Practice Management Q&As

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Do you have to bill all carriers the same?

Q. Even when we meet the requirements for a level 1 visit, our group never bills for it when a nurse performs the service. Our rationale: Because Medicare pays when a nurse sees the patient but some managed care plans don't, it may be discriminatory to bill for the Medicare cases, but not the others. Is there a law that requires physicians to bill all insurance carriers equally?

A. No law requires you to bill all payers the same. And our consultants think you're making a mistake. You should never fail to report a service you actually performed. Always select the most appropriate CPT code and accept your contractual reimbursement from each carrier.

Q. Our small waiting room has space for only one sturdy, armless chair, big enough to accommodate one of our patients who's morbidly obese. Can you suggest a tactful way to ask a patient of normal weight to relinquish the chair when this patient comes in? Also, what else can we do to protect-and avoid embarrassing-an extremely heavy patient who has the capacity to break chairs and stepstools?

A. Asking someone to give up his chair to an extremely obese patient will likely embarrass both of them, so don't do it unless the heavy patient has difficulty standing. If his size makes it difficult for him to negotiate your office and he seems self-conscious about it, ask if he'd prefer to be seen either before or after hours or on a weekend. This solution will provide privacy and give you more time to deal with his special medical needs.


An alternative is to treat the patient at home. That will eliminate the risk of his damaging your furniture or getting injured on the premises. A home visit also allows you to address those aspects of your patient's environment that may affect his health. And if he permits it, you can include family members in your discussion of his care. However, unless you can document the medical necessity for why your patient can't travel, you may have trouble getting paid by health plans. Travel inconvenience is not an acceptable reason. But some plans, like Medicare for example, may pay if such a patient is "homebound," meaning he has an illness or injury that makes it difficult to leave home without supportive devices or another person's help.

When to discard files of former employees

Q. How long should I keep personnel files of terminated employees?

A. Keep the personnel records for at least seven years. By that time, you'd know if a former employee had filed a lawsuit against you and whether you needed the files as evidence.

Also, if you keep your files that long you'll be well within the record retention requirements of federal laws such as the Age Discrimination in Employment Act and Title VII of the Civil Rights Act, the USERRA (the veterans' employment law), as well as state laws (which generally require keeping certain records from 60 days to three years after an employee's termination).

You should keep employee payroll records for at least three years for purposes of the Fair Labor Standards Act and four years for the IRS.

In this issue, the answers to our readers' questions were provided by: Judy Bee,, La Jolla, CA; Jack Rue Coleman, CHBC, Dental-Medical Economics, Dallas, TX; Barbara Fick, Assoc. Professor, Notre Dame Law School, Notre Dame, IN; Alec Ziss, Snug Harbor Consulting, Falmouth, MA.

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