Doctors have enjoyed more than a decade of relatively affordable medical malpractice premiums. But for many, those good times are ending.

The turnaround is documented in a white paper published earlier this year by the investment management firm Conning. The company found that after peaking in 2006, premiums dropped 20% between 2007 and 2013, then remained fairly steady before increasing by 5% in 2019.

, in its 2019 annual rate survey, found that more than 25% of medical professional liability premium rates increased during the preceding year, the first time that has happened since 2006.

“2018 marked the year in which premiums were the lowest we’ve seen in this century,” says Robert E. White Jr., executive vice president for medical professional liability at The Doctors Company, a malpractice insurance provider. “But in the last year or two we’ve seen the market become firmer.”

Still unknown is how the COVID-19 pandemic will affect the medical malpractice market. The answer to that question won’t become clear for several years, White says, because most malpractice suits aren’t filed until several years after the incident on which they are based, and then take more years to move through the judicial system.

Matt Gracey, CEO of Danna-Gracey, a malpractice insurance broker headquartered in Delray Beach, Florida, says rate increases in the 5% range actually are on the lower end of the scale he has seen, and are generally limited to smaller practices. Some large multispecialty groups his company works with have seen their rates go up by as much as 100% over the last 18 months, he adds.

Gracey says premiums were held down in the years prior to 2019 because of a combination of factors, including new competitors entering the market and a decline in the number and severity of malpractice suits around the country. The latter development was due in part to a wave of tort reform legislation prior to 2006 in which states placed caps on the dollar amounts of damage awards in malpractice cases and/or made it more difficult for plaintiffs to sue physicians and hospitals.

But those drivers of lower premiums have ended or reversed over the past few years. White notes that there is less competition in the market, with about 100 companies writing policies today compared with approximately 130 four or five years ago. Meanwhile, states such as Texas, Florida and Oregon have seen their caps on damage awards either struck down by the courts or modified by their legislatures.

The result, says Gracey, is that “every A-rated carrier specializing in malpractice insurance now is running a combined loss ratio of over 100%, meaning that for every dollar of premium they bring in they’re paying out more than a dollar, which means they have to raise their rates.”

To be sure, not all doctors have seen increases in their malpractice premiums. Melissa Lucarelli, M.D., a family practitioner in Randolph, Wisconsin, and member of the 

® editorial advisory board, is paying $10,288 in 2020, a slight decrease from the $10,357 she paid in 2015. Similarly, Damon Raskin, M.D., an internist in Pacific Palisades, California, says his malpractice premiums have changed “hardly at all” over the past five years.

That there are exceptions to the overall trend doesn’t surprise White. “The fact is, there are 50 different states and 50 different markets in the MPL (medical professional liability) business, and when the market starts to change it trends slowly,” he says. And although an insurance carrier may be experiencing an overall loss in a state, “there may be specialties in that state where no increase is indicated.”

As for the legal risks to doctors posed by COVID-19, experts say these could take several forms. One stems from the prohibitions on elective surgeries most states imposed at the start of the pandemic. “If a doctor deemed something to be nonemergent during the elective surgery ban and (it) turned out they were wrong, they could be sued,” White says.

A second category of risks is from patients claiming they contracted COVID-19 at a physician’s office. Some practices are trying to protect themselves by requiring patients to sign an “exculpatory clause” agreement, limiting the patient’s ability to sue if they experience any harm while being treated. But White warns that relying on exculpatory clauses for protection is dangerous.

“We tell these physicians upfront that an exculpatory clause probably won’t provide the protection they’re looking for because they generally aren’t viewed with favor by the courts,” he says. “Probably the best they can hope for in that regard is some form of state or federal legal immunity for physicians.”

Doctors can also take heart from the difficulty inherent in proving that a person contracted COVID-19 in a particular place, says Frederick M. Cummings, J.D., a health law attorney with Dickinson Wright in Phoenix, Arizona.

“Exposure could come from a myriad of places,” Cummings notes. “If I were a plaintiff’s lawyer, I wouldn’t take that case because there’s still so much community spread.”

White urges practices to follow the CDC’s COVID-19 safety guidelines as a way of defending themselves in the event of a patient lawsuit. “‘We followed the standard of care, what else could we have done?’ That will be the best defense,” he says.

Probably the greatest potential danger, however, comes from the exponential growth in the number of remote visits caused by the pandemic. As the use of telehealth increases, so does the possibility of a doctor missing a change in a patient’s health status or not following up with the patient in person, thereby leading to a malpractice suit.

“Remote examinations have inherent limitations when it comes to diagnosing,” White notes. “That means doctors have to make sure their antennae are out for those symptoms that require a patient to be seen in person in order to ascertain a potentially life-threatening condition.”

He points to the decline in emergency department visits for strokes and heart attacks since the pandemic began (20% and 23%, respectively, from mid-March through May, according to the CDC) as cause for concern. Symptoms of both conditions often are first detected by a patient’s primary care doctor, and speedy treatment is crucial to good outcomes for both. “Failure to pick up on the need to get these patients seen right away, that’s where most of the exposure comes from in these cases,” he says.

Cummings points out that many doctors already have experience in deciding when a patient requires an in-person diagnosis. “I don’t see it as any different than when a patient called you on the phone and said, ‘I’m having these symptoms,’ and the doctor judging whether they should come in,” he says. “But it does require some previous knowledge of the patient (and) things like their history and comorbidities.”

But despite doctors’ best efforts at remote diagnosing, Cummings notes, the number of deaths from causes other than COVID-19 unexplained causes increased substantially after the pandemic started. (According to results from a July study in 

, there were approximately 122,000 more deaths between March 1 and May 30 than would normally be expected during those months, which was 28% higher than the number of COVID-19–related deaths.) He speculates that many of those unexplained deaths were due to the disease’s exacerbating underlying conditions in patients.

“The big issue for many of my clients is not whether they recognized COVID(-19), it’s whether they paid attention to any of the other health issues that were lurking in those patients,” he says.

Cummings adds that doctors can defend themselves in a lawsuit stemming from a remote diagnosis by thoroughly documenting the encounter. This is especially the case for patients who have missed in-person visits because of concerns over COVID-19.

“It’s more important than ever to make sure that whatever information they get on calls from patients they’re no longer seeing regularly is documented and whatever their thought process was at the time is reflected in the note,” he says.

In the end, experts say, a doctor’s best defense against a malpractice suit is to prevent it from occurring. And that requires building a trusting relationship with patients, fostered by honesty and good communication.

Gracey points out that one of the most common malpractice charges primary care doctors face is failure to diagnose. “But when you drill into those claims, you find a lot of what’s really behind them are communication issues,” he says. And although occasional miscommunications in relationships are inevitable, “if we have terrible relationships with each other, those miscommunications get blown out of proportion, and in the case of doctors and patients, they end up before judges and juries.”

Articles

What’s happening with cost and claims in the wake of COVID-19

The ongoing pandemic and resulting public health emergency (PHE) has brought about massive and quick changes in the health care industry, notably the temporary suspension of Medicare Fee-For-Service (FFS) audits. The Centers for Medicare & Medicaid Services (CMS) suspended most audits on March 30, 2020, and this change was nearly universally welcomed by the health care industry.

Although the PHE continues, the hiatus of audits was short-lived. CMS announced the end of exercising audit enforcement action during late July, and it resumed program integrity audits effective August 3, 2020. The agency acknowledged the continuing PHE, but determined the importance of and need to resume medical review activities.

If your organization is selected for an audit, remember that you have options. CMS recognizes that staffing and resources to respond to audits may be limited. Providers may contact Recovery Audit Contractors (RAC) to explain any COVID-19 related hardships they are experiencing that may impact response time.

Many assumed that payers would not audit claims adjudicated during the PHE, especially because of the associated waivers issued by CMS. The agency communicated it would audit for potential fraud or abuse during the PHE. This guidance was somewhat confusing to the industry, with many assuming CMS and commercial payers would audit claims adjudicated during the PHE.

CMS published its last approved RAC audit in February 2020. On August 3, 2020, the agency published five new RAC focus areas including ambulance services, hospital inpatient, hospital outpatient, ambulatory surgical centers, and professional services.

This audit downtime has enabled payers to shift their focus to data-mining claims. This is why medical records requests and overpayment demand letters from RAC contractors and commercial payers will likely resume during the next few weeks.

Audits, disruptive during the best of times, become even more so when fewer staff are available to process record requests and otherwise respond. A timely response is imperative.Third-party medical record release vendors have gained appeal among practices. Vendors can handle all third-party record requests without administrative or financial burden to an organization. The resources and expenses are left to the vendor. Outsourcing record requests is one part of the equation. There will be overpayment letters which flow from all payer audits.

Heed every overpayment and audit letter, whether from a government or commercial payer.The rules applicable to telehealth, supervision, inpatient rehabilitation facilities and nursing homes changed rapidly at the onset of the PHE. This increased the likelihood of audit errors, misapplication of rules, and application of rules and regulations to inapplicable dates of service.

Nearly all health care providers have experienced a financial hit. Avoid prematurely and unnecessarily returning any overpayment by confirming all overpayments before you accept audit findings. Qualified staff or third-party vendors should re-audit records identified as having overpayments. Parameters of the confirmation process must include all appropriate regulations and/or payer policies that were applicable on the date of service.

Claims adjudicated during the PHE, and particularly within the first 60 days of the PHE, may ultimately be subject to several different rule changes that varied from day to day. This is why these audits are at a higher risk of errors having occurred. Generally, audits reflect a specific date range and auditors apply appropriate payer rules. The appropriate guideline or regulation may not be applied correctly or to the applicable timeframe, which could reveal an erroneous overpayment. Numerous executive orders at the state and federal levels have further complicated audits during the PHE.

The uptick of audits will continue to approach previously unseen levels. Providers need to understand how to efficiently handle this and have a well-designed process in responding to the audits. Prevention is always the best practice.

Joe Rivet, Esq., CPC, is a reimbursement attorney and founder of Rivet Health Law, PLC. Send your legal questions to medec@mjhlifesciences.com.

If your organization is selected for an audit, remember that you have options.

CMS resumes practice audits

Physician contracting is becoming extremely important today, as more physicians are working for hospitals, large health systems and multiphysician practices in nonownership roles.

® recently sat down with Richard Roberts, M.D., J.D., a professor emeritus of family medicine at the University of Wisconsin School of Medicine and Public Health. Roberts was an attorney and has counseled numerous young doctors on employment matters and contracts. He believes it is very important for doctors to investigate the core culture of a potential employer before signing a contract with them. The below transcript of this interview was edited for length and clarity.

: Why is it important for doctors to learn about the culture of a particular institution or practice before going to work for them?

Roberts: The typical physician will spend more awake hours at work than with his or her family and friends. …The sense of your feeling welcomed and supported, and the sense of professional growth, those are all the things that make a workplace a good or bad place for you to be. And so, if you don’t get that, it really doesn’t matter what the contract says because you’re going to be miserable.

ME: How can adoctor investigate a potential employer to learn about their culture?

Roberts: Usually it’s about just asking the physician recruiter, that’s typically the first person you’ll be talking with about the job; talking with other physicians, especially in your department; the staff that are there, even those employees sitting out in the reception area; and watching how the receptionist and patients interact. Do the nurses seem to enjoy working with each other? Is there a sense of teamwork and camaraderie? These are all key.

And then you can step away from the practice and ask the community. Ask doctors in the community, ‘What do you think of this group? I’m thinking about joining them.’ The nurses are often, in many ways, the better people to ask because they typically have more interaction with the physicians from the group you’re looking to join. So, it’s that kind of reaching out.

ME: Are there areas of flexibility where doctors can negotiate in a contract, and what are some typical examples?

Roberts: Absolutely, there are all kinds of areas to negotiate. But when hospital people say to me or to a young doc, ‘Well, we try to treat everybody the same,’ my immediate answer is, ‘Does that mean the custodial staff is getting paid the same and has the same benefits as a CEO?’

The reality is, nobody is exactly the same as anybody else, because people have unique needs. You may have a young mom who’s got scheduling needs that don’t match what the typical young male physician may feel is a good schedule for him. If the contract doesn’t reflect that, it has not done a good job of really identifying and addressing the priorities of the individual. It’s in the organization’s best interest to try to make you happy. Yeah, you do take up more of their time. Yeah, you do generate more legal fees for them as these things have to be reviewed by their lawyers. But hey, it’s your life.

In an ideal world, at the end of the day, when both you and the organization are prepared to sign, you can both look at that set of papers and say, ‘This is pretty good. This meets our needs but isn’t perfect.’

Roberts: The example that I’ll often turn to is …the group at Harvard called the Harvard Negotiation Project (cofounded) by professors Roger D. Fisher and William L. Ury. Their book called 

 lays out some basic ideas on what they call “principled negotiation,” because their view is that if a contract …or an agreement unfairly gives one the advantage over the other party, it’s in the end not going to succeed.

I usually say to people to identify two to three things. One thing might be having the ability to do certain kinds of procedures. And if that’s something that’s really, really important to you, put it in the agreement. On the other hand, there may be certain things that you’re being asked to perform, a certain task or service, and you absolutely cannot deal with that or don’t want to do that. So, it should say, basically, in the agreement that you don’t have to do them. But it’s not an infinite list, because then you’ll never manage to get through the contracting process. It’s a list that really highlights the few things both that you must have and that are deal breakers.

Now, the thing to be careful about in all of this is that language is important and the tone that we set is important. I think, as a physician, you always want to be professional, you want to be polite. You want to assume good intentions on the other party’s part. But you also need to ask good, hard questions and not be afraid to push gently but persistently.

ME: Can you provide a stepy-by-step guide for thinking through a job offer?

Roberts: Well, just like planning for a procedure or visit with a patient in the office, I think the first step is (that) you want to think ahead. And that means planning and prioritizing and developing an overall game plan with a pretty clear sense of the things that you really need to have to be a happy, successful physician and the things that you really must avoid or must not have. Now, you may only be able to identify one or two, that’s fine, or you may identify 10. That’s not so good. But you want to make sure that whatever you’ve identified as key issues for you and for those who are important to you in your life are reflected in the document.

Don’t ever be afraid to speak up for yourself. I think many times, we physicians are so used to deferring gratification and putting the needs of others before ourselves that we feel a little embarrassed asking for this or asking for that, especially when you go from kind of minimum wage jobs as a college student to pretty substantial salary offers. When the recruiter or whomever you’re talking with from the organization says to you, ‘Well, this is the same agreement that everybody signs,’ my advice is that your first response should be, ‘I’m not everybody.’ And I tell people, when you get the first draft of the contract –– because it’s always written by the system’s lawyer not by your lawyer –– change something, even if it’s the date, because under the law, the two bargaining parties have equal rights until you sign on the bottom line. Because what you do when you sign a contract is you give away certain rights to the employer. So, you want to be sure that your rights are protected sufficiently around the things that you care the most about.

And the third thing that I would say is you need to always be thinking ahead and reflecting on this whole process as your career plays out, because what you find is that most people today, especially professional people, usually have several careers. And not only in terms of where we might work, but the particular kinds of duties or jobs. And so, as a young physician, I’m going to find myself constantly going through this prioritization and identifying what I must and must not have, in terms of my list, the standard of living that I’m trying to fund, the investments I’m trying to make for my children’s future — all the things that we all have to think about. And always doing that on a regular basis puts you in a better position when something comes up that feels more pressured or all of a sudden.

It’s the planning ahead that keeps you out of trouble.

Doctors need to investigate the core culture of a potential employer before signing a contract with them. 









Physician employment contracts

Twenty-two years ago, the National Institutes of Health published the first ever evidence-based guidelines for identification and treatment of obesity. This 262-page report was an important milestone, but at the time, the authors stated that the “understanding of how and why obesity develops is incomplete.” Today, we know much more. And because of that knowledge, obesity care has changed radically in twenty years.

Today we know that obesity is an altered physiologic state.

Obesity researchers know that obesity results from the effects of environmental triggers on genetically susceptible individuals. These triggers are many but may be grouped into four categories:

 are most cited – the composition of food, its quantity, and its promotion to consumers. Research has identified many dimensions of the food supply that may contribute.

 that makes routine physical exertion less common.

 can act as endocrine disruptors with the effect of promoting obesity.

Perhaps the most important change in understanding the physiology of obesity comes from a 2011 study in the 

. Sumithran et al. demonstrated that weight loss causes changes in metabolic hormones that serve to return the body to its prior level of adiposity. Simply stated, the authors documented how the body acts to protect fat mass in subjects with overweight or obesity.

In other words, they documented that the physiology of obesity makes weight loss, by itself, unlikely to be an effective treatment for the chronic disease of obesity. It requires chronic treatment —just like dyslipidemia, hypertension, or diabetes.

The meaning of these insights for primary care is straightforward. When obesity is a clinical concern, simply advising a patient to lose weight will have a negligible benefit. The physiology of this disease state will make long-term clinical improvement very unlikely – even though many patients might lose weight in the short term.

The emerging standard of care is to use a range of treatments to help a patient reach and maintain a better state of health. These include dietary interventions, physical activity, behavioral therapy, pharmacotherapy, and metabolic surgery. Most often, a combination of these will yield the best outcomes, tailored to the needs of the patient.

A growing number of primary care physicians are seeking certification in obesity medicine to equip themselves to provide such treatment. Others might instead refer to an obesity medicine specialist. Either way, the patient will benefit from evidence-based care for this complex, chronic disease.

Ted Kyle is a pharmacist and health innovator living in Pittsburgh.

What are the implications for primary care?

The physiology of obesity

Here are 5 tips to help you buy the right malpractice insurance policy:

Daniel Cavanaugh, vice president of membership development for malpractice insurer Cooperative of American Physicians Inc., says young physicians going into private practice generally search the internet for information and coverage options or ask a colleague for a carrier or broker recommendation. Both of these, he notes, are a good start. Meanwhile, midcareer and older physicians are often more familiar with the insurance market and will gravitate toward carriers that have been in the marketplace for many years

Older physicians are also more likely to seek coverage through an intermediary such as an insurance broker or financial adviser.

Diane Robben, JD, an attorney with Sandberg Phoenix’s medical malpractice group, advises physicians to pay attention to the laws for whatever jurisdiction they practice in. Talking to colleagues can help with this as well.

Bill Fleming, chief operating officer for The Doctors Company, says independent physicians should choose a carrier with an A.M. Best rating in the “A” range and be aware of the class size from I to XV, as the smaller the number, the smaller the company. Even with a rating in the “A” range, if the carrier is very small, a few large losses can have a devastating effect on its financial security.

“You’ll want a carrier with history and experience in your state and specialty,” he says. “Medical professional liability insurance has an industry reputation of producing more volatile results, so you’ll want an insurer that has weathered the cyclical conditions of this market.”

Remember, if it’s too good to be true …

Fleming also advises physicians to be wary of policies that offer numerous one-year discounts, because prices will almost always increase substantially and physicians will often be stuck paying more than what they were first led to believe.

Also, if a practice is multi-state or might become multi-state in the future, it’s important to choose a company that is licensed in the states where a physician might practice, including telemedicine visits.

Before finalizing a policy, a physician should read the entire document, including all addendums and exclusions and be proactive if there is something that is excluded that they thought was covered before it becomes an issue.

“Know the scope of what is not included in the coverage such as HIPAA liability or cyber insurance coverage,” Robben says. “Also pay attention to whether the policy provides coverage for defense of licensure board complaints, or governmental investigations. Having a trusted and experienced lawyer to guide you through those scary and complex proceedings can help ease your fears and anxiety, and knowing there is coverage for the expenses is important.”

A physician who does it the right way compares policies, including commercial carriers and risk retention groups, which are liability insurance companies owned by the people it insures. This will help physicians determine which offer the best protections and provide the ability to consent and/or select counsel of his/her choosing, says Christopher J. Kutner, J.D., MBA, of Rivkin Radler LLP’s Health Services Practice Group.

When buying malpractice insurance, Fleming says, be candid with the underwriter. The more accurate and comprehensive the application is, the better.

“It is best to deal with issues like prior claims, changes in practice locations, negative news or social media, at the beginning,” he says. “That way you have established that you are open and candid in your relationship with the carrier.”


Even if physicians are happy with their malpractice insurance, they shouldn’t ignore it. It should be evaluated yearly and kept up to date.

“Whenever you change in size, add or drop practitioners, or have a significant change in the scope of practice, you should evaluate your medical malpractice insurance needs,” Robben says. “At a minimum, I would recommend calendaring to review your malpractice insurance on an annual basis. You want to be sure there are no gaps in coverage and that you have coverage from term to term.”

And don’t wait until the last minute to make a change. It’s important to leave enough time before the expiration of one term to be able to evaluate other options and test the market.

How to find the right malpractice policy for your situation.

Tips for buying the right malpractice coverage

The COVID-19 pandemic has added a wrinkle to my pediatric office’s plans to administer more than one thousand influenza vaccines to our patients and their parents.

In previous years we would put families in an exam room, administer the shot or live nasal vaccine, and send everyone back out through the waiting room packed with other families awaiting their turn. We did this both during regular office hours and also during some after-hours times in the evening and on weekends.

This traditional approach will not work this year for several reasons:

The requirement for social distancing means we can’t have several families waiting in the reception area for their turn in an exam room.

Time between each family would now need to be built in, drastically reducing the number of persons we could vaccinate per hour.

Cleaning all the surfaces in a room between each family’s use — something not required previously — would also add time and expense.

So, here in Raleigh, North Carolina, we have come up with a plan.

We have all seen pictures on TV of long lines of cars with people waiting their turn for a COVID-19 test or picking up some free groceries for the unemployed. Why would this drive-through approach not work for your office in giving vaccines?

If your office is in a commercial building, check with your landlord or fellow tenants to see whether you could commandeer the parking lot for a Sunday morning or afternoon or both. A school parking lot on a weekend morning or a large church’s parking area during the week are also options, but you would need to obtain permission.

You may want to have some tents for your staff and proceed even if it rains. Or, have an alternate date and time. We intend to set our date up on a Saturday afternoon with a plan to move it back 24 hours to Sunday afternoon should it rain.

Tell your patients about your plan for a drive-through vaccination clinic. Social media, your website, your on-hold phone message, signs in your office, and e-mail blasts to all your patients are some options to consider. A press release to your local paper or TV station might lead to some free publicity at the risk of having nonpatients show up on the day of the clinic.

Appointments avoid traffic jams and ensure you have enough supplies on hand on the day. I would suggest one car every five minutes. Some cars will have a single person wanting a vaccine and some may have four or five. For our office I think the average will be between three and four people per car.

We will be offering either the shot or the nasal vaccine. Both take about the same amount of time to administer to a cooperative patient. Children will be left in their car seats. A parent may be required to hold their arms, and car doors may need to be opened.

office staff print out the appointment log

Print it out for next day’s staff the day before the clinic. We plan to have a preprinted sheet for each car with lines for each scheduled patient or parent and a few empty spaces in case of an unexpected extra. As the administration site of the vaccine is supposed to be recorded, four choices for the nurse to circle will be present next to each name — left arm, right arm, left leg and right leg — which cover the four extremity choices in pediatrics. Adult patients require just two, right arm and left arm.

Each preprinted sheet will have the initials of all staff administering the vaccines because that information also must be recorded. Additionally, the sheet must have a list of the vaccines being offered. As we won’t need any vaccines for patients older than age 65, we will simply list the shot or live attenuated influenza vaccine as options for the nurse to circle. The administering provider will circle their initials, the vaccine given, and the location of administration.

You will need PPE for your staff, alcohol wipes, Band-Aids, antiseptic hand gel for use between cars for staff, sharps containers, an emergency medical kit with epinephrine available, tables and chairs for staff, and proper storage gear for the vaccines. We will be using prefilled syringes to save time. A laptop on site will allow you to remotely access electronic medical records if required. The CDC has guidelines for off-site vaccine clinics and proper storage requirements at this link: https://www.cdc.gov/vaccines/hcp/admin/mass-clinic-activities/.

One is for check-in and one for administration, on your clinic day.

, a staff member will confirm who in the car is receiving vaccinations. Your preprinted sheet will have the names already listed, but you will have to expect some no-shows and also be ready to add someone extra. Names of no-shows will be crossed out and an extra person’s name can be added to the sheet, which will eventually be required for billing.

Vaccine Information Statement sheets should be available

 here and offered. If you have standard screening questions, this is the place and time to ask them. When check-in is complete, the staff member will hand the driver the preprinted sheet and direct them to the administration station ahead.

Have the nurse collect the preprinted sheet at the administration station

Ask if any other questions need to be answered, and vaccinate those patients who are on the sheet. If the driver is receiving a vaccine, you may want to suggest they pull over into a parking space for 15 minutes to cover yourself from a medical-legal point of view in case of syncope. Someone from your office will need to monitor those spaces. The vaccine administrator then circles the initials, the vaccine given, and the site and saves the sheet for later when information is entered into the medical record and billing. You may wish to have some preprinted sheets available for those patients requesting a copy of what they received (eg., as proof for an employer).

Our office is planning to do a trial run with 12 cars the week before we have our mass clinic(s). Most likely, we will need to modify some things. In pediatrics, we always have a few resistant, uncooperative school-aged children dragged to the office by their parents. In previous years we would leave such families alone in the exam room for that parent-child discussion that can sometimes take 15 minutes. When this happens this year, we will give the vaccine to everyone willing in the car, then the family will be required to get out of line and go back through the check-in line when they think their child is ready.

COVID-19 has caused a lot of changes in our lives. We have all had to think outside of the box and make changes to long-established routines. Some of those changes may end up being for the better (eg., an elbow bump instead of a handshake).

Hopefully, we will find that this drive-through clinic works out better than our old way of doing things.

Terry Brenneman, MD, is a pediatrician and the founder of Pediatrics Partners in Raleigh, North Carolina.

The best way to issue flu shots might be for patients to never enter your office.

How to set up a drive-thru flu shot clinic

Getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting with symptoms of dementia; see if you can choose the correct codes.

Resident is followed for Dementia, Hypertension, HLD, anxiety, insomnia, and debility. Meds reviewed and updated. Resident continues to be in long term care at facility. Labs reviewed and will be ordered as clinically indicated. Res denies c/o pain.

Constitutional: Positive for activity change.

Respiratory: Positive for cough and shortness of breath.Aspiration PNA

Cardiovascular: Negative for leg swelling. HTN

Musculoskeletal: Positive for back pain and gait problem.

Psychiatric/Behavioral: Positive for confusion and sleep disturbance.

Acetaminophen (Tylenol) 325 mg tablet, Take 650 mg by mouth 3 (three) times daily Maximum dose of acetaminophen is 4,000 mg from all sources in 24 hr

ARIPiprazole (Abilify) 2 mg tablet, Take 4 mg by mouth daily

Donepezil (Aricept) 10 mg tablet, Take 10 mg by mouth, Nightly

Hydrocortisone 0.5 % cream, Apply topically 2 (two) times daily, Apply to rash

Lorazepam (Ativan) 0.5 mg tablet, Take one tablet (0.5 mg total) by mouth daily, 30 tablet

Magnesium hydroxide (Milk of Magnesia) 400 mg/5 mL suspension, Take 30 mLs by mouth nightly as needed for constipation

Trazadone 50 mg tablet. Take 100 mg by mouth nightly.

Constitutional: He appears well-developed.

Eyes: EOM are normal. Pupils are equal, round, and reactive to light.

Neck: Normal range of motion. Neck supple.

Cardiovascular: Normal rate, regular rhythm and intact distal pulses.

Pulmonary/Chest: Effort normal and breath sounds normal. o2 sats 95%

Abdominal: Soft. Bowel sounds are normal.

Musculoskeletal: He exhibits no edema, Moves all extremities independently

Neurological: He is alert, Oriented x1, Able to follow simple commands

Skin: Skin is warm and dry, Noted right ankle wanderguard intact

Psychiatric: Cognition and memory are impaired.

Late onset Alzheimer’s disease without behavioral disturbance

Resident to continue to be in long term care at facility

When documenting dementia, include the following:

F01.51
Vascular dementia with behavioral disturbance P

F01.50
Vascular dementia without behavioral disturbance P

F02.80
Dementia in other diseases classified elsewhere without
behavioral disturbance P

F02.81
Dementia in other diseases classified elsewhere with
behavioral disturbance PP

F03.90
Unspecified dementia without behavioral disturbance

F03.91
Unspecified dementia with behavioral disturbance P

F10.27
Alcohol dependence with alcohol-induced
persisting dementia P

F10.97
Alcohol use, unspecified with alcohol-induced persisting dementia P

F13.27
Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced
persisting dementia

F13.97
Sedative, hypnotic or anxiolytic use, unspecified
with sedative, hypnotic or anxiolytic-induced
persisting dementia

F18.17
Inhalant abuse with inhalant-induced dementia

F18.27
Inhalant dependence with inhalant-induced dementia

F18.97
Inhalant use, unspecified with inhalant-induced persisting dementia

F19.17
Other psychoactive substance abuse with psychoactive substance-induced persisting dementia

F19.27
Other psychoactive substance dependence with psychoactive substance-induced persisting dementia

F19.97
Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia

P
Code first the underlying physiological condition or sequelae of cerebrovascular disease

P
Code first the underlying physiological condition, such as:

Alzheimer’s (G30.-), cerebral lipidosis (E75.4), Creutzfeldt-Jakob disease (A81.0-), dementia with Lewy bodies (G31.83), dementia with Parkinsonism (G31.83), epilepsy and recurrent seizures (G40-G40.B19), frontotemporal dementia (G31.09), hepatolenticular degeneration (E83.01), human immunodeficiency virus [HIV] disease (B20), Huntington’s disease (G10), hypercalcemia(E83.52), hypothyroidism, acquired (E01-E03.9), intoxications (T36-T65.94XS), Jakob-Creutzfeldt disease (A81.0-), multiple sclerosis (G35), neurosyphilis (A52.17), niacin deficiency [pellagra] (E52), Parkinson’s disease (G20), Pick’s disease (G31.01), polyarteritis nodosa (M30.0), prion disease (A81.9), systemic lupus erythematosus (M32-M32.9), traumatic brain injury (S06.-), trypanosomiasis (B56-B56.9, B57-B57.5, ), vitamin B deficiency (E53.8)

Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere (Z91.83)

Use additional code for blood alcohol level, if applicable (Y90.-)

Use additional code to identify dementia with behavioral disturbance (F02.81), dementia without behavioral disturbance (F02.80)

Dementia in other diseases classified elsewhere without behavioral disturbance

Are you missing out on revenue because of improper coding?

Coding case study: Dementia

Stay in network or out? Accept Medicare or don’t? What’s better for physicians or more appealing to patients?

For physicians changing to a membership medicine model, these are some of the most pivotal questions to consider. Under the membership medicine umbrella, concierge models usually accept insurance while direct primary care (DPC) generally does not. The lines, however, are not solidly drawn, and in certain situations and markets, concierge physicians have launched thriving payer-free practices in an effort to simplify payment arrangements for themselves and their patients.

The majority of physicians in our concierge medicine network 

 choose to participate in both Medicare and remain in-network with commercial insurance, which is a decision fueled by patient preference. From the patient’s perspective, the ability to use Medicare, a program they’ve paid into for decades, is a valued benefit. It’s also important to note that the entire insurance submission process is not as unwieldy or time-intensive for physicians caring for between 300 and 600 members in our concierge model versus nearly 2,000 patients in traditional fee-for-service practices.

But our model is tailored to reflect each doctor’s individual vision while ensuring optimal care and convenience for their patients. We have successfully partnered with doctors who prefer to practice outside of insurance networks and be freed of the need to file or submit claims, enter insurance data into the EHR or comply with insurance oversight and restrictions.”

For Chicago-based internist and endocrinologist Robert Sobel, M.D., who changed to concierge medicine with the help of Specialdocs in 2016, the decision to practice without payers was carefully considered but seemed almost inevitable.

“The direction of reimbursement payments continued to go south over the last two decades, and cost controls and increased regulations for professional services were becoming unmanageable for our practice,” Sobel explains. “In my opinion, more bureaucracy seldom means better care. Our healthcare system is evolving with increasing complexity as more advanced diagnostic and therapeutic tools are introduced, and it’s vital that we use only the best clinical decision-making to incorporate and implement these into our practice.”

Sobel stresses that being out of insurance networks does not eliminate interaction with their systems and processes.

“We are still intimately involved in advocating for our patients’ treatments and medications, and in providing referral entities with essential information,” says Sobel. “However, practicing in this model allows me to focus on making the right clinical decisions for my patients as well as the time and resources to fight through bureaucratic tangles to help them get what they need.”

Family medicine physician Larry Leibowitz, M.D., who hasn’t participated in any type of insurance network since establishing his Connecticut-based Matrix Personalized Medicine practice with Specialdocs’ support in 2017, says he’s never regretted his decision.

“There’s really no advantage to patients by my accepting insurance or Medicare,” he says. “If I were in-network, patients would be responsible for copays and would incur out-of-pocket costs for office visits and other procedures until they met their deductibles, on top of my annual membership fees.In my model, they’re responsible for none of that.”

Once he clarifies for prospective patients that all services beyond the ones he renders will continue to be covered by insurance, patients rarely object to the arrangement. In fact, Leibowitz says he has never had a prospective patient opt to not enroll as a member of his practice because of insurance concerns.

“On a personal and professional level, I couldn’t have anticipated how much more unfettered I feel over the course of the day,” he says. “While I still need to obtain prior authorizations for medications and imaging studies for my patients, I no longer have to please insurance companies or Medicare or meet the proper metrics for reimbursement.”

The decision to stay in-network or remain outside of it is a personal one for physicians, not based on finances, but on their perception of how they can make it easier for their patients to receive care. The concierge medicine model is not sustained by insurance reimbursement but by membership fees. On average, 87% of a concierge physician’s revenues come from members paying an annual fee, while only 13% of revenues are realized through insurance reimbursement.

Leibowitz acknowledges that he’s leaving a relatively small amount of money on the table by not filing for reimbursements, but says the resulting independence is worth every penny.“I’m able to care for patients without the daunting administrative burdens that most participating providers face.And the personal and spiritual freedom I’ve gained in this model has been priceless to me.”

He adds: “I’m also able to modify my fee schedule as I please in order to accommodate a patient who has fallen on hard times. I can simply say ‘I’ve known you for years... so let’s make this work for you’ without concerns about insurance backlash.”

My advice for physicians weighing whether to accept insurance as they make the change to a personalized practice model is keep in mind the potential downside of not accepting insurance in terms of practice growth. Insurance coverage remains the top-ranked factor influencing American consumer decisions about where and with whom to seek medical treatment. Other surveys show that patients typically first evaluate potential providers by posing just one question: Do they take my insurance? And if you do feel strongly that remaining outside of insurance networks is the right choice for you?

Consider your patient panel carefully. Doctors who successfully practice without accepting insurance have exceptionally loyal patients who stay with them because of the value placed on their relationship.

Thoroughly understand your community’s demographics. Price your services in a manner that both sustains your practice and is affordable for current and future patients.

If you are in a membership medicine model, is working with payers the right way to go?

Medical Economics October 2020

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