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Practice Collection Rates; Payer Penetration Rates; Medicare Denials; Splitting Overhead; Charting Quality Assurance; Inter-practice Consult; Withholding Care; Good Documentation Pays; HIPAA and Patient Objections; Giving Away Care; Report by Billing Date; Comparing Malpractice Rates Q I need to find the average percentage that doctors collect of their patient responsibility. For example, hospitals, after insurance and charity write-offs, generally collect 40 percent to 50 percent. Where can I find the comparable numbers for physician practices? A According to data we have from athenahealth, practices collect about 80 percent of deductibles and coinsurance. With smaller bills and a closer relationship to the patient, you'd expect practice collection rates to be better than those of hospitals. To get more data, type "self-pay" into the Search box on the left side of the PhysiciansPractice.com homepage. Q How do I find out more on the market penetration of various commercial managed companies in my county? I live in Florida. A Generally, insurance commissioners and state hospital associations are good places to ask. Here are some specific links for Florida: • http://www.flains.org/ • http://www.fha.org/
Q Medicare seems to be denying 93000 (EKG) more than usual. Should I be using a modifier? The denial code is 16: Claim service lacks information, which is needed for adjudication.
A Given the denial code, I don't think coding is at issue. But apparently, there is some information that is missing on the claim. Look for a remark code on the far left side of the paper remittance. This will advise you about what is missing or incomplete.
Q Do you have a "norm" for how multi-physician practices typically split overhead? I know most practices set compensation as the amount docs earn, less overhead. But how do some practices come up with the percentage of overhead for each doc, if some are more or less productive than others?
A Yes, overhead allocation can be a burden for multi-specialty groups as the primary-care docs generally can't carry an equal burden of overhead relative to surgical or procedural specialists. And, yes, compensation and overhead need to be looked at as a whole. There is no norm, per se. It's more like negotiation for temporary truces that work for each practice.
Q I am looking for a tool I can use to improve quality assurance in my physicians' charting, especially updating their problem lists. Do you have a suggestion?
A I suppose my response would depend on what process you use now, and I'd like to know why your physicians aren't updating their problem lists. For example, nursing staff may be able to update the list for them at intake, so physicians would just have to add what is revealed in the exam. Do they use a superbill to designate ICD-9s? If they update there, they can go back to the chart later. Do they follow a template for documentation? If there is a printed document that has a field for the problem list, they may be prompted to fill it in. If you are using EMR, of course, the system can prompt them to review the current list and do updates. Take a look at your current process to figure out where the speed-bump is.
Q Can a family physician refer a patient to an internist in the same practice for a complex medical case?
If so, would the internist bill that service as a consult? A You can get consults from other physicians within the same practice in different specialties, yes. What's less clear to me is whether you really are asking for a consult - which means a written report and advice that comes back to you, and you continue holding primary responsibility for this patient's problem. Or perhaps you want the internist to take care of this problem for the patient, which is a transfer of care. These are two different animals. Transferring care is fine, too, but the IM would bill a new-patient visit E&M, not a consult. Type "consult" into the Search box on the left side of the Web page for more articles clarifying this point.
Q Can a doctor refuse to see an established patient until he pays his account balance? Would this be considered withholding treatment?
A You can set a written policy, communicated to patients in advance, that you will refuse to see established patients who have not met their financial obligations. You'll want to define this very clearly - any bill left unpaid after three months? Account balances exceeding $500? You'll also want to define what you'll do when the patient is re-instated. Do they need to pay for all services in advance, for example? Are they dropped from the practice if they go into arrears again? If so, promise to see the patient for the next 30 days, on a cash basis, until they can find another physician or arrange a payment plan/pay in full. Download Physicians Practice's sample dismissal letter to use as a guide: http://www.physicianspractice.com/index/fuseaction/tools.details/activityType/patients/tool/29.htm You might also want to confirm that your malpractice carrier agrees with this advice.
Q I read with interest your tools on physician documentation tips. Is giving these to physicians considered leading them to be able to up-code?
A Not to my knowledge. If they performed a service, they should document it - and be paid for it. Good documentation is never a problem. Lack of documentation or documenting things not done is. Q What is my legal position in the state of California if the patient says she doesn't want me to send her records to a psychiatrist? What if the psychiatrist calls me to ask questions? Are we required to comply with the patient's request? A Alas, you ask about a gray area. The HIPAA privacy rules allow physicians to share health information for treatment purposes without patient authorization, but they don't say anything about what to do if the patient actively prohibits the information sharing, according to Abner Weintraub, who's with The HIPAA Group. Under HIPAA "A covered entity must permit an individual to request that the covered entity restrict uses or disclosures of protected health information about the individual to carry out treatment, payment, or health care operations; and disclosures permitted under § 164.510(b)." However, while you have to allow individuals to request restrictions, you don't actually have to agree with the request. The HIPAA regulation continues: "A covered entity is not required to agree to a restriction." State laws in California also seem to vet this issue insufficiently. Here is a summary of state rules: http://www.healthprivacy.org/usr_doc/CA2002.pdf But you're in a real quandary, aren't you? Clearly, you are not taking good care of the patient if you do not share the info. But sharing it without the patient's consent may not be the best choice either, whatever the legalities. I suggest you call the risk department at your malpractice insurer and ask their opinion. They'll need to defend you should something go wrong with either decision you might make, so their guidance is necessary. Q Is it legal to give free care to anyone? Can we give free care to our employees that are self-pay? What if they have Medicaid, Medicare, or private insurance? A If patients are insured, I assume we are talking about making the patient responsibility-free but you'd still be billing the payer. Don't do it. It's a breach of your contract with commercial payers and Medicare looks upon it as an illegal inducement. Frankly, I don't think you should see your employees at all, since breaches of privacy and conflicts of interest are darned near inevitable. If you do, the rules for them are no different than the rules for everyone else. You can sure offer time-of-service discounts to self-pay patients. Q We were told by our practice management vendor that we should always run our financial reports by the billing date instead of the date of service. Why would running a report on charges, for example, be better by billing date as compared to date of service? A Well, the main reason is that industry benchmarks typically use date billed. For example, the Medical Group Management Association measures days in A/R from date billed. Of course, this leaves open the possibility that you are creating delays by not submitting claims promptly, but you should be doing so automatically. Q Are there any current published reports that provide information on what different insurance companies are charging for malpractice for internal medicine in our region? Where can we get the best rates? A The Medical Liability Monitor publishes a rate survey at http://www.medicalliabilitymonitor.com/ Still, you really should call around and see what you can get for your specific practice. | 
