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Seeking Deeper Knowledge and Wisdom

Experts Invited … A Call for Professionally Generated Content

Are you a health economist, policy wonk, attorney or accountant, HR or HIT guru, CXO or industry expert in a specific topic or subject related to medical practice management, or physician-focused financial planning?  

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Reducing Medicare Payment Denials and Reductions

Start with Diagnosis Coding Documentation Guidelines

By Patricia A Trites; MPA, CHBC, CPC, CHCC, CHCO, CMP™(Hon) 

[CEO: Healthcare Compliance Resources, Inc]

A 2003 audit of Medicare claims by the Office of the Inspector General (OIG) found that Medicare fee-for-service payments that did not comply with all of the Medicare laws and regulation was $13.3 billion in fiscal years 2001 and 2002. 

Improper payments in 2002 occurred mostly in three areas: medically unnecessary services (57.1 percent), documentation deficiencies (28.6 percent) and miscoding (14.3 percent).

And so, how do you prevent or reduce denials or reduction of payment when claims are adjudicated as “not medically necessary”?  

Begin by following the diagnosis coding documentation guidelines, which are: 

  • Code to the ultimate specificity. There is a significant difference between 716.90, Arthritis, Type and Site Not Otherwise Specified, and 716.39, Menopausal Arthritis, Multiple Sites-Joints.
  • Use Additional Codes and Underlying Disease Codes. Many conditions require, by medical-record coding rules, that you use two ICD-9 codes and that these codes are put in the appropriate order. For example, 533.30 Peptic Ulcer-Acute and Without Obstruction, and 041.86, Due to Helicobacter Pylori Infection.
  • Use multiple codes to fully describe the encounter. This includes coding any additional co-morbidities and/or signs and symptoms that affect the patient’s current encounter.
  • Choose the appropriate principals diagnosis and properly sequence secondary codes. List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. Then list additional codes that describe any co-existing conditions or symptoms.
  • Avoid using .8 and .9 “catch-all” codes. In the ICD-9 system, descriptions and digits are provided for times when a physician lack information about a patient’s exact condition or diagnosis. The codes commonly end in .8 or .9 and are commonly referred to as catch-all codes. Under Medicare coding guidelines, these codes should be used only when the specific information required to code correctly is unknown or unattainable. 

Do you use a professional coder in your healthcare entity; or do you do-it-yourself?

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Appraising a Medical Practice

Types and Levels of Medical Practice Appraisal Services 

By Dr. David Edward Marcinko; MBA

Staff Writers

Medical office valuation is as much art as managerial accounting science. And, most physicians are unaware that – much like CPT® codes and office visits – there are several levels of acuity which may be obtained for various reasons.

Although not standardized, the following are typical valuation engagement types for the industry.

Comprehensive Valuation 

An extensive service designed to provide physician-owners and/or potential purchasers with an unambiguous opinion range on the value of a medical practice, Ambulatory Surgery Center or healthcare entity. It is supported by all procedures that appraisers deem relevant to the engagement with onsite visit mandatory.  This valuation type is suitable for contentious situations like divorce, partnership dissolution, sale, etc.

The report includes a formal written Opinion of Value suitable for litigation support activities like depositions and trial. It is also useful for external reporting to bankers, investors, the public, etc.

An onsite visit is usually included. This valuation type generally adheres to appropriate USAP [Uniform Standards of Professional Appraisal Practice] guidelines

Limited Valuation

This type of engagement is the next step down in acuity from a comprehensive appraisal as it lacks the performance of additional procedures that are suggested in an USPAP appraisal.  This type of assignment can be considered an “agreed upon procedures” appraisal that should be used in circumstances where the client is the only user of the appraisal, or as an organic internal practice growth ingredient; but not for external reporting. 

An onsite visit is usually not needed for this US mail or fax delivered valuation. A formal Opinion of Value is not rendered.  

Informal Ad-Hoc Valuation 

This is the lowest level engagement where the appraiser is to provide a very gross and non-specific approximate indication of value based upon the performance of limited benchmark procedures of the firm.

No onsite visit is needed. Neither a written report nor an Opinion of Value is rendered.  May be a voice based consultation. 

Forensic Investigations  

These services are comprehensive, extra-ordinary, expensive and used for medical income and personal asset determinations and tracings; but not as an essential component of most medical practice valuation services. Often used in criminal investigations, and/or upon IRS, legal and/or FBI request. 

C.Y.A. 

This report is an opinion whether or not a medical practice valuation is required. It is ideal for the physician client or health law attorney who is unsure if a practice has value or as a way to “cover your assets.” 

Conclusion 

The above impressions and levels of service are subject to change depending on circumstances and the operating policies and procedures of the individual appraiser, or consulting firm. Nevertheless, they represent a cogent basis for further investigation. 

What have your medical practice appraisal and valuation experiences been like? 

More information: http://www.springerpub.com/prod.aspx?prod_id=23759

The Employed Physician Business Model

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Employed Doctors Enjoy Several Compensation Options

By Dr. David Edward Marcinko; MBA, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™

biz-book1According to corporate medical recruiter Kris Barlow RN MBA, physicians can select from various employment models that may include fringe benefit packages (life, health, dental, disability insurance; medical society and hospital dues, journals, vacations, auto, and CEUs, etc.) equal to 25-40% of salary [personal communication]. 

And, this medical business model is fast growing as the various types below demonstrate. 

Independent Contractor or Employee 

A payer has the right to control or direct only the result of the work done by an independent contractor, and not the means or methods of accomplishing the result.

By contrast, anyone who performs services for another is an employee if he or she can control what will be done and how it will be done. Employed physicians are usually not compensated as independent contractors. 

New Practitioner Salaries: 

Published annually for new practitioners by The Health Care Group®, the Physician Starting Salary Survey collects and collates nationwide data on new physician employment compensation.

The guide reports first, second and third year of starting physicians’ salary and incentives, but with large high-low spreads. It also includes information about co-ownership provisions, benefits and restrictive covenants.

The survey is categorized by specialty and results are based on information provided by medical practices, health care advisors, physicians, and health care consultants across the country. The figures represent basic elements of the bid/ask process for establishing optimal salary and benefit amounts for new physicians entering private practice.

Available for no charge from the Health Care Group (800.473.0030 or www.HealthCareGroup.com) 

Public Equity Relationships 

The public equity roll-up model of medical partnerships in the late 1990s offered employed physicians experience within a large group whose decisions were made by managers.  Compensation was controlled and replaced with the stress of investor expectations, as Physician Practice Management Corporations (PPMCs) needed to grow revenues by 10-15% annually to maintain price-to-earnings ratios. If stock was held in a growing PPMC, physician employees shared in both practice and corporate compensation

But, by 2007, a survey of the Cain Brothers Physician Practice Management Corporation Index of public PPMCs, revealed a market capitalization loss of more than 95% since inception.

Newer Healthcare Delivery and Physician Compensation Models

Today, whether independent or employed, physicians can pursue several creative compensation models not available a decade ago:

MSO Contracting: 

According to consultant Jeffrey Peters, physicians maintain private practice in this model, but contract with a management services organization to relieve administrative burdens. Physicians maintain control with less stress, but, as MSO contracts are expensive (18-45% revenue), compensation diminishes, and rests on MSO competence.

Locum Tenens Practitioner:

Locum Tenens (LT) is an alternative to full-time employment for most specialties. Some younger physicians enjoy the travel, while mature physicians like to practice at their leisure.

Employment factors to consider include: firm reputation, malpractice insurance, credentialing, travel and relocation expenses (which are negotiable).  However, a LT firm typically will not cover taxes. 

Cash Based Compensation:  

A Cash Based Compensation (CBC) model attracts patients who pay cash for desirable services, such as surgeons who dispense scar reducers or in areas such as pain relief, weight loss, aesthetic procedures, and natural health.  

Any well-rounded CBC program should include: patient demand; low entry cost; little marketing costs; existing employees to administer the program; and an operational plan. With time and effort, profit for physician compensation may increase 10-20% annually.

Values Based Health Insurance Model:

According to some pundits,instead of the one size fits all approach of traditional health insurance, a “clinically-sensitive” cost-sharing system that supports co-payments related to evidence-based value for targeted patients seems plausible. 

In this model, out-of-pocket costs are based on price and a cost/quality tradeoff in clinical circumstances: low co-payments for interventions of highest value, and higher co-payments for interventions with little proven health benefit. Smarter benefit packages are designed to combine disease management with cost sharing to address spending growth.

Global Healthcare Model: 

American businesses are extending their cost-cutting initiatives to include offshore employee medical benefits, and facilities like the Bumrungrad Hospital in Bangkok, Thailand (cosmetic surgery), the Apollo Hospital in New Delhi, India (cardiac and orthopedic surgery) are premier examples for surgical care. Both are internationally recognized institutions that resemble five-star hotels equipped with the latest medical technology.  

Countries such as Finland, England and Canada are also catering to the English-speaking crowd, while dentistry is especially popular in Mexico and Costa Rica. Although this is still considered “medical tourism,” Mercer Health and Benefits was recently retained by three Fortune 500 companies interested in contracting with offshore hospitals and JCAHO has accredited 88 foreign hospitals through a joint international commission.  

To be sure, when India can discount costs up to 80%, the effects on domestic hospital reimbursement and physician compensation may be assumed to increase downward compensation pressures.

dhimc-book1Conclusion

Regardless of the salaried compensation model, its review and understanding is vital for long-term success.

How have the above compensation models affected your medical practice business model, and salary, if any? 

More info: http://www.springerpub.com/prod.aspx?prod_id=23759

Speaker: If you need a moderator or a speaker for an upcoming event, Dr. David Edward Marcinko; MBA is available for speaking engagements. Contact him at: MarcinkoAdvisors@msn.com

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The Independent Physician Business Model

Self-Employed Physician Compensation Models Vary

By Dr. David Edward Marcinko; MBA, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™ 

According to medical benefits consultant Eric Galtress, physicians can still select from traditional self-employment compensation models [personal communications] as outlined below.  

But, the trend does seem to be against self-employment.  

Independent Physicians 

A self-employed physician has great freedom but less security, because relationships with an employer are defined in return for a set compensation. Typically, this option is ideal for those who desire control, don’t work well in structured environments, and are committed to maximizing personal compensation.

Same-Specialty Group Partnerships

A same-specialty partnership is more restrictive than independent practice, and must balance control with the security that comes from working with colleagues along a continuum-of-care. Internal competition may be fierce, but partners maintain some autonomy while reaping rewards from economies of scale. More personal time is available too, but compensation is based on individual and group performance.

Multi-Specialty Group Partnerships

The partners of a multi-specialty group have even more restrictions, but harvest power from an expanded group of physicians and the presence of a vertically integrated referral chain. Because more disciplines are within the group, a partner might be well-positioned to capture additional prospective payment contracts.

The Compensation versus Value Paradox 

Regardless of the model, physician compensation is inversely related to practice value.

In other words, the more a doctor takes home in compensation, the less the practice is worth and vice versa. This is the difference between a short-term and long-term compensation strategy.

In-Sourced Entrepreneurs 

The classic example is an inpatient specialist or hospitalist. The National Association of Inpatient Physicians (NAIP) estimated the model encompassed 40,000 hospitalists in 2005, with an average salary of $171,001. Both figures are growing.

Out-Sourced Entrepreneurs

Some physicians are risk-tolerant and utility-neutral when seeking other compensation opportunities.

For example, Vanderbilt University-trained neurologist Michel Burry, MD is a hedge fund manager at Scion Capital, LLC; Dimitri Sokoloff, MD, MBA is a venture capitalist on Wall Street; and Harvard-trained emergency room physician Gigi Hirsch, MD, is the founder of a pharmaceutical industry physician executive search firm.

Conclusion

Regardless of the independent business or physician compensation model, degree or medical specialty, its review and understanding is vital for long-term success.

Now, going forward, will the independent medical business model survive; or is it domed?

More info: http://www.springerpub.com/prod.aspx?prod_id=23759

Speaker: If you need a moderator or a speaker for an upcoming event, Dr. David Edward Marcinko; MBA is available for speaking engagements. Contact him at: MarcinkoAdvisors@msn.com

 

 

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