Practice Management

If a patient's family refuses to pay for his care

QI have a semicomatose patient in a nursing home. Family members are responsible for payment, but have ignored my bills. Would it be ethical to tell them to pay or find another doctor? This is a small town, so it's possible no other doctor will take the case.

A It would be unethical to abandon the patient unless another equally competent physician is willing to assume care. Several consultants suggest that you—and a social worker, if there's one available—meet with the family to discuss their ability to pay and to determine whether the patient is eligible for Medicare or Medicaid benefits.

When a case is settled before you testify

Q One of my patients informed me that I'd be expected to testify in her lawsuit against the driver of a car who injured her in an accident. I sent the patient's lawyer a letter stating that my fee would be $500 an hour for preparation and appearance as an expert witness. On a Saturday, I received a subpoena to appear the following Monday. I canceled my Monday appointments and spent the weekend preparing my testimony. An hour before my scheduled appearance, the lawyer called to say the case had been settled. He's now refusing to pay me anything. How can I collect for all my work and loss of income?

A Have your attorney attempt to resolve the matter with a phone call to the other lawyer. You might also ask the state or local bar association's grievance committee to intervene on your behalf. If such efforts fail, you can file a small-claims action if the amount in dispute doesn't exceed the maximum allowed in your state.

In the future, get a written agreement from the patient's lawyer, stating exactly what compensation you'll receive for research, time spent waiting to testify, and actual testimony time, and when you'll receive the money. You also could ask for an advance payment of, say, $1,000 for two hours. But remember that if you're subpoenaed, you must show up in court—whether you have an agreement or not.

Reduce employee stress with 10-minute meetings

Q The sometimes frantic pace of our busy internal medicine practice leaves our staffers feeling overwhelmed. We currently hold monthly staff meetings, but I wonder whether more frequent sessions would give employees a better idea of where to turn for assistance and help create a team spirit. If so, how often should we meet, and how much time should we set aside?

A Meet first thing every morning to review the charts of patients to be seen that day. This will let staffers know what to expect and give them an opportunity to ask questions. Keep the meetings short—10 to 15 minutes at most—and stay centered on the day's tasks. Save other topics for your monthly sessions.

Rewarding nonphysicians for their hard work

Q I employ two full-time NPs who contribute greatly to the success of my practice. I want to reward them for their effort, but unfortunately I can't afford to raise their salaries. Instead, I'd like to institute a productivity bonus or some other type of incentive program.

A quarterly bonus makes more sense to me than an annual one, because the reward is given closer to when the NPs did the actual work. But I can't figure out how to calculate such a bonus when so many payers take 90 to 120 days to pay. What do your consultants recommend?

A First, they recommend that you not calculate the bonus based on collections, since that's something NPs have no control over. Instead, use a measure like billings, base salary, number of patients seen, or RVUs produced. Then, award the bonus on a quarterly basis, but delay the actual payment for two or three months to prevent a cash-flow problem.

Is it legal to vary RVU conversion factors by specialty?

Q I'm an FP employed by a hospital-owned primary care practice. Under the hospital's new contract, physician compensation will be based on RVUs. But the fee schedule uses a different conversion factor for each specialty (FPs would earn less than internists, for example). Is this allowable?

A Yes. Although the conversion factor that HCFA uses to calculate Medicare reimbursements is set by law, an individual practice can use any method it chooses to set its own internal compensation policy.

How to compensate a partner who works longer hours

Q One of the partners in our four-doctor practice is having financial problems, and asked if he could work one extra day a week until he's back on his feet. (Each of us now works four days a week plus one day of call.) We want to help, but there's concern about the effect this could have on the corporation. Since we're equal partners, how can we structure the agreement so that he is paid fairly?

A If your agreement bases compensation on income generated less overhead, that should be fair. But put a time limit—six months to one year—on the arrangement.

When clinical discussions are overheard by patients

Q Patients have mentioned that employee conversations can be overheard in the waiting room. Since most of what employees do relates to patient care, I'm concerned about confidentiality. Employees sit behind a sliding window that opens to the waiting room, but conversations can be overheard even when the window is closed. What can we do to better protect our patients' privacy?

A If possible, install soundproof panels between the waiting room and the area where patients interact with staff. Consider other noise mufflers in the reception area such as thick carpeting, curtains, soft wall hangings, and piped-in music. If these measures aren't feasible, set aside a private room out of earshot where patients can pay bills and discuss clinical matters.

In addition, spell out to employees the things that are for the involved patient's ears only—payment or insurance problems, diagnoses, test results, and specialist referrals. Instruct employees to say patients' names as infrequently as possible and never to shout out a name.

Interviewing your interviewers

Q I'm interviewing for a position with a five-doctor pulmonology practice. What questions should I ask to help me evaluate the financial stability of the group?

A Ask the following:

• How long has the practice been in existence?

• Does the group have enough patients to support a new physician?

• How many new patients a year does the practice attract? How many does it lose?

• Does the group have a marketing plan?

• What will the group do to send patients my way?

• How many managed care contracts does the group have? Do the contracted payments cover the costs of treating patients?

• Do payers pay on time?

• By how much does annual revenue fluctuate?

• What sort of cost controls are in place?

• Does the group set financial targets? What are they based on? How often are they met?

• What is the breakdown on aging receivables? What strategy is in place to collect payments?

Edited by Kristie Perry,
Senior Associate Editor

 

Joan Rose. Practice Management. Medical Economics 2001;5:132.