How to ensure that conflicts won't destroy your group, When a patient is covered by an HMO and an indemnity plan, Getting Uncle Sam to help you treat staffers to lunch, Is there ever a good reason to sidestep insurance rules? A parachute for workers you must layoff, Medicare rules on supervising nonphysician providers, When a patient of means acts like a deadbeat, Accommodating patients who are self-conscious about their weight, Should you close your practice to a retiring doctor's patients?, Whether to retain an associate who turns down your partnership offer
Q Some of my managed care patients have secondary coverage under their spouses' insurance. Often, the secondary payer is an indemnity plan. Shouldn't that payer cover the balance left after the patient's managed care plan pays its contracted fee? If it doesn't, can I write off that unpaid amount?
A Insurance companies handle coordination of benefits in different ways, so you have to check each of these patient's plans. In general, when an indemnity plan is the secondary payer, it will cover anything left over, up to its maximum allowable fee. You must send the plan a copy of the primary payer's explanation of benefits. Some capitation plans may prohibit you from billing a secondary carrier.
QYou recently suggested that physicians take staffers out to lunch a few times a year as way of boosting morale. Can I write off these lunches as a business expense?
A If the lunches are strictly morale boosters, you can deduct 50 percent of the cost at tax time. If they're bona-fide business meetings where lunch happens to be served, you can deduct the full cost.
Q A managed care patient I've been treating asked me to alter his prescription for antidepressants so that what would look like a one-month supply of drugs would actually be a two-month supply. (He asked me to prescribe 40 mg/day instead of the 20 mg he actually needs. But since he'd continue to take only one pill, the prescription would last twice as long.)
Although I refused to do it at that time, I'm now wondering if I should indulge the patient's request. I know he's experiencing financial difficulties, and a small favor like this would help a lot. Is there any way the HMO could find out I've bent the rules?
A Yes. If the plan discovered this fraud during an audit of your medical records, it could yank your contract. Plus, you could face fines and disciplinary action from your state medical board. Instead, help the patient by giving him free drug samples.
Q I recently merged my practice with two others. All the partners agree that we need to reduce the size of our staff, but we don't agree on what the severance package should be. What do your consultants suggest?
A Every employee you dismiss should get at least two weeks' pay. Add another week's pay for every year beyond five a person has been with the practice. But set a cap of two months' salary.
Q Now that my nurse practitioner is billing Medicare under her own provider number, must I still sign off on her progress notes from visits performed in my office or a nursing home?
A It's not necessary when the NP is serving as the patient's primary care provider. But you are required to sign her notes in cases where you're the patient's primary care provider and the NP is simply assisting you.
Q For about five years, I've treated a woman who has worked steadily and has medical insurance. Yet her outstanding balance is now more than $1,000. I've been unable to collect anything close to the full amount. She'll pay, at most, $10 a month, apparently thinking this will keep me from turning her account over to a collection agency. What should I do?
A If you're sure that the patient doesn't have serious financial problems, notify her by certified letter that she must clear up her debt or start paying it off in larger installments within 30 days. Warn her that if she doesn't comply, you'll send her account to a collection agency and transfer her records to another physician of her choice. If you continue to treat her, insist on her full copay or coinsurance at each visit.
Remind your front-office staff that it's their job to collect from all patients at the time of visit and that exceptions to this rule must be cleared by your manager.
Q My practice has one scale, located in the hallway near our exam rooms. I'd hardly call this a public place, but sometimes a patient being weighed will complain about a lack of privacy. Should I get a scale for each exam room?
A If the purchase won't break the bank, why not? Alternatively, you could screen the area with panels or curtains.
Q Over a three-month period, my partner and I absorbed some 30 patients from a colleague who retired. We're inundated! Would it be a public relations disaster for us to close our suburban practice to additional new patients?
A First of all, congratulations! Landing 30 new patients is a coup. But, to answer your question, it's always risky to close your practice. If you're reaching your new-patient limit, consider hiring an associate to help handle the extra load. Or when new patients call, have your staff candidly explain that your practice has been swamped since the other doctor retired, but you can schedule them a few weeks hence. If the patient makes an appointment, offer to call with an earlier slot in the event of a cancellation.
Q To my surprise, a doctor I hired two years ago wants to remain a salaried associate instead of buying into my practice. He says he's happy working with me and wants to remain in the community, but he doesn't want the responsibility and stress of practice ownership. Should I consider his request or send him packing?
A Base your decision on how well you like working with this doctor and how much he brings to your practice in terms of patients and revenues. If he's a good fit, entertain his request. Although he may not be ready to buy in yet, that could change. You're completely within your rights to set up a contract whereby you revisit the issue of ownership in two to five years.
In the meantime, take another look at what you're paying the associate. If it's as much as what he'd earn as a partner, then maybe that explains why he has no motivation to buy in. Forgo raises in his salary, adjust his incentive formula, or both.
Q My primary care group has just been set free from a hospital contract, and we've decided to stay together. What safeguards should we build into our corporate documents to deal with the possibility of inharmonious practice styles?
A The corporation's employment agreement should require each doctor to consent to periodic recredentialing, as well as to a review of his utilization, patient care, and outcomes. Allow unsatisfactory results to be grounds for dismissal, and establish how you will handle the financial details if you ask a partner to leave.
Kristie Perry. Practice Management. Medical Economics 2000;21:165.