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Q:With my employer's blessing, I plan to start moonlightingat a nursing home. I may later become the facility's full-time medical director.How should I bill for the work I do there? Does it pay for me to incorporateand bill under the corporation's name, or should I bill under my own name?What are the tax ramifications of these scenarios?
A: It would be simplest to bill through your employer. If youbill under your own name, you'll need to file quarterly tax returns declaringthat income and, possibly, take out a separate malpractice insurance policy.
If you incorporate, the corporation will pay part of the taxes and couldcover the cost of the additional malpractice insurance. But it doesn't makesense to set up a separate billing entity if you plan to become medicaldirector at the nursing home, since, presumably, you'd become a salariedemployee there, too.
Q:More and more of my patients are beginning to ask for referralsto naturopaths, homeopaths, chiropractors, and massage therapists. ShouldI put together a list of recommended practitioners? I don't know many peoplein the alternative medicine community. How should I decide whom to includeon my list? Would I incur any liability by providing patients with thisinformation?
A: Don't refer to practitioners you don't know. Instead, givepatients a list of professional associations to contact. In general, youwon't be held liable for another doctor's substandard care unless it canbe proved that you knew or should have known the doctor wasn't competent.
Q:Our office manager is having a problem with a nurse who'shighly prized by one of the group's doctors. Unlike the rest of our clinicalstaff, this nurse refuses to pitch in on front-office tasks when needed.She often flouts chart-filing procedures and says she's too busy tendingto patients to clean up the exam room after a visit. Her behavior is destroyingstaff morale. What should we do?
A: The manager and the doctor who favors her must tell the nursethat she's obligated to follow the same policies and procedures as the restof the staff. Make sure the doctor is willing to back up the manager inwords and deeds if the employee doesn't shape up.
Q:My partner treats a chronically ill patient who recentlyreached the limit on her health care coverage. Because this patient is facingfinancial hardship, my partner is now billing for her care under her daughter'sname. I know this is fraud, but I feel for the patient, so I've turned ablind eye to it. Could I be held liable for my partner's actions if theinsurer discovers the fraud?
A: Yes. You could both face heavy fines, loss of managed carecontracts, and disciplinary action by your state medical board. If yourpartner wants to help this patient, he should consider reducing or waivinghis charges. Or he should direct the patient to the social service agencyin your state that coordinates coverage for low-income or chronically illpatients.
Q:The billing software provided by my region's Medicare carrieris terrible. Can commercially available software programs be used to fileelectronic Medicare claims?
A: Yes. You should ask your hospital and colleagues what programsthey use and whether they're happy with them. Once you get a few recommendations,invite the vendors to your practice for software demonstrations, and askyour staffers to judge each program's ease of use. Find out what kind oftechnical support and warranty each company offers for its products.
However, all Medicare carriers have agreed on a single set of protocolsfor billing software. So if your carrier's program isn't up to snuff, youmight first want to see if it will fix the problems.
Q:I'm the medical director for a hospital's occupational healthprogram. In addition to our main function, the program provides treatmentfor hospital employees injured on the job. When employees are ill or havenon-work-related medical problems, we refer them to their own doctor orthe emergency room.
We're considering offering full primary care services to the employees.But none of our doctors belongs to any managed care plans. Plus, other occupationaland employee health departments have told us that it's unwise to expandour services. What do your experts think?
A: They agree with your colleagues. The first hurdle would besigning on with managed care plans. Handling these contracts requires anextra level of administrative support, which can be expensive. Then, inorder to make managed care contracting profitable, each doctor would needto attract approximately 500 patients. To do that, you'd have to bring inadditional patients from outside the hospital staff. Such a move would putyou in competition with other primary care doctors in the community andmake them reluctant to send you referrals.
If your goal is to expand your services, you'd be better off simply beefingup your occupational health program.
Q:Our IPA is having a hard time holding on to doctors. Whatcould we be doing wrong?
A: In order for an IPA to retain doctors, the benefits it providesmust outweigh the hassles and costs of membership. Examine the followingissues:
Patients often give me gifts as a "thank you," or for occasionssuch as Christmas or my birthday. I see no problem with the fruit basketsor home-baked cookies, but I'm uncomfortable with expensive gifts like theatertickets or jewelry. Is it appropriate to accept such things?
Yes. Patients would be offended if you didn't. Ask your accountant whetheryou need to declare expensive gifts on your tax return. You could donatepricier items to charity for use as raffle prizes.
Be sure to send thank-you notes.
Do you have a practice management question that may be stumping otherdoctors, too? Write PMQA Editor, Medical Economics magazine, 5 ParagonDrive, Montvale, NJ 07645-1742, or send an e-mail to firstname.lastname@example.org(please include your regular postal address). Sorry, but we're not ableto answer readers individually.
Kristie Perry. Practice Management. Medical Economics 1999;21:287.