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Your Top Questions Answered
Setting Charges; Considering Partnership; Learning to Negotiate; Billing Incident-to; Seeking Career Alternatives
SETTING CHARGES
QUESTION: We have not raised our charges in a couple of years but have seen our reimbursement increase slightly, especially for E&M codes. My net collected revenue is pushing 100 percent, and I think that the charges need to be increased to maximize reimbursement. We have looked at our EOBs for our major insurers and are now ready to make an increase in our charges. What is an easy method we can use and be able to update annually?
ANSWER: Try creating a fee schedule for all your codes based on a multiplier of Medicare RVU, usually around 150 percent. You'll want to make sure no one is paying you more than that, of course.
Then you can annually adjust the Medicare conversion factor on your spreadsheet and update all charges at once.
If your charges have been low and you have many patients paying cash or with high-deductible plans, you can step your way to higher fees or create a written policy establishing a reduced fee schedule for cash patients who pay in full at the time of service. You don't want to shock your patients.
CONSIDERING PARTNERSHIP
QUESTION: I am in my third year as a salaried employee in a three-physician practice and am looking into partnership. However, the practice situation is a little complex.
According to the business manager, the financial outlook for the practice is healthy, but I wouldn't know since I am only employed and am not privy to the information. The accounting seems a little confused.
I am currently paid $150,000, and my partner keeps telling me it's a very competitive salary. I don't know whether it's true. If I am to negotiate my situation, then who is the best person to represent and advocate for me? A mediator or a lawyer?
ANSWER: You should definitely encourage the practice to clean up its accounting and show you the data as soon as possible. You have now invested three years in this practice with the goal of becoming a partner, but you don't have any idea of what sort of business you're proposing to join. If the other physicians potentially want you on board as partner, they should start training you now on being a part of the business side as well, and it's only fair to tell you what is going on. The assurances of the manager are not sufficient.
It would no doubt be worthwhile to have a consultant clean up the systems and reporting and educate everyone on what to review monthly. The accounting really should be transparent.
Becoming a partner is a business decision. You are buying into a business, not playing a game of flattered egos and academic-style approval seeking. You should also lay down the law contractually about what your job is - hours, doing paperwork for colleagues, call schedule, productivity expectations, etc. - so you don't get railroaded later and so they know what to insist on.
As for the second part of your question, go ahead and ask salaried physicians in other practices like yours what they make. Why not? They want to know what you make, too. And this is not price-fixing.
According to the Medical Group Management Association, physicians in your specialty make a median compensation of $187,138.
Speaking very broadly, lawyers are best at reading contracts. Have one review the terms of any contract or partnership agreement. You might be able to find an attorney who can both review documents and negotiate on your behalf. If not, you might consider retaining two lawyers: one for document review, the other for negotiating.
Also, arm yourself. You need to know good financial performance when you see it, how to judge salaries and overhead, how to read reports from the practice's management system, what reports to ask for, what a typical buy-in looks like, how your productivity compares with that of your potential partners, and so on.
LEARNING TO NEGOTIATE
QUESTION: I am a pediatrician working in a clinic affiliated with a large academic faculty group.
In our office, there is insufficient room for our nurses and other staff, and at times our parking lot overflows. Our administration has been aware of the problem for some time and has promised an expansion, but this is now on hold.
I can see about 30 patients a day. We are now fully utilizing an EMR, which has slowed things down a bit for us. The current pace is barely tolerable. Yet each day my schedule fills up by morning, and we are turning patients away. This is unpleasant for everyone and is not good medical care. Our administration has failed to respond to requests to help us work out solutions for these problems. Adding provider time wouldn't be an option due to space constraints.
As a result of all of this, I asked to close my practice. I was denied. I was told that I can't close because HMO patients who've selected me as their primary-care provider have the right to see me even if I have not yet seen them and they have no appointment on the books. Is this legally correct? What are my responsibilities regarding new HMO patients? What are my options if I truly feel that taking on new patients compromises my ability to provide quality medical care?
ANSWER: Try to view everything you've described as a negotiation.
To start, you need to review your practice's HMO contract. The administration will no doubt deny this request, explaining that you don't need - or have no right - to review the documents. Perhaps you can simply see a photocopy of the language pertaining to closing the practice. Or can you see the language that explains why you can't close? There's no need to get nasty. Much of what practices think is "illegal" is merely an opinion about something someone heard once. That said, it might be absolutely true. You just need to know for sure what you are dealing with.
Ideally, of course, you will decide to keep your practice open. But it's certainly not acceptable to be forced into delivering what you consider inadequate patient care.
It is not in the interests of the administration, which doesn't want you to leave, for you to have insufficient space or access.
In any case, your options basically are: find a new job, find a way to work it out, or suck it up. The middle option is the best, unless you really think you can find a different practice that will be better.
To achieve the middle option, try to identify the administration's concerns and then attempt to propose and negotiate solutions that work for everyone.
For example, if there is a nearby practice that isn't as busy as yours, you could route patients there or have one of its providers work in your practice on a part-time basis. I understand that your office is already overcrowded, but if someone else - a physician needing more hours, or a PA - comes in from 5 p.m. to 7 p.m. and Saturdays (when you and some others are not working), there is no additional demand on space. And if you can prove that another provider working such hours would add profitability and access, isn't the administration likely to go for it?
You also need to press hard for maximum efficiency. In terms of space, can physician offices be transformed into exam rooms? You shouldn't need to use them for dictation since you have an EMR and can do real-time documentation. Set aside one small room that all physicians share for patient counseling. What happened to the space where all those paper records were stacking up? If you still have them, store them securely off site and use that space for staff or exam rooms.
As you grow more accustomed to the EMR, you'll become more efficient there, too. Spend as much time as you can entering data into the system ahead of time so that documentation happens faster at the patient visit.
In short, think it through yourself. Propose solutions to the administrators. If they don't go for them, a possible next step is to call a meeting of all physicians to share ideas and seek proposals for the leaders of the organization. Your practice surely isn't the only frustrated one. That should get their attention.
BILLING INCIDENT-TO
QUESTION: I hired a nurse practitioner for our practice with the intent of using her as an additional provider. I planned to have her credentialed. Another administrator said I was better off to bill her "incident-to" the supervising physician. Which is the more appropriate avenue? I am trying to partially offset the departure of a physician.
ANSWER: It depends. First of all, "incident-to" is a Medicare-only concept. You'll need to call or review the rules of all other payers to determine whether what I'm about to recommend applies to them as well.
By billing "incident-to," the NP gets 100 percent of the provider fee schedule. Sounds great. But certain conditions must be met.
The NP can't see new patients or even patients with new conditions. She's limited to providing services incident to the physician's or following a course of treatment the physician already established.
Also, a physician must be in the office suite while the NP is practicing. Finally, incident-to is an outpatient-only concept. It does not apply to anything done at the hospital.
If she bills under her own name, she makes 85 percent of the physicians' fee schedule but can provide any services at any time, as long as they're permitted by state license and supervision rules.
SEEKING CAREER ALTERNATIVES
QUESTION: I have been unable to practice for several years due to a rare and incurable disease. My health has stabilized to the point where I can work 20 to 30 hours a week, but I have no idea how or where to market myself. I will continue to need accommodations such as no night call and limited weekend duty. I would consider doing nonclinical work for an insurance or drug company. I love clinical practice above all else, but I recognize that most employers want docs who can do a lot of hours and a lot of nights. Private practice is not an option; I have no money to invest. In addition, I may lose my board-certified status; it requires an active license, and I had to put mine on inactive status to save money. I have a good reputation as a clinician, but since I haven't practiced in four years, it might be hard to find current references. Any suggestions?
ANSWER: Yours is a heartbreaking story. Many practices are becoming more accepting of part-time physicians, largely thanks to an influx of female physicians who insist on it while raising children.
If you indeed feel that you want to continue to practice in the clinical setting, consider telling your story to some of the larger physician recruiting firms such as Merritt, Hawkins & Associates or Cejka Search. See what they can come up with. Generally, they are happy to hear from physicians looking for work. They get paid by the hiring company.
In the meantime, look into what it will take to get your license activated and board certification renewed.
If the recruitment firms don't come up with anything, you could look at the math of opening a very small part-time practice of your own. The key to making it work is maintaining as little overhead as possible: Sublet a small space, greet and schedule patients yourself, and outsource billing. Be sure to crunch the numbers first.
Do a sort of self-analysis. If the clinical work isn't going to happen, assess what parts of it, what skills, and what interactions you like best. Can you find those in other settings? If you like to work quietly, look into acting as an editor of a journal or Web site in your field. Perhaps you could work for your specialty society. Or you might find part-time work in a hospice. Or help the airlines deal with passengers with severe anxiety. In other words, pinpoint what you love, and find other ways to do that.
Really, this isn't a limitation. It's a chance to explore endless opportunities. You just aren't accustomed to thinking about what else is out there.
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