For doctors, choosing the right malpractice insurance and insurance carrier are crucial decisions. They need coverage that is affordable, tailored to their specific requirements, and provided by a financially sound company whose judgment they trust.

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Here are answers to some basic questions and answers about malpractice insurance. 

The ABCs of malpractice insurance

Q: I’m confused about the  various Medicare preventive visits. The Initial Preventive Physical Examination (IPPE) and annual wellness visit (AWV) list depression screening (G0444) & alcohol screening (G0442) in the CMS documents online, but doesn’t CMS forbid the use of these codes during welcome to Medicare and initial wellness visits?


	
	A:  There are several documents on the CMS website outlining the IPPE and AWV service and the required components of those. Some just list all the potential “other Medicare Part B Preventive Services.” But you are correct about the G0444; that is bundled into both the G0402 and the G0438. 

You can bill G0444 with a G0439, the subsequent AWV, which does not list depression screening as a required element.
	
	But none of the AWVs or the IPPE specifically name alcohol screening or counseling- and neither the G0442 or the G0443 is currently bundled with these codes, suggesting that they can be billed along with the G0402. G0438 and G0439. The IPPE does mention alcohol, tobacco and other drugs under “Review the patient’s history”, but that’s not the same as counseling.
	
	However, the health risk assessment (HRA) that is required for the G0438 and G0439, includes a review of Psychosocial and Behavioral risks-which would surely include alcohol. And the questions in the standard HRA are enough to score a patient’s risk. If taken out of the HRA-and set up as a discrete screening section in the chart with some actual detail and, of course, time documented-this could support a G0442 in addition to any of these codes.
	
	You would likely only do this with patients that scored positive, and not make this a routine part of IPPEs or AWVs.
	
	

Q: I was wondering if you could provide guidance on using time for coding when the time is 20 minutes since that is exactly between the 15 minute/99213 and the 25 minute 99214?  I am running into this quite often because they have changed most of my appointments to 20 minutes. 
	
	I have been billing anything 20 minutes or less as 99213 and 21 minutes to 30 minutes as 99214.  If it is case by case based on insurance that the person has (which I do not have time to look up for every patient) then should I just use the lower time frame every time?

  It would appear that based on your comment about “insurance” that you are at least vaguely aware that governmental and commercial payers may do this differently.
	
	The bad news is that Medicare has pretty clearly said that the “midpoint” rule (meaning more than halfway between two time listed as below qualifies you for the higher code) does not apply to evaluation and management (E/M) codes.
	
	The AMA and the CPT manual do endorse the midpoint rule. Medicare specifically doesn’t for E/M codes.
	
	At least for Medicare/Medicaid and TRICARE, if you are between two typical times you have to use the lower. For commercial payers you could go with the midpoint, i.e., 21 minutes being enough for a 99214.
	
	But providers rarely have perfect knowledge of a patient’s insurance, so the safe play is to stick with 25 to 39 minutes for a 99214 based on time, for everyone.
	
	This is changing for everyone in 2021. The AMA is redefining some time parameters for the office visit codes 99202-99215. This would appear to eliminate the ‘midpoint’ rule for commercial payers. So stay tuned.

Explaining what can and can't be done for an initial visit.

Clearing up preventive visit confusion

Mergers in healthcare are nothing new, but sometimes they can go too far.

Medical Economics cartoon: When mergers go too far

Managing patients with multiple chronic conditions-who, according to the RAND Corp., account for about a quarter of the U.S. population but more than two-thirds of healthcare costs-is critical to success in value-based models.
	
The only problem? The health system was purpose-built for episodic care rather than the ongoing, community-based care this population typically needs.
	
To learn more about the challenges of managing chronic care, Sage Growth Partners conducted a survey of over 100 healthcare leaders in early 2019. Respondents were roughly equally divided between health system executives and leaders of physician practices.
	
What we found is a large gap between need and ability. While virtually all (98 percent) respondents believe chronic care management is very important, only about half (53 percent) say they’re doing it very well.
	



	
What’s getting in the way? Respondents say their main barrier is insufficient human resources (61 percent), followed by inadequate reimbursement (52 percent), and capital constraints (35 percent).
	
It’s not surprising that managing the care of those with chronic conditions is difficult. Nor is it surprising that-despite the emergence of thousands of new technology solutions-respondents think people are essential to managing care:

71 percent of respondents say that an even mix of people and technology is needed to drive care management success, while 19 percent think staffing is more important than technology.

Over two-thirds (69 percent) of respondents believe a trusted relationship with a nurse or other clinicians is central to managing chronic conditions, and 76 percent say these relationships are extremely likely to improve patient loyalty.

Overall, the industry is sober about its ability to manage chronic care and readmissions, and hospital executives are less sanguine about their abilities than are leaders of physician practices:

Only 4 percent of hospital leaders say they manage care “extremely well,” compared with 29 percent of physician leaders.

Only 24 percent of hospital leaders rate their effectiveness at preventing readmissions as very/extremely good, compared with over half (56 percent) of physician group leaders.


Why is there such a big gap? The survey findings reveal that only 20% of hospital executives believe office-based care is most important, compared with 75 percent of those running physician practices. That indicates that physician leaders view office-based care as key to managing chronic conditions, while hospital executives appear to place a greater value on home-based care. Or, perhaps, physicians feel more in control of care delivered outside the hospital than do hospital leaders.
	
Where both groups agree: telephonic nurse outreach is the second most important type of care.
	



	
The CMS Chronic Care Management (CCM) program has been available since 2015, when CMS established new reimbursement codes to cover the cost of managing chronic care remotely. While this was a step in the right direction, it appears that only a small percentage of Medicare patients are actually receiving care under these codes.
	
The survey findings indicate that CCM reimbursement isn’t sufficient to cover the costs of delivering care in this program. Many providers struggle to enroll enough patients in this program to cover their staffing and technology time and costs. And even a number of chronic care management companies have folded because they couldn’t make the model work.
	
Creating a pool of experienced nurses that can work closely with physicians’ staff to give the higher acuity patients the extra support they need-to catch problems early so they don’t become crises-is key. It’s also important to have technology that can readily integrate with the EHR so that physicians don’t waste precious time getting the program up and running.
	
When programs are implemented effectively, health systems with 1,000 enrolled Medicare patients can generate an additional $500,000 in annual revenues, without spending a dime up front.
	
The challenges of delivering chronic care are multiple and significant. But for those who can operationalize this care model with the right combo of people and technology to make a program work, the rewards can be great.

Why chronic care management isn’t gaining traction

Burnout has become as much a part of medicine as the stethoscope, with too many doctors feeling overworked, over-regulated, and underappreciated. The result is physicians retiring early, changing careers, or losing their love of medicine at a time when there is already a shortage of primary care physicians.
	
	In the Medical Economics 2019 Physician Burnout Survey, 92 percent of respondents indicated they have felt burned out from practicing medicine at some point in their career, 68 percent said they are burned out right now, and 73 percent said they have thought about quitting medicine. Despite the prevalence and scope of the problem, only 13 percent plan to seek or have sought professional counseling.  
	
	Solutions are elusive, because the causes can vary by specialty, location, or practice, and doctors rarely have any control over contributing factors like regulations or EHR design. But that doesn’t mean all doctors have given up or are willing to tolerate the status quo. In fact, as burnout has become increasingly common among physicians, so, too, has the fight against it.
	
	Here are the stories of seven health professionals and what they are doing to battle burnout in the profession.

Gabe Charbonneau, MD, experienced burnout in 2009 when the demands of practice limited the time he and his wife, also a practicing physician, were able to spend with their new son. When the family grew to three kids, something had to change. His solution was to share a practice with his wife, so that one of them would always be at the practice while the other was with the kids.
	
	“It was super scary, but the best decision we ever made,” says Charbonneau. “We gave up a massive amount of income and had to throw some material things overboard, but our quality of life went way up.”
	
	From there, he began to think about how he could help other doctors fight burnout. “I met so many people who were intelligent, smart, and good doctors, but they were stuck with issues that were insurmountable,” says Charbonneau. “I had an idea that I needed to come up with something symbolic that would give hope to these smart people that they could get to a better place than where we were stuck.”
	
	The result was an image of the Rod of Asclepius being lifted out of the ashes by a phoenix that he printed on a shirt and displayed on his website, fightburnout.org. The American Medical Association wrote an article about his efforts, interest in the shirts and the cause grew, and now he describes himself as “an accidental person who became an expert on burnout.”
	
	He hopes that his efforts lead to greater awareness of the problem, and that employers will take a hard look at physician workloads and start indexing their burnout so they can measure progress-or lack thereof.
	
	“Leaders often talk about well-being and burnout, but it doesn’t make it onto their financial spreadsheets,” he says. “They offer wellness classes and nice things that are supposed to be helpful, but there is no accountability for physician well-being. They can make a decision in the boardroom that can destroy their doctors, because they are chasing after every dollar.”
	
	One proven solution for reducing burnout is to have physicians meet in a social setting outside of work to share experiences, where they can see they are not alone in their feelings and can share coping advice, he says. There is also a doctor-to-doctor peer support group on Facebook if no local group is available.
	
	“I throw down the challenge that all of us need to start to help unravel this problem before we lose more good physicians and drive them out of medicine,” he says. “I know we can do better. As a society, we have to own this problem.”
	

Tyree Winters, DO P
	Pediatrician, Morristown, NJ

Tyree Winters, DO, wanted to be a physician since he was five, with a great desire to help others. “But then you get out there and realize it can be a thankless job,” says Winters. “Even though you want to help people, sometimes as much as you do, it’s never enough.”
	
	His loss of interest created an internal conflict: What do you do when you’ve wanted to be a physician your entire life only to achieve your goal and realize that maybe it wasn’t the best choice?
	
	The breaking point came about five years ago. His mother had just passed away, and the next day, while trying to be both an administrator and filling in as a pediatrician, he diagnosed a child with a cold and offered the mother advice on basic care measures that would help. The mother was furious, telling him, “You don’t care about my child. You physicians don’t care about anything.”
	
	“It was the perfect storm,” he says. “I was thinking to myself that I don’t want to do this anymore.” Winters accepted the fact that he was burned out and needed help, not only by seeking counsel, but also in identifying what his passion was. He found a different way to reach his dream of helping people.
	
	“Even if I’m not seeing patients, I’m doing things like teaching and attending community events, using my medical degree to educate people to make an impact in their lives,” says Winters, who is medical director of the Healthstart Pediatric Clinic and associate program director of pediatric residency for Atlantic Health System. “That’s what motivated me to get over the feeling of burnout. I’m not immune to burnout, but I want to get up in the morning.”
	
	Winters says medical students need to be educated on the challenges of being a physician and the risks of burnout. “They need to be able to seek help-not even professional counseling, but just surrounding themselves with individuals who are going through the same thing. There’s an unwritten rule where doctors are taught to believe if you are not able to handle things, then that’s a weakness. So people keep it to themselves and we need to get over that stigma.”
	
	Winters says doctors don’t always recognize signs of burnout in themselves, such as apathy, or coping through alcohol or food. “They write it off as just having a bad day or just needing some sleep,” he says.
	
	Physicians need to focus on what brings joy in their lives and find a way to escape from the rigors of their day. He recommends finding a couple of hours to do something that isn’t work-related, whether it’s exercising, binge-watching Netflix, or in his case, dancing.
	
	“Doctors have to be able to step away and just live their life,” he says. “And don’t be afraid to be open and direct with your supervisor or department chair to tell them you are starting to feel burned out and that you are looking for advice. You might be surprised how a lot of institutions respond.”

president for clinical education, Philadelphia

Smith leads the ACP’s efforts to demystify and build awareness about burnout, including how physicians can identify warning signs in themselves. “We need to fix the water clinicians are swimming in,” says Smith. “We know medical students are more resilient when they start medical school, but their risks increase as they complete their training.”
	
	She says it’s important for doctors to recognize burnout in colleagues, because it can be contagious, spreading through an entire staff. “It is part of your responsibility to not only identify and address it when you see colleagues suffering, but to also help intervene and fix the overall culture.
	
	“The overall causes of burnout are a workload where people keep adding more and more things to front-line clinicians, but nothing gets taken away,” says Smith.
	
	Physicians should look for sudden changes in behavior in their colleagues as a warning sign that all is not well. “If someone who was outgoing and is now withdrawn, that can be an indicator,” says Smith. Missing meetings or conferences, or even not answering pages can also be a sign of potential burnout. Physical pain, difficulty sleeping, changing appetite or a crisis of confidence are other warning signs.
	
	“They may have a lack of confidence in their work that comes from a sense of powerlessness because they can’t change things or make things better,” she says. “They may become more cynical, be quick to anger or have relationship problems or trouble getting along with family or friends.”
	
	The ACP has resources on its website for physicians who feel burned out and has trained a cadre of 160 members around the country to fight burnout. “Our message is, don’t worry, you are not alone in this,” says Smith. “This is a common issue and a problem that everyone needs help with sometimes. We encourage them to reach out to a friend, a colleague or call their employee assistance line-whatever they feel comfortable with.”
	
	In addition, the ACP is looking to patients as allies in fighting burnout. “The same things that bother doctors are bothering patients,” says Smith. “They want more time together. We think if we join forces with patients and patient advocacy groups to reform healthcare delivery, we might be successful.”

Marie Brown, MD
	Internist and AMA practice transformation officer, Oak Park, Ill.

Brown says that many organizations are well intentioned when they set up mindfulness training or yoga classes for physicians, but that while such programs may be helpful in some regards, they can also contribute to burnout.
	
	“Offering classes without fixing the working environment just sends the doctor home an hour later and exacerbates their time away from their family, and takes away time that could be used for exercise or sleep,” says Brown. “We also know burned out physicians write more prescriptions, send out more referrals, make more errors, order more tests, and have higher readmission rates. In every other profession, the higher the education level, the more control the person has over their day and the work they do, with the exception of physicians.”
	
	Brown focuses much of her efforts on helping doctors find small solutions to free up more time. “They often say, ‘What can I do, I can’t fix the whole system?’” says Brown. “What I suggest is to begin by looking at their practice and the things they control.”
	
	For example, Brown changed how she prescribes medication for chronically ill patients. It’s common to write a prescription for three months with one refill, so physicians are refilling the same prescription every six months. She suggests changing that to three months plus four refills, so that doctors are writing the prescription once per year. “If you do that, six months from now, the number of refills decreases by half,” says Brown. “With that extra hour, you can stop drowning long enough to see what else you can do.”
	
	Another area to examine is the EHR.  Brown says doctors need to look at all the notifications they are receiving. She turned off discharge summaries and notifications about tests that did not include results.
	
	“I decreased my inbox by about 50 percent,” she says. “It doesn’t take any resources and doesn’t cost a lot of time. When you are at your wits end, this is something you can do tomorrow.” She also encourages physicians to seek peer-to-peer training on using their EHR more efficiently.
	Whenever possible, make sure patients who require lab work have their labs completed before the visit. “That way when you see them, you’ll have everything you need to have a discussion,” says Brown.
	
	“The greatest driver in preventing burnout is being able to deliver quality care, but there are so many obstacles that stop us from delivering it,” says Brown.

Adam S. Holzberg, DO, FACOG
	Urogynecologist, director of physician engagement, Rowan University School of Osteopathic Medicine, Stratford, NJ.

“If you do not have engaged physicians who have a vested interest in being there five years from now, you are not going to be able to provide a good patient experience,” says Adam S. Holzberg, DO, adding that healthcare organizations that want to improve their patient experience must tackle physician burnout. “Every study has shown that if you have engaged providers, the patient has a better experience and that results in better outcomes.”
	
	Healthcare administrators must start by measuring burnout in their organization. They should do this by enlisting an outside company to survey the doctors, says Holzberg. “You have to be willing to then act on it and create an action plan,” he says.
	
	Progress is possible when leaders take the time to listen. In a prior position, Holzberg helped move the physician engagement scores from the 24th percentile compared to the national average to the 73rd percentile in less than five years. “It wasn’t because we gave them so much more, we just listened to them,” says Holzberg. “We had good methods of communication.”
	
	The organization created a blog to keep physicians up to date on changes. It included a way for doctors to make suggestions on how to improve working conditions. Doctors always got a response to their suggestions, even if they weren’t feasible. “You can say no with a good explanation-you would be surprised at how much they appreciate that compared to no response at all,” Holzberg says.
	
	Listening is a great way to reduce burnout. “There’s not a lot that providers want,” says Holzberg. “They want to take care of patients, have a say in the plan for the organization, and have some recognition for what they do. They want to have the supplies and tools they need to do their jobs and do it without a lot of obstacles. If you pay attention to a lot of that, you will be surprised at how much difference it can make.”

Lakshman Swamy, MD, MBA
	Pulmonary/critical care fellow at Boston Medical Center


	
	Swamy was a third-year medical resident working nights with two small children at home when burnout hit him. “I became very cynical and laughed about a lot of things-beyond the gallows humor physicians typically use to get by,” he says. “I was falling apart, getting less sleep, and I felt like I was failing with my patients and at home.” He says his work was becoming shoddy and he was being selfish and passing patients off to the next shift.

“It was unprofessional and a really bad spot for me,” he adds. “The big takeaway is, at the time, I could not have told you it was because I was burned out. I couldn’t recognize it in myself, and if I had done so, there were innumerable supports that could have helped.” When he rotated off that shift, his situation improved. Now, he advocates for doctors to look for signs of burnout in each other and to take action when they do.
	
	He advises doctors who suspect a colleague might be heading for burnout to meet with them outside of work to discuss it. “Say, ‘Hey, is everything OK?’ or use other open-ended questions,” says Swamy. “You don’t have to say burnout, because people are often sensitive to that. They might be defensive in the moment, but it lays the groundwork to actually talk to them.”
	
	Speak with them alone, he adds, and not from a position that implies they are unable to do their job. If there is no personal relationship, talk with someone who knows them better and tell them about your concerns. For residents, Swamy advises speaking to the chief resident, but choose your words carefully.
	
	“There’s a big stigma speaking about mental health in medical culture, and burnout relates to that” says Swamy. “If you are in a world where you cannot show weakness and someone is very clearly suffering, the answer is not to go to their seniors and effectively say you think they are weak.
	
	You never want to throw people under the bus.”
	
	While he appreciates employers providing yoga or massages for physicians, those do not address the root causes of the problem. “I personally find a lot of wellness in running and doing yoga, but that doesn’t address the root cause of sitting in front of a computer going mad trying to click all the boxes.
	
	“Burnout is a symptom of an incredibly broken healthcare system,” says Swamy. “It needs addressing, but the root causes are deep and pervasive."

Physicians fight burnout

In a small Kansas town, an independent medical practice is taking an innovative step to attract talent.
	
	The practice owner and his team of six clinicians believe they need at least one more physician but expect the position will be part-time, at least at first.
	
	The owner developed a training program with a local hospital that allows newly-hired physicians to get hours at the hospital, thereby creating the equivalent of a full-time position attractive enough to draw high-quality applicants, says Jillian Schneider, MHA, manager of practice support at the American College of Physicians, who has worked with the practice.
	
	Many practices have difficulty recruiting and retaining clinical staff, but small and independent practices often face the biggest challenges as they try to compete for talent against larger entities that are better able to promote all they can offer. Small, independent and rural practices don’t have as many recruitment and retention resources.
	
	They typically aren’t able to offer compensation packages as generous  as larger or system-owned practices, or offer the high-profile work environments found in urban research healthcare centers. They might not even have a full-time schedule to offer to start, as the Kansas example illustrates.
	
	Management experts stress that a well-crafted plan can help these practices be more successful in hiring the right people, ensuring the longevity of their practices, and ultimately serving their patients in the most efficient and effective manner.
	
	“At a small practice, there’s only so much money that can be spent on compensation, so they have to consider the types of the benefits they can offer, like flexibility and work-life balance. Those are big perks that money can’t buy,” Schneider says.
	
	


	
	Smaller, rural, and independent practices can be particularly hard-pressed to attract qualified candidates, says Travis Singleton, executive vice president of Merritt Hawkins.
	
	These practices sometimes struggle to attract physicians and other clinicians because prospective employees are often unfamiliar with smaller practices, how they operate, and why they can be good places to work. Singleton says younger physicians typically train at hospitals or in larger practices affiliated with healthcare systems, so they’re only familiar with practicing in such settings.
	
	To attract physicians, Singleton says independent practices should search for candidates who come from rural areas and are therefore likely familiar with life in those areas, the sense of community they can offer and perhaps even how healthcare practices in those areas operate. Practices should use professional networks, medical schools, or physician associations to identify clinicians who fit that profile.
	
	That’s just the first step,  however. Independent practices also should work with medical schools or regional medical associates to attract potential candidates. “Physicians in small and rural practices should be reaching out to schools, saying, ‘We want students to come to us. We want them to learn about small-practice medicine, rural medicine, so let’s form programs so they can be exposed to this kind of environment,’” she says.
	
	Russell Kohl, MD, had a solo family practice in rural Oklahoma from 2006 to 2012. He relied on networking to help attract candidates when he had positions to fill. But he also worked with his local vocational high school and area colleges, offering to be a preceptor for nursing students.
	
	“Some physicians say they don’t want to be a training center. Some might think it slows down the practice. But if you think about it as an on-the-job interview for both-you get to see these people, they get to see the culture of your practice-then you realize you both really get a feel for whether it’s the right fit,” Singleton says.
	
	Indeed, Kohl, who now practices in Stilwell, Kan., and is a director of the American Academy of Family Physicians, had hired a nurse practitioner and two licensed practical nurses from the training programs he had established with area schools when he was still with his previous practice in Oklahoma.
	
	


	
	An attractive compensation package includes a competitive salary and standard benefits, such as health and dental insurance as well as paid time off for vacations, sick days, and bereavement. Schneider acknowledges that small and independent practices often don’t have the money to fund a new position as soon as they recognize the need for more staff, so she advises practices to plan strategically so they can start budgeting for new positions a year or two in advance of recruiting and hiring.
	
	To ascertain the compensation that other practices in their region offer, practice owners can look at compensation surveys, such as those done by the Medical Group Management Association (MGMA), and talk to colleagues, says Nick Fabrizio, Ph.D., FACMPE, an MGMA principal consultant.
	
	“One of the best strategies is to talk with others. People will share what they’re paying, or share a range. That gives the hiring physicians the best benchmark,” Fabrizio says.
	
	He notes that physicians don’t have to offer the exact same compensation package that others in their region do, particularly because small practices generally can’t afford to match the benefits packages offered by the largest healthcare systems. Still, Fabrizio says the practice must be close to what others in their area are offering. That could mean a higher salary but a less generous benefits package, or vice versa.
	
	

Have options on employment, ownership arrangements


	
	While salary is important, small practices also can attract and retain staff by structuring compensation to reward hard work or finding other ways to boost the total compensation package.
	
	“Even more important than competitive pay is providing employees a sense of how they can earn more,” says Laurie Morgan, MBA, a practice management consultant and partner at the practice management consulting firm Capko & Morgan.
	
	She suggests creating bonuses for clinicians who meet productivity goals. “Creating that type of job structure, and then communicating it clearly, can be a powerful way to compete against larger organizations with more cookie-cutter employment policies for doctors,” she says.
	
	Kohl established a profit-sharing program for employees, which became an effective tool for retaining staff and boosting practice efficiency. “It made my employees very creative in getting work done. They were very focused on being effective and efficient, so we could do all the procedures we needed to do,” he says.
	
	Similarly, Singleton advises practice owners to be open to various types of employment arrangements. He points out that many physicians don’t want to be practice owners, so there should be a career path for them, as well as an option for those who want to become partners.
	
	Practices should also determine ways for their clinicians and members of the support staff to grow professionally, Morgan says.
	
	“Not all employees are interested in doing the same job forever; many people are aiming to progress. Enabling employees to pursue more education conveys that your practice is investing in your staff,” she says, adding that investing in continuing education can also save the practice money over time.
	
	“The cost of the training plus a raise and promotion for the employee could be less than the salary you’d wind up paying an external hire. And you likely foster more loyalty in that employee you invested in,” she says.
	
	Kohl says he used professional development opportunities as a recruitment tool. He encouraged members of his clinical team to pursue further education, and he worked with those who continued their studies to create schedules that gave them time to take classes while still having the practice adequately covered. As a result, he retained top talent and his practice gained more skilled employees.
	
	


	
	During his years running his small practice, Kohl says he learned that staff members often didn’t use the benefits he expected them to need, but did want some degree of individualized benefits.
	
	For example, he found that most of his staff didn’t need health insurance because they were covered by their spouses. Some, however, were more interested in flexible hours or more vacation time. Kohl says he sought to learn what his staff members valued most and tailored what he offered to each as a way to help retain them.
	
	“One of the benefits of having a small practice is you have the flexibility to meet [employees’] needs. That’s a big selling point, particularly for younger physicians who are raising kids or still going to school,” he adds.
	
	Practice owners should determine what benefits or perks they can offer, such as flexible schedules, and highlight those to prospective employees.
	For example, practice owners could allow new physicians to hire their own care teams, determine how broad to make the scope of their practice coverage, and even set their office hours, Singleton says.
	
	“That control goes a long, long way in recruiting and retaining physicians,” he says, citing a group of physicians that decided to join an independent practice where they’d make less money but could have more say in the way they provided care for their patients.
	
	Management consultants say practice owners also should emphasize the unique qualities or professional opportunities that their practice offers as a way to attract clinicians seeking professional experiences different than those offered in larger settings.
	
	For example, Schneider says, rural practices can sell the fact that their physicians  generally practice a broader range of medicine and that they’re often a bigger part of these communities than their suburban and urban counterparts.
	
	


	
	While management consultants say small and independent practices should use individualized employment packages as a way to recruit and retain top talent, they advise practice owners to establish policies and procedures regarding available benefits so that even if employment packages are individualized they won’t seem capricious. 
	
	Fabrizio says practice owners who want to recruit and retain skilled professionals need to focus on being good employers- not just good healthcare providers. He adds: “Be the best employer you can be. Respect your staff, be responsive to your staff.”

Even small practices can get top talent with the right recruiting strategies.

How to attract provider talent to your practice

The clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide to just trust your instincts and go with a code that feels right so you can move on to the next patient.
	
	Choosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making (MDM]-or time spent counseling and coordinating care) for each E/M level.
	
	If physicians don’t document these elements adequately-or the elements they document don’t make sense given the patient’s presenting problem (for example, performing a comprehensive exam for a patient with a sinus infection)-payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.
	
	It’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity-a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, CEO of Alpha Coding Experts, LLC. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.
	
	

Focus on quality E/M documentation-and the dollars will follow


	
	Knowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services they rendered and why.
	
	Only two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established.
	
	Sound confusing? Experts agree that even the most experienced medical coders find it hard to translate physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians-lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component.
	
	We asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said.
	
	


	
	When billing a level 4 or 5 new patient E/M code (i.e., 99204 or 99205), remember to document one specific item from the past medical history (i.e., illness, operations, injuries, treatments, medications, or allergies), one specific item from the family history (i.e., medical events or hereditary diseases that place the patient at risk), and one item from the social history (e.g., use of tobacco, drugs, or alcohol).
	
	Also document a review of systems that relates directly to the problem identified in the history of the present illness (HPI) in addition to a review of all additional body systems, says Elhoms. Physicians frequently forget to include all of these elements, often leading payers to down-code these services to a level 2 or 3 on post-payment review, she adds. That means physicians could lose as much as $133 per encounter.
	
	Similarly, when billing a level 3 new patient E/M code (i.e., 99203), don’t forget to document one specific item from either the past, family, and/or social history that’s directly related to the problem in the HPI. Omitting one or more of these details usually prompts payers and auditors to down-code the service to a level 1 or level 2 on post-payment review, says Patel. Revenue loss in this case could be as much as $64 per encounter.
	
	Be as descriptive as possible when documenting the HPI. Specify the location, quality, severity, timing, context, modifying factors, and associated signs and symptoms that are significantly related to the presenting problem, says Patel. These descriptors help physicians gain points when choosing an E/M level, she adds.
	
	Don’t repeat the same HPI for every visit. This is true even for follow-up appointments related to chronic conditions. Payers want to see what’s new with the patient-for example, new pain, new flare-ups, new concerns, or new lab results-or acknowledgement that the patient has been stable and symptoms are controlled, says Patel. Repeating the HPI could be a red flag that a physician is cloning their documentation, she adds.
	
	


	
	Only review body areas or organ systems that affect MDM for the current encounter, says Michael Miscoe, JD, CPC, founding partner of Miscoe Health Law LLC in Central City, Pa. Most subsequent visits, for example, don’t require a multi-system exam even though it’s very easy in an EHR to pull this information forward from the initial visit. Doing so inflates the E/M level and could expose a physician to audit risk, says Miscoe. “More isn’t necessarily better,” he adds. “Because many docs either don’t understand this or let their EHR system flood the record with irrelevant content, we see skewed E/M profiles that lead to post-payment liability.”
	
	Explain negative findings. Miscoe says documentation should reflect the following: For example, what did the physician specifically ask the patient about each body system, and how did they respond? How did this contribute to the physician’s overall assessment and evaluation? In the examination, what element of the organ system did the physician evaluate, and why? Physicians who don’t explain their analysis in the context of the patient’s complaints often end up with what Miscoe terms “healthy sick people records” (i.e., level 4s and 5s with mostly negative findings and no explanation of why the physician performed certain services) that tend to raise a red flag with payers and auditors.
	
	Know whether your Medicare Administrative Contractor (MAC) uses the 1995 or 1997 E/M guidelines. These guidelines differ in their options for the exam component of the E/M level, says Patel. More specifically, the 1997 guidelines provide additional options for single organ system exams, allowing providers to report higher-level services for intensive, problem-specific examinations. Once you know which guideline your MAC uses, ensure that your EHR vendor incorporates them into any templates you use, she adds.
	
	


	
	Know how payers calculate the MDM. “MDM is all about the cognitive labor a physician puts into the encounter,” says Elhoms. This includes the number of diagnoses and management options considered, the amount and/or complexity of data reviewed (e.g., urinalysis, EKG, lab results, or additional workup planned), and the risk of complications, morbidity, or mortality. Therefore, documenting each of these elements is critical because it can help justify a higher-level E/M code, she adds.
	
	Know how your MAC interprets MDM. Contractors publish frequently-asked questions and other guidance describing what they look for in all E/M documentation, including MDM. For example, some MACs define ‘additional workup’ as any service that’s performed outside of the current encounter while others state it’s any work that goes beyond the E/M service-even when the physician performs it during the current encounter, says Shannon O. Deconda, CPC, CPMA, founder and president of the National Alliance of Medical Auditing Specialists in Knoxville, Tenn.
	
	


	
	Document the total time (in minutes) spent face-to-face with the patient and/or family during the visit, and specify how much time (in minutes) was spent counseling the patient and/or family or coordinating care, says Miscoe.
	
	Summarize specific details of the conversation with the patient and/or family (i.e., what was discussed with patient and/or family and why), says Elhoms.
	
	


	
	Experts agree that with all the buzz about upcoding, it’s easy to forget that under-coding is also problematic because it results in revenue loss. Though less common, under-coding occurs when physicians report a lower than necessary E/M level out of fear they will be targeted by a payer for an audit. It can also happen when physicians don’t document all the services they render or the complexity of their MDM.
	
	Most physicians become aware of a trend of underpayments after hiring a consultant to perform an internal audit, says Elhoms. The good news is that physicians can submit corrected claims to try and recoup some of the revenue to which they’re entitled. Medicare allows providers to submit corrected claims up to a year from the date of service, while many commercial payers require resubmissions within 120 days or sooner.
	
	Is it worth the time and effort of resubmitting a claim? Elhoms provides this hypothetical example: A provider sees 100 patients per month, 50 of whom receive level 4 E/M services based on the documentation. However, the provider bills a level 3 for these 50 patients out of fear of being audited or because they don’t understand documentation requirements for each E/M code. The difference in payment between a level 3 and level 4 established patient is $35, equating to a $21,000 revenue loss over the course of a year.

Choosing an E/M code based on gut feeling is one of the biggest mistakes a physician can make.

Top E/M tips to boost revenue and mitigate compliance risk

After four hours of pushing, I was utterly exhausted. “Nicole, you can’t keep pushing. We can try a forceps delivery and if it doesn’t work we will have to do a c-section. We would have to take you to the operating room just in case. What do you want us to do?” My obstetrician needed an answer. My eyes began to well up with tears. Tears rooted in fear and born from exhaustion.
	
	In that moment I wasn’t a physician, I was a patient and I had no control over the situation I was in. I was incapable of using my years of medical education and knowledge to make a coherent decision about my own care. This was one of the most important decisions I ever needed to make. I looked at my obstetrician and asked her what she would do if she were me. She raised my bedrails in answer, preparing to move me to the OR. I made her promise the baby and I would be OK.
	
	We made our way to the operating room in preparation for delivery. I was met by my medical team--dozens of faces in light blue scrubs and surgical masks. As a doctor, I see people like this every day. But as a patient, I was scared. My nurse held my hand as the anesthesiologist hooked me up to sensors and monitor leads. My husband sat nervously by my side, awaiting our new arrival.
	
	Thirty minutes later I held my newborn boy for the first time. My joy was overwhelming as I shared the incredible moment with my husband and nearly 30 other medical personnel in the operating room. After Owen was delivered, my medical team worked diligently on us both. They attended to Owen, assessing him and providing support for his breathing. Hours of pitocin and magnesium resulted in postpartum hemorrhage and my obstetric team worked to stop the bleeding. My nurse continued to comfort me as anesthesiologists stood watch, helping with my resuscitation. I felt weak and powerless, but I was also humbled and grateful.
	
	The days and weeks following my son’s arrival continued to humble me. Profound anemia made climbing a flight of stairs or doing a load of laundry exhausting tasks. I made biweekly follow-up appointments to my OB’s office to check my blood pressure and lab work.
	
	The walk from my car to the office felt miles long and I always arrived weary and short of breath. At home I tried to keep up with simple household chores, and spent hours nursing or hooked up to my hospital-grade breast pump. I was an anemic, sleep-deprived milk-making zombie fueled by Doritos, Oreos, and iron supplements.
	
	A week after my delivery, my baby blues morphed into overwhelming anxiety and depression. I struggled to find balance in my new life and feel like myself. My medical training did not prepare me for my postpartum experience and I found myself continually struggling to navigate simple daily decisions.
	
	In the emergency department, I was a decision-making expert, tasked with making thousands of decisions during an average shift. I had lost my edge. At a postpartum visit to see how things were going, my OB listened carefully as I tearfully recounted how I had been feeling. “I think you should go see one of our psychiatry colleagues,” she softly urged.
	
	I had postpartum depression and anxiety--something I knew very little about, despite being a physician. Postpartum depression is common and it affects one in seven women. This statistic likely underestimates the prevalence of the condition due to lack of recognition and underreporting. Most women do not see their medical provider until six weeks after their delivery, making postpartum mood disorders even more difficult to recognize and treat. Additionally, studies put rates of postpartum anxiety at 9 percent and postpartum OCD at between 3 and 5 percent.
	
	I was home for three months before I went back to work. Three weeks after returning, I took care of a new mom in my emergency department. She had come in with psychiatric concerns and I needed to provide a medical screening before the psychiatrist would see her. I pulled up a chair and listened to her describe how she was struggling at home. She described thoughts of inadequacy, feelings of anxiety and at times bizarre thoughts bordering on paranoia.
	
	I told her I understood;  just a few months ago I had been feeling the same things. I told her there was a path back to the person she used to be, to someone she actually recognized. I was grateful for the opportunity to connect with her-more grateful than I had felt in my profession in a long while.
	
	I encounter many new parents in the emergency department. They bring their new loved ones in for concerns that physicians often find easy to address. Their faces are weary and full of concern. I now see these new parents in a new light. They are more than just the stewards of my patient-they need my attention too. I have an opportunity to ask them about the subtle signs and symptoms of postpartum fear, anxiety and depression.
	
	I can show incredible love and compassion by asking them, “How are you sleeping? When did you last eat something healthy?” I can make a human connection even though the stress and sleep deprivation may make them feel less than human. Most importantly, I can show empathy: I care about them and their family more than just the little one I am tasked to examine and treat.
	
	In many ways my son made me a better physician. I am more patient and more empathetic. The line separating doctors from patients is thin, and it is not something we should be afraid of. Our shared experiences and humanity can make our practice stronger. Through my time of complete vulnerability and powerlessness I became a better physician.

An honorable mention entry in the 2019 contest.

2019 Physician Writing Contest: My unexpected use for postpartum

Real estate is the second highest expense behind payroll for most healthcare practices. The benefits of capitalizing during lease negotiations can include a healthy raise through increased profitability, reduced debt, a nicer office and more. On the contrary, if negotiations are not handled properly, the results can be decreased profitability; resulting in the need to produce tens to hundreds of thousands of additional dollars just to pay the same bills that should have cost dramatically less.

While there are many key concepts and strategies you should always do prior to and during any lease or purchase negotiation, there are an equal or greater number of mistakes you should avoid. Having represented thousands of healthcare professionals over the last decade, we have gathered some of the most common mistakes healthcare professionals make during lease and purchase negotiations with the goal of helping others avoid the same mistakes. Here are three of the most common mistakes:

#1: BELIEVING THE LANDLORD OR SELLER WILL SIMPLY OFFER THEIR BEST TERMS.

Landlords and sellers are in business to make money. They are no more likely to voluntarily reduce lease rates or give up any extra money through concessions as you would be to voluntarily reduce your reimbursement from an insurance company or cut your patient fees if you didn’t have to. While it sounds pleasant to hear a landlord talk about giving a ‘fair deal’ or ‘reasonable price’, your odds of getting either are bleak without truly understanding the market, entering the negotiation process with multiple other options and having the needed guidance to capitalize. Trusting a landlord or seller without the help of professional representation will most likely result in the forfeiture of tens to hundreds of thousands of dollars that could have stayed in your checking account. Case and point: if you were about to sell your home and a fair price was $400,000… but your agent told you a buyer would pay $500,000… what would you list or sell it for? The “fair” price of $400,000… or the most you could get for it? Exactly. You would sell it for the most you could. Your landlord will treat you the same way. They will charge you the highest they can while giving you the least they can get away with.

#2: DETERMINING MARKET VALUE BY ASKING WHAT YOUR NEIGHBORS ARE PAYING.

Several years ago, we were reviewing the lease terms of a doctor who had been in a building for 20 years. In looking at his lease, he was paying $30 per SF, and had not received any free rent or tenant improvement allowance in his last negotiation. When we posed the question: “Do you believe $30 per SF with no concessions is a good deal?”, his response was: “I believe so.” “Why, we asked?” His response: “There are four other healthcare practices on this floor. We all know each other and talk about our leases. We are all paying $30 per SF and the landlord has told all of us they don’t give free rent or tenant improvement allowances.” Our response: “I understand the logic behind that approach… but what if I told you we just did a lease with a brand-new tenant on the first floor at $21 per SF ($1,800 per month in savings if it were your lease rate), while also obtaining 3 months of free rent and over $100,000 in tenant improvement allowance!” The bottom line is that landlord got away with convincing five different practices the market was far higher than it really was and that they didn’t deserve any concessions. Imagine finding out that you have been overpaying by $1,800 per month for the last 5 to 10 years and forfeiting money that could have completely renovated your space? This scenario happens every day to uneducated tenants who consult with other uneducated tenants and compare terms that were the result of having no posture, no knowledge of the market and not applying leverage through representation.

#3: NOT KNOWING MARKET AVAILABILITY AND COMPS.

The foundation of a successful negotiation starts with understanding what your other viable options are, how they compare to each other and how to execute on them. When dealing with landlords or sellers, many healthcare providers try to bluff their way into and through negotiations. A savvy landlord or seller can often read a bluff from a mile away. Here is the problem with this approach: it communicates you are too busy, you don’t know who to hire and you don’t know what you could achieve.  Trying to wing it in these scenarios will not work! This approach typically results in less respect from a landlord and the exact opposite results you were hoping for. Also, overly aggressive offers or unrealistic requests can compound the problem, as can emotional responses to the conflict inherent in most high-dollar negotiations. If you are going to be successful in your next negotiation, understanding market availability and comps is the first place to start. You can hire representation to do this for you, or you can invest dozens of hours yourself into the process.

These are just a sample of the more common mistakes you should seek to avoid when looking at your real estate decisions. Unfortunately, there are several more you need to avoid.

Don’t be taken advantage of during your next purchase or lease negotiation. There is too much on the line. Losing tens to hundreds of thousands of dollars affects your income and can also impact the quality of care you provide. Hire professional representation to level the playing field, start the transaction at the proper time, know the market and top available options and negotiate with multiple owners. If you do these things you are very likely to capitalize on your second highest expense.

Leon Dayries is a real estate agent in Louisiana for CARR, the nation’s leading provider of commercial real estate services for healthcare tenants and buyers.  Every year, thousands of healthcare practices trust CARR to help them achieve the most favorable terms on their lease and purchase negotiations. CARR’s team of experts assist with start-ups, lease renewals, relocations, expansions, additional offices, purchases and practice transitions. Healthcare providers choose CARR to help them save a substantial amount of time and money, while avoiding costly pitfalls and ensuring their interests are always first

Real estate is the second highest expense behind payroll for most healthcare practices. 

February 10, 2020 edition