Laws that govern phone communications; HIPAA rules and the small practice; Is this on-call policy a liability risk? Protocol for contacting patients at work; Vacation guidelines for your staff; Haul an insurer to court for libel? How to stay on top of your dictation; The pros and cons of weekend office hours; Remedies for handling errant faxes; Help for physicians working on a shoestring; When a doctor's spouse wants a job on staff; Don't play favorites with phone lines; Using customized records-release forms
Q: I'd like to record telephone conversations I have with patients' insurers. Must I disclose this at the beginning of a call?
A: That would be a good idea, even though only 12 statesCalifornia, Connecticut, Florida, Illinois, Maryland, Massachusetts, Michigan, Montana, Nevada, New Hampshire, Pennsylvania, and Washingtonrequire that all parties to a conversation consent to the taping.
Q:I'm confused about the HIPAA transaction rules that went into effect last October. Is it true that a solo practitioner must bill electronically? I've heard that there are exceptions to this rule.
A: You're not required to submit Medicare claims electronically if your practice is a paper-only one and has fewer than 10 employees. Nor do the new rules apply to paper-only practices of any size that don't accept Medicare patients.
But health care is clearly moving in the direction of universal electronic submissions. As we reported in our Feb. 7 issue ("Missed the HIPAA deadline? Now what"), both Medicare carriers and private insurers pay electronically submitted claims faster. Moreover, some payers are threatening to cut off doctors who don't file electronically or to deduct something from their payments.
Q: My community is so short on some specialists that our hospital allows certain solo specialists who don't have a call-coverage group to be on call for the ED only every three weeks. The hospital also allows us four weeks of "vacation" from call a year. Could this arrangement lead to accusations of abandonment?
A: No. A claim of abandonment is legally justified only when a patient-physician relationship is terminated improperly by act or omission. As long as the ED is properly staffed and you've instructed your patients to contact the ED when you're unavailable, you won't be found liable for abandonment.
Q:A new patient has asked us to call her at the office, rather than at home. But it's been difficult to reach her directly at work. So we've resorted to leaving messages with her secretary and on her voice mail.
We're concerned about violating her privacy. How much information should we reveal in a message?
A: Ask her what she's comfortable with. If she wants detailed messages left with her secretary or voice mail, get her permission in writing. In the meantime, leave only your name, phone number, and a request that she return the call.
Q:How far in advance should our three-physician family practice require our 10 employees to request vacation days? On what grounds can we deny requests?
A: Ask employees to give you two weeks' notice for one or two vacation days and a month's notice for five or more.
Your office manager should coordinate requests so that no more than one staffer is out at once. If two employees request the same vacation days, give preference to the one who asked first. But rotate who can take time off around the holidays.
You can deny requests for time off if a staffer's absence will disrupt the practice. All of this should go in your office-policy manual.
Q:A health plan has begun telling its members that my fees are higher than those charged by others in my specialty for similar services. So I called a few colleagues and found that my fees are on par with theirs. This insurer's statements have caused quite a bit of heartache for my staff, my patients, and me. Does the carrier's behavior give me grounds for a libel suit?
A: This carrier might have set its "usual, customary, and reasonable" fees below what's typical for your community. Many carriers have ceased using that phrase because it has provoked challenges by patients and physicians.
Before pursuing legal action, send the insurer's director a lettervia certified mail, return receipt requested. In it, state that your fees fall within the normal range for your community. Explain that for the insurer to say your charges are "above the usual and customary" is misleading and interferes with the physician-patient relationship. Ask whether the carrier is ready to substantiate its judgment of "above usual and customary" with facts in court. Send copies of the letter to your state's insurance commissioner.
In addition, send letters to the affected patients emphasizing your high standards of care. Tell them that your fees are normal for your community and that their insurer is paying below that.
Have an attorney review your correspondence before sending it out. He'll be able to advise you further if your initial actions don't bring the desired results.
Q: I often fall behind on dictation. What tips do you have for staying on top of this task?
A: Dictate chart notes immediately after seeing each patient. Set up your dictation equipment in your lab or consulting room, assuming it's near your exam rooms. An alternative is to use a portable recorder and dictate right in front of the patient. Some consultants say this method helps prevent miscommunication and makes patients feel like they're getting more of your time. (But you'll have to word your dictation carefully to avoid frightening patients when you "rule out" conditions.)
Q:My partner and I are thinking about opening our family practice on Saturdays and Sundays. Is this a good idea? Should we accept only emergency and sick patients, or should we offer routine visits like well-baby checks, too?
A: Offer all of the above, but schedule loosely enough so that you can make emergencies a priority, just as you would during the regular workweek.
Keeping weekend office hours is a good way to build loyalty among working patients, who often find it difficult to make appointments Monday through Friday. But make sure you, your partner, and staffers are getting enough time off to rest.
Q:We often fax medical records to specialists, insurance companies, or lawyers. What should we do to prevent information from going to the wrong place?
A: Use the fax only when there isn't time to mail the information. Put a sticker on the machine that reminds staffers to confirm recipients' fax numbers before hitting the "send" button. Program frequently used numbers.
The fax's cover sheet should include your name, fax number, and telephone number; the intended recipient's name and fax number; a statement of confidentiality; and a request for the recipient of a misdirected fax to destroy the information and contact your office immediately. If you suspect a fax went to the wrong place, get the fax number from the machine's internal logging system and refax a request to destroy the information. Then, if you can identify the business from the fax number, call to confirm that they've done so.
Q:I volunteer at a nonprofit health clinic that claims it can't afford dictation equipment. But writing notes by hand takes way too much time. Do you have any information on equipment prices or transcription service fees that could help me make the case for bringing this clinic into the 21st century?
A: The newest voice recognition software runs between $2,000 and $3,000. Some vendors will let physicians try out their packages for free. Transcription services vary from 10 to 17 cents per line, depending on locale. If you go this route, ask colleagues for referrals and check references.
The least expensive option is to talk to retiring physicians about purchasing their transcription equipment. Equipment sales representatives may also be able to connect you with used machines.
Q:The office manager for our two-doctor primary care practice insists she needs her own phone line. Should we grant her request?
A: No. Doing so would irk your other employees. But make sure your practice has enough phone lines to handle your incoming and outgoing calls. To find out, ask your patients whether they have trouble getting through. Or ask your phone company to audit your group's incoming and outgoing call patterns.
Q:A partner's wife has applied for our soon-to-be-vacant receptionist's position. She's as qualified as our other applicants. And since we don't have an antinepotism policy, we can't refuse her an interview.
How should we handle concerns from our office manager, staff, and doctors who worry that having a spouse on staff could bring headaches?
A: For now, you'll have to hope that you'll find a more qualified candidate than the partner's wife.
For the future, establish a policy that prohibits the hiring of relatives. Without such a policy, you're inviting strife: Some employees view relatives as spies and perceive them as getting all the breakshigher pay, easier work, better vacation timeseven if it never happens that way.
Q: Hospitals and other doctors occasionally send me requests for patient records that lack a witness signature, date, proof of identification, or specifications. I'd like to return every incomplete request to the sender with instructions to fill out my customized authorization form instead, which covers all the bases. Will my caution irritate colleagues?
A: It might bother some, but that shouldn't stop you from using sound risk-prevention measures. Don't hold up patient records in emergencies, however. If you receive an incomplete request that requires immediate attention, call the requesting physician's office and ask that it fax the necessary information.
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 firstname.lastname@example.org (please include your regular postal address). Sorry, but we're not able to answer readers individually.