Medical practices across the country are reopening. But are they doing it safely? Although physicians are eager to return to normal, it’s vital that they have robust protocols and procedures ready to ensure patients and staff are safe. 

® sat down with Kerin Torpey Bashaw, vice president of patient safety and risk management with The Doctors Company, to discuss how physicians can prepare to reopen and manage their risk in this new normal of health care after COVID-19.

The following interview was edited for length and clarity.

 What criteria should physicians be using to make reopening decisions?

: I think it’s really important for them to have a framework to use. So when we think about opening a practice, I would recommend four things.

The first thing is for them to look at their operations pre-COVID-19, because that’s what the staff is used to. That’s what the patients are used to. They also need to take a look at what’s happening from a federal perspective and from a state perspective. Local, it’s all about local public health, but the physicians should be getting their direction from the local public health authority; that’s where they’re going to get the most information that’s relevant to their practice. Then it’s really important for them to be checking, every single day, those websites with that information — so, having a framework, getting the information together and then making sure that the staff are up-to-date and know what’s going on. The staff and the patients, especially, are very, very frightened. Physicians are telling us that the patients are not coming in; hundreds of patients are not coming to their appointments. So, they’re fearful. Getting communication out, making sure that the patients know that you’re following the CDC (Centers for Disease Control and Prevention) guidelines, is going to be really, really important. And the criteria for opening really come from that local public health authority.

ME: Let’s talk about staff training. What kinds of training should be conducted or refreshed?

: In general, you want to train staff regarding infection control principles. And the nice thing is, you can go right to the CDC website and pull it down at the staff training page. You cannot educate staff enough, because the rules have all changed. So before you even reopen your office, provide standard training regarding infection control and use of PPE (personal protective equipment) donning and doffing. If you are on the primary care medicine side, you’re probably used to wearing gloves, but you’re not used to wearing a mask. If you have a procedure or you’re doing wound care or something that has to be done in the office, you’re going to want to gown up, and you need to put that on correctly. For example, most practices are not used to using an N95 mask.

Communication cannot be stressed enough. Your staff members are afraid. They have been through a lot.

I highly recommend a leadership evidence-based practice: the daily huddle. So, at the beginning of your day, every day, you’re going to check the CDC website, you’re going to talk about the plan for the day, you’re going to look at the patient list and see who’s there and what their issue is. And you can explain what your process is; make sure that everyone on the team knows what the plans for the day are for the patients. And then do check-ins during the day. The staff will do many things that they have never done. Tackling COVID-19 is about standardization. It’s about standardizing your practices, so you can improve them and then tweak them every single day.

So, a huddle at the beginning of the day is going to be key, but you also need a debriefing at the end of the day. What went well? What didn’t go well?

I have a story, if you want me to share it. We had a practice call. The practice had done extensive work: They had their protocols in place; everybody was trained; they had their PPE. They did all their work offline with regard to educating the patients. The patients didn’t come into the waiting room. They didn’t allow family or staff to come in the patient rooms. In this instance, the provider went to give a deep injection and pulled the mask down to have a conversation with the patient and then left it down partway while giving the injection. And the family of this elderly person went ballistic, because that is not the standard of care. There are so many things that are changing, and one little slip is a break in the standard of care, which can be very, very problematic. Despite the extensive work that happened with this practice, one little slip—it can cause immense problems.

So, standardization, education briefings, debrief at the end of the day so you learn from your mistakes and figure out what you can do differently tomorrow. That’s going to be really important for keeping up staff morale and making sure that they’re energized and feel cared for and that they have a voice about what’s happening in the practice.

ME What have you found to be some of the best practices in terms of communicating a standardized message?

: People want to know that you’re doing the right thing. We have had a couple of stories about patients walking in videotaping or wanting to videotape the whole visit because they want to make sure that people are doing what they are supposed to be doing. It’s a good idea to call your risk manager so you can have a conversation and understand what the patients want.

We had a practice call in because they had a problem. They said they have had hundreds of patients cancel and not show up for appointments that were either scheduled or that are for follow-up, and there can be some liability in that. So the practice standard was “Hey, you know what? We’re going to call a patient who misses an appointment, and in three months we’re going to send a letter and document that we asked the patient to come in.” You can do that via your website or the patient portal, however you want to do it. But I can’t overemphasize the need to document all your attempts to communicate with your patients. And if you do communicate, you need to put that information in the chart, so it shows your due diligence by reaching out and communicating and making sure that the patients understand the implications.

ME: Is there anything else that you think is important for physicians to consider as they reopen their practice?

: Physicians go into medicine because they want to practice good medicine. No physician goes in with the intent to harm. And so I think I would be remiss if I didn’t use this opportunity for those that aren’t physicians. You know, right now, our physicians and nurses are heroes, and they are putting their lives on the line to help their patients because they care about their patients. I can’t say it enough: I think we need to support providers and offer them protections. These are crisis times, and practices are doing the best they can. Malpractice is about not meeting the standard of care, and the standard of care is changing daily. But when you’re trying to do the best that you can in a complex and ever-changing environment, I think we owe it to our providers to take a stand and provide them with some protection. I don’t need to tell the physicians out there that going through a medical malpractice case is incredibly stressful.

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Medical practices across the country are reopening. But are they doing it safely? 

Managing new practice risks in the COVID-19 world

There is a growing recognition in health care that many chronic conditions can be improved by addressing social determinants of health (SDOH) first.

“Social determinants of health are those aspects of how we grow, how we live, how we play and how we worship that affect our overhaul health, in addition to the systems and resources set up to provide that,” says Jeffrey F. Hines, M.D., medical director of diversity, inclusion and health equity for Wellstar Health System in Atlanta.

SDOH encompass critical socioeconomic aspects such as access to food, transportation issues, housing conditions, education, neighborhood and environment conditions, access to health care and ethnicity, Hines explains. Experts recommend that, to better help patients with chronic illness, physicians learn more about these potential obstacles to health and how to identify patients struggling with them.

Physicians can begin by gaining an understanding of SDOH’s measurable impact on health, if they haven’t already studied it, says Alexandra Schweitzer, M.P.P., a senior fellow at the Mossavar-Rahmani Center for Business and Government at Harvard Kennedy School in Cambridge, Massachusetts.

“It is well documented that unstable housing, inadequate nutrition, social isolation and other social determinants of health worsen chronic conditions like diabetes, heart disease and mental illness,” Schweitzer says. “Physicians in primary care and emergency departments can and do help patients by screening them for social needs, connecting them to community health workers, referring them to social service agencies and helping them navigate through the social services system.”

SDOH tend to affect marginalized and underserved communities the hardest, such as people of color — especially African Americans, who are already at increased risk of a number of chronic illnesses, from hypertension to diabetes — members of the LGBTQ community and the homeless, Hines says. “Because of systems of disparities that have been in place for decades, those communities continue to have higher incidences of chronic illnesses, which affords them [poorer] health outcomes than appropriately resourced communities,” he says.

 states that “upwards of 70% of health outcomes are driven by factors beyond health care and that poverty is associated with more years of lost life than smoking and obesity combined.” In addition, a 2014 study in “Public Health Reports” suggests that health behaviors, linked to increased risk of illness and mortality, “are strongly shaped by social factors, including income, education and employment.”

The proof that SDOH affect health is perhaps better represented by the successes that follow when these needs are addressed, Schweitzer says. She notes that fixing a problem related to, for example, housing or food insecurity can change a person’s health outcome. She references a case study of a homeless woman with diabetes whom she calls “Regina.” When Regina got into public housing at age 46, her diabetes improved. She was able to refrigerate her insulin and had a safe space to give herself injections, and she could prepare and eat healthy food on a regular basis.

“That’s one way housing has a ripple effect on diabetes,” Schweitzer says. “By addressing housing, and with a lot of case management, [Regina] was able to get into a much more sensible routine of prevention.”

Although physicians cannot solve their patients’ socioeconomic problems alone, they can use SDOH screening questions to get to know their patients’ needs better and connect with community resources and care navigators, if appropriate, Schweitzer says.

“The best way to integrate this work into their practices is to build it into what they are already doing; for example, by using medical assistants to do screening and documenting results in the electronic medical record,” Schweitzer says.

Erin Jospe, M.D., chief medical officer at Kyruus, a provider data management platform in Boston, says physicians need not create their own SDOH screening documents; a number of options already exist. These include:

The Hunger Vital Sign, a two-question screening method to determine food insecurity.

The Everyone Project, organized by the American Association of Family Physicians (AAFP), a series of tools that focus on social needs.

A toolkit from the American Academy of Pediatrics to assess SDOH in children.

A guide by the American Hospital Association to help physicians create their own SDOH screening protocols.

For physicians who want support in building their SDOH screening tools, Schweitzer recommends an AAFP publication titled “The Feasibility of Screening for Social Determinants of Health: Seven Lessons Learned.” The authors recommend the following steps:

Determine readiness to start screening; the guide offers a related checklist.

Identify the community’s specific SDOH needs.

Build connections with community resources and develop a strong team to work together on these issues.

Build the screening into the workflow so it is seamless.

Make a plan to sustain follow-up with patients over time.

The Centers for Medicare & Medicaid Services began a program in 2016 called the Accountable Healthcare Communities Model, which promotes clinic-community collaboration around SDOH, to screen and report on health outcomes.

Jospe recommends that physicians “assume nothing” about who might be experiencing hardship in which area and screen every patient for SDOH in the same way.

If physicians who make recommendations find that their patients don’t seem to be improving, Nicole Washington, D.O., M.P.H., a psychiatrist based in Tulsa, Oklahoma, advises probing a little more deeply into the patient’s situation. “Telling a patient to exercise is fine. But what if [patients] don’t have sidewalks or a safe place to walk? We just can’t give cookie cutter advice when people aren’t living cookie cutter lives,” she says. “We may all be in the same storm, but we’re in very different boats.”

Washington recommends asking patients struggling with adherence what is stopping them from implementing a healthy behavior or treatment. “Sometimes we don’t ask those questions. We just label people as being nonadherent,” she says.

Chirag Patel, MD, medical director of population health at Wellstar, recommends asking intentional questions, such as “Are you having trouble getting food to eat? Are you afraid of being evicted? Is there mold in your house?” If patients provide answers that indicate difficulty with one of these key SDOH, the physician can offer a resource list or try to connect the patient with a care navigator, social worker or related staff person.

It’s important to begin the process of assessing for SDOH, but Schweitzer cautions against doing it alone: “Physicians probably shouldn’t try to do it all themselves,” she says. “Often one of the best ways to get some help is to provide a community health worker, a nonclinical person who comes from the community and speaks the right language, to establish a rapport and some trust [with patients].”

Helping a person who struggles with an SDOH such as food insecurity isn’t as simple as providing a link to a local food bank, she says. It might require assisting them with filling out the application for Supplemental Nutrition Assistance Program benefits. It might take providing nutritional education and even support with obtaining basic kitchen supplies so patients can cook for themselves.

“A lot of [the difficulty with adopting healthy behaviors] is that people have to struggle to wind their way through the system and figure out all the bureaucracy in the middle of what are probably fairly hectic lives,” Schweitzer says.

Patel says he believes in strong partnerships and advocacy at a local level: “This includes community organizations, corporate, philanthropic and policy partners that want to make a difference in this space.” He suggests partnering with local faith and spiritual groups, which often have “significant influence” on healthy behaviors and practices of their members.

For physicians who don’t yet have a lot of connections, Schweitzer recommends referral platforms like Healthify that help physicians find sources for SDOH needs.

Though it is important for physicians to become better educated in SDOH and health equity practices, Patel stresses that it’s equally important to improve patients’ health care literacy. “I think one of the areas we need to explore more in our country is helping patients know what questions to ask when they go to see the doctor,” he says.

As an example, he cites the high incidence of fibroids in African American women. Many doctors recommend an intervention such as a uterine fibroid embolization or partial hysterectomy, but those treatments can impair the ability to become pregnant. Many young African American women opt for these treatments in their childbearing years because they don’t know about alternatives or what questions to ask. “That’s not an equitable outcome compared to other ethnicities,” Patel says. “We have to give the tools of education and information to our patients so they know what to ask.”

There are numerous ways physicians can think about and screen for SDOH, but what matters is that they begin somewhere, Jospe says: “We need to think about our familiarity with the resources we can bring the best way to highlight them and offer them to our patients, so that when there is stigma about needing to ask for help, that can be taken away.”

There is a growing recognition in health care that many chronic conditions can be improved by addressing social determinants of health first.









Address social determinants improve patient outcomes

2020 Burnout Survey Results: Physicians facing unprecedented crisis

Physician burnout was already at a crisis level. Has COVID-19 made it worse?

 has asked our physician audience to tell us how burnout affects them, both professionally and personally.

This year, physicians have had to deal with all of the normal difficulty that often lead to burnout, with an unprecedented crisis looming over it all in the form of the COVID-19 pandemic.

Below you will find the complete and exclusive results of our survey, including physicians detailing how COVID-19 has affected them — in their own words.

More than two-thirds of physicians say they feel burned out in 2020.

Over the past 20 years, hospitals have entered many markets previously serviced exclusively by private practice physician groups, either by hiring individual physicians or acquiring entire practices. These developments have changed many health care markets, often to the detriment of physicians. For independent physician groups, this means three things:

 Hospitals are now their major competitors.

 Referrals may dry up as hospitals that employ large numbers of primary care physicians steer referrals in-house.

 Access to hospitals and other key facilities essential to running their practice may be cut off as retaliation for competing effectively.

This does not mean that hospitals and physicians are locked in mortal combat from which only one will emerge. In many instances, it can be beneficial for independent physician groups and hospitals to work together.

Unless a hospital has its sights set on monopolizing physician markets, it may not make economic sense for it to enter a variety of medical specialty markets or even expand its position in specialties in which it has only limited offerings. Expansion requires a hospital to directly employ physicians, which increases costs, and the hospital may not be able to realize sufficient integrative efficiencies to offset these costs. Hospitals can hire physicians from existing practices, but that can trigger lawsuits, create ill will and result in higher salaries than recruiting physicians from outside the community. At the same time, recruiting from outside the community can be riskier than hiring known and established local physicians.

Physicians with established practices typically have long-standing relationships with their patients and the community, and they have established referral networks and skills that a hospital may have significant difficulty replicating. This is exactly what the hospital hopes to build.

Overall, hospitals and physicians each have qualities the other wants, which is the bedrock of any potential joint venture or collaboration. Federal and state antitrust laws, however, limit the types of arrangements hospitals and physicians can draft. The antitrust laws, for example, make agreements between competitors that unreasonably harm competition and consumers unlawful. Although agreements between firms that do not compete against one another can raise antitrust issues, these types of agreements are subject to less scrutiny than those between preexisting competitors. This means that the best time for a practice to enter into a joint venture with a hospital is before the hospital enters the physician’s area of specialty.

Even if the hospital and private practice can come to terms on a joint venture, they need to do so in a way that does not prompt government intervention. Agreements between existing competitors are subject to certain limitations. For example, agreements to fix prices, allocate markets and customers, or boycott rivals can violate antitrust laws.

However, competing hospitals and physicians can embark on a broad range of collaborative endeavors. Joint ventures in which hospitals and physicians share risk can create significant efficiencies, benefit consumers, bring new services into a community, and prevent redundant and wasteful capital expenditures. Further, certain joint ventures may bring a new medical service into the community, which benefits consumers.

Even a joint venture with a legitimate objective can raise antitrust issues. The government will look for two key concerns:

Will the joint venture have market power?

Does the framework contain anticompetitive agreements?

A significant market power problem can make a joint venture untenable under antitrust laws, but this might be easily remedied by structuring the agreement differently. An ancillary anticompetitive provision might have an alternative that does not raise antitrust problems. Taking steps to avoid anticompetitive outcomes goes a long way with the government.

 is an antitrust attorney who has represented physician practices in antitrust matters across the country. Send your legal questions to medec@mjhlifesciences.com.

Not all hospitals and physicians are locked in mortal combat from which only one will emerge. In many instances, it can be beneficial for independent physician groups and hospitals to work together.

How practices can negotiate with a competing hospital

There’s nothing more frustrating than rendering a service and not being paid. Sometimes the problem comes down to a single code.

Nuanced coding rules are difficult to understand, and physicians aren’t taught this information in medical school. Still, health care is a business. As business owners, physicians need to know how they’re paid, including what codes to use, what modifiers to append and what details to document. Brushing up on common coding mistakes helps avoid costly recoupments and denials. We asked several experts, all certified professional coders, for their best advice on how physicians can maintain compliance and collect all the revenue to which they’re entitled.

Office visit evaluation and management (E/M) coding is the bread and butter for practices nationwide. Yet experts say physicians continue to make mistakes that cost them thousands or even hundreds of thousands of dollars annually.

It all goes back to the three critical components of an E/M code: history, exam and medical decision-making (MDM), says Deborah Grider, senior health care consultant at KarenZupko & Associates Inc. in Chicago. Every office visit E/M code has its own requirements for each component, with medical necessity being the ultimate deciding factor for which E/M level to assign.

Physicians often oversimplify E/M coding, Grider says, making them easy targets for post-payment audits. For example, they incorrectly assign 99213 (established patient level three office visit) if a patient has three diagnoses and 99214 (level four) for four diagnoses. “That’s not the way it works,” she says, emphasizing the need to follow Common Procedural Terminology (CPT) guidelines that dictate specific requirements.

Consider these three common reasons for post-payment recoupments and advice on how to maintain compliance.

Post-payment audit: The reason for the visit doesn’t support the level of E/M code assigned. In other words, the service wasn’t medically necessary.

“I always tell doctors to take a step back and look at their documentation,” Grider says. “Does the level make sense given the problem they’re addressing and managing?”

For example, physicians should not assign 99214 for a patient with allergic rhinitis. However, if they see an obstruction in the nose and recommend an MRI to make sure it isn’t a tumor, 99214 may be warranted. To report 99214, physicians must perform and document a detailed history, examination and moderate complexity MDM.

Angela Jordan, senior clinical documentation improvement consultant at Trusted i10, agrees. For example, physicians shouldn’t bill a level four or five E/M service for a patient with stable chronic conditions that don’t warrant testing or medication changes. “An E/M leveling tool may map it to a 99214, but if you know in your gut that it’s not a level four, then don’t go with it. Your gut instinct is probably right,” she says.

Physicians who rely on the E/M calculator in their electronic health record (EHR) should ask a certified coder or external consultant to vet the tool and determine its accuracy, according to Jordan. “I don’t want to make a blanket statement that all these tools are bad, because they’re not,” she says. “However, an audit of the tool will tell you what it does well and what could pose problems.”

History doesn’t support a higher-level E/M service.

 Ensure that documentation reflects the detailed conversation with the patient, says Sonal Patel, a health care coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, South Carolina.

For example, when billing a level four or five E/M service for a new patient or a level five E/M service for an established patient, physicians need to document a comprehensive history. This includes a chief complaint, an extended history of present illness (HPI) and a complete review of systems, including those directly related to the problem identified in the HPI, as well as all additional body systems and a complete past, family and social history.

When billing a level four E/M service for an established patient, a detailed history must be documented, including the chief complaint, an extended HPI, an extendedreview of systems and a pertinent past, family and/or social history directly related to the problem.

Typically, each of these scenarios lacks the extended HPI — either the status of three chronic conditions or four or more of the following elements: quality, location, duration, severity, timing, context, modifying factors and associated signs/symptoms.

“You can easily get four elements in the HPI just by hearing the patient talk about their pain or the particular problem that brought them in,” Patel says. “We know that the physician is touching the patient and talking with them, but if it’s not being documented, an auditor can’t score it.”

Post-payment audit: Documentation doesn’t support time-based billing.

Document the specific details of counseling and coordination of care that dominated at least 50% of the visit, says Patel, noting what you discuss and with whom. “An auditor wants to see why this extra time was spent. What was the greater purpose?” she adds.

Experts say chronic care management (CCM) — care coordination services given to patients with two or more chronic conditions that are expected to last at least 12 months and place the patient at significant risk of death, acute exacerbation/decompensation or functional decline — can help improve patient outcomes and generate revenue for the practice.

“As we’re ramping back up from COVID-19, I’m telling practices to think about CCM,” says Sandy Giangreco Brown,director of coding and revenue integrity at CliftonLarsonAllen LLP in Loveland, Colorado. “It’s totally feasible, and you can provide better care for your patients.”

Consider the following CCM codes and average Medicare payments:

CCM provided by clinical staff directed by a physician or other qualified health care professional

Each additional 20 minutes per calendar month (may be billed twice a month)

CCM provided personally by a physician or other qualified health care professional

Complex CCM provided by a physician, other qualified health care professional or clinical staff under the direction of a physician or other qualified health care professional

Each additional 30 minutes per calendar month

Not sure about return on investment? Think again, says Brown. A physician who bills 99491 for 250 patients every month for a year could generate $252,270 annually. That can more than cover the salary of a nurse whose sole responsibility is to communicate with the patient, assess for medication adherence, identify community and health resources, facilitate access to care, and more, she adds.

However, experts say CCM can also pose compliance risk when physicians don’t code and document it correctly. Consider the following four reasons for denial and how to avoid them:

Reason for denial: There is no separate documentation of CCM services.

Create a separate note tracking the provider’s work related to CCM, says Manny Oliverez,CEO of Capture Billing & Consulting Inc. in Leesburg, Virginia. Don’t add this information to an existing note, he adds.

Physicians can also work with their EHR vendor to create a CCM template that includes documentation requirements and helps physicians and their staff track time spent rendering CCM services, Brown says.

Reason for denial: Another provider already billed CCM.

 “Only one provider per month can be reimbursed for CCM,” Oliverez says. He provides the example of a patient with end-stage renal disease in a skilled nursing facility who is managed by the facility’s medical director, a primary care physician and a nephrologist. Each provider can technically bill CCM; however, to avoid denials and costly rework, they should agree on who will bill it. The billing provider should be the one who ultimately performs all or a majority of the care management activities, including addressing the patient’s psychosocial needs, Oliverez adds.

Reason for denial: The wrong codes, depending on who provided the service, were billed.

When medical-directed clinical staff perform CCM, report 99490, says Oliverez. When physicians perform it, report 99491.

Reason for denial: Complex CCM was billed when it wasn’t warranted.

 Document specific changes in the care plan, as well as medication or treatment changes, Oliverez says. Physicians or other qualified health care professionals can’t report complex CCM when the care plan is unchanged or requires minimal change (e.g., only a medication is changed or an adjustment in a treatment modality is ordered), he adds.

CPT modifiers communicate important information to payers, and physicians must ensure the message they send is accurate, says Rhonda Buckholtz, CPC, CPMA, owner of Coding and Reimbursement Experts LLC in Pittsburgh, Pennsylvania. Consider the following:

 The physician performed a significant and separately identifiable E/M service on the same day as another procedure or service.

Pay for both services because the E/M service went above and beyond the usual pre- and post-operative work.

Pay for two or more procedures/services because they were performed during different sessions or on different anatomical sites, organ systems or lesions or for different injuries.

Sending the wrong message could lead to costly post-payment audits and recoupments, Buckholtz says. Consider these myths and truths about modifiers 25 and 59, commonly used in primary care/internal medicine:

Myth: Physicians should automatically report an E/M code with modifier 25 in addition to a procedure when the physician documents a history, an exam and an MDM.

Truth: Report modifier 25 only when the E/M service goes above and beyond the usual pre- and post-operative work associated with a procedure that has a global fee period, Grider says. For example, an otherwise healthy patient with knee pain presents for a second routine injection in a series of three injections; physicians can’t bill a separate E/M with modifier 25 because the physician didn’t perform additional workup. “That E/M service should be part of the preevaluation workup and not billed separately,” she adds.

Buckholtz agrees. When the decision to perform the procedure has already been made and the patient presents for that scheduled procedure, physicians can’t bill a separate E/M service, she adds.

Grider offers this example of when an E/M service with modifier 25 may be warranted: A patient with diabetes and knee pain presents for a joint injection, and the physician changes the patient’s insulin regimen based on blood sugar levels.

The same is true for a patient who presents for an immunization but also complains of headaches, Buckholtz says. When the physician performs and documents a history, an exam and an MDM related to the headaches, they may be able to bill an E/M code with modifier 25 in addition to the joint injection. “This modifier is always heavily scrutinized by payers,” she says. “It must be clearly documented that the E/M service isn’t what the patient originally came in for.”

Myth: Physicians need two different diagnoses to report a procedure in addition to an E/M service with modifier 25.

Truth: The diagnoses for the procedure and the E/M service may be the same. Buckholtz’s example: A patient presents with knee pain; the physician performs a workup to determine that a cortisone injection is necessary and administers the injection. When the decision to perform the procedure is made the same day it is done, the physician can bill both the procedure and the E/M service with modifier 25. The diagnosis code for each service is knee pain.

Myth: When payers deny a service, practices should automatically submit the service with modifier 59 to bypass payer edits.

Truth: Modifier 59 should be a last resort because it’s likely that a different modifier is more appropriate, Buckholtz says. Other options: RT (right), LT (left) or 50 (bilateral procedure). Payers may also accept modifiers XE (separate encounter), XS (separate organ or structure), XU (unusual nonoverlapping service) or XP (separate practitioner). Each payer policy will dictate what modifiers it requires in each circumstance. An encoder that includes payer-specific policies can help practices maintain compliance, she adds.

Myth: Once published, payer policies for modifier 59 remain largely unchanged.

Truth: Payer policies change frequently, and these revisions are often communicated via electronic remittance advice, Buckholtz says. For example, a payer may add and delete codes for which modifier 59 is appropriate. “If nobody is paying attention to these remittance advice communications, that’s when you get into trouble, because you’re billing per an old policy,” she says.

She shares these tips to help practices stay on top of policy changes:

Appoint someone in the practice (e.g., a coder or practice manager) to check the policies monthly.

Print each payer policy. Make sure the printed policy includes the date it was printed.

Read the entire policy. “People often go straight to the coding information, and that information is not valid unless you’ve met all the other criteria in the policy,” Buckholtz says.

Address coding vulnerabilities to protect practice revenue.

2020 Coding Guide: Get Paid What You're Owed

Practices have been creative during COVID-19 to ensure safe patient access: Telephone visits. Curbside immunizations. Drive-up virus testing. Even checking patients in for their in-office visits while they wait in the car. However, each of these scenarios poses one significant challenge: Collecting copayments and coinsurance.

“With COVID-19, you’ve got to find ways to meaningfully engage the patient,” says Denny Flint, chief commercial officer at Millennia, a tech-enabled patient engagement company specializing in the recovery of end-to-end patient financial obligation. “That’s the key to a successful collections strategy.”

Experts provide nine tips to help practices successfully collect patient balances during COVID-19 and beyond:

1 Educate patients about the cost of virtual services

This includes having a conversation at the time of booking about how much each service will cost, says Flint.

Although some payers may waive cost-sharing for virtual services during the pandemic, those waivers will likely expire at some point, making it critical for patients to understand their financial responsibilities. For example, patients may not understand why they need to pay for a telephone appointment or why a telehealth visit costs the same as an in-person one. Explain that these services require provider time and expertise, which is why payers consider them compensable.

2 Decide whether the practice will require upfront collections

Many practices became lax during COVID-19 because they simply wanted to maintain or rebuild patient volumes. Now it’s time to revisit their strategy, says Reed Tinsley, CPA, health care consultant in Houston, Texas. “A medical practice is a business,” says Tinsley. “You need to have cash coming in to pay expenses.”

Cheryl Mongillo, practice manager in Wilmington, Delaware, says her family medicine practice has been less aggressive with upfront collections during COVID-19 because payer policies regarding patient financial responsibility have changed so frequently. “It’s very complicated,” she says. “Depending on who the carrier is, it’s a different rule — even for the same payer.”

She spends an hour each day monitoring payer websites for changes. She also taps into resources through a listserv managed by the Professional Association of Health Care Office Managers (PAHCOM), an organization that includes thousands of medical office managers, practice administrators and physicians managing their own private practices.

“Not collecting these amounts upfront has increased our accounts receivable, but we’re willing to work with that for a little while,” she says, adding that federal funds continue to help. Her practice received $63,000 through the first round of Medicare advanced payments. They also received financial assistance through the Paycheck Protection Program.

Mongillo’s staff continue ask for an upfront copayment either in person or ahead of time when confirming appointments via phone, but they don’t insist on it. “We don’t want to alienate patients because this is a stressful time for them,” she says.

One challenge with upfront collections is that the clinical circumstances of the visit are frequently unknown before the encounter, says Flint. This makes it difficult to know exactly how much patients will owe, he adds.

For example, a patient may come in for a simple follow-up appointment. However, during the appointment, the physician might perform a minor procedure that’s separately billable (e.g., a biopsy or lesion removal). Another example is a level three office visit that turns into a level four because it requires more complex medical decision making.

With that said, practices should strive to avoid over-collecting from patients so they don’t end up owing money they’ve already spent on salaries and supplies, says Flint. He says to calculate 90% of the Medicare fee schedule amount (which is typically the lowest fee schedule among federal and commercial payers), and then apply the patient’s insurance. “You’re going to underbill, but at least you’re getting the patient invested in their care upfront,” he adds.

Also print an aging of accounts receivable (credit balances only) report on a monthly basis so the practice can refund patients in a timely manner and according to payer requirements, says Tinsley. Medicare, for example, requires providers to refund patients within 30 days of the payment date, he adds.

“If a small practice wants to survive, it can’t just send a statement and hope patients pay,” says Flint, adding that practices must tailor patient financial engagement strategies to fit the age and tech-savviness of the demographics they serve.

“Portal-driven online bill-pay and mobile payment methods may attract the millennials and Gen-Xers who are comfortable with DIY technology,” says Flint. “However, baby boomers generally prefer the human touch delivered by a U.S.-based call center that gently informs and educates them about why they owe what they owe. COVID-19 has taught us our goal is a seamless, personalized billing experience where one size does not fit all.”

Mongillo’s practice sends a text message to patients as soon as their account includes a patient responsibility. Patients simply click through the link to a secure site where they can make the payment. She says this technology has increased their collections by 30% in the last year and a half.

Obtaining patient consent to receive these messages is easy because Delaware law doesn’t require providers to ask patients whether they want to opt in to receiving these messages. It only requires them to let patients opt out. Mongillo says many patients don’t opt out because they want to receive appointment reminders and payment receipts via text as well.

Mongillo doesn’t want patients to forgo or delay care because they can’t afford it. “Most of our patients who are on these plans are people we’ve seen for 20 or 25 years who have fallen on some rough times,” she says.

However, remember that the longer it takes patients to pay off their debt, the less value that money has to the clinic because of overhead, salaries and other expenses, says Sergio Quiej, Texas-based independent revenue cycle consultant who recommends three or four monthly installments.

5 Continue post-visit collections calls … but with sensitivity

Flint suggests calling patients after the same invoice remains unpaid after two billing cycles to make sure they received it, answer any questions they have and try to connect in some way.

To minimize questions, be sure to send a clear and concise invoice. This includes the service date, location, provider, description of the service rendered, amount insurance paid (including primary and any secondary insurance), and the amount the patient owes, says Flint. Differentiate between copayment and co-insurance amounts, he adds.

However, don’t just call and ask for money, says Quiej. Inquire about the patient’s family and job — even if it takes a few extra minutes. “The way you treat the patient directly impacts how they’ll react to the debt,” he says.

Tinsley agrees. “What I tell all of my clients is don’t change your process,” he says. “Send out your statements, make your collection calls, and forge ahead.” Temporarily relaxing your processes can have a negative effect in the long-run because patients may come to expect and even demand that leniency indefinitely, he adds.

6 Employ enough billers or consider outsourcing

Many practices may have laid off staff when patient volumes decreased. However, once volumes resume, they need to make sure they have enough staff for timely billing and collections, says Flint. In some cases, it may make more sense to outsource revenue cycle management (RCM) to a company that is a branded extension of the practice and staff. Working with an external vendor also helps practices avoid internal staffing challenges as patient volumes continue to ebb and flow during a potential second wave of the virus.

Flint provides these tips for negotiating a favorable contract with an RCM vendor:

Require the vendor to charge only a percentage of what they collect.

Ask the vendor to waive its implementation fee.

Demand an easy-out contract. “If the vendor doesn’t perform within six months, you should be able to walk away without cause or penalty,” he adds.

This enables practices to simply charge the card once a patient responsibility is assigned, says Flint. However, there are caveats. “If your practice intends to accept card payment as well as store, process, and transmit cardholder data, you need to host your data securely with a Payment Card Industry (PCI)-compliant hosting provider that ensures the data is encrypted, password protected and compliant with PCI Data Security Standards,” he adds. These standards cover technical aspects of handling and managing cardholder data.

If the practice makes a reasonable effort to collect from a patient who is experiencing financial hardship (e.g., job loss due to COVID-19), providers may be able to offer a discount (e.g., settle for 70% of the amount owed) without violating Stark Law, says Tinsley. “But remember that just because even if someone doesn’t have a job, they could still have money,” he adds. “There are a lot of people out there with big savings accounts.”

“It’s uncomfortable for people to ask patients for money,” says Tinsley. Provide training on how to communicate effectively to increase the likelihood of collections while maintaining positive patient relationships, he adds.

Think of COVID-19 as an opportunity to improve patient collections and the patient financial experience, says Quiej. “This is an opportunity to create and develop relationships with patients — to learn how to approach each patient,” he adds.

Collecting copayments and coinsurance is challenging because of the COVID-19 pandemic.

Nine tips for collecting patient balances

Chronic diseases are a recent part of human history. In the past people only when to healers, physicians or hospitals when they became sick. Generally these were due to infections, injuries or other maladies. Even cancer was very rare in the past as described by Mukherjee (“The Emperor of All Maladies,” 2010). The concept of chronic diseases emerged in the 1970s with high blood pressure (hypertension) being the first. Type 1 diabetes (a complete lack of insulin) became understood in the early 20th century, but the far more common Type 2 diabetes (due to excess carbohydrates and insulin resistance) emerged with the epidemic of overweight and obesity. High cholesterol became recognized as a disease in the 1980s. Auto-immune diseases were known in the past but exploded in frequency in the 1970s and a new medical specialty developed — rheumatology.

Chronic diseases are often referred to as Western diseases due to being more affluent and industrialized. But affluence and industry do not lead to disease, the lifestyle that commonly goes along with them does. We have learned that all these diseases are reversible through lifestyle change. That is what Restore Health is all about. By guiding people through the necessary lifestyle changes, people are able to get off most medications and erase chronic diseases from their active medical history.There are six elements to a healthy lifestyle:

Nutrition is the most important and is estimated as an 80% factor in causing most chronic diseases,

Physical activity, both movement and strength,

Social connections (important and usually not a problem for most in the Coachella Valley), and

Having meaning and purpose to life (the spiritual dimension). The Restore Health approach will be to explore and seek to optimize each of these elements for a healthy lifestyle.

Chronic diseases number in the hundreds and can be grouped into categories.

Our modern lifestyles may give us greater longevity but our healthy years (health span) is in decline. Our muscles and our skeleton ages and causes many reversible problems. At Restore Health we use the BioDensity and Power Plate technologies to naturally restore strong bones reversing osteopenia and osteoporosis. The result is healthy normal bone. Drugs do not do that. After getting a body composition and balance test, our expert training will add muscle strength and restore balance, turning back your physical clock many years.

Our modern American diet and culture is loaded with sugar and refined carbohydrates that have made the majority of Americans overweight with an elevated blood sugar leading to dementia and many other problems. Forty percent of Americans are obese with excess body fat as stored energy. Restore Health uses a healthy human diet of Superfoods that has healthy fats, protein and low carbohydrate resulting in the reversal of overweight, obesity, prediabetes, Type 2 diabetes, high cholesterol, fatty liver and metabolic syndrome. Exercise and stress reduction help this process.

3 Diseases of inflammation and an unhealthy gut microbiome

Inflammatory proteins and fats in common foods cause us to have systemic inflammation and an unhealthy gut microbiome (dysbiosis). Common gastrointestinal problems result from this including acid reflux, irritable bowel syndrome and inflammatory bowel disease. Our stomach acid is good for us and the drugs to reduce stomach acid harm us in the long run. The entire spectrum of auto-immune diseases originate in the gut as a result of dysbiosis and small intestinal bacteria overgrowth. The RH diet and lifestyle reverses all these problems.

Life today is stressful for most everyone. Achieving a life controlling stress is an important skill that can be learned. This leads to equanimity during the day and natural restorative sleep at night. Hypertension (high blood pressure) can be reversed along with many common mental health problems such as anxiety and depression. At RH we use mind and body solutions for stress reduction and optimal mental health.

These common health problems respond to optimizing nutrition and lifestyle. With chronic fatigue improving immune function is vital when a chronic virus in at the core of the problem.

Dale Bredesen (“The End of Alzheimer’s”) and Daniel Amen (“Memory Rescue”) have shown that cognitive decline can not only be avoided but even reversed!The three most common factors are blood sugar levels, inflammation and toxins. At RH we use the Bredesen protocol to preserve cognitive function and reverse cognitive decline if caught in stage 1 or 2 dementia.

While cancer occurs for many different reasons once it exists it is a metabolic disease. It must be fed and nurtured to cause disease and death. Much has been learned about maximizing your changes for cancer remission. At RH we will guide you in a cancer remission diet and lifestyle to improve your changes for remission and a full recovery.

Much has been learned about the biology of aging. We are designed to age and die. The modern diet and lifestyle often accelerates aging and death. At RH we will guide you to have the longest healthspan possible. We will also provide the latest knowledge about how to extend your biologic life through medications and supplements that delay the processes leading to aging and death.

Restore Health is an office devoted exclusively to promoting health rather than treating diseases with drugs and procedures. The goal is for you to discontinue as many of your medications as possible and to erase chronic diseases from your medical problem list. All practices are based on the latest science information. Whenever possible real foods are used over supplements. All six elements of a healthy lifestyle are addressed in every person. Health Insurance is about covering you for disease treatment so it will not be used for coverage of these services.

 is a family physician at Eisenhower Health in La Quinta, California, and is a member of the Medical Economics® editorial advisory board. He is also a core faculty member with the Eisenhower Health Family Medicine Residency Program. Dr. Scherger is clinical professor of family medicine at the Keck School of Medicine at the University of Southern California (USC), and is a leader in transforming office practice.

 has an extensive background focused in physical health, kinesiology and exercise physiology and is a formerU.S.Olympic athlete.

Chronic diseases are often referred to as Western diseases due to being more affluent and industrialized. But affluence and industry do not lead to disease, the lifestyle that commonly goes along with them does. 

Medical Economics September 2020

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