Category Archives: Healthcare Regulatory Matters

The Accountable Care Act: New Malpractice Risks for Physicians

Posted on May 12, 2014 by | Comments Off on The Accountable Care Act: New Malpractice Risks for Physicians

The Accountable Care Act, through various regulations and through policy adopted by exchanges, create new malpractice risks for providers.  In this recent article, insurers point to some new risks created by the law’s reliance on nurse practitioners and physician assistants.  Technology and telemedicine create new risks, as well.

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Posted in Current Affairs, Healthcare Regulatory Matters

10 KEY ISSUES THAT PHYSICIANS SHOULD BE AWARE OF WHEN REVIEWING THEIR CONTRACTS WITH QUALIFIED HEALTH PLANS UNDER THE AFFORDABLE CARE ACT

Posted on April 30, 2014 by | Comments Off on 10 KEY ISSUES THAT PHYSICIANS SHOULD BE AWARE OF WHEN REVIEWING THEIR CONTRACTS WITH QUALIFIED HEALTH PLANS UNDER THE AFFORDABLE CARE ACT

By: Pamela Tahim

1) Legally Required Amendments – 28 California Code of Regulations Section 1300.71(m) allows Qualified Health Plans (QHPs) to make material modifications to the underlying contracts so long as they provide 45 days advanced notice with the opportunity to terminate the underlying agreement if the physician does not agree. This is how QHPs are contracting with Physicians to be part of the Exchange, rather than by entering into new contracts.
a) Some Physicians are not aware that they are part of the Exchange and should confirm whether they received this Amendment by calling or emailing the QHPs. Physicians should also determine whether they agree to legally mandated amendments (i.e., to be part of Covered California and the applicable rate schedules.)
b) If a Physician does not agree to an amendment, the Physician should review the underlying contract with the QHPs to determine whether they have time to opt out of the amendment or the entire contract. If there is not time to opt out, Physicians should find out what other options they have.
2) Payment – QHPs will reimburse the Physician according to a fee schedule, typically attached to the Agreement. Language in Agreements: “In exchange for the provision of Covered Services to Members, QHP shall pay Provider the lesser of (i) the applicable reimbursement rates set forth in Exhibit B thereto, or (ii) Provider’s billed charges, in either case, less the Member’s applicable Copayment.”
a) Reimbursement rates may vary depending on the type of health plan the patient is enrolled in. Physicians are advised to get all fee schedules. Understand your patient population and the issues that will come from a different population from the Exchange, to make sure that the pricing is sufficient to cover costs. Physicians are recommended to check each Health Plan’s website on the first day of each calendar quarter for updated pricing.
b) Physicians are required to use their “best efforts” to accept electronic methods of payment and receive related explanation of benefits via electronic funds transfer. This means Physicians will need to take steps to make sure they can accept electronic methods of payment to prevent being in breach of the contract with the QHPs.
3) Physicians are Required to Collect Copayments, Deductibles and Coinsurance – Only Physicians are responsible for collecting copayments, deductibles, and co-insurance. This can create collections issues with grace periods under the ACA.
a) Physicians should be aware that depending upon the type of plan selected, a patient can have significant cost-sharing for copays and deductibles with an Exchange. This may result in greater incidence of bad debt and increased administrative costs due to increased collection efforts.
b) Physicians should require copays at the time of service.
c) Physicians should implement a policy to check the insurance eligibility of each patient prior to seeing them.
d) Physicians should implement a policy to require copayments and deductibles be paid prior to seeing a patient unless there is an emergency situation.
e) Physicians should consider hiring a billing/collection company to assist with the above.
4) Termination of Contracts – The contracts with the QHPs have two ways of terminating, either mutually without cause, or unilaterally if it is for cause. Generally, either party may terminate the contract without cause by providing fair written notice (typically 120 days prior). Generally the term of the contracts is for one year with automatic renewal annually.
If the termination is for cause, the QHP must give notice of deficiency to cure. There are provisions that allow for immediate termination, which Physicians should review and make sure they are aware of. Physicians can terminate the contract if a legally required amendment causes financial hardship. Physicians are advised to review termination clauses associated with exchange products carefully because for some contracts such as Blue Cross and Blue Shield, if they did not opt (in/out) prior to the deadline under the QHP, then they have to opt out of the entire PPO Plan.
5) Dispute Resolution Procedures – Contracts with the QHPs have specific dispute resolution procedures that require the Physician to first file a complaint with the QHP’s internal grievance department, meet and confer, and then use binding arbitration if not resolved by the prior methods. If the Physician does not follow this process, the QHPs can argue that the Physician failed to exhaust the administrative remedies and be barred from pursuing his/her claim.
6) Out of Network Referrals – Contracts with QHPs have very strict provisions regarding out of network referrals and it can be a breach of the contract with the QHP if it is not followed. Generally QHPs require Physicians to refer patients to participating providers unless written authorization has been granted in advance by the QHP, unless it is an emergency.
7) Nondiscrimination Clauses – Contracts with QHPs have nondiscrimination clauses so that Physicians cannot deny care to patients simply because they are enrolled in Covered California.
8) Compliance with state and federal laws – Physicians should be aware of their obligations to have an up to date Health Insurance Portability and Accountability Act (HIPAA) and Electronic Medical Records (EMR) compliant system or they will be in breach of the contract with the QHP.
9) Maintenance of Malpractice Insurance and Medical License – Physicians are obligated to maintain their medical license free from any restrictions or limitations and also to maintain medical malpractice insurance, or they will be in breach of the contract and could be terminated for cause without the ability to cure.
10) QHP’s Policies and Procedures – Physicians are generally required to comply with all QHP’s policies and procedures, so it is highly recommended that they obtain a copy of the QHP’s Provider Manuals and review them.

 

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Posted in Current Affairs, Healthcare Regulatory Matters, HIPAA, Medical Insurance, Tredway, Lumsdaine & Doyle, LLP

Regulatory Backdrop for Direct Primary Care: The Future of Concierge Medicine Under the Accountable Care Act.

Posted on April 28, 2014 by | Comments Off on Regulatory Backdrop for Direct Primary Care: The Future of Concierge Medicine Under the Accountable Care Act.

How does the Accountable Care Act deal with cash practices?

Actually, quite well. Well, sort of.

The ACA authorizes HHS to permit qualified health plans (QHPs) to provide coverage through a qualified “direct primary care medical home” plan. The plan has to provide coverage that meets certain criteria (as developed by the Secretary of HHS) and that the QHP, meeting all other applicable requirements, ensures coordination of such services with the entity offering the QHP. Huh?
With respect to implementing guidance, this provision was addressed in 2012 in CMS Exchange/QHP final regulation, in which CMS codified the treatment of direct plans. The provision authorizes QHP issuers to provide coverage through a direct PCMH that meets the standards established by HHS, provided that the QHP meets all standards otherwise applicable. CMS in its final rule addressed comments raised during the proposed rule-making process relative to what those standards might look like, noting in the final rule that direct PCMHs need not be accredited in order to participate in QHP networks. However, CMS “encourage[d] QHP issuers to consider the accreditation, licensure, or performance of all network providers.”

CMS opted in the final rule not to set firm requirements or thresholds
that would necessitate that QHP issuers contract with a specified number or percentage of direct PCMHs. Thus, CMS in its final rule, does not direct that Exchanges create incentives for contracting with direct PCMHs; instead CMS “encourage[s] Exchanges to promote, and QHP issuers to explore innovative models of delivery along the care spectrum.” Thus, there does appear to be an opportunity for Exchanges and QHP issuers alike
to promote and include such models, but per the final guidance on this provision, there is no obligation to do so.

In California, Covered California does not explicitly recognize direct primary care.  There are attempts in the legislature to allow for these cash practices. However, it is generally agreed that practices that accept monthly payments for primary care — similar to the way insurance covers health care, but without the insurance—will pass muster in the state. Instead of filing claims through an insurer, participants — individuals and employers — pay a monthly membership fee directly to their health care providers.

The newer primary care models could come in many flavors:

• Hybrids that offer fee-for-service insurance or a flat monthly fee (not insurance);
• Access model, which charges members an annual or monthly fee for providing enhanced services and bills insurance companies; and
• Qliance’s brand of care, the direct practice model, which charges a flat fee for unrestricted access to primary care services and does not bill insurance.

Does the cash practice make sense?  Take a look at the practices on Yelp that have taken the leap.

By Matt Kinley, Esq.

 

 

 

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Posted in Current Affairs, Healthcare Regulatory Matters, Medical Insurance, Tredway, Lumsdaine & Doyle, LLP, Uncategorized

CALIFORNIA’S NARROW NETWORKS: WILL IT BRING DOWN THE EXCHANGE?

Posted on April 13, 2014 by | Comments Off on CALIFORNIA’S NARROW NETWORKS: WILL IT BRING DOWN THE EXCHANGE?

California Physicians Express Concerns 

Physicians are expressing deepening frustration with California’s version of the Accountable Care Act’s Health Insurance Market place, known in California as “Covered California,” or the Exchange.  Covered California has the reputation for being the best run health care exchange in the nation but even it is suffering from severe problems during this early going.  Physicians are frustrated with administrative issues, the collection of deductibles and co-pays, and the lack of clarity in qualified health plan’s provider contracts.  Most of all, they express contempt for Covered California’s  “narrow networks” and what it means for the physician’s practice and their patients.

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What is a Narrow Network?

Bernard Wolfson at the Orange County Register describes the Narrow Network like this:

“Welcome to the “skinny” medical provider network.

The insurers say they are pressured to keep premiums in check but have been left with fewer tools to do it. Health plans that applied to sell their wares in Covered California, the state-run insurance exchange, competed largely on price.

But at the same time, they’re required to provide standardized benefits that not everybody needs or wants, including things like prenatal care, pediatric services and treatment for substance abuse. That tends to raise premiums.

One of the few effective ways to reconcile these countervailing demands, insurers say, is to eliminate higher-cost hospitals and doctors. As a result, consumers are getting thinner pickings, but at lower prices.”  (OC Register, November 13, 2013.)

Narrow networks are needed to keep premiums down.  The idea is to first find those doctors and hospitals agreeable to receiving lower reimbursement for healthcare services. Second,  load them up with patients.

2014 contracts from Covered California Qualified Health Plans are really not much different than provider contacts from prior years.  They still maintain the “fee for service” model that providers have grown use to.  Change is coming. Buried in the contracts with the qualified health plans are agreements to move over to value based payment in the future.  That is, providers will be expected to take the risk that payments from the health plans will cover the actual cost of treatment.

What’s Wrong With Narrow Networks?

Some of the issues physicians have been suffering from are listed below:

  1. Finding Specialist.  Many primary care physicians are unable to find specialist who are participating in Covered California’s qualified health plans.  Finding the specialist, even an orthopedic to set a broken arm, as proven to be impossible in some areas.
  1. Hospital Utilization.  Many hospitals have not agreed to the lower rates offered by qualified health plans under the Exchange. Often, a patient will find that their doctor is under one Covered California health plan, but their hospital is not.
  1. For Medicaid recipients it will be even harder. California is expected to enroll two million Obamacare Medi-Cal beneficiaries. Only about half of California doctors accept new Medi-Cal patients and the Medi-Cal doctor payment rates, already among the lowest in the nation, are going to be cut by 10 percent just as the Obamacare expansion begins. Medi-Cal waiting lines for specialist care are already critical.
  1. Health Plans are not accepting doctors.  Some specialists have been told that the health plans are no longer accepting physicians.
  1. Patients will not be able to go to their old doctor, and in some cases won’t find a doctor that will take them at all.

Policy Concerns.

The problem with fixing California’s narrow networks is that premiums for the health insurance will skyrocket. Federal regulations do require that health plans under the exchanges  have “reasonable” provider networks.  Health and Human Services is looking to stiffen these regulations in the near future.  California law has provider network requirements.  California’s Health and Safety Code  has certain requirements for provider networks, requiring a hospital to be located within 15 minutes of each and every enrollee and requires certain care to be completed within certain time frames. (Title 28, California Code of Regulations, Section 1300.51(c). California Health & Safety Code sections 1342, 1367 & 1367.03.)

While Covered California has tacitly accepted these narrow networks as a method of keeping premiums low, there is growing concern about how such networks will change healthcare in California.  David Jones, the California Insurance Commissioner held hearings in December on this issue.  Look for proposed regulations from the Department of Insurance later this year.

By Matt Kinley, Esq.  Mr. Kinley is a healthcare attorney in Long Beach, California. 

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Posted in Current Affairs, Healthcare Regulatory Matters, Medical Insurance, Tredway, Lumsdaine & Doyle, LLP

THE FEDERAL GOVERNMENT ISSUES IT REPORT; TUSTIN DOCTOR ARRESTED FOR FALSE CLAIMS UNDER THE FCA

Posted on February 26, 2014 by | Comments Off on THE FEDERAL GOVERNMENT ISSUES IT REPORT; TUSTIN DOCTOR ARRESTED FOR FALSE CLAIMS UNDER THE FCA

The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2013

The HHS report details efforts to recover for fraud claims under the Federal False Claims Act, including convictions against physicians, hospitals, device manufacturers and drug manufacturers.

For California, the star of the report goes to this Tustin doctor and hospital.  As stated by the report:

‘In December 2012, a California physician was sentenced for his role in a hospital fraud scheme to 1 year and 1 day in prison and ordered to pay $11 million in restitution. He previously pleaded guilty to conspiracy to receive kickbacks. According to court documents, Tustin Hospital paid marketers to recruit patients and drive them from “Skid Row” around Los Angeles, past other hospitals, to be admitted to its facility. The physician admitted these patients and then he and the hospital billed Medicare for in-patient services, even if the services were not medically necessary. The physician admitted that many of the recruited patients had been coached to recite false symptoms, and that he falsified medical records to justify the admission of some patients. On average, he admitted approximately 60 patients per month to the hospital, even though some did not require hospitalization”

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Posted in Criminal Prosecution, Current Affairs, Healthcare Regulatory Matters, HIPAA

THE ACA AND NURSE PRACTITIONERS UNDER CALIFORNIA LAW

Posted on February 14, 2014 by | Comments Off on THE ACA AND NURSE PRACTITIONERS UNDER CALIFORNIA LAW

NURSE PRACTITIONERS REQUIRE SOME DUE DILIGENCE

The ACA utilizes the idea of non-physician professionals to help bridge the gap presented by having insufficient physicians to handle patients.  It is hoped that utilizing these professionals will help increase communications with patients, particularly chronic patients who could avoid hospital stays by seeing a nurse practitioner for an office visit or even email communication with a knowledgeable professional  Finally, utilizing non-physicians should lower costs.

In California, this presents some major issues.  California carefully regulates the use of such professionals, particularly nurse practitioners.    Specialists need to  pay attention to creating the right environment for such professionals.  Standardized Procedures should be updated to conform to the needs of the practice.  The California Code of Regulations (Title 16, section 1472) requires physicians to have “standardized procedures” before permitting registered nurses to perform treatments and procedures.  The purpose of the standardized procedures is to establish policies and protocols for NPs so that they are able to perform their authorized duties.  It is particularly important to update these standardized procedures because your NP will most likely be characterized as your employee, which will expand the scope of your liability for her acts.

California Code of Regulations Title 16, section 1474 establishes specific guidelines for the standardized procedures and provides that each standardized procedure must:

v    Be in writing.

v    Specify which functions the nurse may perform and under what circumstances.

v    State specific requirements to be followed by the nurse in performing specific functions.

v    Specify experience, training, and education requirements for the performance of the procedure function.

v    Establish a method for initial and continuing evaluation of the competence of the registered nurse.

v    Provide for a method of maintaining a written record of who is authorized to perform standardized procedure functions.

v    Specify the scope of supervision required for performance of standardized procedure functions.

v    Set forth specialized circumstances under which the nurse is to immediately communicate with the patient’s physician concerning the patient’s condition.

v    State the limitations on settings.

v    Specify patient record keeping requirements.

v    Provide for a method of periodic review of the standardized procedure.

 

            (a)       Furnishing Scheduled Drugs

                        Of particular importance are the standardized procedures on Furnishing Scheduled Drugs.  California law requires that you specifically list “which drugs or devices may be furnished or ordered” and “under what circumstances.”  (Bus. & Prof. Code, § 2836.1(c)(1).)  We recommend to physicians that they review the “List of Scheduled Drugs” to ensure that it is consistent with the drugs that the NP may prescribe to patients.  

            (b)       Dispensing Hormonal Contraceptives

                        California law also has strict guidelines for a nurse’s dispensation of self-administered hormonal contraceptives.  In order to administer hormonal contraceptives, your practice must have standardized procedures developed in compliance with Business and Professions Code section 2725.2.  These standardized procedures must include, but are not limited to, the following:

v    Which nurse may dispense the hormonal contraceptive.

v    Minimum training requirements regarding educating patients on medical standards for ongoing women’s preventative health.

v    Competency in providing the appropriate prior examination of checking blood pressure, weight, and patient and family health history, including medications taken by the patient.

v    List of the contraceptives that may be dispensed or administered under specific circumstances.

v    Criteria and procedure for identification, documentation, and referral of patients with contraindications for hormonal contraceptives and patients in need of a follow-up visit to a physician and surgeon, nurse practitioner, certified nurse-midwife, or physician assistant.

v    The extent of physician and surgeon supervision requested.

3.         Ensure that Your Nurse Practitioner is “Clinically Competent”

           NPs  must be “clinically-competent” to treat a particular population.  Standardized procedures should establish a method for the continuing evaluation of the competence of your NP to perform the specified procedures.

Following these procedures will help you utilize nurse practitioners to help your patients.  You will also avoid accusations of failing to follow state law in guiding the NPs to perform as if they were an extension of your care.

BY:  Matt Kinley, Esq,

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Posted in Current Affairs, Employment Agreements, Healthcare Regulatory Matters, Medical Licensing, Tredway, Lumsdaine & Doyle, LLP

REPORT ON EHR COMPLIANCE: What Providers are Not Doing

Posted on February 13, 2014 by | Comments Off on REPORT ON EHR COMPLIANCE: What Providers are Not Doing

The Department of Health & Human Services, Office of Inspector General, has issued a report entitled “CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs.”

According to the OIG, few Medicare contractors were effectively utilizing EHRs, and most still utilized paper medical records.  Much of the report is devoted to guidance that can be offered t providers by CMS, especially on detecting fraud in the medical records.   CMS should also assist with providing information on what is necessary in the EHR file, and electronic signatures.

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Posted in Current Affairs, Healthcare Regulatory Matters, HIPAA, Medical Insurance, Uncategorized

PRIVACY: BREACH NOTIFICATION UNDER CALIFORNIA AND FEDERAL LAW

Posted on February 7, 2014 by | Comments Off on PRIVACY: BREACH NOTIFICATION UNDER CALIFORNIA AND FEDERAL LAW

WHAT HAPPENS WHEN A PROVIDER ACCIDENTALLY REVEALS PERSONAL HEALTH INFORMATION?

Let’s say someone in your office accidentally sends a patient the information about a different patient?  Or, your web portal  allows patients to see other patients information? What to do?

Notifying Patient of Revealed Information

Both under Federal and State Law, the covered entity must notify all individuals whose unsecured protected health information has been accessed as a result of a security breach.   Such notification may not be “unreasonably delayed” but must be within 60-days of the breach.  It must be specific as to content disclosed.  Also the Secretary of the Department of Health and Human Services must be notified.  (See, generally:  HSS Website.)

Review Your Policies

Security and Privacy procedures must be reviewed, and the review must be documented, and changes must be made to prevent reoccurrence.

California Law Has Additional Requirements

State law must be further consulted for further requirements. California’s general privacy laws and the Confidentiality of Medical Information Act apply.

There are civil and criminal penalties and there is a private cause of action

Talk to a Lawyer

When making a decision about revealed health information, speak to an attorney.   The decisions about what to do should not be taken lightly as there can be major fines from both the federal and state government, as well as likely lawsuits by the patients involved.

Insurance

Make sure you have the right insurance.  This is usually not included with your normal civil insurance or your malpractice insurance.  Review your policies, talk to your broker.  These policies can save you from the high costs of attorneys and helping your patients deal with the problems.  

By Matthew L. Kinley, Esq. 

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Posted in Criminal Prosecution, Healthcare Regulatory Matters, HIPAA, Tredway, Lumsdaine & Doyle, LLP, Uncategorized

ALL THE AGENCIES THAT REGULATE HEALTHCARE ALL IN ONE PLACE!

Posted on February 5, 2014 by | Comments Off on ALL THE AGENCIES THAT REGULATE HEALTHCARE ALL IN ONE PLACE!

Oversight of Health Care Industry

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Posted in Current Affairs, Healthcare Regulatory Matters, HIPAA, Medical Insurance, Medical Licensing, Tredway, Lumsdaine & Doyle, LLP, Uncategorized

MEANINGFUL USE AUDITS TAKE BACK INCENTIVE PAYMENTS

Posted on January 28, 2014 by | Comments Off on MEANINGFUL USE AUDITS TAKE BACK INCENTIVE PAYMENTS

EHR Incentive Programs/Supporting Documentation For Audits

Contact Matthew L. Kinley, Esq at Tredway, Lumsdaine & Doyle if you are subject to audit or need advice about your compliance program.

877.923.0971

According to the Centers for Medicare and Medicaid Services, about 10% of the healthcare providers who took advantage of the meaningful use incentives will be audited by a private contractor hired to look for errors.

THE MEANINGFUL USE PROGRAM

Under the 2009 HITECH Act, health care providers who demonstrate meaningful use of certified electronic health records will receive incentive payments through Medicaid and Medicare. States can receive a 90% federal funding match for incentive payments distributed to Medicaid providers who adopt EHRs under the meaningful use criteria.  Eigible physicians who see Medicare and/or Medicaid patients, as defined by the HITECH Act summary, will be compensated from $44,000 to $63,750 over a 5 year term for fulfilling the recently defined ‘meaningful use’ criteria. To further promote the use of certified systems, if these same physicians do not utilize healthcare IT that meets the Federal requirement by 2015, they will be faced with increasing penalties of up to 5%.

Providers started receiving Medicare or Medicaid bonuses for using certified EHR technology in 2011 and will get around $20 billion over five years. The meaningful use incentive program requires hospitals and eligible professionals (e.g., physicians) to use EHRs to improve patient safety, quality of care and patient-provider communication. Providers must buy EHRs from vendors on the Certified Health IT Product List (see http://healthit.hhs.gov/chpl). If they don’t, they face a Medicare payment reduction after 2015.

REQUIREMENTS FOR HITECH

Documentation to support attestation data for meaningful use objectives and clinical quality measures should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.

MEANINGFUL USE AUDITS

States and their contractors will perform audits on Medicaid providers. When providers are selected for an audit, they will receive an initial request letter from the auditor. The request letter will be sent electronically from a CMS email address and will include the audit contractor’s contact information.

The initial review process will be conducted at the audit contractor’s location, using the information received as a result of the initial request letter. Additional information might be needed during or after this initial review process, and in some cases an onsite review at the provider’s location could follow. A demonstration of the the EHR system could be requested during the on-site review

If there is any deficiency in the audit, providers will have to give back their entire meaningful use incentive payment.  That means their payments for the audit period are at risk unless their electronic health records show they kept every promise they made to the government when they accepted the money.

One letter from the EHR HITECH Incentive Payment Center said a meaningful use audit had determined that “an overpayment of HITECH funds has been determined and is owed.” CMS gave the provider 30 days to repay the money, although it had the right to appeal.

Most providers are having negative audit findings and owing the money back, often because they thought they met most of the core elements, but they didn’t get them all done, or they weren’t all properly documented. If you miss a core element, they ask for all the money back.

HIPAA and PRIVACY POLICIES

The security risk analysis is a problem area in meaningful use. Providers must attest that they conducted a risk analysis, which is a core measure as well as required by the HIPAA security regulation.  Most providers fail to do such an analysis.

BEST PRACTICES TO AVOID AN AUDIT

The following practices should be employed as soon as possible by all providers.  Those who worked for and obtained benefits for meaningful use are particularly vulnerable.

Best Practices

• Enter accurate numbers when you attest to meaningful use of an electronic health record (EHR).

• Keep your supporting documentation.

• Know that dated screen shots provide a good source of documentation.

• Save paper or electronic copies of reports used to attest if the practice’s EHR automatically changes numerator and denominator values after the reporting period ends.

• Turn on, for the entire reporting period, EHR features that track functionality issues, such as drug interaction checks and clinical decision support.

• Understand that the security risk analysis must be specific to the EHR and the practice and is required every year.

By Matthew L. Kinley

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Posted in Current Affairs, Healthcare Regulatory Matters, HIPAA, Tredway, Lumsdaine & Doyle, LLP