Telehealth Guidelines For Providers And Telemedicine Requirements

Access to Telehealth appointments has become more essential than ever in light of the COVID-19 public health pandemic. This pandemic highlighted many of the flaws in the public health system, with the accessibility and effectiveness of Telehealth being one of the most significant. 

Telehealth is a wide topic that includes online communication with patients and storing patient data in a secure online portal that the patient can access in addition to phone and video appointments in lieu of having the patient physically visit the office. 

Great strides have been made in Telehealth in the past two years, and there are now several ways that providers can offer these invaluable services to their patients. 

Telehealth Services For Patients

For patients, Telehealth services can provide several benefits including but not limited to:

  • Extended access to care beyond normal business hours
  • Reducing the time and cost of transportation 
  • Provide better care to rural and underserved populations
  • Enabling long-term support for patients with chronic and disabling health conditions
  • Easier access to primary screening of symptoms for appropriate referrals
  • Preventing the spread of infectious diseases by keeping the patient at home

While it is not appropriate in every situation, Telehealth has quickly become an efficient and effective method of providing care to the majority of the population.

Telehealth appointments are perfect for patients that are planning to visit the doctor for the following reasons:

  • General wellness visits or yearly checkups
  • Chronic pain management
  • Medication refills for chronic conditions
  • Going over laboratory results or care instructions
  • Going over diagnostic, therapeutic, or alternative treatment options
  • Minor Dermatological concerns
  • Weight loss management and nutrition guidance
  • Mental health care, counseling, and therapy appointments

There are, however, several instances where Telehealth appointments may not be beneficial, or may not provide the appropriate level of diagnostic care. These situations may include:

  • Severe abdominal pain, particularly when localized
  • Concerns with vision or hearing
  • Dental pain or discomfort
  • Situations that require a physical examination such as a tear, sprain, or broken bone
  • Any situation that may require surgical intervention
  • Situations that involve multiple conditions that are interacting with each other
  • Gynecological or Obstetric concerns 

While it is not impossible to diagnose or treat patients in these situations, it is generally in the best interest of the patient to receive in-person care for these conditions when possible. 

For situations where Telehealth is a logical and reasonable method of providing care, there are several methods of offering Telemedicine.

Remote Patient Monitoring

Remote patient monitoring allows patients to remain in the comfort and security of their own homes while still providing essential patient health data to their medical care provider. 

This is achieved through the use of in-home medical monitoring devices such as blood pressure cuffs, glucose monitors, pulse oximeters, pacemakers, weight monitors, and spirometers. These devices capture and monitor patient data regularly throughout the day and then transmit the medical data directly to the providers’ systems. 

This allows providers to continuously monitor their patients’ vitals which enables them to provide accurate and up-to-date treatment options and assessments. In turn, this eliminates unnecessary and often costly trips to the doctor, emergency room and urgent care visits, and hospitalizations for their patients. 

In many situations, remote patient monitoring may also allow for relatively healthy elderly and disabled patients to remain in their own homes for longer without having to be transferred to skilled nursing facilities or retirement communities. 

Remote patient monitoring can be utilized to support both asynchronous and synchronous health care.

Asynchronous Telehealth Care

Asynchronous telehealth care, sometimes referred to as store and forward care, is common in healthcare settings that require imaging, laboratory results, or other diagnostic indicators in order to properly treat a patient. 

In these situations, patient information is obtained at one time and is then forwarded to the physician to review when they have the time to do so. This is beneficial for providers as it eases the strain on their resources and time, and it is beneficial for patients as the provider will have had time to review all of the necessary information before their appointment. 

Asynchronous care can be performed by any provider, but it is most common in the following medical fields:

  • Dermatology
  • Radiology
  • Cosmetic surgery
  • Orthopedics
  • Ophthalmology

Some primary examples of asynchronous telehealth are Xrays or MRI imaging sharing, wound imaging, symptoms surveys, and patient reports sharing.

Synchronous Telehealth Care

Whereas asynchronous telehealth care is performed with pre-gathered data at a later date, synchronous telehealth care takes place in “real-time”. More commonly known as virtual visits, synchronous telehealth care allows for efficient evaluation and acquisition of data directly from the patient and enables immediate communication between patient and provider. 

Synchronous telehealth care often occurs in the form of a video call and is common for:

  • Direct consultations between a primary care provider and a specialist
  • Physical therapy evaluations and subsequent sessions
  • Diagnosing and prescribing treatment for minor to moderate ailments 
  • Behavioral evaluation & therapy sessions
  • Quality of life consultations for patients in hospice

In addition to these benefits, synchronous telehealth care is extremely efficient and beneficial for patients that may not have adequate transportation or monetary resources to see medical specialists.

Finding The Right Telehealth Technology

There are several types of telehealth technology available, and some may be better suited for your practice or the type of care that you wish to provide. The most widely available forms of telehealth include:

  • Live video: A face-to-face interaction between patient and provider over the computer. 
  • e-visits: Visits communicated through an online patient portal (not face-to-face).
  • Store and forward: Evaluation of submitted images or diagnostic aids at a different time than the patient’s appointment. 
  • Audio-only visits: Telephone visits between patient and provider.
  • Remote patient monitoring: Utilizing digital technologies to monitor patient vitals and statistics from a remote location
  • Mobile health (mHealth): Utilizing secure phone applications to allow patients to review their personal health data and submit questions or concerns to their physician via a messaging or email system. 
  • Care-based teleconferencing: Providing interdisciplinary and integrated treatment options to patients, often while including family members in the treatment plan. 

Once you have decided on what type or types of telehealth you want your practice to offer, it is time to identify any technology that may already be available that you are currently using. A phone and internet connection is enough for live, e-Visits, and audio-only visits for example. 

Many providers also already have some version of a patient portal that is used to store test results, imaging, and other items used in the diagnosis and treatment of their patients. These can be easily converted to allow patients access to their information in addition to a messaging feature so that they can ask their provider questions as they come up without having to wait for an appointment.

When researching further options for offering telehealth care, it is important to consider HIPPA guidelines when choosing which video communication services to use. Some other things to consider when deciding upon telehealth technologies and telehealth vendors are:

  • Is a contract required?
  • Does it offer a waiting room feature?
  • Do you need to purchase any special equipment for it to function properly?
  • How will patient consent be obtained? Directly through the patient portal or prior to granting access?
  • Does it offer end-to-end encryption?
  • Does it offer an in-application scheduling feature for both patients and providers?

It is important to consider what your practice’s unique needs are concerning telemedicine technology to ensure that you choose the right vendor. 

Scheduling And Managing Appointments

When you choose to offer telemedicine options to your patients, it is essential to implement a telehealth workflow and protocols to ensure that you and your team do not get overwhelmed by telehealth requests. 

Some of the key things that you should consider before implementing a telehealth system are:

  • When will you offer telehealth appointments? How often will you be available?
  • What type of services will you offer? 
  • How will you offer services to patients that do not speak English? Will you have an interpreter available? 
  • Will your staff schedule appointments or will patients be able to schedule their own? 
  • How can you easily access patient information prior to and during their appointment?
  • Will you have a medical assistant greet the patient and ask the initial questions at the start of the visit? 
  • What options will you provide for patients with visual or hearing-related disabilities? 
  • How can caregivers use the system to facilitate telehealth appointments between you and the patient?
  • How will you collect payment after the visit?
  • How will you obtain the patient’s consent for the visit?
  • Will the patient have access to their medical records via an application or a patient portal during and after the visit?

In addition to these basic considerations, it is also important to ensure that your patients know about the availability of telehealth appointments as well as how to use the necessary technology to participate in these appointments. 

It can be beneficial to send an email or a text message to the patient after their appointment has been created detailing any necessary instructions on accessing the telehealth portal at the time of their appointment. 

If an application or certain website needs to be accessed for the appointment, it will help both the patient and the provider if that information is sent ahead of the appointment with instructions. This will give the patients time to familiarize themselves with the process so that there are fewer technical issues on the day of the appointment. 

Finally, it is important to ensure that your staff is familiar with the technology as well as the protocols in place. Conduct a training session with the new equipment and software, and encourage them to use the system to gain familiarity with it. It may also be beneficial to have a FAQ sheet available for them should they have any questions. 

Preparing To Visit A Patient

When preparing to conduct a telehealth visit with a patient make sure that you are in a private room and that you have placed a sign on the door to not be disturbed. From here, ensure that your equipment is working properly and that you have the patient’s information readily available before the appointment begins. 

If the patient is new, introduce yourself and greet the patient, then confirm the patient’s identity by having them show you their driver’s license or another form of identification. Determine if the patient’s consent has already been given for the visit and if not obtain their consent at the beginning of the appointment.

At this time, you should also verify that the patient is alone, or that if anyone is in the room with them, such as a caregiver or family member, that the patient has given their consent for them to remain. Ensure that the patient feels comfortable with the visit and that all of their questions about privacy and security have been answered. 

Finally, before the clinical portion of the visit begins, ensure that you have a good phone number to reconnect with the patient in the event that either side loses internet connectivity or the call drops during the visit. This will allow you as the provider to reach out immediately after the patient has been disconnected to finish the visit. 

Visiting A Patient And Following Up 

Once the patient’s information has been verified and both parties are confident that their connection is secure, it is time to begin the actual telehealth visit. 

First, confirm that the patient’s health history is up-to-date and that there have not been any major new medical events that have taken place, such as a trip to the emergency room. 

From here, if possible, attempt to get any vitals for the patient that you can. Use any technology that the patient has on hand that they are comfortable using. For example, if the patient has a smartwatch or Fitbit then they can provide you with a pulse reading. The same applies if they have access to a blood pressure cuff. This will be more common if the patient has a caregiver. 

Another useful and readily available vital should be the patient’s weight. Once you have obtained as many vitals as possible, document everything that the patient was able to provide as well as the information that they couldn’t for insurance purposes Then it is time to move on to the subject of the visit.

Ensure that you are taking your time with the patient and answering all of their questions just as you would during an in-person visit. It is especially important to pay attention to the patient’s verbal cues and body language in addition to what they are saying to ensure that you are not missing any information that you would catch in an in-person conversation. 

Ask them to describe any symptoms that they are having in detail and ask probing questions to get as much information as possible that can help with a diagnosis or treatment decision. 

At the end of the appointment, let the patient know that they can email or message you with any questions or concerns that they may have forgotten to bring up. After the appointment, provide any necessary referrals, submit prescriptions to their pharmacy, and send the patient any follow-up care instructions that are necessary.

Making Telehealth Accessible

It is important to ensure that the majority of your patients have reasonable access to the telehealth options that you are offering. It can be beneficial to announce that you are going to start offering telehealth options in the future. 

By announcing your plans for telehealth ahead of time, you will not only allow your patients to get accustomed to the idea, but it will also give them time to familiarize themselves with the options that will be available to them. 

Consider sending an email to your current patients to inform them of the anticipated date that telehealth services will be available and update your website to reflect the change that will be coming. It is always better to keep your patients in the loop instead of surprising them with drastic changes to the way that your office operates. 

The Barriers To Telehealth

There are several potential barriers to a patient’s ability to access telehealth services. These include the lack of interpreters for patients that do not speak English, lack of access to accessibility devices that can help patients that are hard of hearing or have vision problems, and a communication barrier for patients with speech difficulties. 

All of these concerns can be worsened when attempting to engage a patient with unique needs in a telehealth setting. 

Per the Americans with Disabilities Act, a provider that is offering telehealth services must be ready and able to accommodate patients with disabilities by offering the services of a qualified notetaker, qualified reader, qualified sign language interpreter, or any equal level of accommodation that will allow the patient and provider to correctly understand each other. 

Providers should also keep in mind the possibility of non-English speakers utilizing the telehealth portals and should be prepared to offer accommodations to them as well. It can be beneficial to have a licensed medical interpreter on staff or on call to conference into video or voice calls to help facilitate communication in these situations. 

Improving Access To Telehealth

The largest and most common barrier to telehealth care is patient access to and availability of the internet. Many rural and remote towns and populations lack access to high-speed internet and the bandwidth that is required to be able to participate in video conferencing. 

Due to their location, these populations also tend to have less access to in-person medical care as well. For many, the nearest doctor, clinic, or hospital may be up to an hour’s drive away. 

Because of this, there has been a recent initiative to improve rural populations’ access to quality healthcare. The Federal Communications Commission Lifeline provides monthly internet services to people with low incomes for a discounted rate, or in some cases, free of charge. 

Some patients may also have access to locations such as public libraries or fast food restaurants that provide access to public Wi-Fi. This may be an option for patients that need a telehealth appointment, but it is important to remind patients to not enter any personal or sensitive information onto any website while on public Wi-FI.

In certain situations, access to video conferencing for telehealth may not be available. In these cases, ensure that your office is equipped to perform voice-only calls to help these patients. 

Lab Work

In the majority of cases, physicians should be able to order the blood work that their patients require during or after a telehealth visit. The laboratory of your choice, or the patient’s choice, should be able to receive the request digitally, but it is also a good practice to send the patient a laboratory requisition form as well.

This enables the patient to go to the lab of their choice when it is convenient for them or to have a service such as the National Phlebotomy Provider Network come to the patient to have their lab work drawn. 

Transitioning To Telehealth

Making the transition to offering telehealth services is a time-consuming, intensive, and potentially expensive process. There is no doubt that telehealth services are more important and essential now than they ever have been, however. 

At the beginning of the COVID-19 pandemic, healthcare providers were unable to meet the sudden demand that was placed upon them, and it took months before adequate changes were implemented as the new standard. Among these changes was a new emphasis on the widespread availability of remote patient care, or telehealth medicine. 

This new need and expectance of accessible healthcare is here to stay. This means that providers who do not currently provide some form of telehealth care are now the minority and it is time to make the transition. 

Throughout the transition process, it is essential to keep your patients informed of any changes that will be made to your existing practice, such as the way appointments are scheduled or how lab results will be available to them. 

Not only will this help to smooth the transition process, but it will also give you the opportunity to get feedback from your patients and staff members about new protocols and programs. When possible, keep an open mind to this feedback and take note of any things that you may have not considered or overlooked. 

Patient Consent

Just as with an in-person examination, getting the patient’s consent to be treated is mandatory in telehealth visits. At the beginning of the appointment, explain to the patient how the telehealth visit will go, what they can expect from the visit, and what their rights are. 

In most cases, getting verbal consent from the patient to proceed with the telehealth visit is sufficient. Be aware of any other people that may be in the room with the patient or in the room with you during the call, and inform the patient of these people. Before proceeding with the visit, ensure that you have the patient’s consent to include these other parties in the visit. 

Consult with your legal team for more in-depth recommendations regarding a patient’s consent to treatment. When possible, it is also advisable to obtain written permission from the patient prior to the appointment as well as verbal consent during the appointment. 

Introducing Patients To The Technology

The transition to telehealth will undoubtedly be challenging for your patients as well. As telemedicine is still a relatively new method of care, it is likely that your patients will have questions about it. 

These are some of the subjects that you should consider discussing with your patients or that you should include information on on your website.

  • What types of care do you offer through telehealth?
  • Are there any conditions that you cannot treat through telehealth?
  • When should a patient choose a telehealth appointment over an in-person appointment?
  • What types of telehealth do you offer? Phone calls, video calls, text messaging, mobile app support, remote monitoring, etc.
  • How is a telehealth appointment different from an in-person appointment?
  • What security measures do you have in place to protect your patients’ information?
  • Is there an additional cost associated with a telehealth appointment? 
  • Will the patients’ insurance cover a telehealth appointment?
  • What days/times do you offer telehealth appointments?
  • How can a patient make a telehealth appointment?
  • What equipment or technology does your patient need in order to have a telehealth visit?
  • Do you offer interpreters for non-English speakers?
  • What accommodations do you offer for patients with disabilities during a telehealth visit?

In addition to addressing all of these questions, it is beneficial to emphasize the benefits that telemedicine can offer, particularly to patients in vulnerable populations such as the elderly. Some of these benefits include:

  • Limiting physical contact which can limit the spread of infectious diseases such as the flu and COVID-19
  • Saves time and money on arranging transportation to travel to and from the doctor’s office – appointments can be done in the comfort of the patient’s home
  • Reduces the need to get time off to travel for an appointment, in many cases telehealth appointments can be done during lunch periods or other downtimes
  • Allows the provider to see more patients in the same amount of time
  • Allows rural populations access to specialists that they may not otherwise be able to see
  • Allows for appointments without having to arrange for child-care or elder-care 
  • Eliminates the time spent waiting in a waiting room – simply log on when it is your appointment time

The important thing to help patients understand is that a telehealth appointment will proceed exactly the same as an in-person appointment. The only difference is that telehealth is more convenient and accessible to both the patient and the provider in most situations. 

Let the patient know that they should feel comfortable asking questions and that they can decide to stop the telehealth visit at any time if they feel uncomfortable or if they decide that they would prefer an in-person appointment instead.

Your Patients First Appointment

Prior to your patient’s first appointment, ensure that they have all of the information that they need to make the visit a success. Send them an email detailing any equipment or technology that they will need for their appointment. Then, include a number or email address that they can reach out to if they need help troubleshooting. 

In the pre-appointment instructions, you should also include any information that you will need from the patient as well as any forms that should be filled out and returned to your office before the day of the appointment. 

Finally, make sure that the patient has all of the necessary log-on information that they will need for the visit, and inform them of any calls that your staff may make immediately before the visit. 

Once you and your patient begin the telehealth visit, explain to them what will happen in the visit and ask the patient if they have any questions or expectations. Check to see if there is anyone else in the room with the patient, and if there is either ask the person to leave or get verbal consent from the patient to allow them to stay. 

At the beginning of the visit, it is important to get consent from the patient for the visit and to obtain a phone number that you can call them back at should you get disconnected. Then, obtain the patient’s medical history if you do not already have it and proceed through the appointment as normal. 

Telehealth Licensing

Each state has unique licensing requirements in regard to telemedicine. For the most up-to-date requirements for each state, see the following:

U.S. States and Territories Modifying Requirements for Telehealth in Response to COVID-19from the Federation of State Medical Boards updated May 31, 2022

U.S. States and Territories Modifying Licensure Requirements for Physicians in Response to COVID-19 – from the Federation of State Medical Boards updated May 31, 2022

COVID-19 Related State Actionsfrom the National Policy Center – Center for Connected Health Policy

Provider Bridge – A directory of resources for providers

Licensing Resources for Social Workers 

Licensing Resources for Occupational Therapists

Substance Abuse and Mental Health Services Administration (SAMHSA) COVID-19 Resources

HRSA Rural FQHC Telebehavioral Health Guidelines

HRSA Telehealth Resource Center

Medicare And Medicaid Policies

Medicare and Medicaid policies on telemedicine frequently change as new technology is presented and new research is done that proves that telehealth can be just as effective as in-person visits. 

It is recommended that your practice regularly review the newest additions and addendums to Medicare and Medicaid policy to ensure that you are billing correctly so that your practice’s claims are approved. 


During the COVID-19 public health epidemic, both Medicare and Medicaid policies were significantly loosened to allow more people to seek healthcare in any form available, including telehealth care. 

Legislation was passed for Medicare that requires 151 days to pass after the end of the COVID-19 public health epidemic before any new legislation or policies can be passed that contradicts or end the current policy. 

In addition to this requirement, there were several other changes to Medicare coverage, reimbursement, and telehealth policies including:

  • Began paying for virtual check-ins
  • Expanded payment and reimbursement for telehealth
  • Began paying for several telemedicine services including:
    • Emergency department visits
    • Initial inpatient and nursing facilities visits
    • Discharge day management services
    • Certain services delivered to patients at home
  • Began paying for group psychotherapy
  • Began paying for psychological and neurological testing
  • Began paying for lower-level rest home or custodial care services
  • Began paying for cognitive assessments
  • Began paying for care planning services
  • Began paying for prolonged services
  • No more geographical restrictions for patients or providers
  • All providers that are eligible to obtain Medicare reimbursement may bill for the above
  • Providers can reduce or wave cost-sharing for telemedicine visits
  • Issued a waiver to allow the use of audio-only equipment
  •  Other temporary services


The majority of states have expanded the coverage offered to Medicaid recipients under the expanded policy benefits as a result of the COVID-19 public health epidemic, however exact coverage varies from state to state

Most states under the new policy are currently providing coverage for:

  • Store-and-forward (asynchronous) healthcare
  • Telemedicine services
  • Telehealth from the home
  • Telemedicine via email, phone, or video call

Review the current state and local laws and reimbursement policies for more information on permanently covered Medicaid services.

Even during the COVID-19 public health epidemic Medicaid and CHIP coverages can lapse. Luckily, there is information available to help your patients retain coverage during the “unwinding” process including:


When billing Medicare, Medicaid, and Private Insurance, it is essential to review all documentation and attached diagnostic and billing codes to ensure that the claim will be approved or reimbursed with minimal delay. 

Other important things to consider when documenting your reimbursement request include:

  • Thorough documentation of procedures, diagnoses, and tests
  • Patient consent
  • Proper documentation regarding code categories, ie. for video calls, audio-only calls, etc. 
  • Time of visit. Only document time spent directly with the patient, not time that the clinical staff engaged the patient. 
  • Store-and-forward documentation is unlikely to be reimbursed. For a list of policies in your state regarding this, check here


A significant number of new Medicare Fee-For-Service services are currently billable as a result of the policy changes in place during the COVID-19 public health epidemic. Telehealth visits are now covered under the same fee schedule as in-person visits. 

While Medicare has drastically increased the number of services that are now covered as a result of the public health epidemic, not all of these services will be permanently covered. 

A list of the codes that will be permanently covered under the Medicare Fee Schedule can be found here. The National Policy Center also has a fact sheet available that details the changes, both temporary and permanent, to telemedicine billing practices. 

Additionally, new allowances have been made for rural health clinics and other federally qualified health clinics to bill Medicare for reimbursement for several covered services. 

Other useful information regarding changes to the way that Medicare is handling billing, payments, and reimbursement are as follows:


As with Medicare, the number of services that are now covered under the expanded telehealth policy have significantly increased. While Medicaid coverage is different from state to state, as of March 2021, Medicaid fee-for-service offers reimbursement for:

  • Live video in 50 states and the District of Columbia
  • Remote patient monitoring in 23 states
  • Asynchronous healthcare in 16 states

Review the General Telemedicine page on for more information on which states provide what type of coverage.  

Private Insurance

Currently, twenty-six states have laws in place requiring that private insurance providers completely reimburse healthcare providers for any telemedicine services rendered. Additionally, another seventeen states have some measures in place to ensure at least partial payment or payment for certain covered services. 

While the laws differ from state to state, the majority state that insurance providers cannot take a patient’s location at the time of service into account when processing reimbursements. This means that whether the patient is at home, at work, or anywhere else, they will still be covered for the telehealth service – providing that coverage is in place for the service.

The majority of insurance providers now cover telehealth video visits, although some may require that a patient be established with an in-person visit before telehealth coverage can begin. Review this list of State Telehealth Laws and Reimbursement Policies to determine eligibility. 

It is also beneficial to keep in mind that coding for private insurance claims is different than coding for Medicare or Medicaid reimbursement claims. Here is a list of coding guidelines and scenarios for private insurances during the COVID-19 public health epidemic. 

Additionally, payment amounts vary between states and between insurance providers. While some states have laws that require telemedicine to be paid at the same rate as in-person visits, others leave the coverage amount up to the provider. If your state does not currently have a parity law, it can be beneficial to call the insurance provider as they may offer coverage anyway. 

Keeping Patients’ Health Information Safe

One of the primary concerns that most patients express when it comes to telemedicine is the safety and security of their personal information and their health information. All communications that occur during a telehealth visit are under the same HIPPA privacy laws as in-person appointments.

Although patients will be connecting to their telehealth appointments using their own internet connection, or in some cases a public Wi-Fi, their information will still be secure. Providers must use a secure patient portal to conduct the appointment which is encrypted per HIPPA privacy standards and guidelines. 

In the majority of cases, a patient will use their phone, tablet, or computer to log into a secure patient portal to interact with their physician during their telehealth visit. In some cases, however, doctors have been allowed to utilize existing video conferencing applications such as Skype, Zoom, and Google Meet to conduct these visits. 

Prior to utilizing this technology, providers should ensure that the vendors that they are using are willing and able to ensure additional privacy and security measures for these telehealth visits. It is recommended that a provider reach out to these vendors prior to using them to enter into a HIPPA business associate agreement to ensure privacy and security. 

Patients should be informed that they should find a quiet, unoccupied room where they can be sure of their privacy during the visit. Providers should also ensure that they are in a room with a door that can close and that they remain alone for the duration of the visit unless express consent is obtained from the patient. 

Other information that should be shared with patients to help them protect their information online includes:

  • Do not access a telehealth appointment with anyone not in your immediate family
  • Try not to use public Wi-Fi to access telehealth appointments – if it is necessary ensure that your provider offers additional safeguards through their patient portal
  • Do not use any Wi-Fi connection that is not password protected – if your personal Wi-Fi does not have a password, add one immediately
  • Ensure that you have an active and up-to-date anti-virus software installed and enabled on your device prior to your telehealth visit and prior to entering any information online
  • Do not provide any information over the phone, via email, or online to any person, number, or website that you do not recognize – when in doubt, disengage from the conversation and call a number that you know leads to your provider
  • Do not enter any private information on a website unless there is a lock icon in the address bar

Additionally, it is essential for healthcare providers to ensure that their computers and systems are protected by strong authentication measures, end-toend encryption, and up-to-date operating systems, applications, and anti-virus software. 

Finally, ensure that your team is trained in recognizing emails, applications, and software that contain fishing attempts or obvious viruses. Phishing is the number one way that sensitive information gets leaked. 

Malpractice And Liability

There are several legal considerations that providers should keep in mind when offering telehealth appointments. One of the most important security concerns to keep in mind is keeping patients’ health information protected. 

Patient health records are frequent targets of phishing efforts, hackers, and malware viruses. For this reason, having a strong knowledge of cybersecurity, or at least an IT department that is well-versed in cybersecurity, is essential. 

Here are a few helpful guides to review when considering what sort of cybersecurity measures your practice should implement:

It is important to note that although HIPPA requirements regarding using existing video conferencing applications for telehealth visits have become more lenient during the COVID-19 public health epidemic, this allowance is not intended to be permanent. 

When the pandemic has been declared over, all telehealth communications will need to adhere to the original HIPPA standards of communication

There are some final things to consider when deciding to offer telemedicine appointments. First, ensure that your existing liability insurance company covers telehealth. While some insurance providers may cover it, some providers may need to purchase supplemental liability insurance. 

For providers who wish to offer telemedicine across state lines, ensure that you will be covered by your liability insurance in each state that you are practicing medicine in. 

Check your local and state laws regarding the way that you are instructed to collect and store protected health information. 

Finally, some additional information on legal considerations:

7 Steps On How to Improve Home Care For Clients

The world of healthcare has been forever changed as a result of the COVID-19 public health epidemic. Home health care has become more prevalent in the past few years and it is certain that this branch of the medical field will continue to expand in the future. 

An increasing number of people are choosing to take advantage of home care services in lieu of extended and expensive hospital stays. The benefits that home health agencies can provide for their clients are numerous, but they can always be improved. 

As more clients choose to utilize the services that home health agencies provide, it is time that these agencies begin to put their clients, the consumers of their service, at the forefront of their business model. 

In this day and age, client-centered care is not only an expected practice but an essential one for home care agencies that wish to thrive. Here are seven steps that your agency can take to attract clients and put itself ahead of the competition.

Be Consistent and Available

One of the most effective ways to build rapport and brand loyalty with your clients is by ensuring that your staff is always consistent and available. This means that during business hours there is always someone available to answer phone calls, emails, and any questions that current or future clients may have. 

It can be beneficial to have an after-hours answering service equipped with the answers to some of the most common questions that your clients may have. If such a service is infeasible, ensure that your staff returns any missed calls or emails that may have been missed the day before. 

In addition, consider implementing a live-chat feature on your website. Many potential clients may be uncomfortable speaking to someone on the phone, and this will encourage them to reach out and ask questions. By being available through multiple mediums, your team can ensure that clients’ concerns are being promptly addressed which builds trust.


After your availability has been broadened, the next step is to ensure consistency. All customer-facing team members should have the same training, and they should all be able to answer questions with the same answers. 

Consistency doesn’t end with answering customer questions, however. It also applies to the experience that clients are expecting. Most home care clients prefer to work with the same caregiver as often as possible, and they may get frustrated and lose trust with a company that is constantly sending them different caregivers.

By investing in a scheduling system, particularly one tailored to home care agencies, this issue can be avoided. Not only will this relieve frustration for your staff due to last-minute changes, but your clients will be happier as well.

Ensure That Customer-Facing Staff Are Personable

There is no denying that knowledge and training are invaluable to the client experience, however,  the way that your staff interacts with their clients is equally important. An ill-trained, rude, or disinterested staff member can do just as much damage to your organization in the age of social media as a staff member that doesn’t know what they are doing. 

Clients appreciate staff members that are empathetic, compassionate, and knowledgeable when it comes to their care. It is not enough to be efficient, caregivers must also be willing to listen to their clients, advocate for them, and ensure that their concerns and questions are addressed. 

Hire caregivers that demonstrate compassion and empathy, and ensure that they understand the importance of body language. The way that a person says something is just as important, if not more so, than what they actually said.

The Importance of Body Language

The importance of body language can’t be overstated. Most experts agree that between 70% to 93% of communication is nonverbal body language and tone of voice. This means that even if your nurses and support staff are saying the right things if their body language and attitude don’t match then it doesn’t matter.  

While most job skills can be taught, it can be difficult to train people to be truly empathetic or friendly. If a person has a naturally negative attitude or has closed-off or reserved body language, then they may not be the best fit for a home care agency. 

Ensure that your staff and nurses understand how the way they interact with others, especially clients, matters. Don’t be afraid to implement training classes and disciplinary measures if multiple clients are reporting an unfriendly or rude staff member. 

Similarly, reward staff members that are consistently friendly, compassionate, and going above and beyond for their clients. Incentives like an extra PTO day, coffee gift cards, or buying them lunch can be effective in encouraging positive behaviors.

Take Patient Concerns Seriously

To ensure that your home care agency excels and is widely respected, it is essential that your support staff and nurses take all patient complaints and concerns seriously. This also extends to the concerns of family members. 

In the majority of cases these concerns are valid and what starts off as a small problem can escalate into something far more serious if left unsolved. Some of the most common complaints that you and your staff may encounter are:

1. Clients feel like they are being treated like a burden or just a job. Home care clients are looking for companionship as much as they need to be cared for. 

2. The care staff is frequently late or leaves before their shift is over. In some cases, they may not show up at all. Enforce accountability. 

3. Significant age gap between caregiver and client can lead to miscommunication and misunderstandings. Ensure that your nurses understand how to interact with their patients properly and professionally. 

4. Caregivers that do not know how to cook even basic meals. Many home care clients are unable to cook for themselves and would like to have a caregiver that can at least make eggs or a sandwich for them.

5. Staffing shortages make it so that caregivers are unavailable at the times that they are needed most. Ensure that you have enough caregivers to take care of all of your clients at the times that they need care,

6. Different caregivers are assigned for each shift. Clients want to be able to get to know their caregivers and want to know what to expect with their care. When possible, try to schedule the same caregiver for a client or use the same substitute when the primary caregiver is unavailable. 

7. The client’s care plan doesn’t match the caregiver’s skills. There is nothing more frustrating for a client than being paired with someone that can’t properly care for them. If your client needs help getting in and out of bed, ensure that the caregiver is strong enough to lift them.  

8. Office staff is difficult to reach via phone call. Most clients aren’t going to be comfortable emailing, texting, or using a chatbot to address their concerns. There should always be someone answering phone calls and responding to voicemails.

Train Support Staff to Follow-Up On Care

Although your nurses will be the primary point of contact between you and your clients, it is important that they are not the only person interacting with them. Train case managers, directors, and administrators to follow up periodically with patients and their families. 

Ensure that these staff members ask how the patient feels that they are being treated, if they have any specific questions or concerns that need to be addressed, and if there is anything that they would like to change about their care. 

By having support staff, particularly higher-up staff and administrators follow up and check in on patients once a month, you will build trust with them. It lets them know that you are taking their concerns seriously and that they are being heard and cared about. 

This system also helps to keep everyone accountable, helps to measure patient satisfaction, to solve small problems before they have a chance to turn into larger ones, and provides the opportunity to improve processes that aren’t as efficient as they could be.

Meet The Patients’ Special and Individualized Needs

While it can seem easier to try to create one standardized plan of care for all of your home health patients, that will only create more work in the long run. Each client is unique and it is important to take that into consideration. 

While nurses are well-trained in performing assessments and should be observant enough to recognize when a client needs something that isn’t being provided, it may not be as clear to other support staff. 


It is important to train your support staff to recognize when a client may be uncomfortable or in need of something, particularly because they may be reluctant to ask for additional help. Some questions that should be asked and considered include: 

  • Does the client have all of the assistive devices that they require?
  • Is the client capable of making their own food or do they need assistance at meal times or making snacks?
  • Does the client feel safe in their current environment? If not, what concerns need to be addressed?
  • Are there any visible safety concerns in the house? For example, are there exposed cords that could be tripped over or steps that are difficult to climb? 
  • How is the client feeling mentally, physically, and emotionally? Are they lonely?

If no immediate concerns can be identified by support staff, it is still a good practice to ask the family and the client directly if they have any specific concerns or needs that their caregiver needs to be aware of.

Take the Time to Get to Know Your Patients

It is important that your caregivers are able to spend time with their patients to get to know them and to improve the quality of care that they are able to give to them. Try to ensure that your caregivers have enough time between their appointments so that they do not feel overwhelmed or rushed.

It can also be beneficial to pay your caregivers by the amount of time that they spend with their patients rather than on a per-visit basis. Per visit pay schedules only encourage caregivers to rush from appointment to appointment to try to fit more visits into their daily schedule.

This severely impacts the quality of care that they are providing to each of their patients which impacts their quality of life. Neglecting the emotional and mental needs of your patients and only fulfilling their physical needs is a surefire way to bring negative reviews and publicity to your agency.

Understand That the Needs of Your Patients Frequently Change

While an initial assessment is essential to better understand the unique needs of your patient, it is also important to have regular meetings with your clients. By meeting with them at least once a month, you will be able to anticipate their changing needs and fix any concerns that they may have in a timely manner. 

If you do not frequently have these meetings with the client or their family, then you are likely not providing them with the best care possible.

Promote a Culture of Safety

The safety of both clients and staff should be your top priority at all times. There is no reason for anyone to ever be put into a dangerous situation as the result of another person’s negligence. 

Safety begins by creating a safety culture within your organization. Although monitoring and paying attention to the little details is also important, true safety thinking requires looking at the big picture and considering all of the things that could be potential hazards in the future so that they can be prevented.

For Care Staff and Providers

Most nurses and clinical staff have gone through safety training before, but it never hurts to have a refresher course once a year. Ultimately, it is up to your staff to ensure that they are following all safety protocols and procedures completely to protect themselves and others. 

The main way that administrators can help improve safety in the workplace is by ensuring that nurses and support staff are not overbooked and rushed throughout their day. Schedule them with enough time between appointments so that they can take their time and do things correctly.

For Patients

Patients, or clients, face a number of unique hazards in their homes as a result of their fragile condition. It is the duty of the caregiver and the responsibility of the agency to ensure that these potential hazards are considered and accounted for. Some things to consider are:

1. Environmental hazards – steps, unmanaged cords, lack of proper heating, cooling, or ventilation, etc. 

2. Infection control and sanitation – Ensure that if your patient is at risk of developing bed sores, has open wounds, or any other potential source of infection that the site is cleaned and rebandaged regularly. 

3. Issues that arise from miscommunication – Ensure that backup caregivers are in place in case of emergency callouts or if the family suddenly needs additional assistance.

4. Lack of training and education – If the client’s family is not properly trained on how to care for the client when a caregiver is not present, they could exacerbate the client’s condition or cause unintentional harm to the client. 

5. Lack of continuous health monitoring – For clients with more severe medical conditions, continuous monitoring should be put into place with an emergency alert system. 

At the beginning of each client’s care, when their care plan is being established, a licensed clinician should help perform the initial assessment to determine if any of the above issues need to be addressed. This assessment should be re-performed on a regular basis to ensure that nothing has changed.

Offer Team-Based Care Coordination

With the widespread availability of technology in the healthcare industry there is no excuse for using outdated and inefficient manual methods to collect data and manage care. There are a few things to consider when choosing your software. 

Your agency should be utilizing an integrated scheduling system that tracks time off, PTO, and vacation time, and that has built-in backups in place for unscheduled callouts. This not only saves time and manpower but also provides a seamless care system to ensure that none of your clients are ever left without a caregiver. 

Similarly, there should be at least two nurses, two aides, and an administrator connected to each client’s information. This ensures that there is always someone who knows the care status of the client and also provides multiple avenues that the client’s family can go through for assistance, information, and care updates. 

Finally, the system that you use should be capable of collecting, storing, and organizing data so that it is easily accessible and understandable. This system must also be extremely secure and must follow all HIPPA and government regulations to ensure the protection of sensitive patient information.

Evaluate and Use the Data You Collect

Your agency should use the data that it collects to increase client satisfaction by creating more client-centric strategies. It can also be useful to see how employees are performing, how clients view them, and what can be improved. 

This kind of data collection can also highlight areas in the care experience that can be improved through employee training.

Be Flexible When it Comes to Client Care

Cookie-cutter approaches don’t work when it comes to home health care. Each client is unique and will have their own needs, wants, and desires in addition to the care that they receive for their health conditions. 

Even among health conditions, no two patients will have the exact same level of dependence or care requirements. These care requirements can frequently change throughout their time as a client as well – some may get healthier and become more independent while others require more assistance as time goes on. 

An additional thing to consider is that the needs of the client’s family may change as time goes on as well. Whether they are able to take on more responsibility for their loved one’s care or if they suddenly have to step away from a caregiver role and need more support, your agency must be able and ready to help. 

Having systems and practices in place ahead of time to anticipate clients changing needs is essential to successfully running a thriving home care agency.

Educate Clients

There are few things more empowering than knowledge. Work with your partnered providers to ensure that they are thoroughly educating their patients about their conditions, treatment options, therapies, and medications. 

The better that clients understand their health, the more likely they are to take steps to maintain and improve it. Encourage healthcare providers to offer advice and steps, both big and small, that the client can take to better manage their health. 

This approach can also help to improve the emotional and mental well-being of clients as they will be able to take a more active role in their own care. 

Additionally, if a client is upset with some aspect of their care and it is not a situation that can be changed due to safety or regulatory reasons, explain that to the client. Taking the time to educate your client as to why some things cannot be done differently will be more effective and beneficial for both sides rather than ignoring their concerns.

Advocate For Your Clients

Beyond ensuring that your clients are educated in their care, it is also important to advocate for those who cannot advocate for themselves. Listen to their needs and understand their wants when it comes to their care and treatment options so that you can ensure that they are properly informed. 

By taking the time to get to know your clients by listening to their concerns and connecting and empathizing with them, you will be able to earn their trust. This encourages the clients to be more likely to listen to their caregivers’ recommendations and will help them feel like they are being properly cared for and that their opinions and preferences matter. 

It is also important to train your caregivers and support staff to recognize when clients are unhappy with their care, the staff, the agency, or anything else. Listen to your client’s concerns, apologize when applicable, and take the necessary steps to ensure that their concerns are taken care of. 

Advocating for and educating your clients on their options will help your home care agency stand out from the competition, and it will improve your reputation among both existing and potential clients.

Uber for Healthcare?

Uber for Healthcare?


Wouldn’t you like to be able to order a doctor or nurse on demand, like you can click a few buttons on your Uber app to order a ride wherever you want to go? The on-demand economy meets healthcare delivery. While there are a few companies attempting some variation of this concept, the reality is that healthcare delivery is so much more complex than getting a ride home from the bar on a Saturday night. Getting a “doc on demand” or a “nurse nightingale” at the press of a button is one thing. Why not a proctologist at your fingertips (pun intended), or a pulmonologist in the palm of your hand? But what if Uber tried delivering you the healthcare you get from all those folks who do the hands on work of it, like the medical assistant who takes your blood pressure, records the five extra pounds you didn’t know you gained since the last time you visited the doctor, and gives you the flu vaccine. Or what about the x-ray tech who jokes with you about “protecting the family jewels” as he places that lead blanket over your groin before zapping radiation at it? Or how about the kid who draws your blood at the clinic lab? All of these are allied healthcare workers who provide you the hands on care you need. They work under the direction of and are supervised by a licensed medical practitioner. They are not, of themselves, qualified to, or authorized by any regulatory body to provide any of that to anyone without that direct supervision and control. In short, these are sub-licenced personnel. They are not qualified to be self employed practitioners of radiology, or clinical pathology, or… phlebotomy. And yet, as noted above, there are a few companies attempting to do this. One such recent entrant into this effort at “Uberizing” healthcare is “Get Labs”. While I am a bit surprised they didn’t try to come up with some “uber cool”, silicon valley-esque, reality bending name for the company, I am not surprised by this latest effort. I mean, come on, compared to universe shattering names like “Meta”, and “Alphabet”, “Get Labs” just seems lame. But I digress. This new boy in town, however, is not so new. I mean, the whole idea has been tried – and failed spectacularly. Have you heard of a company called Iggbo? Now, there’s a name to remember! No, you probably don’t recognize that name either. But that’s because they don’t exist anymore. Well, to be clear, the company had to “rebrand” and reinvent itself after only a few years in business. Who & What is Iggbo? Iggbo was formed in 2015 by Shaiv Kapadia, Nuno Valentine, and Mark Van Roekel. The company sold “service connections” to laboratories, practitioners and phlebotomists. They offered phlebotomists who provided blood draws to laboratories and practitioners. But Iggbo, like Uber, was a technology company, not a direct service provider. They did not actually perform the service, they only provided a platform on which transactions could occur between buyer and seller, like when you (buyer) purchase a taxi ride from a taxi driver (seller) through Uber’s mobile app. It’s the same transaction model that Igbbo was using. A Laboratory (buyer) wants to purchase phlebotomy services from a phlebotomist (seller), and Iggbo facilitated that transaction. Seems simple enough, right? But underneath this thin veneer of simplicity is a morass of complexity desperately masquerading as legal. But what makes this transaction model so dangerous for delivery of allied healthcare? Before we examine that question, we need to first take a good look at the context in which this attempt at applying the Uber model to the laboratory industry is occurring. The History of Mobile Phlebotomy – How did we get here? Born from the laboratory testing industry, the mobile phlebotomy industry is relatively new, and yet complex, multifaceted, logistically and technically challenging, and still struggling to define itself. Organizations that seek to engage in the practice of mobile phlebotomy should carefully consider these factors and build a venture upon the laboratory industry’s best practices. While diagnostic innovation has expanded in recent years, thanks to advances in bioscience and technology, industry infrastructure required to facilitate this work has not kept pace. In fact, the laboratory testing industry itself has only just finished a decades long period of consolidation and regulatory maturation. Biotech companies, specifically diagnostic assay developers, wishing to commoditize their testing products, have been hamstrung by a marked lack of partners among established laboratories whose brick and mortar infrastructure can be utilized as product delivery channels. In other words, there aren’t enough local and regional, independent medical testing laboratories left with whom biotech companies can partner to facilitate specimen collection so that they can sell the new diagnostic tests they develop directly to prescribers. The remaining large corporate medical diagnostic reference laboratories, like Quest Diagnostics and Laboratory Corporation of America (LabCorp), now view most diagnostic assay developers as acquisition targets or competitors. In addition, there are many smaller specialty diagnostic laboratories who have resisted and survived the industry consolidation phase of the last few decades. These laboratories have survived in large part to owning some proprietary testing method and/or product(s). But, because these labs don’t have the brick and mortar presence that the big corporate labs do, their growth is largely constrained to targeting only practitioners that perform specimen collection in office, which severely limits their potential customer base. For both of these sectors, attempting to partner with the big corporate labs, or even other local regional outpatient or hospital labs to leverage their outpatient service centers is a little like letting the fox into the hen house. Furthermore, partnering with other laboratories to leverage their brick and mortar puts these companies in a very weak position to control the preanalytical process and ensure quality sample collection as well as quality service delivery. Other labs have zero vested interest in their success, and successful ventures exert control over nearly every aspect of their business. Conversely, direct hiring phlebotomists to perform mobile and on-site work is a highly risky proposition unless the organization is prepared to provide regular full time employment to attract the highest quality candidates, the requisite regulatory training, oversite and direction to ensure compliance, and have the systems necessary to implement, maintain and manage the logistical issues inherent in managing a mobile workforce. And while many biotech companies seem to be flush with investment dollars, it is exceptionally costly to build out a national brick and mortar presence and would require the resources of a fortune 500 company. As such, the mobile phlebotomy industry has emerged in support of these and a variety of other constituencies needing fully outsourced specimen collection solutions. Partnering with an independent, fully outsourced specimen collection organization allows the testing provider to maintain control. They become a direct extension of the testing provider, at a very cost effective price point. Indeed, partnering with an independent specimen collection, processing, and delivery support solution is just plain smart! While modern phlebotomy and indeed, mobile phlebotomy, has been a common medical practice for decades, its evolution as an industry of its own is recent and still maturing. As has been the story with most new industry sectors, the drive for its development is demand based on need. As the saying goes, “necessity is the mother of all invention.” As such, the field’s existing and developing constituencies have been searching for ways to fulfil their respective need for high-quality phlebotomy, specimen collection and delivery. In response, a variety of creative approaches have emerged resulting in a patchwork of solutions but none that serves all the mobile phlebotomy sector’s constituencies well. Enter Iggbo, a technology company proposing to solve this labor supply problem for the constituencies of the nascent mobile phlebotomy industry. But before we get into that, let’s learn a little bit about the mobile phlebotomy industry and the broader laboratory industry to which it belongs. A Niche Field “Mobile phlebotomy” i.e., mobile and on-site specimen collection, processing, and delivery services, is the very definition of a niche business. Many healthcare consumers, even practitioners, have never heard of mobile phlebotomy, let alone that there exist companies that actually specialize in offering such a service. Furthermore, even the industry’s own core customer base (laboratories) seem to be unfamiliar with the general status of the mobile phlebotomy industry and in particular, the legalities of engaging a mobile phlebotomy service. Therefore, consumer and provider education is a critical component of mobile phlebotomy service delivery. The mobile phlebotomy industry is a segment of the laboratory testing industry, but it has its roots in the insurance paramedical exam service. The medical and life insurance industry began to boom in the 80s when employers began offering medical and life insurance plans as a standard part of benefits packages. Actuaries of these insurance companies needed to ensure their growing risk exposure was kept in line with their financial capacity. So, insurance companies began requiring medical exams of certain new applicants. The insurance companies started accruing data sets that enabled them to fine tune their product offerings and prices. Wanting to expand on these successes they began expanding the medical exam requirements to even more applicant demographic groups. However, the cost of a full medical exam by a licensed practitioner prohibited ever increasing screening of applicants. So, a shortened version of a medical exam was created, called a paramedical exam, that could be performed by allied healthcare personnel, instead of licensed practitioners. So today many life insurance and medical insurance screening exams (paramedical exams) are conducted by phlebotomists who are simply collecting basic physical data through a few blood samples, height and weight measurements, and blood pressure readings. A cottage industry of paramedical exams services developed to support the insurance industry’s ever increasing practice of evaluating and screening potential customers. The laboratory testing industry saw a new constituent customer in these insurance companies as testing samples became a common part of insurance paramedical exams. In fact, one laboratory, Quest Diagnostics, was so interested in capturing this growing new revenue stream that it created its own wholly owned paramedical exam subsidiary, called Exam One. Demand and competition in the new paramedical exam business became acute. The new industry was challenged by price pressure and demands to scale nationally (the same as the mobile phlebotomy industry is experiencing now). The larger services began to cobble together networks of contract labor through partnerships with local providers, who also struggled to meet the demand at the price points expected. Thus the job of the contract mobile phlebotomist was born, which facilitated rock bottom labor cost and the easiest path to national coverage. As the life and medical insurance industry has waned in the last decade, these paramedical exams services have failed or consolidated, and desperately began seeking other revenue streams besides the insurance industry, like corporate wellness companies that needed onsite specimen collection support to perform annual employee wellness screenings as a part of a corporate wellness program. This dovetailed into doing specimen collection for specialty medical diagnostic labs who were trying to expand their market reach but didn’t have the brick and mortar presence (a network of patient service center locations) through which to collect samples for lab orders being prescribed by their practitioner clientele. Many of these smaller labs have gleefully and wantonly engaged these insurance paramedical exams services to perform mobile phlebotomy for them, happy to see their market reach expand and revenues soar. In short, everyone began doing it so others assumed the practice must be legitimate and legal. A Highly Fragmented Market As it stands, the delivery of ancillary healthcare services is highly fragmented in general, and this is acutely evident in the mobile phlebotomy sector. Still, the demand for such services from a variety of constituencies is strong and growing at an astounding rate. Most of the companies specializing in mobile medical services operate locally and within an urban geographic area, where consumers are far more likely to have the income to afford to pay out-of-pocket for alternative and convenience-based healthcare providers and concierge services. For this, and a variety of other reasons, at present there are no companies that can provide mobile phlebotomy services on a national scale, who also have an appropriate operating model to provide mobile phlebotomy to all the industry’s constituent customers, specifically medical diagnostics providers. And yet, the industry’s customers are clamoring for just such a solution. As one potential customer told me, “we need to dispatch a phlebotomist, on demand, within 3 to 5 hours, to any location, anywhere in the country.” I frequently find myself explaining to these potential customers, in diplomatic terms, just because you need it, doesn’t mean it exists. The customer demand is certainly far ahead of the industry’s current capacity. It is this demand and the corresponding lack of existing solutions that has enticed the insurance paramedical exams services, and others, to venture into offering medical diagnostic specimen collection as well. And many of the industry’s constituents, lacking a full understanding of the structural issues and legalities of mobile phlebotomy, have been all too eager to rush into partnerships with any organization promising a national scale, without much evaluation of the appropriateness and legality of the service model employed. Financial Realities of the Market So, why then has the market for mobile phlebotomy not yielded any players that have a national reach and an appropriate service model? Comparable industry statistics suggests multiple reasons why the niche mobile phlebotomy sector has yet to produce an organization with nationwide reach and whose operating model can service all the sector’s constituent groups, while complying with all applicable regulations. First and foremost, the industry is still very young and there hasn’t really been sufficient time for truly adequate solutions to develop. Next, mobile phlebotomy service is a small margin business. The reasoning behind this is twofold: First, there are regional economic variations in price point expectations for certain medical services. For example, the price point the market will bear for mobile phlebotomy services in the San Francisco Bay Area is very different than the price point in Oklahoma City. Specifically, the market price point for mobile phlebotomy service nationally across all major metro markets has an estimated 300% variance, yet the labor rate variance for phlebotomy technicians is only 67%. This means that in low price point markets, the wage demand leaves very little margin after labor cost. Second, while the demand for mobile phlebotomy comes from at least ten distinct customer constituency types, this serves as a market strength but a challenge for organizations that offer mobile phlebotomy exclusively or as a part of their suite of services. Culling together enough of this low margin work from these different constituent groups to yield a workable business model is challenging enough but in addition, there are significant regulatory, administrative, and logistical challenges managing the varied needs of each of these distinct constituent groups. For example, managing the administrative and field support needs like scheduling, billing, and client management for individual patients is vastly different than serving a managed care organization like Kaiser Permanente, or a laboratory client like Quest Diagnostics. As a result, many organizations that offer mobile phlebotomy usually just specialize in offering support to one or two different constituent types in just a few concentrated metro markets. However, because most of these organizations take this approach, they struggle to maintain consistent profitability which affects their ability to expand into new markets. The Business of Mobile Phlebotomy Within this sector are two types of organizational models: an employed model and a vendor/contractor model. Organizations that employ the latter model utilize networks of contract technicians, allowing them to claim a relatively large geographic presence and national service capabilities. However, because these organizations utilize contract labor, they cannot exercise direct control and oversight of the technician-contractor’s work by virtue of the technician’s contract status. These specimen collection vendors typically utilize inexperienced technicians who lack practical, real-world experience. This inexperienced, low wage labor is all they can attract because the compensation rates they offer barely meet minimum wage requirements. As a consequence, there is a high degree of turnover, zero institutional memory, and poor customer satisfaction. Under this vendor/contractor model, the trade-off for offering low price points for mobile phlebotomy support are high turnover rates, poor customer satisfaction, and limited ability to provide services to specific customer constituent groups that need or require tight control and oversight, such as medical diagnostic and research specimen collection regulated by CLIA and certain other stricter state regulations. Thus, organizations using this model mainly target and offer support services to the insurance and forensics sectors; they simply cannot offer phlebotomy support for any medical diagnostic specimen collection, processing and delivery purpose by virtue of the technician’s contractor status. The fact that some of these organization do attempt to supplement their primary revenue stream by offering phlebotomy support to medical diagnostic laboratories is a violation of the law, contrary to the CLIA mandates and puts the laboratory’s accreditation at risk. The regulatory requirements for any specimen collection for medical diagnostic purposes demands that the performing entity exercise direct control and oversight over the technician labor, i.e., that the technician be an employee of the organization performing the specimen collection, processing and delivery. The regulatory and certifying entities make a very clear distinction between specimen collection for “screening purposes” (like insurance exams) and specimen collection that can be used for medical diagnostic purposes, including CLIA certified laboratories offering direct to consumer testing services. On the other hand, organizations that actually employ their phlebotomy technicians avoid the disadvantages and arguably unethical practices observed by the vendor/contractor model described above. The employed model allows for direct oversight and control not only of the technician employee but, most significantly, the quality and quantity of work performed by the technician. Under this model, an employer is directly responsible for the work of employee technicians and because of this responsibility, the employer is more likely to invest in the technician’s skill, training and development. This fosters a “team” environment where all employees in the organization, owner, technicians and support staff, each have a vested interest in ensuring that each provide the best service possible to all customers who request mobile phlebotomy and specimen collection services. Also, because of the employee status of the technicians, the organization can service a broader range of customer constituencies, provide a wider range of services and most importantly, comply with all applicable regulatory requirements within a given jurisdiction. The Regulatory History As a prerequisite to understanding why it is important consider the labor model as a critical factor in evaluating the mobile phlebotomy industry, it is necessary to review some of the key turning points that steered the course of the commercial lab industry’s development. On December 5, 1967, the U.S. enacted Public Law 90-174, which included in Section 5 the “Clinical Laboratories Improvement Act of 1967.” CLIA ’67 set regulations on the licensing of clinical laboratories. + By the mid-1980s, however, the relevance of CLIA ’67 to a vastly changed procedural and technological clinical laboratory landscape began to be questioned. In response to public furor about several deaths attributed to false-negative Pap smear readings and a growing awareness among practitioners, regulators, and the general public that there was high variability in laboratory testing, Congress held hearings to investigate.  Congressional hearings revealed serious deficiencies in quality among physician office laboratories and in Pap smear testing. The Office of the Assistant Secretary for Health for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services commissioned a study to assess the effectiveness of federal regulations affecting clinical laboratories and their goal of protecting the public health. On April 8, 1986, the Final Report on Assessment of Clinical Laboratory Regulations by Michael L. Kenney and Don P. Greenberg was submitted to the ASPE.[3] + The analysis found that many federal regulations were technically obsolete and operationally and functionally ineffective. These ineffective regulations had resulted in a growing variability in laboratory testing practices and pervasive incompetence in their performance that had, in some cases, caused harm and even death. On August 5, 1988, a new set of proposed regulations were put forth by the Health Care Financing Administration (now CMS) as Medicare, Medicaid and CLIA Programs; Revision of the Clinical Laboratory Regulations for the Medicare, Medicaid, and Clinical Laboratories Improvement Act of 1967 Programs. This ultimately led to the proposal becoming law on October 31, 1988 under Public Law 100-578 as the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88).[5] Prior to 1988, less than 10% of all clinical laboratories were required to meet quality standards. Approximately 12,000 hospitals and independent laboratories were regulated under the Clinical Laboratory Improvement Act of 1967 (CLIA ’67) and the Medicare and Medicaid programs. Currently, under the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88), all 150,000 clinical laboratories, including physician office laboratories, are regulated to ensure the quality of test results. In the years since implementation, studies have demonstrated that laboratories meeting minimum personnel and quality requirements perform better than those that do not. The CLIA ’88 law is now a bedrock standard providing assurance to the public that access to safe, accurate laboratory testing is available. CLIA and Phlebotomy Even after CLIA passed and was fully implemented, phlebotomy as a procedure remained a relatively unregulated practice. Because, for many decades prior, it was mostly performed by doctors and nurses until the development and growth of the commercial laboratory testing industry. Phlebotomy then started to become the purview of the commercial laboratory employer who needed low cost labor to perform high volume specimen collection (phlebotomy). These “specimen collectors” were mostly given on the job training. It wasn’t until 1998, 10 years after CLIA, passed when a phlebotomist in California was caught reusing butterfly needles that regulators enacted training and certification requirements for phlebotomists. Yes, people sometimes do bad things when they don’t have adequate training and when they know no one is watching – even healthcare providers. So, curricula and training programs were developed nearly overnight and fueled a small boom in allied healthcare career training schools offering phlebotomy training. Soon after, allied healthcare certifying organizations began adding phlebotomy certification to their offerings. Large corporate healthcare employers then began requiring their phlebotomists to be certified by a certifying agency. Over the last few decades, the laboratory industry has become more regulated, the number of clinical laboratories has declined through attrition and consolidation, and the labor pool used in laboratory sciences has changed dramatically in scope of practice and specialty and has shrunk as training requirements and certification requirements were imposed by regulations, and more recently, as it relates to phlebotomy. Iggbo & The Contract Phlebotomist Against this backdrop enters Iggbo, proposing to solve this labor supply problem for the constituencies of the nascent mobile phlebotomy industry by applying the “Uber model”, leveraging technology to provide customers on demand access to a flexible, scalable, lowest cost labor force ready and willing to provide the service desired – the new “sharing economy” meets healthcare delivery. Allison Griswald of is a journalist who follows trends in the “sharing economy”. Interested in Iggbo’s attempt to apply the Uber model to laboratory specimen collection services, she interviewed Iggbo’s CEO, Nuno Valentine. In her article on she writes, “Like Uber, Iggbo is building its business on independent contractors, which is how it hires phlebotomists. The sales pitch to phlebotomists on Iggbo’s website includes “be your own boss” and “build your own future”. Contractors work when they want and are paid, on average, around $20 for each blood draw.” In this article Mr. Valentine is quoted as saying, “We are a technology company, and provide deal flow and processes and so forth for the labor force.” Ms. Griswald writes, “This is also very much like Uber, which as you recall is a technology company, not a taxi company. What a lot of these companies tend to realize too late is that the Uber model doesn’t really fit for them. Sometimes that’s because the service they’re selling is complicated (more so than driving a car), but they can’t really train workers who are contractors, as that’s typically considered indicative of an employer-employee relationship.” “Iggbo will probably realize this too, sooner or later.” Ms. Griswald raises a very good point. And the question is more than worth exploring. Iggbo, Laboratories & The Current Regulations What are the relevant regulations regarding mobile phlebotomy? Does Iggbo’s use of contract phlebotomists comply with these regulations? Can a laboratory even outsource phlebotomy (or for that matter any other workflow)? It is CLIA regulations and a host of other state regulations that provide the answers to these and other very important relevant questions regarding Iggbo. The U.S. Code Title 42 (42USC), section 263a and The Code of Federal Regulations title 42 (42CFR), part 493 codify and implement The Clinical Laboratory Improvement Amendments (CLIA88). The Centers for Medicaid and Medicare Services (CMS), formerly the Healthcare Financing Administration (HCFA), is in part responsible for the administration and enforcement of this law and its ensuing regulations. In addition, various states have implemented additional laws and regulations governing laboratories, laboratory personnel, and phlebotomy specifically. First, let’s establish that the phlebotomist need not be employed by the lab directly. CA DHS Laboratory Field Services guidance on interpretation of the California BPC 1246 and CCR 1034, state that the phlebotomists may work outside of a lab and that the W2 need not originate from the lab (not that the phlebotomist can be an independent contractor, just that they don’t have to be an employee of the lab directly). Furthermore, CLIA regulations allow labs to “outsource” labor. However, all of the relevant regulations state explicitly that regardless whether the lab directly employs the labor or outsources it to another entity who employs the labor, the entity must have the same oversight and compliance structures prescribed by law for labs certified under CLIA. There is no other organizational structure under which a phlebotomist can be employed to perform medical diagnostic specimen collection. Basically it’s either a lab, a “pseudo-lab” (like mobile phlebotomy companies), or a licensed medical provider (like a doctor or medical group), that can employ phlebotomists to perform specimen collection for medical diagnostic testing. There are a lot of reasons for this, but basically it boils down to the fact that the lab (the organization with the CLIA license under which the results are reported), per strict and explicit CLIA regulations, IS ultimately held responsible for the outcome, regardless of who employs the phlebotomist. It is the lab who accepted the specimen for testing. By virtue of accepting that specimen for testing, they are in essence “vouching” for that specimen’s integrity – that it was properly collected, labeled, processed and handled. Section 493.1407(b) states that, “If the laboratory director reapportions performance of his or her responsibilities, he or she remains responsible for ensuring that all duties are properly performed.” So, while it is permissible for the lab director to “reapportion” or outsource some of the laboratory’s duties, it is ultimately still responsible for ensuring the delegated entity or individual(s) perform as prescribed by law. Further emphasizing this point is section 493.1407(c) which states, “The laboratory director must be accessible to the laboratory [meaning all personnel involved in the testing processes] to provide onsite, telephone or electronic consultation as needed.” This requirement even extends to the laboratory’s clients. But, Iggbo’s compliance with 493.1407(c) is questionable at best. It would appear that Iggbo is not concerned with ensuring compliance with 493.1407(c). Based on the information posted on Iggbo’s site for phlebotomists, they’re support hours for phlebotomists are limited to 8am to 6pm EST. But according to this regulation, access to supervision and direction must be made available whenever laboratory personnel are working. What happens when a phlebotomist working in the pacific time zone needs technical direction at 3:30pm PST/6:30pm EST?. Section 493.1407 (e)1, (e)3i, and (e)3iii further emphasize that it is the laboratory’s responsibility to ensure that the personnel and systems used, even in the preanalytic phase, provide the highest quality test result. In essence, these regulations state that because it is the laboratory reporting the test result it is ultimately the lab’s responsibility to ensure that the sample(s) they accept for testing have absolute integrity, regardless of who collects the sample, by specifically ensuring that all personnel involved in the “test procedures”, from sample collection to result reporting, are compliant with all applicable regulations. This means that they must ensure all personnel who come in contact with specimens they test are competent and comply “with all applicable regulations”, and this includes the pre-analytic phase. To put an even finer point on this matter, in the State Operating Manual Appendix C, issued to states to provide more specific interpretive guidelines on the implementation of the regulations, CMS states in section D6004, “The requirement that a laboratory must be under the direction of a qualified person is not automatically met simply because the director meets the education and experience requirements.  It must be demonstrated that the individual is, in fact, providing effective direction over the operation of the laboratory. In determining whether the director responsibilities are met, consider deficiencies found in other conditions, e.g., facility administration, general laboratory systems, preanalytic systems, analytic systems, post-analytic systems, and proficiency testing.” In fact, the meaning and intent of some of these regulations have been adjudicated through administrative hearings. In 1999, Oakland Medical Group, P.C. had its CLIA license revoked by the HCFA (now CMS) for several reasons, but in part for failure to provide the requisite oversight and direction of personnel responsible for laboratory processes on specimens it tested. In its appeal to the Department of Health and Human Services Appellate Division Appeals Board, Oakland Medical Group attempted to argue it was not in material breach of the regulation because the CLIA regulations refer to the requirement to control “employees” of the laboratory and the personnel in question was a contractor. The administrative law judge ruled that the employment status of individuals authorized by the laboratory is immaterial as 42CRF 493.1445 specifically provides that delegation of duties and responsibilities of the laboratory does not relieve the laboratory of the responsibility for their proper performance. As noted already, CLIA regulations even require laboratories to provide technical direction, instruction, and assistance to the laboratory’s own clients who might collect their own patients’ specimens and then submit them to the laboratory for testing. The regulations were clearly written with the assumption and implication that the preanalytical phase would be performed by trained personnel under the laboratory’s control or by the laboratory’s clients – who are assumed to be competent to perform or oversee the performance of procedures outlined by the laboratory for collection, processing and handling of specimens intended for the lab to test – medically licensed personnel. And while phlebotomists can now be certified, certification is not a medical license, and certification is certainly not a substitute for proper training, oversight, and direction. Because there are, as yet no national standards – no national licensing standards for phlebotomists, it is wholly inappropriate to rely on certification as evidence of a phlebotomist’s capacity to be self-governing – autonomous, as if they were licensed practitioners like nurses and doctors. So, the question becomes, from whom should the laboratory accept specimens for testing if the laboratory is ultimately to be made responsible for the outcome? Arguably, any straight forward reading of the regulations means that who is “authorized” and “under the laboratory’s control” is anyone from whom the lab accepts a specimen for testing – by default, whether intended or not. At minimum, prudence would dictate then that, the lab should only allow for specimens to be collected by and accepted from either 1) the lab’s own clients (medically licensed practitioners authorized to prescribe testing), or 2) personnel determined by the laboratory to be appropriate, trained, competent, and monitored by the specific required oversight architecture prescribed by CLIA for any personnel involved in the testing process of specimens accepted by the laboratory. In simplest terms, the lab is permitted to outsource but the outsourcing must still meet the same regulatory requirements the lab is required to adhere to because the lab will still be held responsible for the outcome. Meaning that anyone the lab hires to perform any part of the testing process (phlebotomy included) is required have the exact same CLIA prescribed oversight structure, to assure the integrity of all specimens the lab accepts. Next, some of the laboratory’s most overarching obligations as prescribed by these regulations are embodied within the obligations and duties of the laboratory director. For example, 42CFR 493.1407 specifies that the laboratory director’s responsibility is to ensure “…the employment of personnel competent to perform test procedures [this includes phlebotomy], …and for ensuring compliance with the applicable regulations.” (13) Ensure that an approved procedure manual is available to all personnel responsible for any aspect of the testing process; and (14) Specify, in writing, the responsibilities and duties of each consultant and each person, engaged in the performance of the preanalytic, …phases of testing.” Since Iggbo is not the laboratory, it is important to know if Iggbo provides oversight by a laboratory director, as required by law. Or do they expect their laboratory clients’ lab directors to provide Iggbo phlebotomists with the required oversight? If the later, are their contractor phlebotomists supposed to be taking training, oversight and direction from each and every laboratory client separately; does each phlebotomist have as many “bosses” as Iggbo has lab clients? From the information on Iggbo’s site, it allows labs to make the decision with regard to if and how much “training” and oversight the client lab exerts over phlebotomists it “authorizes” to perform sample collection for them through Iggbo. + So, while some labs may require some training, others may not require any. This would potentially mean that labs that required training – those that are exerting some measure of control over the phlebotomist, could be exposed to legal liability for the performance of work the phlebotomist does for other labs that exert no control. Regardless what the truth is about Iggbo’s “authorization” scheme, phlebotomists performing specimen collection for a medical lab, must have ongoing, active supervision by someone qualified to be a CLIA licensed laboratory director. + Subsection (e)(12) requires the laboratory to do the following, “Ensure that policies and procedures are established for monitoring individuals who conduct preanalytical… phases of testing to assure that they are competent and maintain their competency; Does Iggbo or do Iggbo client labs have a compliance monitoring program to provide ongoing proactive monitoring of Iggbo contractor phlebotomists? So, then what would a compliant organizational structure for a mobile phlebotomy company look like? In separate legal opinions written to provide certain mobile phlebotomy companies guidance on the proper formation and operation of a phlebotomy service, attorneys Kevin Keener and Anaheeta Kohla, having reviewed all applicable laws and regulations, outline the specific applications of law and succinctly summarize the regulatory obligations a mobile phlebotomy company bears: [Kevin Keener, JD] “The corporation’s structure and performance of phlebotomy must meet the requirements and guidelines established under law. Specifically and most importantly, the corporation must have implemented the proper review of its technicians through the hiring of a medical director qualified per the applicable regulations. The “general supervision” requirements of technicians are specified by CBP Section 1246 (c)(2)(B). The supervision requirements are also mirrored in 17 CCR § 1034(b)(2)(B) and (C). These provisions require the medical director to ensure that the technicians are competent to perform draws initially and at least annually thereafter. The supervisor must also review the work of each technician on a monthly basis. The corporation must have hired a medical director to oversee the performance of these tasks in order to be in compliance with the supervision requirements of the law. The supervisor must be available to where the technician is working to provide a consultation either in person, via telephone, or via electronic means within thirty minutes. See CBP Code Section 1246(c)(2)(B). Only this structure, whereby the medical director [or their qualified designate] is available to a technician either in person, via telephone, or via electronic means within thirty minutes is thus in compliance with the law.” [Anaheta Kohla, JD]; “Pursuant to CLIA’s pre-analytic systems, §§493.1240-1249, Corporation’s conducting only pre-analytic systems of specimen collection, transport and processing are regulated by CLIA. In performing this function, the Corporation must have verifiable written/electronic policies and procedures as prescribed by CLIA of any diagnostic laboratory. Further, the Corporation must have a compliance system in place for any test request that documents the patient’s name/unique identifier, sex and age or date of birth, the test(s) to be performed, the source of the specimen, the date and time of specimen collection, all additional information that is relevant and necessary for a specific test to make sure that accuracy and timely testing are met for the reporting of results by the receiving laboratory. Also, pursuant to CLIA §493.1249, the Corporation must assist its contracting laboratories to remain in compliance themselves, because the Corporation has an obligation under law to have written policies and procedures for monitoring, assessing and (if warranted) correcting identified problems in the pre-analytic system. The Corporation must conduct its own assessment procedures by reviewing the effectiveness of corrective actions in order to resolve problems, to revise policies and procedures continuously and systematically, to achieve legal and ethical standards, to prevent new problems and to report all findings to the contracting laboratories. Moreover, corporations operating in states like California are subject to regulations such as 17 CCR 1034, California Business and Professions Code §1209 and §1246, California Health and Safety Code §§120580, 120900-120920, and California Civil Jury Instructions (CACI) 600, the Corporation must be in compliance with the required phlebotomists’ certification, training, and education, and with oversight by a contracted Medical Director(s) for the maintenance of the legal standard of  care while drawing blood or collecting specimens from patients for delivery to the contracting laboratory.” “Concurrently, the Corporation and contracting laboratories must have open lines of communication in which they facilitate the transfer of vital information for the compliance of the ancillary phlebotomy service; the Corporation must be able to demonstrate the successful implementation of its delegated authority to achieve said compliance. Further, the Corporation must conduct a diligent application of quality control to monitor their phlebotomists’ education, training, licensing, accreditation, professional continuing education, patient interaction and communication skills training and legal standard of care education, to fully demonstrate that the Corporation is proficient at taking on delegated authority by the contracting laboratory to ensure compliance of its phlebotomy and specimen delivery service.” Fundamentally, the regulations relevant to phlebotomy are implicit in all regulations related to the laboratory’s responsibility to have, monitor, and maintain specific personnel, procedures and systems to ensure the integrity and accuracy of the specimen and its collection, processing, transport, testing, and results reporting. If the lab outsources the pre-analytical process, it also outsources the compliance structure required by CLIA of the pre-analytical systems. The bottom line is this, although 42CFR – CLIA Amendments don’t prohibit the use of contract phlebotomists in explicit terms, they do prohibit the use of contract phlebotomists by virtue of the type and extent of oversight and control required to be compliant with the law. In short, CLIA oversight requirements cannot be fulfilled through a contractor relationship, as is defined by the IRS. Iggbo vs. CLIA & the IRS Let’s briefly review who the IRS considers “a contractor”. As taken directly from the IRS website: “The general rule is that an individual is an independent contractor if the payer has the right to control or direct only the result of the work and not what will be done and how it will be done. You are not an independent contractor if you perform services that can be controlled by an employer (what will be done and how it will be done). This applies even if you are given freedom of action. What matters is that the employer has the legal right to control the details of how the services are performed.” There are three types of evaluations that can and should be done to evaluate if an individual is an employee or a contractor: the common law test, the economic reality test, and the reasonable basis test. The Common Law Test The IRS uses a 20 factor test to determine if labor is classified as an employee or a contractor. This is referred to as the “Common Law Test”. The IRS common law test factors that specifically apply to Iggbo’s use of contractor phlebotomists are listed below: • Level of instruction: If the company directs when, where, and how work is done, this control indicates a possible employment relationship. As evidenced by statements obtained from the Iggbo website, Iggbo and/or Iggbo client labs are clearly providing a level of “instruction” and direction characteristic of an employment relationship. And if they aren’t, they should be, because that is the nature of the oversight compliance required by CLIA. • Amount of training: Requesting workers to undergo company-provided training suggests an employment relationship since the company is directing the methods by which work is accomplished. Again, according to statements made by Iggbo representatives and information on Iggbo’s website, Iggbo and Iggbo client labs both require specific training as a prerequisite to any work assignments. • Degree of business integration: Workers whose services are integrated into business operations or significantly affect business success are likely to be considered employees. Remember that the workflow in laboratory services are divided into three phases: pre-analytical, analytical, and post-analytical. Iggbo, sells labs the labor to perform the pre-analytical process. That work, is absolutely integral – it is key to the operation and success of the laboratory’s business. • Extent of personal services: Companies that insist on a particular person performing the work assert a degree of control that suggests an employment relationship. In contrast, independent contractors typically are free to assign work to anyone. Iggbo client labs engage specific phlebotomists to perform their specimen collection services by authorizing certain phlebotomists and not others. Furthermore, Iggbo permits their lab clients to set what they call “preferences” so that assignments will only go to certain pre-selected phlebotomists. • Continuity of relationship: A continuous relationship between a company and a worker indicates a possible employment relationship. Through this screening, selection and rating system, Iggbo and Iggbo client labs develop a dedicated workforce of phlebotomists working exclusively through Iggbo for Iggbo client labs. It is very clear that a long term, on going relationship is established between Iggbo lab clients and the phlebotomists performing their specimen collection. And we might argue this is exactly what you want in this type of work. You want a dedicated workforce where churn and turnover are kept to a bare minimum so that the personnel develop expertise and builds institutional memory. • Sequence of work: If a company requires work to be performed in specific order or sequence, this control suggests an employment relationship. The very nature of laboratory work requires a specific sequence in the performance of the work. Furthermore, laboratories often have specimen collection, processing and handling requirements that are developed as a part of a protocol unique to that labs performance of certain types of testing. • Provision of tools and materials: Workers who perform most of their work using company-provided equipment, tools, and materials are more likely to be considered employees. Although Iggbo states that their phlebotomists are responsible for procuring and maintaining a centrifuge and phlebotomy supplies, this is contrary to CLIA regulations and accepted standards. The laboratory must have and maintain specific protocols with regard to all equipment and supplies used in the performance of specimen collection for any test on their test menu. The equipment must be regularly tested and maintained and the testing and maintenance recorded in a log. The supplies have storage and use requirements as well as expiration dates. The lab must have evidence that the supplies were stored and used properly and a procedure to ensure that expired supplies aren’t used in the performance of specimen collection for any test. For this reason, many lab clients provide the phlebotomist equipment and supplies – and this creates an employment relationship. • Availability to public: If a worker regularly makes services available to the general public, this supports an independent contractor determination. As we have noted previously, phlebotomists are not licensed medical providers. They cannot offer phlebotomy directly to the public in the same way a physician can offer medical care. • Control over discharge: A company’s unilateral right to discharge a worker suggests an employment relationship. In contrast, a company’s ability to terminate independent contractor relationships generally depends on contract terms. Iggbo does not allow phlebotomists to negotiate any terms of their contract. The terms that Iggbo requires are very one sided by permitting Iggbo to take overarching unilateral actions without any recourse to the phlebotomist. • Right of termination: Most employees unilaterally can terminate their work for a company without liability. Independent contractors cannot terminate services without liability, except as allowed under their contracts. The Iggbo phlebotomist contract also provides for unilateral termination without liability for both parties – which is essentially the characteristic of an employment relationship. Economic Reality Test Court decisions interpreting FLSA coverage rules require that employers use an economic reality test in determining whether an employment relationship exists with respect to a given worker. Similar to the common law test, the economic reality test focuses on the degree of control exercised by the employer as an essential factor in determining whether an employer-employee relationship exists. Reasonable Basis Test While the common law test looks at the nature of the working relationship, the reasonable basis test is based on how the courts and the IRS have classified similar workers in the company or the industry in the past. The reasonable basis test is considered a “safe harbor.” That is, if you can show you had a reasonable basis for treating a worker as an independent contractor, you may not be penalized for doing so. For example, a court ruling in favor of treating workers in similar circumstances as non-employees, or a longstanding, widely recognized practice in an industry of treating similar workers as independent contractors. In fact, the reasonable basis test provides evidence contrary to any industry support for the use of contract phlebotomists. Even Quest Diagnostics subsidiary, Exam One, recently began to abandon its use of contractor phlebotomists for staffing corporate wellness events among other types of work. Iggbo Phlebotomists – Contractor or Employee? The Laboratory – Iggbo – Phlebotomist relationship fail significant components of all of these tests. Mr. Valentine asserts that Iggbo provides phlebotomists instructions and monitors performance. But as Ms. Griswald writes, these policies, “…could be viewed as employer like, and threaten its independent contractor model. Again, whether or not a company provides training for their workers is viewed as an important test of whether those workers are “employees.” Mr. Valentine’s response is telling… again, Ms. Griswald writes, “Valentine says Iggbo doesn’t provide …training”, but it does provide “information” to workers on how to draw, package, and send blood tests to labs.” However, on Iggbo’s website “training” was referenced several times in relation to phlebotomists and compliance. So was Iggbo claiming to provide just “information” or was it “training” its phlebotomists? More importantly, is either sufficient to be compliant with all applicable laws and regulations relevant to the pre-analytical process? It would appear that Iggbo was desperately attempting to thread the needle on both compliance with the CLIA regulations and compliance with IRS labor classification rules. Claiming to provide enough training and oversight to be compliant, but not too much so as to run afoul of the IRS rules on employment classification? To me this sounds all too much like wanting your cake and eating it too. It’s like talking out of both sides of your mouth while trying not to appear duplicitous. By having labs “authorize” each technician, with an option to provide the technician with one time “training” and/or “documents”, it would seem they are trying to absolve themselves of compliance responsibility. But this still begs the question, is this initial “training” or transmittal of some policy document sufficient to comply with the requirements of ongoing oversight and direction? Furthermore, does this conflict with the contractor status of the technician – would it be considered an employer-employee relationship being established? So my fundamental point is still valid, that they can’t have it both ways. They (and/or their lab clients, more precisely) cannot claim to fully comply with contract phlebotomist labor. Either they are providing full compliance – which necessitates an employer-employee relationship OR they have contractors and therefore are not providing complete oversight and direction. Iggbo was stating the phlebotomist is responsible for compliance, but the law says the lab is responsible. Iggbo does have to frame it this way because to say otherwise would clearly require an employer-employee relationship. The fact of the matter is that to be fully compliant with CLIA and other state laws is plainly incompatible with the very characteristics that make a contractor, a contractor. Iggbo & HIPAA Iggbo exercised zero control over the use, handling and retention of legally protect personal health information handled by their phlebotomists. Iggbo instructed phlebotomists to “retain records” but apparently provided no method for securing protected health information and no guidance, policies and procedures to ensure its contractor technicians were compliant with HIPAA. And yet, it is the laboratory who will be held responsible for any security breach and unauthorized release of personal health information. Most phlebotomy technicians are ignorant of the complexities involved in compliance with HIPAA and the HIPAA HITECH security laws. It is incredulous that Iggbo would treat HIPAA compliance so casually as to foist off HIPAA compliance responsibility to low wage technician level labor. Iggbo & OSHA OSHA standard 1910.1030 regulates the prevention of exposure to blood borne pathogens such has Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV). OSHA requires an organization engaging in any business activity where there is potential for exposure to blood borne pathogens, hazardous chemicals or any other injury risk to provide certain work practice controls to ensure worker and public safety and health. Organizations should demonstrate commitment to ensuring the safety of their employees by providing training on blood borne pathogen exposure prevention as well as the provision of equipment that will assist in the prevention of Blood Bone Pathogen Exposure. There is a very high risk of exposure to blood home pathogens in laboratory services, especially phlebotomy. The incidence of needle stick injury and blood borne pathogen exposure in laboratory services is ??? As such, universal precautions must be practiced by all laboratory personnel. This means treating all specimens as potentially infectious. All supervisors and management staff are responsible for ensuring that all personnel are complying with universal precautions and that employees not following universal precautions are subject to disciplinary action. Needle-sticks are a real concern for all people performing phlebotomy. Utilizing proper technique and physical work place controls such as needles with safety devices helps to avoid these occurrences. However, since Iggbo uses a contactor model of employment, they do not provide any such support, guidance, training, oversight, supervision and monitoring of adherence to the OSHA standards and regulations. If a needle-stick occurs to either the patient or the phlebotomist, there is no one to contact, no one taking responsibility, no support or guidance for either the phlebotomist or the patient. There is no company paid medical provider to evaluate and treat the possible exposure. This is not just a workplace hazard to contract technicians, this is a public health and safety risk without any remediation provided by Iggbo. All healthcare provider organizations are required to have an Infection Control Policy to ensure technician safety and protect public health. Iggbo has no procedures to prevent and minimize public health risks – the spread of disease, etc. when a technician is entering many different homes of individuals who may be infirmed, have weakened immune systems, etc. In addition, biohazardous materials waste (the used needles and bloody gauze, etc.) must be disposed of properly as required by regulations. The waste materials generated from phlebotomy must be disposed of through a licensed medical waste disposal company. Those companies typically contract with medical provider organizations and licensed medical personnel, not individual phlebotomists. Iggbo does not provide medical waste disposal contracts for its phlebotomists, and state on the Iggbo website that phlebotomists are responsible for medical waste disposal. This is contrary to the regulations and accepted standards of practice, and presents yet another risk to public health and safety as it is highly likely that this medical waste is not being disposed of correctly. Furthermore, The Federal Transportation Safety Administration also has regulations governing the handling and transport of any biohazardous or potentially infectious material. These are:
  • The Hazardous Materials Transportation Act of 1975 (HMTA), 49 CFR Parts, 101, 106-107, and 171-180.
    • HMTA, section 112, 40 U.S.C. 1811 preempts state and local government requirements that are inconsistent with the statute, unless that requirement affords equal or greater levels of protection to the public than the HMTA requirement.
  • The Hazardous Materials Transportation Uniform Safety Act of 1990 (HMTUSA) (intrastate, interstate and foreign commerce, 55 FR 52402).
Iggbo provides no training or guidance, no supervision or monitoring to ensure compliance with these laws and regulations. Lastly, Iggbo contractor phlebotomists are bearing the burden of the financial risk of injury. Because Iggbo phlebotomists are contractors, not employees, they are provided no workers compensation protections. Summary Iggbo used contractors for medical diagnostic specimen collection. Contract relationships of laboratory to individual phlebotomist do not meet the CLIA oversight compliance requirements. The employment relationships created by Iggbo were not contractor relationships by the IRS definition. Iggbo had no control over HIPPA protected personal health information used by the contractor phlebotomists in the field. And Iggbo provides no OSHA compliance to protect the safety of its workers or to protect the public health. Ergo, their model was non-compliant and therefore illegal. Iggbo may have been a new company, but the concept is not new and its operating model is based on one that has already been tried in the lab industry and consistently fails to meet customer expectations, let alone satisfy regulatory requirements. The concept of Iggbo is even more egregious than paramedical exam companies using contract labor to perform medical diagnostic sample collection because Iggbo doesn’t even claim to have any vested interest in the labor performing the draw. Per their own testimony, they were only a technology company facilitating “deal flow” between labs and independent contract phlebotomists. This is not by any measure an acceptable model for the performance of laboratory processes. This is the kind of wild west, outlaw dynamic the CLIA law and its regulations were intended to prevent. The Uber model may be able to quickly solve a labor supply problem, but that does not mean it’s best applied to all scenarios where such challenges exist. If ever there was a case study demonstrating this fact, it is Iggbo utilizing “contract labor” to perform highly regulated, high risk, medical diagnostic specimen collection, processing, and delivery services. Laboratories utilizing Iggbo style services, whether offered by Get Labs, or any other similar service, should be aware they are putting their licensing in grave jeopardy. Let me state it clearly, laboratory directors will be held liable for any and all actions of phlebotomists utilized through these vendor-contractor service models. If your lab is going to be held responsible, wouldn’t you rather have the assurance that the labor performing your processes are employees of a company exercising direct control and oversight? The laboratory testing industry tends to focus on control of the testing phase, and much of the emphasis of the regulations is indeed centered on controlling the testing, but we would be remiss to forget that a properly controlled pre-analytical process is prerequisite to a valid test result. Consider the following, the greatest number of errors in laboratory testing occur in the pre-analytic phase. And the greatest number of complaints received by CMS and from the CA DHS LFS Division are related to independent mobile phlebotomists performing uncontrolled and unsupervised phlebotomy as contractors. As such, many states are now implementing more rigorous regulations governing laboratory testing and laboratory personnel. California, New York, and others now explicitly prohibit phlebotomists from working independently to perform medical diagnostic sample collection. As an example, The California Department of Health, Laboratory Field Services Division enforces the state laboratory laws, CA BPC 1246 and CCR Title 17, section 1034. These regulations require medical diagnostic specimens to be collected by phlebotomists that are specifically employed by an entity that provides, among other things, training, oversight, and direction. The same training, oversight, and direction as required by laboratories for their own personnel. And so, many states have now codified in explicit terms what CLIA clearly implies with regard to the outsourcing of labor and the use of contract phlebotomy technicians. But even where states don’t prescribe specific rules or regulations on phlebotomist training, certification, and scope of practice, they of course must still adhere to the explicit and implicit mandates imposed by CLIA. The primary purpose of which, as we all know, is to ensure that the diagnostic data that is used to make life and death decisions is as close to error free as humanly and technically possible. And yet, still, errors in laboratory testing occur and the industry seems to have a penchant for circumventing the law to achieve financial gains. For this reason, the trend in laboratory medicine has been toward more controls and regulation, not less, as many states have done already. Healthcare, The Contractor & The Sharing Economy Look, even if it were legal, we need to ask ourselves, is it smart? Is this good healthcare? What does “the sharing economy” have to offer healthcare? A recent study and report by PBS provides some very useful insights into the dynamics at play in this new “sharing economy” model. “Imagine that you made $20,000 last year. In addition, you experienced high income variability in which one week you earned $60 and, another week, you received $800. To add to this complexity, imagine that your taxes were not automatically withdrawn from each paycheck. Instead, you were responsible for calculating the amount you owe in taxes and paying those taxes on a quarterly basis. “1) Close to two-thirds of contractors are contracting as a side gig. Only 36 percent are full-time independent contractors. The vast majority of independent contractors are contracting on a part-time basis. Over 64 percent were either full-time or part-time employees, students or retired employees. This finding runs counter to the common assumption that most contractors rely solely on their contracting income.” 2) Most contractors are just starting out. “In our study, over 72 percent of workers were contracting for one year or less. Not only are these new contractors forced to learn how to master a new skill, they are also thrusted into a complex tax environment with relatively little experience.” “3) Being an independent contractor often means variable pay. The median income for full-time contractors in 2015 was $20,000 — below the median personal income of $28,851. For those contracting part time, the median contracting income was just $7,000. Our survey participants experienced a 10 times differential between their largest paycheck and their smallest paycheck in 2015, suggesting large income variability throughout the year. Would you be able to actively manage all of your expenses? Would you be able to properly save? For most of us, the answer is no. This is the challenging reality for most independent contractors. In the last decade, independent contracting accounted for almost all net U.S. job growth. Yet, the research community knows very little about the financial lives of these independent contractors.” So, now imagine these are the individuals providing you healthcare. Would you be a little hesitant, even a little afraid? We have seen too many examples of the consequences of unregulated markets engaged in high risk activities. We have seen the result of entities and individuals attempting to thwart regulations or push the boundaries of acceptable practices. Just recently a laboratory company called Theranos drew the attention of regulators, and received fierce criticism from its peers in the lab industry when it was caught utilizing questionable testing practices. The point being that the industry and its regulators do not take kindly to secrecy and risky behavior. And rightly so, we are literally dealing with peoples’ lives. This should be a clarion call – a cautionary tale to the industry, if a tech company comes alone promising “disruptive change” and “revolution”, be skeptical! While I certainly understand that for profit businesses have a need to maximize revenue and minimize costs, we must recognize that this instinct will always be in conflict with core tenets of good healthcare, transparency and best practices. And in the science of laboratory medicine in particular, there is no place for practices that “pretend” to be good patient care, like children “playing doctor”, just because it makes for good profits. Iggbo was desperately trying to thread the needle on these regulations in order to force the creation of a model of healthcare delivery that maximizes profit at the cost of worker and public health and safety – fortunately they failed at the attempt. But now Get Labs is trying it all over again.  These laws and regulations were developed to improve patient care and protect public health and safety, because people got hurt and died as a direct result of uncontrolled, non-standardized healthcare practices. The Solution – A Practical and Legal Framework So what is the solution then? What would a practical and legal framework for meeting the industry’s constituent needs look like? Organizations looking to engage in the performance of mobile phlebotomy ought to establish themselves in the niche mobile phlebotomy and specimen collection market by building an organization with a fierce dedication to quality, dependable services, built on the best practices of the more experienced broader laboratory industry. Doing so will attract a wide-range of customer constituencies yearning for freedom from the constraints of the laboratory industry’s brick and mortar bond holders. Doing so will establish a brand identity with a reputation for providing superior service and will attract a stable contractual service clientele including large institutional clients. Doing so will facilitate diagnostic care by providing practitioners and their patients with a link to medical diagnostic and research testing providers by helping laboratories, practitioners and patients successfully overcome the structural barriers to diagnostic utilization wherever and whenever they exist. I firmly believe that the industry needs a new model for delivery of diagnostic care. But we must do so carefully, with deliberation and attention to best practices that first and foremost result in reliable and effective patient centered care. The laboratory industry needs to develop partnerships with exceptional providers to provide in-home and in-office specimen collection support solutions. Demonstrating our commitment to partnerships that emphasize and enhance the delivery of patient centered care, produces good will among practitioners and patients in the communities we serve, and shows your organization to be at the forefront of a customer service culture in healthcare, as well as a leader and innovator in diagnostics. There’s lots of small “mom & pop” mobile phlebotomy shops all over the country with years of experience and dedicated to their customers. Sure, on their own, these are not venture worthy partners. However, if they’re part of a larger organization that can provide them support, oversight, compliance, training, and logistics, then they might be made ready for prime time. One of the organizations that is beginning to do this is The National Phlebotomy Provider Network, an industry organization that provides an infrastructure for compliance, oversight, training, logistics and other support to its members. Its evidence that there are responsible members of the industry, and that it is trying to begin establishing standards and best practices on which an orderly consolidation can occur, that is both beneficial to the industry players, acceptable to risk averse clients and industry regulators, and safe for patient’s. Because this is a very young industry and as such it is still highly fragmented, consolidation is inevitable, and an organization with national scale is only a matter of time. The same thing happened with the home healthcare industry on the late 90s. There was a proliferation of small boutique home health agencies and they eventually got gobbled up by corporations that consolidated the industry. The same thing will happen to mobile phlebotomy, but I’d put my bets on those companies that are demonstrating leadership and innovation in this sector, not just any contractor or fly by night tech company trying to cash in on a boom, willing to make big promises and tell you what you want to hear. References & Citations CMS State Operations Manual CDC CLIA Chronology PBS News Article Lims Wiki – CLIA History

Warfarin Diet: 23+ Foods To Avoid When Taking Warfarin or Blood Thinners like Coumadin or Jantoven

People who use blood thinners have to constantly watch their Vitamin K intake due to how this vitamin interacts with blood thinning medication. This nutritional obstacle becomes even more difficult because Vitamin K levels are not required to appear on food labels.

How does Vitamin K work in the body?

Leafy Green To Avoid On A Warfarin Diet

Vitamin K is a fat-soluble vitamin that comes in two forms. The main type is called phylloquinone, found in green leafy vegetables like collard greens, kale, and spinach. The other type, menaquinones, are found in some animal foods and fermented foods. Vitamin K is important as it helps to make various proteins that are needed for blood clotting and the building of bones throughout the body. Prothrombin is a vitamin K-dependent protein directly involved with blood clotting. Osteocalcin is another protein that requires vitamin K to produce healthy bone tissue (

Vitamin K

Warfarin works by disrupting the role of vitamin K in a complex series of molecular events that cause blood clotting. But vitamin K is a nutrient essential for heart and bone health (Mayo Clinic). You and your doctor should keep an eye out for how much vitamin K you are and have consumed. It’s all about consistency about how much vitamin K you should consume daily. The “Warfarin Diet” or the “Coumadin diet” is all about taking a consistent amount of Vitamin K. Medical professionals recommend that adult men should take 120 micrograms (mcg) while adult women should intake 90 mcg of Vitamin K. Foods that contain more than 60 mcg per serving should be avoided in large portions.

23+ Foods To Avoid When Taking Warfarin or Blood Thinners like Coumadin or Jantoven?

There are so many foods to avoid when on blood thinners. Specifically, these foods can inhibit the effectiveness of the drugs, putting the patients at risk for bleeding and other complications.

Both men and women should avoid large amounts of the below foods (Mayo Clinic):

  • Amaranth leaves – These leaves are a good source of calcium with 275 MG, but carry too much vitamin K, 66% of your daily intake.
  • Asparagus – Is a healthy vegetable that’s also a good source of fiber. Talk to any diet or nutrition coach and they might encourage you to eat asparagus as part of your fitness regime. Unfortunately, Asparagus has 55% of the recommended daily dose of Vitamin K.
  • Broccoli – Is a great source of vitamin C (35mg) but contains too much vitamin K when you are taking Warfarin, around 64% of a person’s daily Vitamin K dose.
  • Brussels sprouts – These powerful foods are high in vitamin C, an antioxidant that helps promote iron absorption and is involved in tissue repair and immune function.  But it has 137% of your daily vitamin K requirement, which is too much for people who are taking blood thinners.
  • Coleslaw – Most traditional creamy coleslaw dressing is made with high fat ingredients like mayo and has sugar added too, which in small doses can be good for you. However, coleslaw has over 100% + of your daily intake of Vitamin K, which is too much.
  • Canned beef stroganoff soup – Overall canned beef stroganoff soup has your daily intake of Folate, but over 206% over your daily intake of Vitamin K.  This food should be avoided if you are taking blood thinners.
  • Endive – This vegetable is low in calories and may enhance digestion but it has too much Vitamin K over 100% of your daily intake.
  • Garden cress – With a little bit of fiber and a good amount of Vitamin C, this vegetable is healthy for you. Unfortunately, this vegetable has 106% of your Vitamin K intake.
  • Kale – This vegetable offers benefits for the entire body. But, for people who are taking blood thinners, it shouldn’t be consumed as it has 4 times the amount of Vitamin K for your daily amount.
  • Kiwifruit – Kiwi provides small amounts of Vitamin A, Iron and Folate. But, it contains too much Vitamin K, around 22% of the daily recommended intake.
  • Lettuce – with just a small amount of fat and a decent amount of fiber, lettuce provides many health benefits. For people who are on Warfarin, they should not consume lettuce. It contains 84% of a person’s daily intake of Vitamin K.
  • Mustard greens – These tasty veggies are considered a very low-calorie food that provides your body with energy primarily in the form of complex carbohydrates. But it has 46% of a person’s daily intake of Vitamin K. Too much for someone who is taking blood thinners.
  • Soybeans – These beans are a great source of protein but have too much Vitamin K, over 35% of a person’s daily intake.
  • Swiss chard – Is a leafy green vegetable that has a high source of iron but contains too much Vitamin K for someone who is taking blood thinners – over 100% of a person’s daily intake.
  • Tuna fish in oil – Depending on how it’s prepared, it can contain over 22% of a person’s daily intake of Vitamin K.
  • Vegetable drinks – Depending on which vegetables are included in these drinks will determine how much Vitamin K will be consumed. Most of the drinks that are prepared have too much Vitamin K for someone who is taking Warfarin.
  • Spinach – Is a great food source for iron, but it contains too much vitamin K. It has over 400% more than a person’s daily intake.
  • Collards – Collard greens are rich in antioxidants that neutralize free radicals and may help reduce your risk of developing certain cancers, but they contain 7x times the amount of Vitamin K a person should consume daily. Too much for someone on blood thinners.
  • Turnip greens – These vegetables are over 100% of a person’s daily Vitamin K intake.
  • Beet greens – beet greens as a very good source of iron, providing 15% of the daily recommended amount in a 1-cup serving. These greens contain 3X times the amount of Vitamin K. Too much for people who are taking blood thinners.
  • Dandelion greens – Because the potassium in dandelions may impact blood flow and clotting, it’s best to avoid anything with dandelions.

A stable diet, containing around 60 to 80 mcg of vitamin K is desirable. Below are the foods that have small amounts of Vitamin K. And can be safe if eaten under the supervision of a doctor (all of these foods have small amounts of Vitamin K, Fruits and Veggies):

  • Egg yolk
  • Canola oils – 10 micrograms
  • Cucumber – 9 micrograms
  • Some nuts – (except pine nuts and cashews)
  • Turnips (raw or cooked) — 0.1 micrograms
  • Beets (raw or cooked) — 0.3 micrograms
  • Sweet Corn (raw or cooked) — 0.5 micrograms
  • Onion (raw or cooked) — 1 microgram per 1 medium onion
  • Rutabagas (raw or cooked) — 0.5 micrograms
  • Pumpkin (cooked) — 2 micrograms
  • Winter squash(cooked) — 2 micrograms
  • Summer squash (cooked) — 3 micrograms
  • Eggplants (cooked) — 3 micrograms
  • Bamboo shoots (raw or canned) — 0 micrograms
  • Mushrooms (raw or cooked) — 0 micrograms
  • Tomatoes (cooked) — 7 micrograms
  • Tomatoes (raw) — 14 micrograms
  • Cucumbers (raw) — 17 micrograms
  • Sweet potatoes – 5 micrograms

What can happen if I eat too much of the foods (Vitamin K) that interact with Warfarin?

Patients that consume an inconsistent amount of Vitamin K and/or foods that contain large amounts of Vitamin K can put themselves at risk of developing a blood clot and further side effects. Here are some of the serious ailments that patients should keep an eye out for and call 911 if these symptoms arise:

  • Pain, swelling, and redness in your legs
  • Difficulty breathing
  • Chest pain
  • Trouble moving your limbs
  • Trouble seeing, walking, or speaking
  • Severe headache (

Foods You Can Eat on a Warfarin Diet

On the positive side, patients are able to consume many foods considered safe if they are taking any anticoagulants. These are the foods that are considered safe to consume:

  • Meat, fish, and eggs
  • Milk, cheese, and yogurt
  • Grains, bread, rice, and pasta
  • Fruits of any type
  • Red, orange, and yellow vegetables
  • Most purple and white vegetables

The safety around anticoagulants?

Patients should take many precautions. Specifically, knowing that taking an oral anticoagulant has a higher propensity to cause adverse reactions putting the patient in the hospital for bleeding-related illnesses (NCBI). Furthermore, anticoagulants can also react negatively to other medications specifically, anti-platelet drugs, in the presence of dosing errors, and when there is improper monitoring. Patients should communicate with their doctor about their diet, current medications, and any follow-up issues that are occurring.

What is the difference between a blood thinner and an anticoagulant?

They are considered the same thing. Though medical professionals usually refer to these specific drugs as anticoagulants (“blood thinners” don’t actually thin blood).

How does the blood circulatory system work?

The blood circulatory system, also known as the cardiovascular system, delivers nutrients and oxygen to all cells in the body. It is comprised of the heart and the blood vessels, all running through the entire body. Briefly, the arteries carry blood away from the heart; the veins carry it back to the heart (NCBI). This helpful system carries oxygen, nutrients, and hormones to cells, and removes waste products, like carbon dioxide in the body (Kids Health).

What makes blood clots so dangerous?

When a blood clot, or thrombus, travels to critical parts of the body like the heart or lungs, it can turn into a very serious health concern. Briefly, blood clots become dangerous when they get stuck in a passageway and turn into what is called an embolus. Once this embolus forms, the blood can no longer pass through the veins and reach organs and the person is at high risk for a heart attack or stroke (

What are blood thinners?

Also known as anticoagulants. These are medicines that help prevent blood clots. These drugs work by interrupting the process involved in the formation of blood clots.  And this interruption can significantly decrease your risk of blood clotting, but will not decrease the risk to zero. Additionally, we usually hear of anticoagulants as “blood-thinning” medicines, although they don’t actually make the blood thinner (NHC).

What are common (name brand) blood thinners?

There are many helpful blood thinners that medical professionals might prescribe. Some of the most common are:

  • apixaban (Eliquis)
  • dabigatran (Pradaxa)
  • edoxaban (Lixiana)
  • rivaroxaban (Xarelto)
  • warfarin (Coumadin)

The generic names are listed first, followed by the name brands of these blood thinners (HeartandStroke.CA).

What is Warfarin?

Warfarin is a blood thinner medication that is usually prescribed to people who have had or are at risk for blood clots. Because this medication prevents blood clots, it can also put you at risk for bleeding.

Who needs to take warfarin?

There are a couple of reasons why someone would get prescribed Warfarin and that is because that person has a mechanical artificial heart valve that is more likely to form blood clots and/or a blood clot in your lungs (Mayo Clinic).

What is Jantoven?

This is another blood thinner medication. This drug helps prevent blood clots from forming in a patient’s body. Jantoven is used to treat or prevent blood clots in veins or arteries. And can reduce the risk of stroke, heart attack, or other serious conditions (

What can you not drink while taking blood thinners?

Alcohol can create side effects when combined with an anticoagulant. Medical professionals suggest avoiding acute alcohol intoxication. Coffee consumption can also alter the effects of blood thinners; as caffeine can inhibit the metabolism of warfarin (NCBI). Also, some juices like cranberry juice, green tea and grapefruit juice can deactivate an enzyme that normally breaks down warfarin, causing an unusual amount of bleeding (NY TImes).

Can drinking water thin your blood?

It is recommended to drink water throughout the day to keep your blood thin, starting with a glass or two in the morning. This lessens the risk of stroke and the thickening of the blood (dehydration).


These terms and conditions are provided by The National Phlebotomy Provider Network (“NPPN”) and fully describe the terms under which the services are provided by NPPN.

1. NPPN provides an independent medical and research specimen collection, processing, and delivery service. NPPN IS NOT a medical laboratory and does not conduct laboratory testing. NPPN IS NOT a partner or subsidiary of any medical laboratory.

2. Once specimens are delivered, NPPN has no control over the handling, processing, and testing of specimens, or reposting of those results to the prescribing practitioner. The laboratory is solely responsible for proper handling, processing, testing, and results reporting. NPPN is NOT responsible IF the laboratory fails to do any of the above properly or in a timely fashion.

3. While most common laboratory tests require the same or similar type of sample (whole blood, plasma, serum, urine, etc.) no matter what laboratory is performing the testing, every laboratory has its own specimen requirements for sample type, processing, and handling. While every effort is made to collect adequate and acceptable specimens, it is impossible to know the specific requirements for every test done by every laboratory. Furthermore, some laboratory tests cannot be collected in the field because the sample requires special handling that is impossible to perform outside a laboratory environment. In addition, some laboratory tests require the sample to undergo additional processing IN THE LABORATORY, as soon as it is delivered to the laboratory, which cannot be done in the field. Given these facts, there is a possibility that inadequate samples or no samples will be obtained. NPPN is NOT responsible [f the laboratory fails to perform any additional pre-analytical sample processing required after we deliver the samples to the laboratory.

4. PLEASE DO NOT CONTACT NPPN ABOUT YOUR TEST RESULTS NPPN has no access to the test results. You should contact the practitioner who ordered the laboratory testing for you or the laboratory who is conducting the testing directly. However, you should be advised that most laboratories are prevented by law firms releasing results directly to patients.

5. NPPN specimen collection and delivery services are provided ONLY at the direction of and under specific order from a duly licensed medical practitioner authorized to prescribe and order medical diagnostic testing. You cannot request specimen collection services without a valid laboratory order from an authorized medical practitioner.

6. NPPN personnel cannot materially change or in any way alter the laboratory order provided by your prescribing practitioner. It is against the law for any medical care provider to change a practitioners order without express consent from the prescribing practitioner. Likewise, you cannot materially change or alter your prescribing practitioner’s laboratory order for you.

7. NPPN is NOT a medical practice and does NOT provide any medical diagnosis, prognosis, treatment, or any medical advice. We do NOT have any information relating to any treatment you are undergoing or any reasons for why samples are being collected. You should seek the advice of a licensed practitioner for any question about any symptom or condition you are experiencing. If you are experiencing a medical emergency you should call 911 immediately! Do not attempt to access emergency care through our service. If you are unsure of what type of care you need, please contact your personal physician. NPPN does not dispense or deliver medicine of any kind. NPPN cannot prescribe medication or evaluate the effectiveness of any medication you may be taking.

8. NPPN is not a limousine or personal courier service. We cannot transport you to any doctor’s office or hospital. We cannot deliver any personal item to any location on your behalf.

9. NPPN services will be provided IN the patient’s home, work, or other appropriate stationary location. An appropriate location is one where patient privacy and safety are provided. NPPN does NOT and will NOT provide services inside any vehicle. NPPN does NOT and will NOT provide services in any public location.

10. NPPN performs all services and functions in the ordinary course of business and during normal business hours. NPPN is a NON-EMERGENT service and should NOT be used for collection and delivery of STAT or UGENT laboratory orders. All services are scheduled in advance and therefore we cannot guarantee accommodation of requests for “same day” schedule changes. Expedited collection and/or delivery of any specimen is NOT possible unless scheduled in advance. Because travel is inherently unpredictable, we do not guarantee or warranty any specific delivery time.

11. Scheduling Policy: We recognize that your medical care is very important to you and we respect your desire for timely medical care. Generally, appointment scheduling is conducted on a first-come, first-serve basis. However, scheduling for some patients may be prioritized based on medical need. NPPN will attempt to contact you to schedule an appointment within 24-48 hours upon receipt of your request. We make every attempt to schedule your appointment at a time convenient for you but cannot guarantee any specific time or ongoing duration of availability.

12. We have a 48-hour cancellation policy. Appointments canceled without at least 48 hours’ notice will be charged a 50% cancellation fee for all services scheduled on that day. Appointments canceled at the time of service or “no shows” “vi ii be charged the full fee for services scheduled on that day.




15. These terms constitute the entire understanding between you and NPPN and no amendment or modification of its terms shall be valid or binding unless in writing and signed by an authorized representative of NPPN.

Last Updated: November 20, 2023

Terms of Use for National Phlebotomy Network Customer Portal


Welcome to the National Phlebotomy Network Customer Portal, accessible at These Terms of Use ("Terms") govern your use of our website and services ("Services"), and by using our Services, you agree to be bound by these Terms.

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By clicking "I Agree" during the sign-up process or by using the Services, you agree to comply with and be bound by these Terms. If you do not agree to these Terms, please do not use the Services.

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Permitted Use: You agree to use the Services only for purposes that are permitted by these Terms and any applicable laws and regulations.

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All content on the Services, including but not limited to text, images, and code, is owned by National Phlebotomy Network and is protected by copyright and other intellectual property laws.


We reserve the right to terminate or suspend your account and access to the Services at our sole discretion, without notice, for conduct that we believe violates these Terms or is harmful to us, other users of the Services, or third parties, or for any other reason.

Changes to Terms

We reserve the right to modify these Terms at any time. If we make changes to these Terms, we will notify you by updating the "Last Updated" date at the top of this document.

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These Terms are governed by the laws of the State of California, without regard to its conflict of laws principles.

Contact Information

For any questions about these Terms, please contact us at (415) 851-2425.

Last Updated: November 22, 2023

Information Privacy Notice

This Information Privacy Policy has been adopted in order to maintain clear standards of privacy and security with the information we are provided by customers for confidentiality. It states:
(1) We will not sell or provide secure proprietary information input by customers to any outside parties except as expressly authorized or implied by specific request for services that requires the disclosure of your information in order to provide said services requested; and
(2) No customer information is kept on a publicly available server.

By accessing this web site, users agree to be bound by all of the terms and conditions of the guidelines set out in this Disclaimer. Do not consult this web site unless you agree not to hold NPPN liable for any errors or omissions.
We offer our services as prescribed by a duly authorized and licensed medical practitioner or other healthcare provider. The services or products found listed on our web site are intended for use by duly authorized and licensed medical practitioners or other healthcare providers in the delivery of appropriate medical care to assist practitioners diagnose and treat disease. We give no warranty that any of our services will prevent disease. All material is provided for educational purposes only and is not intended to be a substitute for a physician’s consultation. Although NPPN encourages increased self-awareness and self-care, all readers are strongly encouraged to consult and work with an experienced healthcare practitioner. Individuals with health disorders, medical conditions, or any condition needing medical supervision assume full responsibility for obtaining such professional medical assistance. Consult your physician regarding any symptoms or medical condition. We specifically disclaim any expressed or implied warranties or merchantability of fitness for any particular usage, application or purpose. NPPN does not recommend self-diagnosis or self-medication, and no information within this web site or presented by NPPN or its associates may be construed or interpreted as recommending self-diagnosis or self-medication.

If a laboratory test result is outside normal range, you should immediately see your prescribing physician. Many tests, to be validated, will need to be repeated at the discretion of a physician. Laboratory test results may vary depending upon age, sex, time of day blood sample is taken, diet, medications, and the limits of modern technology. A single laboratory test or group of tests cannot guarantee good health. False positive and false negative test results are possible. There are various medical diseases that cannot be uncovered by these tests alone. Testing by the medical laboratory staff to whom your medical specimen is delivered by us, only constitutes a partial evaluation of your state of health and does not represent a diagnosis or treatment of disease.

NPPN shall not be liable to you or anyone else for any loss or injury caused in whole or in part by procuring, compiling, interpreting, delivering or reporting information through this web site. In no event shall NPPN be liable to you or anyone else for any decisions made or action taken or not taken by you in reliance on such information. Material placed online by users does not represent medical advice of NPPN and we make no representations with respect to the accuracy, reliability, completeness, timeliness or usefulness of the contents.

Privacy Policy
The general position of The National Phlebotomy Provider Network on implementation and compliance with HIPAA and other privacy laws is as follows:

A. Protect and enhance consumer’s rights of access to information.
B. Improve healthcare quality by restoring trust in the system.
C. Improve efficiency of delivery with national framework.
D. NPPN will not use or disclose an individual’s protected health information (PHI) except as otherwise permitted and/or required by HIPAA.
E. PHI may be used only for treatment, payment, or healthcare operations. All other uses and disclosures will be by authorization only and Patient may revoke authorization.
F. All NPPN Patients will receive and acknowledge the Privacy Notice. It is also available for the asking by mail or email. It is also carried by each field service technician and available upon request.
G. Privacy Notice will describe how medical information about Patients may be used and disclosed and how they may access said information.
H. NPPN will make reasonable efforts to limit disclosure of PHI as much as possible.
I. Continuing compliance with HIPAA will be achieved through ongoing assessment, oversight and informational training, as coordinated through the privacy officer.
J. NPPN shall address all complaints received from patients, clients, employees or third parties in an expeditious and meaningful manner.
K. NPPN respects the rights of individuals, including employees, to make complaints, ask questions or inquire as to NPPN’s compliance with HIPAA and other privacy laws.
L. No adverse action or retaliation shall be taken against any such individual or employee based on any legitimate complaint, question, or inquiry.
M.NPPN must identify those members of its workforce that require access to protected health information to perform their duties, specify the protected health information to which they require access and make reasonable efforts to limit their access accordingly.
N. All employees will be trained in order that NPPN will be HIPAA compliant. New employees will be trained on a regular basis to ensure continued compliance with new personnel. Personnel will be retrained if significant changes occur which affect HIPAA or privacy laws. Employees, who fail to follow HIPAA requirements and/or the policies of NPPN with respect to privacy rules, shall be sanctioned appropriately. Such sanctions may range from verbal reprimand to termination. Any intentional breach of patient confidentiality, not permitted by law, shall be severely punished. All such sanctions shall be documented, in writing, by NPPN.
O. To the extent practicable, NPPN will mitigate the harmful effects of any known use or disclosure, by itself or its business associates that is in violation of the privacy rule and/or NPPN’s policies and procedures.

For more information on our information privacy practices, or to file an information privacy concern, please contact The National Phlebotomy Provider Network’s Information Privacy Officer at: The National Phlebotomy Provider Network, Inc. 8871 W. Flamingo Rd. Ste 202 Las Vegas, NV 89147.