Anesthesia Business Consultants: Communique fall07

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ANESTHESIAANESTHESIA
BUSINESSCONSULTANTBUSINESSCONSULTANTS
FALL2007VOLUME12,ISSUE2
ABC offers The Communiqué in electronic format
Anesthesia Business Consultants, LLC (ABC) is happy to announce that The Communiqué
will be available through a state-of-the-art electronic format as well as the regular printed
version. The Communiqué continues to feature articles focusing on the latest hot topics for
anesthesiologists, nurse anesthetists, pain management specialists and anesthesia
practice administrators. We look forward to providing you with many more years of
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please send your email address to info@anesthesiallc.com.
THE THREE-PRONG
CHANGES TO “STARK”THAT
YOU MUST UNDERSTAND
By Mark F.Weiss, J.D.
If you have any concern about com
plying with Stark, the federal prohibition
against self-referral, you need to under
stand the three-prong changes that have
occurred since the beginning of July.
Without this understanding, you will be
unable to make an informed decision as to
whether your activities conform to Stark’s
requirement of absolute compliance.
Although Stark is a civil, not a crimi
nal statute, if you have a financial
relationship, as defined by Stark, in an enti
ty to which you make Medicare or
Medicaid referrals for “designated health
services,” you must strictly fall within an
exception in order to avoid substantial civil
penalties and exclusion from Medicare and
Medicaid program participation. tions has spanned seven years, including
Complying with Stark is akin to trying four major regulatory pronouncements.
to hit a moving target: Since the original Even though it is difficult to argue that
statute’s enactment in 1989, the law has the government should not have a role in
been amended multiple times and the fighting fraud and abuse within federally
Centers for Medicare and Medicaid funded healthcare programs, Stark’s tor-
Services’ process of issuing final regula- tured and esoterically complex legislative
Continued on page 4
➤ I N S I D E T H I S I S S U E :
THE THREE-PRONG CHANGES TO "STARK" . . . . . . . . . . . . . . . . . . . . 1
THE MEDICAL DIRECTION TEAM AND COMPARISONS . . . . . . . . . . . . . 2
ASA FEE SURVEYS – 1997 TO 2007 . . . . . . . . . . . . . . . . . . . . . . . . . 6
COMPLIANCE CORNER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
KARIN BIERSTEIN JOINS ANESTHESIA BUSINESS CONSULTANTS . . . . . 11
CODING CORNER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
EVENT CALENDAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

THE COMMUNIQUE´ FALL 2007 PAGE 2
THE MEDICAL DIRECTION TEAM AND
COMPARISONS IN CLINICAL WORK MEASURES
By Amr Abouleish, MD, MBA
Department of Anesthesiology, University of Texas Medical Branch
When an anesthesiology group is more work and should be paid more. In practice.i,ii Listed in order of prevalence,
small and covers only one facility, the issue this situation, the group will need to the systems used are based on (1) shift-
of “who is working hard” is moot. In a reevaluate its compensation plans and worked (includes revenue split up
small setting, everyone can “see” everyone, how it measures “work done,” the majori- equally), (2) charges or billed ASA units,
and all the members take the same call and ty being clinical work. (3) time billediii, or (4) a combination. (I
take the same time off. In contrast, as a For clinical anesthesiology work, sev- do not list “revenue-collected” since this is
group grows and begins to cover more eral categories of measurements can be a measure of financial productivity, and
than one facility, invariably there will be used – all reflect the different types of not clinical productivity.)
members of the group who think they do compensation plans that exist in private- Each of these categories values work
I hope that all of our loyal readers
have had a nice summer. There is some
thing about fall in Michigan that always
takes me back to my college days. I love
the cool, crisp weather and the beginning
of a new football season. For many of my
classmates Fall marked the end of the
summer, but for me it ushered in the
beginning of a new year of opportunity,
the promise of interesting new discover
ies, making new friends and, most of all,
the satisfaction of gaining new insights
and skills to make me more successful.
And so it is for ABC as well. Our staff
has spent the summer settling into our
newly renovated offices in downtown
Jackson. Our purchase and restoration of
the old Jacobsen’s department store build
ing has proved to be an uplifting
experience not only for our employees but
for the community as a whole.You cannot
help but feel good about an investment
like this in a community like Jackson.
As the collection of articles in this
issue of Communique clearly indicates,
there is still much to learn about our
ever-changing business and the specialty
of anesthesia. Once again, we touch all
the important bases, from the technical
details of compliance and coding, to the
legislative environment to the ongoing
saga of anesthesia practice-hospital rela
tions. Hopefully at least one of these
thoughtful pieces will intrigue, fascinate,
affirm or challenge you to look at your
group or practice situation in a new way.
As many of you have already heard
we have been especially fortunate this fall
to have Karin Bierstein join our team. I
think you will find her explanation for
the transition quite intriguing. Not only
do we consider her a tremendous asset
and feel immensely grateful that she
wanted to work with us, but we look for
ward enthusiastically to the insights and
guidance she will give our people. We
have always tried to be forward looking,
to anticipate the next significant devel
opment and to make investments that
anticipate our clients’ practice needs. I
am thrilled that we can now do this at a
whole new level.
Soon we will pack our bags to join
many of you at the ASA annual meeting
in San Francisco, the PGA in New York
and the Practice Management
Conference in
Tampa which our
very own Karin
Bierstein planned
with Committee Chair Robert
Johnstone, M.D. Each hold a unique
promise of new insight, increasing our
professional network of resources and
exploring aspects of practice manage
ment that we never realized were so
critical to our survival and success. May
we all find it a time of discovery, adven
ture and personal fulfillment.
I would like to personally thank you
for your interest in our efforts on behalf
of the specialty and your support for the
various services we provide the commu
nity. As always, we welcome your
comments and suggestions. With your
input and Karin’s vision in addition to
the publication management skills of
Cortney Shepherd, these pages will soon
take on a whole new look.
Sincerely,
Tony Mira, founder and CEO
THE FALL PERSPECTIVE

slightly differently and devalues different
types of work. Briefly, shift-worked values
availability to work and assumes every
one’s daily caseload will even out in the
end (since it gives no value to the actual
charges billed). Charges or billed ASA
units values actual charges but those billed
units are dependent on OR scheduling,
surgical duration, and type of surgery.iv
Time billed values anesthesia time with a
patient and not total time worked (since
any turnover time and down time are non-
billable). And finally, a combination
represents a group’s attempt to minimize
the downsides of each category.
One factor that is essential to consider
is the effect of anesthesia care team model
on any comparisons of work done.When a
group begins to consider measuring indi
vidual work, the group will invariably look
at measuring work done“per doctor” or in
business“per FTE”(where FTE = full-time
equivalent). For a physician-only group,
there is no problem with this methodolo
gy since the work done is done only by
each member. On the other hand, once
you introduce anesthesia care team model,
then each doctor will be producing units
billed in more than one room and the
issue of staffing ratios becomes important
to consider. It should be noted that this
issue of staffing ratio is only important if
billed units – either total ASA
units/charges or time-billed – are used as
the measurement of work.v
Since 2005, the MGMA has published
an annual anesthesia survey entitled “Cost
Survey for Anesthesia Practices.”vi In one of
the breakdowns of the data, the data is pre
sented by staffing models: physician only, <
1 CRNA/AA per physician, and >1
CRNA/AA per physician. The effect of
staffing models is seen clearly when one
looks at the data in these surveys. From the
2006 report, time and total units per case
are almost identical among the three
staffing models. (See Table) On the other
hand, there is a marked differences between
the models (especially between physician-
only and >1 CRNA/AA per physician)
when looking at time and total units billed
per physician. This is not surprising since
the medical direction groups bill more than
one OR per physician while the physician-
only group bills one OR per physician. On
the other hand, when one takes the staffing
model out of the equation, the work “per
OR” shows fewer differences.
Within a group that covers more than
one facility, differences in staffing models
may confound comparisons of any meas
urements similar to the survey data. For
instance, if a group covers a traditional
inpatient facility and a newer ambulatory
surgical center (ASC), the group may
choose to cover the inpatient facility with
1:2 to 1:3 MD: CRNA ratio but 1:4 in the
ASC. In this situation, billed units per FTE
will favor the ASC due to the increased
staffing ratio. Another example is the way
some groups cover cardiac anesthesia
cases with physicians only, and other cases
with medical direction. In this situation,
the differences in staffing models would
confuse comparisons using “units per
FTE”.
In conclusion, measuring and com
paring clinical productivity is difficult. It is
not surprising that so many anesthesiology
groups choose to split the money up even
ly or only track shifts worked. If a group
does choose to use units billed as a meas
ure, staffing ratio differences should be
reviewed. Even if the group does not use
units billed for compensation, they may
use them to track group productivity.vii
NOTE: The Cost Survey for Anesthesia Practice
is sent out every Spring, and the report is pub
lished in the late fall. The 2007 report has just
been released. It is available at a discount for
ASA members. Even better, every group complet
ing the survey receives a copy of the final report
free of charge. This article discusses only a small
portion of the comprehensive survey.
i Abouleish AE et al. Measurement of individual clinical
productivity in an academic anesthesiology department.
Anesthesiology 2000;93: 1509-16
ii Blough GG, Scott SJ. Presentation of AAA survey on
practice patterns at the ASA Practice Management
Conference in San Antonio, Texas, on January 31
February 2, 2003
iii Feiner JR et al. Productivity versus availability as a meas
ure of faculty clinical responsibility. Anesth Analg
2001;93:313-8
iv Abouleish AE et al. The effects of surgical case duration
and type of surgery on hourly clinical productivity of
anesthesiologists. Anesth Analg 2003;97:833-838
v Abouleish AE et al. Comparing clinical productivity of
Anesthesiology groups. Anesthesiology 2002;97:608-616
vi Medical Group Management Association. Cost Survey
for Anesthesia Practices: 2006 Report Based on 2005
Data. (Denver 2006)
vii Abouleish AE et al. Organizational Factors Affect
Comparisons of Clinical Productivity of Academic
Anesthesiology Departments. Anesth Analg 2003;96:
802-812
Table: Median Values
Physician-only <1 CRNA/AA per physician >1 CRNA/AA per physician
Per Physician
Total time units 4,939 4,887 6,965
Total units 9,888 9,078 12,692
Per OR
Total time units 5,001 5,907 5,413
Total units 8,306 10,729 9,249
Per Case
Total units (sum of time and base) 12.5 12.0 12.9
Time units 6.4 6.8 6.9
Base units 6.1 6.2 6.0
Adapted from Table 5.9f, 2006 Report Cost Survey for Anesthesia Practices, MGMA

THE THREE-PRONG CHANGES TO “STARK”THAT YOU MUST UNDERSTAND
Continued from page 1
and regulatory scheme makes clear that the
law’s authors, and the government employ
ees charged with writing the interpretive
regulations, have little understanding of
business reality. They certainly have no
appreciation of the impossibility of plan
ning and executing complex business
transactions in a regulatory environment is
continually changing – what was legal
under Stark yesterday is illegal today.
Three recent legislative and regulato
ry actions have increased this complexity.
PRONG ONE: PHYSICIAN FEE
SCHEDULE PROPOSALS
This past July, the Centers for
Medicare and Medicaid Services (“CMS”)
issued its Proposed Revisions to Payment
Policies Under the Physician Fee Schedule.
Those revisions impact the Stark regula
tions, including:
• Suggestions of possible changes to
the “same building” and “central
ized location” definitions
pertaining to Stark exception.
• Suggestions that percentage based
compensation deals would be con
sidered to meet the “set in advance”
requirement only in those circum
stances in which they are based on
revenue from services personally
performed by the physician receiv
ing the compensation.
• Proposed changes to the definition
of an “entity” to include both the
person or entity that presents the
claim and the person or entity that
either provides the designated
health services or causes the claim
to be presented. The impact of this
would be to make illegal “under
arrangements” services contracts
between physicians and hospitals.
• Expanding the definition of owner
ship and investment interests to
include a physician’s, or her family
member’s, interest in a retirement
plan, such that if the retirement
plan has an interest in a DHS enti
ty, the physician’s referrals to that
entity would be prohibited unless
subject to an exception.
• The requirement that the burden
be on the entity submitting the
claim to prove that the service was
not furnished pursuant to a prohib
ited referral.
PRONG TWO: SCHIP LEGISLATION
In August, the United States House of
Representatives passed the Children’s
Health and Medicare Protection Act of
2007, commonly referred to in the press as
the “SCHIP amendment legislation,”
which includes language severely limiting
Stark’s “whole hospital” exception.
As presently in effect (that is, unaf
fected by the proposed new law), there is
an exception to the general Stark law pro
hibition on referrals by a physician to a
hospital in which the physician has an
ownership interest. This exception is
referred to as the “whole hospital” excep
tion as it permits an ownership interest in
the whole facility, as opposed to an inter
est in merely a part of the facility.
The House version of the Children’s
Health and Medicare Protection Act of
2007 eliminates that exception. It grand
fathers in hospitals with physician
ownership that were in operation with
Medicare provider agreements as of July
24, 2007, as long as they do not increase
the number of beds or the number of
operating rooms that were in existence on
that date. However, it requires grandfa
thered hospitals to reduce physician
ownership to an aggregate of no more
than 40% of the facility and to no more
than 2% individually within 18 months of
enactment. It also mandates new disclo
sure of ownership rules as well as the
disclosure to patients if the hospital fails

to have 24 hour physician coverage.
The version of SCHIP amendment
legislation passed by the Senate does not
include this Stark law change. Although it
is unknown in what final form the Act will
emerge from conference committee or
whether it will be signed into law, the
prospect of loss of the whole hospital
exception is already having a chilling effect
on physician ownership of hospital deals.
If the Stark amendment language of
the House version of the Act becomes law,
the market for, and valuation of, hospitals
will be affected greatly. Facilities which
are owned largely, or entirely, by referring
physicians will face particularly tough
challenges: Divest to whom? Who must
be cut from the investor roster entirely
and who may remain? Stop participating
in Medicare and Medicaid? Close? Cease
any plans for expansion? Divestiture may
create bargains in the hospital market;
however, as physician ownership patterns
change, so too will referral patterns, plac
ing, in some instances, doubt on the
continuation of historical operating mar
gins and, therefore, on valuation.
PRONG THREE: PHASE III STARK
REGULATIONS
On September 2007, CMS released its
purportedly final phase, Phase III, of the
Stark regulations.
As it did with the proposed revisions
to the Physician Fee Schedule, CMS used
the Phase III regulations to further attack
percentage based compensation. CMS has
a history of flip-flopping on this issue.
Originally, CMS took the position that
percentage compensation failed because it
did not meet the “set in advance” require
ment. Next, under pressure from the
industry to recognize percentage payment
as a common practice, CMS retreated
from its former position, such that a per
centage set in advance was seen as
compensation that is set in advance.
However, in the Phase III regulations,
CMS reverses itself on the larger issue of
percentage arrangements, taking the posi
tion that percentage compensation
arrangements will often fail because they
will not meet the additional requirement
that compensation not take into account
the volume or value of referrals.
In its Phase II final Stark regulations,
issued in 2004, CMS created a safe harbor
definition for fair market value of physi
cian compensation that was based upon
specific compensation survey data. CMS
eliminates that safe harbor definition in
the Phase III regulations.
CMS made clear in Phase III that for
an independent contractor to qualify as a
“physician in the group practice,” the
group’s contract must be with the individ
ual physician or his professional
corporation and not via a separate entity,
such as another physician practice or a
staffing company. Leased physician
employees are not within the definition of
physicians in the group practice.
The Phase III regulations include
clarifications by CMS that within group
practices, productivity bonuses may be
paid based on services that the physician
has personally performed and/or services
and supplies “incident to” such personally
performed services. However, the alloca
tion of profits within a group is subject to
different rules, in that they must be allo
cated in a manner that does not relate
directly to designated health services
referrals, including those services which
are billed “incident to.”
The regulations include new policy
statements by CMS in connection with
shared space and equipment. Specifically,
physicians in more than one medical
group may not simultaneously share space
or equipment. A physician sharing a DHS
facility in the same building must control
the facility and the staffing at the time the
that DHS is furnished to the patient. The
practical effect is that block-leasing
arrangements may be required. All shared
facility arrangements must be carefully
structured and operated in order to be
compliant.
The definition of “indirect compensa
tion arrangements” has been changed. A
physician is deemed by the Phase III regu
lations to“stand in the shoes”of her group
practice such that an arrangement
between the group and an entity contract
ing with the group to provide DHS creates
a direct compensation agreement with the
physician. Previously, those sorts of rela
tionships created “indirect” compensation
relationships or perhaps no compensation
relationship at all.
Phase III restates CMS’s position that
when DHS is personally performed by the
referring physician, there is no Stark law
“referral.” However, CMS states in the
preamble to Phase III that this position is
not likely to apply to the provision of
durable medical equipment, as there are
few, if any, situations in which the refer
ring physician is enrolled in Medicare as a
DME supplier and personally performs all
of the duties imposed on such suppliers.
CONCLUSION
The rules for Stark law compliance
have changed and they will undoubtedly
change again soon. The “finality” of the
regulations is transitory. Existing referral
relationships, in addition to new ones,
must be tested for compliance with Stark’s
ever changing requirements in order to
avoid significant monetary penalties and
exclusion from participation in Medicare
and Medicaid.
Mark F. Weiss is a nationally recognized expert,
and a frequent author and speaker, on the busi
ness and legal issues affecting physicians. He
practices law with Advisory Law Group, A
Professional Corporation, representing clients
across the country from offices in Los Angeles
and Santa Barbara, California. He is a Clinical
Assistant Professor at USC’s Keck School of
Medicine. Mr. Weiss offers our readers a series of
complimentary educational materials. Mr. Weiss
may be contacted via e-mail at markweiss@advi
sorylawgroup.com or via phone at 877-883-2803.

ASA FEE SURVEY OF COMMERCIAL
PAYMENT RATES 1997 - 2007
By Joe Laden
Business Manager, Anesthesia Associates of Louisville, PSC
ASA FEE SURVEYS – 1997 TO 2007
The American Society of
Anesthesiologists published its sixth bien
nial survey of commercial payment rates
in the July ASA Newsletter. The surveys
have been conducted by the ASA
Washington office and the results reported
in the ASA Newsletter Practice
Management column written by Karin
Bierstein, J.D. M.P.H. The first two sur
veys (1997 and 1999) were distributed to
members of various ASA committees and
given to attendees at the annual ASA
Practice Management Conference.
Beginning in 2001, the Anesthesia
Administration Assembly of the MGMA
was asked to participate. Participation in
the survey has risen significantly each year
culminating this year with 284 respondent
anesthesiology practices employing a total
of 5,870 anesthesiologists.
In consultation with AAA leaders
Shena Scott and Genie Blough, Ms.
Bierstein has refined and improved the
survey methodology each year and as the
number of participants increases, the
results become more reliable. All of the
past survey articles and the survey instru
ments are available on the ASA web site.
The URLs are at the end of this article. Ms.
Bierstein’s columns explain how this sur
vey can be conducted legally within the
antitrust enforcement policy guidelines set
forth by the Department of Justice and
Federal Trade Administration.
WHY IS THE SURVEY IMPORTANT?
Most anesthesia fee-based revenue
comes from government health programs
and, in greater proportions, from con
tracted commercial payers. There is not
much control an individual anesthesiolo
gy practice can exercise over government
rates, but a practice can negotiate the
terms on which it will contract with com
mercial payers. Typically 2-5 commercial
payers represent the bulk of a practice’s
non-government revenue. Negotiating
favorable rates with these payers is one of
the most important functions of anesthe
siology practice managers. Having good
data on the rates paid by commercial car
riers nationally and regionally can help in
the negotiation of fees. These data will be
most helpful in the case of a commercial
payer with a low unit conversion factor
relative to others in your geographic area.
If the payer is reasonable and wants to pay
a fair price for anesthesiology services, the
survey data may help your negotiations.
Or course, there are payers with near
monopolistic market power that can pay
low rates with impunity. In this situation,
you may be able to use the survey to justi
fy financial support from your hospital to
the extent that your services are underpaid
by this payer relative to the cost for you to
provide anesthesiology services.
If the rates paid by your contracted
commercial carriers are at or above the
median, you can use the survey data to
show your anesthesiologists that you have
done a good job negotiating your conver
sion factors.
HOW HAVE COMMERCIAL PAYER RATES
EVOLVED SINCE 1997?
The survey has asked for three con
version factors from each anesthesia
group. The first four questionnaires sim
ply requested the respondent’s three
highest-volume payers’ rates. In 2005 and
2007 the questionnaires instead called for
the conversion factors paid to the group by
its low payer, median payer and highest
payer. Using these three numbers, ASA
published the survey mean (average),
median (mid point), minimum, maxi
mum, 25th percentile and 75th percentile
for each on a national and regional basis.
A simplified way to look at the results over
the past 10 years is to plot a graph of the
statistical mean of the high, median and
low of the biennial national results. (see
Chart 1) It may be helpful to plot the con
version factor received by your practice by
its major commercial contracted payers
for comparison purposes. An illustration
of this is also plotted on Chart 1.)
Over the 10 years from 1997 to pres
ent, the mean (average) of the median
conversion factors has increased 32.3%
from $42.82 to $56.66 which is an annual
compounded rate of 2.8%. This rate is
below inflation over this time period and

ASA National Commercial CF vs. My Practice
$0.00
$5.00
$10.00
$15.00
$20.00
$25.00
$30.00
$35.00
$40.00
$45.00
$50.00
$55.00
$60.00
$65.00
$70.00
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
High
Mid
Low
My Practice
CHART 1
therefore no gain has been made in dollars
adjusted for inflation. The mean of the low
payer’s conversion rate has increased
27.5% from $42.26 to $52.16 which is an
annual compounded rate of 3.1%. The
mean of the high payer’s conversion rate
has increased 46.5% from $44.41 to $65.08
which is an annual compounded rate of
3.9%. It is interesting that the better pay
ers’ rates are increasing the most rapidly.
USING THE SURVEY DATA TO YOUR
ADVANTAGE
It is well known that anesthesiologists
are underpaid by the government pro
grams, Medicare, Medicaid and
CHAMPUS/Tricare. The ASA survey
shows that payment increases from com
mercial payers over the past 10 years do
not exceed the national inflation rate. If
one plots practice expenses over the same
time period (e.g. malpractice, health
insurance, CRNA salaries) the results will
undoubtedly show that these practice
expenses have increased at a rate far
greater than inflation. This explains why
many anesthesiologists express concern
that they are working harder for the same
or less pay. Also, there has been an
increase over this time period in the num
ber of anesthesiology practices that have
had to ask hospitals for financial support
because revenue from fees is insufficient
to pay anesthesia personnel for required
operating room coverage.
In order to advance the payment rate
for anesthesiology services, anesthesia
practice managers will need to become
better negotiators with their principal
contracted commercial carriers. A good
way to start is by reviewing the six ASA fee
survey articles and comparing the historic
rates paid by your top commercial payers
with the survey data. If there are one or
more payers that fall below the survey
averages, you will need to develop a strat
egy to bring these rates to parity.
To download the data table in
Microsoft Excel format, please visit
www.communiquenews.com.
SUPPORT
LEGISLATION
to Fix the
Medicare
Anesthesiology
Teaching Rule
Last month Sen. J.D. Rockefeller
(D-WV) introduced legislation that
would eliminate the discriminatory
Medicare payment policy toward
teaching anesthesiologists.
For information on how to support
this legislation visit the “What’s
New?” section of the ASA website
at http://www.asahq.org/news/
asanews091807.htm.

As part of our desire to keep both clients and
readers up to date, the Communiqué has been
printing compliance information since its
inception. In the Compliance Corner, we will
now formally keep you abreast of the various
compliance issues and/or pick out a topic that
would be of interest to most of our readers.
GET READY FOR INCREASED MEDICARE
AUDIT ACTIVITY AS RECOVERY AUDIT
CONTRACTORS ARE GOING NATIONWIDE
The financial pressure on hospitals,
physicians and other healthcare providers,
as a result of increased scrutiny of claims
and audit activity by third party payors,
will not end soon. To the contrary, as part
of the Tax Relief and Health Care Act of
2006, Congress directed that the Medicare
Recovery Audit Contractor (“RAC”)
demonstration program expand to all 50
states by no later than 2010. CMS plans to
aggressively move forward with this
expansion. CMS has already announced
the expansion of its program from three
states to an additional nine states, with
intentions for nationwide RAC auditing to
take place by spring 2008, three-years
ahead of schedule. Providers, including
anesthesiology and pain management
groups are well advised to prepare now for
the expansion of the RACs and increasing
Medicare audit activity.
RECOVERY AUDIT CONTRACTORS
The original three-year RAC pilot
demonstration project was a result of
By Abby Pendleton, Esq.
Jessica L. Gustafson, Esq.
Wachler & Associates
Section 306 of the Medicare
Modernization Act, which directed CMS
to investigate Medicare claims payments
using RACs to identify overpayments and
underpayments. The pilot demonstration
targeted the three states with the highest
Medicare expenditures (New York, Florida
and California), and has proven highly
successful from the financial perspective
of CMS and the RACs. The CMS RAC
Status Document for FY 2006 reflects
$303.5 million as total “improper” pay
ments identified by the RACs for FY 2006,
with a high percentage being linked to
inpatient hospital claims.1
The RAC process is designed to iden
tify and recover overpayments (and
underpayments) made by Medicare to
providers. This process has ramifications
that may significantly impact the financial
status of providers. The current RAC
experiences of many California hospitals
highlights the significant impact the RACs
will have on Medicare providers as the
project goes nationwide. To date,
providers have found the RAC process
burdensome; significant resources have
been dedicated to responding to volumes
of record requests and defending claims
denials.
Notably, CMS compensates RACs on a
contingency fee basis, and RACs are enti
tled to keep their fee if a denial is upheld
at the first level of Medicare appeal (i.e.,
redetermination to the Carrier or Fiscal
Intermediary), regardless of whether the
provider prevails at a later stage in the
appeals process. Amazingly, subsequent
appeals after the first level of appeal do
not impact a RAC’s ability to retain the

contingency payment. This fee arrange
ment appears troublesome, as it provides
incentives to private companies to aggres
sively review and deny claims. This
includes denying claims alleging that serv
ices were not medically necessary or
appropriately documented, areas that con
tain much subjectivity and are often
highly disputed by the provider. CMS’
payment agreement seems to guarantee
that RACs will audit with a highly moti
vated work ethic to identify as many
overpayments as possible.
Given what New York, Florida, and
especially California providers are experi
encing in the pilot RAC demonstration
project, Medicare providers are well
advised to begin the process of preparing
for the RACs now. Although providers
may not be able to stop RAC audits,
providers can engage in activities that
should assist with the process. For exam
ple, providers need to prepare by
dedicating resources to:
1) Internal monitoring protocols to
better identify and monitor areas
that may be subject to review;
2) Responding to record requests;
3) Compliance efforts including, but
not limited to, documentation and
coding education; and
4) Dedicating personnel and
resources to properly work up and
defend denials in the appeals
process.
MEDICARE APPEALS PROCESS
Claims denied as a result of a RAC
audit are subject to the standard Medicare
appeals process. Medicare providers
should utilize the appeals process. In
addition to substantive arguments, such as
attacking claim denials on the merits, it is
important for providers to understand
that other legal arguments and strategies
exist and can be utilized in the appeals
process. These legal arguments and strate
gies may prove invaluable to the case. For
example, the Social Security Act contains
provisions, such as the Medicare Provider
Without Fault and Waiver of Liability pro
visions, which can be used and developed
with certain facts and circumstances that
may exist in the case.
In 2005, a new uniform Medicare
appeals process was created resulting in
the same appeals process for both Part A
and Part B providers. This process
includes:
• A redetermination appeal to the
Carrier or Intermediary;
• A reconsideration submitted to a
Qualified Independent Contractor
(“QIC”);
• An appeal to an Administrative Law
Judge (“ALJ”);
• An appeal to the Medicare Appeals
Council (“MAC”); and
• An appeal to Federal district court.
In order to pursue the various levels of
appeal, certain requirements must be met
at certain stages in the appeals process.
Although many providers have not seen
much success at the redetermination stage
of the appeal, the later stages of appeal,
particularly the ALJ stage, may prove more
successful. Providers must use due care in
complying with the timeframes and other
requirements set forth in the appeals
process. Failure to do so may result in the
inability to pursue the appeal.
The first level in the appeals process is
redetermination. Providers must submit a
redetermination request in writing within
120 calendar days of receiving notice of an
initial determination. There is no amount
in controversy requirement.
Providers dissatisfied with a Carrier’s
redetermination decision may file a request
for reconsideration to be conducted by the
QIC. This second level of appeal must be
filed within 180 calendar days of receiving
notice of the redetermination decision. As
with the redetermination stage, there is no
amount in controversy requirement. The
QIC reconsideration stage of appeal has
important ramifications for both Part A
and Part B providers. With respect to Part
B providers, the QIC reconsideration stage
replaces the in-person Carrier Hearing that
Continued on page 10

GET READY FOR INCREASED MEDICARE AUDIT ACTIVITY
AS RECOVERY AUDIT CONTRACTORS ARE GOING NATIONWIDE
was afforded under the prior regulations.
In an important negative change for Part B
providers, the QIC reconsideration is an
“on-the-record” review, rather than an in-
person hearing. The previous process
afforded Part B providers with an actual in-
person hearing.
Moreover, it is important to note, as
many providers may be unaware, that the
reconsideration stage of the appeals
process contains an early presentation of
evidence requirement. This means that a
provider’s failure to submit evidence to
the QIC at the reconsideration stage of
appeal will likely preclude the provider
from introducing the evidence to an ALJ
or later stages in the appeals process.
Accordingly, it will be crucial for providers
to fully work up their cases at the recon
sideration stage of appeal.
The third level of appeal is the ALJ
hearing. A provider dissatisfied with a
reconsideration decision may request an
ALJ hearing. The request must be filed
within 60 days following receipt of the
QIC’s decision and must meet the amount
in controversy requirement. ALJ hearings
can be conducted by video-teleconference
(“VTC”), in-person, or by telephone. The
final rule requires the hearing to be con
ducted by VTC if the technology is
available; however, if VTC is unavailable,
or in other extraordinary circumstances
the ALJ may hold an in-person hearing.
Additionally, the ALJ may offer a tele
phone hearing. Notably, the provider is
not automatically entitled to an in-person
hearing at the ALJ stage of appeal.
The fourth level of appeal is the MAC
Review. The MAC is within the
Departmental Appeals Board of the U.S.
Department of Health and Human
Services. A MAC Review request must be
filed within 60 days following receipt of the
ALJ’s decision. Among other requirements,
a request for MAC Review must identify
and explain the parts of the ALJ action with
which the provider disagrees. Unless the
request is from an unrepresented benefici
ary, the MAC will limit its review to the
issues raised in the written request for
review. The final step in the appeals process
is judicial review in federal district court. A
request for review in district court must be
filed within 60 days of receipt of the MAC’s
decision. In a federal district court action,
the findings of fact by the Secretary of HHS
are deemed conclusive if supported by sub
stantial evidence.
SUMMARY
CMS has announced its intention to
aggressively expand the RAC pilot demon
stration project, with plans for nationwide
auditing to take place as early as spring
2008. The contingency payment arrange
ment between CMS and the RACs ensures
that the RACs will aggressively audit
providers, with an eye towards denying as
many claims as possible. Providers are
well advised to act now to prepare for the
expansion of RAC activity. Providers
should dedicate resources towards com
pliance education and towards timely
addressing any document requests and/or
claim denials. Because claim denials made
by the RACs will be subject to the
Medicare appeals regulations, providers
must be cognizant of the appeal rules.
1 November 22, 2006, CMS RAC Status Document FY
2006, available at http://www.cms.hhs.gov/RAC/Downloads/
RACStatusDocument—FY2006.pdf (last accessed
September 10, 2007).

KARIN BIERSTEIN, J.D., M.P.H.
JOINS ANESTHESIA BUSINESS CONSULTANTS
Anesthesia Business Consultants is
pleased to announce that Karin Bierstein,
JD, MPH has joined our team as Vice
President for Strategic Planning and
Practice Affairs. Ms. Bierstein comes to
ABC from the American Society of
Anesthesiologists, where she served for
nearly 13 years, most recently as Associate
Director of Professional Affairs. At ASA,
her major responsibilities included advis
ing anesthesiologists and administrators
on practice management issues and devel
oping the annual Practice Management
conferences, representing the specialty
before the Centers of Medicare and
Medicaid Services (CMS), making anes
thesiology a player in the
Pay-for-Performance world, and working
closely with the Committee on Quality
Management and Departmental
Administration and its Hospital
Consultation program. Using her expert
ise to provide consulting and planning
services to ABC’s clients is the logical next
step, Karin believes – and Tony Mira, ABC
President and CEO, strongly agrees.
Karin originally came to the
Washington, D.C. area to become the first
Socioeconomic Affairs Coordinator for
the American Academy of
Otolaryngology-Head and Neck Surgery.
Between specialty organizations, she
served as Washington Counsel for the
American Medical Association.
Karin hastens to point out that her
prior experience is not limited to non
profit physician organizations. Upon
graduating from Cornell Law School, she
enjoyed taking care of private-sector
clients as an associate in the labor depart
ment of a large New York City law firm
and then moved to Los Angeles to engage
in corporate litigation. She obtained her
Master’s degree from the Harvard School
of Public Health on her way to
Washington.
Her base will continue to be the
Northern Virginia suburbs while she trav
els frequently to ABC’s headquarters in
Michigan and to ABC clients’ locations.
The next home state for Karin, in a few
years, will be Colorado. Beginning now,
though, she will be happy to ski the cele
brated powder and glades with any
member of the ABC family whose vaca
tions in Steamboat Springs coincide with
her own.
If you don’t want to wait for snowfall
to see Karin, you can attend her upcom
ing speaking engagements at the ASA
Annual Meeting in San Francisco:
WHAT’S WRONG WITH THIS
CONTRACT?
Sunday, October 14, 2007; 4:00PM –
4:50PM
Moscone Center West; San Francisco, CA
Objectives: Attendees will learn to identi
fy and negotiate certain disadvantageous
terms appearing in hospital contracts.
Using examples of clauses in recent con
tracts between anesthesiologists and
hospitals, this course will analyze a num
ber of common onerous provisions and
suggest negotiation strategies and poten
tial counter-offers. A financial modeling
tool to support stipend requests will be
presented.
THE ASA CONSULTATION PROGRAM:
COULD IT BE JUST WHAT THE
DOCTOR NEEDS TO ORDER?
Panel presentation with William H.
Montgomery, M.D.; Walter G. Maurer,
M.D.; and James S. Hicks, M.D.
Saturday, October 13, 2007; 1:30PM –
3:30PM
Moscone Center South; San Francisco, CA
Having served as counsel to the hospital
consultation program for 12 years, Karin
will elaborate on the topic “You Knew
There Would Be Legal Issues, Didn’t
You?”
SEPARATE WRITTEN INFORMED
CONSENT IS NECESSARY FOR
ANESTHESIOLOGISTS
Point-counterpoint presentation with
Timothy B. McDonald, M.D., J.D.
(Karen B. Domino, M.D., M.P.H.
moderating)
Wednesday, October 17, 2007; 11:00 AM
– 12:30 PM
Moscone Center West; San Francisco, CA
Objectives: The point-counterpoint
panel will review pros and cons of a sepa
rate written consent for anesthesiologists
compared to using the written surgical
consent and performing a verbal
informed consent for anesthesia care.
After attending this panel, participants
will: 1) Understand the essential elements
of appropriate informed consent for anes
thesia care; 2) Pros and cons of using a
separate written informed consent for
anesthesia care.
Karin is very enthusiastic about join
ing ABC and states: “I am proud to be
part of a team that includes so many first-
rate professionals in the fields of
anesthesia and pain medicine practice
management, financial services, compli
ance, and planning for growth. ABC has
the resources and the lengthy national
experience in anesthesia business opera
tions to justify my confidence that
together we can do everything possible to
ensure our clients’ success.”

Coding CornerCoding Corner
ARE YOU REPORTING PRE-OPERATIVE
ANTIBIOTIC PROPHYLAXIS UNDER THE
PHYSICIAN QUALITY REPORTING
INITIATIVE (PQRI)?
The Tax Relief and Health Care Act of
2006 (TRHCA) Section 101 authorized,in
Title I, the Physician Quality Reporting
Initiative. This voluntary quality reporting
program began on July 1st and ends on
December 31, 2007. Unlike its predecessor,
the Physician Voluntary Reporting
Program (PVRP), the PQRI will pay
physicians a bonus if they report the
applicable quality measure(s) on at least
80% of the claims for eligible services
performed during the second half of 2007.
The only PQRI measure applicable to
anesthesia care is #30, the timely
preoperative administration of antibiotic
prophylaxis.
Although groups seeking the bonus
already have more than three months’
experience with the program, questions
about the mechanics are still surfacing. A
set of Frequently Asked Questions
(FAQs)and answers furnished by
members of the MGMA Anesthesia
Administration Assembly (AAA) and by
American Society of Anesthesiologists
(ASA) staff recently appeared on the AAA
list serv. These FAQs, as amended in
October, appear below.
Without additional legislation and
funding it is not clear whether the PQRI
will continue into 2008. Although
Congress has failed to pass Medicare
By Sharon Hughes, MBA, RHIA, CCS
legislation thus far, it still has more than
two months to do so. The Centers for
Medicare and Medicaid Services (CMS)
expects to be administering the PQRI or a
similar program next year.
PQRI FAQs
The following answers to the Frequently
Asked Questions were produced by
MGMA and ASA staff in consultation
with the Centers for Medicare and
Medicaid Services (CMS) and are intend
ed as an educational resource and refer
ence guide only. They should not be
considered legally binding or definitive
statements of law. Differing answers may
be warranted, based on varying facts
and/or circumstances.
PQRI comments related to Perioperative
Prophylactic Antibiotics:
Measure #20 is intended for the ordering
physician and pertains to the surgeon.
Measure #30 is intended for the adminis
tering physician – typically an eligible
professional providing anesthesia services
– giving the prophylactic antibiotic at the
correct time.
Eligible professionals include anesthesiol
ogists, CRNAs and Anesthesiologist
Assistants (AAs).
Question 1: Can both the
Anesthesiologist and CRNA or AA receive
credit if PQRI Measure #30 (antibiotic
prophylactic timing) is submitted?
Answer 1: Any eligible professional
with privileges to perform the clinical
action described in Measure #30 can
report CPT® II codes on the Medicare FFS
claim. Therefore, both the anesthesiologist

and the CRNA or AA may report Measure
#30 (antibiotic prophylactic timing) if the
actions described in the measure specifica
tion were performed for a given case.
There is no medical direction issue or
need to allocate the measure to one or the
other of the clinicians.
Question 2: Can an anesthesiologist
and CRNA or AA report and get credit for
delivery of prophylactic antibiotics if they
are “hung” in the pre-op area and there is
documentation that that they have been
given pre-op as specified in PQRI Measure
#30?
Answer 2: Yes, the anesthesiologist and
CRNA or AA can report Measure #30 to
indicate the prophylactic antibiotics were
“hung” pre-operatively as long as there is a
documented order and documentation of
the timing of prophylactic antibiotic
administration in the anesthesia record.
Question 2a: What about with a
patient who comes down from the floor
on antibiotics, so none are given prophy
lactically, how is this reported?
Answer 2a: In the scenario described
above, there is no order for prophylactic
antibiotics and the dosing schedule of the
therapeutic antibiotics is unrelated to the
procedure start or incision; therefore,
Measure #30 would not apply to anesthe
siology.
Question 3: PQRI Measure #30
“Timing of prophylactic antibiotics-
administering physician” contains only
two available numerators; 4048F-Given in
timely manner and 4048F-8P-Not given in
a timely manner. Modifier 1P is not listed
with Measure #30. Can this modifier be
used even if it is not listed on the measure
for when a patient comes down from the
floor already on an antibiotic?
Answer 3: No, there are no allowable
performance exclusions for PQRI Measure
#30 identified by the measure developer.
Reportable numerator codes include
4048F or 4048F-8P as instructed in the
measure specification.
Question 4: In a case with a deep
abscess or wound infection, the surgeon
states, “I do not want the prophylactic
antibiotics to be given until after I obtain
cultures from the wound” (i.e., after the
incision has been made and the abscess
has been located). May I report on PQRI
Measure #30 using 4047F-8P and 4048F
8P?
Answer 4: Since there was no order for
prophylactic antibiotics to be adminis
tered prior to the surgical incision (or start
of procedure when surgical incision is not
required), Measure #30 does not apply.
4047F-8P is not a reportable code for
measure #30.
Question 5: Is the reporting of
PQRI Measure #30 “Timing of
Prophylactic Antibiotic-Administering
Physician”only for surgical site prophylax
is or will SBE (Subacute Bacterial
Endocarditis) Prophylaxis, when indicat
ed, be included as well?
Answer 5: No, SBE prophylaxis is not
included. The clinical recommendation
statements and rationale refer to surgical
Continued on page 14

ARE YOU REPORTING PRE-OPERATIVE ANTIBIOTIC PROPHYLAXIS
UNDER THE PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)?
wound infections which do not include
SBE. See guidelines referenced for this
measure in Measure #30 worksheet (avail
able on the CMS website at
www.cms.hhs.gov/pqri ).
Question 6: When reporting PQRI
Measure #30 should we use the same diag
nosis used when reporting the surgical
procedure?
Answer 6: Yes, codes should be sub
mitted via the CMS 1500 as part of your
routine claims processing.
Question 7: How should one
report PQRI codes on the claim form
when Medicare is the secondary insur
ance? If the measure is applied to the
primary insurance claim will it result in
denials? Has CMS worked this out with
other insurance carriers?
Answer 7: As referenced in FAQ #8467
on the CMS website: “Providers should
not include the PQRI codes on claims sub
mitted to primary payers (when Medicare
is secondary) unless notified or approved
to do so by that payer. Providers should,
however, place the PQRI codes on the
claim when submitting that claim to
Medicare for secondary payment. When
Medicare is primary there is an automatic
cross-over of claims to payers who enter
into agreements with CMS. Some payers
may also elect to receive claims where
Medicare is the secondary payer.”
Question 8: Should one report
both the 4047F and 4048F for PQRI
Measure #30 or does 4048F indicate an
order was given?
Answer 8: Measure #30 requires you to
submit both 4047F for the order and
4048F (with or without the 8P as indicat
ed) for the administration of the
prophylactic antibiotic. The denominator
coding for Measure #30 includes 4047F
(Documentation of order for prophylactic
antibiotics) and the numerator coding
includes 4048F with or without the 8P
modifier (Documentation should note
that prophylactic antibiotic was given
within one hour (if fluoroquinolone or
vancomycin, two hours) prior to surgical
incision (or start of procedure when no
incision is required).
Question 9: If 4047F has to be
checked off by the anesthesiologist, must
there be documentation that the surgeon
ordered the prophylactic antibiotic for
PQRI Measure #30?
Answer 9: Yes. For the purpose of
reporting for PQRI, standing orders (clin
ical pathways and protocols) may be
included; however, what is submitted on
the claim should match the documented
actions in the patient’s chart. Each physi
cian or other eligible professional would
need to refer to internal policies and stan
dards from other governing bodies to
determine whether the use of standing
orders is permitted.
Question 10: How should report
ing of the perioperative care measures be
documented in the medical record?
Should they be taken from the pre-opera
tive nurse notes? Do they need to be noted
in the anesthesiologist’s pre-operative
evaluation and plan? Do they need to be
on the anesthesia record?
Answer 10: Medical record documen
tation is required for all clinical actions
described in a measure. Each eligible pro
fessional will need to determine the
appropriate forms (paper or electronic)
that require documentation (i.e. nurse’s
notes, anesthesia record, etc.). The anes
thesia provider should document the time
the prophylactic antibiotic was initiated
verifying the timing was appropriate for
reporting the measure.
Question 10a: In the event that a
pre-op or hospital RN administers the
medication in the presence of an
Anesthesiologist or CRNA, who should
report the measure?
Answer 10a: Only eligible profession
als can report PQRI Measure #30.
However, if an Anesthesiologist or CRNA
or AA is responsible for the administra
tion of the prophylactic antibiotic,
including observation of the pre-operative
nurse administering the medication, they
may report Measure #30. Note: The meas
ure must be reported on the same claim as
the procedure with which it is associated.
Question 11: Regarding PQRI
Measure #30, does the time of administra
tion of the antibiotic and the time of
incision (or start of procedure if no inci
sion) need to be documented together on
the anesthesia record or other document?
Answer 11: Each physician or other
eligible professional would need to refer to
internal medical record documentation
policy. For Measure #30, the timing,
dosage, and route of administration of the
prophylactic antibiotic must be docu
mented in the medical record at the time
of administration. Appropriate documen

tation may be more easily accessible for
anesthesia providers if it were document
ed in one place, i.e. the anesthesia record.
The incision time should be noted either
in the anesthesia record or the operative
record of the patient’s chart. (For more
information on reporting measure #30 see
www.communiquenews.com/)
Question 11a: Does the type of
antibiotic used, the time and signature
have to be on the record?
Answer 11a: Yes, please refer to inter
nal policies and standards from other
governing bodies (i.e. JCAHO), which
require this documentation.
Question 12: If a case is scheduled
as an orthopedic “closed procedure/possi
ble open procedure” how should this be
handled for PQRI reporting purposes?
The antibiotics may not be ordered until
after the closed procedure is not successful
and the open procedure is planned.
Answer 12:
Note that prophylactic antibiotics may be
given for planned open or closed proce
dures: “or start of procedure when no
incision is required”. In this scenario, the
antibiotics would be ordered to be given
within 60 minutes of the incision and the
relevant PQRI codes may be reported. It
does not matter that the closed (non-eligi
ble measure) intervenes between
induction and incision.
Question 13: What should occur
when a surgeon fails to write an antibiotic
order, for a procedure or does not give the
verbal order until the incision has been
made? In this situation there would be no
time to prepare and administer the pro
phylactic antibiotic “on time” because of
this “late” order.
Answer 13: Late ordering of prophy
lactic antibiotic will result in performance
failure for Measure #20. The surgeon
responsible for the “late” order could
report 4047F-8P (antibiotics were not
ordered within one hour….) providing
the surgical procedure performed was
part of the denominator inclusion codes
for the measure. The eligible professional
providing anesthesia services would not
be accountable to report Measure #30
since there was no documentation of the
order for prophylactic antibiotics prior to
the incision.
Question 14: The patient is an
inpatient and has been receiving regular
scheduled doses of one or more therapeu
tic antibiotics. When the patient arrives in
the operating room, the previous dose of
antibiotics may not have been given with
in the “one hour prior to the incision”
timeframe. How should the anesthesia
provider report Measure #30?
Answer 14: In this scenario, the patient
is receiving therapeutic, not prophylactic,
antibiotics and the dosage schedule is unre
lated to surgical incision or procedure start.
Measure #30 is inapplicable unless an
additional dose or additional antibiotic
agent is ordered to be administered in the
specified timeframe for wound prophy
laxis. For more information please visit
www.communiquenews.com.
For additional information please visit
http://www.cms.hhs.gov/PQRI/15_Measu
resCodes.asp.

PROFESSIONAL EVENTS
DATE EVENT PLACE CONTACT INFO
Oct. 12, 2007
Oct. 12, 2007
Oct. 12, 2007
Oct. 12, 2007
Oct. 13-17, 2007
Oct. 13, 2006
Oct. 28-31, 2007
Nov. 2-4 2007
Nov. 12, 2007
Nov. 15-18, 2007
Dec. 7-11, 2007
Jan. 25-27, 2008
Feb. 12-16, 2007
Feb. 14-17, 2008
Apr. 30-May 4, 2008
Jun. 18-22, 2008
May 15-18, 2008
May 17-18, 2008
May 18-21, 2008
May 30-Jun 1, 2008
June 18-22, 2008
American Society of Critical Care
Anesthesiologists 20th Annual Meeting
Society for Ambulatory Anesthesia
Mid-Year Meeting
Society for Pediatric Anesthesia
Annual Meeting
Society of Neurosurgical Anesthesia & Critical
Care Annual Meeting
ASA Annual Meeting
American Association of Clinical Directors
Annual Meeting
MGMA Annual Conference
Association of Anesthesiology Program
Directors/Society of Academic Anesthesiology
Chairs Annual Meeting
Minnesota Society of Anesthesiologists
American Society of Regional Anesthesia and
Pain Medicine
New York State Society of Anesthesiologists
Postgraduate Assembly in Anesthesiology
ASA Conference on Practice Management
American Academy of Pain Medicine
Annual Meeting
Arizona Society of Anesthesiologists
Annual Mtg.
Society of Obstetric Anesthesia and Perinatology
Annual Meeting
Society of Cardiovascular Anesthesiologists
Annual Meeting and Workshops
Association of University Anesthesiologists 55th
Annual Meeting
MGMA Pain Management Preconference
MGMA AAA Annual Conference
CSA/UCSD Annual Meeting & Clinical
Anesthesia Update
Society of Cardiovascular Anesthesiologists
Annual Meeting and Workshops
Grand Hyatt Hotel,
San Francisco, CA
San Francisco Hilton,
San Francisco, CA
Hilton San Francisco,
San Francisco, CA
The Westin Market Street Hotel,
San Francisco, CA
Mascone Center,
San Francisco, CA
San Francisco Hilton Hotel,
San Francisco, CA
Pennsylvania Convention Center,
Philadelphia, PA
Mandarin Oriental,
Washington, D.C.
Crowne Plaza Northstar,
Minneapolis, MN
Boca Raton Resort and Spa,
Boca Raton, FL
New York Marriott Marquis,
New York, NY
Tampa Marriott Waterside Hotel,
Tampa, FL
Gaylord Palms, Orlando FL
Scottsdale Resort and Conference
Center, Scottsdale, Arizona
Renaissance Chicago Hotel,
Chicago, IL
Vancouver Convention Center,
Vancouver, BC, Canada
Washington Duke Inn & Golf
Club, Durham, NC
Philadelphia Marriott Downtown,
Philadelphia, PA
Philadelphia Marriott Downtown,
Philadelphia, PA
Hilton Los Angeles/Universal City,
Los Angeles, CA
Vancouver Convention Center,
Vancouver, BC, Canada
www.ascca.org
www.sambahq.org
www.pedsanesthesia.org
www.snacc.org
www.asahq.org
www.aacdhq.org
www.mgma.com
www.aapd-saac.org
www.mmaonline.net/Specialty
Societies/msa.cfm
www.asra.com
www.nyssa-pga.org
www.asahq.org
www.painmed.org/annual
meeting/
www.az-anes.org
www.soap.org
www.scahq.org
www.auahq.org/annualmtg.html
www.mgma.com
www.mgma.com
www.csahq.org
www.scahq.org
ANESTHESIAANESTHESIA
BUSINESS CONSULTANTSBUSINESS CONSULTANTS
255 W. MICHIGAN AVE.
P.O. BOX 1123
JACKSON, MI 49204
PHONE: (800) 242-1131
FAX: (517) 787-0529
WEB SITE: www.anesthesiallc.com
PRSRT STD
US Postage
PAID
Holland, MI
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