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Ask the Experts: Your Top Questions Answered Setting Marketing Budget; Unique Fee Schedule for Medicare/Medicaid; Relocating an Office; Who Handles Office Squabbles?; Best Optical Character Recognition; Starting a New Practice; Consults on Established Patients; Pain Pump Coding;
Q I am looking for benchmarks for marketing budgets for physician practices.
A The benchmarks are included in the Medical Group Management Association's Cost Survey. For multispecialty practices - not hospital owned - the median is 0.39 percent of total medical revenue, or $2,927 per FTE physician. Q Is it legal for a practice to charge Medicare/Medicaid according to one fee schedule and to charge commercial carriers at another fee schedule? My office would have two fee schedules. The reason is that the allowable from CMS and some of the commercials are so varied, especially for surgery, that the practice is concerned that Medicare/Medicaid may see it as overcharging CMS. I am aware the OIG is unsuccessfully pushing for Medicare charges to exceed no more than 120 percent of the allowable amount. In this scenario self-pay patients would be charged a fee equal to the Medicare allowable or up to the limiting charge (115 percent) of the Medicare allowable depending on practice. A There is no legal reason not to charge Medicare/Medicaid more than they pay. It is your usual and customary charge. Furthermore, you run the risk of commercial payers insisting that what you charge Medicare/Medicaid is your usual and customary charge, and they'll happily pay you the same. Plus, you run the risk of making mistakes and charging wrong. And, your gross collection rate will be whacked out. Why try to solve a problem that does not exist? There are enough problems that do exist.
Q I have been unable to find any tips for managing the relocation of a medical office. We will be moving in six months and this would be most helpful.
A Much depends on exactly what kind of a switch you are making, but consider these issues: • Incorporation - Are you just moving, or are you setting up a new practice? Most states will let you practice as a "foreign" corporation when you relocate to a new state, but there may be more hassle. If so, you'd be better off liquidating the old corporation and incorporating again in your new community. • Finding and filing paperwork with all payers, vendors, etc. - Assuming you have an address picked out, fill out the paperwork to change your address with the post office, payers, and everyone who bills you. It might help to make a list from your management software of everyone you've paid or who has paid you. Also contact the state medical board and the DEA, if you have licenses from them. You'll also want to inform the state and feds for tax-related reasons. • Prepare budgets - You may want to prepare a couple of budgets to plan ahead for possible glitches. Account for property acquisition and remodeling, marketing the new location, and temporarily increased operating costs as you work out the kinks. You can also expect to lose at least a few patients, even if all you are doing is moving a few miles away, so you might project lower income at first. Over time, of course, if the area is busier, more visible, or convenient to better-paying patients, you can project growth. • Marketing - Let your patients know you are moving and prepare to get some new ones. Set a budget and work with a designer to create a postcard or other announcement of the move, complete with map, and a very short explanation of how the move will benefit the patients. Send it to everyone you have seen in the past three years if you are in primary care. If you depend on referrals, market to your referral base. Also market in the community where you are moving. The neighborhood paper might wish to cover the move; call them and offer to write a story about the move or a series of articles on healthcare issues that will include your address at the bottom. • Patient rights - You are required to let patients know where to find you and their charts. Publish a notice announcing this in the city and the local paper. The notice must contain the date of sale, termination, or relocation, as well as an address from which patients may obtain their records or have them transferred. You should also place a sign with the same information in a conspicuous location in your office or on its facade at least 30 days before the change, and you should write patients. • Hospital - Do you need to get credentialed with a new hospital? Can the hospital help you market your practice? • Staff - Let your staff know about the move sooner rather than later. If some don't want to change locations, you better find out now so you are not caught short-staffed.
Q When staff bicker should I get involved or is that a job for the office manager?
A Generally, I like to see staff issues resolved by the manager. You need to focus on treating patients. That said, the office manager should work under your direction. Meeting privately, the manager ideally suggests a course of action, you reach agreement, and she goes forth and implements it. You then need to back her up fully and direct any staff complaints back to her. Now, it may be that in a small practice like yours, the manager isn't really "managerial" enough, if you will, to handle this task. If so, then one of the two physicians needs to be responsible. What matters more than whose job it is, is that it is one person's job. Staff need to know who to go to with issues. They need to know that the person in charge speaks for the practice and there is no point in trying to get a different answer from the other physician or the manager. They need to know that every case is being handled the same way.
Q We scan all of our EOBs as a record of our work and frequently need to go back to an individual patient's EOB to appeal. I have experimented with different optical character recognition (OCR) programs for our PDF documents but have found nothing is really getting better than about an 80 percent find rate. Do you know software that is better or an integrated solution?
A According to technology expert Rosemarie Nelson, the best "find" rates come with an integrated scanning/indexing solution that is married to the practice management system. For example, IDX (now GE Centricity) has a very strong solution that indexes the EOB directly to the charge transaction on the patient's financial record. It may also be helpful if they are applying the ERA (electronic remittance advice) as they will have detail (including dates) that will help drive to the desired info. Bottom line: try to work with the provider of your practice management system. Q I am an employed pediatrician considering going into equal partnership with the administrator of another practice. Our goal would be to develop offices in several locations, employing others to staff them. What is wrong with this picture? What should I be aware of? What precautions should I take? A Here are a couple of things that come to mind: What are the state laws concerning how your practice can be organized? Is it an LLC? You may not be allowed to form a professional corporation with a manager as a partner and there may be negative tax consequences. Just look into how you'll form. Carefully work through what happens if you or the administrator leaves or are asked to leave. Why multiple locations to start? You'll have extremely high overhead and low revenue in the beginning. You'll want a robust business plan with detailed expected revenue and cost projections over the first year. It would be less risky to grow organically. Consider the reimbursement scenarios for your employed physicians. Pediatrics is high-volume, as you know. Flat salaries don't encourage productivity. Consider recruitment scenarios for employed physicians. A good, experienced doc with a following is unlikely to join as an employee. She'll want a piece of the pie and longer-term security. She'd certainly not want to report to a manager. It may be OK to have mostly young physicians who rotate out as they get older, but keep in mind the impact on patient loyalty and revenue (slower physicians, high recruitment costs). What distinguishes these practices from all the others in your area? What is your brand? What would make a mom switch practices to you? Or would you target newcomers? If so, would you do hospital rounds to infants? How does that impact the staffing and reimbursements model? None of these issues are insurmountable. You'll just want to make sure you have it covered.
Q I'm an ENT. Last week, I saw a patient previously referred to me by an internist. The patient's last visit was 13 months ago for otalgia. He is now referred to me by an ophthalmologist for an entirely unrelated medical problem (obstructed lacrimal duct).
The ophthalmologist obviously wants a consult-like report. Can I bill it as a consult even though the patient is established? What if the patient was sent by the same referring doc but for an entirely different medical problem? A Yes, you can code a consult for an established patient, regardless of the condition. For example, primary-care physicians can code for preoperative consults requested by surgeons even for patients they see all the time for related issues. I think your bigger issue is whether this is indeed a referral or a consult. If the ophthalmologist specifically seeks your opinion, it's a consult. If she is asking you to solve this problem for the patient to take over care - then it's a referral and should be billed as an established visit.
Q Is there a procedure code for placement of a pain pump after 15830 and 49587?
A You'll need to check with your carriers. However, most do not reimburse separately for insertion of pain pumps, considering it part of the surgical package; this is Medicare's stance. According to the Medicare Carriers Manual section 4820-4830 or 100-04 Claims Processing Section 30, postop pain management is included in surgical procedures. There are no CPT or HCPCS codes that describe placement of a pain pump catheter. For example, code 37202 is a cardiac procedure, not a pain pump insertion into a muscle or site. | 
