,854
Percentage of Net Write-Offs to Revenue
6.21%
Annual Activity
2007-08
133,320
2006-07
113,523
6.34%
6.08%
Total Reimbursable Indigent Care Cost
31,697
54,558
43,652
State and Federal Funding
31,697
54,558
43,652
Total Indigent Care Cost Funding As a Percent
of Total Indigent Care Cost
100%
Unfunded Indigent Cost
-
100%
100%
-
-
Annual Activity
January
2008-09
BAD DEBT
Net Charge Write-Offs
20,030
Percentage of Net Write-Offs to Revenue
1.48%
2007-08
31,472
1.50%
2006-07
32,843
1.76%
Note:
Provisions for bad debt write-offs and indigent care write-offs are recorded for financial statement purposes based on the
overall collectibility of the patient accounts receivable. These provisions differ from the actual write-offs of bad debts and
indidigent care which occur at the time an individual account is written off.
18
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 3, 2008
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.C.
ACTION REQUIRED:
None
Capital Projects
BACKGROUND: The Medical Center is constantly improving and
renovating its facilities. We will provide a status report of
these capital projects at each Medical Center Operating Board
meeting.
DISCUSSION: The current Medical Center capital projects report
is set forth in the following table:
19
The University of Virginia Medical Center
Capital Projects Report
April 2009
Scope
Budget
Funding
Source
BOV
Approval
Date
Projected
Completion
Date
$8 M
Bonds
Jan 2003
2009
1. Pre-Construction
Clinical Office Building:
Board of Visitors approved project
to complete the 3rd floor fit out for
the Spine Center and Orthopaedic
Services. Design work underway.
West Main Street Development including Children’s Hospital:
Feb 2008
$117 M
Bonds and
Outside
Fundraising
TBD
2013
$15.6 M
Bonds
Feb 2008
2010
Bonds
Feb 2008
2010
$7.6 M
Bonds
Feb 2008
2011
$2.5 M
Bonds
Feb 2008
2010
Design started on December 12,
2008.
*University Hospital:
Renovate Heart Center invasive
procedure areas – design
underway.
*University Hospital:
Add two Operating Rooms and
Magnetic Resonance Imaging
Room (with equipment) – design
underway.
University Hospital:
(21,600 GSF)
$14.3 M
(2,330 GSF)
Add elevators – evaluations
underway.
Moser Radiation Therapy Center:
Construct addition for 2nd linear
accelerator – design complete.
(3,000 GSF)
Bonds
**University
Project modifiesHospital:
original HEP project$6.5M
Renovate and relocate
Surgical Pathology
Laboratory – design
underway.
(8,800
GSF)
20
Feb 2008
2010
The University of Virginia Medical Center
Capital Projects Report
April 2009
Scope
Budget
Funding
Source
BOV
Approval
Date
Projected
Completion
Date
$21.2 M
Bonds
Feb 2008
2012
General Fund
Appropriation ( @
$25 M) , Bonds
and Outside
Fundraising
Oct 2004
2010
2. Under Construction
University Hospital:
Renovate Radiology Department –
phased construction underway
Emily Couric Clinical Cancer
Center:
Construction underway.
(52,000 GSF)
$74 M
(including
added shelled
floor)
July 2006
(B&G
Committee)
June 2007
University Hospital Bed
Expansion:
$80.2 M
Bonds and Health
System Operating
Revenue
Project to increase inpatient bed
capacity in University Hospital by
adding 72 private, ICU-level
rooms. Column reinforcing is
underway in anticipation of
structural steel erection
commencing in March 2009.
Primary Care Center:
$6.6 M
Bonds
Repair brick façade and replace
roof – work commenced in August
2008.
21
Sept 2005
2011
June 2007
Feb 2008
2010
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 2, 2009
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.D.
ACTION REQUIRED:
None
Annual Compliance Report
BACKGROUND: The Office of Corporate Compliance and Privacy
provides an annual update of significant issues affecting the
Medical Center‟s corporate compliance program. This year, the
Medical Center will face increased activity as a result of the
Federal Trade Commission Red Flags Identity Theft Rules and the
economic stimulus legislation signed by President Obama on
February 17th, containing the most significant changes to
federal health care privacy and security law since the enactment
of Health Insurance Portability Accountability Act. The Medical
Center is also preparing for the Recovery Audit Contractor
program to begin in Virginia.
DISCUSSION:
Red Flags Identity Theft Rules
In November, 2007, the Federal Trade Commission, in
conjunction with other agencies, published the Red Flag rules
defining what creditors and financial institutions must do to
implement an Identity Theft Prevention Program. The Red Flag
Rules require those covered to identify at-risk accounts and to
define, detect, and respond to Red Flags to prevent or mitigate
identity theft. The Fair Credit Reporting Act governs the
identify theft process, and there are civil monetary penalties
for noncompliance. The Medical Center must comply with the Red
Flag Rules, and the Medical Center Operating Board is being
asked to approve Medical Center Policy as described in the
Action Agenda (Section I) above. The Medical Center Compliance
and Privacy Office will provide guidance and monitor compliance
in the Medical Center with this program.
22
Economic Stimulus Legislation Affecting HIPAA Privacy and
Security Law
Congress passed the American Recovery and Reinvestment Act
of 2009 in mid-February, and a few days later President Obama
signed it into law. Title XIII of the Act is entitled “Health
Information Technology for Economic and Clinical Health,”
referred to as HITECH. Most of the Act‟s provisions take effect
February 17, 2010, although the increased penalty provisions go
into effect immediately. Other provisions require implementing
regulations and will take two or more years. The new patient
privacy and security requirements will affect all hospitals and
other providers, health plans, and other HIPAA covered entities,
as well as HIPAA business associates. The Medical Center will
be determining any operational or policy changes needed to
comply with the changes in law and the privacy audit plan will
be modified as necessary.
Recovery Audit Program
Section 306 of the Medicare Modernization Act of 2003
required a demonstration project that directed the Centers for
Medicare and Medicaid Services to identify overpayments and
underpayments. The recovery audit contractor (RAC)
demonstration program was launched in 2005 and ultimately
included six states. The Tax Relief Act of 2006 makes the RAC
program permanent and nationwide no later than January 1, 2010.
The purpose of the program is to identify underpayments and
overpayments under Parts A and B of the Medicare program and to
recover overpayments. According to the Centers for Medicare and
Medicaid Services report during the demonstration project
between March 2005, and March 2008, the RACs succeeded in
correcting over $1.03 billion of improper Medicare payments.
Virginia is in Region C, with an anticipated rollout of the RAC
sometime after August 1, 2009. Connolly Consulting Associates,
Inc., of Wilton, Connecticut, has been selected as the Recovery
Audit Contractor for Region C. The Medical Center is assembling
a team to prepare for the RAC arrival and the medical record
requests and is developing a tracking process and role
assignment. The Medical Center Compliance and Privacy Officer
is the coordinator for this project.
23
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 2, 2009
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.E.
ACTION REQUIRED:
None
Health System Development
BACKGROUND: Health System Development will provide reports of
recent activity to the Medical Center Operating Board from time
to time.
DISCUSSION:
SIGNIFICANT GIFTS
A team of University of Virginia infectious disease
researchers was recently awarded a $6.8 million grant from the
Bill & Melinda Gates Foundation for a three-year pilot study of
the interaction of enteric infections and human genetics on
nutrition in the developing world.
The Focused Ultrasound Foundation committed $3.1 million
to construct a new facility at the University of Virginia.
A family member of a grateful patient committed a
$500,000 bequest to the Cancer Center in support of a
lectureship in emerging therapies in cancer care.
A former faculty member and his wife pledged $500,000 to
create a named resident education fund in Orthopaedic Surgery.
The Ivy Foundation committed $260,000 to fund five
research projects in 2009 through a new Biomedical Innovation
grant program at the University of Virginia.
A donor made a planned gift in support of the Claude
Moore Medical Education Building valued at approximately
$250,000.
Other gifts and pledges received include:
A $200,000 commitment to the Emily Couric Clinical Cancer
Center;
24
A $120,000 commitment to the Emily Couric Clinical Cancer
Center;
A $100,000 verbal commitment to the Children‟s Hospital
building campaign;
A $50,000 commitment in support of breast cancer research;
A $50,000 commitment for scholarships in the School of
Medicine;
A $33,000 corporate gift for cancer research;
A $30,000 commitment in support of a fellowship in the
Department of Microbiology;
A $30,000 commitment to the Emily Couric Clinical Cancer
Center;
A $28,000 disbursement from the Pink Ribbon Polo Cup to the
Patients & Friends Research Fund; and
A $25,000 commitment to a scholarship fund for medical
students.
OTHER DEVELOPMENT INITIATIVES
On December 3, Drs. Scott Lim, John Dent, Mike Ragosta,
and cardiology fellows Drs. Amy West and Fadi Atassi traveled to
Santo Domingo, Dominican Republic, to conduct echocardiogram
screenings and other procedures as part of a collaborative
project partially funded by a $56,000 grant. Health System
Development staff also participated and met with Dominican
philanthropists to discuss a $3.2 million underwriting
opportunity to build a sustainable joint teaching partnership
with Cedimat Hospital in Santo Domingo.
Representatives from Garth Brooks‟s Teammates for Kids
Foundation participated in a site visit of the University of
Virginia Children‟s Hospital to explore their interest in
funding a $1.5 million state-of-the-art education and
therapeutic play area or “Child Life Zone,” within the renovated
7th floor Health Education Program/Terrace space.
On December 13-15, Hartwell Foundation President Fred
Dombrose visited the Grounds to interview the University of
Virginia‟s four nominees for the 2008 Hartwell Investigator
Award. The visit included a dinner hosted by Provost Garson,
lunch with the 2007 and 2008 Hartwell Fellows, and meetings with
School of Medicine Dean Steven DeKosky, Vice President for
Research Thomas Skalak, and other School of Medicine and
University leadership. The University of Virginia is eligible
to receive $400,000 in funding this year, with the investigator
awards to be announced in April 2009.
25
Karen Rendleman and Health System Chief Marketing and
Strategic Relations Officer Patricia Cluff met with chairs and
representatives of the volunteer boards affiliated with Medical
Center Programs to discuss the Health System‟s marketing
strategy. Attendees included representatives from the Cancer
Center Advisory Board; the Patients & Friends Research Fund; the
Children‟s Hospital Committee; the Emergency Medicine Center for
Education, Research and Technology Advisory Board; and the Heart
and Vascular Advisory Board.
In December, Health System Development sent its third
direct mail solicitation to 23,000 donors and former patients.
The letters, signed by Health Foundation Chair Rick Sharp,
offered giving options for several Medical Center priorities.
The Development Communications team completed several
projects, including: the end of year publication of Investing in
Hope, a newsletter focused on events, news, and giving
opportunities in cancer; a series of planned giving handouts
focusing on specialized methods of giving that have been
customized for use with Health System donors and prospects; the
addition of new electronic communications to reach new audiences
and to decrease publication costs in the upcoming year; and the
ongoing development and production of materials in support of
the Barry and Bill Battle Building, including a periodic
fundraising progress report to the Children‟s Hospital
Committee.
CAMPAIGN PROGRESS THROUGH JANUARY 31, 2009
Through the end of January 2009, the Health System
campaign total is $446,367,035. This represents 89% of the
campaign goal, with 64% of the campaign period elapsed. The
following table shows the Fiscal Year 2009 totals for new
commitments, including new gifts and pledges in comparison to
this same time through Fiscal Year 2008.
Fiscal Year to Date
(7/1/08 through 1/31/2009)
FY „09
New gifts
New pledges
Total new commitments
(excludes pledge payments on
previously booked pledges)
$26,776,464
$3,850,377
$30,626,841
26
FY „08
(through
1/31/08)
$23,257,588
$7,981,380
$31,238,968
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 2, 2009
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
II.F.
ACTION REQUIRED:
None
Continuum Home Health Annual Report
BACKGROUND: The Joint Commission accredits the University of
Virginia Medical Center, as well as over 19,000 other health
care organizations. It requires that an annual report be
presented to the governing body of the Medical Center describing
major performance improvement activities in key areas.
DISCUSSION:
Continuum Home Health Care, structured as a department of
the Medical Center, provides two primary lines of business, home
health and home infusion services. Continuum is accredited by
The Joint Commission and certified for Medicare and Medicaid
separately from the Medical Center.
Home health services include the direct provision of
skilled nursing; physical, occupational and speech therapies;
home health aides; and medical social work to patients residing
within a 10 county area, which includes the counties of
Albemarle, Greene, Madison, Orange, Louisa, Fluvanna,
Buckingham, Nelson, Augusta, and Rockingham. Additionally
Continuum offers specialty care through its Psychiatric Service,
Pediatric Service, and an interdisciplinary Wound Care Team.
Home infusion provides services in these same 10 counties
(with Continuum providing any needed direct services), and also
provides pharmaceutical services on a statewide basis and out of
state as needed to patients residing in Maryland, North Carolina
and West Virginia. For home infusion patients residing outside
of Continuum‟s direct service area, Continuum works with another
Medicare certified home health agency to provide the direct
services required.
It is important to note that Continuum internally manages
all of its own patient registration, insurance pre-authorization
and coding. It has implemented a stand-alone Electronic Medical
Record utilizing point of care technology (i.e., laptop
computers) for patient documentation in the home and for
27
telehome monitoring. Continuum has a patient specific supply
ordering system developed in concert with the Medical Center‟s
leading medical supply vendor, Owens & Minor and, with the
exception of several hours of centrally provided general
orientation, manages all the orientation needs for its new
employees.
Activity Levels – I HEAL
Unduplicated
Admissions
Total
UOS(visits)
Unduplicated
Admissions
Total UOS
(therapy days)
Home Health
FY06
FY07
FY04
FY05
3,339
3,124
3,400
3,676
FY08
4,160
55,657 51,519 49,575 47,981 49,748
FY04
Home Infusion
FY05
FY06
FY07
831
962
873
951
FY08
1,168
53,052 54,586 56,802 61,499 69,168
Both home health and home infusion continue to demonstrate
steady growth. Continuum‟s goal for 2008 was to achieve an
increase in home health referrals of greater than 5%; it well
exceeded that goal with a 13% growth in unduplicated admissions.
Additionally, Continuum saw an increase of 10% in referrals from
Martha Jefferson Hospital. Gaining new home health patients
while delivering fewer visits overall is supportive of a more
positive reimbursement picture for home health, and Contiuum far
exceeded its 2008 goal by providing 3.7% more visits overall
while serving 13% more new patients.
The same is not true for home infusion, where an increase
in therapy days generates increased reimbursement. Continuum
home infusion experienced a 12% increase in therapy days in
Fiscal Year 2008, while experiencing an increase of 23% in
unduplicated therapy admissions. Many home infusion patients
are repeat patients or on service for life (i.e., cycles of
chemotherapy, tube feeding and TPN patients) so this growth is
substantial.
28
Operations – I BUILD
Significant differences in payor mix continue to exist
between the home health and home infusion business lines, adding
to the complexity of intake and pre-authorization requirements.
Traditionally Medicare Parts A and B covered very few home
infusion therapies, but the advent in Fiscal Year 2007 of the
Medicare Part D prescription drug plans significantly shifted
patients to Medicare D coverage from secondary coverage or self
payment.
Both home health and home infusion continue not only to
demonstrate their significant contribution to the Medical
Center‟s bottom line, but they also continue to provide services
critical to supporting the institutional priority of timely and
effective patient discharge. Continuum‟s case weight (1.582)
continues to exceed the National level (1.372), indicative of
the acuity level of patients Continuum manages effectively at
home. Of interest is that while the national case weight
decreased somewhat in Fiscal Year 2008, Continuum‟s case weight
increased in Fiscal Year 2008 from a Fiscal Year 2007 case
weight of 1.530. This is thought in part to be a direct
reflection of the increasing level of acuity of patients in the
Medical Center being discharged to home and in part a reflection
of “cherry picking” by some proprietary agencies who have moved
into the local market, leaving the more acute, expensive, and
resource intensive patients for Continuum. Agency
responsiveness and the skill level of staff allows Continuum to
support the discharge of hospitalized patients that many home
health agencies cannot or will not service at home.
Quality/Outcomes – I CARE
External benchmarking. Contiuum continues to improve in
all areas on the Centers for Medicare and Medicaid Services
Home Health Compare data and has surpassed all local area
home health agencies (both proprietary and neighboring
hospital based) in all State and National clinical
outcomes.
Extensive staff training was provided to all staff on
Continuum‟s clinical and financial outcomes, resulting in
improved outcomes in both areas with Continuum‟s risk
adjusted standing demonstrating high patient outcomes with
low visit utilization.
Patient Satisfaction. Continuum continues to incrementally
increase its Press Ganey scores, ending Fiscal Year 2008
with an overall mean score of 91.2 on all standard
questions, compared with a Fiscal Year 2007 average of
29
90.1. It ended Fiscal Year 2008 in the 100th percentile of
its peer grouping.
Continuum successfully decreased its patient readmission
rate to 23%, well below the national average of 28%.
Given the high acuity level of its patients, Continuum is
especially proud of its continued improvement in this area
because the national average has remained stable despite
concentrated efforts throughout the home health industry.
Continuum‟s fall rates were 1.2%, well below the national
average of 1.49% for home health patients.
30
UNIVERSITY OF VIRGINIA
BOARD OF VISITORS AGENDA ITEM SUMMARY
BOARD MEETING:
April 2, 2009
COMMITTEE:
Medical Center Operating Board
AGENDA ITEM:
III. Report by the President of the
Clinical Staff
ACTION REQUIRED:
None
DISCUSSION: The President of the Clinical Staff of the Medical
Center will inform the Medical Center Operating Board of recent
events regarding the Clinical Staff which do not require formal
action, but of which the Medical Center Operating Board should
be made aware.
31
ATTACHMENT
Medical Center Policy 0286
MEDICAL CENTER POLICY NUMBER NO. 0286
A.
SUBJECT:
Prevention, Detection, and Mitigation of the Theft of Patients’
Identities
B.
EFFECTIVE DATE:
May 1, 2009
C.
POLICY: In accordance with the University of Virginia’s overall Identity Theft Prevention
Program, the Medical Center maintains an Identity Theft Prevention Program in order to prevent,
detect and mitigate the incidence of the theft of patients’ identities (“identity theft”). This
Identify Theft Prevention Program coordinates, reviews and oversees Medical Center policies and
procedures in order to:
1.
2.
3.
4.
identify indicators of identity theft (“red flags”);
detect identified red flags and respond appropriately to detected red flags in order to
prevent and mitigate identity theft;
educate employees, staff, and others providing services at the Medical Center regarding
their responsibilities under the Identity Theft Prevention Program; and
update the Identity Theft Prevention Program to appropriately respond to new or evolving
risks.
To augment its Identity Theft Prevention Program, the Medical Center requires staff and
employees to appropriately identify patients and confirm personal demographic information as
well as insurance information at time of registration for each patient visit, during treatment, at
time of billing, and before confidential patient information can be released. Additional policies
relevant to the prevention, detection and mitigation of incidents of identity theft include Medical
Center Policy No. 21 (Confidentiality of Patient Information); MCP No 27 (Charge
Documentation and Control); MCP 92 (Release of Patient Information); MCP 201 (Patient
Identification), and MCP 253 (Verification for Release of Patient Information).
D.
PROCEDURE:
1.
Identifying red flags: the following are relevant “red flags,” or indicators of possible
identity theft (this list is not intended to be inclusive and may change from time to time):
a.
b.
notification by a patient or patient’s representative that an identity theft may have
occurred;
a complaint or question from a patient or patient’s representative based on the
patient’s receipt of a bill for products or services which the patient denies that
he/she (or his/her family member) received, or a notice of insurance benefits paid
(or denied) for health products or services that were never received;
Page 2
Policy No. 0286
(SUBJECT: Prevention, Detection and Mitigation of the Theft of Patients’ Identities)
c.
d.
e.
f.
g.
h.
i.
j.
2.
records showing medical treatment that is inconsistent with a physical
examination or with a medical history as reported by the patient;
suspicious documentation, or documentation that appears to be altered or forged;
documents that contain information that does not match the characteristics of the
presenting patient as to such factors as age, gender, race, demographic
information (i.e., address or telephone number), insurance information or where
appropriately requested, social security number;
identification or other information provided by the patient, family or visitors
which does not match the identification provided on a prior visit;
notifications from third party payors of potential identity theft;
information provided by a patient that matches information submitted by another
patient as to date of birth, social security number, medical record number,
insurance, or demographic information;
a complaint or question from a patient about information added to a credit report
by a health care provider or insurer;
a notice or inquiry from a law enforcement agency or an insurance fraud
investigator concerning possible identity theft
Detecting and responding to red flags to prevent and mitigate identity theft
a.
b.
c.
The CEO of the Medical Center shall designate a Program Coordinator who shall
be responsible for administration of the Identity Theft Prevention Program (“the
Program Coordinator”).
When a red flag is detected that involves a patient, staff will immediately report
the incident to the manager or administrator on call. The manager or
administrator on call will then notify the Program Coordinator of the incident.
Responsibilities of the Program Coordinator. When a red flag incident is
reported, the Program Coordinator shall:
i.
ii.
iii.
iv.
coordinate an investigation of the red flag incident, which may include,
but would not be limited to, interviewing the patient, reviewing the
patient’s registration and scheduling history; reviewing the patient’s
billing records, reviewing the patient’s medical records, and determining
any other points of contact between the patient and the Medical Center;
notify all appropriate areas, including Health Information Services and
the Health Services Foundation billing department and the Medical
Center’s Patient Financial Services or Continuum Home Health billing
department so that they may place a hold on the patient’s account
pending outcome of an investigation;
ascertain what additional actions may be needed to determine whether an
identity theft has occurred, and alert appropriate areas to carry out those
actions. As appropriate, the Program Coordinator may also contact
and/or cooperate with law enforcement agencies and/or investigators for
third party payors;
report to the Medical Center CEO, who in turn, shall report to the
University Comptroller (coordinator of the University’s overall Identity
Theft Prevention Program) as to the outcome of the investigation of any
identity theft incidents, making recommendations for preventing their
recurrence.
Page 3
Policy No. 0286
(SUBJECT: Prevention, Detection and Mitigation of the Theft of Patients’ Identities)
3.
Education
Medical Center staff and employees will be trained on this Identity Theft Prevention
Program as appropriate to their duties and positions. Training will cover (1) how to
recognize potential red flag activity; (2) applicable policies and procedures for detecting
and preventing identity theft.
4.
Oversight of Service Provider Arrangements
The Administrator of Supply Chain Management (or his/her designee) will identify
proposed service contracts involving access to identifiable patient information, and will
require that such service providers sign a Business Associate Addendum obligating the
provider to have policies and procedures to detect and report relevant red flags that may
arise in the performance of the service provider’s activities, and to take appropriate steps
to identify, prevent, mitigate and report incidents of potential identity theft related to
Medical Center patients.
5.
Oversight of Identity Theft Prevention Program.
The Program Coordinator will conduct an annual review of the Program and assessment
of its effectiveness. The Program Coordinator shall report annually to the CEO of the
Medical Center, or his/her designee who is at the level of senior management, who, in
turn, shall report to the University Comptroller, on issues of significance related to the
Program. The annual report shall include an assessment of the effectiveness of the
program in addressing the risk of identity theft; any significant incidents involving
identity theft and the Medical Center’s response; service provider contracts; and
recommendations, if any, for material changes in the Program to address changing
identity theft risks. The Medical Center CEO or his/her designee, shall review the report
and approve any material changes in the Program.
SIGNATURE:
______________________________________
R. Edward Howell, CEO, UVA Medical Center
DATE:
Medical Center Policy No. 0286
Approved March 2009
Approved by Chief Financial Officer
Approved by Medical Center Administration
______________________________________