Ericka L. Adler, JD, LLM has practiced in the area of regulatory and transactional healthcare law for more than 20 years. She represents physicians and other healthcare providers across the country in their day-to-day legal needs, including contract negotiations, sale transactions, and complex joint ventures. She also works with providers on a wide variety of compliance issues such as Stark Law, Anti-Kickback Statute, and HIPAA. Ericka has been writing for Physicians Practice since 2011.

As the end of the year approaches, physician practices need to start planning for 2022. From a legal perspective, this planning should include a review of the practice’s compensation methodology to assure compliance with Stark regulation clarifications, which will take effect January 1, 2022.

The Stark law generally prohibits a physician from referring a Medicare patient for a designated health service (DHS) to an entity with which the physician has a financial relationship, unless there is an applicable exception. DHS includes many ancillaries which are used in physician practices, such as DME, laboratory, and radiology services. Referrals within the physician practice implicate the Stark law since physicians have a financial relationship with their own practice.

Physician practices that qualify as “group practice” under Stark’s definition can take advantage of an exception to Stark known as the in-office ancillary services (IOAS) exception. Under this exception, physician practices can self-refer Medicare patients for DHS by generally meeting certain location, billing, and supervision requirements.

Five questions to ask about wRVU compensation

A key component of being a “group practice” under Stark is making sure that the group practice is allocating revenue for DHS profit in a compliant manner. This means that a physician practice must have a methodology that at all times allocates the revenue from DHS in a manner that does not reward physicians directly for their referrals. Although Stark’s DHS allocation rules have been in place for years, CMS felt that clarification of the requirement was appropriate. Among the key points CMS clarified about the profit allocation rules were the following:

A group practice cannot distribute profits from DHS on a service-by-service basis (also known as "split pooling"). This means, for example, that dividing up MRI DHS equally, but dividing up lab DHS based on overall profits, is not acceptable. Instead, CMS wants group practices to aggregate all revenue and expenses from all DHS service lines and then distribute that revenue using the same methodology. Popular approaches to allocate revenue and expenses within a group practice included equal distribution, based on ownership percentage, or based on overall productivity (not including the DHS).

A group practice can also segregate and allocate DHS profits generated by "pods" of at least five physicians and within those pods, the group is permitted to use different profit allocation methodologies. However, within each pod, groups must use the same one methodology for all DHS.

Five Telephone Etiquette Tips for Medical Practice Staff

To start the process of evaluating a practice’s compensation approach, consider the following:

Draw a diagram of the practice so you can clearly see which physicians are rendering services in the practice and how they are organized (i.e., location, specialty, etc.)

Identify any groupings of five (5) or more physicians.

Identify the DHS being offered by the practice. This should include Medicare ancillary services only. Confirm the current DHS codes at 

https://www.cms.gov/license/ama?file=/files/zip/list-codes-effective-january-1-2021-issued-december-1-2020.zip

. Note that some DHS are not listed based on CPT Code, but the category of the service is considered DHS, such as drugs, pathology and durable medical equipment.

Identify how revenue and expenses of the DHS are being allocated to physicians in the group practice. If all DHS is being allocated in a permissible manner among all physicians in the practice, the analysis is complete.

If DHS is being allocated in multiple different ways among the practice physician, the practice must choose a single methodology to put in place starting January 2022. If the group has identified pods of five or more physicians, a single methodology must be chosen to allocate the DHS generated by the pod. It need not be the same methodology as the remainder of the group practice as long as it is compliant. 

If the group determines that it has been allocating DHS in a manner that is based on physician referrals, the group should take steps to bring the practice compensation approach into compliance by January 2022. The practice should then talk with counsel for guidance about reporting any Stark non-compliance. CMS has a specific Self-Referral Self-Disclosure Protocol to report identified Stark compliance issues. 

Put in place a plan to review the group practice’s compensation approach annually. Because group “pods” can change in size over time as physicians join and leave a practice, and DHS covered by Stark changes annually, it is advisable to conduct an annual audit of the group practice’s compensation methodology.

Compliance with Stark is essential for physician practices that see Medicare patients and self-refer for DHS. The consequences of non-compliance are financially and legally significant. Talk to your health law counsel and financial advisors so that a plan can be in place before the end of the year.

, JD, LLM has practiced in the area of regulatory and transactional healthcare law

for more than 20 years. She represents physicians and other healthcare providers across the country in their day-to-day legal needs, including contract negotiations, sale transactions, and complex joint ventures. She also works with providers on a wide variety of compliance issues such as Stark Law, Anti-Kickback Statute, and HIPAA. Ericka has been writing for Physicians Practice since 2011.

Articles

Here’s how to make sure your practice is in compliance with Stark regulation clarifications taking effect January 1st, 2022.

Review your practice’s compensation methodology before the end of the year

, JD, has practiced law exclusively in the areas of asset protection, risk management and wealth preservation for the last 16 years. He helps protect a national client base with more than $5 billion in personal assets, including several thousand physicians. He is a contributing author to multiple books for physicians and a frequent medical conference speaker and CME presenter. 

Asset Protection Attorney and regular Physicians Practice contributor 

, an investment advisor representative and the founder and president of 

 to discuss the most common and costly asset protection and wealth preservation mistakes high-earners make, what high earners need for a compressive asset protection and wealth preservation plan, and more.

Videos

Two experts discuss the most common and costly mistakes high-earners make.

Ike Devji, JD and Anthony Williams, Part 2

Is your practice plagued with no shows, cancellations, and a schedule filled with blanks? Are your waiting rooms only half filled? Well, let me ask you this question: Do you have the contact information for all of your patients in a place that is easily accessible? I'm guessing it's somewhere in your medical record going unused. Let me teach you how to hack one of the most important things to a successful practice: patient retention.

I promise if you follow these instructions, you will be well on your way to marketing automation and this will keep your patients in your practice for the long term.

Retain more patients with these four tips

, is passionate about using technology to improve the lives of patients and healthcare providers. She graduated from the University of Illinois College of Medicine and was a pediatric resident in the Kaiser Permanente Oakland/Berkeley MPH program before making a career shift into digital health. She advises and directs early-stage health technology startups with her carefully honed skills in communication, strategy, research, and product development. She is a licensed California physician and runs a boutique medical practice in San Francisco specializing in health optimization.

Slideshows

These four tips can make current patients long-term ones.

Alfredo Rosing is the Vice President of Marketing at Greenbox Capital®. 

With over 25 years of combined experience in marketing and financial services, Alfredo is an expert on innovative financial technologies with a passion for connecting consumers and businesses with socially responsible funding. Prior to joining the Greenbox Capital team, Alfredo launched an award-winning online lender that was recognized as the winner of the 2017 Fintech Awards US Firm of the Year for Lending Innovation Award. Alfredo is a graduate of Southern New Hampshire University with a BS in Marketing.

Whether you’re opening a private practice, supplementing your cash flow, or expanding your offices, medical practices of all sizes and specialties can benefit from an infusion of working capital.

Between traditional SBA and bank loans and new forms of alternative funding, it can be difficult to determine what medical practice funding is best for you. Keep reading to learn more about 6 of the most popular physician business loans.

Two things every standout healthcare manager does

1. Small Business Administration (SBA) loans

SBA loans are not actually provided by the SBA—they are disbursed by partnering banks and guaranteed up to 85% by the SBA. Multiple SBA loan options exist, including the popular 7(a) Guaranteed Loan program, microloans, express loans, and 504 Local Development Company Program loans.

SBA loans typically offer the lowest rates, longest terms, and largest loan amounts (up to $5M), making them the preferred option for many physicians. However, these loans are the most difficult to acquire with the longest application process and extensive paperwork requirements, including years of detailed business and personal financial documentation. Collateral or a personal guarantee are typically also required.

Business owners with exceptionally strong credit seeking a long-term loan

Bank loans may be easier to acquire than SBA loans, especially if you have an existing relationship with a lender. Terms and rates are competitive and typically depend on the size of the loan; however, similar to SBA, it may take weeks or longer to learn whether you’ve been approved, and approval is never guaranteed. Collateral or a personal guarantee is often required.

Some lenders, including Wells Fargo and Bank of America, offer funding options designed specifically for doctors. These loans consider the unique profile of medical practices, including factors like student debt or low cash reserves.

Start-ups looking for customized funding that considers unique circumstances like student debt

Established, larger practices with strong financial histories and a clear idea of how they’ll use their funding

A merchant cash advance (MCA) is a non-loan form of financing that is available from alternative lenders, including direct online lenders like Greenbox Capital®, OnDeck, and Kabbage. With an MCA, a business is granted a cash advance in exchange for a percentage of their daily or weekly debit and credit card sales until the advance has been repaid.

Rates may be higher than traditional forms of funding, but lending requirements are more flexible and the application process is significantly streamlined. Approvals are based on the overall health of your practice, not just your credit records and financial history. In some cases, approval can even be made in as little as one business day.

Businesses who need immediate funding or fast access to working capital

Businesses seeking smaller loan amounts and shorter terms

Businesses who would not be approved by traditional lenders, such as businesses with low credit scores

Lines of credit are available from traditional banks and alternative lenders. They function similarly to a business credit card, but typically for longer terms and with larger limits.

Lines of credit offer the most flexibility, allowing you to draw and repay from the line whenever needed. You only ever pay interest on the amount borrowed.

Business with a strong credit history who want a cushion to fill cash flow shortages

Businesses who need flexible access to working capital

Practice acquisition loans are designed specifically for the purpose of 

purchasing a retiring doctor’s practice

Some lenders, including Wells Fargo and the Bank of America, offer specific lending programs designed for doctors looking to purchase an existing practice. Collateral or a personal guarantee are required.

Practice acquisition loans are ideal for:

Established businesses with strong financial histories who are looking to expand to a new location

Start-ups looking to purchase an existing practice from a retiring physician

Why you should know your patient’s behavior styles

Medical equipment can be expensive to purchase and repair. Equipment financing is designed to finance the purchase or repair of medical equipment, such as imaging machines, diagnostic equipment, lab equipment, exam tables, computers, wheelchairs, and more.

The equipment serves as collateral, and terms will typically match the lifespan of the equipment. A down payment may be required.

Businesses with significant or immediate equipment needs

The best medical practice loan ultimately depends on your goals and your practice’s creditworthiness. 

Six medical practice funding and physician business loan options

Founder and CEO of San Francisco based Curebase

Their solution is a decentralized clinical trial software platform and clinical service provider. Curebase enables any patient, anywhere, to participate in clinical trials at home and with their own doctor.

The COVID-19 pandemic proved that the healthcare industry’s traditional model for clinical trials represents a limited model for medical research. What we define as conventional trials are costly, slow, and cap diversity and participation, and as a result often stifle the research that they are intended to promote. However, decentralized clinical trials (DCTs), which leverage technology to collect patient data remotely, are now changing the industry by helping to increase trial access and participant diversity.

As DCTs continue to evolve, we see that technology is allowing us to bring research into almost any clinical setting. In fact, patients can even identify trials and bring their own physician on board to administer most of the care. This is a concept I like to call “Bring Your Own Physician” (BYOP). 

Abrupt switch to patient-centric decentralized clinical trials

 encouraging CROs, PIs, and sponsors to adjust their clinical trials to better navigate the challenges presented by the pandemic. Some trials that began centralized became DCTs, making the process more patient-centric. The industry quickly saw that the recruitment, diversity, and speed benefits of the DCT approach were compelling. The FDA continues to support this guidance today. 

The volume of DCTs is expected to grow in the coming years, as demonstrated by 

 that captured the dramatic shift in attitudes by pharmaceutical companies and contract research organizations (CROs) toward virtual clinical trials. In December 2019, 38% said they expected virtual trials to be a significant component of their portfolios, and 48% expected to run a trial with most activities conducted in participants’ homes. However, a year later, in the midst of the pandemic, 100% expected virtual trials to be a major component of their portfolios, and 89% expected to run a trial with most activities conducted in participants’ homes. The industry is changing. 

In the foreseeable future we will see DCT continue to evolve and find the best methods for executing effective and efficient research. During this time of iteration, technology will be leveraged to advance DCT solutions around issues like recruitment, data integrity, trial diversity, and security. But most importantly we will see research trials becoming part of a healthcare practitioner’s daily arsenal for treating their patients. More simply, research will center around the patient and their healthcare team, not the other way around.

Leveraging participants’ doctors as part of the trial team

One of the industry’s most recent and significant DCT innovations is BYOP. The idea is simple, focus on working with the patient’s preferred physician administering the majority of standard medical care and data collection, while validating and submitting the details through technology to the PI’s team, thereby improving recruitment, compliance, and completion rates. This approach is exceedingly valuable to the industry because not all trials can be done from home, many require detailed and intricate treatment plans, and people are reluctant to travel to participate.

The BYOP model is crucial to unlocking the greatest capabilities for a decentralized trial. First, travel issues are eliminated by the program design and the local accessibility is more attractive to the patient. Second the patient continues to use with their trusted care team, which improves engagement and compliance with the trial, regardless of complexity. And finally, recruitment is markedly improved with the ability for medical doctors across the nation to make the trial available to their patients.

Mid-pregnancy is a time when you are very unlikely to pry an expectant mom away from her clinician and into a research environment. However, leveraging the BYOP model, the patient’s own trusted care team can conduct regular exams, collect real-world data, and talk about trial-related issues and experiences, while adding this information to the trial database.

Having trial participants work with their own OB/GYN can also improve trial retention and consistent compliance. Simply, moms-to-be are already attending many health appointments, so additional touchpoints are rarely necessary, making the experience easier on the patient. Also, these trusted patient-physician relationships establish more open lines of communication, enabling trial sponsors to boost the quality and accuracy of information gathered throughout the process.

Further, technology integrations mean that OB/GYNs are not required to do any additional work, in most cases. The data is recorded as part of the patient’s normal care, then technology securely provides the necessary information to the researchers.

Overcoming patient transportation barriers to care

Thanks to modern technology, both patients and physicians can suggest the idea of a clinical trial as a care option under the BYOP model. Clinical research could then potentially be considered a standard interventional treatment offered as a care alternative to eligible patients, making local primary care physicians, specialists, and clinic teams key members of many clinical trial teams. Furthermore, solving for the many challenges associated with recruitment and compliance will dramatically advance research as a whole.


The future of medical research is patient focused. Increasingly, qualified patients will participate in clinical trials locally with their own doctors via BYOP and trial participation will become a standard of care option. As access and diversity expand, each study’s scale, depth, and quality will continue to improve. Although there are undeniably some state and federal 

 ahead, DCTs have already demonstrated their efficacy and earned the support of regulators and other industry stakeholders. The future of clinical trials is here, and it is a future of decentralization, virtual technology, greater patient access, and wider participant diversity.

Technology is allowing physicians to bring research into almost any clinical setting.

How physicians and patients are partnering to evolve the decentralized clinical trial model

 to discuss the impact of Covid-19 on assets, alternatives to hedge against downside risk, what high earners can expect with impending tax changes, and more.

Two experts sit down and talk about asset protection.

Ike Devji, JD and Anthony Williams, Part 1

In part eight of our ongoing series on medical malpractice and asset protection, we look at the important details every doctor must understand about their medical malpractice insurance, and why not all polices are equal.

Among the most important layers in a physician’s asset protection planning is their 

 as we touched on in part five of this series. We’ve previously discussed on many occasions that asset protection has three primary layers:

 Following industry best practices (like maintaining strict standards on 

), laws and compliance, and ethical standards in all areas to avoid liability in the first place.

 This means all the right kinds of insurance, to the right coverage limits with the right features and scope of coverage. This includes medical malpractice insurance to cover both any possible judgment against you and the significant and unavoidable costs of legal defense, which are easily six figures on their own.

Legal tools to proactively separate business and personal assets and liabilities.

 This limits your personal exposure for any gaps in your insurance for issues that are either 

 by insurance, or which create a liability 

Passive Real Estate Investing: Basics and Benefits

Basic Medical Malpractice Policy Vocabulary Every Physician Must Understand

 you must pay for unexpected or excessive liability that your insurance carrier may incur. Assessment risk is most common in risk retention groups and captive insurance arrangements where there may not be adequate excess reserves to cover this variance. Most commercial insurance policies, on the other hand have this risk built into their premiums, so buyers should know if their coverage carries this assessment risk (an extra bill) and carefully consider if the lower premium is worth the potential additional risk.

How ambulatory care practices can reduce cybersecurity risk

 insurance indemnifies you from malpractice “claims made” by patients when the policy is active and requires tail coverage. 

 insurance covers any incident that occurs when the policy is active, regardless of when a claim is made, more inclusive, no tail required.

 clause determines if your consent is required by your insurance carrier to settle your case. The 

 determines how the insurance carrier’s liability may be limited, and how yours may actually be increased if you do not provide consent to settle and a trial results in a verdict that is larger than the amount they wanted to settle for. Patricia Legant, MD, PhD a solo oncologist who served on the board of a physician-run malpractice insurance company, 

Some carriers prefer to settle a suit, even one without merit, because the cost of defense might exceed the amount of settlement. But any settlement made on your behalf must be reported to the National Practitioner Data Bank, so a settlement can adversely affect your insurance status, ability to participate in a managed-care group, and application for hospital privileges.

Before you purchase a policy, try to negotiate the terms so that your policy includes a consent-to-settlement clause and omits a hammer clause.

Defense Inside the Limits vs. Defense in Addition, who pays the lawyers?

 It’s vital that you understand who bears the liability for the costs of your defense including legal fees, court costs, experts, and all other related expenses. You should be able to answer the following questions about your policy:

Is that coverage limited to a specific dollar amount?

Do defense costs come from inside the policy, thereby reducing the amount available for judgments or settlements, or are they separate; if so, is there a limit? Example, $1MM policy limit, $300K for defense costs may equal $700K available for judgment or settlement.

 There are two important numbers here, first the 

, how much your policy covers per each claim filed. Second, the 

, the total dollar amount the policy will pay out during the policy period. For Example, many doctors have $1 million 

 during the policy period and are personally financially responsible for 

 and Exclusions. Know if the policy covers your staff, your practice and 

, JD, has practiced law exclusively in the areas of asset protection, risk management and wealth preservation for the last 16 years. He helps protect a national client base with more than $5 billion in personal assets, including several thousand physicians. He is a contributing author to multiple books for physicians and a frequent medical conference speaker and CME presenter. Learn more at

What doctors must understand about their insurance and why not all polices are equal.

Medical Malpractice and Asset Protection, Part 8: Med Mal Insurance

Recent surveys show that everyone, even older patients, uses the Internet to access healthcare information and discover providers. As a result, a nicely-designed website has never been more important for practices.

“This is the new phone book,” said Derek Kosiorek, at the time the principal with the Medical Group Management Association’s (MGMA's) consulting arm. “Websites are your new front door. This is the first impression people will get of you.”

Kosiorek shared some tips with attendees at an MGMA conference on building the ideal website to attract potential patients. Here are a few of them.

Tips for building your practice’s website

Editor's Note: This slideshow originally appeared in article format on Physicians Practice in 2015. 

Planning on building an engaging website to attract patients? Here are nine tips that should get you started.

MBA, CFP®, AIF® began her career in financial planning in 1988 and co-founded Atlanta Financial Associates in 1992, merging into 

in 2020. She specializes in working with physicians and executives in the healthcare industry. Her passion for working with physicians comes from being a pediatrician’s spouse for more than three decades. Julie has been featured on Forbes’ list of America’s Top Women Wealth Advisors since 2017 as well as Forbes’ 

For affluent parents and grandparents, 529 plans are synonymous with college planning, but they can offer a variety of potential benefits that go beyond their traditional role. In fact, a 529 plan can be a worthwhile estate planning tool for physicians looking to reduce the size of their taxable estate while maintaining control of their assets.

Making prior authorizations less burdensome

Using a 529 Savings Plan to Save for College

529s are first and foremost a college savings tool. College savings plans come in two forms: prepaid college tuition plans or 529 savings plans. The former allows you to lock in today’s tuition rates, while the latter allows you to choose from a selection of investment choices depending on your personal preference. 529 savings plans are state sponsored but administered by one or more investment companies. Keep in mind, you aren’t limited to the plans in your home state. You can participate in national plans sponsored by other states as well. When making this choice, check into any tax advantages your state may offer if you utilize the 529 plan sponsored by your home state.

There are a number of benefits that make 529 plans appealing, but the most popular perks include:

They allow investment earnings to potentially grow while remaining sheltered from federal (and possibly state) income taxes.

Withdrawals made for qualified purchases (related to higher education) are made income-tax free.

In some states, contributions can be used to lower state taxable income.

Eligibility to contribute to a 529 plan is not limited by age or income (a plus for high-earners).

Funds can be used to pay for tuition and fees for undergraduate school, graduate school, or tuition at an elementary or secondary public, private, or religious school.

Withdrawals that do not fall under the IRS’s definition of "qualified education expenses" are subject to ordinary federal and state income taxes and may be subject to a 10% additional federal tax penalty unless a specified exception applies.

Using Your 529 to Reduce the Size of the Taxable Estate

It’s clear to see why 529s are often the preferred method for college savings, but how about the role they can play in limiting estate taxes? What’s little known to many investors is how 529s can support a long-term gifting strategy that allows donors to maintain control over the assets while also removing them from their taxable estate.

Contributions made to 529 plans are considered gifts from the donor to the beneficiary, despite the accountholder’s authority over the money in the account.

Federal tax law allows individuals to give up to $15,000 (indexed to inflation) tax-free to as many individuals as they choose each year (up to $30,000 for couples).

Scheduling gifts up to these tax-free limits each year reduces the taxable estate.

Parents and grandparents, then, can make scheduled gifts up to the tax-free limit each year, gifting $15,000 to each grandchild (and/or great grandchild) on an annual basis.

But what if you need a bigger impact on a shorter time frame? Luckily, gifting can be accelerated to accommodate. Individuals can elect to make a lump-sum contribution of five years’ worth of gifts, or $75,000 in one year, tax-free. Of course, any other gifts made outside the 529 in those five years (to the same individuals) will count toward this allowance, so be sure not to exceed the threshold unless you’re prepared to potentially pay gift taxes on the excess amount.

The wealth transfer potential here is unmatched by virtually any other savings tool available. An individual who has four grandchildren, for example, could immediately remove up to $300,000 from his or her taxable estate by contributing the money to four separate 529 plan accounts. Every five years, this process can be repeated. And if the donor is married, the spouse can follow the same strategy.

Again, it’s worth stressing that the assets gifted into the 529 remain in the control of the accountholder, not the beneficiary. There will be no need to worry about the beneficiary using the funds without your express involvement in or oversight of the withdrawal. The accountholder also can change the beneficiary of the account if desired to any first degree relative of the original beneficiary (e.g., sibling, cousin, etc.) making these very flexible investment vehicles while still remaining outside of the donor’s estate.

Coding and billing for advanced practice clinicians

Including 529s in Your Gifting and Estate Planning Strategy

Beyond their place in college planning, state-sponsored 529 college savings plans have the potential to double as high-powered estate planning tools for affluent physicians and their families.

All expressions of opinion reflect the judgment of the author as of the date of publication and are subject to change. Some of the research and ratings shown in this presentation come from third parties that are not affiliated with Mercer Advisors. The information is believed to be accurate, but is not guaranteed or warranted by Mercer Advisors.

The ranking of the Forbes “Top Women Wealth Advisors” and “Best-In-State Wealth Advisors,” was developed by SHOOK Research and is based on in-person and telephone due diligence meetings to evaluate each advisor qualitatively, a major component of a ranking algorithm that includes: client retention, industry experience, review of compliance records, firm nominations; and quantitative criteria, including: assets undermanagement and revenue generated for their firms. Investment performance is not a criterion because client objectives and risk tolerances vary, and advisors rarely have audited performance reports. Rankings are based on the opinions of SHOOK Research, LLC and not indicative of future performance or representative of any one client’s experience. Neither Forbes nor SHOOK Research receive compensation in exchange for placement on the ranking. For more information:

Mercer Global Advisors Inc. is registered with the Securities and Exchange Commission and delivers all investment-related services. Mercer Advisors Inc. is the parent company of Mercer Global Advisors Inc. and is not involved with investment services.

All expressions of opinion reflect the judgment of the author, are as of the date of publication, and are subject to change. The information discussed is believed to be accurate but is not guaranteed or warranted by Mercer Advisors. Due to various factors, including changing applicable laws, the content may no longer be reflective of current opinions. Moreover, you should not assume that any discussion or information contained in this blog serves as the receipt of, or as a substitute for, personalized investment advice from Mercer Advisors. Mercer Advisors is neither a law firm nor a certified public accounting firm and no portion of the blog content should be construed as legal or accounting advice.

These plans can offer a variety of potential benefits that go beyond their traditional role. 

Using a 529 Plan for estate planning 

Podcasts

Physicians Practice® spoke with Hari Prasad, CEO of Yosi Health, about how what practices need to know about setting up and making the most of their virtual waiting rooms.