With the COVID-19 pandemic upending traditional ways of physicians to communicate with their patients, its a perfect time for physicians to make the most of your patient portal.Gary Hamilton is chief executive officer of patient portal software provider InteliChart.

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Make the most of your patient portal in the time of COVID-19. 

6 ways to put your patient portal to better use

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With the physician shortage remaining a major concern for healthcare providers, a 2018 study from medical employment firm CompHealth identified ways young physicians find their first positions, what they want in a job, and why they leave.

Not surprisingly, the survey found that young physicians want good compensation. But money’s not all they’re looking for. Lisa Grabl, president of Midvale, Utah-based CompHealth, says facilities should be aware that young physicians also want to work in a place that has a great culture and offers a good work/life balance.

“If you’re not strong in these areas, look for ways to improve, or you’re going to lose out on attracting the best talent,” Grabl says.

For many years, physicians were willing to work long hours and make their career the center of their lives. Younger physicians still care about their patients and career, but they also want to have time for family, friends and interests outside of medicine, which is why many healthcare facilities have adjusted their recruiting tactics to show how they can meet all of their physicians’ needs-not just their workplace requirements.

Jennifer Moody, an associate principal at ECG Management Consultants, a Dallas, Texas-based medical staffing company, says physicians in their first job are looking to build upon the clinical expertise they’ve been developing in
	residency/fellowship.

“It is important to many that they find a practice opportunity that allows them an interesting case mix,” she says.

Also important, she notes, are opportunities for improved financial stability-such as loan forgiveness, net income guarantees or a signing bonus, because new physicians frequently have a great deal of educational debt.

Chris Borasz, manager of physician and provider recruitment for OhioHealth in Columbus, Ohio, says when recruiting, it’s important to think about the entire family, not just the physician, and consider what in the community can support the spouse or partner.

“It’s finding things that are helping to engage that person in connectivity to community,” Borasz says. “The development and support as they ramp up is important, but also think about that long-term development.”

According to the CompHealth study, 40 percent of placements are a result of referrals and networking. Only 12 percent of young doctors use social media to find work, despite spending between five and 19 hours a week online for personal reasons.

Moody says that millennials  often will use social media to look for practice opportunities, confer with peers about salary norms or contract requirements on socialmedia-based message boards, and research potential job locations on the internet. Therefore, if practices are only advertising in specialty journals or hoping to network at society meetings, they will miss out on many candidates.

The survey found that physicians are generally quite satisfied in their jobs but are also willing to change employers if they can find a better fit. The key to retention, Grabl notes, is listening to physicians to ensure their needs are being met.

She suggests holding interviews after the physician has been recruited-at intervals of three months, six months and a year-where they can monitor how the physician and his or her family are integrating into the practice and community. This would involve simply talking to the doctor and his or her family about what they like, what they feel is missing in their lives, and recommending solutions to fix any problems and concerns.

Grabl says this is important because young physicians today want more than just a good working opportunity.

“They are still willing to work, and work hard, but they also want more in their lives,” she says. “That could be implementing more flexible schedules, reducing on-call requirements or bringing in locum tenens physicians to allow for vacation time or help with patient load.”

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Young physicians want good compensation. But money’s not all they’re looking for.

Recruiting and retaining young physicians

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 to start.

The owner developed a training program with a local hospital that allows new physicians he hires 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 don’t have the financial capacity to offer compensation packages as generous as larger or system-owned practices, or offer the high-profile work environments that exist in major 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 for their teams, 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 the physician recruiting firm 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 often have 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. 

But that is just the first step. 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,” he says. 

Indeed, Kohl, who now practices in Stilwell, Kan., and is a board member 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 don’t often 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 access compensation surveys, such as those done by the Medical Group Management Association (MGMA), and talk to colleagues, says Nick Fabrizio, Ph.D., FACMPE, FACHE, a 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 offer their employees. 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 can also 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 an employee profit-sharing program, 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 physicians, non-physician providers, and support staffers 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 in the long run.

“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 individuals who continued their studies to create schedules that gave them time to take classes yet still have 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 his 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 members did not need health insurance because they were already 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 one 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 then highlight that to prospective candidates.

For example, practice owners could offer new physicians the ability 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 should also 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 physicians working in them generally practice a broader range of medicine and that they’re often a bigger part of these communities than their suburban and urban counterparts. 

Although 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 have policies and procedures in place to establish available benefits so that even if employment packages are individualized they won’t seem capricious.  

“To a certain extent, you have to determine what you can do for each one and still maintain a practice, and you have to be fair,” Fabrizio says.

Fabrizio adds that 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.”

How to attract and retain physicians and other providers

Hiring clinical staff

Doctors are fond of complaining that they didn’t go to medical school in order to practice business, but independent physicians do spend much of their time on their practices’ finances.  

That requires mastering revenue cycle management (RCM), the financial process practices use to administer all the functions associated with claims processing, payment, and revenue generation.

At the level of the individual patient, RCM begins when that patient makes an appointment and ends when all claims and payments resulting from the appointment and subsequent services have been settled. At a higher level, it means ensuring that the practice generates enough income to pay expenses and yield a profit.  

Revenue cycle management has never been easy, but the move to value-based care and reimbursement, as well as more risk-based payer contracts, has made it harder than ever. A 2016 survey by research firm Black Book found that 90 percent of small, independent practices were unprepared
	financially and technologically to implement value-based care.

Difficult thought it may be, efficient and disciplined RCM is key to an independent practice’s ability to remain so. “Effective revenue cycle management isn’t going to guarantee your practice’s financial success, but neglecting revenue cycle management might result in its failure,” says Melissa Lucarelli, MD, a family physician in Randolph, Wis., and a member of the 

As RCM becomes increasingly demanding, more practices are turning to vendors to handle part or all of it.

The Black Book study predicted that the U.S. market for physician and ambulatory RCM outsourcing and extended business office services would grow by 42 percent between the end of 2016 and the beginning of 2019. The same survey of 2,000 independent physician practices found that 59 percent of providers intended to outsource some or all of their billing. 

“High-impact drivers of the physicians practice outsourcing market include the increasing emphasis on compliance and risk management, and the need for more efficient and cost-effective processes,” Black Book managing partner Doug Brown says in the study.

The rising costs of operating a practice also underscore the importance of RCM. A 2018 Medical Group Management Association study found that over the past five years median operating costs for primary care practices have risen by 13 percent, from $391,798 to $441,559 per physician. And while revenue can fluctuate, expenses such as salaries, rent, insurance, and equipment payments must be paid on a regular schedule.

Outsourcing RCM is comparable to a primary care physician referring a patient to a specialist, says Todd Van Meter, senior vice president, ambulatory care, for Optum360, a revenue cycle management firm based in Eden Prairie, Minn.

The specialist has greater resources, knowledge, and expertise to handle the task than does the generalist, he says. And unlike a practice whose primary mission is providing healthcare, a vendor is focused solely on RCM, making it easier for them to stay current on regulatory and reporting requirements while discovering new efficiencies.   

Lucarelli says outsourcing much of her RCM has been a boon for her small, rural practice. “These are tasks we could do and we used to do, but the system does the heavy lifting and the drudgery stuff that keeps us away from the medical stuff we want to do,” she says.

Lucarelli uses her EHR vendor, Athenahealth, for coding, billing, verifying insurance coverage, interfacing with payers, and other functions. She adds that outsourcing the RCM function has made it possible for her to reduce the practice’s back office staff from four to two, a part-time billing clerk who posts claims and an office manager.

The system has been particularly helpful for meeting reporting requirements under the Merit-based Incentive Payment System, as well as providing upgrades, such as free interfaces with labs. “There is no way that I would go back to the old way and be able to provide medical care the way I want to,” she says. 

Not all practices find it beneficial to outsource RCM, however. 

Associated Physicians is a 20-doctor independent practice in Madison, Wis., that offers comprehensive primary care services, including physical therapy, nutrition counseling, and diabetes education while operating its own lab. 

The accompanying volume and complexity of paperwork, reporting, and regulations would push some practices to outsource their RCM, but Associated Physicians does nearly everything with its own employees. “We want to remain independent. Part of that independence is wanting to do as much inside as possible,” says Executive Director Terri Carufel-Wert, RN, MHA.

The practice employs 11 back office personnel, including coders and billing and payment specialists. While that’s substantial overhead, Carufel-Wert and Business Operations Manager Margaret Wilkinson, CMC, say the team saves money by performing at a very high level.

Communication and coordination are key, Carufel-Wert says. Everyone, from physicians to billing clerks, works from the same guidelines, and new providers are quickly trained on office procedures. The coders are so well-versed in regulations that they seldom make billing errors and even occasionally correct private payers, she adds.

Employees are cross-trained on jobs so there’s no drop-off in performance during someone’s absence. The staff analyzes potential new practice offerings and equipment to determine if reimbursement will make them profitable.

The practice is proactive with patients as well. Whenever possible, it obtains payment upfront and frequently has to educate patients about what their insurance covers and how much it pays. 

The hard work pays off. The average time between billing and reimbursement from payers and patients is 22 days, which Wilkinson says is much shorter than average.

“We had to do a lot of training and educating, but we are now able to deliver quality care at an affordable price,” Wilkinson adds.

Newton Family Physicians has done its own RCM for all 37 years of its existence and expects to continue to do so, says practice administrator Melissa White. 

“We find it just works better for us,” says White. The Newton, N.C, practice has six physicians and four nurse practitioners. Doing its own RCM requires three full-time-equivalent employees doing coding, billing, and other back office tasks, while White and a part-time employee handle collections. 

The practice has considered using a vendor for RCM and probably would save money by doing so, White says, but worries that introducing a third party would hurt long-standing patient relationships in the rural communities it serves.

For example, the practice knows when a patient has lost a job or been sick and will take that into consideration during billing, White says. It also offers no-interest payment plans.

“It’s not always about saving two cents,” she says. “From a community perspective, we just have better reception.”  

While the practice will use a collection agency for some unpaid debts, it prefers to rely on the personal touch, White says, adding, “We found that it works better for us because when you call someone and they know you they’re more likely to deal with you than they are with a collection agency.”

Their personal, in-house approach works, she says, adding that Newton has a reimbursement rate of 97 percent to 99 percent.

As part of his RCM, Jeffrey Kagan, MD, an internist and member of the 

 editorial advisory board, meets with his accountant annually to project income and expenses for his two-physician practice in Newington, Conn.

The accuracy of those predictions determines whether the practice is profitable or if Kagan must tap into a line of credit to pay himself and employees. After 25 years in practice, he has identified reimbursement patterns, such as slower and fewer patient payments in the first half of the year because people have not yet met their insurance deductibles.

This trend has gotten worse as more employers switch to high-deductible plans, he says.

The practice uses an outside vendor for billing and occasionally hires a collection agency, but performs other functions itself. Kagan does everything he can to get patients to pay their co-pays and other costs at the time of their appointment. “If I can get my money in three months, I’m thrilled,” he says. “There are some who take longer, but none of my expenses get held up for three months.”

He takes payments via credit cards, accepting the service fee if it means getting paid faster. He also has had to get stricter with non-paying patients, either dropping the worst offenders or refusing to schedule new appointments until their debts are settled.

His staff also knows to verify insurance eligibility at the beginning of an appointment. “It only takes a few minutes to do that in the beginning, but it probably takes an hour to fix it later,” he says. 

Using an RCM vendor does not have to be an all-or-nothing proposition. Many independent physicians, like Melissa Lucarelli, MD, a solo practitioner in Randolph, Wis., choose to outsource some functions and keep others.

She recommends developing policies and processes for each phase of RCM, from pre-authorization to collections, then scrutinizing them to determine if it makes financial sense to outsource that phase. That self-examination led her from doing virtually everything in-house to outsourcing most of the work.

Whether outsourcing all RCM functions or only some services, here are some guidelines for selecting a vendor from industry sources:

1. Choose a reputable and experienced vendor. Ask about qualifications, certifications, and association memberships. Check references. 

2. Know what you’re paying for. Vendors offer a variety of services and packages and comparison shopping can be confusing. Make sure you get what you need and aren’t paying for services you don’t need. Ask an experienced attorney to review the contract.

3. Make sure the vendor provides a customizable and usable dashboard. This is a practice’s interface with RCM and if it’s hard to use or difficult to read the operation will suffer.

4. Get analytics. A good RCM vendor will not only handle coding and billing, but offer real-time analytics tools that filter data, generate the necessary reports, and make it easy to identify problem areas that should be addressed. 

5. Make sure the vendor provides regular updates. Reimbursement is constantly changing, and RCM software must be current to avoid problems with denials and failure to meet reporting and performance standards.

6. Check the vendor’s customer service record and references and know exactly what type and how much help your contract stipulates.

7. Make sure it’s compatible with your EHR system and that you will be able to run your own reports.

8. Set agreed-upon performance goals. You’re hiring a vendor in order to improve RCM and having benchmarks in place will let you know if that’s being accomplished. 

Pros and cons of outsourcing versus managing it yourself

Mastering revenue cycle management 

For many physicians, living with debt is an integral part of their training; but few learn how to manage it once their “real” paychecks begin rolling in. 

In fact, many physicians continue to dig themselves deeper into debt as their careers progress, says Cory S. Fawcett, MD, a personal finance coach and author. “As can happen to anyone, physicians often just become totally numb to the consequences of debt,” says Fawcett.

“We end up feeling like it’s Monopoly money,” agrees James M. Dahle, MD, editor and founder of the White Coat Investor LLC. “We owe so much money, what’s a little bit more?”

Here are four signs that a physician may already owe too much:

“You would be surprised by how many physicians there are who have not sat down and written out what they owe altogether-because it’s terrifying,” Dahle says. “But you can’t formulate a plan until you know what you’re up against.”

Once a physician musters the courage to analyze his or her problem, he or she can create a budget and work toward resolving the debt.

“The word ‘budget’ can be difficult for some people,” Fawcett says. “But you have a limited amount of income. You already have a restriction on the amount you want to spend. So why not be in charge of the restriction by being proactive-not reactive-about what you want to spend?”

As a result of a mentality in which debt is the norm, it’s not unusual for established physicians to live paycheck to paycheck-albeit with larger checks than the average American, says Fawcett. 

“Just because your income jumped to $260,000 a year doesn’t mean you have to spend it all this month,” he says. For new residents coming out of training, he recommends they live on roughly $60,000 a year until their finances catch up.

A key danger of depending on one’s entire income every month, he adds, is that there is no cushion to protect the physician from loss of income due to job loss, illness, or maternity leave.

Physicians’ financial problems can be compounded by a societal expectation that conflates practicing medicine with wealth.

Thus, physicians can easily fall prey to misconceptions such as, “I’m a doctor. I can afford it,” or “I work hard. I deserve a nice car and vacations,” says Gail L. Clifford, MD, an internist in Phoenix, Ariz.

In reality, these purchases are premature if they need to be bought with credit cards.

“Physicians are just like everybody else, and we all want to have stuff before we can actually afford to do it,” says Dahle, who recommends that physicians avoid taking on any debt besides student loans and a mortgage.

When physicians are fuzzy on what they owe or what standard of living they can afford, it’s nearly impossible to plan for the future. Specific, individual financial goals can help physicians ascend from a rut, says Fawcett. 

Whether that goal is to buy a new home, retire at a certain age, or live debt-free, you can make a plan to get there. “Once you see where you are and where you want to go, you can plot out a map to get there. Following it isn’t as hard as you’d think,” he says.

Debra A. Schute is a contributing author. Send your financial questions to medec@ubm.com.

Four signs that a physician may already owe too much

Debt: How much is too much?

Nurse practitioners rise because primary care has changed radically

I would like to respond to Dr. Dinklage’s opinion in your last issue. First, his statement: “It seems that everyone wants to be a doctor, but not everyone wants to go to medical school.”  I would give anything for the opportunity to go to medical school.  As the sole provider in my household, I cannot quit work and go to medical school.  If there were an articulation program for nurse practitioners that would allow me to continue working full time to support my family, I would proudly go to medical school.

You are correct in the statement that our training is not the same as an MD. You did forget, however, that many of us spent countless hours of clinical time caring for critical patients and catching problems for the physicians that rounded for about 5 minutes on the patient. We learned to critically think. We learned pathophysiology, pharmacology, and differential diagnosis. I agree that some students lack a significant clinical experience, however, please do not generalize all of us into the same category. 
	From my current perspective, I am responsible for basically an internal medicine practice seeing 20 to 30 patients a day and diagnosing patients that have previously been seeing an MD who “did not listen to them” or ‘never put his hands on me.” 

There are good and bad practitioners on both sides of this coin. It is sad that we do not get compensated for what we do and we do not receive the recognition or respect from administration or other providers. Many of us are very capable of ascertaining zebras from horses. Please do not judge all of us by the few that you have been in contact with.

Just like with physicians, there are good and bad nurse practitioners

Keith Dinkage, MD, in his letter “Nurse practitioners are valuable members of the team-but they aren’t doctors” (January 25, 2019 issue) disapproves of nurse practitioners providing primary care because they are not doctors, but I disagree.

The scope of primary care has changed radically. Much of the training that primary care doctors receive has little relevance in primary care today. Most no longer see hospital or nursing home patients.  Primary care doctors spend most of their days treating non-life threatening diseases and coordinating care with specialists.  These are services that nurse practitioners are able to provide, a role supported by the National Academy of Medicine. Moreover, many states have already given them licenses to practice independently.

The shrinking scope of primary care, the increase in administrative tasks, insurers’ low fees and the pressure to see too many patients in order to make a decent living have made most medical students shun primary care. And who can blame them?

Less than 20% of American medical students enter primary care residencies. A national shortage of primary care doctors exists. Unless it is streamlined by simplifying the basic science curriculum and providing clinical training in community health centers, not hospitals, it will get worse because it takes about 11 years to train a primary care doctor.

In rural areas there will still be a need for primary care doctors who are broadly trained to do obstetrics, office orthopedics, even some surgery like appendectomies.  They can get extra training to prepare them.  But most primary care doctors live in areas where specialists are available to take care of these problems.
	In the future primary care doctors’ training and scope of practice and that of nurse practitioners will be similar. Both groups may combine their training and result in a new classification called ‘primary care practitioner.”

Your voice: Nurse practitioners rise because primary care has changed radically

I am an internist with my own practice and am called on by specialists to evaluate patients for diabetes management and for pre-operative clearances.  Can I bill these services as consultations?  Also, can my nurse practitioner bill consultations for these services?

A: These are great questions, and we will need to delve into the definition of consultations in order to answer them.  

First, per Current Procedural Terminology (CPT) guidelines, consults may be requested by persons other than physicians (e.g., physician assistants, nurse practitioners, chiropractors, physical therapists, occupational therapists, speech-language pathologists, psychologists, social workers, lawyers or insurance company representatives). 

So yes, consults can be performed by a physician or other qualified non-physician practitioner (NPP) (e.g., nurse practitioner and physician assistant) if the service is within his or her scope of practice and licensure requirements in the state where he or she practices and the requirements for physician collaboration and physician supervision are met.

Let’s look at the basic elements that are required for consultations. Medicare no longer reimburses for consultation; nevertheless, the guidelines were developed by the Centers for Medicare and Medicaid Services (CMS). Check with your local payers to see if they reimburse for consultations.

According to CPT, a consultation is an Evaluation and Management (E/M) service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

Per CMS, the basic consultation elements include:

The report from the consulting physician.

You can remember these as the four R’s: request, reason, render and report. Here are the steps to document these requirements:

1. The requesting physician should document the request for consultation in the patient record, including the specific reason for the consultation and how the consultant physician was contacted (e.g., phone, fax or letter). Likewise, the consultant physician should document that the consultation was requested, by whom and why.

2. The consultation services rendered should be documented following the Evaluation and Management (E/M) guidelines. Consultation codes require all three elements (i.e., history, exam, medical decision making) to be met in order to support a code level.  Time-based coding can also be utilized when more than 50% of the time is spent in counseling/coordination of care. 

3. The consultant physician should provide a written report of services provided, findings and recommendations or planned follow-up. When the requesting physician and consulting physician share a common patient record, this documentation can be included in the patient’s progress notes. Otherwise, a copy of the consultant’s written report should be included in the patient’s record.

If any of these requirements aren’t met, then the appropriate code should be billed based on place and type of service.  

When is a consultation not a consultation?

A consultation is not a transfer of care. A transfer of care occurs “when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition” (Medicare Claims Processing Manual, chapter 12, section 30.6.10.B).

For instance, if a patient who doesn’t have a medical home seeks care at an urgent care facility, the nurse practitioner at the facility might recommend that the patient contact a certain family physician to establish ongoing care. This is not a consultation because the nurse practitioner in the urgent care facility is not requesting advice or an opinion on managing the patient’s condition.  

The same reasoning applies when a patient is referred from an emergency department. A referring physician documents or intends a “referral and treat.” You know your referring physicians/NPP’s. If you know that the referring physician expects you to treat the patient’s condition, the visit is not a consultation.

These scenarios are transfers of care or referrals.

A consultation is not when a surgeon asks you to manage an aspect of the patient’s care in the post-op period. The surgeon is not asking for your opinion or advice, so this care is concurrent to the surgeon’s care.

A consultation is not  a request from a patient or family member. The fundamental requirements of a consultation is a provider or other source (listed above), so requests from a family member or patient should be reported using office visit, home service or domiciliary/rest home care codes, not consultation codes.

Consultations are not routine between physicians in the same group. Consultations can be requested of another physician in your group who has expertise in a specific medical area; however, these requests should be kept to a minimum.

A consultation is not a split/shared visit. The guidelines preclude a consultation being performed as a split/shared visit.

A consultation cannot be billed more than once per consultant per facility admission.

A consultation cannot be billed as a 99211. This is a minimal service and doesn’t meet consultation guidelines.

It’s not uncommon for a surgical specialist to request preoperative clearance from the patient’s family physician. As with other consultation services, the preoperative clearance consultation should involve a request for opinion or advice. For example, do the comorbid conditions of this patient require any special considerations? Can this patient safely undergo this procedure?

When you report a consultation for preoperative clearance, use the appropriate CPT code for the level of service and setting where the consultation services were rendered as well as diagnosis codes that indicate the necessity of the consultation. Also, code any diagnoses that arise during your consultation.

Medicare guidelines state that, following a preoperative consultation, if the consultant assumes responsibility for managing a portion of the patient’s condition(s) during the postoperative period the consultation codes should not be used. In this situation, you should use the appropriate subsequent hospital care codes to bill for the concurrent care in the hospital setting and use the appropriate established patient visit codes for services provided in the office.

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Ind. Send your billing and coding questions to medec@ubm.com.

Additional initial and subsequent consultations instructions

Here are some additional tips to keep in mind:

In an office or outpatient setting, if an additional request for a consultation regarding the same or a new problem with the same patient is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation codes may be used again.

For a second opinion evaluation (patient and/or family requested) in the facility setting arranged through the attending physician, the evaluation is reported as an Initial Inpatient Consultation service if the consultation requirements are met.

Medicare does not require a written report  to be sent to a physician or qualified NPP when a second opinion evaluation visit has been requested by the patient and/or family.

A written request for a consultation should be included in the requesting physician’s or qualified NPP’s plan of care, but the absence of a request should not be held against the consultant in a post-payment review.

A consultation request  may be written on a physician order form in a shared medical record.

The reason for the consultation service must be documented by the consultant in the patient’s medical record. 

What is-and isn't-considered a healthcare "consultation"? 

To consult or not consult 

In an age of healthcare consumerism, patients increasingly use the EHR portal to communicate with physicians. 

It’s about convenience. They ask for prescription refills, request appointments, pose clinical questions, and more-all without having to call the office or come in to see a provider. Until now, physicians haven’t been able to bill for responding to these messages.

But there’s good news: effective this year, physicians can potentially report HCPCS codes G2010 (remote evaluation of pre-recorded patient information) and G2012 (brief communication technology-based service) to receive Medicare reimbursement, depending on the specific services rendered.

Here’s an example of how it would work:

A patient takes a picture of their rash or records a video of their gait following knee surgery and uploads it to the portal. The patient’s physician reviews the image or video and provides additional instructions or feedback to the patient. The physician may be able to bill G2010, provided all
	other requirements for the code are met, says Nathaniel Lacktman, a healthcare lawyer at Foley & Lardner and chair of the firm’s national telemedicine & digital health industry team. 

HCPCS code G2012 offers another potential portal tie-in, though this code also requires an element of synchronous communication. For example, a patient has symptoms of a cold, but she isn’t sure whether she needs to schedule an in-person visit with her physician.

The patient provides some information via the portal that the physician reviews. The physician then briefly communicates with the patient in real-time (e.g., via telephone or via a portal with audio-video capabilities) to advise whether the patient actually needs to come into the office for an in-person appointment.

The physician determines that no in-person visit is necessary and instructs the patient to call the office if symptoms worsen. The physician may be able to bill G2012 as a virtual check-in, permitted all other requirements for the code are met, says Lacktman. 

Another example is a patient who remotely transmits physiologic data (e.g., blood sugar levels taken from a glucometer) to the physician via the portal. The physician reviews that data and calls the patient to discuss the results in real time. In this scenario, G2012 may potentially apply if the physician determines no in-person visit is needed. 

Using the portal for these types of communications can be highly efficient, particularly when the physician uses clear protocols and care pathways, explains Lacktman. In addition to generating revenue, a benefit of asynchronous remote evaluations and virtual check-ins is that physicians may be able to  care for additional patients without having to add more hours to their workday, he adds.

“These codes could reduce physician burnout and the need to double- or triple- book appointments,” says Lacktman. “Unlike traditional Medicare telehealth services, these codes have no rural geographic limitations. The patient can be anywhere, including at home. These are game-changing codes.”

However, there are some caveats with these codes. If the remote evaluation or virtual check-in originates from a related E/M service provided within the previous seven days by the same physician or other qualified healthcare professional, then the service is considered bundled into that previous E/M service, says ­Lacktman.

In this case, G2010 and G2012 are not separately billable, which means physicians can’t bill the patient or Medicare, he adds. The same is true when the remote evaluation or virtual check-in results in an E/M service within the next 24 hours or during the next available appointment.

Jaci Kipreos, CPC, CPMA, president of Practice Integrity LLC in Henrico, Va. is encouraged by these new codes but is unsure whether commercial payers will accept them. “Do they look good? Yes, Medicare is finally recognizing all of the additional work providers perform. But you’ve got to start talking to your private payers so you know what they’re going to do-or not do-for you,” says Kipreos. 

She advises practices to  contact the provider representative at each payer, and ask whether the payer accepts G2010 and G2012 as reimbursable codes.

If the answer is no, ask the payer whether they will allow the code to at least pass through its system and trigger a single line item denial-or whether it will it deny the entire claim. Practices can also flag these claims and review them manually after payer processing occurs.

If the payer allows the codes to pass through with a single line item denial, physicians should continue to report them-even if they receive a denial. “You need something to bring to the table,” says Kipreos. “You can’t just say, ‘I’m doing this, will you pay me?’ The payer will want to know the frequency, and there’s no way to account for what you’re doing unless you report the codes.”

Physicians can also advocate for payers to accept and pay these codes by explaining how these services improve access to timely care and ultimately reduce costs, she adds.

As with any new code, CMS will be watching G2010 and G2012 closely for inappropriate use, says Lacktman. “There’s a learning curve. I definitely recommend that practices take the time to understand these new codes and make sure they’re billing them correctly,” he adds.

New ways to get paid for interacting with patients

March 25, 2019 edition