Mnet Health News delivers the latest news and information articles for the world of healthcare.

A+ A A-

Uncollectibles Continue to Improve, But Fall Short of Benchmarks

A separate study of hospitals’ charity care costs and bad debt shows overall quarterly improvement in uncollectible performance.  The latest Hospital Accounts Receivable Analysis survey, based on data from the fourth quarter of 2013, finds that U.S. hospitals improved their performance in uncollectible write-offs, which includes gross dollars of bad debt and charity care divided by the total year-to-date gross revenue.

However, the hospitals participating in the survey have fallen behind on meeting the overall performance benchmark of the major financial indicator.  U.S. hospitals contributing to the survey report that 5.32 percent of the total 2013 fourth quarter gross revenue was written off as charity or bad debt, a decline from 5.44 percent in the third quarter of 2013. The benchmark goal, however, is to limit charity and bad-debt write-offs to a combined 5 percent or less of total gross revenue.

Hospitals did reach the benchmark goal in the first quarter of 2013 with 4.97 percent of total first quarter revenue reported as a charity or bad debt write off.  Since then, the goal has been out of reach.  Bad debt continues to be a higher percentage of hospitals’ write-offs than charity care. Of the 5.32 percent in fourth quarter gross revenue written off last year, 3.26 percent was assigned to bad debt and 2.06 percent was assigned to charity.

Looking at the past 12 quarterly financial reporting periods, U.S. hospitals met the uncollectibles benchmark three times, according to the HARA survey.  The best results came in during the second quarter of 2011, when U.S. hospitals limited uncollectibles to 4.28 percent of total gross revenue, according to the survey.

In the first quarter of 2012, U.S. hospitals significantly reduced their uncollectible write-offs from 7.28 percent of total gross revenue to 4.55 percent.  The most recent decline in the first quarter of 2013 was from 5.38 percent to 4.97 percent.

Report: Fewer People Have Problems Paying Medical Bills

The percentage of people having problems paying their medical bills is declining, according to an April 2014 report from the National Center for Health Statistics, which is part of the U.S. Centers for Disease Control and Prevention. Specifically, the percentage of people under age 65 who were in families having problems paying medical bills decreased from 21.7 percent (57.6 million) in the first six months of 2011 to 19.8 percent in the first six months of 2013. The report defines “family” as an individual or a group of two or more related people living in the same home.

“Almost 5 million fewer people than two and a half years ago are in families having problems paying medical bills,” said report co-author Robin Cohen, a statistician with the U.S. Centers for Disease Control and Prevention, in a HealthDay News article.  According to the report, the percentage of people under age 65 with private coverage who were in families having problems paying medical bills decreased from 15.7 percent in the first six months of 2011 to 14.1 percent in the first six months of 2013. For those with public health insurance, that rate decreased from 28 percent in the first six months of 2011 to 24.7 percent in the first six months of 2013. 

It also states that in the first six months of 2013, among people under age 65, 34.3 percent of those who were uninsured, 24.7 percent of those who had public coverage and 14.1 percent of those who had private coverage were in families having problems paying medical bills in the past 12 months.  More information: http://1.usa.gov/1ga1m4b

Determining the Impact of Revenue Cycle Outsourcing

Health care providers have several options when it comes to choosing revenue cycle services to outsource.  Experts in health care collections recently discussed the impact of full revenue cycle outsourcing during ACA International’s Spring Forum in March 2014.  Terry Armstrong, president of State Collection Service Inc., in Madison, Wis., moderated the session, which featured panelists Stephan Bernard, vice president of professional services for Connance Inc. in Waltham, Mass., and Gregory M. Snow, vice president of corporate solutions strategy for Conifer Health Solutions in Carmel, Ind. 

“When we talk about full outsource, this is the whole continuum of what happens in a revenue cycle from scheduling all the way through the admissions, discharge, medical records and then the billing and receivables,” Armstrong said.  Bernard discussed different pieces of the revenue cycle that a provider can choose to outsource, including scheduling, financial clearance, patient receivables management and coding. 

“You have to ask yourself the question, of these functions, which ones benefit from economies of scale [and] which ones are portable, meaning they can be centralized and possibly be moved off site,” he said. “Pretty much every hospital does outsource some component of revenue cycle management. Generally speaking, it will be highly specialized, such as charge reconciliation or clinical documentation or bad debt collections.

Most hospitals outsource bad debt collections.”  “In general it’s the question of, is this the direction the industry is going? To some extent I would say yes it is. Full service revenue cycle has established itself and it is here to stay,” Bernard said.  According to Bernard, hospitals elect to outsource services because:

• The most appropriate rationale for using full outsourcing is the core competency concept. Is the health care provider in business to manage a revenue cycle or is it just an ancillary function that frankly distracts from core competencies? For most hospitals, managing the revenue cycle is not a core competency.

• They know they need to update the revenue cycle, and they don’t have the capital to do it themselves. Using an investment partner is one of the key motivating factors in acknowledging that a revenue cycle has been left unattended for many years.

• It has come into a state of disrepair, and management has lost confidence in their ability to execute. Most often this occurs when new leadership comes into an organization, takes over, does an assessment of their own internal operations and feels they need to essentially bring in someone new who can really shake things up.

Snow addressed another aspect of revenue cycle management that can be outsourced—pre-service clearance.  “In the future, other than identification for security, the patient will be greeted and told the doctor will see them. It is to perform everything that needs to be performed … from an administrative point of view prior to the patient coming in for service,” he said. “What you’re attempting to do is make that visit 100 percent clinical in nature versus being half clinical and half administrative.”  The health care payment system is highly fragmented, inefficient and expensive to administer, Snow explained. 

“We’re looking at new payment models that are much more focused on quality, cost effectiveness and the patient experience,” he said.  Larger health care systems in one regional framework are the most interested in outsourcing revenue cycle management and viable for the process, according to Bernard.  “It’s a difficult model when you don’t have a sufficient scale and opportunity for centralization within any health system,” he said.

Scammers Keep Medical Debt Collectors Busy Validating Debt

Scammers have become masters at impersonating debt collectors.  Because of this, people today have no choice but to be suspicious when their phone rings, particularly when the person calling claims to be a debt collector.  Even when the caller seems to already have a lot of personal information, the sad fact is that the caller could easily be a swindler trying to make use of the so-called “phantom debt collector” scam or some other fake collection scheme.

Scam artists like this often pretend that they are part of the police, government agency, or a law firm, and many victims have stated that the callers are typically very aggressive in their “debt collection style.”  Some have pointed out that such fake collectors have threatened garnishment of wages, seizure of assets, and even use the threat of arrest and jail time if the debt is not paid immediately.

The Federal Trade Commission has received thousands of complaints about “phantom debt collectors.”  In fact, they have already filed four cases that involve the collection of fraudulent debt and the total loss from these cases alone have been estimated to be in the vicinity of the $20 million mark. 

The FTC, therefore, is currently advising that no matter how real a letter or phone call may seem, it needs to be checked out thoroughly.  To accomplish this, they recommend looking up real numbers to government agencies, offices and employees to prove their validity.  The FTC also warns that consumers should be suspicious of anyone, regardless of who they claim to be, particularly when they ask a consumer to pay back a debt by loading a rechargeable money card or wiring money, since there is no valid reason to request payment in such a way.

Since this is the current climate that business must continue to operate under, what should medical billers and collectors expect with regard to the normal activities of medical debt collection?  In a world filled with an excess of information, medical debt collectors should assume that a majority of the patients they speak to are aware of the latest “phantom” scam and thus, understandably, will act to prevent being scammed as well. 

“Debt collectors should expect that patients might be a bit nervous about speaking to them right now, even though the patient is aware that they recently received medical services,” said Stacy Vink, Credit and Collection Manager at Mnet Financial.  “We advise our collectors at Mnet Financial to take the time that the patient needs to validate the medical debt in question is real and that the collector that they are speaking to is legitimate and not part of a scam,” said Vink.

“Our collectors work diligently to put the mind of the patient at ease.  A patient who has never spoken to one of our collectors before and has not yet developed a rapport with them can verify with the collector key pieces of information concerning their services thus validating our collection activity,” Vink said.  “We are known within the healthcare community for being ‘patient friendly’ and always tell patients that if they have any trepidation whatsoever to feel free to check in with their medical provider first to confirm that what we are doing is on the up and up,” said Vink.

Why Hire a Collection Vendor That Works with Healthcare Providers Exclusively?

In July of 2013, the Federal Trade Commission fined Expert Global Solutions $3.2 million in what was viewed as a record-setting settlement that alleged that Expert Global, the largest debt collection company in the world, regularly violated the rights of consumers.

The complaint was filed in the U.S. District Court of Dallas with the FTC charging that Expert Global, as well as its subsidiary debt-collection companies operating under names such as Transworld Systems, North Shore Agency, ALW Sourcing, & NCO Group were harassing consumers which is illegal; particularly since many of these consumers actually denied ever owing the debt.  This was a violation of the Fair Debt Collection Practices Act.

This legislation, the Fair Debt Collection Practices Act, prevents debt collectors from contacting consumers late in the evening, in the early hours of the morning, or while they are at work.  This Act also prevents debt collectors from continually calling a consumer if the consumer has requested them to stop.  A debt collector is also required not to discuss the details of a debt collection action to anyone other than the debtor; and they must investigate the legitimacy and validity of a debt if the consumer claims that they do not owe the debt in question.

Expert Global, Transworld, NCO and its other subsidiaries regularly violated each of these terms according to the complaint filed by the FTC.  The $3.2 million civil penalty levied against the company bars the company from any future violations and requires the company to record phone calls to help prevent such violations.

“The problem that arises when using a huge corporation for debt collection is that they have a ‘one-size-fits-all’ approach to collecting” said David Hamilton, CEO of Mnet Financial.  “So whether they are collecting for auto loans, credit cards, utilities or medical debt; every consumer basically receives the same type of debt collection approach; which can be dangerous” said Hamilton.  

Debt collectors are required to abide by the rules set forth in the Fair Debt Collection Practices Act and many collection agencies do comply with the Association of Credit and Collection Professional’s International Code of Conduct.  However, those dealing with medical debt must also abide by rules set forth in the Health Insurance Portability Accountability Act as well.  But how much attention is really paid to healthcare rules by companies that mainly focus on credit card and utility bill debt?

“In order to meet the requirements of Federal Regulations, agencies and their vendor partners are going to need to be extremely knowledgeable about the rules set forth for a specific industry” said Hamilton.  “That’s why we are seeing more companies doing the opposite of what was the norm just a few years ago.  The trend used to be for a company to take on as many different revenue stream laterals as possible but now we are seeing companies becoming much more niche than ever before” said Hamilton.

“At Mnet Financial we only work with health care providers so we not only adhere to the rules and guidelines set forth by the FDCPA and ACA but also completely understand and comply with the healthcare insurance rules of HIPAA” said Hamilton.  “Being so industry specific has allowed us to produce a higher level of service for the providers that we work with as well as the patients they care for” said Hamilton.

Two-Midnight Rule Delay Doesn’t Address Provider Concerns

In October, the Centers for Medicare and Medicaid Services will begin enforcement of its new Medicare hospital admissions policy, known as the two-midnight rule.  CMS has delayed enforcement of the rule several times since last year.  Its most recent delay, in response to opposition from health care providers and trade groups does little to address the concerns of providers about the rule itself, however.

The new rule requires a physician to determine that a Medicare patient will need to stay in the hospital for two nights in order to receive reimbursement under Medicare Part A. Care for a patient who stays in the hospital for less than two nights will be identified as outpatient treatment and reimbursed under lower Medicare Part B rates.

Speaking for the Association of American Medical Colleges, which represents teaching hospitals and medical schools, senior director and regulatory counsel Ivy Baer told Modern Healthcare,

“It does not make any sense. The decision should really be based on patient need, not how many midnights they were in the hospital.”

Some Medicare patient admissions under the new rule could be subject to random audits during the moratorium, according to CMS. Contractors with Medicare will continue to select claims for review dated between March 31, 2014 and Sept. 30, 2014. 

Paid claims dated Oct. 1, 2013 through Oct. 1, 2014 will not be reviewed. However claims without payment dated after Oct. 1, 2013 but before Sept. 30, 2014 are subject to a review.

More information: http://go.cms.gov/1fazn5h

 

 

 

Will Your Facility and Collection Vendor be the Next to be Sued?

Lawsuits stemming from seemingly minor infractions by collection vendors are quickly on the rise in the United States. Providers who make use of collection vendors are currently under scrutiny because of communication channels such as cell phones, voicemail messages and automated dialers.

Recently, a District Court in Florida rejected a collection agency’s motion to reconsider a case that is seeking damages for a class of defendants under the Telephone Consumer Protection Act. The Judge wrote that reconsideration was “only appropriate in limited circumstances,” then pointed out that reconsideration is “not designed to…relieve a party of consequences.”

The class representative received treatment from Memorial Hospital Pembroke emergency room department. While at the hospital, the representative was treated by an attending physician. During the process of admissions, the patient filled out paperwork and provided his cellular phone number to the hospital. But the patient claims that he never expressly consented to the use of his cellular phone number being used for the purpose of debt collection.

Services obtained through this hospital in particular are billed through a vendor billing company and are later referred to a vendor collection agency if a patient’s medical bills remain unpaid. A noteworthy point is that the class representative never paid for any of the services that he had received from the hospital, therefore because he was in default his account was forwarded to the hospital’s collection vendor for collection purposes.

The collection agency used the number that the patient provided during the admissions process to collect the hospital debt that was owed by the patient. However, the phone number provided was listed under the name of a woman who was his girlfriend on the date of service but later became his wife. On June 17, 2010, the collection vendor left a prerecorded voicemail for the patient stating that they looked forward to helping them, but failed to identify that they were a debt collector.

Avoid a Lawsuit

Understanding the currently litigious climate within the debt collection field in this country, the question of how to protect a medical facility from the unscrupulous comes forth. What are some things that a facility’s business office can do to help prevent a similar situation from befalling them? A facility should start by reviewing their intake forms to be certain that patient disclosures contain properly updated verbiage.

Such a disclosure to the patient should point out that the form obtains written consent that in providing contact information, the patient is consenting to allow third party billing and collection agents to contact them by whatever means necessary. This may include, but is not limited to, home phone and cellular phone, and may involve leaving a voicemail which will include the name of the facility where the patient was treated. This disclosure should also obtain consent to use automated dialers to communicate information to the patient regarding the procedure performed at the facility.

“Mnet Financial recently added an addendum to their collection agency service agreement to include language that addresses the responsibility of a provider to obtain the proper consent from the patient upon admission into the health care facility,” said Mnet Financial CEO David Hamilton.

“The legal system hasn’t yet addressed the use of some of the newer technologies, so this has created a window of opportunity for attorneys to create lawsuits based on harmless technicalities of the billing process. Since we cater to the health care industry, we will continue to be diligent about giving our providers what they need to avoid frivolous lawsuits pertaining to patient billing and collection procedures,” said Hamilton.

While no one can truly predict what the future holds concerning business or any other aspect of life, common sense steps can certainly help reduce the risk of getting caught up in such a lawsuit. Ensuring that the facility’s collection vendor takes the issue seriously and works diligently to prevent this type of situation in the first place is an excellent place to start.

High Deductible Health Plans Irresistible to Employers

The recent trend of larger employers choosing to offer only high-deductible health plans for their employees health care coverage is growing according to recent surveys and is beginning to have an effect on the American hospital system.

The number of employers who offer only high deductible health plans has grown, particularly in the last few years according to one recent employer survey. Along the same lines, it has now become apparent that nearly 75% of all larger employers are offering at least one high deductible plan to employees during this year’s open enrollment period.

However, this trend toward high deductible plans is likely to bear consequences for both providers and their patients. Logically speaking, if patients are going to be held responsible for a greater portion of their health care expenses, the demand for disambiguated pricing data is very likely to intensify.

Another likely scenario is that provider organizations will have to deal with greater collection and billing issues that are tied to the patient’s deductible. Some industry insiders are encouraging hospitals to provide financial counseling services pertaining to patient responsibility and point of service estimates for services.

Recently many hospitals have seen an increase in the amount of patients who have high deductible plans, which is causing an increase in bad debt because of patients who only come to the realization that they have a larger portion of the cost of their care after they have already been treated.

Even though so many have moved to such plans, many hospitals still appear to be leery about discussing the increased costs of a patient’s plan before an elective surgery is provided. Furthermore, some hospitals are reporting that high-deductible policies are discouraging patients from seeking out health care services.

The hesitation to seek medical attention that patients who have high deductible plans feel is one of many issues that these plans present for patients and providers. Recent studies imply that lower income enrollees in such plans have reduced their use of emergency departments by as much as 30% in the last few years. Other studies show that men in particular are visiting hospital emergency departments much less, even in severe cases.

“The thought of patients doing without the medical attention that they need is not only tragic but completely unnecessary,” said David Hamilton, CEO of Mnet Financial. “Mnet offers financial products that are designed to help patients in need of therapies, procedures and surgeries prescribed by their medical practitioners. For instance, our online payment plan management solution allows the patient to set up a payment plan that they can afford so they can resolve the portion they are responsible to pay under their health plan,” said Hamilton.

A recent insurance enrollee survey shows that overall satisfaction with high deductible health plans is steadily gaining momentum, likely due to the lower premium costs. While the ultimate impact from the use of such plans will only truly become apparent in the future, employers are making it clear that they view them their most effective tool to control the costs of health care.

Health Care Professional Shortage Crisis Coming Soon

The coverage of an additional 30 million Americans due to health care reform, commonly known as Obamacare, in tandem with the fact that more than 15 million patients will become newly eligible for Medicare in the very near future are being touted as major contributing factors of a looming health care crisis.

This prediction points out that the coming shortage of more than 90,000 specialists, primary care physicians, and other health care professionals, such as physician assistants and nurse practitioners, will be a reality by the end of this decade. The knowledge of such a stinging prediction ultimately begs the question: “Who will offer care to all of these patients?”

A shortage of doctors and other health care clinicians looming on the horizon is expected to change the landscape of health care across the country. In fact, the Association of American Medical Colleges has predicted that the United States be short of more than 90,000 physicians by 2020; by the year 2025, the shortage will be more than 130,000.

As mentioned, the problem doesn’t exist due to a lack of interest in the health care field but instead is born out of a rare set of circumstances that have exacerbated the situation. The individual insurance mandate set forth in the Affordable Care Act will result in millions more people across the country seeking out doctors since they have become insured. But at the very same time, people nowadays are living longer and estimates also appear to imply that approximately 30 percent of doctors are less than a decade away from retirement.

A proposed remedy to the situation is to increase the number of health care professionals, such as physician assistants and nurse practitioners, to work in collaboration with the physician as a team. This approach could be viable since these professionals are trained to work with routine or common medical issues while referring more complex cases to a physician.

This type of team approach could result in a more cost-effective use of the entire team of professionals while allowing the physician the opportunity to focus on issues that are more appropriate for someone with their level of education. In fact, many physician groups are already relying on the help gained from physician assistants and nurse practitioners.

“Although nobody can truly predict what’s going to happen in the future, it seems clear that changes are coming to the medical community and the world of health care in general,” said Mnet Financial CEO David Hamilton. “Even with so much uncertainty, it’s a positive step that the medical community is taking note of the possibilities and moves to respond accordingly,” said Hamilton.

Ambulatory Surgery Cases Remain Hot

Ambulatory Surgery represents a large portion of business according to industry leaders throughout the country. As much as half of the patients being seen each year are admitted on an outpatient basis and of those, a majority of the patients are admitted for surgery. In the last four decades, surgeries performed on an outpatient basis have grown from less than 10% to more than 70% of all elective surgeries.

Advances in medical care and technology as well as preferences in the marketplace are driving this explosion in the sector of health care. New techniques and drugs are now being used to help the patient manage their pain, which allows procedures to be done on an outpatient basis that previously would have been inpatient only.

The trend toward an increase in these cases is part of a shift from inpatient to outpatient care. Outpatient surgery is typically elective in nature and is thus scheduled well in advance which contributes to the profitability of the medical facility. Many hospitals across the country are in the process of creating programs based on the more profitable outpatient procedures, such as orthopedics, pain management, gastroenterology, and gynecology to name a few.

However, competition for such cases is strong, coming from outpatient hospitals as well as physician owned ambulatory surgery centers. Many physicians see surgery centers as a good option to help offset any cuts by commercial payers and Medicare, malpractice insurance premiums and increased expenses.

Some physicians have noted that hospitals typically tend to mix inpatient surgery and emergency department surgeries with ambulatory surgeries. This causes delays that create longer turnaround times for the operating rooms and also diverts the focus of the support staff and nurses, which can be exasperating for doctors. Thus hospitals that wish to compete with a competitor as adept at ambulatory surgery as an ASC will need to strategically consider how to reconfigure services to meet the expectations of very demanding marketplace.

Cutting edge surgical and anesthetic practices have created an opportunity for outpatients all over the world to make use of ambulatory surgery. Since the emphasis has shifted to more value based health care, it has become clear that ambulatory surgery can provide optimal patient care at the most reasonable price.

As the American population grows older, the obvious expectation is that the number of surgeries being performed will steadily increase. No doubt, many of these will be ambulatory surgery. It seems apparent at this point that such a rise in cases will likely create enough demand for everyone involved in ambulatory surgery within the health care world.

Outpatient Facilities in High Demand as ObamaCare Takes Shape

Many Americans believe that the health care industry will benefit from President Obama’s health care legislation known as the Affordable Care Act. Growth in the area of outpatient medical centers was something that was already expected as the immense baby boomer generation ages. However, the prospect of extending health insurance to an estimated 30 million currently uninsured citizens through the new health care law, known by most as ObamaCare, will likely spur a surge in the need for health care space. Experts believe that the real estate market for the health care industry will reach a feverish pace in the very near future.

ObamaCare is being touted as a way to lower the price of health care but experts are saying that for this to happen, the efficiency of medical office space will have to increase to provide the current level of care at less expense. Due to this concept, some are saying that the need for medical office space with large amounts of square footage will be leased by hospitals and medical groups, which will allow providers to see more patients in a quicker time frame. Some claim that small, independent physician offices will ultimately disappear and be replaced by new and different floor plans and office models than those typically seen in the past.

An increase in transaction volume for health care buildings has already been noted, with some providers aspiring to own their own buildings or to lease new ones. Medical offices are not as costly to purchase and operate as is an in-patient facility, so they are garnering interest from hospital systems and medical groups alike. Experts in the field point out that it costs about $1,000 per square foot to build a hospital as opposed to $200 per square foot to build out a medical office building; not to mention the fact that running a medical office is much cheaper since a hospital must be maintained 24 hours per day.

The trend that appears to be coming into focus is that hospitals are looking to provide more convenient services closer to where people live and work, and are looking for ways to be more cost effective. This trend is increasing the demand for medical office space throughout the country.

Some, however, see the ObamaCare issue in a different light. Their thoughts are that ObamaCare will not create a need for 30 million more people to now require health care services. Instead, they believe, those 30 million people are already receiving health care services through the hospital emergency department system or other alternatives.

“Some believe that patient demands will increase because so many newly insured patients are now going to require services while others say that newly insured patients will simply stop using hospital emergency departments as their primary source for health care, instead using more traditional methods. But, It seems pretty clear that in either scenario, the demand for treatment in outpatient facilities is definitely growing,” said David Hamilton, CEO of Mnet Financial, an outpatient facility and ambulatory surgical center- specific A/R solutions company.

Industry experts are now projecting growth by as much as 30 percent over the course of the next decade, whereas in-patient hospitals should see a slight decline. Regardless of one’s views on the new health care law and its implementation, it seems clear that those working in ambulatory surgery centers and outpatient facilities should be very busy in the foreseeable future and beyond.

CMS Proposes Help for Consumers Navigating the Health Insurance Marketplace

The Centers for Medicare & Medicaid Services (CMS) released a proposed rule outlining standards that Navigators in federally-facilitated and state partnership Marketplaces must meet, and clarifying earlier guidance about the Navigator program. Navigators are organizations that will provide unbiased information to consumers about health insurance, the new Health Insurance Marketplace, qualified health plans, and public programs including Medicaid and the Children’s Health Insurance Program.

Millions of Americans will be eligible for new coverage opportunities in 2014. For those who are not familiar with health insurance, have limited English literacy, or are living with disabilities, Navigators will serve an important role in ensuring people understand the health coverage options available to them. Navigators will provide accurate and impartial assistance to consumers shopping for coverage plans in the new Marketplace.

Navigators are a significant component of efforts to enroll Americans in the Marketplace. And CMS will ensure that all consumers who need customer service can receive it from trained professionals. In addition to Navigators, consumers will have access to assistance through services such as a call center, where customer service representatives can provide referrals to the appropriate state or federal agencies, or other forms of assistance programs including in-person assistance personnel, certified application counselors and agents and brokers. Open enrollment in the Marketplace begins Oct. 1, 2013, with coverage to begin Jan. 1, 2014

Subscribe to this RSS feed