Practice Management

Practice Management

When computerizing your office slows things down

Q:Ever since my solo practice switched to computerized billing,turnaround time on claims has slowed to as long as six months. How can wesolve this problem?

A: Ask the software vendor to perform an audit to determine thecause of the delay. It could be human error in your office, a computer glitch,incorrect coding, a problem at certain payers' end, or a combination ofstumbling blocks.

Among the factors the vendor should consider:

• Is information accurately transcribed from a patient's chart to the computer in a timely fashion?
• Is your computer set up to send the claim correctly?
• Is each carrier properly set up to receive the claim?
• Are carriers bouncing claims because of recurring documentation or coding problems on your part?
• Is your staff resubmitting problem claims promptly?
• It might also be a good idea to contact the carriers for their input and suggestions.

Separating the wheat from the chaff when you recruit an associate

Q:My partner and I are looking for a third physician to joinour practice. We've whittled down a pile of resumes to 10 suitable candidates.Should we do preliminary phone interviews with all 10 doctors, or shouldwe first narrow the field even more?

A: It would be more efficient for you to rank the 10 candidatesand conduct phone interviews with your top three choices. If you don't findthe doctor you're looking for, proceed to the next three choices.

How Stark rules affect referrals within an IPA

Q:About 85 percent of the physicians in my small town wantto form an IPA. Of that group, about half are primary care doctors. As anIPA, we'd like to offer MRIs, CT scans, and outpatient surgery. Would referralswithin the group violate Stark rules, even if the IPA is physician owned?

A: Your proposal raises a lot of red flags.

tice would be more likely to pass the Stark exemption tests--which examineownership and compensation arrangements--than an IPA. To be exempt fromStark rules, your IPA would have to meet these requirements:

• Its doctor members must provide 75 percent or more of their total patient care through the IPA, using jointly shared office space, facilities, equipment, and personnel.
• The IPA must bill for substantially all services under the same provider number.
• It must base compensation on something other than the value or volume of referrals.
• The IPA must furnish the ancillary services under the supervision of one of the physician members in a building where the referring doctor or other IPA physicians provide unrelated services.

Since these regulations are so complicated, you should ask a health careattorney to examine the particulars of your situation.

Will Medicare woes follow you into retirement?

Q:Could I be subjected to a Medicare audit after I've soldmy practice?

A: Yes. The statute of limitations on look- backs for overpaymentsis as long as six years. If fraud or abuse is suspected, Medicare can lookback as far as 10 years.

A help-wanted ad that gets results

Q:Our two-doctor suburban practice is recruiting a managedcare coordinator. How can we boost the number and quality of responses toa help-wanted ad?

A: Our consultants suggest that you run the ad for three days--Friday,Saturday, and Sunday. They also say you can attract more and better applicantsby:

• Making the first word of your ad "medical." Most newspapers index ads based on the initial word.
• Not being too demanding. If you list all the attributes and credentials of the ideal candidate, good ones may screen themselves out.
• Being creative. You want your ad to stand out from the others.
• Listing salary and benefits.
• Accepting calls or faxed resumes, to make responding easier.

Buying into bricks and mortar

Q:The three doctors in our practice own our office buildingand rent it to our professional corporation. How should we handle the buildingownership when it's time for associates to buy into the practice?

A: It's a good idea to have new shareholders buy into the building.That way, everyone is on equal footing and has an equal stake in the practice.But you should handle the purchase of the practice and the building separately.

Before you set the wheels in motion, have the building appraised. Thepractice's equity in the building should equal its fair market value lessthe mortgage and other debt. The appraiser should also determine whetherthe practice is paying a fair market rent. Typical monthly lease rates rangefrom 1 to 1.25 percent of the building's fair market value.

It's customary to have new shareholders buy into the building at thesame proportion of ownership that was used for the practice buy-in. Thenew partners will then sign on for an equivalent share of the mortgage.

Ease your receptionist's workload by managing patients' drugs correctly

Q:My front-desk staff complains that they're inundated bycalls for prescription refills. What can we do about it?

A: There are a number of steps you can take. Whenever it's appropriate,authorize more automatic refills when you initially prescribe. Implementa voice mail system for refill requests, which your staff should check hourly.Ask patients to call their pharmacies instead of your office, and have thepharmacies fax refill authorizations to you.

Don't let same-day appointments wreck your schedule

Q:Over the past year, my primary care practice has lost anumber of patients who became upset when they couldn't get a nonemergencyoffice visit on demand. What is the appropriate number of slots we shouldleave open for nonemergency same-day appointments?

A: This varies by practice and specialty. In general, one openslot in the morning and one in the afternoon works well for most doctors.

To find out if your practice needs a few more open slots, ask your receptionistto track the number of calls you get in a typical week for same-day appointments.You'll probably notice a pattern, with the most requests on Mondays andFridays. Try adding more slots on those days. And give yourself extra flexibilityby avoiding complete physicals and time-consuming procedures on the dayswhen work-in appointments are heaviest.

If patients are having so much trouble getting in to see you, it maybe time to hire an associate or midlevel provider.

Making sure false accusations don't stay on your record

Q:A Medicare patient came to my office requesting antianxietymedication. As I do with all female patients, I asked a nurse to be presentduring the exam. Later, my state's professional review board notified methat this patient had complained that I had touched her inappropriately.After an investigator interviewed my nurse and me, he told me to forgetabout the whole thing. How can I make certain that the incident is removedfrom my record?

A: Contact your state review board to find out what happens toa complaint that's decided in favor of the physician. If it remains on yourrecord, send the board a certified letter, return receipt requested, askingit to expunge the incident.

How to scale back bloated salaries

Q:I've discovered that I pay my staff more than any otherpractice in my specialty in this community. How can I bring salaries inline without upsetting my employees?

A: If your staff and your practice perform better than the communityaverage, don't do anything. Hard work and positive results deserve higherpay. But if that's not the case, notify your staff that automatic raisesare being discontinued, and explain why.

Tell employees that pay increases will be based solely on job performance,and that if they don't achieve certain specified goals, they shouldn't expecta raise. If necessary, terminate underachieving workers and replace themwith people you can start at a lower wage.

Consider alternatives to salary increases, such as additional paid timeoff or enhanced benefits.

Whether to warn colleagues about disruptive patients

Q:I share call and rounds with four other solo practitioners.Although we each have our own S corporation, we appear to be partners becausewe share office space and a practice name. Like any doctor, I occasionallydischarge problem patients. If I circulate a list of these patients to theother doctors, will I be violating confidentiality?

A: You might be, if you disclose information about the patients'medical conditions. Stick to listing names only. If a colleague inquiresabout a dismissal, state only that the patient was noncompliant. The "appearance"of a partnership isn't a strong enough relationship to justify divulgingadditional information.

How soon will you see profits from an X-ray machine?

Q:How many X-rays per year would our three-doctor primarycare office need to do to justify purchasing an X-ray machine? How muchwould the machine cost initially, and what would our ongoing expenses be?Are there self-referral prohibitions we need to be aware of?

A: You'd probably need to do at least 1,000 X-rays annually tobreak even. The start-up costs would be at least $40,000, which includesadding lead lining to the room where you'll put the machine. Annual operatingcosts run approximately $40,000 for labor and supplies on 1,000 X-rays ayear. The vendor can give you a more precise estimate.

To avoid self-referral violations, you can't share profits based on thevolume or value of referrals. Instead, play it safe by dividing profitsequally or as a percentage of ownership.

Has that employee won the lottery or pilfered practice funds?

Q:Our office manager has been showing up for work in expensiveclothes and jewelry. I've read that this is a sure sign that an employeeis embezzling money. What should I do?

A: You can't accuse your office manager of theft simply becauseher wardrobe has improved. But if you have reason to be suspicious, hirean independent auditor to examine your records. If the review turns up signsof embezzlement, file a police report, and let the authorities conduct aninvestigation. And if your employees are bonded, contact your insurancecarrier.

Edited by Kristie Perry, Senior Associate Editor

Do you have a practice management question that may be stumping otherdoctors, too? Write PMQA Editor, Medical Economics magazine, 5 ParagonDrive, Montvale, NJ 07645-1742, or send an e-mail to mepractice@medec.com(please include your regular postal address). Sorry, but we're not ableto answer readers individually.

Kristie Perry. Practice Management. Medical Economics 1999;18:209.