HIPAA and Dentistry

About Ahlstrom’s Controversial HIPAA Testimony

By Darrell K. Pruitt; DDS

pruitt

Dr. Robert H. Ahlstrom, representing the ADA as well as all US dentists, testified in July 2007 before the standards and security subcommittee of the National Committee on Vital and Health Statistics (NCVHS) about the benefits of HIPAA in dentistry.  His testimony is featured as an official HHS document titled “Testimony of the American Dental Association, National Committee on Vital and Health Statistics Subcommittee on Standards and Security”, July 31, 2007. 

http://www.ncvhs.hhs.gov/070731p08.pdf

The NCVHS Document 

The document was presented by NCVHS to HHS Secretary Michael Leavitt as fact – a mistake that not only set back healthcare IT in dentistry, and miracles from trusted Evidence Based Dentistry [EBD] a decade or more – but seriously stained the reputation of the American Dental Association, crippling my profession’s influence in the nation’s capitol. Dr. Ahlstrom is a prosthodontist from Reno, Nevada and a tireless ADA volunteer. At one time, he was a respected proponent of paperless dental practices, and was rewarded with prominent appointments in the ADA, which he continues to silently cling to. However, at some point in his efforts, his enthusiasm for healthcare IT in dentistry caused him to lose perspective of who he was serving. When Dr. Ahlstrom chose to ignore the warnings of the danger from digitalized patient information, he abandoned the needs of dental patients and dentists.

Discussion Avoidance 

For at least the last few years, Dr. Robert Ahlstrom has suspiciously avoided discussing the dangers of digital records with ADA members – including me – even in front of a crowd of a hundred or so witnesses in ADA Headquarters. 

http://community.pennwelldentalgroup.com/forum/topics/evidencebased-dentistry-my?page=1&commentId=2013420%3AComment%3A17400&x=1#2013420Comment17400

The Challenge

Even though I think it is unlikely that he will accept my open challenge, I emailed him an invitation to defend his testimony here, or on the PennWell forum. In my opinion, the time has come for Ahlstrom to either show courage or be terminally irrelevant. If he fails to respond, I personally call for his resignation from all ADA positions because of clear unaccountability to ADA membership.  

Robert Ahlstrom is the only dentist left in the nation who applauds HIPAA, and I don’t expect any official from the ADA to come to his defense. It would be wonderfully entertaining, but that is just too much to ask of the shy good ol’ boys I have bumped heads with. My questions to the ADA about HIPAA have been evaded for years.

Ahlstrom’s Eleven Selling Points 

Here are the 11 selling points Ahlstrom presented to our lawmakers in support of HIPAA – which I will contest individually and in depth: 

1. Dental office computer systems will be compatible with those of the hospitals and plans they conduct business with. Referral inquiries will be handled easily.

2. Vendors will be able to supply low-cost software solutions to physicians/dentists who support standards-based electronic data interchange. Costs associated with mailing, faxing and telephoning will decrease.

3. All administrative tasks can be accomplished electronically. Dentists will have more time to devote to direct care.

4. Dentists will have a more complete data set of the patient they are treating, enabling better care.

5. Patients seeking information on enrollment status or health care benefits will be given more accurate, complete and easier-to-understand information.

6. Consumer documents will be more uniform and easier to read.                                  

7. Cost savings to providers and plans will translate in less costly health care for consumers. Premiums and charges will be lowered.

8. Patients will save postage and telephone costs incurred in claims follow-up.

9. Patients will have the ability to see what is contained in their medical and dental records and who has accessed them. Patient records will be adequately protected through organizational policies and technical security controls.

10. Visits to dentists and other health care providers will be shorter without the burden of filling out forms.

11. Consumer correspondence with insurers about problems with claims will be reduced.

Pruitt’s Response 

1. Dental office computer systems will be compatible with those of the hospitals and plans they conduct business with. 

Referral inquiries will be handled easily. Just how important is that to dentists other than you and the insurers you repeatedly represent, Dr. Ahlstrom?  Adequate communication with other healthcare professionals has never been an issue in my office, and the US Post Office is hard to beat for safety. Dentists’ offices are not emergency rooms. Even in the most urgent situation, I cannot imagine a general dentist needing anything faster than the telephone and fax machine.  And if it is a life-threatening emergency, rather than going online, we simply dial 911 in my office. 

Common forms of communication are much more convenient, inexpensive and dependable than computers.  But most importantly, like the US mail, they do not endanger dental patients’ welfare like digital records do. In fact, because universally accepted communications are not covered by the HIPAA rule you support, they cannot draw inspections and fines from the HHS.

As far as aiding communication with insurers, that has always been an insurance problem – commonly used to delay and deny payments to dentists. Since dental insurance companies continue to avoid transparency with their own clients for strategic reasons, their greed must never again be officially declared as dentistry’s problem by representatives of the ADA. You are wrong to mislead the federal government. It has never been the mission of the ADA to protect the profits of dental insurance companies. In fact, those you assist compete with dentists for dental patients’ dollars. That means it is unethical as well as against the Hippocratic Oath for you to assist them, Dr. Ahlstrom.

2. Vendors will be able to supply low-cost software solutions to physicians/dentists who support standards-based electronic data interchange.  Costs associated with mailing, faxing and telephoning will decrease.

Supply solutions for what problems?  How can a prosthodontist be so imprecise as to include vague words like “low-cost” in such important testimony to lawmakers on behalf of the nation’s dentists? Low-cost compared to what – no software? Just how expensive are the postage and telephone bills compared to the $40 thousand vendor problem you describe later in your testimony to the NCVHS? 

“One dentist contacted the ADA recently and said that their current vendor was not going to update the current version in use today and instead the dental office would be forced to purchase a new system for $30,000-$40,000 dollars or return to submitting paper claims.” Dr. Ahlstrom, please leave baseless advertisements to healthcare IT vendors. They follow a code that forces them to maintain credibility. 

3. All administrative tasks can be accomplished electronically. Dentists will have more time to devote to direct care.

As the best, if grossly exaggerated selling point for HIPAA that Dr. Ahlstrom highlights, this is still a blatant reach that is silly. I find it odd to read that any dentists sacrifice chair time for administrative tasks.

The business of dentistry is actually so simple that it was managed successfully for decades in even the busiest offices with pegboards and ledger cards.  The bottleneck in dentistry has never been the front desk. It has always been the speed of the dentist. As a matter of fact, HIPAA forms have actually hurt efficiency. In addition, operatory turn-around is further delayed by another unfunded and unproductive mandate called OSHA, which also offers nothing to hold down the cost of compliancy. 

What is the difference between the two? OSHA makes a little bit of sense, is hundreds of times cheaper and it does not harm patients other than increasing the cost of dental care. As for Ahlstrom’s incredible claim that “All administrative tasks can be accomplished electronically,” HIPAA compliance itself increasingly adds serious administrative tasks to covered entities’ overhead even before HIPAA inspections of dental offices begin. Let me provide a partial list of documents that are expected to be handy for HIPAA inspectors:  In April 2005, long before Ahlstrom’s deceptive suggestion that HIPAA reduces non-productive tasks, Piedmont Hospital in Atlanta was inspected by HHS for HIPAA violations.

http://www.computerworld.com/action/article.do?command=viewArticleBasic&articleId=9024921

As a result, Piedmont officials were presented with a documented list of 42 items that the agency wanted information on  “… including physical and logical access to systems and data, Internet usage, violations of security rules by employees, and logging and recording of system activities.  The document also requested items such as IT and data security organizational charts and lists of the hospital’s systems, software and employees, including new hires and terminated workers.”

Has the ADA prepared members for HIPAA inspections?  Not at all! They never mention it. Isn’t that odd?

I personally conducted a survey that I posted on the Executive-Post titled “HIPAA Rules and Dentistry.”

https://healthcarefinancials.wordpress.com/2008/09/01/hipaa-rules-and-dentistry/

The results show that the range of compliancy was found to be from 0% for the requirement of a written workstation policy to 88% for that of password security. The average was 49%, meaning that less than half of the requirements are being respected by the dentists in this sample. Once again, neither Ahlstrom nor the ADA has mentioned a word about HIPAA inspections to membership.

4. Dentists will have a more complete data set of the patient they are treating, enabling better care.

This is beyond reaching. This is absurd. If Ahlstrom had not obviously included this false testimony to placate members of the NCVHS who know nothing about dentistry, the intention of his misrepresentation would not make sense at all. What more do dentists need to successfully treat a patient’s oral problems than an uncomplicated, up-to-date and concise health history like the hundreds of millions of paper ones safely in use today in dental offices? Even if one pulls up an interoperable electronic health record, the dentist still must review it before initiating treatment. No time saved there. As more eHRs become imperceptibly altered by health insurance thieves who are not likely to be allergic to the same medications as the true owners of the records, I am determined that my patients’ health histories will always be paper – even if I am forced to pretend to have a paperless practice as mandated by an absurd law. It will cost my patients more to have two sets of records, but they will enjoy less risk of anaphylactic shock. 

Let’s face it, dentistry is not heart surgery. Dentists don’t even need to know blood types. A health record complicated with superfluous and possibly tainted information clearly increases the chance for serious error without providing patients any benefit. One complaint already heard from physicians using eMRs is that there is simply too much information in digital records that complicate treatment rather than enhance healthcare. 

In addition, unethical employers, bankers, ad executives and insurers find detailed electronic information about patients’ frailties of value and worth paying for, while eHRs are being breached millions at a time.  Why should a dentist maintain any more medical information than necessary?  There is no black market value for dental records. Why on Earth create one?

5. Patients seeking information on enrollment status or health care benefits will be given more accurate, complete and easier-to-understand information.

This should have never been mentioned by Dr. Ahlstrom. Incomprehensible dental insurance policies can no longer be defended by the ADA. Otherwise the insurance industry will continue to encourage complexity in order to take advantage of their clients. As healthcare providers for trusting patients, we cannot allow agents of the ADA to force the nation’s dentists to be enablers of deceit. Otherwise, like Ahlstrom, we are guilty of deceit as well. 

Adequate communication between an insured and the insurer has always been an insurance problem and not a dental problem. ADA leaders must immediately stop encouraging members to assume insurers’ responsibilities of explaining their intentionally complicated dental plans to their clients. The ADA should never again spend a penny of members’ dues to assist insurance companies. Once again, performing work for insurance companies is outside the mission of the ADA.  It always has been.

6. Consumer documents will be more uniform and easier to read.

This is pure fantasy. Computerization does not fix sloppy, it empowers sloppy.

7. Cost savings to providers and plans will translate in less costly health care for consumers. Premiums and charges will be lowered.

Although it is undeniable that electronic records benefit insurers more than anyone else, one has to pay close attention to Ahlstrom’s use of the words “cost savings.”  If Ahlstrom had said that HIPAA will lower dentists’ overhead, like head ADA lobbyist Michael Graham claims on his ADA website, Ahlstrom’s statement would be just another lie from another ADA representative.

http://www.ada.org/prof/advocacy/agenda.asp

By calling it a “cost savings,” Ahlstrom technically concedes that HIPAA will indeed require an increase in overhead – which dental patients will ultimately have to pay to obtain dental care.  Ahlstrom cleverly skirts the lie that Graham continues to post by promising “savings over what it could cost otherwise” – perhaps without the “low-cost” vendors he previously mentioned.

It can no longer be denied by employees of the ADA like Michael Graham. ADA members will have to raise fees to cover the purchase and maintenance of untried and expensive information technology that neither patients nor dentists want. It is also undeniable that because of their deceit, more children will go to bed with toothaches; So much for increasing access to care, ADA.

Will there be problems? You bet! Big expensive ones attached to very angry ADA members similar to the $40 thousand problem mentioned by Ahlstrom himself.

Here is another problem that the ADA has kept hidden from membership: In Subpart D, §160.426, of the HIPAA enforcement rule, there is a section titled “Notification of the public and other agencies” which gives HHS the right to inform virtually everyone if they find a violation in a dental office. When inspections begin, I expect HHS to publicly punish violators.  For good reason, there is a growing bi-partisan push for accountability for data breaches which continue to occur copiously. There is no doubt that news about HIPAA violations will be made public on the Internet through the NPPES using dentists’ NPI numbers. Since dentists freely volunteered for the numbers, it makes this legal. Volunteering is legal consent to abide the laws of the revised 1966 Freedom of Information Act which in 1996 was turned 180 degrees away from government entities such as the HHS and directed against US citizens who happen to be dentists.  The ADA has also failed to inform members that an investigator can show up unannounced in any covered entity’s office and demand everything digital immediately.  This means that office computers can be instantly confiscated even before one is publicly labeled as a HIPAA violator on the Internet.

And to think that some rookie healthcare IT enthusiasts are still foolish enough to mention Hurricane Katrina as a swell reason for going paperless. One can see hurricanes coming.

8. Patients will save postage and telephone costs incurred in claims follow-up. 

Once again, this problem will never be solved electronically. Insurers will merely save money for postage on denial letters – which will naturally encourage more denials – and an insurance executive will receive a bonus.

9. Patients will have the ability to see what is contained in their medical and dental records and who has accessed them.  Patient records will be adequately protected through organizational policies and technical security controls.

My patients can drop by my office at any time to see their dental records. If they want copies, I can provide those as well. I can even mail them. Nobody has ever had access to my patients’ paper records without my patients’ permission. As for protection, a huge, clunky sheet-metal file cabinet stuffed with hundreds of pounds of paper records, including radiographs, is hard to slip down a flight of metal and concrete stairs quickly without making at least a little noise. On the other hand, hackers, or even dishonest or angry employees raise no alarm whatsoever, and they can be gone in a flash with thousands of IDs. How can Dr. Ahlstrom possibly promise that with HIPAA, electronic records will be adequately protected?  What about the organizational policies he casually mentions?  Does this mean more staff meetings? I should remind everyone that selling point number three was a decrease in administrative work. Did Ahlstrom change his mind in mid-testimony? 

Lastly, effective technical security controls just do not exist.  For example: If electronic health records show who has accessed them, can someone discover who has accessed the more than 160 million records that have been reported lost in the last few years?  Impossible!

10. Visits to dentists and other health care providers will be shorter without the burden of filling out forms.

Does this mean fewer HIPAA “Notice of Privacy Practices (NPP)” forms? How much time would it take for new patients to actually read the NPP form they sign? How much more time would it take for dentists to disclose to the patients that the form does nothing to protect their rights to privacy?  Quite the contrary; “Patients also may ask covered entities to restrict the use or disclosure of their information beyond the practices included in the notice, but the covered entities would not have to agree to the changes.” – abstracted from “Protecting the Privacy of Patients’ Health Information,” released in April 2003 from the HHS.

http://www.hhs.gov/news/facts/privacy.html

11. Consumer correspondence with insurers about problems with claims will be reduced.

Since I am never a legal party in my patients’ insurance decisions, and since very few dental insurance companies hold themselves accountable to anyone, including their own clients, why should I care about patients’ contractual agreements with their dental insurance companies? I do not want that responsibility and such earthly bad advice from an ADA leader is simply not consistent with the mission of the ADA.

Assessment

In closing, I have to ask why Dr. Robert Ahlstrom would invent the fantasy he told lawmakers. It is as if he told the NCVHS what he thought HHS wanted to hear. Why couldn’t he just tell the truth?  HIPAA offers no benefit to dental patients. In fact, the mandate endangers their welfare, making it unethical for a dentist to become a covered entity, even if encouraged to do so by a representative of the American Dental Association.

If I am wrong about any part of this national disgrace, Dr. Robert Ahlstrom should immediately stand up and publicly defend HIPAA on this forum. It is failing in dentistry on a national scale and pulling the ADA down with it.  If nobody can clear up the apparent absurdity, not only will it hurt my profession, but the Department of Health and Human Services as well as Obama’s administration will suffer embarrassment when the media discovers that HIPAA is in reality, a grand fraudulent scheme of historic proportions.

The Challenge

It is your turn now, Dr. Robert Ahlstrom. Meet the professionals whose interests you misrepresented in front of lawmakers. Otherwise, be forever silent. I will always hold you accountable for abetting fraud against my profession. 

Conclusion

Your thoughts and comments on this polemic and Medical Executive-Post are appreciated; especially from dentists, attorneys and health policy wonks, and IT gurus. Does the dentist have a point; or not?

Note: Dr. Pruitt blogs at PenWell and others sites, where this post first appeared.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Medical Office Expensing v. Depreciating

Some Tax Basics for Medical Professionals

By Edwin P. Morrow; III, JD, LLM

56371606Astute financial advisors and healthcare focused accountants know that there are simple and overlooked strategies that can significantly add to the bottom line of any business or medical practice; as much as increasing practice revenues or reducing expenses. Physicians and medical professionals themselves should also understand some basic accounting and simple tax strategies that do not require five figure consulting fees or excessive risks of audit. Here are some basic concepts of financial accounting to know.

Tax Deductible Expenses

Medical professionals should understand the basic concept of a tax-deductible expense, which can be used to offset income in the year paid or accrued, and a capital expenditure.

Capital Expenditures

 A capital expenditure must either be depreciated (similar terms are amortized or depleted), meaning that there is a deduction made over several years, or the expenditure may be required to be added to the tax basis of the property, meaning that there is only a tax benefit upon sale of the property.

An expense that adds to the value or useful life of medical office property is a capital expense.  Capital expenses include expenditures for buildings, significant improvements or instrumentations and related medical machinery. For instance, a repair on an office roof may be a deductible expense, but a new roof will be a capital expenditure.  Although both may be expensive, the repair reduces income dollar for dollar in year one, and the new roof reduces income only gradually over many years.

Understanding Accounting Concepts

 This is a very important tax accounting concept. In essence, any significant asset purchased or expenditure that has a useful life of more than one year cannot be expensed, but may be eligible to be depreciated over the life of the asset. This means you have to wait many years to get the full tax benefit from the expenditure.

Depreciation Useful Life

Some common assets and their default useful life according to the IRS are:

  • Computers and Peripherals – 5 years
  • Office Machinery and Equipment – 5 years
  • Transportation Equipment – 5 years
  • Office Furniture and Fixtures – 7 years
  • Certain Watercraft – 10 years
  • Farm Buildings – 20 years
  • Residential Rental Property – 27.5 years
  • Leasehold Improvements – 39 years
  • Non-residential Real Property – 39 years
  • Land without improvements – cannot be depreciated
  • Items held for inventory or ultimate sale – cannot be depreciated

Assessment

Note that even if your office computer hardware becomes obsolete in one or two years that the IRS may make you use the five-year depreciation schedule, but see the following section on Section 179 elections for exceptions. Computer software bundled and included with hardware must use the same rule. Software that has a useful life of less than a year, such as tax preparation software, may be a deductible expense, but other software costs may be amortized over 3 years.  IRC § 167(f)(1).  There may also be exceptions to the depreciation requirement for environmental cleanup costs, which may be eligible to be expensed as a deduction IRC § 198.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. How have you used these strategies in the past?

Speaker:If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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