Practice continuation agreements

I meet and talk with many physician sole practitioners. Honestly, I find them fascinating and have many as clients. Being solo provides a variety of challenges. One is succession. One thing I see out there is that solo practitioners have no contingency plans in plan should something happen to them like a disability or a death. Of the two, disability is the most common occurrence.

So to me, the biggest question they face is: What would happen if you were unable to work for a period of time, or permanently? Would your physician practice continue to operate as usual during your absence, or would it be chaos? This is why sole practitioners need a practice continuation agreement in place right now.

We all know how patients will leave the practice the longer the physician is away from it. And if the physician passes away suddenly without a practice continuation agreement in place, the value of the practice immediately drops to zero. That leaves nothing to provide for a spouse and family. The estate could also be sued if returns aren't filed in time due to a lack of a succession plan.

Do you have a practice continuation agreement in place? If not, find a colleague who would be willing to take over your practice in the event of a permanent disability or death or will cover your practice during a period of temporary disability. Protect yourself and your family.

Merging? Issues to consider.

Physicians are continuing to consolidate, as predicted. Here are a few issues you should focus on when considering a merger with another medical practice:

1. Careful review of compensation differences.  You need to look at everything including salary.  Car allowances, coverage for insurance, meetings, disability, other personal fees covered by the practice, etc. typically differ by practices.
2. 401(k), profit sharing, and healthcare plans need to be looked at carefully and a plan for integration be established.
3. Practice Valuation Model - If you are merging in a similar practice this should be easy.  If you are merging in different disciplines like Gyn Onc or Rad Onc, the perspectives on a valuation model will likely differ significantly.
4. Salaries for staff are likely different and need to be carefully reviewed.  It may force you to cap some salaries if they differ from your standard ranges.
5. You will need to involve the lawyers but work to keep them out of detailed discussions.  They will end up costing you a lot of money if they are involved each step of the way.
6. Establish a timetable with some slack time but stick to the schedule.  It is easy in busy times to defer meetings and analysis but without a schedule, the process can drag on and on.
7. If there are going to be any staffing changes that result in the merger, get these agreed upon in writing before the merger is consummated.  This applies to other key items as noted above.  If you do not have agreement in writing that certain changes are going to happen, human nature will impact this process and you will have to continue to fight for some of the changes that were agreed upon as part of the merger in the first place.
8. Establish a post merger plan and timelines for integration of billing, IT, and other services before the merger is complete.  This way you have given those involved a expectation of the changes to come versus individuals interpretations.
9. Establish a compensation plan for after the merger.  You may have to establish new departments with their own cost centers that drives differing compensation if you become more multi-specialty.
10. The easy work is the merger and getting final agreements signed.  The hard work comes afterwards so be prepared for surprises.  You will need to assure your key leaders are involved and informed and hold the course.

Do you think Stark has enforcement teeth?

You damn well better believe it because this week it was announced that Covenant Medical Center in Iowa has agreed to pay the U.S. government $4.5 million to settle allegations of health care fraud regarding the center's financial relationship with five doctors. The settlement resolves allegations that Covenant submitted false claims to Medicare by engaging in financial relationships with five physicians in violation of the federal law. The government alleged that Covenant violated the law by paying commercially unreasonable compensation far above fair market value to five employed physicians who referred their patients to Covenant for treatment.

"These physicians were among the highest paid hospital-employed physicians not just in Iowa, but in the entire United States," the U.S. Attorney''s Office said in the release.

For the local article on this, go to:

http://www.wcfcourier.com/articles/2009/08/25/news/breaking_news/doc4a94156271f78380125347.txt

 

How can a health care provider apply for and obtain a National Provider Identifier (NPI)?

I’ve covered this ground before but it seems the question still arises. A health care provider may apply for an NPI in one of three ways:

1. Apply through a web-based application process – this is the easiest and fastest way. The web address to the National Plan and Provider Enumeration System (NPPES) is https://nppes.cms.hhs.gov.

2. If requested, give permission to have an Electronic File Interchange Organization (EFIO) submit the application data on behalf of the health care provider (i.e., through a bulk enumeration process). If a health care provider agrees to permit an EFIO to apply for the NPI, the EFIO will provide instructions regarding the information that is required to complete the process. More information on this option is available at: www.cms.hhs.gov/NationalProvIdentStand/04_education.asp#TopOfPage.

3. Fill out and mail a paper application form to the NPI Enumerator. A copy of the application form (CMS-10114), which includes the NPI Enumerator’s mailing address, is available only upon request through the NPI Enumerator. The NPI Enumerator’s phone number is 1-800-465-3203 or TTY 1-800-692-2326.

When applying for an NPI, providers are encouraged to include their Medicare identifiers, but also those issued by any other health plans. If reporting a Medicaid identification number, include the associated State name. The legacy identifier information is critical for health plans in the development of crosswalks to aid in the transition to the NPI. Once the NPI application information has been submitted and the NPI assigned, NPPES (or an EFIO, if the health care provider was enumerated by way of an EFIO) will send the health care provider a notification that includes their NPI. This notification is proof of NPI enumeration and provides the information that will enable trading partners to verify a health care provider’s NPI.

Inspire the front desk staff

As I have mentioned many times over, I believe the front desk is arguably the most important position in a physician’s office. As such, you should always look to inspire these people to provide exceptional customer service. For example, by them (and everyone in the office) the book entitled Five-Star Customer Service: A Step-by-Step Guide for Physician Practices. It can be found at http://www.hcmarketplace.com/prod-3688/FiveStar-Customer-Service-A-StepbyStep-Guide-for-Physician-Practices.html. Have your staff listen to a set of CDs called How To Handle Difficult People http://www.pryor.com/mkt_info/products/4.asp.  

 

Also remember the “touchy feely” things work very well with employees. Send your front desk people e-cards to thank them for exceptional work. And it never hurts to bring in small gifts, baskets of candy, lotions, etc. This is always a good moral booster and lets them know that you appreciate them and the hard work that they do on a daily basis. Finally, as you well know, praise is always a positive message to the staff.

Internet based credit card processing

If you accept credit cards in your medical office, take a look at an internet-based option called Medireceipt (www.medireceipt.com).  Not only will it save you money on credit card processing fees, here are a few other things you might like about it:

First, your check-in/check-out staff will like un-cluttering their desks by getting rid of the credit card units.  Second, anyone at any terminal can take a co-pay without having to move from their seats.  You can eliminate renting credit card at anywhere from $10-15/unit/month.

Third, the reporting is better.  You can use it to tie out your cash, checks, and credit cards every day.  hYou can ave a single summary report rather than one for each terminal. Finally, you can use the same process to do electronic check processing.

Technical revenues, incident to, and Stark

Keep in mind there is an "incident to" aspect of the Stark in office ancillary services exception, the exception that applies to the technical component. As I understand it, if the technical service is "incident to" the physician's professional service, then it can be included in the physician's personal productivity part of the formula. If the technical service is not "incident to" the physician's professional service, then it must be included in the Designated Health Services earnings that are distributed in a manner which does not take into account the volume or value of the physicians' referrals. In distinguishing between technical services that are "incident to" a physician's professional service and ones that are not, one must navigate the "supervision" requirements.

Stark generally defers to the Medicare billing rules on the level of supervision required, although it does specify that the physician(s) who must supply the appropriate level of supervision for billing must be either the physician who orders the test or another physician in the same group practice. The levels of supervision required by the billing rules are something I have to revisit each time I'm faced with this issue for a client. My head is beginning to hurt just laying this much out, and I'm doing it primarily to hear from others on your thoughts on this subject.

The soundest advice I can give is that if you want to give direct credit to any physician for technical revenues, you might want to retain legal counsel experienced in the Stark law as it applies to physician practices to ensure that whatever compensation formulas/methods you devise will be Stark compliant.

Management Practices That Spell Doom

There was an excellent article in a recent issue of Business Week which addressed the issue of well-intentioned but misguided managers (are you listening medical practice administrator?) who are sinking their employers because they don't understand the science of human behavior. Boy is this sure true (and that is why I’m a solo practitioner – I certainly couldn’t figure it out and really didn’t want to!). The following is a brief excerpt from the article with a link to the full article. If you are in managing people, read it:

With executives under fire for driving their companies into the ground—and taking the economy with them—it's time for a managerial paradigm shift that focuses on the root of all booms and busts: individual behavior. Many time-honored management practices, such as layoffs, yearend bonuses, and automatic pay raises, actually reward employees' bad habits and punish good behavior, often with devastating results.

These practices stem from theories of performance that have little to do with the science of learning. As such, they result in many mistakes initiated by senior leadership at great cost. They're endorsed for the best of reasons but fail to lead to the desired result.

So why do so many organizations continue to embrace faulty practices? My 30 years of experience with Corporate America have led me to believe most business leaders are trained in the math of balance sheets, not the science of human behavior. They don't understand that you can't change organizational behavior without changing human behavior. Only when managers understand the basic principles of behavioral science and apply them skillfully will they realize the full potential of their employees and their organizations.

http://www.businessweek.com/managing/content/aug2009/ca20090811_861931.htm?chan=careers_managing+index+page_top+stories

Discourage complainers to encourage five-star customer service

Everyone has been involved in a group that included complainers, and everyone knows that complainers love company. Get rid of them. If your complainers are physicians, have a serious discussion with them about change.

For example, a manager at the Ritz-Carlton explains that complainers simply do not last long at the Ritz. They are not fired-rather, they become frustrated because their coworkers won't give them the time of day. The message is clear: If you are a naysayer or a complainer, you simply will not fit in the five-star culture, and you will need to change or leave. Let these employees go to your competitor. Complainers negatively affect your culture, and you want staff to be positive. Of course, be sure to follow office employment policy and procedure and state and national laws and regulations.

Choose the best type of advertising for your open position

The right type of advertising for an open position, especially for leadership roles, can effectively reach potential candidates. However, it can be expensive, depending on the publication in which you choose to post your position, and you may end up spending unnecessary time speaking with candidates who will not fit well with your practice. Consider the advantages and disadvantages of the following three types of advertising:

Journal advertisements. Journal advertisements have become a popular sourcing avenue. Most medical specialties have specific associations that publish journals, which can be great places to advertise your available position. Although this can be effective, it may take as long as three months to receive responses. Be aware of the journal's deadline and make sure to send in the ad far enough in advance to get it printed in the next edition.

 

Local, state, and national professional societies. These venues have a much faster turnaround than do journals. Once you post your opportunity on one of the societies' Web sites, you will receive access to the job-finder portion of the site, and you can then contact respondents immediately. When placing an ad of this type, make sure to list all of the position's requirements. Doing so can unofficially screen unqualified candidates, which will save you time and money. Like a journal, this type of advertising is not always as targeted or focused as other methods can be, such as local and state newspapers.

 

Websites.  I’ve had great luck at monster.com and careerbuilder.com. Also check out:

http://www.ihirehealthcareadministration.com/