Practice Management Q&A

September 21, 2007

Signing bonuses; locum tenens billing; building your practice

Billing for a locum tenens

Our practice hasn't been able to find a replacement for a doctor who'll be leaving soon, so we plan to hire a locum tenens. However, Medicare allows us to bill for a locum for 60 days only. What happens if we still need him after that?

Let him go and hire a new locum doctor. By law, after 60 days your practice can no longer file claims and be reimbursed for his services as a locum. So if you retain him, he'll have to bill Medicare under his own name. That means if he's not a participating provider in Medicare he'll have to apply, and he won't be able to see Medicare patients until his paperwork gets approved-and that can take months.

No weekend or evening hours, fee for service only

I plan to open a solo internal medicine practice that will be strictly fee for service. Office hours will be 8 a.m. to 5 p.m., weekdays only, and if patients need medical attention after those hours, they'll have to go to an urgent care clinic or an ED for emergencies.

Are there any potential problems or malpractice concerns in this arrangement?

Our consultants don't see any particular liability red flags-as long as your patients understand when you're available and where they should go for care when your office is closed. To make sure, record a message on your answering machine with directions to the nearest source of care and instructions to call 911 or go to the hospital in case of an emergency. Call your state medical association to find out if there's anything else you're required to do.

Under your fee-for-service arrangement, you'll need to opt out of the Medicare program so you can charge what you want for services Medicare normally covers. Have your Medicare patients sign a contract agreeing that they-not Medicare-will be responsible for paying you, and that they understand that they retain the option of seeing a doctor who hasn't opted out. Remember that by opting out, you agree to forgo any Medicare payment for two years for services provided to any Medicare beneficiary.

Can a signing bonus foster resentment?

Our six-doctor multispecialty group is having trouble attracting an ob/gyn to staff our new satellite office. So we're considering offering a signing bonus to lure the right one. But we didn't offer a bonus to any other new associate. Do your consultants foresee problems with this?

It depends. If the physicians are satisfied with their jobs and income, and confident about their future with the group, it probably won't matter to them if the new hire gets a signing bonus. However, if they're not happy with the practice in the first place, they may resent the "special treatment" the new ob/gyn is getting. But either way, you should explain the rationale for the bonus: the challenges of finding someone to fill the position and why attracting the right person should pay off for everyone.

You also need to figure out why you're having trouble hiring. Ask the candidates who turn down your offer why they refused. Perhaps you'll learn what you have to do to make it more attractive.

A midlevel practice without a doctor?

Is it possible to have a clinic manned by PAs only, without a doctor present? I know of two PAs who practice psychiatry, and the doctor comes in only periodically to review and sign charts.