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Your Top Questions Answered
Going Solo; Electronic Visits; Payer Credentials; Staff Medical Errors
PROS AND CONS OF GOING SOLO
QUESTION: I have been employed for the past eight years in a pediatric practice, earning $150,000 annually plus about $25,000 in perks. I never get home or eat dinner until, at best, 9 p.m. I would like to start my own private practice in a brand-new office. My accountant figures it will cost me $26,000 per month in operating expenses. I have to see 25 patients per day to pay for this monthly budget. I have some personal debt and a daughter in college interested in graduate work. Is starting a new practice a risk I should take?
ANSWER: Before making the big decision to start your own practice, explore all your options. Start by assessing where your passion is. Then determine what's truly driving your need for change.
Let me spin this out a little in the hope it will help.
Do you thrive in an entrepreneurial setting, enjoy the business side of medicine, and don't mind long hours? Then by all means, open your own practice. But be very sure you're up to this. Risk and stress go hand in hand with new ventures. Maybe you prefer not to have that pressure with a daughter in college, existing debt, and ever-looming retirement.
Seeing 25 patients a day - every day - will be hard, and you probably won't reach this level for six months to a year. This means operating at a loss at first, and even when you hit the 25-patient mark, you will only be breaking even - not coming anywhere close to your current salary, never mind the perks. Oh, and you'll have administrative duties as well as clinical duties, so your days will still be long.
Sound terrible? Then consider ways to make your current situation better.
How about finding employment at another practice? Or, if you decide to stay, can you find ways to be more productive or streamline your work flow more effectively? Would negotiating some changes with your employer increase your satisfaction? Perhaps a productivity-based bonus or getting your own PA would do the trick. You can't get what you don't ask for.
Truth be told, $150,000 plus benefits ain't bad in pediatrics, especially when you have none of the risks or obligations of partnership. That's a nice, relatively carefree job in many ways. If you want more money and more time, I'm not sure the practice you envision will provide that. But if you want more autonomy and thrills, have at it. Don't be afraid to take less pay if what you really want is to run a practice your own way.
If you're set on breaking away, hire a consultant to advise you. Work with a financial planner to reduce your debt and costs so you'll have more options down the road. Think twice about that advanced degree for your daughter - do you need to fund it? This is a chance for you to set your own priorities, rather than those of your family or others.
So really, your options aren't limited to starting your own practice or sticking it out where you are. Examine what motivates and energizes you, and do that: Change your current position, seek another employed position, or, heck, get a real-estate license if that's what you really want.
ELECTRONIC VISITS & CPT CODES
QUESTION: I've been told that temporary CPT codes were created in 2004 for Web-based evaluations. These are not for treatment via e-mail, but to provide secure links for patients to access medical data from a doctor. Do you know which CPT codes are used for e-visits?
ANSWER: The CPT code is 0074T - Online evaluation and management service, per encounter, provided by a physician, using the Internet or a similar electronic communications network, in response to an established patient's request.
The introductory text incorporates the following admonition: "Reportable services involve the physician's timely response to the patient's inquiry and must involve permanent storage (electronic or hard copy) of the encounter. This service should not be reported for patient contacts (e.g., telephone calls) considered to be pre-service or post-service work for other E&M or non-E&M services. A reportable service would encompass the sum of communication (related telephone calls, prescription provision, laboratory orders) pertaining to the online patient encounter or problem(s)."
Keep in mind that simply having a CPT code does not necessarily mean the service will be paid.
OBTAINING PAYER CREDENTIALS
QUESTION: I'm planning on opening a new office. I have only been able to be credentialed by a few insurance companies. How do I go about charging patients on plans with which I am not credentialed?
ANSWER: There are no easy answers here.
Some insurers will review partial contracts and - if you provide the missing pieces - expedite your application.
Conversely, some practices hold the billing and wait for the credentialing to be complete (not recommended, as you may pass timely filing limits). Other practices bill the physician as a locum tenens. This is usually contract-dependent, and you may want to contact the health plans you expect to credential you to determine whether this is an option for you.
Still other practices submit claims knowing they will be denied and then resubmit them once the credentialing is complete. Again, this may or may not work, depending upon your final contract language.
Some write off the work owing to "non-covered provider"; however, you obviously shouldn't pursue this option unless you have to - it will cost you too much money.
STAFF MEDICAL ERRORS
QUESTION: I received an e-mail from a patient who had come into my office for an injection. The medical assistant (MA) gave her an intradermal injection. The MA then came back and told the patient that she had actually gotten a pneumonia vaccination rather than what she needed. The MA proceeded to give the patient what she needed and told her the pneumonia vaccine was really expensive but not harmful, and then added that this matter was to be kept between her and the patient.
There is absolutely no documentation of this, and the MA told no one. What do you recommend I do? My first inclination was to fire her on the spot.
ANSWER: Oh, dear.
This certainly is a fire-able offense, especially since you found out through the patient. It's hard to tell whether this happens frequently.
I would call the risk-management contact at your malpractice carrier. This person can usually offer frank advice and give you details on how to document your decision. You might also ask for advice about how to communicate your course of action so the patient will know that you've done something about this and aren't taking it lightly.
If - for whatever reason - your risk-management contact can't offer advice, I'd have a documented conversation with your MA. Find out what happened. If it was a simple one-time mistake, OK, but I'd still develop a written compliance plan for your staff that states that any and all errors must be reported to you.
I'd also look into the processes you're using to place injection orders and locate the correct medications. Would the mistake have been made if the medication had been labeled more clearly? Or did your employee misunderstand your order? Document any improvements you make.
Responding to the possible procedural errors may be more important than responding to an individual's error. You want to make sure errors don't happen, regardless of whether this staff member is worth keeping.
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