Editor's Note: The print version incorrectly referred to physician assistant as physician's assistant. The online version was updated on 10/31/18 with the correct title.

 For the last 10 years, insurance companies have been conducting, “home visits,” which I call “home invasions.” They hire a third-party company to send a mid-level provider-a nurse practitioner or physician assistant-to the home of a patient with phone notice. They send the physician’s office a letter saying that they are going to “gather healthcare data,” on their patient and will forward a report. This process was started and motivated by CMS, who pays insurance companies to gather data, to supposedly improve care. But does it? No, it actually worsens it.  These home invasions are generally unwarranted, unwelcome, and ultimately useless in the grand scheme of medical care. The insurance companies want to gather data to reduce their exposure to risk, raise rates, and get paid by federal government programs for millions of subscribers. The insurance companies themselves have a ton of conflict of interest, as only they stand to gain by this government and insurance industry-funded procedure, not patients or physicians. Another concern is that these invasions become patients’ yearly wellness visit. Instead of getting a wellness visit with a personal physician, the visit is usurped by an employee of the insurance company. Not only does the insurer collect data, but avoids a claim from an independent physician who might otherwise handle the wellness visit. The insurer can essentially divert the money CMS pays for these visits for their own data mining operation. The report gives a physician’s office much of the historical information they already have and an inadequate physical exam. In some cases, the mid-level providers find or detect a problem and, because they say they are not in a “care capacity,” don’t act on the problem, putting patients at more risk than before.  One of my elderly couples was harassed by phone by their Medicare “advantage plan” HMO insurance company designees to perform this home invasion. After asking questions and finally saying “no,” the phone agent badgered them into accepting a visit. The mid-level practitioner came and took a history and a set of vital signs and a cursory physical exam. The patient later told me that the nurse detected a blood pressure of 180/110 and failed to instruct them to seek immediate medical care. As a physician I found this out a week later when the patient came in for routine follow-up and his BP was still elevated.  These government- and insurance-directed home invasions are unwarranted, unsafe, and may obfuscate the medical care that a patient is receiving. Patients can and should refuse insurance company representatives coming to their house for any medical history or exam purposes. Physicians should also reject the concept vocally and with action. In my office, I shred the reports, as I will not, and cannot be responsible for someone else’s unsolicited shoddy work.  Craig M. Wax, DOMullica Hills, N.J.

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Your voice: Stop Medicare 'home invasions'

Cryptocurrency, such as Bitcoin, is an alternative currency that lives in the digital world and can be used either as an investment, or to buy real things. Depending on who you ask, it’s either the next big thing, or risky business. 

Is investing in cryptocurrency something to avoid, as financial titans such as Warren Buffett have said, or are physicians missing out on a prime investment opportunity if they don’t give it a try? The answer is somewhere in the middle.

Cryptocurrency is definitely not the place to pour an entire retirement savings, nor is it likely that medical practices will be adopting Bitcoin as a standard payment option anytime soon. However, if doctors are interested in the technology supporting cryptocurrency, generally distrust banks, or just want to try a new kind of investment, Bitcoin and other digital coins are worth learning about.

Though there are now about 2,600 types, Bitcoin was the first cryptocurrency (invented in 2009) and it’s still the most ubiquitous. 

Consumers can buy and sell Bitcoin and other digital coins, and use this digital currency to pay for purchases. It’s different from traditional currency because there are no bills or coins. Also, cryptocurrency is decentralized.

“When you send cryptocurrency to someone or use it to buy something, you don’t need to use a bank, credit card, or any other third-party type of intermediary to coordinate that transaction. The transaction goes directly from you to the other person (electronically) and arrives securely and almost instantly-all without any middleman involved,” says Mark Grabowski, JD, an associate professor at Adelphi University who teaches courses on Bitcoin and internet law. 

The decentralized model is what makes Bitcoin so attractive to many consumers and investors. 

“This is the first time in the last 100 years [consumers] have a medium of exchange that isn’t related to government, and we have full control of,” says Ofir Beigel, who runs 99Bitcoins.com, one of the oldest and largest information sites about Bitcoin and cryptocurrency. The lack of regulation is also what makes Bitcoin volatile, subject to both large gains and losses in a short amount of time. “Never invest more than you can afford to lose,” Beigel says. That’s true for buying Bitcoin or other cryptocurrency.

Whether physicians want to spend it or stockpile it as an investment, getting started with Bitcoin requires a Bitcoin wallet, which is a program similar to email that helps someone send and receive Bitcoin. 

An investor can either download a free software wallet to their computer or phone, or purchase a hardware wallet, which is a physical device that’s virtually unhackable. 

“Don’t spend money on hardware the first time, because it costs $80 or $90,” Beigel says. He advises starting with a small amount and only investing in a hardware wallet once someone gets comfortable with how Bitcoin works and/or are making larger investments.

After downloading a free wallet, a user will receive a Bitcoin address, which is a randomly generated long string of numbers and characters that acts as the user’s identifier. The second thing a wallet provides is a private key or seed phrase. This acts as the password to the wallet and should be kept secure.

Once the wallet is set up, the user can begin buying Bitcoins (or more likely fractions of Bitcoin, since a whole Bitcoin was worth $7,364 at press time). Buying from brokers, such as Coinbase-which both Beigel and Grabowski recommend to get started-is the simplest option, but it does cost more. 

“You should only buy from trusted exchanges online,” Beigel says. Another option is to buy from a trading platform, such as CEX.IO or Bitstamp, which securely connects buyers and sellers. These platforms are a less expensive way to buy Bitcoin, but Beigel says they are more difficult to use, especially for newcomers.  

The third way to buy Bitcoin is directly from other sellers. “This is the method I least recommend,” Beigel says, because there is a chance of fraud.  

In theory, Bitcoin spends like traditional currency. But that doesn’t mean it’s always easy to use. Bitcoin debit cards are available, Beigel says. The consumer loads the debit card with Bitcoin to use for spending, and the merchant gets paid in their own currency (dollars, Euros, etc.). 

That’s not highly practical though. Each time a person trades, sells, or uses cryptocurrency, that’s a taxable event, since the IRS considers them an asset, not a currency. “So, if you use your Bitcoin to buy a cappuccino, you’ll need to pay taxes at the capital gains rate in addition to paying sales tax,” Grabowski says.  

The cryptocurrency market is a lot more unpredictable than the stock market, Grabowski says. It’s volleyed back and forth since Bitcoin’s inception in 2009, and it still fluctuates wildly in any given 24 hours. 

“Unlike the nine-to-five hours of the New York Stock Exchange, cryptocurrency is traded around the world 24/7. So, you may go to bed at night feeling pretty happy about your portfolio only to wake up the next day and see you’ve literally dropped 25 percent overnight,” he says. 

That said, plenty of smart, experienced investors are betting on the future of cryptocurrency. One reason people are paying attention to crypto is because of the blockchain technology that supports it. The blockchain is the transparent ledger where every transaction is recorded independently; each participant in the network holds an identical copy (versus a central authority holding a master copy). Blockchain is already starting to influence healthcare. 

“This technology has many applications beyond cryptocurrency. In healthcare, patients’ records could be encoded and stored on the blockchain with a private key, which would grant access only to specific doctors. This could help ensure that medical privacy laws aren’t violated,” explains Grabowski.

Blockchain technology is the major reason most people who wouldn’t normally be keen on high-risk investments are looking more closely at investing in crypto, including investing in initial coin offerings (ICOs). 

Michael Kapilkov, a partner at MMVIII Capital, is an adviser to several ICO startups-meaning he works with companies who create a currency and want to offer coins to the public, the way a company would offer shares to the public. He also advises individuals looking to invest in ICOs. 

“When I talk to people, I tell them, you can make a lot of money, but you can also lose a lot, too. It’s high-risk, high-reward,” he says.

At any point in time, there are several dozen ICOs underway, Kapilkov says. There are a few basic things to keep in mind when thinking of investing. He advises that physicians to carefully study the ICO’s whitepaper, or rationale for why the currency exists. 

Also, it’s important to understand the “why” behind the coin: Is it solving a problem? Taking a new approach? Compare it to other coins, and check to make sure it has a solid advisory board. Do the people behind the coin have experience? Do they seem trustworthy? Investing is always a gamble, and it’s worth it to do basic research and work with an advisor who understands ICOs and crypto in general.

The barrier to entry for purchasing, trading, and investing in cryptocurrency is still rather high (given the purchase of a wallet and the details above), but that may change in the coming years. The technology that supports decentralized currency may very well be the path forward for significant innovation in many industries, and there is money to be made there, one way or another.

Is investing in cryptocurrency something to avoid or are physicians missing out on a prime investment opportunity if they don’t give it a try?

Cryptocurrency: good investment or financial disaster?

Nearly every day, Justen Rudolph, MD, has a conversation with a diabetic patient who is upset about the rising cost of insulin. 

Just recently, the internal medicine specialist spoke with an 86-year-old patient who was very concerned about the price of the life-saving medication and worried because she was unable to get enough test strips covered under Medicare rules and guidelines.

It’s a discussion physicians are having more and more often with their diabetic patients-especially those who are uninsured or underinsured or have hit the “donut hole” in the Medicare Part D program-as a result of the skyrocketing prices of insulin. “We’ve seen retail costs go up 250 percent in the last 10 years,” says Rudolph, director of St. Vincent Diabetes Center in Billings, Mont. 

As a result, some patients who can’t afford insulin will underuse it to stretch out the medication, Rudolph says, a dangerous practice that can lead to serious, long-term complications, including kidney failure, blindness, and lower-limb amputations. A study published in July in Diabetes found that one in four patients at Yale Diabetes Center reported cost-related insulin underuse that was associated with poor glycemic control. 

“It’s a horrible situation,” says Hayward Zwerling, MD, FACP, an endocrinologist at the Lowell Diabetes & Endocrine Center in North Chelmsford, Mass. Zwerling says 90 percent of his patients use insulin, so he personally spends much of his time on the websites of health insurance companies trying to determine which type of insulin they will cover and how much it will cost his patients. But the information isn’t always up to date and he frequently finds out later from patients their prescription isn’t covered.

So what can physicians do to ensure their patients are able to find affordable insulin? Consider these strategies that internal medicine physicians, endocrinologists, and physician practices have used to ensure their diabetic patients get the insulin they need:

Walmart sells one of the most affordable insulins on the market, a godsend for uninsured patients or those with high-deductible health plans, says David M. Nathan, MD, director of the MGH Diabetes Center and Clinical Research Center in Boston. The retailer sells ReliOn, its store-brand version of Novo Nordisk’s Novalin for $25 a vial and in many states doesn’t require a prescription. Nathan says it’s an older generation of insulin that many doctors are unaware of because drug manufacturers spend more money advertising newer, longer-acting insulins. 

Jeremy A. Greene, MD, PhD, associate professor of history of medicine at the Johns Hopkins University School of Medicine, who also practices internal medicine at the East Baltimore Medical Center in Maryland, says many of his patients with Type 1 diabetes depend on the insulin Walmart sells even though it is short-acting and thus requires more than one dose a day. The problem, he says, is that the retail chain could discontinue the program at any time and patients need to live near enough to a Walmart to be able to purchase the medication.

Use a website to find the best prices for medication

Yul D. Ejnes, MD, MACP, an internist at Coastal Medical Inc. in Providence, R.I., is a fan of GoodRX.com. The website has a tool that allows patients and physicians to find out the cost of a medication within their geographical area, which pharmacies have it, and it will even link to a discount coupon for the prescription if available. 

“It’s a wonderful tool for that situation where a patient is going to have to pay out of pocket,” he says.

Check whether the drug company has discount cards or coupons

For patients with commercial insurance, Coastal Medical will also check to see if manufacturer coupons are available for insulin, according to Sarah Thompson, PharmD, the practice’s director of clinical services. If available, a coupon can lower the cost of the patient copay to $20 or in some cases to zero she says.

However, patients who don’t have insurance or are covered by Medicare and/or Medicaid can’t take advantage of discount cards or coupons due to a federal rule, notes Rudolph. 

“It makes zero sense to me. People on fixed incomes who need the help the most are the ones who can’t use discount cards,” he says. 

Insulin is far less expensive in other countries. Irl B. Hirsch, MD, professor of medicine at the University of Washington Medical Center-Roosevelt in Seattle, Wash., says his patients can take a two-hour drive to the Canadian border and purchase insulin for a tenth of what it costs in the U.S. 

But realistically that option is available only to those who live near the border with Canada or Mexico, because it’s illegal to mail insulin internationally. But Hirsch says that his patients can buy insulin at a Canadian pharmacy and take it over the border as long as the insulin is for their use or for a family member. 

Some drug manufacturers offer assistance to patients who don’t have prescription drug coverage and who meet certain income and eligibility requirements. In some cases the patient may receive medication at no cost, explains Thompson. She says Coastal Medical’s pharmacy technician team helps patients who can’t afford their insulin with the application process.

Ejnes also recommends that physicians suggest that patients explore the website Needymeds.org to find out what programs may be available to help them afford insulin. Patients who are computer literate can do a lot of the legwork themselves to see if they meet the income requirements, he says. 

Pharmaceutical companies typically provide physician practices with samples of newer medications they want to sell. 

Claresa S. Levetan, MD, takes advantage of this practice to give patients drugs at no cost. Levetan, who specializes in endocrinology, diabetes and metabolism, and internal medicine at Jefferson Health Endocrinology in Philadelphia, says it’s not unusual for patients to ask for samples because they can’t afford the out-of-pocket costs. 

Encourage patients to form relationships with community or retail pharmacists

For practices that don’t have a lot of resources, Ejnes suggests that they encourage patients to get to know the pharmacists at the place where they get their medications. Ejnes says that they may be able to guide patients to less expensive options under their insurance plans because they have access to the different payers’ formularies.

Develop formulary information to head off prior authorizations 

It’s frustrating for physicians when what they think is the best medication for a patient isn’t covered by the patient’s insurance, thus triggering a prior authorization request.

To help streamline the prior authorization process, Coastal Medical’s pharmacy technician team has researched the most common insurers that cover their patients and created a preferred formulary list for physicians. This way they can prevent patients from delays due to the need for a prior authorization or step therapy, Thompson says. 

However, “part of what makes this difficult is that formularies change frequently. Patients often experience multiple medication conversions, sometimes year after year. This makes medication adherence challenging,” she says. 

Elbert Huang, MD, MPH, professor of medicine and director of the Center for Chronic Disease Research and Policy at the University of Chicago, says because each health plan has its own preferred insulin analog, and that plan may change year to year, he talks with his patients about the problem. 

If patients agree to use the drug preferred by their prescription drug plan, Huang will prescribe it. For those patients who don’t want to change medications, he explains that he’ll have to go through a prior authorization process that will take time and may not be approved. 

Educate patients about the importance of diabetes management 

Thompson would like insurers to provide incentives, such as reduced costs for testing supplies or medications, to patients with diabetes if they attend classes or work with a care manager or diabetes educator. “I think programs that empower patients and give them a tangible benefit might be one additional strategy” for patients to better manage the disease, she says. 

Levetan also recommends that physicians focus on patients’ pre-diabetes so they can reduce the risk of the disease progressing. This requires physicians to start educating patients who have higher than normal blood glucose levels before they develop ­diabetes. 

But she also suggests educating children about the disease. 

“Our healthcare system still hasn’t focused on prevention of disease too well,” Levetan says, noting that the number of children with Type 2 diabetes is on the rise. Teaching children about healthy lifestyles at office visits and in schools could make a big difference in preventing diabetes, she says. 

9 strategies physicians can use to help their patients with diabetes improve access to this vital medication.

The quest to find affordable insulin for patients

Practices sell regularly, many for a good price with minimal fanfare. At least half of all practices offered for sale never sell, however. Not every practice has value, nor does every seller try to sell their practice properly. This low sales rate is not peculiar to medicine-it’s similar for most small businesses according to business broker industry reports.

The more profitable your practice, the easier it usually is to sell, and the more it is worth to a buyer.

Hospitals have been the top practice acquirers since Obamacare started, and often the easiest purchasers to sell to. 

Unfortunately, hospitals usually will only pay the fair market value of your practice’s assets, and nothing for its intangible “goodwill” value. Hospitals do this to avoid government charges that they violated the law by “paying for referrals.” They likely will offer you good-paying employment and benefits; often more than you can earn on your own.

Venture capital and private equity groups pay top dollar for leading group practices in some specialties, but they are extremely selective and their terms may be onerous.

I find that graduating residents and fellows are rarely the buyers of practices. Many get 50 to 100 job offers prior to finishing their training, mostly from large and hospital-owned groups. These job offers are inundating them and not just more preferable, but easier than taking on a new practice.

Dissatisfied employed physicians re-entering private practice, and physicians relocating to be nearer to their or their spouse’s family are the primary candidates for buying a practice. They have a choice of joining another group, starting their own practice, or buying your practice. You therefore are not competing just with other practices for sale but also with employment in groups and start-ups.

Your most likely buyers are already practicing in your area, since they don’t have to move or re-license, and they have a strong reason to be there. In many cases, the most likely buyer might be your competition.

For a seller, putting a practice up for sale not only can result in financial reward, it can also dispose of the ongoing expense of custodianship of a career’s worth of patient records. This can easily run into the tens of thousands of dollars, so sometimes it’s even worth it to pay a buyer (like a colleague in your call group) a nominal amount to take over your practice. 

Check your state laws or guidelines with your malpractice insurance carrier or state medical association regarding medical record custodianship laws.

If you are considering the sale of your practice-even if you are just early on in the thought process-here are some initial steps.

Plan at least a year ahead if possible, but also be ready to sell to the first candidate on short notice, and maybe stay employed by them during the transition. That candidate might have been looking for a while, and now your opportunity pops up and they respond. 

There is no guarantee there will ever be a second candidate.

Don’t slow down your practice in advance. Growing practices are more attractive than stagnating ones. 

Consider merging your practice with a local group in lieu of a sale to a unknown single buyer, with a higher compensation for one to three years in lieu of a sale price.

Overpricing is the number one reason why businesses don’t sell. Get a professional appraisal-both to price the practice correctly and to convince a buyer of its value-using a medical practice expert that can ­demonstrate compliance with the Uniform Standards of Professional Appraisal Practice (USPAP). 

Learn what EBITDA stands for, and use a multiple of it in your pricing strategy.

Get your business pre-qualified for a 100 percent bank loan at the asking price for a qualified buyer, which reduces low-ball offers. Both the buyer and the practice must qualify for the loan. 

If you pre-qualify the practice to support a loan for the asking price, the seller then only needs to get the buyer qualified when they appear. 

On the other side of the coin, if the buyer qualifies, and the bank then refuses to loan because the practice doesn’t qualify, that’s a bad thing to learn later. Get qualified in ­advance.

Most purchase candidates now come via internet searches. Prepare a proper professional promotional package, including a dedicated search engine optimized website separate from the practice’s business site. 

You should also have a regular website for the practice and be on LinkedIn and Facebook.

Clean up the office-and your desk-to make them appear modern and attractive. Fresh paint, carpet, and furnishings are inexpensive and create quality “staging.” Perhaps ask a local real estate broker for a referral to a stager.

You have to assume the buyer will engage competent advisers to evaluate your practice, so engage competent counsel yourself including an experienced medical practice broker, certified public accountant, and business attorney. 

Many can be found through the National Society of Certified Healthcare Business Consultants( NSCHBC.org) and HealthLawyers.org. 

Make sure your last one to three years’ accounting and statistics conform to standards like those developed by the NSCHBC or Medical Group Management Association This will give the buyer and their advisers more confidence in your data and ­operations.

Remember, you aren’t only courting a physician

Be prepared to convince the buyer’s spouse and children to live in your community, with a tour of local homes with a real estate agent, visiting schools, malls, local attractions, etc. 

Consider offering the buyer a chance to work for one to three years at reduced income, then purchasing the practice for the value of the hard assets, “without goodwill.” 

Your offer to sell then will look more competitive with employment. An offer document can cover all the relevant information to help an investor to make his or her investment decision.

Get everything in writing to avoid future misunderstandings or litigation. You can work with your lawyer or broker to list everything required for due diligence. The seller must assemble this for the buyer’s review.

In this current down market for practice value, sell for reasons of personal lifestyle-like reduced administrative hours, retirement, or disability-not for anticipated financial gain for equity to fund retirement or something else. 

The practice is built to create continuing income, already harvested through work years, not for future equity.

Consider waiting until after the 2020 elections to sell, as hopefully the medical environment will have stabilized at that point, with any luck improving practice fiscal ­value.

 is a licensed and certified business broker, appraiser, author, and member of the National Society of Certified Healthcare Business Consultants (NSCHBC.org) specializing in outpatient medical practices for over 30 years. He is a regular contributor to Medical Economics and many medical association journals. He is the author of The Medical Practice Valuation Workbook. 

Not every practice has value, nor does every seller try to sell their practice properly.

 How to sell your medical practice

In June, the U.S. Department of Labor expanded access to health coverage options for small businesses and their employees through Association Health Plans (AHPs).

AHPs allow small businesses and self-employed workers to band together by geography or industry to obtain healthcare coverage as if they were a single large employer, thereby providing, according to the Trump administration, more choice, access, and coverage. However, AHPs generally do not cover as much as other health plans, which could spur frustration and concern among both patients and doctors as they learn what an AHP actually covers. 

The American College of Physicians, for one, opposes the introduction of the new plans. “As a physician, I know from experience how crucial it is that patients have access to insurance plans that meet full healthcare needs,” Ana MarÃ­a LÃ³pez, MD, FACP, ACP’s president, said in a statement after the ruling. “This rule will do the opposite.”

Proponents of the new rule argue that it will provide small employers the same opportunity for coverage available to large employers with self-insured plans. “Many of our laws, particularly Obamacare, make healthcare coverage more expensive for small businesses than large companies,” U.S. Secretary of Labor Alexander Acosta said in a statement. 

Kevin Lucia, MHP, research professor and project director at Georgetown University’s Health Policy Institute, notes that since the 1990s, congressional proposals to create federally certified AHPs have been opposed by a broad spectrum of stakeholders, including the National Association of Insurance Commissioners. Opponents point to a history of association health plans that is rife with insolvency, fraud, loss of consumer protections, and market segmentation.

“Prior to this rule, under federal law, it was only in the rarest instance that an association of small employers could make the claim that they were so tightly connected that they were actually a large employer for the purpose of sponsoring a health plan, and that was the Obama Administration’s stance,” Lucia says. 

Once established, AHPs may offer market coverage locally or nationally, provided the plan applies to members of a shared industry or profession or geography.

Lucia explains that for states, AHPs are important because they are trying to maintain a significant competitive market for insurance. However, if companies gravitate toward plans that have fewer protections or have a regulatory advantage, it leaves other in the insured market vulnerable to higher premiums.

Under the new AHP rule, Lucia says, it will be easy to form an AHP and market large group coverage to members. 

He believes this may lead to AHPs offering less comprehensive coverage because these arrangements will not be required to offer coverage that is as comprehensive as what’s required under current law.

“Some AHPs will offer comprehensive plans that work to the [advantage] of their members, but one way you get the cheaper premiums is by offering fewer benefits, which means providers face more consumers with skimpier coverage,” he says. He also notes that past expansions of AHPs have resulted in spikes in scams and insolvencies.

James Schutzer, vice president of JDM Benefits, a New York-based insurance and benefits consulting company, says that AHPs can’t discriminate by age or health status, but they can choose what they offer and who they allow in. In regard to the nondiscrimination provision, Schutzer says the rules generally prohibit discrimination based on the health status for eligibility, benefits, or rates within groups of similarly situated individuals. The concept is that the AHP will create a separate risk pool for these individuals and rate accordingly. This will create problems for doctors because many patients won’t be covered for a variety of things they perhaps once were.

America’s Health Insurance Plans, a political advocacy organization representing commercial insurers, is concerned that expanding AHPs will lead to higher premiums for consumers who depend on the individual or small-group market for their coverage. In a statement released after the ruling, it said: “Ultimately, the rule could result in fewer insured Americans and may put consumers at greater risk of fraudulent actors entering this market.”

All AHPs are required to provide summaries of benefits, so these should be reviewed by patients and their doctors’ offices prior to a visit. Lucia says many patients aren’t going to be pleased with those talks as they will learn of the limitations and not realize what their plans really cover.

Schutzer notes that states still have authority over insurance regulations within their borders pertaining to AHPs and some state insurance regulatory agencies like New York and Massachusetts have released guidance which limit the availability of AHPs. 

Bill Ashley, CEO of Allied National, which provides benefit plans to employers and individuals, believes that AHPs are not going to have much impact on the price of insurance.   

“Any impact AHPs will have is by adjusting benefits or being positioned to appeal to the healthy,” he says. But once people are in an AHP, no one can control what happens, so if injuries or health problems come up, there is no mechanism to deal with changing health status. 

Some of the major carriers, he adds, may see a way to offer plans that compete against the ACA insurance exchange. While not necessarily directly lowering plan costs, it could bring some carriers back to the individual market and that will foster some competition.  

“The academic types are talking like AHPs are going to have traction, but I’m hearing very little from payers to support that,” Ashley says.

Trump’s rule may lead to AHPs offering less comprehensive coverage than current plans, experts predict.

What association health plans mean for physicians and their patients

New patient presents for follow up of radiculopathy, hypothyroidism. She’s had pain in her neck, upper back and shoulders for 10 years. She has long history of depression.

: no cyanosis, clubbing, edema. No varicosities or spider veins

: S1& S2 within normal limits, regular rate and rhythm.

: no thrill or palpable murmurs, no displacement of PMI

: no enlargement or bruits; difficult to assess because of obesity

: Right dorsalis pedal pulse present  2+; Left dorsalis pedal pulse present  2+

: normal, able to ascend and descend table without assistance.

Shoulders are without overt deformity; no erythema, warmth or edema. There is pain with movement; ROM of the shoulders without crepitus or popping.

She has neck pain and then also numbness (dormido) in the left hand 4th and 5th digits. Mostly positional.
Muscle strength normal; reflexes somewhat diminished in upper extremities; no sensation loss.

: loses interest in normal daily activities, feels hopeless at times, lacks productivity at work. Has not tried therapy.

: Will order x-ray of cervical region; she can try her linaments and also the patches like salon pas and aspercreme that contain lidocaine 4% - apply 12 hours on and 12 hours off

: TSH; will contact patient with results

: Continue Lexapro; ambulatory referral to psych for therapy; we will monitor progress at next visit

: Blood pressures should be less than 130/80; document regular BP checks at home and bring with you at next visit

Due to medicamens and other exogenous substances

 requires choosing a code based on region:

 Congenital hypothyroidism with diffuse goiter

Hypothyroidism due to medicaments and other exogenous substances*

Major depressive disorder, recurrent, moderate

Elevated blood-pressure reading, without diagnosis of hypertension

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

Check out the following scenario and see if you can choose the correct codes.

Coding case study: hypothyroidism and radiculopathy

Medical malpractice insurance is one of the greatest expenses physicians face during their careers. A primary care doctor can expect to pay hundreds of thousands of dollars in premiums over the decades.

But knowing what to look for in a policy is a mystery for many physicians, as well as a time-consuming chore that rarely gets the attention it deserves. And buying the wrong type or incorrect amount of insurance-or buying it from the wrong carrier-can be extremely costly. 

Physicians who take the time to understand how to buy malpractice insurance will not only save money, but ensure that they’ve got the right type and amount of liability coverage.

Policies typically cover expenses incurred while defending and settling malpractice suits. These can include attorney fees, medical damages, arbitration and settlement costs, court costs, and punitive and compensatory damages. Liabilities incurred from criminal acts or sexual misconduct usually are not covered. 

There are two basic types of malpractice insurance: claims-made and occurrence. A claims-made policy provides coverage only if the policy is in effect both when the incident took place and when a lawsuit is filed. Occurrence policies cover any claim for an event that took place during the period the policy was in effect, even if the claim is filed after the policy lapses.

Because a claim can be filed years after an event and after a claims-made policy expires, these policies often include a “tail” that extends coverage for a set number of years beyond the expiration date. If it’s not part of the original policy, tail coverage can be bought separately. 

Tail coverage offers protection when a physician is changing jobs or carriers or retiring. Sometimes, the cost of tail coverage will be covered by a previous employer to protect itself or can be negotiated with a new employer. Occurrence policies generally don’t require tail coverage, but are not available in all states.     

If buying a claims-made policy, be sure that the beginning date for coverage is accurate and matches the date on the prior policy to ensure there are no coverage gaps between policies, says Jennifer Richard, ARM, RPLU, vice president of sales and marketing, Professional Risk Associates., a Virginia-based malpractice insurance broker.

“Physicians should ensure all services they are providing have been fully disclosed and reviewed by their agent and underwriter to ensure there are no gaps in coverage in their practice,” she says. 

“Additionally, it’s important they review all other professional liability exposures within cyber, regulatory, directors and officers, and employment practices liability. There are situations where these coverages could overlap, or come into play, based on the risk exposure of the practice.”

The appropriate amount of coverage can vary by state, specialty, and contractual arrangements with hospitals and other healthcare organizations, says Richard. Some states require providers have minimum levels of coverage, but a physician can still need more. 

In general, carriers’ standard coverage limits are $1 million per claim and $3 million aggregate, which is the most the policy will pay in a year for all claims. However, certain states require different limits based on medical malpractice caps on damages. States with more litigious climates might require more.

Richard cites the example of Virginia, which does not have a statutory requirement for medical liability insurance. However, the state has a medical malpractice cap of $2.35 million (which eventually will increase to $3 million). For that reason, hospitals require physicians to carry at least that amount with an aggregate that is three times higher ($2.35 million per claim/$7.05 million aggregate).

Some states have patient compensation or catastrophe loss funds, which provide an additional layer of coverage over the primary policy limits, says Eric Anderson, vice president of marketing and communications for Medical Professional Liability Associates, an industry group. 

Providers pay into these state-run funds through a surcharge on medical malpractice insurance premiums. If a lawsuit is filed and found to be legitimate, malpractice insurance will cover the injured patient’s costs to a limit set by the state. The rest is paid by the fund.

Carriers must be licensed in each state in which they operate and follow that state’s rules and regulations. While many carriers operate in multiple states, not all do. Patrick Lawn, owner of Physicians Insurance Consultants in Pennsylvania, estimates that there is an average of five to six carriers in each state.

Price is an important factor, but it shouldn’t be the only one, says Lawn, adding that shopping on price alone can lead to hiring an unreliable or financially precarious carrier.

“You can’t just jump (carriers) for a penny; you’ve got to be able to rely on the carrier,” Lawn says.

Make sure the policy has a consent to settle clause, which prevents the insurer from settling a claim without permission of the insured doctor, Lawn advises.

The best carriers will act as resources for their clients, offering advice on how to avoid claims and other matters, says Kenneth Hertz, FACMPE, principal consultant at Medical Group Management Association (MGMA). “Partner with them as a resource. They’re the experts. They’re only too happy to help and they can help you stay out of trouble. It’s to their benefit as well,” he says.

He recommends screening potential carriers on a variety of criteria, in addition to price:

Ask medical colleagues and people in the insurance industry about the carrier’s reputation. How responsive is it? What’s its history on settling claims?

Check the carrier’s financial security on A.M. Best, which reports on the financial stability of insurers and rates individual companies. Look for a carrier with an “A, Excellent” rating or better and a “Stable” outlook.

How long has the carrier been in business? Does it specialize in certain fields, such as obstetrics?

Does the carrier have a local office or counsel? Is it willing to visit the practice and become familiar with the caregivers?

Virginia Kladder, MD, considers herself fortunate that she’s never had to shop for malpractice insurance. “If I had to go out on my own there is no way, as a physician, I could figure it out,” she says.

The Richmond, Va., internist works for PartnerMD, a concierge practice. Buying insurance for Kladder and 23 other physicians across eight offices in five states is the responsibility of PartnerMD’s Chief Operating Officer Jack Bretcher, who, in turn, relies on insurance broker Professional Risk Associates.

A broker has the depth of knowledge and the experience to know the coverage a practice needs and the best insurers to provide it, Bretcher says. 

“They help us keep abreast of what’s out there and what our needs are,” he says, adding that he’s bought extra layers of coverage, including cyber insurance, at the recommendation of his broker.

Even small practices are better off using independent brokers rather than spending the time to research policies and carriers, says MGMA’s Hertz, a former practice manager. 

“If you can find a broker who is knowledgeable, it’s a lot easier to hire them to do the legwork, get the quotes, and educate you as a manager,” he says.

An alternative to traditional malpractice insurance is a risk retention group (RRG). These are liability insurance companies that require all company owners to be policyholders and vice versa. 

All owners/policyholders must be in the same type of business, such as physicians. RRGs can offer lower premiums than traditional carriers and, if they are profitable, the owners are paid dividends, but there are some drawbacks as well, says Hertz. They must be incorporated in at least one state but can operate nationwide, largely exempt from the oversight of other state insurance departments.

Because they were created by federal law, they are not subject to the same level of state regulation as private carriers. They may not have to disclose as much financial information and they are not backed by state guaranty funds in case of financial troubles. 

Practices should perform due diligence on RRGs before deciding to join one, Hertz says. Sources of information about them are Demotech and Risk Retention Reporter.  

Shopping for malpractice insurance can be a time-consuming task, so it’s not surprising that physicians tend to stick with a carrier and policy unless something changes, such as a large increase in premiums or a contentious claim. That complacency can be costly, says Lawn.

“I’ve seen doctors who are looking to save expenses, but they don’t bother [comparison] shopping one of their highest overhead expenses. It makes no sense to me,” Lawn says.

But that doesn’t mean shopping every year, says Richard, who adds that practices should review their policies and compare prices every two to three years. 

Ask carriers about ways to earn discounts, says Hertz, who adds that some insurers will offer discounts of up to 10 to 15 percent if doctors attend carrier-led risk management programs on how to avoid malpractice claims through such things as documentation and better patient communication.

Even if not shopping for a new carrier, physicians should periodically check if their coverage needs updating to account for developments since the policy was purchased. Richard says the following can result in a need for policy changes:

Any changes in practice parameters, such as new services or using new equipment  

“If you have any questions at all, you should reach out to your agent, as they can guide you through practice exposure changes,” she says.

Should you use your own attorney to defend you?

 Should a physician who’s being sued for medical malpractice use a personal defense attorney instead of, or in addition to, the one provided by the insurer? In most cases the answer is no, according to the experts.

As part of the policy, the insurer provides a defense team with expertise in medical malpractice, a highly specialized area of the law. Attorneys who don’t specialize in medical malpractice would be at a significant disadvantage in preparing a defense, says Patrick Lawn, owner of Physicians Insurance Consultants in Lafayette Hill, Pa.

“You want someone who’s an expert,” Lawn says. “A lot of the malpractice attorneys are well-versed in the law, so there’s really no need to spend your own money.”

Private attorneys are at another disadvantage because they do not have a prior relationship with the carrier, which can lead to miscommunication, mistrust, and a disorganized defense, says Jennifer Richard, ARM, RPLU, vice president at Professional Risk Associates, a healthcare insurance brokerage in Midlothian, Va.

Involving a private attorney can even lead to penalties. “Some policies will deny coverage if you have retained your own attorney to handle the case without the carrier’s written permission and the case is adjudicated and/or settled without the carrier’s knowledge,” Richard says. She advises physicians to familiarize themselves with the part of their policy that dictates the carrier’s and physician’s duties when a claim is filed.

The exception would be if the carrier informs the client that a claim is not covered. In that case, “it is good to enlist your own attorney, at your own expense, to protect your potential uninsured interests,” she says. In some cases, if the client insists and the insurer thinks it is to their advantage, the carrier will hire on the client’s attorney for the duration of the case, Lawn says.

Physicians worried that the insurer’s attorney will not adequately represent them should be sure to purchase polices with strong consent to settle clauses, which don’t allow insurers to settle a claim without the insured physician’s permission. However, many consent to settle policies also have a “hammer” clause which an insurer can invoke if a doctor refuses to settle. Typically, it states that if a doctor insists on going to court and is found liable then the doctor is responsible for any damages beyond the proposed settlement, as well as any further defense costs.   

Kenneth Hertz, FACMPE, principal consultant with Medical Group Management Association, says he has seen a practice’s private counsel brought in to help settle disputes between members of the practice as to whether to settle a claim. He adds that, even if they are not involved in the malpractice case, a practice’s attorney and the physician’s personal attorney should be kept informed of malpractice proceedings.

Here are six ways to better protect yourself and your practice. 

September 25, 2018 edition

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