Practice Management

How to resolve a dispute with your hospital

QMy board-certified emergency medicine group has worked for our local hospital for seven years. Without our input, the hospital's new administrator changed our schedule from three 12-hour shifts per week to four 10-hour shifts. He also now requires us to find our own substitutes when we're sick—or forfeit sick pay. As if that weren't enough, he's denied us raises this year. Our salaries are well below the average for our region. We've tried discussing our differences, but the administrator isn't open to hearing us. What should we do?

A Find out whether other hospital departments have the same complaints. If they do, you should band together and bring your grievances to someone above the administrator. If necessary, approach the hospital's board of directors.

If that doesn't work, hire an attorney or practice management consultant to work out a fairer agreement.

When a patient doesn't follow directions

QOne of my hypertension patients skips regularly scheduled triglyceride testing that I arranged with a local lab. I've discussed the importance of this testing with her, and I've also made the arrangement as simple as possible (the lab doesn't require appointments). Am I justified in terminating the physician-patient relationship?

A Yes. Send her a certified, return-receipt letter stating that because she's failed to follow your instructions you are discharging her from your practice. Tell her she has 30 days to find a new physician.

Must you see patients who claim bankruptcy?

QIf a patient declares bankruptcy and my practice writes off the debt, am I obligated to continue seeing him? If Yes, may I insist on cash payments at the time of service for out-of-pocket obligations?

A In general, you're not obligated to treat anyone. (There are a few exceptions, such as post-op patients.) However, you must give patients adequate notice of discharge in order to avoid accusations of abandonment. If you decide to continue seeing the patient, send him a certified, return-receipt letter stating that until further notice, he must pay for out-of-pocket expenses at the time of service. Explain that if he can't, he will be required to provide proof of indigence. You may want to include information about how the patient can apply for Medicaid.

Pointers on supervising PAs and NPs

QMy group wants to hire a PA or NP. What do we need to know about billing for their services?

A Medicare requires you to bill under the PA's or NP's provider number if he delivers patient care without your direct supervision. For this, Medicare will reimburse you at 85 percent of your normal fee schedule. If the PA or NP provides services "incident to" yours, then bill Medicare under your number. Services that qualify as "incident to" must be:

• Performed on an outpatient basis.

• Provided under your direct personal supervision. Although you don't need to be in the exam room, you must be on premises.

• Provided after you've first initiated the course of treatment. So you must perform the initial exam for a new patient, as well as the exam for an established patient with a new problem.

Private plans' billing rules and reimbursement rates vary widely. Therefore, you should find out how much your contracted plans pay for a PA's or NP's services before you hire one or sign a new payer contract. You should also research "scope of practice" laws in your state so payers can't take advantage of vague statutes to deny you payment.

Handling charts for patients who don't like your buyer

QI've just sold my practice. May I charge patients who choose to leave the practice for the administrative costs of copying and mailing their records to a different physician?

A Yes. But call your state medical society first to find out whether state law limits how much you can charge.

Whether to use focus groups to assess your practice

QOur five-doctor primary care group wants to get some patients together to ask them what they like and don't like about the way we run our office. What do your consultants think of this idea?

A Most aren't big fans of "focus groups." It's too hard to get enough people to show up to ensure a balanced representation of your patient population. Plus, in these situations, people are often reluctant to state how they really feel. (This is especially true when doctors and their staffers are present.)

To get a wider sample and more-candid responses, mail out questionnaires, which can be answered anonymously. Or save on postage by giving them to patients when they come in for appointments. Either way, include a stamped, pre-addressed return envelope.

Wait until you receive at least 100 replies before you analyze results. And consider doing an annual survey, so you can compare your practice from year to year.

Build staff morale by closing at lunchtime?

QInstead of staggering employee breaks, I'd like to close my small-town office for an hour at noon. I think it would be a boost to morale if staffers could socialize at lunchtime. Good idea?

A No. You need to be available to patients during lunch hour, since that may be the only time many of them can get in to see you.

When interviewing job applicants becomes a chore

QIs it necessary to ask every job candidate the same questions? After two or three interviews, I feel like a robot, and I'm afraid that candidates may perceive this as lack of interest. What can I do to keep interviews lively, but still gather the information necessary to compare candidates fairly?

A Refreshen the recruiting process by rephrasing questions, asking them out of order, and limiting yourself to no more than three interviews a day. Encourage candidates to talk about themselves by asking open-ended questions.

Just make sure you ask all candidates the same things. If you don't, not only won't you have comparable data, but you also could expose yourself to discrimination charges if you fail to give all applicants an equal chance to discuss their skills and experience.

Do your homework before investing in pricey software

QIn reviewing a contract for an $18,000 practice management software program, I found a couple of red flags: (1) The vendor offers a skimpy 90-day warranty, and (2) the vendor accepts no liability for any problems the software might cause. I told the vendor that I was uncomfortable with these provisions, but the company will make no concessions. Should I walk away from the contract?

A Yes. Besides, one of the consultants we contacted said that you shouldn't spend more than $6,000 on that kind of software anyway.

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;11:152.