Delivering Physician Services: A Horse of a Different Color.
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Transcript of Delivering Physician Services: A Horse of a Different Color.
Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded
Delivering Physician Services: A Horse of a Different Color.
• When is the right time?• Should we hire, guarantee or other
support?• Should we share our TIN or set up new?• Should we set up RHC, FQHC or practice
model?• How will it affect current medical staff?• Are we “equipped” to handle delivering
physician services?
Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded
The Decision
• Hiring as knee jerk reaction or to bail out.• Hiring when not justified by outmigration.• Hiring when only bad payer mix subject to shift.• Hiring based on gut feelings (without proforma).• Hiring wrong specialty (PCP vs SCP).• Hiring with guarantee without mechanism to promote
proper set up and maximization of volume and reimbursement.
• Hiring under hospital TIN.• Hiring with physician “issues.”• Hiring without executive leadership/oversight.
Bad Practices:
• Review market share analyses:– HERMES data– Outmigration by payer by specialty– Lost cases with financial impact
• Develop proforma– Use market share– Identify specialized equipment, office space, staffing needs– Project both hospital and physician impact
• Determine specifics of purchase– Buying old A/R?
• Review licensure and any “issues.”
Best Practices:Do Your Homework!
• Determine correct legal structure– Separate physician group TIN (make TIN decision and stick
with it – avoid changes!)– All physicians under one (non-hospital) TIN– Establish physician group name (i.e. Evans Family Centered
Medicine)– Establish as physician group practice initially; transition to
RHC.
Best Practices:Legal Set-Up
• Determine correct corporate structure.– Hire good Practice Manager– Hire experienced physician office staff
• Integrate functions that don’t hinder practice effectiveness (i.e. HR).
Best Practices:Corporate Set-Up
The Preparation
• Insufficient lead time for enrollment and office set up.• Failure to assist in practice set up.
– Provider enrollment– Office start-up– Billing– Training
• Establishing too much like hospital.• Attempting to incorporate into hospital business office.• Adjusting corporate structure in middle of process
(changing TINs, adding addresses).
Bad Practices:
• Start early (very early)!• Determine participation strategy.• Identify staff member responsible.• Set up physician credentialing file.• Establish appropriate NPI numbers.• Establish CAQH.• Enroll electronically in Medicare and Medicaid.• Enroll in EDI/EFT.
Best Practices:Provider Enrollment
• Contract as HEALTH SYSTEM!• Obtain PHO or Group contracts whenever possible.• Negotiate language and reimbursement.• Watch for operational implications.• Only Hospital CEO or CFO signs group contracts.• Train physician and office staff NOT to sign anything;
send to you.
Best Practices:Contracting
• Set up as practice initially (if qualifies and beneficial)!• Determine eligibility.• Review financial benefits.• Review operational requirements (NPs, etc).• Review billing components (POS and copay
differences).• Understand time frame for conversion (9-12 months).
Note: Must be primary care with mid-level and at least 4,200 visits annually.
Best Practices:Research RHC Status
• Hire Practice Manager.• Implement processes to support claim payment:
– Patient registration (ABNs, HIPAA notices)– ID card recognition– Referral/preauthorization– Check-out processes (ask for the MONEY!)– Billing
• Know how to handle OON patients (make whole?).• Know what to collect and how to ask for it.• Train, train, and retrain.
Best Practices:Practice Operations
• Set comprehensive charge master (get help with this!).• Select good practice specific software (not a hospital system!).• Set up insurance master accurately (get help with this!).• Load reimbursement schedules into software; analyze against
payments.• Know payer plan participation status (when to take and not to
take contractual adjustments).• Consider outsourcing to billing expert (i.e. PPM).• Provide up-front training (i.e. HTHU and PPM).
Best Practices:Revenue Cycle Set-Up
Best Practices: Insurance and Risk
Management
Charley Malmquist CPCU, ARM, AAI
Potter Holden & Company 888-528-0589
Serving the Insurance Needs of Georgia’s Healthcare Community Since 1918
Best Practices: Insurance and Risk Management
HTH SURVEY RESULTS:HOSPITALS EMPLOYING
PHYSICIANS
How many are employing physicians?
88% currently employ physicians. Of those hospitals… 88% employ 1-5 physicians, 12% employ 11 or more
78% plan to hire new physicians in the next 18 months 57% in primary care, 42% both primary care & specialists
Best Practices: Insurance and Risk Management
Who are you hiring? 67% of the physicians responding hospitals typically recruit have
6 or more years of experience; 22% are new to practice; 11% have 2-5 years experience
How are you hiring?
78% use outside search or recruiting firms56% Recruit from physician practices within their community22% recruit from referral of existing employees
HTH SURVEY RESULTS:PHYSICIAN EMPLOYMENT
Best Practices: Insurance and Risk Management
PRE-EMPLOYMENT CONSIDERATIONS
• Prior practice locations• Prior insurance carrier… compatibility• Prior Acts Coverage / Nose Coverage• Past loss history, open losses, & incidents
not yet reported• Board consent orders or license restrictions• Health issues / drug or alcohol abuse (*as it
relates to licensing)• Prior insurance cancellations of declinations
Best Practices: Insurance and Risk Management
How are you structuring coverage? 89% provide professional liability protection for their employed
physicians.75% under the hospital’s policy: 25% on a separate policy.
33% said the hospital’s deductible applies to their physicians;22% said the hospital’s deductible does NOT apply, and55% said they weren’t sure/didn’t respond.
100% of respondants provide $1 mil/ $3 mil limits of liability for their employed physicians
HTH SURVEY RESULTS:PROGRAM STRUCTURE
Best Practices: Insurance and Risk Management
How are you structuring coverage? “Does your hospital’s umbrella/excess policy
include coverage for employed physicians?”44%- yes22%- no22% - hospital does not carry an umbrella or excess policy11%- aren’t sure
Best Practices: Insurance and Risk Management
PROGRAM STRUCTURE ISSUES
• Ownership of policy
• Policy type— claims made or occurrence
• Individual or group policy
• As an endorsement to the hospital’s policy
• Separate or shared limits
• Application of any retention or deductible
• Retirement options
Best Practices: Insurance and Risk Management
“How do you address employed physician's malpractice exposure prior to joining your hospital? (prior acts coverage)89%- It is the responsibility of the physician to purchase tail coverage0%- hospital assumes the prior acts by maintaining an original retroactive date11%- weren’t sure
“Does the hospital have a clearly defined plan to address the cost of “tail coverage” should the physician leave the employment of the hospital?” 67% said ‘yes’22% said ‘no’
HTH SURVEY RESULTS:EMPLOYMENT CONTRACTS
Best Practices: Insurance and Risk Management
EMPLOYMENT CONTRACTS
Clearly identify insurance responsibilities:
• Who will purchase coverage?• What constitutes an acceptable insurer?• What limits of coverage required or provided?• Who will hold consent to settle? (if available)• Who is entitled to receive dividends or return
premium?• Will moonlighting be allowed?• Mutual hold harmless or indemnification clauses
Best Practices: Insurance and Risk Management
OTHER INSURANCE CONSIDERATIONS
• Workers Compensation
• Business overhead
• Key man life
• Billings Errors & Omissions
• Business Interruption
• Medical Equipment
• Offices Premises Liability
Best Practices: Insurance and Risk Management
BEST PRACTICE- “DO’S”• Do your due diligence on the physician
candidate before you employ
• Do ask for full disclosure on any potential, pending or open claims
• Do consider all potential ramifications associated with insuring the physician before finalizing your approach
Best Practices: Insurance and Risk Management
BEST PRACTICE- “DON’Ts”• Don’t make assumptions regarding each
party’s responsibilities – spell them out clearly in writing
• Don’t assume unknown liabilities
• Don’t assume all insurance policies are the same
• Don’t assume a departing physician will automatically purchase “tail” coverage: get proof
Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded
The Oversight
• Payment addresses; mixed payments.• Mixed physician and hospital posted on general ledger.• Little to no oversight over practice A/R.• Little to no practice reports reviewed.• Reporting GL and A/R/Revenue to hospital center.
Bad Practices:
• Establish lock box for payments (separate from hospital).
• Ensure cash poster is properly trained.• Use payment verification software component.
Best Practices:Practice Payments
• Review routine A/R reports; ask questions.• Review variance reports; require payment
verification/write-off support.• Review Collectability Analyses.• Review routine A/P reports; ask questions.• Establish PM reporting lines; meet regularly.• Set up separate GL department for physician practice.
Best Practices:Reporting
HINDA GREENE,D.O., SR VP, MEDICAL AFFAIRS
HOSPITAL PHYSICIAN PARTNERSAPRIL 30, 2010
Best Practices for Integrating Physician Services into Your
Hospital
Integrating Physician Services
Emergency Department
Great Care Standardization Protocols in triage Quality Review
Shorten LOS Door to admission or
discharge
Patient Satisfaction
Staff satisfaction
Hospitalist Program
Great Care Less “push back” for
admissions Increased Risk Aversion Quality review: inpatient
Shorten LOS By decreasing LOS, increase
reimbursement Patient Satisfaction
Staff satisfaction Less on call Vacation Coverage Protect office time
Win Win
Emergency Department
Initial workup and stabilization
Less resistance for admissions
Standard protocols
Hospitalists
Increased admissionsDecreased length of
stayStandard admission
orders
Coordination
Emergency Physicians and Hospitalists work together
What can I do for you?Expedite exit from EDCover hospitalist for a few hours per night by
bundling admissions and use of standard orders
Patients and hospital both win Happiness is spending less time on a one-inch
mattress
Mike ScribnerStrategic Healthcare Partners
Helen Williams, CPCPrecision Practice Management
Charley Malmquist, CPCU, ARM, AAIPotter-Holden & Company 888-528-0589
Dr Hinda GreeneHospital Physician Partners
What else can I say?