If you were unable to attend, or would like an electronic version of this session’s handout, please click on the link below and download her handout containing valuable information for your medical practice.

Medical Malpractice Danger Zones – October 2007 Handout

If you were unable to attend, click on the link below and download her session handout that includes valuable information for your medical practice to review and implement.

The Managed Care Settlements-September 2007 Roundtable Handout

If you were unable to attend, or would like an electronic version of this session’s handout, please click on the link below and download her containing valuable information for your medical practice to review and implement.

Legal Obligations: Refunds, Balance Adjustments, and Other Payment Issues

If you were unable to attend, click on the link below and download her session handout that includes valuable information for your medical practice to review and implement.

Self-Pay Fee Schedules and Collections – July 2007 Roundtable

HSAs and Medical Practices
Heather’s next Complimentary Roundtable topic is “Fee Schedules for Self-Pay Patients and How to Collect” and takes place on Friday, July 27 (12:00–1:00 p.m. – Lunch Provided) at 401 N. Tryon Street, Charlotte, NC 28202. To register, for more information, or to sign up for a monthly email reminder, please send your name and practice name with address and phone to info@doctorslawyer.com. Or call us at 704-643-9076.

Managed Care Contracting – A Review and Some Tips

As a result of insurance claims filed on behalf of consumers, insurers already have the information needed to provide PHRs, and are in a unique position to build them for consumers in the near term, AHIP said in a press release.

PHRs are distinct from electronic health records, which providers use to store and manage detailed clinical information, the release explained.

“Efforts such as those by health insurance plans to provide consumers with portable PHRs are a step forward in the national health IT agenda. We welcome your continued work to achieve interoperable, consumer-centric health information,” said Robert M. Kolodner, MD, Interim National Coordinator for Health Information Technology at the Department of Health and Human Services.

According to AHIP, insurers worked closely with standards organizations to ensure the plans’ PHRs are compatible with standards that are being developed for the goal of a fully interoperable healthcare system.

To view the press release, visit the AHIP website.

If you would like to have this, or any other Legal Checkups sent to you, just email us your contact information and we’ll send along this edition and add you to our mailing list.

Increasing Practice Revenue by Negotiating your Managed Care Contracts (pdf)

Many practices have found they can drastically improve their percentages of collections by putting some thought into what is and what is not working. A small increase can turn a struggling practice into a healthy one. A large increase can mean more time off or earlier retirement.

The Bill

If you have control over the format of your bill, examine it closely. If it is like most medical bills, it difficult to read and contains information that is not helpful to the patient. The typeface should be large enough for older patients to see. There should be clear directions on what action needs to be taken by the patient. (Note that some practices have stopped sending out the notice advising patients of charges and insurance pending that “is not a bill” because it is costly, confusing, and seems to slow down payment later on.) If possible, use simple descriptions of the services rendered rather than CPT codes or medical terminology that a patient does not understand. An unambiguous summary of payments and what the patient still owes should also be included. Train staff to provide good customer service if a patient calls with questions regarding a bill. A patient-friendly bill can go a long way in the successful collections effort.

The Process

Practices vary widely in both the staff resources they dedicate to billing and the actual process. A 2001 MGMA survey reported that on average, for every physician in a multi-specialty practice, there was three-quarters of a billing staffer allocated. If you have a large billing staff, it is a good idea to assign each person distinct duties. Ideally, this can be divided by payors so that staff can become familiar with an insurance company’s methods and have better success managing the accounts.

Any staff member who collects from payors must be persistent and understand the procedures. Someone also needs to be responsible for collecting from patients. Always collect a copayment upfront, unless a patient can supply proof of indigence. If a patient has an outstanding balance, prior to their next appointment call and remind them to bring their payment. Those patients that can afford to pay but don’t should be terminated according to practice policy, always allowing for adequate continuity of care.

Outsourcing

A billing company may be a better option for some practices, but that decision should be made thoughtfully and analytically. Weigh the long-term costs versus the benefits of building a good in-house team. If you are a good candidate for a billing service, be sure to choose a company that has good collection results. Find out the specialties of their other clients and whether they have adequate staff and knowledge to service everyone. Always ask if the billing company has a compliance program based on the OIG’s suggested guidelines. Remember too, that the government frowns on paying billing companies a percentage of collections due to increasing the incentive to upcode.

In summary, make the time to analyze your accounts receivable and collections process. It may be the quickest way to make a significant positive impact on your practice.

The Office of Inspector General (OIG) of the Department of Health and Human Services issued Final Compliance Program Guidance for Pharmaceutical Manufacturers in April of this year, yet there continues to be rampant rumors of pharmaceutical companies offering long weekends for physicians and their wives in exotic places and, in one example, a five figure check in return for “attendance at a lecture” on a particular drug. Physicians work very hard, and such offers are obviously appealing for many reasons. The question that needs to be asked before accepting such a gift is whether it is appropriate according to the OIG, the Food and Drug Administration Office of Criminal Investigations, the Federal Bureau of Investigation, and the Department of Justice.

This summer AstraZeneca Pharmaceuticals learned the hard way that its marketing efforts to physicians were not appropriate. The government alleged that AstraZeneca paid illegal remuneration in the form of free samples, unrestricted educational and other grants, travel and entertainment, and honoraria. The company’s punishment was, among other things, $355 million in criminal fines, civil penalties, and False Claim Act liabilities for improper marketing practices of its prostate cancer drug Zoladex. It is not the only company in trouble or currently under investigation.

Fortunately, there is guidance available to help determine where to draw the line. The American Medical Association (AMA) has maintained guidelines on this subject for many years. In general, the AMA Guidelines advise that cash gifts should not be accepted. Compensation by pharmaceutical companies is permissible as long as it is reasonable and for genuine services rendered by the physician. The AMA discourages subsidies for travel, lodging or other personal expenses of physicians attending conferences, unless the meeting serves a bona fide research purpose. This means there should be a valid study protocol, physicians recruited with the proper expertise, and enough physicians recruited to produce a valid statistical sample.

The Pharmaceutical Research and Manufacturers of America (PhRMA) also adopted guidelines in July 2002. The guidelines are called the Code on Interactions with Healthcare Professionals. Compliance is voluntary, and it has a few different requirements than AMA. For example, it does approve of reimbursement for consulting services (which is not directly addressed by AMA), including travel, lodging and meal expenses. It specifically states that spouses and other guests should not receive any benefits, even if it is only a modest meal. Financial support for CME is acceptable because it can contribute to the improvement of patient care.

Lastly, there is the OIG’s Final Compliance Program Guidance for Pharmaceutical Manufacturers. Since it is the government enforcing the rules, it is a good idea to read the government’s guidance on the rules. The document focuses on the potential risks under the Anti-Kickback Statute for pharmaceutical companies and those with whom they have relationships.

The basic principle is that remuneration from a pharmaceutical manufacturer is illegal if that remuneration is intended to generate any federal healthcare business. Several types of arrangements with physicians that the OIG may find problematic are: inappropriate discounts to physicians, offering substantial inducements for a physician to use or prescribe a particular product, educational grants that may be directly or indirectly conditioned upon the purchase of a product or service, personal service contracts that are not structured to fit within an available “safe harbor” (seek legal assistance for proper documentation), or research funding that is not legitimate.

The analysis of gift or compensation appropriateness is mostly common sense with a little knowledge of the law. Some good questions to ask are:

• What is the nature of the relationship with the pharmaceutical company and what is the degree of the physician’s influence on the success of the product?
• Does the remuneration depend on the volume or value of “referrals” for the manufacturer’s product?
• Is the value of the remuneration substantial?
• Does the remuneration have the potential to negatively impact the costs of a federal healthcare program?
• Would the acceptance of the remuneration affect the physician’s professional judgment?

The bottom line is that physicians should not rely on the pharmaceutical companies to know and follow the rules. Before accepting that free trip, consider the risk of substantial fines, unwanted publicity, civil and criminal liability, and being on a first name basis with government investigators. Is that worth a long weekend at Disneyland?