HIPAA Audit - Learn From Recent $750,000 Settlement Between Medical Practice and HHS and OCR on Deficiencies in HIPAA Compliance After Data Breach

In our practice, we conduct HIPPA and HiTECH compliance audits for health care clients and business associates (companies that service health care companies). We also represent them when a HIPAA complaint has been filed or reported. 

We do this as a law firm since our communications are protected by the attorney-client privilege unlike regular consultants. 

Most small and mid-sized practices are not fully compliant and have not had audits. We go in, evaluate all existing policies and documents, create or revise a HIPAA compliance plan and employee handbook, document updated employee training, and peform a HIPAA HITECH initial audit which is confidential. 

We work on a flat fee that gets spread out over the year and includes phone calls, emails and meetings to avoid high hourly charges and encourages efficiencies. We help make sure that HIPAA is integrated into the culture.

Some companies or practices have staff to implement changes and other times we perform them. During our attorney-client privileged meetings, we have a master list and then implement a master action plan that will culminate in a final HIPAA audit to be documented. We bring in less expensive consultants as needed to save money for the company or practice as needed. 

Why is it important these audits be documented? If there is a HIPAA complaint by a patient or a data breach reported to OIG or Office for Civil Rights (who handles HIPAA complaints) or to the State of Californa DHCS Officeof HIPAA Compliance, they conduct audits. If there is a breach but it is found that there was prior compliance, proper policies and procedures, documented training, and a documented audit in place - the fines and punishment will be far less. It also helps avoid civil lawsuits by patients for state privacy breaches (since HIPAA does not give a private right of action). 

California Medical Board Increases Request For Patient Records From Pain Management Physicians - Be Proactive Now And Stay Current

Physicians who treat for pain management physicians are clinicians. They did not go to medical school to become DEA agents, police officers or judges -- even though in today's climate it can seem like they feel pressured to take on these roles. In California and other states, physician who prescribe opioids or controlled substances for pain treatment are under greater scrutiny and have a greater chance of having their records requested by the Board or the DEA for review.

The Los Angeles Times ran an article entitled "Oxycontin maker guards its closely guarded list of suspect doctors" about Purdue Pharmacy and how it has sold $27 billion worth of Oxycontin since 1996. It criticizes the company for not alerting law enforcement or medical authorities to the physicians who are suspected of overprescribing or illegal prescribing. This is part of a series of stories ran by the Times regarding prescription drugs and is a reminder that practitioners in this field are currently under a microscope.

We have had a number of clients whose records have been reviewed by the Board to see if their patient care for pain management was within the standard of care. The request for records are often triggered by a single complaint (such as a pharmacy complaining about overprescribing for a single patient). The Board runs the CURES report on the physician and selects for additional review 8 to 10 patients who are younger, middle-aged or on high opioid treatment dosages or where there are some other red flags with these patients.

In these cases, it is important to get legal counsel immediately even for a consultation to ensure that you are well prepared for any interview and that your complete file is submitted (and in many cases with a summary of the patient's care). In some of our cases, we found weaknesses in our client's practices and procedures and while not conceding any problems, we made positive changes immediately and it was helpful in showing that we had responsible professionals who are staying current with the changing landscape. In some cases, early expert retention may be needed or we found that a patient or two was diverting medications and had to make adjustments at that point.

If pain management treatment is part of your practice, it is time to perform an audit of your practice and make sure that your record keeping, consent forms, screening tools, treatment agreements, referrals for depression, referrals to other physicians as needed, patient education forms, and monitoring practices (urine testing, CURES reports, pill counting, etc.) are keeping up with the changing standard of care and changing laws and regulations. Do you modify your treatment plan when the patient reaches in excess of 120 mg morphine equivalent dosage (MED)? Do you document with specifics how the benefits of opioid treatment outweigh the risks? Build this into your staff and practice so it's part of the process.

It is becoming more important to have "universal" precautions in dealing with patients to ensure there is no risk of diversion. We have had clients who run urine tests and CURES reports on some patients but not on others who seem low risk. However, you cannot simply assume that just because someone is elderly (for example) that they do not pose a risk for diversion. This also makes it easier in your practice in that you then can tell the patients -- this is how we manage everyone -- and they do not take it personally. Drug tests are becoming the standard of care since you're ensuring that the patient is taking the medication as prescribed and that there is not diversion. CURES reports are also the standard of care now since you're ensuring that the patient is not doctor shopping.

Keep up with new monitoring methods. For example, one relatively new practice is to have the patients bring their pill bottles in for a "pill count" (sometimes randomly) -- especially for high risk patients -- for additional monitoring. Follow up on any issues raised by family members or the patient (nodding off during the day, sleep issues at night, preoccupation with the prescribed opioid, etc. Use the opioid risk management tools to assess the patient especially since many of these such as SOAPP are available free on the Internet.

For those in California, review the California Medical Board website on pain management periodically for updates on pain guidelines. even though it is behind the times and do not set forth in detail the standard of care and medical necessity -- but it is does set forth the basic law and policies of the Board.  

Chronic pain is complicated and implementing audits for your practice will not only help with any investigation by the Board or DEA but will also help protect yourself against any potential malpractice case and help prevent any potential criminal liability. The law is clear that unless there is legitimate medical purpose for prescribing scheduled narcotics -- the prescription is not legitimate. If the records are not sufficient or if the patients are diverting medications, there can be a criminal or DEA investigation. We have also represented physicians in criminal investigations, search warrants and criminal cases involving pain management medications -- and our goal is to prevent such cases and investigations.

With the issue of prescription overdose deaths featured prominently in the press, physicians need to take these issues seriously even if they are board certified pain management specialists. We help practitioners ensure legitimate patients' access to appropriate pain care and the right of physicians to practice responsible pain medicine.

Posted by Tracy Green, Attorney at Law
Green and Associates,
(213) 233-2260
Email: tgreen@greenassoc.com

California Court of Appeal Revives Suit Over Medical Group’s Internal Fight - Were Physicians Improperly Forced Out And Levied An Illegal Assessment?

A recent Court of Appeal decision (Dec. 2009) illustrates what happens when a group of doctors allege they were improperly forced out of their medical group. In such cases, early legal advice is essential since the corporate rules on who has standing to sue the corporation are complicated.

It is important for each shareholder to understand how to position themselves in the event of a legal battle. Some medical corporations are fun like fiefdoms with minority shareholders being deprived of their rights and earnings.

The case is Haro v. Ibarra, B213499. Although this is a technical legal discussion, it will assist shareholders in understanding how shareholder battles play out in the court system.

The plaintiffs in the case were physicians Carlos Haro, Carlos Meza, Marcos Lemor, Antonio Alarcon, Miguel Rodriguez and Jose Delgado. They claimed they were improperly forced out of their medical group and that an assessment of nearly $58,000 per share was illegal because it was not levied at a properly noticed meeting and because it was not levied on all shareholders.

The defendants include Fernando Ibarra, Alfonso Barragan, Manuel Figueroa, Maria Christina Hernandez and Omar Perez—all officers, directors and/or shareholders of AHP—as well as Alpha Medical Management, LLC, which manages AHP, and Medical Management Consultants LLC, which is the parent company of Alpha and is owned by Ibarra and Barragan.

Unfair Dealing Alleged

The plaintiffs allege that they collectively owned nearly 30 percent of AHP’s stock, that they had objected to what they believe was unfair dealing by Barragan and Ibarra—who owned one-third of AHP’s shares—and that Barragan and Ibarra had schemed to oust them from the corporation. To that end, they say, the pair declared Alarcon’s shares to be forfeited—without cause—and levied the assessment, warning the plaintiffs that they would be forced to sell their shares if they did not comply.

The stated purpose of the assessment, according to the pleading, was to fund the purchase of a medical practice in Mexico, which the plaintiffs alleged to be “a radical departure from the normal business of AHP.” They characterized the assessment as a violation of the corporation’s articles and bylaws, and as imprudent and fraudulent, and claimed that material information about the proposed acquisition was being withheld.

They also alleged derivative causes of action, charging that Ibarra and Barragan had damaged AHP through their control of its management company, and raised personal claims for conversion of their shares and for diminution of the value of the shares through manipulation of earnings and expenses.

Los Angeles Superior Court Judge Maureen Duffy-Lewis sustained demurrers to all causes of action, reasoning that since they no longer owned shares, the plaintiffs could not plead derivative claims, and that the remaining claims were barred by Corporations Code Section 423(m).

Statutory Language

The statute provides that “[n]o action shall be maintained to recover shares sold for delinquent assessments, upon the ground of irregularity in the assessment, irregularity or defect of the notice of sale, or defect or irregularity in the sale, unless the party seeking to maintain the action first pays or tenders to the corporation, or the party holding the shares sold, the sum for which the shares were sold, together with all subsequent assessments which may have been paid thereon and interest on such sums from the time they were paid.”

Justice Victoria G. Chaney, writing for the Court of Appeal, said that with respect to the personal causes of action, the plaintiffs adequately pled an exception to the statute by alleging that the assessment was void. Justice Chaney was very well respected when she was a trial court judge in Los Angeles County Superior Court and her opinions are very well drafted and reasoned. Apart from being a legal scholar she is also pragmatic and understands the real world.

Justice Chaney cited Herbert Kraft Co. Bank v. Bank of Orland (1901) 133 Cal. 64 and Cheney v. Canfield (1910) 158 Cal. 342 is the leading authorities to be addressed. Both of these are old cases.

In Kraft, the California Supreme Court held that Section 423(m)’s predecessor did not apply to a claim that the plaintiff’s stock in a bank was forfeited when he failed to pay an assessment that was not levied on any other stock. The justices reasoned that if the allegation was correct, the assessment was void, and thus the plaintiff did not have to pay it as a prerequisite to bringing the action.

Justice Chaney, similarly, declined to apply the statute to a claim that an assessment had been levied at a board meeting at which a quorum was not present.

Justice Chaney declined to limit Kraft to the situation in which forfeited shares are sold to the directors who caused the shares to be forfeited. That argument, she said, was based on an out-of-context reading of the case.

Derivative Causes

With respect to the derivative causes of action, Justice Chaney also concluded that it was error to sustain the demurrers. While the usual rule is that the plaintiff must own the shares continuously from the time the cause of action arises to the time it is adjudicated, there are equitable exceptions, she said, concluding:

“Appellants have alleged equitable considerations that warrant an exception to the continuous ownership requirement, such as the allegations in the [second amended complaint] that other shareholders were not required to pay the assessment and yet did not have their shares forfeited.”

Posted by Tracy Green. Should you have any questions regarding your own situation or this post, you can email Tracy at tgreen@greenassoc.com. Green & Associates in Los Angeles, California focus their practice on the representation of licensed professionals, individuals and businesses in civil, business, administrative and criminal proceedings. Tracy Green is a well known health care attorney. She has been a physician attorney in hundreds of legal matters involving physician business disputes that are not malpractice related. The firm website is: http://www.greenassoc.com/

Negative Online Reviews: What Legally Can Your Business Can Do About Them?

The other day my dog was injured and I looked up my veterinarian's address on Google and came across a slew of online reviews about its office on Yelp. The comments mainly fell into the two categories of either love 'em or hate 'em. I read the negative comments (dirty floors, letting dogs run loose near cats, etc.) while also looking at those that were positive about the treatment for their "fur babies" (their word, not mine). Some of the negative comments were years old when the practice was run by a different veterinarian. If I did not have prior positive experience, I don't know that I would have gone there in light of these comments.

With the Internet, everyone is a potential critic -- and an anonymous one at that. For professionals and many businesses, the criticism focuses on service rather than skills or the product or service provided. For example, one anonymous comment on the website RateMDs.com was unsparing: "Very unhelpful, arrogant," it said of a doctor. "Did not listen and cut me off, seemed much too happy to have power (and abuse it!) over suffering people."

In our practice, we have received calls from doctors and other professionals (or their publicists) about what to do about negative online reviews. In today’s world of instant Internet publishing, any professional or business can become the victim of an online attack from any disgruntled client/patient or competitor. Because of the nature of online search, negative reviews, blog posts, and comments can quickly tarnish a reputation when potential customers find harsh criticisms when conducting a search for your or your company’s name on Google or the Internet.

There are ways to understand and counter these type of posts:

#1 Understand the law before you take action or hire an attorney to take action. Your ability to sue the Internet service provider is limited by the Communications Act of 1996 which states that Internet service providers cannot be sued for any allegedly defamatory statements. Next review the comment and determine objectively whether it is opinion or fact. The law on defamation, libel, and slander makes clear that truth is a defense. Thus, statements that can be refuted by the public record—like court judgments or licensing board actions—are in one category. Opinions are in a different category and give the writer much more leeway under the First Amendment.

#2 Determine If You Are Going To Accept The Online World Or Seek To Opt Out By Having Clients Or Patients Agree Not To Post Information On The Internet.
Some professionals are having patients and clients sign agreements not to post any information on the Internet as a condition of being a patient or client. For some practices, this may be a solution especially if the professional decides they do not want an online presence outside their own website. Most patients and clients will sign such agreements without hesitation. However, the Internet is here to stay along with the ability of patients to post comments. Proving a patient posted a comment could be very difficult to prove. If adopted, this is only one way to control the issue.

#3 Ask Internet Publishers to Remove Defamatory Information Or Vicious Attacks You or your attorney can contact the Internet publisher in writing and demonstrate that the review has false facts, is unfounded or blatantly slanderous attacks and ask them to remove them. This can be successful. However, many content publishers will not remove material once it has been published unless it is proven to be defamatory or outrageous. Once you have attempted to remove as much of the negative commentary as possible, instead of spending your money on legal fees attempting to sue the Internet publisher, the best plan is to have an Internet marketing plan to push the negative comments and links as far back in the search engine results as possible so they do not land on page 1 or 2.

#4 Monitor Your Online Presence

A key component in any Internet marketing or reputation management campaign is to continuously monitor what others are saying about you online. When and if negative information is published about your or your company, you’ll want to be aware of it quickly in order to take action. The simplest way to do this is to set up a Google Alert for your name and your company name, as well as any other key terms associated with your line of business.

#5 Think Carefully Before You Respond Online Or In Any Other Manner

Unlike a private conversation, online comments will be recorded and leave an online record for years to come. If you read a negative comment about you or your business, gather the facts and have an objective party review your response. We have advised clients in some cases to send an email to the reviewer to offer to straighten out the issue, hear their complaints and this has gotten some to revise or update their comment online. At that point, in the client's response we can state truthfully that the person was contacted to satisfy them and then factually state our client's position. If the response is not handled properly, it can create even more negative publicity.

#6 Be In Control Of Your Internet Presence

Ask your satisfied clients or patients to post reviews on the sites at issue. Have a website or blog or other positive content to dilute the negative information and push it further back in the search engine results. Most people only search the first page of search results.

Any questions or comments should be directed to: tgreen@greenassoc.com. Tracy Green is a principal at Green and Associates in Los Angeles, California. They focus their practice on the representation of licensed professionals and businesses in civil, business, administrative and criminal proceedings.  Some businesses and professionals have had issues with online reviews and postings and we have assisted them during this process.

Practice Management: Texting Patients Can Cut Costs And Increase Efficiency

Health care providers are looking for ways to cut the amount of time their practice spends in calling patients to confirm and remind them of appointments, lab calls and follow-ups. Text messages can also be used for "outreach" messages reminding patients of needed mammograms, Pap smears and cardiovascular disease lab tests. They can also be used for other reminders such as: "You have a physical at 9 a.m. tomorrow. Please do not eat or drink anything after 12 p.m. midnight."

They can also be used for billing reminders: "You have a balance of $55. Please remit." Daily reminders can also be set up for patients in reminding them to put on sunscreen or other reminders to help patients be compliant. They can also be used to develop patient relationships such as "happy birthday" greetings. Many providers report that patients like it and do not find it overly intrusive.

Although we have written this to address health care providers, many other professional practices can use the ideas in this article and adapt for their business. For example, in our own practice we are sending text messages to confirm the time and place of appointments and court or hearing appearances. This helps confirm that the person will receive and see the message without checking home answering machines, cellphone voicemails or emails. All professional practices that rely on appointments could benefit from the idea although it is usually medical practices that have the volume of patients to justify using a web-based text messaging program.

There are many Web-based text messaging options. Most are free to set up, with users billed a set fee for the month, generally in the $200 range. Also available are physician-specific systems that can mine data from a practice management or electronic medical records system, which means the messaging is all done automatically. For other systems, cell phone numbers would need to be entered manually each day. Some of the text messages can also be sent to a phone as a voicemail.

Since many people have cell phones with text-messaging capabilities, some health care providers (including test programs by Kaiser Permanente) have decided that texting is the way to go. These providers are saving numerous staff time hours per week by using a text-messaging system that automatically sends the reminders. Some practices are reducing staff time from one hour, per doctor, per day to less than 10 minutes by using text messaging systems for appointment reminders, lab calls and follow-ups. They are also able to better predict the number of "no shows" so that revenue can be increased by filling that time with additional patient visits. This can boost the bottom line of practices significantly.

Many providers have enthusiastically adopted texting. However, to make sure texting is effective for your practice, it takes some groundwork and preparation. to make sure texting is effective for your practice.

First, determine what the texting system will be used for which will help make it easier to decide which system to buy.

Second, the practice should draft the outgoing messages that will be sent and have them cleared by the practice's attorney for possible HIPAA security rule violations. Our opinion is that in general, the use of text messaging is permissible on the same basis that telephone messages have been permissible under current law. However, there should be guidelines to ensure HIPAA compliance.

Third, patients need to be given the option of whether to use the communication mode. The patients should also be given instructions on how to opt out of receiving text messages. Senior patients may need instruction on how to check their text messages. Some text messages allow you to opt out. For example, in Kaiser's case, each message ended with, "Txt STOP to end msgs."

Fourth, your practice should start collecting cell phone numbers if they have not already been collected. For physicians just getting started it might be a slow process before the system reaches its fullest potential, as it might take several months for the databases to be populated with cell numbers.

Fifth, practices need to be vigilant about making sure data fields are updated regularly to avoid invalid numbers or bounced-back messages.

Sixth, if your practice sets up a two-way system, the staff must be equipped to deal with the return messages. Some providers' systems allow patients to respond to the text message to confirm appointments, for example. The messages are sent back as an e-mail that the staff must receive. Then, the staff manually enters any schedule changes or confirmations into the practice management system.

Finally, determine in advance the format and content of the messages so the staff has little discretion in what they write. To further protect yourself, it may be that the less specific the messages, the better. Messages about test results, for example, could say something like, "Everything looks normal," or in the case of a positive result, "UR lab results are in. Call 2 discuss."

Any questions or comments should be directed to: tgreen@greenassoc.com. Tracy Green is a principal at Green and Associates in Los Angeles, California. They focus their practice on the representation of licensed professionals and businesses in civil, business, administrative and criminal proceedings, with a specialty in health care providers.

Closing Or Selling A Medical Practice -- Some Considerations

Under California law, there are minimal formal rules for closing a medical practice. However, due care should be exercised when selling, closing or departing from a medical practice. There are several important items which should be considered and planned in advance. The list given below is not complete, but it should be helpful. Even thought this is written for physicians, the same concepts can be used for all types of health care providers.

1. NOTIFICATION OF PATIENTS

Notifying patients helps with the transition from the current physician to the new treating physician, but it also reduces the liability of "patient abandonment." Therefore, to ensure this occurs with a minimum of disruption in continuity of care, the physician terminating the physician-patient relationship should notify patients sufficiently in advance.
We recommend a written notice sent our a minimum of 30 days before the transfer or closing of the office. Put forth in writing that you plan to close your office and on what date so that they will have sufficient time to obtain another physician. It is also suggested that, in the letter of notice to the patients, you enclose a form for the patient to sign authorizing the release of records should they wish to request that a copy of their records be sent to the new physicians of their choice. A list of all patients notified should be retained in your files.
You can save postage, in the case of current patients, by inserting the letter with a monthly statement or billing; letters to other patients will have to be mailed separately. For patients you cannot reach and to avoid any claims of patient abandonment (especially where patients are low-income and move frequently), you also may wish to place an announcement in one or more of the local newspapers.

2. RETENTION OF MEDICAL RECORDS
Medical records, including case histories, treatment records, x-rays, laboratory reports, correspondence with physicians and others, should not be destroyed until the statute of limitations has expired with regard to each patient. This is because the physician's record and liability insurance policies could be your chief source of defense in a future law suit.

The Statute of Limitations in California allows actions involving adults to be initiated within one year from discovery of the injury, but not later than three years from the occurrence. For retained foreign body cases, the statute is tolled until the claimant discovers or should have discovered the injury. These time limitations also apply to minors six years of age and older. In the case of a minor under six, the action must be filed within three years of the date of the injury or before the minor’s eighth birthday, whichever time period is greater.

While there are no specific statutory requirements pertaining to the general preservation of medical records, physicians are advised to retain their records for at least 5 years following the death of a patient 10 years after the most recent discharge of a patient or 15 years after the most recent discharge of a minor patient. The most prudent case is to keep records indefinitely but studies show that 99% of malpractice claims are filed within 10 years.

There are specific record retention rules relating to certain categories of patients. These rules include but are not limited to the following: Medi-Cal patients (3 years after last date of service); prescription books (3 years); patients for whom you have dispensed Schedule II through III (3 years); workers compensation medical-legal reports (5 years); OSHA rules (30 years); and others depending on contracts with HMOs, malpractice carriers, etc. Check with your legal counsel for more detail.

The patient has a general right to know what is in his medical records and thus you should make it known where such records can be obtained. Copies of records can be given to the patient or forwarded to another physician of the patient's choice with the consent and at the request of the patient, in writing.

3. DESTRUCTION OF MEDICAL RECORDS
If you decide to destroy medical records, use a method that will preserve the confidentiality of the records. It is a violation of California confidentiality laws to negligently abandon, destroy or dispose of patient records. Burning or shredding is recommended. The safest course is to shred any medical or confidential records, keep records of what is shredded, use a reputable service or have a responsible employee perform the shredding, and obtain certificates of destruction.

4. DISPOSAL OF DRUG STOCKS
The Regional Administrator of the Drug Enforcement Administration has jurisdiction over the State of California with regard to disposal of unused controlled substances. The following procedure has been approved as a guide to physicians:

The physician's DEA number (Controlled Substances Registration Certificate), unused Government order forms and controlled drugs should be disposed of as soon as possible. The registration certificate and unused Government order forms (DEA-222c) should be returned to the Drug Enforcement Administration. Procedures for destruction of controlled substances may be obtained by calling the Los Angeles Divisional Office.

5. SALE OF MEDICAL PRACTICE
If you are selling your practice, you should make certain that the buyer is a physician or health care provider licensed, or eligible to be licensed, in California. You want to be careful so that you do not sell to an unlicensed person. Avoid any claims that you have aided and abetted the unlicensed practice of medicine or similar charges. Any licensing information can be obtained from the appropriate State of California Board or Committee or the Department of Consumer Affairs.

6. YOU CANNOT SELL MEDICAL RECORDS
Under California law, records relating to patients cannot be sold. However, the sale of a practice may include, as one of its terms, unlimited access to the records of those patients who seek the services of the purchasing physician. Obtain legal advice on how to transfer patient files legally. The prohibition agains the sale of medical records is part of the same law that makes it illegal to receive any remuneration for the referral of a patient.

7. MALPRACTICE INSURANCE
Your policy should be examined to determine whether it is written on an OCCURRENCE or a CLAIMS MADE basis. Consult your insurance agent. If the policy is written on a CLAIMS MADE basis, only those claims made while the policy is in force will be covered and you should either continue your coverage or purchase coverage extension to protect you until all statutes of limitation have run.

8. ACCOUNTS RECEIVABLE
Not all of your patients will have paid their bills by the time your practice is closed. It will be necessary to have someone available to accept, record, and deposit payments received after the official closing of your practice. You may wish, after a suitable waiting period of three or four months, to turn those accounts still unpaid over to a reputable collection agency. If your accounts receivable is part of the sale of your practice, ensure that the terms are clear as to who has the right to collect.

9. LEGAL IMPLICATIONS AND TAX ASPECTS OF CLOSING/SELLING PRACTICE
It is recommended that you work closely with your attorney, accountant or business manager on the legal and tax issues involved in selling and/or closing a practice. This issues include, but are not limited to: the contract for selling your practice, any covenants not to compete, payment for the sale and how to handle any potential breach, obtaining security (such as a deed of trust or assignment of an insurance policy) for carrying a note on the sale, patient record retention issues, legal structuring issues and tax aspects of closing or selling your practice.

10. INCOME TAXES
Copies of your income tax returns and all supporting documentation, including ledgers and accounting records, should be preserved until the Internal Revenue Service can no longer assess additional tax. For Federal returns filed on time and containing all correct and pertinent data, this is usually three years; for returns where gross income has been understated by 20 percent or more, it is six years.

11. PAYROLL TAXESFinal returns and payments of all Federal and Social Security taxes must be made after the last employee has been terminated and the last payroll paid.

Any questions or comments should be directed to: tgreen@greenassoc.com. Tracy Green is a principal at Green and Associates. They focus their practice on the representation of individuals, businesses and professionals, with an emphasis on health care professionals.