Some US Federal Budget Proposals

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Government Shutdown Hoopla for Retirees, Inheritors and Savers

By Rick Kahler CFP® http://www.KahlerFinancial.com

Rick Kahler CFPLost in the hoopla over the government shutdown, defunding Obamacare, and raising the debt ceiling are some proposals contained in President Obama’s budget that will have a significant impact on retirees, inheritors, and savers.

Most of the President’s proposals are aimed at enforcing higher taxes on savers who maximize their retirement plans. This is a way to raise revenue for government entitlement programs, like subsidies for health insurance, Medicare, and Social Security.

Retirement and Retirees

Back from last year is his proposal to cap contributions to IRA’s and 401(k)’s when the balance reaches a level determined by a set formula which is tied to interest rates. The proposal sets the cap at $3.4 million initially. As interest rates rise, the cap will lower. When a saver’s IRA balance hits the cap, he or she will not be allowed to make further contributions to any retirement plan.

This will mostly affect savers who terminate employment and roll large accumulations from profit-sharing plans and lump-sum distributions from defined benefit plans into their IRA’s. It will shut down their ability to save into the future.

Taxes and Inheritors

The President has yet another plan to end tax-deductible contributions for upper income earners. Only 28% of a contribution would be deductible for any taxpayer whose bracket exceeds 28%. For a taxpayer in the highest bracket, this means a tax increase of about 50%.

Another of the President’s proposals would end the ability of anyone other than a spouse to inherit a tax-deferred IRA. Under the proposal, all non-spouses inheriting an IRA would have five years to terminate the IRA and pay income taxes on the distributions. This proposal really impacts Roth IRA conversions, as most parents convert traditional IRA’s to Roths with the intention of leaving their children a non-taxable sum of money that can continue to grow tax free during their lifetime. If the President’s proposal passes, many older savers will discover that the intentions behind their Roth conversions have been nullified.

Forced Savings and Savers

While President Obama wants to cap what successful savers can stash away in retirement plans, he also wants to force employees to save for retirement. Employers will be required to open IRA’s for every employee and to fund the plan at a minimum of 3% of the employee’s pay, unless the employee specifically opts out. The employee can contribute more than 3%, up to the $5,000 cap for those under 50 and $6,000 for those over 50.

Of course, savvy savers and ME-P readers know most of us need to be saving 20% to 50% of our salaries, depending on our ages, so saving just 3% of pay won’t amount to much in the way of retirement income.

Good News

On the positive side, the President wants to end required minimum distributions on IRA balances under $75,000. This will reduce some paperwork for savers with smaller IRA’s who are not making withdrawals.

Typically, most retirees with small IRA’s are those with less savings anyway, who need to take withdrawals from their IRA’s to make ends meet. So it’s doubtful this rule change will have much impact.

Finally, the President proposes letting inherited non-spousal IRA’s enjoy the same benefit of a 60-day rollover window on any distribution, similar to what they can do with a non-inherited IRA. This will simply eliminate a lot of confusion, as most people don’t understand the 60-day rollover provision does not include inherited IRA’s.

Shutdown[US Federal Government Shut-Down]

Assessment

Of course, whether any or all of these proposals make it into law is anyone’s guess. Anyone whose retirement and estate planning includes saving in IRA’s will want to keep an eye on these provisions as the budget moves through Congress.

Conclusion

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Affordable Care Act HIEs at Launch

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Some Important Launching Information for Doctors and Business Owners

By Bobby Whirley CPA

[Whirley & Associates LLC – Alpharetta, GA]

Dear ME-P Readers,

The ACA (Affordable Care Act) requires employers to provide their workers with a notice about the state health insurance exchanges.

Today October 1st is the deadline for providing these notices.

These exchanges will sell insurance to individuals who don’t get coverage through their employers. The exchanges are also available to medical practices and small businesses, which may or may not currently offer heath care coverage.

The Fines?

Some doctors or business owners are concerned about paying a fine of up to $100 per day under the general non-compliance penalty provisions.

The recent notice of the Affordable Health Care Act states that there will be no penalty.  Please refer to http://www.dol.gov/ebsa/faqs/faq-noticeofcoverageoptions.html

If your medical practice, clinic or company is covered by the Fair Labor Standards Act (you have one or more employees, sales of over $500,000, and deal in interstate commerce), you must provide a written notice to your employees about the Health Insurance Marketplace by Oct 1, 2013.

Model Notices

The U.S. Department of Labor has two model notices to help employers comply. There is one model for employers who do not offer a health plan and another model for employers who offer a health plan or some or all employees.

More:

The model notices are also available in Spanish and MS Word format at http://www.dol.gov/ebsa/healthreform/

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Health-Information-Exchange

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Assessment

Employers may use one of these models, as applicable, or a modified version. More compliance assistance information is available in a Technical Release issued by the US Department of Labor.

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How the IRS’s Nonprofit Division Got So Dysfunctional

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The IRS Controversy

By Kim Barker and Justin Elliott

ProPublica, May 17, 2013, 5:14 p.m.

The IRS division responsible for flagging Tea Party groups has long been an agency afterthought, beset by mismanagement, financial constraints and an unwillingness to spell out just what it expects from social welfare nonprofits, former officials and experts say.

The controversy that erupted in the past week, leading to the ousting of the acting Internal Revenue Service commissioner, an investigation by the FBI, and congressional hearings that kicked off Friday, comes against a backdrop of dysfunction brewing for years.

Moves launched in the 1990s were designed to streamline the tax agency and make it more efficient. But they had unintended consequences for the IRS’s Exempt Organizations division.

Checks and balances once in place were taken away. Guidance frequently published by the IRS and closely read by tax lawyers and nonprofits disappeared. Even as political activity by social welfare nonprofits exploded [1] in recent election cycles, repeated requests for the IRS to clarify exactly what was permitted for the secretly funded groups were met, at least publicly, with silence.

All this combined to create an isolated office in Cincinnati, plagued by what an inspector general this week described [2] as “insufficient oversight,” of fewer than 200 low-level employees responsible for reviewing more than 60,000 nonprofit applications a year.

A Major Mistake

In the end, this contributed to what everyone from Republican lawmakers to the president says was a major mistake: The decision by the Ohio unit to flag for further review applications from groups with “Tea Party” and similar labels. This started around March 2010, with little pushback from Washington until the end of June 2011.

“It’s really no surprise that a number of these cases blew up on the IRS,” said Marcus Owens, who ran the Exempt Organizations division from 1990 to 2000. “They had eliminated the trip wires of 25 years.”

Of course, any number of structural fixes wouldn’t stop rogue employees with a partisan ax to grind. No one, including the IRS [3] and the inspector general [4], has presented evidence that political bias was a factor, although congressional and FBI investigators are taking another look.

But what is already clear is that the IRS once had a system in place to review how applications were being handled and to flag potentially problematic ones. The IRS also used to show its hand publicly, by publishing educational articles for agents, issuing many more rulings, and openly flagging which kind of nonprofit applications would get a more thorough review.

All of those checks and balances disappeared in recent years, largely the unforeseen result of an IRS restructuring in 1998, former officials and tax lawyers say.

“Until 2008, we had a dialogue, through various rulings and cases and the participation of various IRS officials at various ABA meetings, as to what is and what is not permissible campaign intervention,” said Gregory Colvin, the co-chair of the American Bar Association subcommittee that dealt with nonprofits, lobbying, and political intervention from 1991 to 2009.

“And there has been absolutely no willingness in the last five years by the IRS to engage in that discussion, at the same time the caseload has exploded at the IRS.”

IRS

Stone Walling

The IRS did not respond to requests for comment on this story.

Social welfare nonprofits, which operate under the 501(c)(4) section of the tax code, have always been a strange hybrid, a catchall category for nonprofits that don’t fall anywhere else. They can lobby. For decades, they have been allowed to advocate for the election or defeat of candidates, as long as that is not their primary purpose. They  also do not have to disclose their donors.

Social welfare nonprofits were only a small part of the exempt division’s work, considered minor when compared with charities. When the groups sought IRS recognition, the agency usually rubber-stamped them. Out of 24,196 applications for social welfare status between 1998 and 2009, the exempt organizations division rejected only 77, according to numbers compiled from annual IRS data books.

Into this loophole came the Supreme Court’s Citizens United decision in January 2010, which changed the campaign-finance game [5] by allowing corporate and union spending on elections.

Sensing an opportunity, some political consultants started creating social welfare nonprofits geared to political purposes. By 2012, more than $320 million in anonymous money poured into federal elections.

A couple of years earlier, beginning in 2010, the Cincinnati workers had flagged applications of tiny Tea Party groups, according to the inspector general, though the groups spent almost no money in federal elections.

Main Question

The main question raised by the audit is how the Cincinnati office and superiors in Washington could have gotten it so wrong. The audit shows no evidence that these workers even looked at records from the Federal Election Commission to vet much larger groups [6] that spent hundreds of thousands and even millions [7] in anonymous money to run election ads.

The IRS Exempt Organizations division, the watchdog for about 1.5 million nonprofits, has always had to deal with controversial groups. For decades, the division periodically listed red flags that would merit an application being sent to the IRS’s Washington, D.C., headquarters for review, said Owens, the former division head.

In the 1970s, that meant flagging all applications for primary and secondary schools in the south facing desegregation. In the 1980s, during the wave of consolidation in the health-care industry, all applications from health-care nonprofits needed to be sent to headquarters. The division’s different field offices had to send these applications up the chain.

“Back then, many more applications came to Washington to be worked — the idea was to have the most sensitive ones come to Washington,” said Paul Streckfus, a former IRS lawyer who screened applications at headquarters in the 1970s and founded the industry publication EO Tax Journal [8] in 1996.

Because this list was public, lawyers and nonprofits knew which cases would automatically be reviewed.

“We had a core of experts in tax law,” recalled Milton Cerny, who worked for the IRS, mainly in Exempt Organizations, from 1960 to 1987. “We had developed a broad group of tax experts to deal with these issues.”

In the 1980s, the division issued many more “revenue rulings” than issued in recent years, said Cerny, then head of the rulings process. These revenue rulings set precedents for the division. Revenue rulings along with regulations are basically the binding IRS rules for nonprofits.

“We would do a revenue ruling, so the public and agents would know,” Cerny said. “Over the years, it apparently was felt that a revenue ruling should only be published at an extraordinary time. So today you’re lucky if you get one a year. Sometimes it’s less than that. It’s amazing to me.”

Other checks and balances had existed too. Not only were certain kinds of applications publicly flagged, there was another mechanism called “post-review,” Owens said. Headquarters in Washington would pull a random sample every month from the different field offices, to see how applications were being reviewed. There was also a surprise “saturation review,” once a year, for each of the offices, where everything from a certain time period needed to be sent to Washington for another look.

So internally, the division had ways, if imperfect, to flag potential problems. It also had ways of letting the public know what exactly agents were looking at and how the division was approaching controversial topics.

For instance, there was the division’s “Continuing Professional Education,” or CPE, technical instruction program. These articles were supposed to be used for training of line agents, collecting and putting out the agency’s best information on a particular topic — on, say, political activity [9] by social welfare nonprofits in 1995.

“People in a group would write up their thoughts: ‘Here’s the law,’” said Beth Kingsley, a Washington lawyer with Harmon, Curran, Spielberg & Eisenberg who’s worked with nonprofits for almost 20 years. “It wasn’t pushing the envelope. It was, ‘This is how we see this issue.’ It told us what the IRS was thinking.”

The system began to change in the mid-1990s. The IRS was having trouble hiring people for low-level positions in field offices like New York or Atlanta — the kinds of workers that typically reviewed applications by nonprofits, Owens said.

In Cincinnati

The answer to this was simple: Cincinnati.

The city had a history of being able to hire people at low federal grades, which in 1995 paid between $19,704 and $38,814 a year — almost the same as those federal grades paid in New York City or Chicago. (Adjusted for inflation, that’s between $30,064 and $59,222 now.)

“That was well below what the prevailing rate was in the New York City area for accountants with training,” Owens said. “We had one accountant who just had gotten out of jail — that’s the sort of people who would show up for jobs. That was really the low point.”

So in 1995, the Exempt Organizations division started to centralize. Instead of field offices evaluating applications for nonprofits in each region, those applications would all be sent to one mailing address, a post-office box in Covington, Ky. Then a central office in Cincinnati would review all the applications.

Almost inadvertently, because people there were willing to work for less than elsewhere, Cincinnati became ground zero for nonprofit applications.

For the time being, the checks remained in place. The criteria for flagged nonprofits were still made public. The Continuing Professional Education text was still made public. Saturation reviews and post reviews were still in place.

But by 1998, after hearings in which Republican Senator Trent Lott accused the IRS of “Gestapo-like” tactics, a new law mandated the agency’s restructuring. In the years that followed, the agency aimed to streamline. For most of the ‘90s, the IRS had more than 100,000 employees. That number would drop every year, to slightly less than 90,000 [10] by 2012.

Change Will Come

Change also came to the Exempt Organizations division.

The IRS tried to remove discretion from lower-level employees around the country by creating rules they had to follow. While the reorganization was designed to centralize power in the agency’s Washington headquarters, it didn’t work out that way.

“The distance between Cincinnati and Washington was such that soon Cincinnati became a power center,” said Streckfus, the former IRS lawyer.

Following reorganization, many highly trained lawyers in Washington who previously handled the most sensitive nonprofit applications were reassigned to focus on special projects, he said.

Owens, who left the IRS in 2000 but stayed in touch with his old division, said the focus on efficiency meant “eliminating those steps deemed unimportant and anachronistic.”

In 2003, the saturation reviews and post reviews ended, and the public list of criteria that would get an application referred to headquarters disappeared, Owens said. Instead, agents in Cincinnati could ask to have cases reviewed, if they wanted. But they didn’t very often.

“No one really knows what kinds of cases are being sent to Washington, if any,” Owens said. “It’s all opaque now. It’s gone dark.”

By the end of 2004, the Continuing Professional Education articles stopped [11].

Recommendations [12] from an ABA task force for IRS guidelines on social welfare nonprofits and politics that same year were met with silence.

Even the IRS’s Political Activities Compliance Initiative, which investigated [13] complaints of charities engaged in politics — primarily churches — closed up shop in early 2009 after less than five years, without any explanation.

Both before and after the changes, the Exempt Organizations division has been a small part of the IRS, which is focused on collecting money and chasing delinquent taxpayers.

US capitol

IRS Employee Count in 2012

Rulings and Agreements, the division that handles applications of all nonprofits, accounted for less than 0.5 percent of all IRS employees in 2012.

Source: IRS Data Books [14], IRS Exempt Organizations Annual Report [15]

Of the 90,000 employees at the agency last year, only 876 worked in the Exempt Organizations’ division, or less than 1 in 1,000 employees.

Of those, 335 worked in the office that actually handles applications of nonprofits.

Most of those — about 300 — worked in Cincinnati, Streckfus estimates. The rest were at headquarters, in Washington D.C.

In Cincinnati, the employees’ primary job was sifting through the applications of nonprofits, making determinations as to whether a nonprofit should be recognized as tax-exempt. In a press release [16] Wednesday, the IRS said fewer than 200 employees were responsible for that work.

In 2012, these employees received 60,780 applications. The bulk of those — 51,748 — were from groups that wanted to be recognized as charities.

But the number of social welfare nonprofit applications spiked from 1,777 in 2011 to 2,774 in 2012. It’s impossible to say how many of those groups indicated whether they would engage in politics, or why the number of applications increased. The IRS said Wednesday that it “has seen an increase in the number of tax-exempt organization applications in which the organization is potentially engaged in political activity,” including both charities and social welfare nonprofits, but didn’t specify any numbers.

Total 501(c)(4) [17] Nonprofit Applications from 2002 to 2012

From 2011 to 2012, applications increased by more than 50 percent.

Source: IRS Data Books [14]

On average, one employee in Cincinnati would be responsible for going through roughly one application per day.

Some would be easy — say, a local soup kitchen. But to evaluate whether a social welfare nonprofit has social welfare as its primary purpose, the agent is supposed to use a “facts and circumstances” test. There is no checklist. Reviewing just one social welfare nonprofit could take days or weeks, to look through a group’s website, track down TV ads and so forth.

“You’ve got 60,000 applications coming through, and it’s hard to do that with the number of agents looking at them,” said Philip Hackney [18], who was in the IRS’s chief counsel office in Washington between 2006 and 2011 but said he wasn’t involved in the Tea Party controversy. “The reality is that they cannot do that, and that’s why you’re seeing them pick stuff out for review. They tried to do that here, and it burned them.”

As we have previously reported, last year the same Cincinnati office sent ProPublica [19] confidential applications from conservative groups. An IRS spokeswoman said the disclosures were inadvertent.

The Commissioner Speaks

Mark Everson, IRS commissioner for four years during the George W. Bush administration, said he believed the fact that the division is understaffed is relevant, but not an excuse for what happened. “The whole service is under-funded,” he pointed out.

And Dan Backer, a lawyer in Washington who represented six of the groups held up because of the Tea Party criteria, said he doesn’t buy the notion that low-level employees in Cincinnati were alone responsible.

“It doesn’t just strain credulity,” Backer said. “It broke credulity and left it laying on the road about a mile back. Clearly these guys were all on the same marching orders.”

The inspector general’s audit was prompted last year after members of Congress, responding to complaints by Tea Party groups, asked for it.

Like former officials interviewed by ProPublica, the audit suggests that officials at IRS headquarters in Washington were unable to manage their subordinates in Cincinnati. When Lois Lerner, the Exempt Organizations division director in Washington, learned [20] in June 2011 about the improper criteria for screening applications, she instructed that they be “immediately revised.”

But just six months later, Cincinnati employees changed [21] the revised criteria to focus on “organizations involved in limiting/expanding government” or “educating on the Constitution.” They did so “without executive approval.”

“The story people are overlooking is: Congress is complaining about underpaid, overworked employees who are not adequately trained,” said Bryan Camp, a former attorney in the IRS chief counsel’s office.

Assessment

In the end, after all the millions of anonymous money spent by some groups to elect candidates in 2012, after all [22] the groups [23] that said in their applications that they would not spend money to elect candidates before doing exactly that, after the Cincinnati office flagged conservative groups, the IRS approved almost all the new applications. Only eight applications were denied.

Source: http://www.propublica.org/article/how-irs-nonprofit-division-got-so-dysfunctional

Conclusion

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Seeking Director of Hospital Accounting

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For an East Coast Facility

By Kathy Williams kathyw@thorgroup.com
Resource Manager
Thor Group, Inc

Dear Dr. David E Marcinko,

Hello!  We are looking for a Director of Accounting for Hospital client located on East Coast. This is a Direct Hire position.  The position will oversee 3 Managers and 15 FTE’s.  This position will report to the VP of Accounting.

POSITION SUMMARY

The purpose of the position is to provide primary oversight, supervision and strategic direction to the General Accounting Department. This position ensures the accuracy of hospital’s consolidated financial statements in accordance with Generally Accepted Accounting Principles (GAAP) and system-wide policy.

Job Requirements

1. Previous Director / Manager experience in Hospital / Healthcare Accounting role
2. CPA or MBA required.
3. 7 to 10 years of experience.
4. The knowledge and ability to direct, control and supervise the activities of the General Accounting Department at a level generally acquired through 7 to 10 years of progressive experience in healthcare accounting
5. Experience formulating business and accounting policies and procedures
6. Extensive experience using computerized accounting systems and Microsoft Office.

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Assessment

If any ME-P reader is interested in this Director of Accounting position, please forward their resume to me at kathyw@thorgroup.com.  If you are not interested in this opportunity, perhaps you know someone who might be … please have them forward their resume to me!

Conclusion

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Moonlighting and Deducting Professional Expenses [video]

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By Andrew Schwartz CPA

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Andrew Schwartz

Content: Video (mp4) – 122.48MB
Title: Andrew Schwartz Webinar 1.16.13 Moonlighting and Professional Expenses

Video: http://www.screencast.com/t/Zksfdssln

Andrew D. Schwartz, CPA, received his B.S. in Accounting and Finance from the Wharton School at the University of Pennsylvania. Prior to forming Schwartz & Schwartz, P.C. in 1993, he worked at KPMG Peat Marwick, LLP.  Andrew is the author of many tax and financial articles on a variety of issues that impact healthcare professionals.  He is frequently quoted as a tax advisor on current topics in national publications, such as the Washington Post and Wall Street Journal.   Andrew is also the founder of The MDTAXES Network,  a national association of CPAs that specialize in the healthcare profession.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Recent Tax Law Changes and Basic Retirement Planning [video]

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Richard Schwartz CPA

Content: Video (mp4) – 105.32MB
Title: Richard Schwartz Webinar 1.23.13 Tax Changes and Retirement

Link: http://www.screencast.com/t/Huco7W8LOl

Richard S Schwartz, CPA, CVA, received a B.A. in Economics from Brandeis University in 1985 and an M.S. in Accounting from the Graduate School of Professional Accounting at Northeastern University in 1990.  Prior to joining his brother at Schwartz and Schwartz,  P.C. in 1993, he worked for the international accounting firm PricewaterhouseCoopers, LLP, in their Emerging Business Services Group.  Since joining Schwartz and Schwartz, P.C. he has worked with individuals providing tax expertise as well as small business owners providing both tax and accounting guidance to help their businesses grow.  In 2006, Rick earned the designation of Certified Valuation Analyst from the National Association of Certified Valuation Analysts (NACVA), which he uses to assist healthcare professionals in their evaluation of whether to purchase a practice.

Conclusion

In any case, early planning is the key to supporting both your kids’ futures and your retirement. Making logical college funding decisions, rather than emotional ones, creates a win/win for everyone.

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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How to Handle Incurred But Not Reported Health Insurance Claims [Webinar]

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Event Information
[Live Audio Conference – Webinar]
Dr. David E. Marcinko MBA
Presenter: Dr. David Edward Marcinko; MBA CMP™
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Conference Date: Tue, Apr 02, 2013
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Here’s How to Augment Bottom-Line Revenues by Understanding IBNR Healthcare Claims

One of most relevant financial issues of the PP-ACA and contemporary healthcare and medical reimbursement is known as Incurred But Not Reported (IBNR) healthcare claims. IBNR claims are an indirect result of prospective payments systems, the insurance industry and commercial risk contracts, and to some extent fee-for-service medicine. IBNR claims represent a risk and an opportunity for managed care companies, healthcare organizations, clinics, physicians and related medical providers alike.

Join this enlightening event presented by expert speaker Dr. David Edward Marcinko MBA CMP™ who will provide you detailed insights on IBNR claims so that you do not face any compliance risk and optimize your organization’s bottom line.

Here is a brief sample of some details you may learn:

  • Historical Review
  • What Is an IBNR Claim?
  • IBNR Problems for Healthcare Organizations
  • IBNR Claims — Management Volume and Consequences
  • Inadequate Cash Flows
  • Reserve Shortfalls and Fiscal Instability
  • Inaccurate Pricing
  • Administrative Cost Increases
  • Regulatory Sanctions
  • Managed Care Organization Exacerbation of IBNR Claims
  • IBNR from a Net Present Value Perspective
  • Tax Strategies for IBNRs
  1. IRS Rules and Regulations
  2. IBNR Tax Qualifications for Managed Care Organizations
  3. How Managed Care Organizations Intensify IBNRs
  4. How Does IBNR Affect Net Present Value?
  • IBNR Challenges and Solutions

1. Tax and Court Penalties

  • IRC Section 4958
  • Excess Benefit Definition
  • Taxes under Section 4958

2.  Tax Deductibility

  • Potential Solutions to the IBNR Challenge
  • IBNR Calculations and Methodology
  1. Actuarial Data Analysis
  2. Open Referral Analysis
  3. Historic Cost Analysis

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

Who should attend? All charge-master coordinators, coding personnel, billing and claims transaction personnel, internal auditing personnel; and financial and compliance personnel! And, all administrators, accountants, comptrollers, office managers, billing clerks and physician-executives, CFOs, CXOs and other interested parties.

IBNRs

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http://www.audioeducator.com/medical-coding-billing/ibnr_problems-040213.html

ORDER HERE FOR WEBINAR

A Hospitalist Asks a CPA – “what happened to my paycheck?”

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Law changes will result in smaller paychecks in 2013

DT&PA number of law changes go into effect in 2013 that will result in employees [like hospitalists, nurses, allied healthcare providers and some pHO members, etc] seeing smaller paychecks, including the expiration of the payroll tax cut, the increase in the Social Security taxable wage base, and the new 0.9% Medicare tax imposed on high wage earners.

The following law changes go into effect in 2013

  • The payroll tax cut, which temporarily lowered the Social Security withholding tax rate on wages earned by employees in 2011 and 2012 from 6.2% to 4.2%, has expired. Accordingly, employees will see a 2-percentage-point bump in the amount of Social Security tax withheld from their paychecks from 2012 to 2013.
  • The Social Security taxable wage base has increased by $3,600, from $110,100 to $113,700.
  • An additional 0.9% Medicare surtax is withheld from wages paid to an employee in excess of $200,000 in a calendar year.

Effect of these changes on paychecks

The following illustrations show the effect of these law changes on employees’ paychecks:

… Employees earning $50,000 in 2013 FICA wages will have $1,000 more in FICA taxes withheld ($50,000 × [6.2% – 4.2%]) than they would have in 2012, due to the 2-percentage-point increase in the Social Security tax rate.

… Employees earning $100,000 in 2013 FICA wages will have $2,000 more in FICA taxes withheld ($100,000 × [6.2% – 4.2%]) than they would have in 2012, due to the 2-percentage-point increase in the Social Security tax rate.

… Employees earning $300,000 in 2013 FICA wages will have $3,325.20 more in FICA taxes withheld than they would have in 2012. This includes $2,202 in additional Social Security taxes due to the increase in the Social Security tax rate ($110,100 × [6.2% – 4.2%]), $223.20 in additional Social Security taxes due to the increase in the Social Security taxable wage base ([$113,700 – $110,100] × 6.2%), and $900 in additional Medicare tax ([$300,000 – $200,000] × 0.9%).

… Employees earning $500,000 in 2013 FICA wages will have $5,125.20 more in FICA taxes withheld than they would have in 2012. This includes $2,202 in additional Social Security taxes due to the increase in the Social Security tax rate ($110,100 × [6.2% – 4.2%]), $223.20 in additional Social Security taxes due to the increase in the Social Security taxable wage base ([$113,700 – $110,100] × 6.2%), and $2,700 in additional Medicare tax ([$500,000 – $200,000] × 0.9%).

… Employees earning $1,000,000 in 2013 FICA wages will have $9,625.20 more in FICA taxes withheld than they would have in 2012. This includes $2,202 in additional Social Security taxes due to the increase in the Social Security tax rate ($110,100 × [6.2% – 4.2%]), $223.20 in additional Social Security taxes due to the increase in the Social Security taxable wage base ([$113,700 – $110,100] × 6.2%), and $7,200 in additional Medicare Tax ([$1,000,000 – $200,000] × 0.9%).

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jobs

Assessment

There is also a new 39.6% income tax withholding rate on high wage earners (previously, the highest withholding tax rate was 35%). This withholding rate is used for single taxpayers with annual wages greater than $402,200 and for married taxpayers with annual wages greater than $458,300.

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Conclusion

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Physician’s Personal Income Tax Review for 2013

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Are Dramatic Increases Ahead – For us All?

By Children’s Home Society of Florida Foundation

Following the November election, Congress will return for a “lame-duck” legislative session. Major decisions are needed on both taxes and spending. If Congress does not take action, there will be dramatic tax increases on January 1, 2013.

These potential changes include personal income taxes, long term capital gains tax, dividend tax, a new Medicare tax and the estate tax.

Personal Income Taxes

The major change in personal income taxes is that the rates will return to the 2003 schedule. The tax reductions passed in 2001 and 2003 are no longer applicable after 10 years. Therefore, tax rates are scheduled to increase. The table below shows the rates for 2012 and the new increased rates scheduled for 2013.

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2012 Rates 2013 Rates
10% 15%
15% 15%
25% 28%
28% 31%
33% 36%
35% 39.6%

Long-Term Capital Gains

The long-term capital gains rate for 2012 is 15%. Most investment property held more than one year qualifies for the 15% rate. In 2013, long-term capital gains will be taxed at 20%. However, the new 3.8% Medicare tax will apply to capital gains for higher-income persons. Their top rate will be 23.8%.

Dividend Taxes

Dividend taxes in 2012 are at a reduced level for payments from U.S. corporations and some foreign corporations. In 2012, most dividends are taxed at the 15% long-term capital gain rate. If the law is not changed, in 2013 they will be taxed as ordinary income. The top rate for dividends could be 39.6%. In addition, the 3.8% Medicare tax applies to dividends, producing a potential tax on dividends of 43.4% for higher-income taxpayers.

New Medicare Tax

The Patient Protection and Affordable Care Act (PPACA) creates a new Medicare tax in 2013. The tax is 3.8% on the amount of income that exceeds $200,000 for a single person and $250,000 for a married couple. The tax is generally applicable on interest, dividends, passive income from a business, sales of property and other income from financial instruments.

Fortunately, IRA and other pension income are not subject to the increased Medicare tax. However, this retirement income may increase your total income levels. If total income exceeds the $250,000 or $200,000 levels, then your IRA distributions may cause other investment and capital gain income to be subject to the Medicare tax.

Other Personal Tax Changes

There are other changes that will affect individuals. Under PPACA, individuals with incomes over $200,000 (single) or $250,000 (married couples), will pay an additional payroll tax of 0.9% on the excess amount. The personal exemption phase out and limitations on itemized deductions will be reinstated.

Finally, the medical expense deduction floor increases from 7.5% to 10% for most taxpayers. It is retained at 7.5% for persons age 65 and older. Only qualified medical expenses in excess of the floor are deductible.

Estate Tax

In 2012, the applicable exclusion amount for gift and estate taxes is $5.12 million. In addition, a spouse may pass away and transfer his or her available exemption to a surviving spouse. The surviving spouse therefore could have an estate exemption up to double the standard amount.

If there is no tax bill, the exemption reverts to $1 million plus indexed increases over the past decade. In addition, the current 35% estate tax rate will increase to a top rate of 55%, starting at a $3 million estate. Estates from the $1 million plus indexed amount to $3 million will pay tax at a reduced rate. The marital portability, or option to transfer your exemption to a surviving spouse, will not apply unless extended by Congress.

Editor’s Note: It is probable that there will be significant tax changes on January 1, 2013. Because the November legislative session is very short, Congress may change some provisions, but is not likely to change all of these tax rates. It will be important for all Americans to be in contact with their tax advisor to take appropriate action to reduce taxes in December of 2012.

Conclusion

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Practice Management: http://www.springerpub.com/product/9780826105752

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Hospitals: http://www.crcpress.com/product/isbn/9781439879900

Physician Advisors: www.CertifiedMedicalPlanner.org

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Update on Tax Inflation Adjustments in 2013

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Tax Bracket Changes Alert

By Children’s Home Society of Florida Foundation

Each year the IRS publishes multiple changes in various tax brackets and amounts that are increased to reflect the rate of inflation. In Rev. Proc. 2012-41; 2012-45 IRB 1 (18 Oct 2012), the IRS released the inflation-adjusted items for 2013.

There were moderate changes in many items. The following includes some of the more significant income tax adjustments:

1. Kiddie Tax – The exclusion for the Kiddie Tax for 2013 is increased to $1,000. For most children, net unearned income in excess of double the exclusion is taxed at the parent’s rate.

2. Savings Bonds for Higher Education – The phase-out for taxpayers receiving income from United States savings bonds used to pay for qualified higher education expenses will start at $112,050 for joint returns and $74,700 for other returns.

3. Medical Savings Accounts – For self-only coverage, the deductible may range from $2,150 to $3,200 and out-of-pocket expenses may not exceed $4,300. For family coverage, the deductible range is $4,300 to $6,450 and the expense limit is $7,850.

4. Token Benefits for Charitable Gifts – A low-cost item is defined as one that has a value of $10.20 or less. It should include the logo, colors or other identification of the charitable organization. Donors who make gifts in excess of $51 may receive a low-cost item and still qualify for a full deduction. A charity may give an insubstantial benefit to a donor provided that the benefit does not exceed 2% of the value of the gift or a maximum of $102.

Gift and Estate Taxes

There are also several provisions that affect gift and estate taxes:

1. Special Use Valuation – Under Sec. 2032A the qualified property may be reduced in value by up to $1,070,000.

2. Annual Exclusion – The present interest annual exclusion is increased to $14,000 in 2013.

3. Gifts to Non-Citizen Spouse – The applicable limit is $143,000.

4. Reduced Interest on Estate Tax – The installment estate tax “2% portion” for Sec. 6166 is $1,430,000.

Conclusion

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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
BLOG: www.MedicalExecutivePost.com
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Social Media for Accountants

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A Brief Audio Teaser

By @PhilBumann – #AcctgChat

Accountants are an important part of healthcare organizations and economies. Whether they work in private practice, corporate enterprise or government, accounts do have vital perspectives and understandings of the language of business.

The Accounting profession has been slow to adopt social and other digital software, but there are value propositions that these financial professionals ought to consider.

This SoundCloud is a brief tease of why accountants should intelligently consider the use of social media to further their professional development, find and strengthen connections, and even market (in a human way) their services.

Assessment

Not the sexiest topic, but even accountants can get something out of social media. The hashtag that has been around for years is #AcctgChat. Tell your accountant friends.

Link:  http://soundcloud.com/philbaumann/social-media-for-accountants

Conclusion

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AICPA Gift and Estate Requests

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The American Institute of Certified Public Accounts Recommend

[By Children’s Home Society of Florida Foundation]

At a September 13th hearing of the House Committee on Small Business, Subcommittee on Economic Growth, Tax and Capital Access, Jeffrey A. Porter of the American Institute of Certified Public Accounts (AICPA) discussed recommended tax provisions to be considered in November.

A section of his testimony covered proposed gift and estate tax provisions:

1.  Generation Skipping Tax – AICPA requests that the technical GST  modifications passed in 2010 be made permanent.

2.  Estate and Gift Exemption – The $5 million exemption with indexing should be made permanent.  If a lower exemption is passed, there should be no recovery of gift taxes for transfers made in 2011 and 2012 with the larger exemption.

3.  Uniform Exemption Amount – The gift, estate and generation skipping tax exemptions should remain uniform to avoid undue complexity.

4.  Marital Portability – The option to permit use of the exemption of a prior deceased spouse should be made permanent.  Marital portability should also extend to generation skipping tax.

5.  State Tax Credits – Congress should reinstate a state tax credit.  Under the current system, many states have “decoupled” and the different federal and state systems have created undue complexity.

6.  Tax Liquidity – Revise the installment payment of taxes under Sec. 6166 and extend it to all types of business interest.

7.  Gift and Estate Brackets – Do not create gift and estate “cliff” brackets.  For example, a 15% and a 30% bracket could create great differences for taxpayers with moderately different-sized estates.

Conclusion

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Is Federal Tax Reform Even Possible?

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More On the National Commission on Fiscal Responsibility and Reform

By Children’s Home Society of Florida Foundation

In 2010, the National Commission on Fiscal Responsibility and Reform considered possible options for reforming the income tax system. The bipartisan commission was co-chaired by former Senator Alan Simpson and former White House Chief of Staff Erskine Bowles.

Bowles-Simpson

The Bowles-Simpson tax solution involved a substantial reduction in the rates by limiting itemized deductions or converting them to tax credits.

In response to the Simpson-Bowles proposal and those from members of Congress and presidential candidates, the Senate Finance Committee leadership met with the Joint Committee on Taxation (JCT). Committee Chair Max Baucus (D-MT) and ranking member Orrin Hatch (R-UT) requested a study by JCT of various tax reform options.

The JCT experiment discussed options if various tax expenditures were repealed. Based on the JCT analysis, there was only a small reduction in rates possible. However, other commentators noted that the JCT study did not consider all of the base-broadening strategies.

In response to the JCT study, Simpson and Bowles issued a joint statement and noted, “Nothing in the JCT analysis changes our belief that it is possible for tax reform to reduce rates and produce additional revenues if policy makers are willing to make the tough choices to eliminate or scale back tax expenditures.”

The Simpson-Bowles proposal showed a potential to reduce rates to 8%, 14% and 23% if there is a drastic reduction in other tax expenditures. The nonpartisan Committee for a Responsible Federal Budget (CRFB) also responded to the JCT study.

The Committee for a Responsible Federal Budget Responds

The CRFB analysis indicated that the Simpson-Bowles commission strategy could work if there is partial or total elimination of tax expenditures. Another CRFB analysis also indicated that there was a 2005 Treasury study by the President’s Advisory Panel on Tax Reform that claimed a combination of base-broadening and rate reduction is possible.

Assessment

CRFB staff noted, “Although these two analyses differ in some respect, both show that the full elimination of all tax expenditures would allow the top tax rate to fall to 23% while still putting aside more than $1 trillion for deficit reduction.”

Editor’s Note: Your editor and this organization take no specific position on these tax reform strategies. The proposed major rate reduction plans all require significant limits on itemized deductions. Most strategies also tax capital gains at 28%. These changes will be difficult to pass during the major tax reform expected in 2013.

Conclusion

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Physician Advisors: www.CertifiedMedicalPlanner.org

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On Financial Institutional Fraud

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About Accounting Fraud

Definition: Any act or attempt to falsify an accounting statement for financial gain.

A clear example of accounting fraud is the act of deliberately overpricing a company’s assets in order to drive up its share price.

Another example is filing bankruptcy to avoid debt, rather than because of financial hardship.

One of the biggest accounting frauds in history occurred during the Enron scandal in 2001.

Conclusion

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Accounting for the Cost of US Health Care

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Your thoughts and comments on this ME-P are appreciated. What are your thoughts on the pre-reform trends and the impact of the recession?

Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Hospitals: http://www.crcpress.com/product/isbn/9781439879900

Physician Advisors: www.CertifiedMedicalPlanner.org

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CBO Director Elmendorf on Debt and Taxes

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A CBO Political Review

By Children’s Home Society of Florida Foundation

The nonpartisan Congressional Budget Office (CBO) is responsible for providing Congress with financial estimates for future budget and tax policies. CBO Director Douglas Elmendorf testified before the Budget Committee of the House of Representatives on June 6.

Elmendorf started by noting that the public federal debt for the past 40 years has averaged 38% of the economy. At the end of 2008, the public debt was 40% of gross domestic product (GDP). By the end of 2012, the public debt will be 70% of GDP.

Elmendorf pointed out that there are two major trends that will substantially impact the federal budget. First, there are 78 million baby boomers that will be retiring and receiving benefits from Social Security and Medicare. Second, the cost of healthcare for the past decade has been increasing more rapidly than the general inflation rate. He suggests that this increasing cost for healthcare is going to continue for the foreseeable future.

Elmendorf then offered two scenarios for the future. He called these the “baseline scenario” and the “alternative scenario.”

Baseline Scenario

The baseline scenario assumes that the current law will be applicable. On January 1, 2013, the existing tax cuts will expire. In addition to higher tax rates, many individuals will be subject to alternative minimum tax. Finally, the 3.8% tax under the Affordable Care Act will apply starting in 2013.

With the substantial tax increases under the baseline scenario, federal tax revenue increases to 24% of the economy by the year 2037. Elmendorf noted that this would be the highest level of taxation since World War II. Under this scenario, the increasing tax revenue permits debt to be reduced from the current 70% to 53% of GDP by 2037.

The alternative scenario assumes that Congress will follow the pattern of the past four years. The tax cuts enacted in 2001 and 2003 will be extended. The alternative minimum tax exemptions will be indexed. The $5.12 million applicable exclusion amount for gift and estate taxes will continue (with indexed increases in future years). Medicare payment rates for physicians will continue to increase. This last provision has been called the “Doc Fix” in Washington. Finally, federal budgets will continue with the same general provisions that exist today.

Under the alternative scenario, the increasing deficits lead to public debt of 90% of GDP by 2022. With the rising expenditures for the baby boom generation, the public debt increases to 200% of GDP by 2037.

Elmendorf Opines

Elmendorf noted that many economists believe that this large debt may lead to creation of fewer new jobs. He suggested that it will be necessary to increase revenue and decrease spending substantially from projected levels to avoid a large increase in the national debt. He did not specify how this should be accomplished.

Assessment

Chairman of the Federal Reserve Ben Bernanke also testified before Congress this week. He pointed out that January 1 is a “fiscal cliff” that could have great impact on the nation. Bernanke believes that the scheduled increase in taxes and reduction in spending should be spaced out over time to avoid a dramatic impact in January. However, he also declined to offer any advice on specific ways to increase taxes or cut spending.

Editor’s Note: These discussions in Congress are preparations for the legislative session that will occur following the November election. Congress is debating the combination of tax increases and budget cuts to pass this year. In addition, preparations are being made for a major tax reform act in 2013.

Conclusion

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

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Physician’s Understanding Payroll Tax Deductions

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Doctor as Employer or Employee [A Primer]

The Payroll and Tax Deductions infographic from Paycor takes an unbelievably dry topic and makes it interesting by visually walking someone through their paycheck. The design allows them to understand all of the different things that may come out prior to the final amount that makes it to their bank account.

Are We Un-Aware

Some American healthcare workers aren’t aware of the factors that determine how much is deducted from their paychecks, yet it’s important to have that understanding so you can speak up about any errors.

Typical Deductions

So what exactly is that payroll software deducting from your paycheck? Typical deductions include federal income tax, OASDI, Medicare tax, disability and state income tax. Your tax bracket will range from 10% to 35% depending on your amount of taxable income. Medicare tax rates will be different depending on whether you work for a hospital or medical company; or are self-employed in private practice.

State Level

At the state level, individual states handle taxes differently, with seven states charging all residents a flat tax rate and nine other states not collecting any income taxes at all.

Assessment

Use this calculator  to help determine the impact of changing your payroll deductions. You can  enter your current payroll information and deductions, and then compare them to  your proposed deductions. Try changing your withholdings, filing status or  retirement savings and let the payroll deduction calculator show you the [approximate] impact on your take home pay.

LinkPayroll Tax Calculator http://www.bankrate.com/calculators/tax-planning/401k-deduction-calculator-taxes.aspx#ixzz1x3EbwgTf

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Some Common Surgeries You Can’t Afford‏

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The Cost of Common Surgeries

By Muhammad Saleem

With a broad range of healthcare options, it is often difficult to understand just what your pocketbook can afford.

So, we took a look at the costs of the most common surgeries performed every year.

Source: Medical Billing and Coding

Conclusion

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A Social Security Owner’s Manual [Book Review]

A New Book by Jim Blankenship

By Staff Reporters

Who he is

Jim Blankenship is a Certified Financial Planner [CFP®], Enrolled Agent [EA] and the owner of Blankenship Financial Planning in Illinois.

Link: http://www.bfponline.com/

What he’s done

We’ve been following his blog Getting Your Financial Ducks In A Row for some time now. We also have referred to his online publication The IRA Owner’s Manual from time to time, with questions about inherited IRAs, etc. Jim knows his stuff.

Our Omission

Now, we admit that we’ve not paid much attention to Social Security because we are all still far from being eligible for it, and at the ME-P, we assume it won’t be here for us.

The Book

Nevertheless, when Jim published a new book A Social Security Owner’s Manual, we took the opportunity to learn more about Social Security.

And, we think, so should all medical professionals and their financial advisors.

Assessment

Jim provides expert guidance for retirement, education funding, and income tax issues, too. In addition to this all this, you’ll find Jim’s writings all around the internet, as he is a regular contributor to Forbes.com, TheStreet.com, and FiGuide. Several other sites also republish his work.

Conclusion                

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The Ins and Outs of Selling Your Business

Cost-Benefit Analysis and FMV for Entrepreneurs

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There comes a time in (almost) every entrepreneur’s life when the question of whether to sell his/her business inevitably arises.

So, if you need a proper cost-benefit analysis, take a look at the info-graphic below.

Assessment

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Conclusion

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Major Accounting Scandals of Interest to MDs and FAs

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Including Health South, AIG and Others

According to Wikipedia, the company HealthSouth was involved in a corporate accounting scandal in which its Chief Executive Officer, Richard M. Scrushy, was accused of directing company employees to falsely report grossly exaggerated company earnings in order to meet stockholder expectations.

The AIG bonus payments controversy began in March 2009, when it was publicly disclosed that the American International Group (AIG) was to pay approximately $218 million in bonus payments to employees of its financial services division.

 

Source:

Conclusion

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What It Costs to Hire and Train New Employees

H. R. Financial Information for Doctors, Clinics and Hospitals, etc.

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Sometimes, during slack periods in the economy, you have to reduce expenses by laying-off workers. Replacing them later, though, can be costly for your hospital HR department, clinic, medical practice or other business. Especially, for the knowledge based healthcare sector.

The Complete Financial Picture

So, whether it’s recruiting, on-boarding, extra salary, or something else, hiring new staff isn’t cheap. Make sure you understand the entire financial picture before you move forward with staffing changes.

 

Assessment

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Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

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Labor Day US Budget Deficit Estimated at $1.32 Trillion Dollars

Office of Management and Budget Report for 2011

By Children’s Home Society of Florida Foundation

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On September 1st, 2011, the White House Office of Management and Budget (OMB) released an updated estimate of the budget deficit. OMB Director Jacob Lew indicated that the deficit projections are now reduced.

OMB Projections

The February projection by OMB had been a deficit of $1.65 trillion for the current fiscal year. The new deficit number for fiscal year 2011 is $1.32 trillion. The larger number would be 10.9% of the economy. The reduced deficit number is still approximately 8.8% of the gross domestic product.

Lew gives credit to the Budget Control Act of 2011, signed by President Obama on August 2nd. Under the provisions of that act, there are substantial spending reductions.

Budget Committee Pleased

Senate Budget Committee Chair Kent Conrad (D-ND) was pleased with the lower budget numbers, but indicated there still is a long road to recovery. Referring to the Joint Select Committee on Deficit Reduction, he stated, “It is my hope the committee exceeds its $1.5 trillion target. It is also critical that the special committee considers measures to address the near-turn struggling economy.”

Assessment

In his address on September 8th 2011, President Obama is expected to discuss both the Joint Select Committee and long-term budget goals.

The OMB report also estimated the total debt by the end of 2011. The federal debt is a combination of debt held by the public and various government trust funds. The debt held by the public at the end of 2011 is estimated to be $10.26 trillion or 72% of the economy.

Conclusion

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Raise the Roof [A Look at the U.S. Debt Ceiling]

How the National Debt Affects You

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The Debt Ceiling and its’ impact on World Markets! Brought to you by mint.com in collaboration with columnfivemedia.com

Conclusion

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Health Dictionary Series: http://www.springerpub.com/Search/marcinko

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Learning from a Hospital Cash Flow Management Case Model

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The Mackenzie Hospital Clinic

[By Staff Reporters]


The Mackenzie Hospital Clinic was offered a private fixed-rate MCO contract that would increase revenues by $50,000 for the next fiscal year. The clinic’s 30% gross margin would not change because of the new business.

However, $10,000 would be added to overhead expenses for another part-time assistant. More importantly, the AR collection time would be lengthened to one year, or paid at the end of the contract period.

The cost of services provided for the contract represents the amount of money needed to service the patients produced by the contract. Since gross margin is 30% of revenues, the cost of services is 70% or $35,000.

The financial manager had to decide whether there would be enough internally generated cash flow to accept the contract.

The Financial Facts

The manager knew that adding the extra overhead would result in $45,000 of new spending money (cash flow) needed to care for the patients. He had to further refine his calculations by dividing the $45,000 total by the number of days the contract extends (i.e., 365 days) to determine that the new contract would cost about $123.29 per day of cash flow. Now, the financial manger had to ask: where would the money come from?

He was reluctant to turn away any business for the clinic, so decided he must develop other methods to generate the additional cash. He made the following suggestions:

  • extend AP timelines and reduce AR times; and/or
  • borrow with short-term bridge loans or a line of credit; and/or
  • discuss the situation with vendors for longer or more favorable terms; and
  • do not stop paying corporate taxes.

Key Issues:

1) Consider what changes the Mackenzie Hospital Clinic might implement to ensure that it regularly makes good cash management, budgeting, and risk projection decisions?

2) If the Mackenzie Hospital Clinic is successful and attracts more long-term managed care fixed contracts, the serious nature of the cash flow problem becomes apparent. For instance, adding another nine contracts would multiply the above example tenfold. In other words, the clinic would increase revenues to $1 million with the same 70% cost of services and $100,000 increases in operating overhead expenses.

3) How much free cash flow would be required?

[Using identical mathematical calculations, we determine that $450,000/365 days equals $1,232.88 per day of needed new cash flow.]

4) What happens if the contract only pays off at the end of the year?

Assessment

Any other thoughts?

Conclusion

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Tax Exempt Hospitals Granted IRS Filing Delay

Recent Developments on Form 990 and Schedule H

By Children’s Home Society of Florida Foundation

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In Announcement 2011-20; 2011-10 IRB 1 (23 Feb 2011), the IRS granted a three-month automatic filing extension for most tax-exempt hospitals.

Form 990 and Schedule H

Following the development of a new Form 990 Return for Charitable Organizations, the IRS published a comprehensive Schedule H for medical centers. With the passage of the Patient Protection and Affordable Care Act of 2010, both the IRS and many medical centers need additional time to properly prepare for filing of Form 990 with the Schedule H for medical centers.

As a result, the IRS indicates that the earliest permitted filing date for tax-exempt medical centers filing Form 990 and Schedule H will be July 1, 2010. This is the earliest filing date whether the filing is in paper form or electronic format.

Filing Extension Form 8868

For those medical centers with return due dates before August 15, 2011, there is an automatic three-month extension of time to file. This extension is available without filing Form 8868, Application for Extension of Time to File an Exempt Organization Return.

However, there may be new organizations that have not filed Form 990 Schedule H for tax year 2009. In this case, they may choose to file Form 8868 to clarify their intention to extend the deadline. If a medical center requires an additional three months to file, then it should file Form 8868.

Assessment

Finally, for those medical centers that qualify for this automatic extension, there will be no penalty if they file within the additional three-month period.

Conclusion

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Financial Planning and Risk Management Strategies for Physicians

Financial Planning Handbook for Physicians and Advisors

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Insurance Planning and Risk Management Strategies for Physicians and Advisors

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Remember Tax Deadline Day is April 18th 2011

Tax Emancipation Day is April 15th 2011

By Dr. Gary L. Bode MSA, CPA, PC

In the 2011 tax filing season, taxpayers have until Monday, April 18 to file their 2010 tax returns and pay any tax due. Emancipation Day, a holiday observed in the District of Columbia, falls this year on Friday, April 15. By law, District of Columbia holidays impact tax deadlines in the same way that federal holidays do; therefore, all taxpayers will have three extra days to file this year. Taxpayers requesting an extension will have until October 17 to file their 2010 tax returns.

Who Must Wait to File

For most taxpayers, the 2011 tax filing season starts on schedule. However, tax law changes enacted by Congress and signed by President Obama in December mean some people need to wait until mid to late February to file their tax returns in order to give the IRS time to reprogram its processing systems. The IRS recently announced February 14, 2011 as the start date for processing these delayed tax returns.

Some taxpayers, including those who itemize deductions on Form 1040 Schedule A, will need to wait until February 14, 2011 to file. This includes taxpayers impacted by any of three tax provisions that expired at the end of 2009 and were renewed by the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010 enacted December 17, 2010. Those who need to wait to file include:

  • Taxpayers Claiming Itemized Deductions on Schedule A. Itemized deductions include mortgage interest, charitable deductions, and medical and dental expenses as well as state and local taxes. In addition, itemized deductions include the state and local general sales tax deduction that was also extended and that primarily benefits people living in areas without state and local income taxes.
  • Taxpayers Claiming the Higher Education Tuition and Fees Deduction. This deduction for parents and students, covering up to $4,000 of tuition and fees paid to a post-secondary institution, is claimed on Form 8917. However, the IRS emphasized that there will be no delays for millions of parents and students who claim other education credits, including the American Opportunity Tax Credit extended last month and the Lifetime Learning Credit.
  • Taxpayers Claiming the Educator Expense Deduction. This deduction is for kindergarten through grade 12 educators with out-of-pocket classroom expenses of up to $250. The educator expense deduction is claimed on Form 1040, Line 23 and Form 1040A, Line 16.

Assessment

In addition to extending those tax deductions for 2010, the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act also extended those deductions for 2011 and a number of other tax deductions and credits for 2011 and 2012, such as the American Opportunity Tax Credit and the modified Child Tax Credit. The Act also provides various job creation and investment incentives, including 100% expensing and a 2% payroll tax reduction for 2011. Those changes have no effect on the 2011 filing season.

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Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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e-Filing Tax Season is Now Open

About IR-20 11-5

By Children’s Home Society of Florida Foundation

In a flurry of information letters, the IRS just announced that e-Filing is now open. According to IR-2011-5, the benefit of e-filing is that any taxpayer may receive faster refunds and ensure that their tax return is accurately reported.

The Commissioner Speaks

IRS Commissioner Doug Shulman stated, “IRS e-File is the best option for everyone, especially for people impacted by recent tax law changes. e-File ensures people can file accurately and get refunds quickly. With a new legislative e-File mandate for tax preparers, we anticipate that more tax return preparers will be using e-File this year and we urge people who prepare their own taxes to give it a try.”

Methods of Filing

The e-Filing may be accomplished through three different methods. Tax return preparers may e-File, commercial software may offer the option or there is IRS Free File. The Free File program is available on www.irs.gov. Taxpayers should click on “Free File” and will be permitted to access tax software to prepare their returns. Free File is available for taxpayers with 2010 adjusted gross income of $58,000 or less.

In the view of the IRS, Free File is “perfect for first-time filers, families looking to save money or older Americans adept at using the Internet.”

e-Signature Needed

Those who file electronically will also need an electronic signature. The electronic signature requires a five-digit personal identification number (PIN). There are three ways to obtain your PIN.

1. Self Select – You may use your tax software and select your own five-digit PIN. If you used a PIN in 2009, you may use that number. Alternatively, you may enter your adjusted gross income from your 2009 return to obtain your PIN. The PIN can be a five-digit number, but may not be all zeros.

2. Practitioner PIN – If you are using a paid tax preparer, you may sign IRS Form 8879 and authorize your paid preparer to generate your five-digit PIN. The paid preparer will retain Form 8879, but will not mail it to the IRS.

3. IRS Issue of PIN – If you do not know your 2009 adjusted gross income or your 2009 PIN, the IRS will request a temporary Form 8879(EFP). The Electronic Filing PIN may be obtained using your tax preparation software or through http://www.irs.gov. With the Electronic Filing PIN you may complete your electronic signature.

Military

If your spouse is a military person serving in a combat zone, you are permitted to use the self-select PIN. You will need to obtain IRS Form 8453, attach a Power of Attorney and mail it to the IRS.

Assessment

This program may also be ideal for FAs, medical students, interns, residents, fellows, nurses, new practitioners and all allied medical professionals who qualify.

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Hospitals & Healthcare Organizations

FOREWORD 

David Nash MD MBA

It should come as no surprise to our readers that the nation faces a financial crisis in healthcare. 

Currently, the United States spends nearly 16% of the world’s largest economy on providing healthcare services to its citizens.  Another way of looking at this same information is to realize that we spend nearly $6,500 per man, woman, and child per year to deliver health services.  And, what do we get for the money we spend?  

This is an important policy question and the answer is disquieting.  Although the man and woman on the street may believe we have the best health system in the world, on an international basis, using well-accepted epidemiologic outcome measures, our investment does not yield much!  

According to information from the World Health Organization and other international bodies, the United States of America ranks somewhere towards the bottom of the top fifteen developed nations in the world, regarding the outcome in terms of improved health for the monies we spend on healthcare. 

From a financial and economic perspective then, it appears as though the 16% of the GDP going to healthcare may not represent a solid investment with a good return. 

It is then timely that our colleagues at the Institute of Medical Business Advisors, Inc. have brought us their greatest work: Healthcare Organizations: [Financial Management Strategies]; a two-volume set of nearly 1,200 pages.  

Certainly, this comprehensive manual, and its quarterly updates, is not for everyone. It is intended only for those executives and administrators who understand that clinics, hospitals and healthcare organizations are complex businesses, with advances in science, technology, management principles and patient/consumer awareness often eclipsed by regulations, rights, and economic restrictions.  Navigating a course where sound organizational management is intertwined with financial acumen requires a strategy designed by subject matter experts. Fortunately, Healthcare Organizations: [Financial Management Strategies] provides that blueprint.

Allow me to outline its strengths and put it into context relative to other policy works around the nation. 

For nearly two years, the research team at iMBA, Inc., has sought out the best minds in the healthcare industrial complex to organize the seemingly impossible-to-understand strategic financial backbone of the domestic healthcare system.   

The periodical print-guide is organized into two volumes in order to appropriately cover many of the key topics at hand.  It has a natural flow, starting with Competitive Strategy and moving through Asset Management, Cost Management, and Claims Management.  

Volume 1, most especially the Competitive Strategy section, has broad appeal and would be of interest to most people in the health insurance industry, including managed care, hospitals, third party benefit managers and the pharmaceutical industry. 

Volume 2 continues in a well-organized theme, progressing from Risk Management and Compliance to Health Policy, Information Technology, and most importantly, Financial Benchmarking. 

Volume 2 would be of greater interest to those in the policy sphere, both in Washington, DC, in state legislatures, consulting companies, medical colleges, and graduate schools of health administration, public health and related fields. Every day colleagues ask me to help explain the seemingly incomprehensible financial design of our healthcare system.  These two volumes would go a long way toward answering their queries. 

I also believe both volumes would be appropriate as text books and reference tools in graduate level courses taught in schools of business, public health, health administration, and medicine. 

In my travels about the nation, many faculty members would also benefit from the support of these two volumes as it is nearly impossible, even for experts in the field, to grasp all of the rapidly evolving details. 

On a personal level, I was particularly taken with the Competitive Strategy section and it brought back enjoyable memories of my work nearly twenty-five years ago at the Wharton School, on the campus of the University of Pennsylvania.  There, I was exposed to some of the best economic minds in the healthcare business and it was a watershed event for me forming some of my earliest opinions about the healthcare system. 

I also very much enjoyed the section on Health Policy, most especially, the section on the Sarbanes-Oxley Act for hospitals and healthcare organizations.  I believe we have not fully embraced the comprehensive nature of Sarbanes-Oxley on the hospital side, and envision a day when hospital boards will be held accountable for quality, in the same way that proprietary corporations are held accountable for the strength and comprehensiveness of their audit reports. Simply put, Sarbanes-Oxley for quality is around the corner and this volume goes a long way toward preparing our basic understanding of the Act and its potential future implications. Congratulations to all authors, but this one in particular deserves specific mention. As a board member for a major national integrated delivery system, I am happy that there appears to be a greater interest in the intricacies of Sarbanes-Oxley on the healthcare side of the ledger. 

In summary, Healthcare Organizations: [Financial Management Strategies] represents a unique marriage between the Institute of Medical Business Advisors, Inc., and its many contributors from across the nation.  As its mission statement suggests, I believe this massive interpretive text carries out its vision to connect healthcare financial advisors, hospital administrators, business consultants, and medical colleagues everywhere. It will help them learn more about organizational behavior, strategic planning, medical management trends and the fluctuating healthcare environment; and consistently engage everyone in a relationship of trust and a mutually beneficial symbiotic learning environment.  

Editor-in-Chief and healthcare economist Dr. David Edward Marcinko and his colleagues at the Institute of Medical Advisors, Inc should be complimented for conceiving and completing this vitally important project. There is no question that Healthcare Organizations: [Journal of Financial Management Strategies] will indeed enable us to leverage our cognitive assets and prepare a future generation of leaders capable of tackling the many challenges present in our healthcare economy.  

My suggestion therefore, is to “read it, refer to it, recommend it, and reap.”  

David B. Nash MD, MBA
The Dr. Raymond C and Doris N. Professor and
Chair of the Department of Health Policy
Jefferson Medical College
Thomas Jefferson University
Philadelphia, Pa, USA
 

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The New 2011 Income Tax Rates

A “First-Look” for Medical Professionals

By Children’s Home Society of Florida Foundation

In Rev. Proc. 2011-12, 2011-2 IRB 1 (21 Dec 2010)

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TABLE 1 – Section 1(a) – Married Individuals Filing Joint Returns and Surviving Spouses

If Taxable Income Is:   The Tax Is:
Not over $17,000   10% of the taxable income
Over $17,000 but
not over $69,000
  $1,700 plus 15% of
the excess over $17,000
Over $69,000 but
not over $139,350
  $9,500 plus 25% of
the excess over $69,000
Over $139,350 but
not over $212,300
  $27,087.50 plus 28% of
the excess over $139,350
Over $212,300 but
not over $379,150
  $47,513.50 plus 33% of
the excess over $212,300
Over $379,150
 
  $102,574 plus 35% of
the excess over $379,150

TABLE 2 – Section 1(b) – Heads of Households

If Taxable Income Is:   The Tax Is:
Not over $12,150   10% of the taxable income
Over $12,150 but
not over $46,250
  $1,215 plus 15% of
the excess over $12,150
Over $46,250 but
not over $119,400
  $6,330 plus 25% of
the excess over $46,250
Over $119,400 but
not over $193,350
  $24,617.50 plus 28% of
the excess over $119,400
Over $193,350 but
not over $379,150
  $45,323.50 plus 33% of
the excess over $193,350
Over $379,150
 
  $106,637.50 plus 35% of
the excess over $379,150

TABLE 3 – Section 1(c) – Unmarried Individuals (other than Surviving Spouses and Heads of Households)

If Taxable Income Is:   The Tax Is:
Not over $8,500   10% of the taxable income
Over $8,500 but
not over $34,500
  $850 plus 15% of
the excess over $8,500
Over $34,500 but
not over $83,600
  $4,750 plus 25% of
the excess over $34,500
Over $83,600 but
not over $174,400
  $17,025 plus 28% of
the excess over $83,600
Over $174,400 but
not over $379,150
  $42,449 plus 33% of
the excess over $174,400
Over $379,150
 
  $110,016.50 plus 35% of
the excess over $379,150

TABLE 4 – Section 1(d) – Married Individuals Filing Separate Returns

If Taxable Income Is:   The Tax Is:
Not over $8,500   10% of the taxable income
Over $8,500 but
not over $34,500
  $850 plus 15% of
the excess over $8,500
Over $34,500 but
not over $69,675
  $4,750 plus 25% of
the excess over $34,500
Over $69,675 but
not over $106,150
  $13,543.75 plus 28% of
the excess over $69,675
Over $106,150 but
not over $189,575
  $23,756.75 plus 33% of
the excess over $106,150
Over $189,575
 
  $51,287 plus 35% of
the excess over $189,575

TABLE 5 – Section 1(e) – Estates and Trusts

If Taxable Income Is:   The Tax Is:
Not over $2,300   15% of the taxable income
Over $2,300 but
not over $5,450
  $345 plus 25% of
the excess over $2,300
Over $5,450 but
not over $8,300
  $1,132.50 plus 28% of
the excess over $5,450
Over $8,300 but
not over $11,350
  $1,930.50 plus 33% of
the excess over $8,300
Over $11,350
 
  $2,937 plus 35% of
the excess over $11,350

6. Child Credits — The credit per child is $3,000.

7. Standard Deduction — For a married couple, the standard deduction is $11,600. Single persons have a standard deduction of $5,800.

8. Aged or Blind — The additional deduction for an aged or blind person is $1,150. It is $1,450 for a single person who is not a surviving spouse.

9. Personal Exemptions — The personal exemption in 2011 will be $3,700.

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A Brief History of the ME-P

Enhancing Health 2.0 Connectivity for Physicians and their Financial Advisors

By Staff Reporters

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The Medical Executive-Post [ME-P] was launched in 2006, and was a resounding success. We first went online in October 2006 with an overwhelmingly positive response. Readers and subscribers alike reported finding it a credible source of information with more than half saying the information was far new to them. Our parent company remains: www.MedicalBusinessAdvisors.com

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US Budget Deficits Require Both Spending Cuts and Tax Increases

The CRFB Speaks

By Children’s Home Society of Florida Foundation

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The nonpartisan Committee for a Responsible Federal Budget (CRFB) has published a release on October 20 that discusses some of the options to tackle the federal deficit. According to a Bloomberg News poll, there are two major issues that are foremost in the minds of voters as they go to the polls on November 2nd. The first is jobs and the US economy. The second issue focuses on federal finances and the budget deficit.

CFRB Suggestions

The CFRB suggests that there are four potential options for reducing expenditures and one for increasing revenue.

1. Fraud, Waste and Abuse – A favorite comment of all political candidates is that he or she will reduce fraud, waste and abuse. While there may be some savings, this historically has been a fairly modest part of actual deficit reduction.

2. Strengthen Social Security – Congress will need to address methods for strengthening Social Security. The Social Security program used to run a substantial surplus each year. However, in 2010 the federal deficit will total approximately $40 billion. That is, the amounts received by Social Security will be $40 billion lower than the amounts distributed for benefits.

Social Security

By 2020, Social Security could be running a $100 billion deficit. Social Security Trustees have stated, “The projected trust fund shortfalls should be addressed in a timely way so that necessary changes can be phased in gradually and workers can be given time to plan for them.”

3. Healthcare – The Congressional Budget Office notes that the current healthcare programs could require nearly one-half of the federal budget by 2030 or 2040. Therefore, there will need to be further changes in healthcare in order to make the program fiscally sustainable.

4. Defense – Defense expenditures in 2010 were 4.7% of Gross Domestic Product (GDP). This amounted to $692 billion. Defense Secretary Gates has acknowledged that there may be opportunities to eliminate some weapons systems and reduce expenditures.

5. Increased Taxes – The CFRB release states, “It is very difficult to lay out a credible deficit plan that would not increase taxes. It is also very difficult to develop a comprehensive plan that would not raise taxes on families making less than $250,000 per year.” The potential for increased taxes has focused on income taxes, capital gains taxes, estate taxes and a consumption tax such as a gas tax or a value added tax.

Assessment

The Fiscal Commission appointed by President Obama is expected to issue a report in December that discusses these issues.

Editor’s Note: Your editor and this organization take no position with respect to the many financial and tax options that are available to Congress. This information is offered as a public service to our readers.

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On the US Budget Deficit in 2010

Now North of $1.3 Trillion Dollars

By Children’s Home Society of Florida Foundation

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The federal fiscal year for 2010 concluded on September 30th. The Office of Management and Budget and Department of Treasury have released the official figures for fiscal year 2010. The deficit was $1.294 trillion.

Geithner Speaks

Treasury Secretary Tim Geithner noted that the cost of the financial rescue of banks and automotive companies was lower than expected. He stated, “By carefully managing the emergency initiatives to stop the financial panic and by accelerating our exit from those investments, we have significantly lowered the cost to taxpayers, bringing the costs of the financial rescue down by more than $240 billion this year.”

TARP

The Troubled Asset Recovery Program (TARP) cost to Treasury was $9 billion in 2010. During this year, the Federal Government also spent $52.6 billion to support the housing industry through troubled lenders Freddie Mac and Fannie Mae.

Deficit Concerns

The deficit declined slightly from 10% in 2009 to 8.9% of the 2010 gross domestic product (GDP). Tax receipts for 2010 were $2.16 trillion or 14.9% of the economy. Government expenditures were $3.45 trillion or 23.8% of the economy. Senate Budget Committee Ranking Minority Member Judd Gregg (R-NH) expressed concern about this deficit and noted, “These abrupt and shocking changes in our fiscal situation cannot be dismissed as “inherited” problems when the tally of the majority’s spending spree has climbed into the trillions.”

Assessment

The Fiscal Commission appointed by President Barack Obama is developing a plan to reduce the deficit. The target for the Fiscal Commission is to reduce the current 8.9% GDP deficit down to 3% of GDP within five years.

Editor’s Note: Your editor and this organization take no position with respect to the many financial and tax options that are available to Congress. This information is offered as a public service to our readers.
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Healthcare Organizations: www.HealthcareFinancials.com

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About D’Alessio & Tocci LLP, CPAs

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New Partner Onboard

By Staff Reporters

Dear ME-P Readers and Subscribers,

It is with great pleasure that the firm of D’Alessio & Tocci, LLP [Certified Public Accountants],
welcomes its newest partner M. Howard Pell, CPA.

About M. Howard Pell CPA

Mr. Pell has over 30 years experience in public accounting.  He was formally Director of Tax for PKF New York, NY.  The company will now be called D’Alessio Tocci & Pell, LLP Certified Public Accountants, and will continue to operate out of its current address:

245 Fifth Ave
Suite 602
New York, NY 10016
with a second address at:
923 Warren Parkway
Teaneck, NJ 07666

Assessment

Visit: http://dalecpa.com/

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners(TM)

 

 

Understanding the 2010 Estate Tax Basis Problems

AICPA Tax Basis Issues

By Children’s Home Society of Florida Foundation

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At a July 27, 2010 conference sponsored by the American Institute of Certified Public Accountants, Treasury Representative Catherine Hughes discussed the basis issues that are arising concerning 2010 decedents.

2010 Estate Tax Repeal

While the estate tax is repealed during 2010, under Internal Revenue Code Sec. 1022 there are new and complex rules on basis adjustments. For large estates, a majority of the assets will be transferred with a “flow through” of the basis. That is, the heirs will be able to use the basis of the decedent in any future sales for the purpose of reporting capital gain. Because many decedents have few or no records of the basis, it is quite possible that these heirs will pay capital gains tax on the full value of future sales.

Allowances for Basis “Step-Up”

However, there are allowances for a basis “step-up” of $1.3 million. In addition, for a surviving spouse, the basis step-up can be $3 million. The step-up in basis cannot be greater than the fair market value of the applicable property. Determining how to allocate the adjusted basis step-up in an estate has caused great concern among estate planning attorneys and CPAs. Treasurer Representative Hughes stated, “I anticipate there will be a lot of mistakes where there isn’t an affirmative allocation” of basis. Treasury is studying the situation and may issue guidance with recommended default allocation rules.

Assessment

While Congress continues to debate estate tax law and, therefore, has not made any decision on a potential retroactive estate tax, the nonpartisan Tax Policy Center this week released an estimate of the potential number of 2011 taxable estates. If a $1 million exemption is applicable in 2011, there will be an estimated 43,500 estates subject to tax. If the 2009 exemption amount of $3.5 million per decedent is applicable next year, the number of taxable estates is reduced to $650,000.

Editor’s Note: The discussion in Washington on the practical aspects of allocating the basis step-up now suggests that there may not be a mandatory retroactive estate tax law. With the pending election, it now seems very likely that Congress will not act on the estate tax before December. The Senate continues to have great difficulty developing a plan acceptable to 60 Senators and to the House of Representatives. However, Senators now recognize that a $1 million exemption and tax on 43,500 estates will impact a large number of middle-class children and other beneficiaries. Therefore, it seems quite likely that a compromise should be passed in December. However, as the AICPA basis adjustment discussion suggests, this compromise is now less likely to mandate an extension of the 2009 exemption for 2010. As a result, attorneys and CPAs will need to address the very complex and uncertain basis adjustment problems for 2010 estates.

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A Voting Poll on eMRs as a Balance Sheet Item?

A Real or Economically Stimulated Need?

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Many doctors – and their CPAs – view an in office electronic medical record [eMR] system as a balance sheet item to purchase for a medical practice; much like any other piece of business equipment or medical instrumentation.

Of course, ARRA and the HITECH Acts also treat eMRs like an asset that the Federal government can motivate doctors to purchase thru their “meaningful use” economic stimulus and rebate program … sort of a social engineering fiscal health policy for medical professionals. 

And so, the question for doctors really is: do you believe in eMRs as a stand-alone item above and beyond their rebate earning capacity?

THINK “cash for clunkers”, or the first time home buyer “mortgage credit rebate program”.

In other words, sans this Federal economic rebate program externality, would you purchase an eMR system despite the HITECH Act? Will you purchase one once the rebate period has expired. Are eMRs a depreciating or appreciating asset?

Please opine with your vote!

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Price Adjustment Medical Costing

End of Life Care Programs

By Dean G. Smith PhD and the Accounting Workgroup

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An alternative to traditional medical resource costing is ‘price adjustment’.  In an international context, this method compares the monetary estimates of resource used, after adjustment for price level differences between countries and over time to standard current values.  In order to attempt comparisons of different cost estimates, analysts must be at least certain as to what items are included in costs and whether costs are being based on opportunity costs, charges, or average costs.

Medicare Cost-to-Charge Ratios

In the US context, the price adjustment approach underlies the use of Medicare Cost-to-Charge Ratios (CCR).  Costs are estimated using the CCR approach by multiplying the number of units of each procedure billed by its Medicare charge and CCR and then summing these costs.  Some health care organizations have begun to invest in sophisticated, computerized cost-accounting systems (CAS) that are capable of providing procedure-specific cost estimates, usually based on relative value units, but these systems often rely on billing data to obtain service units.

The Studies

A couple of studies have used a combination of CCR and CAS to estimate costs (costs to the institution – costs to Medicare are the Medicare charges). In both studies, the CAS was for hospital costs only, with Medicare reimbursement (not institution costs) being used for professional services by using relative value units and a conversion factor from the Medicare Fee Schedule.

Inaccuracy

To overcome the issues of inaccurately (or non-transparently) measuring resource units, it has become more common in clinical trials (a distinct sub-set of possible study methods) to develop case report forms to capture all study end points, including medical service use.  These studies then translate medical service use into costs using standard charges or costs, or a series of representative data sets of charges or costs, to the resource units. These methods have become so common that all submissions to the British Medical Journal are required to document methods using a 35-part form that includes items such as: part 16) Quantities of resources are reported separately from their unit costs; part 17) Methods for the estimation of quantities and unit costs are described; part 18) Currency and price data are recorded; and part 19) Details of currency of price adjustments for inflation or currency conversion are given.

Following these guidelines, a Michigan-based study is collecting data through a resource use data collection form and applying to standard costs per unit of service to produce costs for a RWJ-sponsored palliative care program.

Not the Usual Medical Care

There are a few studies on the costs and cost-effectiveness of end of life programs or the impact of serious illness on patient’s families.  Those studies that do evaluate end of life care programs are usually small in scope, compare the end of life program (e.g., as in hospice) to “usual care,” or have no comparison group, or do not evaluate the costs of the program.

Assessment

Criticisms of studies of only one medical resource/cost item often surround the total costs of care – suggesting that the use of focused studies may not be well received.  In fact, even studies that capture the total costs of medical care services are criticized for not capturing the indirect costs – family expenses on end of life care are substantial and are not factored into most cost-analysis studies. Very few studies try to capture all costs to enable adjustments of costs for selection processes that may influence resource use.

Editor’s Note: Accounting workgroup members:

1 Stephen Seninger PhD: Professor, Bureau of Business and Economic Research, University of Montana, Missoula, MT

2 Ira Byock, MD: Director, Promoting Excellence in End of Life Care, Practical Ethics Center, University of Montana, Missoula, MT

3 Carol D’Onofrio,DrPH: Research Director, Sutter Visiting Nurse Association & Hospice, Piedmont, CA

4 Jennifer Elston-Lafata PhD: Director, Center for Health Services Research, Henry Ford Health System, Detroit, MI 

5 Joe Engelhardt PhD: Research Coordinator, Life Institute VA Medical Center, Albany, NY

6 Carol A. Lockhart PhD: Project Director, Phoenix Care, Hospice of the Valley, Phoenix, AZ

7 Steven H. Miles MD: Professor of Medicine, Center for Bioethics, University of Minnesota, Minneapolis, MN

8 Herbert A. Rosefield: Corrections Care Consultant, Volunteers of America, Raleigh, NC

9 Anne M. Wilkinson PhD:Senior Health Policy Analyst, RAND, Arlington, VA

10 Barbara Volk-Craft RN, MBA  Program Manager: Phoenix Care, Hospice of the Valley, Phoenix, AZ

11 Dean G. Smith, PhD  Professor and Chair, Department of Health Management & Policy, University of Michigan, Ann Arbor, MI

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Will Fiscal Commission Consider a VAT to Reduce the Federal Deficit?

Moro on the National Commission on Fiscal Responsibility and Reform

By Robert Giese
bob.giese@chsfl.org

The National Commission on Fiscal Responsibility and Reform [NCFRR] continues to develop a comprehensive proposal to address the federal deficit. It has invited comments from members of Congress, leaders of all types of American organizations and private individuals.

We invite ME-P contributions, as well.

A Four- Point Proposal

James Q. Riordan, Sr. sent a letter this week to co-chair Alan K. Simpson, the former Senator from Wyoming. Mr. Riordan made four basic points about the fiscal problems and suggested a Value Added Tax (VAT) as a solution.

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First, he indicated that there is too much “unaffordable spending.” Even with limited spending growth, the income tax cannot be sufficiently increased to pay for current and future proposed spending without doing damage to the economy and increasing unemploymen.

Second, Riordan claims that the only potential solution is a VAT. However, because the VAT is a tax on consumption and would have great impact on middle and lower incomes, it needs to be accompanied by a progressive income tax.

His third point is that the new income tax would need to be very simple. In his view, there would be no deductions for home mortgage interest, charitable gifts or medical expenses.

Fourth, he would tax all income only once. There would presumably not be a corporate-level tax or an estate tax under this theory.

Inadequate Staff Resources

As the fiscal commission considers the options for reducing spending and increasing taxes, it has indicated that the current staff resources are inadequate. In response to a request by the commission, Senate Majority Reid sent a letter this week to the White House and requested additional staff support. The White House indicated that it will be pleased to “work with him” to provide additional assistance.

At a hearing on the financial challenges, Senator George Voinovich (R-OH) noted that the commission is under great pressure to develop an effective plan. He stated, “If we don’t get something out of that commission, we are over the cliff.”

Assessment

Senate Budget Committee Chair Kent Conrad (D-ND) was the prime supporter of the commission. He stated, “This is not a time to impose austerity in my judgment.” However, he indicated that austerity will be necessary in the future, and that budget cuts and tax increases “must be imposed in a way that is convincing.”

Editors Note: For now, we take no specific position on VAT or other tax and spending recommendations by the Fiscal Commission. This information is offered because potential Fiscal Commission plans may affect many of our ME-P physician readers, subscribers, consultants and advisors.

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Bank Deals Similar to Goldman Sach’s Gone Awry

Other Major Banks Participated, Too?

By Marian Wang, ProPublica – April 16, 2010 1:36 pm EDT

As you may have heard, or read on this ME-P, Goldman Sachs is being sued for fraud [1] by the Securities and Exchange Commission [2] for allegedly misleading investors about a deal that Goldman helped structure and sell. In the civil suit, the SEC specifically faulted Goldman for failing to disclose that a hedge fund was helping create the investment while betting big the deal would fail.

According to the SEC, Goldman Sachs knew about the hedge fund’s bets, knew it played a significant role in choosing the assets in the portfolio, and yet did not tell investors about it. (Goldman Sachs has called the SEC’s accusations “completely unfounded in law and fact.” And in another more detailed statement [3], it said it “did not structure a portfolio that was designed to lose money.”) 

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In ProPublica

As we reported at ProPublica last week, many other major investment banks were doing a similar thing [4].

Investment banks including JPMorgan Chase [5], Merrill Lynch [6] (now part of Bank of America), Citigroup, Deutsche Bank and UBS also created CDOs that a hedge fund named Magnetar was both helping create and betting would fail. Those investment banks marketed and sold the CDOs to investors without disclosing Magnetar’s role or the hedge fund’s interests.

Here is a list of the banks that were involved [7] in Magnetar deals, along with links to many of the prospectuses on the deals, which skip over Magnetar’s role. In all, investment banks created at least 30 CDOs with Magnetar, worth roughly $40 billion overall. Goldman’s 25 Abacus CDOs — one of which is the basis of the SEC’s lawsuit — amounted to $10.9 billion [8].

One reporter Jake Bernstein explained the investment banks’ disclosure failures on Chicago Public Radio’s This American Life [9]:

On the Magnetar Hedge Fund

The role of Magnetar, both as equity investor and in their bets against the very CDOs they helped create were not disclosed in any way to investors in the written documents about the deals. Not the marketing materials, not the prospectuses, not in the hundreds of pages that an investor could get to see information about the deal was it disclosed that it was in fact Magnetar who’d helped create the deal, and who’d bet against.

That is, of course, along the lines of what the SEC is suing Goldman Sachs for now. The SEC’s suit also says CDOs like the ones Goldman built “contributed to the recent financial crisis by magnifying losses associated with the downturn in the United States housing market.”

Notably, the SEC did not sue the hedge fund [10] involved in Goldman’s Abacus deals — Paulson & Co. — or its manager, John Paulson. Instead, it’s going after Goldman. And as we pointed out in our reporting, there’s no evidence that what Magentar did was illegal [11].

Assessment

We’ve called the major banks involved in Magnetar CDO deals to see if they were concerned about similar lawsuits. Thus far, Bank of America, Citigroup, Deutsche, Wells Fargo (which bought Wachovia) and UBS have responded and have all declined our requests for comment. Here is Magnetar’s response [12] to our original reporting.

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Tim Geithner’s Letter Shows Opposition to Fixed Capital Requirements for Banks

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In Financial Reform Bill

By Marian Wang, ProPublica – April 2, 2010 2:10 pm EDT

Remember how earlier this week, in a post about financial reform and liquidity requirements [1], we noted how vague [2] Treasury Secretary Tim Geithner was being with The New York Times about setting hard and fast rules about how much cash should be required to hold?

Here’s what we excerpted from the Times on Tuesday: Mr. Geithner insists that if there is one change that needs to be made to the banking system to protect it against another high-stakes bank run like the one that claimed the life of Lehman Brothers, increasing capital requirements is it.

Bank

Pinning Down Geithner

But try pinning down Mr. Geithner, or anyone else in the Beltway, on how much capital banks should be required to keep, or even how the word “capital” should be defined, and certainties disappear.

Turns out he had a lot more to say on the subject than what he told the Times. Mike Konczal [3], blogging for Ezra Klein, unearthed a letter Geithner sent to a lawmaker in January, explaining his hesitancy—really, his opposition—to setting fixed capital requirements in current financial reform proposals. From the letter [4]:

Although the Administration strongly supports imposing a simple, non-risk-based leverage constraint on banks, bank holding companies, and other major financial firms, we do not believe that codifying a specific numerical leverage requirement in statute would be appropriate.

Assessment

So when Geithner said, “We have not made a judgment yet on the number,” what he really was thinking—if this letter is any indication—is that as far as financial reform legislation itself goes, he doesn’t want a number, period. And when it comes to actually imposing tighter capital requirements on financial institutions, he wants the Treasury, the Fed or some combination of regulators to have a free hand to pick and change the number. In other words, pretty close to the way things are now.

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Lehman Brothers Autopsy

Repo 105 and Why Auditors Have Some “Splainen to Do”

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[By Staff Reporters]

According to ProPublica on March 16, 2010 on 9:07 am EDT, a post-mortem report on Lehman Brothers revealed a shady accounting maneuver through which the bank hid its financial troubles for nearly a decade.

Pleading Ignorance

In this repot, Marian Wang takes a closer look at the parties pleading ignorance and the auditors who admit they knew, but insist they did no wrong.

Assessment

Link: http://www.propublica.org/ion/bailout/item/lehman-brothers-autopsy-repo-105-explained-auditors-in-trouble

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Risk Assessment of Medical Coding Services

Office of Inspector General

By Pati Trites MPA CHBC, with Staff Reporters

Any readers considering enrolling in a medical coding school should read this ME-P.

Why? Because the written policies and procedures concerning proper health insurance and Medicare coding should reflect the current reimbursement principles set forth in applicable statutes, regulations and Federal, State or private payer health care program requirements, and should be developed in tandem with organizational standards.

Furthermore, written policies and procedures should ensure that coding and billing are based on medical record documentation; which is now the “reality” rather than just a “reflection” of the reality.

Focus on the Codes

Particular attention should be paid to issues of appropriate diagnosis codes, CPT, DRG and MS-DRG coding, individual Medicare Part A and B claims (including documentation guidelines for evaluation and management services) and the use of patient discharge codes. The billing company should also institute a policy that all rejected claims pertaining to diagnosis and procedure codes be reviewed by the coder or the coding department. This should facilitate a reduction in similar errors.

Problem Areas

Among the risk areas that some billing companies who provide coding services should address are:

  • Internal coding practices;
  • “Assumption” coding;
  • Upcoding and Downcoding;
  • Alteration of medical records and documentation;
  • Coding without proper documentation of all physician and other professional services;
  • Billing for services provided by unqualified or unlicensed clinical personnel;
  • Availability of all necessary documentation at the time of coding; and
  • Employment of sanctioned individuals.

Assessment

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Billing companies that provide coding services should maintain an up-to-date user-friendly index for coding policies and procedures to ensure that specific information can be readily located.

Similarly, for billing companies which provide coding services, the physician-executive and billing company should assure that essential coding materials are readily accessible to all coding staff.

Finally, billing companies should emphasize in their standards the importance of safeguarding the confidentiality of medical, financial and other personal information in their possession.

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On the Cash Conversion Cycle for Healthcare Organizations

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Understanding Why Cash Flow is King

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

The manager, administrator or COO of a hospital’s working capital, or physician executive of a private medical practice, strives to optimize the amount of cash on hand to ensure daily operations. Too much cash generates little return, while too little may jeopardize the healthcare enterprise, incur borrowing costs or cause missed investment opportunities.

Also, the extent to which current assets cover current liabilities, determines whether the entity is considered liquid and thus able to meet its payment obligations on time.

The Balancing Act

When faced with the management balancing act of current assets and current liabilities, the alternative with the highest net present value (NPV) and internal rate of return (IRR) is typically selected. This is often a difficult balancing act since providing healthcare services generates little immediate cash, and then cash receipts are variable depending upon payers or other third parties.

Yet, each hospital or practice distribution transaction requires immediate liquid cash for employees, vendors, debt holders, and investors in the form of dividend payouts or retained earning disbursements. The cash conversion cycle (CCC) length measured in days is composed of two ratios:

  1. The first is the average inventory holding period (ending inventory divided by revenues per day),
  2. The second is the collection period (ending ARs divided by revenue per day). For both ratios, faster is better.

CCC Averages

Sample CCCs for an industry-average hospital (45 days average-non-electronic) are:

1. hospital admission to patient discharge (5 days);

2. patient discharge to hospital bill completion (5 days);

3. hospital bill completion to insurance (third-party administrator or TPA) payor receipt (5 days);

4. receipt by TPA to mailing of hospital payment (25 days);

5. payment mailed to receipt by hospital (3 days); and

6. payment receipt by hospital to bank deposit (2 days).

Assessment

Naturally, healthcare managers, administrators, physicians and hospital executives should be interested in motivating changes in the behavior of staff such that processes within the control of the enterprise can be streamlined and completed in less time.

For example, a day or two reduction in the amount of time it takes from patient discharge to hospital bill completion, as achieved with the use of electronic charts and medical records systems, can significantly increase cash flow. Likewise, the use of electronic funds transfers and/or lock box collection mechanisms can reduce the amount of time it takes for an account receivable to make it into the bank.

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