Thursday, March 29, 2007

Looking for a job? Here's how you can be screwed!

A friend of mine asked me an interesting question and for my opinion. I think that this will make for an excellent blog topic. So with her permission, here is the issue.

Her daughter-in-law is a dermatologist in an academic practice in a large city. She is married and her husband is still in school, thus has no income. She is unhappy in her current position and has been interviewing for jobs in the suburbs. She has 2 options, according to my friend. Option A is to join a group, on a partnership tract, for straight salary. Option B is to join a group on a non-partnership tract with a compensation package based on a percentage of collections minus overhead. What sould she do, asked my friend. The answer is, "I don't know" but here are the pitfalls that she should try to avoid and, here are some possible solutions.

First, how can she get screwed. Oh, let me count the ways.

  1. Options A: She takes a straight salary, and then they work her like a dog with all the patients they don't want to see, at all the times they don't wish to see them.
  2. Option B: she gets a percentage of what she brings in, minus expenses, right. Ok, she sees all the poor payers and time-consuming diagnoses, and then they give her an "overhead" of 50-65% (don't scoff, it happens). Therefore, no matter how hard she works, she makes relatively little money, for a dermatologist. Overhead for someone joing a group, in my view, should never be > 50%.
  3. Options A and B: She wants to do cosmetics because it is what she enjoys and is good at, plus it is the most profitable. Only, her partner insists, either directly, or via office policies, on doing all cosmetics. Tough luck, you're an employee.
  4. Options A and B: "Call is equal" the partners say. Well, there is equal and there is equal. Somehow, the junior person always gets the "extra" call;the 5th weekend, every Mother's Day, all holidays in year one, every Christmas "because your Jewish." What ever you don't want, you'll get. It may sound petty, and it is, but if done consistently to you, it will really grate on you nerves.
  5. Options A and B: The no-compete clause. This says that if you leave the practice, essentially you are barred from practicing with-in that community for a period of time. For eample, 10 miles, 2 years. Mine was 5 miles, 2 years, which I believe is fair. It is designed to protect the employer, as it should. Unfortunately, if you are an employee and are unhappy and wish to leave, you will have to uproot your family and move. And believe me, no-compete clauses are enforceable in court. You will not win.
  6. Options A and B: They have multiple offices and guess who does all the driving. Also, makes the no-compete clause even worse.
  7. Options A and B: You have no hiring and firing power, and you get all the new hires; all the inexoerienced hires.
  8. Options A and B: You get all the "high risk" liability cases and emergencies.
  9. Option A: Partner deal to be negotiated later, rather than at the time of initial employ. This is one of the oldest tricks in the book and allows your employers to string you along for the term of your employ and then make the partnership details noxious.
  10. Nebulous buy-in terms.

So here are some possible solutions:

  1. Don't sign a no-compete clause.
  2. Work without a contract.
  3. Pick a job in a different community from which you live.
  4. Ensure, in writing, that patients will be assigned on an "as they call" basis. If patients are then assigned by any other method, the contract is nullified (consult a lawyer first).
  5. Make sure the call schedule is agreeable to you, in writing. Think 3-5 years ahead, when you have kids, etc, and re-think the call schedule.
  6. Make sure all details of partnership are negotiated before you sign the contract. Consult a lawyer.
  7. Be prepared to walk from the contract.
  8. No your own true worth.
  9. Trust your misgivings. If you don't feel right on the way in, things will only get worse.
  10. Find out the group's or partner's entire history of associates, talk to the associates and read between the lines.
  11. You must have a very clear understanding of the buy-in, in real numbers, not "the accounts receivable" or other such fudgable terms.
  12. Be prepared to go solo.

Tuesday, March 27, 2007

Here's a good one.

I had a patient with 606.8 from CBAVD (congenital bilateral absence of the vas deferens) who needed to undergo a 55899. 55899, according to the CPT book is: genital procedure NOS. In this particular case, it was an epididymal and testicular sperm aspiration and extraction, done in conjunction with an IVF procedure. Though the patient had coverage for 606.8, the carrier could not say whether or not the patient had coverage for 55899, because it was a 55899--an unlisted code. They would only make that determination after the fact. In other words, they expected me to do the procedure on faith.

Since I can't pay my bills on faith, I asked for $750 up front from the patient, which is comparable to what I had been paid in the past for this exact procedure. The patient paid and I performed the procedure and his wife is now expecting.

Today I received a check in the mail for $219 for the 55899, 95 days after I performed it. Apparently, the insurer felt that $219 is the usual and customary for this procedure. A medical director may--or may not--have looked at the operative note that we supplied and said, "Well, I think it is basically a 54505 (biopsy). Let's pay'em for a biopsy." Hence $219. Therefore, I owe the patient ~$500.

My problem is--and I'll send back the money--is that ~$200 is the usual and customary for a testis biopsy, but certainly not for a testis sperm extraction, which requires significantly more expertise and time and has much more complex administerial and scheduling issues.

So now what do I do; appeal their usual and customary decision.

The IU.

Monday, March 26, 2007

Going Solo?: Develop Routines.

Developing routine ways of doing things is critical to the success of your practice, or any business for that matter. From how your staff answers phones to the order in which you take your medical history, and everything else; it should be rote. A routine. This does not imply that you are Rain Man, but simply that you have automated and are efficient. Here are some reasons why routines are important.

  • Efficiency: When you have a well formed routine, things seem to slide into place. Patients are put in the correct rooms in the correct order, automatically. Forms are filled out easily. Everything works like a well oiled machine. You will be able to communicate with your staff without the need for words.
  • Predictability: Having a routine way of doing business and not veering from it allows your patients and staff to experience what every baby craves, predictability. Everybody likes predicability, even thrill seekers. It is why we go to McDonalds or The Ritz Carlton or our favorite hair salon: to have a prectictable experience and outcome each time.
  • Outcomes: When you follow a routine and seldom veer from it, your outcomes will improve. You'll make less mistakes. Patients who require antibiotics before the cysto, will receive them. Patients who ought to have cytologies, will get them. Specimens will not get mixed up.
  • Growth: Having routines will allow you to grow your practice in a more effortless manner, with less "thrown out" money, and less overhead because your routines will enable you and your staff to work smarter.


The IU.

Something in my phones is actually trying to kill me!

This weekend my phones were down. Only this down, it was my home phones. Not my VONAGE phones, my Optimum Voice phones. I do have a separate VONAGE line at home, and that worked fine. SOMEONE IS MESSING WITH ME!

The IU.

PS: and my toilet overflowed twice.

Thursday, March 22, 2007

Chain of custody.

There was an interesting post in KevinMD today regarding a law suit brought against a reproductive center that does IUI. As a fertility specialist, I find this particularly interesting as the suit hits directly at a major aspect of any lab: chain of custody.

Chain of custody details who has direct control of a specimen, be it a blood sample, biospy specimen, vas deferens post-vasectomy, or semen sample from the time the specimen leaves the patient's body until the it reaches the lab, even beyond. Breakdowns in chain of custody may result in big problems down the road for patients, labs, physicians, and everyone involved. As a solo practitioner, you are the number one responsible person when it comes to chain of custody. Fortunately, as a solo practice owner, you can set up policies that control every aspect of chain of custody. Here is how I do it.

  • Patients label all their own urine samples immediately after voiding. Pen and label are kept in bathroom.
  • Unlabeled specimens are discarded unless the patient can verify that the specimen is theirs.
  • Semen samples are labeled in the same way as the urines.
  • Overnight semen samples (I have a method to preserve the quality of the semen over a 24 hour period) are labeled by the patients.
  • Blood samples and taken into the lab immediately after blood draw and labeled. The label number must match the requisition form. The requisition form is immediately marked with the patients name and identifying data.
  • In-office biopsy or vasectomy specimens are handled as the blood samples.
  • Reproductive samples, for example, a testis sperm retrieval sample, are immediately labeled with the patient's name and identifying data. The specimen is then transported by either the patient or my office staff to the cryolab. If we do the transporting, the specimen never leaves our direct possession. The cryolab then verifies the name and identifying data on the specimen, matches the name to a photo ID, and makes the patient or me (whom ever delivers it) sign a chain if custody form.
  • When the reproductive specimen is used, the specimen is again matched to the patient via photo ID and the match is attested to on a signed form.

Any breakdown in protocol can result in disaster. Perhaps that is what happened in the above case. Who knows.

The IU.

Wednesday, March 21, 2007

I'm vexed. Terribly vexed!

I know I have been blogging in a somewhat schizophrenic way about Vonage, my VOIP phone provider. I guess it is a love-hate relationship. When it works smoothly, I love it. Otherwise, I hate it.

I suppose that a phone service provider ought to be like a urethra: if you have to think about yours, you have a problem.

It seems that in the past 4-5 weeks I have had 4 different problems with the service, all of which were quickly rectified by the company. Most recently, today, for a 2 hour period I was unable to receive any calls. Callers got either a beeping tone or a greeting saying that all circuits were busy. Ultimately we were able to see a log of who called and we called them back. One of the callers was a new patient who wanted a vasectomy reversal. Though a stressful 2 hours that involved language that my kids will never use, we eventually retrieved all calls and messages and every thing worked out.

My questions for the world wide practice manager:
  1. Do I leave VONAGE?
  2. Can I port my VONAGE phone number? (Only answer this is you actually know the answer for fact!!!)


The IU.

Tuesday, March 20, 2007

Another internet success story.

I had a new patient today, a hispanic woman and her husband. They spoke no English. As they were filling out the forms, I noticed my staff giving the husband a HIPAA compliance form to sign. The form was in English. He signed it.

Something told me that that probabably would not hold up in court.

Off to the internet.
  • Google "HIPAA forms spanish"
  • 30 seconds later click on link to Montefiore Med Center in the Bronx.
  • Adobe PDF HIPAA form downloaded 5 seconds later and printed.
  • Patient signs Spanish form 5 seconds after that.
  • PDF file saved in FORMS directory as "Spanish HIPAA".

Now we're ready for the next Spanish speaker.

Gotta love it.

Monday, March 19, 2007

5 reasons for denials

Denials of claims are a way of life for physicians. In my practice, 15% of claims are denied after first file, and we are electronic. Why? Typically, the denials are the results of admitted mistakes by the insurance companies and, of course, all we need to do is re-submit the claim to get paid--after another 45 days have elapsed. Here are the top 5 reasons that my claims--claims that ultimately get paid on--are denied up front.
  1. Referral Issues: Some insurance companies never require referrals while others always require referrals. With these companies, we know the rules and can play by them. However, most insurers are somewhere in between and they have plans within their plans that may or may not need a referral to see a specialist. Yet many of these companies do not publish or notate or list which of these plans within the plan within the plan need referrals. In other words, one can not tell simply by inspecting the member's ID card whether or not a referral is needed and, short of the doctor calling the company on every patient, there is no way for the doctor to know who does and does not need a referral. With some plans, it is up to the patient to know if they need a referral but sometimes the onus of responsibility is on the doctor. So, with these plans, if the patient swares up and down that they don't need a referral when in fact they do, you're out. And, you have no recourse. Tough luck. Of course, from the perspective of the insurance companies, this makes great business sense because the carrier can legally deny payment while simultaneously absolving themselves of any fault in the breakdown of the process. It is beautiful. Fraudulent, but beautiful. And if they do ultimately pay, they at least have had your money earning interest for them over a 6 month period.
  2. Missing information: Sometimes, the insurer requests additional information, like an operative note. Of course, these extra items typically are never "received" the first time.
  3. Incorrect numbers: Claims can be denied for incorrect NPI, PIN, TIN, PRIS, or member ID numbers. Sometimes a company that has been paying me flawlessly over a several month period mysteriously substitutes a 6 year old, inactive provider ID number for my current ID. Go figure. Other times, the patient's member ID number is entered incorrectly, by a company claims handler. These mistakes can be fixed, but they take time and effort; lots of both.
  4. Mis-information: I do male infertility and insurance coverability issues for these patients are anything but straightforward. Since I do this for a living, I have learned the ins-and-outs of determining whether a fertility procedure will be covered. On more than a few occasions, we have determined that a procedure was covered, with authorization numbers and all, only to have it denied because, in fact, the pre-cert person and the claims adjuster were not in agreement. And we got stiffed.
  5. Mistake: About 10% of claims are denied simply be mistake: for no good reason. Everything seems OK, everything is in order, everything is place, yet the computer spits out "pay amount: $0.00."

So there you have it. This is the true bane of our collective existences. So many mistakes and so one sided that they can only be intentional.

Hope you enjoyed reading this, because I did not enjoy writing it.

Friday, March 16, 2007

Never say die!

I just received an EOB with a payment for a 99214 from July. July! An 8+ month old claim. It was denied 4 times previously. The first time because the insurer claimed that the ID# was incorrect. We re-submitted the claim and proved that the number we had was correct and that their number was incorrect. We marked 2nd claim on the submittal, onlyto be denied again, this time by, "sorry, that must have been a mistake." We re-submitted claim number #3, which was denied for late filing. After fighting that, because we had proof of our previous attempts, we re-submitted and then were paid, $50.00.

$50 bucks. Was it worth it? Was it worth the hassel? You betch-ya! 50 bucks is 50 bucks is 50 bucks. It's a month of cell phone service. It's a bottle of UA dip-sticks. It is my money, rightfully. Not the insurance companies.

Notice that we never billed the patient, because that would have been wrongful, in my view. The patient had the coverage, we accepted it and did our part for the claims process. The insurer played games and profitted from the delay. Imagine denying 10,000 claims for $50 dollars each for 6 months at a modest 4% return, then ultimately paying the $50 dollars to the 20% of doctors that persisted as we had. By my calculation, an insurer can make an extra $420,000 dollars over a 6 month period. Technically this is not legal, but it can be done, and probably is done "by mistake." In the past this was common practice of some insurers and ultimately cost these carriers millions after a successful law suit filed by the NY State Medical Society. And you know what, it is still done.

It is not your job to subsidize the insurers and your patients already pay enough in premiums. Make the carriers pay what is owed, no matter how small.

Never say die.

Tuesday, March 13, 2007

Payment not guaranteed.

Have you ever looked at a pre-authorization notice for, oh, let's say, a surgery. If you have you would have certainly noticed the following disclaimer, "pre-authorization does not guarantee payment."

What the hell is that. I simply am unable to comprehend it. What the insurers are saying, unless I'm missing something, is that despite getting permission to do the procedure, despite the carrier's determination that the procedure is warranted, despite the determination that the patient has coverage for the procedure, and despite the determination that you are a participating provider, you may, in fact, get stiffed on payment. Interesting.

To me, that is like going to a restaurant, ordering a burger, acknowledging the price for the burger, ordering, eating it, and then saying, "nahhh, I'm not gonna pay for it. The burger that you provided was not really a beef burger, in my opinion, and that is what I ordered. You can appeal my decision though." Of course, that would be crazy, not to mention illegal.

Yet that is what happens daily to physicians across the country, in all specialties. Will someone please explain to me, like I'm 5, what "payment is not guaranteed" means.

Friday, March 09, 2007

I have a project that I want your help with.

Here is the problem:

I have 3 forms forms that patients must read and sign: The HIPAA compliance form, the e-mail usage consent form, and the Patient Information Form. I need the patients to sign all 3 forms, and to complete the patient demographic form with things like name, address, phone number, insurance info, etc. These forms comprise a total of 4 pages, which is 4 too many.

Here is what I want:

I want to have the signature on file and to have the information from the demographic form automatically placed into unique, searchable fields within a database, only I don't want to design the database. In addition, any software or hardware I use must be inexpensive and mass produced. I am open to purchasing a Tablet PC, if no other ideas are better.

I am turning to the collective power of the entire internet community to help me.

Please email any responses directly to me at or via posted reply at this blog. If you can't help, please forward a link to this site to anyone who may be able to help.

This is a grand experiment. I believe it may be the first of it's kind. We'll call it the World Wide Practice Manager.


The Independnent Urologist.

Thursday, March 08, 2007

Going Solo?: Determine what is absolutely essential.

Opening your own medical practice is not cheap, even when done on the cheap. The real trick to keeping costs low is to question the need for anything and everything. Do you need 2 rooms or will 1 suffice? Do you need to purchase an electronic medical record or will paper work for now or can you build your own system? Do you need 2 staff members or can you function with one? I believe that this is the essence of the micropractice movement, first popularized by L Gordon Moore in primary care and on the specialist side, as I have been told, by The Independent Urologist (risking obvious shameless self-promotion).

When I left the safety of group practice I had one major constraint common to all start-up businesses: no money. That constraint forced me to question every thing I had been taught or had learned. Here are a few examples.

• I was told I would need at least 2000 square feet. I rented 1100.
• I was told I would need 3 phone lines, I took 1
• I was told I would need a staff of 3+ me. I have me + 1 other full timer.
• I was told I would need to start staff at $14/hr. I started at $9.
• I was told I would need people with experience. I hired people with none.
• I was told I would need a copier. I still don’t have one, 1 year later.
• I was told I would need an answering service. I haven’t.
• I was told to never give patients’ unfettered access to me. I do.

And on and on and on! When you do decide to go off on your own, it is imperative to question everything. Frankly, you’ll need to anyway or you’ll rack up huge debt and risk bankruptcy unnecessarily. It’s just a change in mindset, but it is an important one. Determine what is absolutely essential. And do that and only that.

Thanks, Dr S.

Wednesday, March 07, 2007

Five Rules for The Lean, Independent MicroTech Practitioner in the age of Web2.0

I believe this is the best time to go solo, despite declining reimbursements and rising costs. But to be successful, you must follow these rules.

1. Your costs must be rock-bottom. You simply must be a miser about costs, yet never be penny-wise and pound-foolish.
2. You can only have tools, no toys, and your tools must be inexpensive, off the shelf, mass produced, and easily trouble-shootable by you. If it can’t be fixed with a re-boot, move on!
3. Your tech-tools must be small and easily mobile. Remember, you pay per square foot for real-estate.
4. You must be digital ready and computer literate. It is a simply a pre-requisite to starting your own Lean MicroTech Practice.
5. Automate, automate, automate, and what you can’t automate it, figure out a way to automate it. Use templates, macros, forms, routines—anything that automates—as much as possible.

Good luck.

The Independent Urologist

Tuesday, March 06, 2007

Going Solo?: Know the difference between tools and toys.

I want to talk a bit about technology, a subject that I have covered in the past, and seems to be of interest to this blog's readers, all 3 of you. Only this time, I want to discuss the difference between a tool and a toy. Whether you work for someone else or yourself, you’ll likely be bombarded by technologies and gadgetries and tech driven marketing. In order to conserve important capital and time and energy, you must learn to differentiate the tools from the toys. It is simply essential.

Tools have a primarily useful purpose. Toys are primarily for entertainment. Tools and toys can be fun and can have useful features and you can be convinced through clever marketing that a toy is a tool, when in actuality it is not. Toys can be every bit as expensive as tools, even more so. Toys are impulse purchases while tools never are. You want toys but need tools. And that is a major distinction. If you buy a piece of technology and then try to rationalize a use for it, you are buying a toy. If you have a problem that needs a solution and you find a technology that works, you are purchasing a tool. Plain and simple. Toys belong at home. Tools belong at work. Not vice-versa. Period!

Here are some examples.
• Camera Phone: For me a toy. The only need I have is that my cell phone receives and makes calls when I need it to or when a patient or doctor is trying to reach me. If the cell phone cost me a dollar more because it has a camera in it, it is not worth it to me. On the other hand, if I did lots of hospital work and needed an easy way to capture patient demographic data from the medical chart, the camera phone would be a useful tool.
• The TRIO Phone. This phone has windows CE, calendar, camera, MP3, GPS features, among others. For me, total toy. Again, I need a phone that works. Everything else is bull. I had a partner who had this phone and used to walk around the office with the phone’s GPS feature. Maybe he had a really bad sense of direction and found this to be a useful tool, but I suspect it was no more than a toy. In his defense, he used the phone as a means to transmit data securely to a company for which he was consulting, so the phone for him was a fun tool.
• Tablet PC. For me, right now, in my current situation, this a toy. If I was working multiple rooms at the same time and needed the handwriting feature or needed my patients to complete forms on it, the tablet PC would become a tool. But I don’t. Not right now. I don’t have a use for it and if I bought one, I’d be buying a toy. If you have to change how you operate to justify the technology, you’re buying a toy.
• Electronic medical record software. Tool. But be careful of paying for features that may be toys masquerading as tools. An example may be an e-prescribing feature that allows you to send Rx refills over the internet to the pharmacy. If this saves you time and money and makes you more effective, it’s a tool. For me, a toy. For you, who knows?
• DaVinci Robot: For my hospital, a small community hospital, in my view, this would be toy. A million dollar toy, but a toy nonetheless. For a larger hospital, like Paul Levy’s, it might, I say it MIGHT!!! be a tool.

Anyway, this is an example of how I approach acquiring new technologies. I’m a technophile, within reason.

Hope you liked the post.

Monday, March 05, 2007

Back from vacation

I'm back from vacation with the family. I did a lot of thinking. I spent time with the girls and the wife. It was good. I took some time off from my practice and from the independent urologist. Though not completely.
Admitting that it may sound pathetic, I was not completely away from my practice. Thanks to technology, I was able to stay as connected as I needed to be and wanted to be. Here are some examples.

1: I booked 4 new patients that called the office between 5-7PM. Their calls forwarded to my cell phone and I made the appointments.

2: I spoke to an urgent care doc--one of my best referring docs--who wanted to run a case by me. He called my office at 6:30PM, and was forwarded to my cell phone, seamlessly. I was happy to help him.

3: I accessed my network by VPN from the hotel, checked messages and labs. On my own time and volition, not someone else's!

If this sounds pathetic to you, you are thinking like an employee, not an owner. It made and makes complete sense to me.
Thanks for listening.