Practice Management

A simple tactic to reduce unreimbursed care

Q Some patients show up for appointments with expired insurance cards. To avoid billing and collection hassles, should my practice call every patient's health plan to verify eligibility each time that patient comes in for a visit?

A Your scheduler should verify coverage before the visit, when a patient makes an appointment, then check coverage again when he or she shows up at your office. A phone call may not be necessary; many plans offer online support for accessing this information. If one of your insurers doesn't, try contracting with a so-called connectivity vendor, a company that connects doctors and insurers online. Two such companies are TriZetto and WebMD.

Before you see patients with expired insurance cards, your receptionist should tell them that they must pay with cash, a check, or a credit card (if you accept plastic).

Don't let buyouts bankrupt your practice

QWithin weeks of each other, our two senior partners announced plans to retire. Buying out both partners at the same time will cut the remaining doctors' income significantly. We didn't anticipate this scenario when we hammered out the details of ownership. What should we do?

A It depends on the group's size. If fewer than five of you will remain after the two doctors retire, you probably won't be able to fund the buyouts and recruit two new associates without a significant income reduction. In that case, you may have to dissolve the practice and split the assets equally.

A better scenario would be to ask the exiting doctors to stagger their retirements and accept smaller payouts over a longer period of time.

How long is too long to file a claim?

QOccasionally, we mail insurance claims instead of filing electronically. One health plan I belong to has started denying payments, citing "untimely submission." Is this legal? If I send a claim via regular mail, how can I prove that I submitted it within the plan's specified time limit? What should I do to collect on these claims?

A The solution is simple: Get proof of the date you submitted the claim by sending it via certified mail, return receipt requested, rather than regular, first-class mail. If the date falls within the plan's filing deadline, you should be able to collect.

Nonetheless, check the fine print of this plan's contract for information on its rules about submitting claims. Some contracts specify that you must submit a "clean" claim within 60 days. If you miss that deadline because you've made errors, that's your problem, not the health plan's.

On the other hand, if it looks as if this insurer is playing games, alert your state medical society and state insurance commissioner.

When exams are interrupted by cell phone calls

QMore and more of my patients accept cellular calls during exams. Some carry on lengthy discussions. Should I post a sign in the reception area asking patients to turn off their cell phones in exam rooms?

A Yes. Post one in every exam room, as well. Phrase the request this way: "So that we may give you the highest-quality service, please turn off your cell phone once you've entered this room."

Making sure your investment passes the "sniff test"

QI'm planning to open a physical therapy facility with a nonphysician business partner. This facility won't be linked financially to my solo primary care practice in any way. I understand that I can't refer patients to the facility, because that would violate Stark rules. But I'm worried that this arrangement might violate other federal or state rules that I'm unaware of. Am I on solid legal ground with this investment?

A You'll need to consult a health care attorney to be sure. Federal law permits you to refer patients covered by private plans to your physical therapy facility, but not Medicare, Medicaid, and other federally covered patients. Your state also may restrict or prohibit referrals.

Whether to let staffers forgo legally mandated breaks

QMy understanding is that, according to federal law, hourly employees working eight-hour days are entitled to a 30-minute lunch break, as well as a 15-minute break in the morning and afternoon. Have I got the facts straight? What if employees choose to skip any of these rest periods?

A There is no such federal wage-and-hour law.

But you do need to comply with state employment laws, so call your state's department of labor to get the lowdown. In most states, it doesn't matter whether a staffer skips a break, because either way, the employee is compensated for that time. As for meal periods, if they last 30 minutes or more, you don't have to pay for them unless the employee works during that time.

Still, you should encourage your staffers to take both types of breaks. They're good for morale, and they allow employees to catch their breath and recharge their batteries. If several staffers are skipping breaks, it may be time to add a staffer.

When a former employer has your patients' charts

QWhen I left group practice to go solo, most of my patients chose to follow me. But my former employer is charging me $15 for each patient's chart. Is this legal?

A Most states allow physicians to charge patients, attorneys, and other doctors a processing and per-page fee for copying records. Call your state's medical society or your liability carrier to find out the standard rate in your community.

Don't forget to have patients sign a transfer authorization form.

Ways e-mail may enhance patient relations

QWe're thinking about setting up e-mail accounts for our various departments. The system would allow patients to e-mail the billing department about charges and insurance, the scheduling department about setting up appointments, and the triage department about medical concerns or prescription refills. Is this a good way to go?

A It could be. Surveys have shown that patients like e-mail. To protect their privacy, however, the content of messages must be secure. Ask your state medical society about the level of security required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and choose an Internet service provider or Web host that can provide it.

Educating patients about the proper use of e-mail is equally important. Allow access only to people who agree (1) to expect the practice to check and answer e-mail messages only within certain hours on certain days, (2) never to use e-mail to report symptoms that could require prompt attention, and (3) never to treat e-mail as a substitute for an office visit.

Should your office staff double as a taxi service?

QMy practice sees some low-income patients who travel by bus to our office. On occasion, I ask a staff member to drive one of these patients home. Is this a risky proposition?

A Yes. You'd be liable if an employee got into an auto accident on such a mission. In most states, public and private agencies, such as the American Red Cross, offer free or reduced-cost transportation for low-income citizens in need of medical services. Ask your office manager to research these options.

New patient privacy rules that may affect your practice

QOur group's risk management consultant just informed us that the Heath Insurance Portability and Accountability Act of 1996 prohibits us from using patient sign-in sheets.

Our sign-in sheets ask only for a patient's name, address, home and work phone numbers, and doctor's name. It doesn't ask for the nature of the visit or any other medical information. We use these lists to keep track of the order of patients' arrival and to prove a patient received care in case there's a billing dispute. Is this illegal under the new regulations?

A Although HIPAA doesn't specifically forbid sign-in sheets, consultants advise against them. Your request for a patient's address and phone number is especially troublesome.

A sign-in sheet is a sorry substitute for a staffed reception desk, and it could alienate some patients. If you must use one, instruct your receptionist not to leave it unattended. Instead, she should jot down relevant information on a list that she keeps out of public view.

And rely on chart notes to verify a patient's visit, not a sign-in sheet.

When your departure leaves the community high and dry

QIn a few months, I plan to relocate. Who should inform patients of my pending departure—the hospital-run multispecialty clinic I work for, or me? Considering that I'm the only pediatrician in the county, do I have any special obligation to the patients I'll be leaving?

A Generally, the employer is responsible for notifying patients. But, to be sure of proper procedure, check with your state's board of medicine as well as your managed care plans.

To protect yourself from charges of abandonment, make sure the hospital contacts patients as soon as possible. And ask it to include names of other doctors patients can see while the hospital looks for your replacement.

How to bill for a dietitian's counseling

QHow should I bill Medicare and private insurers for my dietitian's services?

A You can try 99211, although Medicare and most commercial plans won't pay it as a stand-alone service. However, some insurers will pay for a dietitian's counseling if the services are included in an appointment for management of a chronic condition such as diabetes.

Have patients who fall outside that umbrella sign an agreement before services are rendered, acknowledging their understanding that this care isn't covered by insurance and that they'll have to pay out of pocket.

What to do when you must turn away new patients

QMy solo practice now has 3,000 active patients. Is it time to start limiting the number of new patients I see?

A No. Instead, think about the long term and consider hiring an associate, physician assistant, or nurse practitioner. Established patients drift away for a variety of reasons. So it's much better to accommodate new ones than to turn them away. Alternatively, you might try reducing your patient load by dropping one or more of the plans that offer the lowest reimbursement.

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;3:120.