Practice Management

When patients complain about your fees

Q How should we respond to patients who complain that my fees exceed what their insurers call "usual, customary, and reasonable"?

Should my receptionist handle upset patients, or should she pass them off to my office manager or me?

A If you've coached your receptionist on how to respond to these complaints, she should be able to deal with them. Nonetheless, your office manager should be available to anyone who requests her assistance.

Train appropriate staffers to respond to such complaints by explaining that what insurers pay for services doesn't necessarily reflect the cost of providing good health care.

Rewarding an NP who works as hard as you do

Q My nurse practitioner puts so much into my practice that I consider her an equal partner. Although I'd like to give her a stake in my business, my state prohibits practice ownership by nonphysicians. What compensation arrangement would you suggest under these circumstances?

A The easiest thing to do is increase her salary. Or you could pay her a regular bonus—monthly, quarterly, or yearly—based on productivity.

Whether a computer frees you from paper records

Q My practice has just begun to computerize patients' clinical and financial information. Must we keep the existing paper copies of patients' medical charts and billing and payment history?

A Yes. If you were to throw out these records and were later charged with malpractice or insurance fraud, an attorney could argue that you altered the records when you transferred them to the computer.

If you're running out of space, store them off-site.

How to reconcile privacy concerns and reimbursement rules

Q What should I do when a patient refuses to provide a Social Security number because "it's private"? I can't receive reimbursement without it.

A First, assure the patient that you won't share his personal information with anyone besides his insurer. Second, explain that if he doesn't provide his Social Security number, you can't get paid, and won't be able to continue as his doctor.

What it takes to make marketing efforts worthwhile

Q Our group's business manager has drawn up a plan to attract new patients. The marketing effort will cost our three-doctor suburban family practice roughly 5 percent of our gross income. How many patients do we need to add in order to make this expense worthwhile?

A Way too many, say our consultants. Assuming your three-doctor practice grosses $1 million, that means a $50,000 tab for marketing. If a typical office visit brings in $25, after expenses, you'd need an extra 2,000 visits just to break even. Scale back your marketing budget.

Could your practice purchase be booby-trapped?

QI've just purchased a solo family practice from a doctor who's been in business for 20 years. If Medicare or Medicaid audits the charts of patients that I've inherited but not yet treated, who's responsible for the costs of providing the government with coding and billing records? Who is financially responsible if the government finds evidence of fraud?

A The seller should be responsible for both, provided your purchase agreement contains an indemnification clause holding him liable for all practice activities up to the date of the closing. If the agreement doesn't contain such a clause, see if it's possible for your attorney to make one an addendum.

A fair benefits package for part-time doctors

Q What benefits should my partner and I offer a part-time salaried physician?

A At the very least, health insurance and malpractice coverage. If the doctor works at least 1,000 hours a year, you may need to include life insurance and retirement benefits, too—depending on how your practice has set up these benefits.

Everything else—such as CME, professional dues, vacation time, and a pager—is negotiable.

Dealing with the charts of patients you see in the ED

QMy hospital sends me the paperwork for all of the ED patients I treat when I'm on call for my group. What should I do with the records of patients who aren't mine?

A Forward copies to their physicians and put the originals in your "on-call file" until your state's statute of limitations on bringing a malpractice suit runs out. Keep in mind that the statute of limitations is different for patients under the age of 18.

Don't let a vendor commercialize your practice

QI'm considering buying practice management software from a vendor that requires my practice to be available as a "promotion and demonstration" site for the company's potential customers. This strikes me as disruptive. Is this a standard contract provision?

A No. But some vendors will pay you or advertise your practice in return for your promotional consideration. If that kind of compensation isn't worth your while, ask the vendor to remove the provision from the contract.

Your liability for treating a patient against his will

Q We routinely take turns covering the ED in our small town hospital. One night, a patient with massive bleeding from a laceration refused to let me treat him, stating that he'd accept care only from his own family physician. While I was trying to contact that doctor, the patient lost consciousness, so I treated him. Now the patient has threatened to sue me for treating him without his permission. Who would be liable for this—the hospital or me?

A Neither. The patient has no case. Physicians who treat patients with emergency medical conditions are generally shielded from liability, regardless of whether they've obtained consent.

Is a nutritionist an asset or a liability?

Q Our four-doctor group plans to hire a nutritionist. What do you think of that idea?

A While this would be a nice gesture to your patients, it will almost assuredly be a net expense for the group. Third-party payers place so many reimbursement restrictions on such services that it's hard to break even, let alone turn a profit, if you employ a nutritionist.

When a staffer can't find a back-up baby-sitter

Q Occasionally, an employee's child care arrangements go haywire. Under extenuating circumstances, should I allow a staffer to bring a child to the office?

A It's not the best solution. Children in the office are a distraction, and allowing your practice to be a back-up day care center for one employee sets a bad precedent for others.

Edited by Kristie Perry,
Contributing Writer

Do you have a practice management question that may be stumping other doctors, too? Write: PMQA Editor, Medical Economics magazine, 5 Paragon Drive, Montvale, NJ 07645-1742, or send an e-mail to mepractice@medec.com (please include your regular postal address). Sorry, but we're not able to answer readers individually.

Kristie Perry. Practice Management.

Medical Economics

2002;13:109.