Rodrigo Martínez is a practicing otolaryngologist and the Chief Medical Officer for 

, a provider of healthcare communication and provider scheduling technology.

The world has shifted a bit in the past few years, hasn’t it? COVID-19 brought us to our figurative knees in 2020, and the weight of its impact continues to grow. And while a pandemic of this nature is bound to expose weaknesses and bring about change, I’d like to explore one area in greater depth: medical practice communication.

Healthcare is almost never the realm of early adopters when it comes to technology, but as patient behaviors evolve, it’s clear that today’s status quo is falling short. According to the 

, more and more patients are “moving away from traditional types of care.” For example, roughly one in three in the Gen Z and Millennial cohorts has used a retail clinic like Walgreens or CVS in the past 12 months.

There isn’t just one reason for this shift, but I can say this much: Patients are less tolerant than ever of disjointed care experiences filled with delays and poor communication. On the flip side, providers are still battling staff shortages and the rising tide of burnout, both of which have been supercharged by the pandemic. It’s a conundrum.

As it turns out, there are pragmatic ways to apply technology in the medical practice setting that can alleviate some of these issues, many of which are rooted in — or heavily influenced by — communication workflows. Here are three tips for leveling up your practice operations with better technology.

I can talk to you all day long about secure messaging and efficient communication, but if you don’t know who’s working or how to reach them, it’s a moot point. It’s time to stop using sticky notes, paper and pencil, fax machines, and emailed spreadsheets to maintain schedules. These are tedious and error-prone methods, and they lead to schedules that are likely to be outdated the minute they’re distributed.

The foundation for reliable communication workflows is an accurate call schedule that can be easily referenced and updated by your staff. The best communication solutions have built-in on-call scheduling management, which equips your practice with one source of truth for all matters related to scheduling. It also means a real-time schedule is readily available to anyone using the communication app, and all changes or updates to the schedule are reflected immediately — no more guesswork.

Clinical communication — whether by phone, text, or any other method — doesn’t do any good if a person who can take appropriate action never sees, hears, or receives it. Maybe the operator from your after-hours answering service calls the wrong doctor to leave an urgent message, or perhaps an important message in the patient record was missed because the notification capabilities aren’t very sophisticated.

Whatever the case may be, technology exists that can ensure all of your practice communications are automatically routed according to up-to-date provider schedules, individual contact preferences, and other predetermined rules. This means messages never fall through the cracks, and as an added bonus, providers can even control how they’re reached based on time, date, urgency, and other factors.

Bypassing manual workflows with smart routing makes it easier for all staff to receive the most comprehensive and timely patient communication. Why settle for games of phone tag, rudimentary secure messaging that delivers texts to unmonitored inboxes, and other unnecessary delays?

It’s likely that many of us have had recent experiences with consumer tech that are more intuitive and satisfying than similar experiences with healthcare tech. Off the top of my head, a friend recently raved about canceling and rebooking a flight in just 10 minutes using the airline’s in-app live messaging function. It was simple, the agent was quick and helpful, and my friend is now a more loyal customer than ever.

Another friend recently messaged his primary care doctor through the patient portal about an important-but-not-urgent issue, and after getting one brief response, all additional inquiries through the portal went unanswered. He was frustrated, to say the least.

With the right setup, your practice can utilize technology that incorporates the aforementioned routing and scheduling capabilities with easy-to-use multichannel communication functionality. That’s a bit of a mouthful, but consider the possibilities of engaging patients in a structured, timely, and reliable manner via phone, text message, or even video call. After-hours call about an urgent issue? Route it to the on-call doctor. Lots of appointments tomorrow? Send automated text message reminders to all patients. Routine check-in that doesn’t require an in-office visit? Host a quick video chat.

I could go on, but the point is that you no longer have to settle for flawed processes or clunky solutions to stay in touch with your patients. By bringing all of that communication together in one orderly system that supports multichannel outreach, you’re meeting patients where they are and giving staff the tools they need to keep up with the times.

The past few years have proven that medical professionals are smart, dedicated, and selfless. Unfortunately, they’re often asked to do more with less, and many have simply reached their breaking point. It’s not possible to juggle so many balls without dropping a few, especially in a demanding work environment.

So my humble proposal is as follows: Think about these tips and consider how day-to-day operations at your practice would improve with technology that enables better communication, scheduling, and patient engagement workflows. There’s a tendency in healthcare to stick with processes no matter how frustrating they are, but that mindset has gotten us into trouble. If it seems crazy that putting together and maintaining provider schedules is a tedious, neverending affair, that’s because it IS crazy. It’s good to question flawed processes because that’s how we get better.

I’m not here to tell you which technology partner to work with or how to evaluate your options, but I know everybody is better served when communication and care coordination are not constant sources of frustration. By using modern technology, you can alleviate many of the factors that contribute to this frustration. And better yet, you’ll free clinicians up to focus on what matters most — taking care of patients.

Articles

As patient behaviors evolve, it’s clear that today’s status quo is falling short.

 3 Ways technology can level up your practice’s communication workflows

10 Worst States for Healthcare in 2022

 revealed the states where Americans can expect to receive the worst healthcare. Results were calculated by looking at metrics such as cost, accessibility, and outcome.

Slideshows

The ten worst states for receiving healthcare in 2022.

Medical Economics is looking for physicians to participate in our 2022 Physician Burnout and Wellness Survey. 

The survey results are completely anonymous and will aid in Medical Economics creating content to address the challenges of physician burnout, work-life balance, and more. The results will be published in our September 2022 print issue, along with some useful articles and other content.

The survey will only take a few minutes. 

The quick survey will help address the challenges physicians are facing.

Take the Medical Economics 2022 physician burnout survey

After a 15-month fight with Long COVID, author Lucien W. Roberts, III, MHA, FACMPE, retired in February 2022 on the advice of his primary care doctor and his wife…perhaps not in that order.In retirement, he spends a few hours a week at a freestanding infusion center he co-owns, writes the occasional article, and tries not to drive his wife too crazy.He may be reached at 

Primary care physicians are graded – and often paid - on their ability to get their patients to undergo preventive screenings; much easier said than done with some patients. As a retired GI practice administrator, I wish to share ideas for helping primary care practices hit their colorectal cancer screening metrics. These ideas should also help GI practices improve their performances as well.

 – I knew year-end would be filled with calls from primary care practices and accountable care organizations wanting to close colorectal cancer screening gaps. There are two issues with waiting.First, many patients don’t want to their holidays tainted by a colonoscopy. Second, there just aren’t enough available colonoscopy slots to appease everyone in the last 3-4 weeks of the year.

Colorectal screenings are preventive care and thus do not hit patient deductibles; waiting does 

 make sense. Make screening outreach a year-round effort.

 – Outreach should be a joint effort.Ask your friendly neighborhood GI if her practice will work together in reaching out to your patients.Screening colonoscopies are the financial bread-and-butter of most GI practices, so their incentives are absolutely aligned with yours. They want to make your life as easy as possible so that you don’t rely on other options such as DNA stool tests.

Catch the ones who have slipped through the cracks

 get a colonoscopy report because a patient didn’t give the GI practice your name – it happens – or the practice didn’t send you the report. Share your ‘due’ list with the GI group and ask them to run your list against the patients they have screened in the past couple of years. It’s straightforward Boolean logic and usually finds a few patients who have been missed.

 – Several GI practices, including my former one, have embraced digital outreach to encourage patients to get screened. It proved exceptionally effective with the “stubborn third”, those patients who rarely come in for a visit and are so good at ignoring letters from both you and the insurance company. If your friendly local GI has not adopted these direct-to-patient techniques, recommend they look into companies such as Hypertargeting.com*. Again, the GI’s incentives are aligned with yours, and their ROI on digital outreach will be rock solid.

 – The American Cancer Society reports that people born in 1990 have twice the risk of colon cancer as people born in 1950. For rectal cancer, the risk is quadrupled! And the incidence of colorectal cancer in persons under the age of 50 has been going up nearly 2% annually in the past decade. That means my children are a lot more likely to get colorectal cancer than me; the same holds true for many of you. Sedentary lifestyles and attendant obesity are the most likely culprits for this unfortunate shift. And while we may not get them off their computers, we can encourage them to get screened.

Ask your friendly local GI to provide brochures and infographics for your patients.Educate your forty-something patients. Educate your older patients, too, so that they might educate their forty-something children.

 – Preventive care offers an opportunity to save lives and save healthcare dollars while helping our bottom lines. That’s perverse, I know, but that’s healthcare circa 2022. We need to approach care differently. The tactics I share above have helped my medical community in all regards, and I hope they will be of benefit to you.

* Disclosure – While Lucien is a fan of Hypertargeting, he is neither employed by Hypertargeting nor paid by them for his recommendation.

These ideas should also help GI practices improve their performances as well.


Improving colorectal cancer screening rates

With all the useful information available on Physicians Practice, it is easy to become overwhelmed.

With this in mind, the tip of the week is a chance to reflect on some of the wisdom found all across the site.

Doctors’ offices are busy places, and it isn’t unusual for patients to call in asking to speak with the doctor. CPT offers codes to report telephone services provided by a physician or other qualified health care professional who may report evaluation and management (E/M) services.

2). 99058: Services provided on an emergency basis

- When a patient is seen on a emergency basis and it disrupts the flow of the office you may be able to bill this code.

- Providers can bill code 96160 when they perform a health risk assessment with a patient or caregiver/guardian in order to assess the risk of conditions such as mental disorder

Be sure to come back next week for another Tip of the Week!

Your weekly dose of wisdom from the Physicians Practice experts.

Practice tip of the week: 3 billing codes physicians should use

Bruce D. Armon, a Partner and Chair in the Healthcare Practice at Saul Ewing Arnstein & Lehr, counsels clients on how federal and state health care laws affect health care providers and businesses.

Justin C. Danilewitz, a Partner in the White Collar and Government Enforcement Practice at Saul Ewing Arnstein & Lehr, and former Assistant U.S. Attorney, represents physicians and practice groups in government investigations.

On July 20, the U.S. Department of Health and Human Services Office of Inspector General (“OIG”) released its first Special Fraud alert since November 16, 2020 (

 The most recent Alert encourages practitioners “to exercise caution and use heightened scrutiny when entering into arrangements with Telemedicine Companies” exhibiting certain “red flags,” and to perform sufficient due diligence to avoid potential violations of criminal, civil, and administrative law. The Alert, which coincided with the announcement by the U.S. Department of Justice (“DOJ”) the same day of a national operation charging several dozen defendants in connection with a $1.2 billion telemedicine fraud (

), nonetheless recognizes and reaffirms the value and need for bona fide telehealth services. Below we offer some thoughts on the Alert, as well as lessons from our own experience defending healthcare providers under investigation for telemedicine fraud.

The Alert notes the OIG “has conducted dozens of investigations of fraud schemes involving companies that purported to provide telehealth, telemedicine, or telemarketing services . . . and exploited the growing acceptance and use of telehealth.” These initiatives have included, for example, “Operation Brace Yourself” in 2019, which involves charges against 24 defendants and losses of over $1.2 billion (

), and, as noted above, the announcement just last week of criminal charges against 36 defendants in 13 different federal districts again alleging $1.2 billion in fraudulent telemedicine, clinical laboratory and durable medical equipment (“DME”) arrangements, including what the government says are “some of the first prosecutions in the nation related to fraudulent cardiovascular genetic testing, a burgeoning scheme.” (

). These are just two of the initiatives in recent years that, by DOJ’s estimation, have involved over $8 billion in fraud (

Although telemedicine schemes vary, the Alert identifies some frequently recurring elements. For example, many schemes involve allegations of orders or prescriptions for medically unnecessary DME, genetic testing, wound care, or prescriptions for medication, each resulting in reimbursement from a Federal health care program. The arrangements have also included domestic or international call centers, staffing companies, and marketers or brokers. Invariably, the arrangements require limited or no direct engagement by the affected practitioner with the patient allegedly in need of the DME, testing, care, or prescription, and no direct access to the patient’s medical record. In some instances, a practitioner may only be provided an intake form, ostensibly completed by another healthcare professional, but possibly in fact completed by a telemarketing representative. Frequently, the practitioner is paid on a volume basis, such as for each prescription written, perhaps characterized as payment “per review, audit, consult, or assessment of medical charts.”

The government’s concerns with these arrangements are several: (1) they result in Federal health programs (e.g., Medicare and Medicaid, among others) paying for medically unnecessary items and services; (2) beneficiaries themselves receive medically unnecessary or even harmful care; and (3) the integrity and independence of medical decision making is compromised. 

Accordingly, the Alert identifies seven potential “red flags” that healthcare providers should bear in mind, while noting that the list is illustrative, not exhaustive, and that the absence of any particular red flag will not serve as a defense, given the totality of the circumstances analysis the government will undertake:

the patient for whom the prescription is ordered is contacted directly by a telemarketing vendor

the ordering provider has limited or no contact with the patient before placing an order

there is no expectation or ability for the ordering provider to conduct routine patient follow-up

federal health programs are the only payor (i.e., commercial insurance may not be accepted to cover the prescribed product or treatment)

the telemedicine company claims to only accept private payor insurance but actually does bill Federal healthcare programs

a narrow range of products is offered by the telemarketing company, limiting the provider’s treating options

Finally, the Alert notes that this latest guidance “is not intended to discourage legitimate telehealth arrangements,” consistent with prior HHS-OIG statements.

 At the same, those acting outside the scope of legitimate conduct face serious criminal, civil, or administrative exposure (including exclusion from Federal health programs).

How then, should a provider distinguish between bona fide telehealth arrangements and those that could result in serious penalties and collateral consequences? In addition to the helpful HHS-OIG guidance, providers should:

confirm the provider’s current primary employment agreement permits extracurricular moonlighting of the kind contemplated by a telehealth arrangement

assuming the primary employment agreement permits participation in the telehealth arrangement, perform meaningful due diligence on the telemarketing company

seek references from other providers working with the company

assure yourself that the telehealth company is willing to provide complete transparency regarding the identity of all involved parties in the business relationship, including subcontractors and affiliates

confirm that an appropriate provider-patient relationship will exist, with unfettered access to the patient and the patient’s medical history, as well as ability to conduct follow-up

understand the nature of the patient intake and referral process

confirm the telemarketing company’s expectations and the term and termination provisions of any written agreement

request that the telemarketing company share any relevant legal compliance opinions

share all relevant facts with your own experienced counsel to obtain the full benefit of independent review

Hard working providers, frequently with the burdens of education debt and other expenses, may be easily targeted and duped by unscrupulous actors. But it remains the case that there is no such thing as “easy money,” and the hint of “easy money” should itself serve to forewarn. Providers who unknowingly enter into illegal arrangements or who do not conduct necessary due diligence face criminal, civil, and administrative exposure.But by acting with caution, asking the proper questions, and sharing all relevant facts with their own experienced counsel to obtain the full benefit of independent review, providers should be able to distinguish between the promise of genuine telehealth that helps patients gain healthcare access necessary to obtain medically necessary care, and a fraudulent mirage.

Justin C. Danilewitz, a Partner in the White Collar and Government Enforcement Practice at Saul Ewing Arnstein & Lehr, is a former Assistant U.S. Attorney who represents physicians and practice groups in government investigations.

 The last alert related to Speaker Programs

 On February 26, 2021, HHS-OIG Principal Deputy Inspector General Christi A. Grimm issued a statement—against the backdrop of the COVID epidemic, noting that “[w]here telehealth and other remote access technologies were once a matter of convenience, the public health emergency made them a matter of safety for many beneficiaries,” and “[i]n some cases, health care providers needed regulatory flexibility to provide safe and effective care remotely during the ongoing pandemic.”

Statement of Principal Deputy Inspector General Grimm on Telehealth (February 26, 2021), 

https://oig.hhs.gov/coronavirus/letter-grimm-02262021.asp

 (last visited July 25, 2022). The statement recognized “that telehealth can be an important tool to improve patient access to behavioral health services,” and that “OIG recognizes the promise that telehealth and other digital health technologies have for improving care coordination and health outcomes.”

Many schemes involve allegations of orders or prescriptions for medically unnecessary DME, genetic testing, wound care, or prescriptions for medication, each resulting in reimbursement from a Federal health care program.

HHS OIG warns healthcare providers of dangers of telemedicine fraud

Editor's note: The information is this story was taken from a recent Medical Economics Bootcamp session. You can find the full video of the session

In 2019 and 2020, the Centers for Medicare & Medicaid Services created new reimbursement codes for providers to monitor and manage patient care remotely. Patients wear small monitoring devices connected to an app on a smartphone that sends data to the physician. Monitoring patients remotely can generate over $150 per patient per month. Remote patient monitoring (RPM) has been shown to improve outcomes for patients while much of the work is done by clinical staff, and it doesn’t require an excessive amount of time from the physician. With inflation hitting record highs and payers focusing more on positive patient outcomes, RPM is the perfect way to both boost revenue and improve patient outcomes. Not every patient is eligible for remote monitoring, but those with a diagnosis of obesity, diabetes or chronic pain usually are, along with patients who require pre- or postsurgical management. Now is the perfect time to see whether RPM makes economic sense for your practice.

Understand the available codes for RPM and the proper way to use them.

Learn about the benefits of RPM for both physicians and their patients.

Gain a full appreciation for the reimbursement/revenue potential of a successful RPM program.

How remote patient monitoring can boost your practice revenue and improve patient outcomes

In a time when inflation is rising, medical practices must look at every way possible to boost revenue. When you can accomplish that with existing patients in a way that also improves their outcomes, you have a solution that is helping both patient and practice health. Remote patient monitoring (RPM) provides exactly that. “(RPM) is a revenue stream that is remarkably untapped, despite how CMS (Centers for Medicare & Medicaid Services) backs it,” Shari Kappell, CPCO, CPPM, CPC, implementation and billing manager at CoachCare, says.

RPM is when a patient uses a wireless device that’s able to upload data in real time to a health care provider so they can track and monitor their condition from their practice. The data are relayed using a mobile app.

The old way of seeing a patient was to start with an in-office visit, then schedule a follow-up appointment for months later. That might be all you see of them unless something major occurs. If it does, now you’re either seeing them in the emergency department or as an inpatient if they have severe issues that haven’t been checked in months. With RPM, the person is transmitting their vitals and information in real time. Staffers are assisting with daily monitoring, which might save a trip to the hospital because a physician can intervene faster.

“RPM has a lot of great benefits for the provider,” Kappell says. “You can improve your patient care (and) connectivity with patients, and it’s flexible and efficient. You can monitor your patients before their health conditions get out of control, which is one of the huge benefits of having a (RPM) program.”

Another bonus is that once the physician orders RPM, a junior staffer can monitor the data and only involve the doctor when necessary. “Patients feel like there is more of a connection with their doctor, even though they are not actually speaking to the provider face-to-face,” Kappell says. “Having that connectivity to your provider and your care team is promoting that next level of care for patients. Accountability is driving patients to have better outcomes by having them become more active participants in their health care decisions.”

For example, one CoachCare study on patients who are obese found 86% more weight loss at the patient level for those using RPM compared with those who were not, and those using RPM stayed on the obesity program 30% longer.

Most patients are eligible for RPM, and although those with chronic conditions are often the best candidates, acute patients can also benefit. An RPM patient will need to have had a face-to-face visit over the past 12 months, with telehealth visits also qualifying.

“It’s really based on insurance coverage, to get a basic understanding of where coverage is for your key payers, but for the most part, insurances are covering RPM,” Kappell says.

If staffing is tight or already overburdened, the monitoring function can be outsourced. Kappell says all devices must be FDA approved, so consumer products such as Apple watches are not eligible for use in a RPM program.

As CMS and other payers move to more value-based care contracts, RPM is the perfect tool for physicians. “It’s intervening prior to a medical catastrophe,” Kappell says. “It’s low cost to patients (and is) creating consistent revenue streams for providers. It greatly reduces the chances of patients having to go undiagnosed for months by giving real-time data to providers in their care teams.”

Monitoring patients remotely can generate over $150 per patient per month.

Summer Bootcamp: Remote patient monitoring economics

 advises clients on compliance, transactions, government administrative actions, and litigation involving healthcare, cybersecurity, corporate and securities law, as well as False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston. Rachel can be reached through her website, 

With remote working and devices being interconnected, it is imperative to appreciate the implications of accessing electronic information without consent, even if it’s a spouse. Importantly, passwords and consent should not be given to a spouse, partner, or roommate. If a person works in a sensitive field such as healthcare, law, accounting, or finance for example (not to mention government employees and contractors), then setting boundaries that adhere to a plethora of laws and professional obligations should be implemented. As an aside the application of providing access to electronic communications that are part of work, even personal archived emails, social media, or smart phones that are accessed without consent are subject to violating a variety of laws including the Computer Fraud and Abuse Act (1986), which enables individuals to use this federal criminal law to sue others for civil claims based on unauthorized access, as well as other laws explained below.

 that brings the significance of not securing information to light is the 25 page indictment brought by federal prosecutors against Seth Markin who allegedly stole from his then-girlfriend, an associate at a prominent law firm who was working at home during the pandemic on an acquisition deal related to a major pharmaceutical company’s acquisition of a therapeutic company. Additionally, the U.S. Securities and Exchange Commission also filed insider trading charges against Markin and one other person.

Enacted in 1986, the Stored Communications Act, 18 U.S.C. §§ 2701,

(SCA) has a primary purpose that is analogous to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule - to protect the privacy and unauthorized disclosure of stored electronic communications. While HIPAA is specific to protected health information (PHI) and the Security Rule is limited to electronic protected health information (ePHI), the SCA extends to stored electronic communications. As the 

 explains, “[e]lectronic storage is defined in 18 U.S.C. § 2510(17) as both any temporary, intermediate storage of a wire or electronic communication incidental to the electronic transmission thereof and the storage of such communication by an electronic communication service for purposes of backup protection of such communication.”Like HIPAA, which extends beyond external hackers, so does the SCA. In 

Ehling v. Monmouth-Ocean Hospital Service Corp.

, No. 2:11-cv-03305 (WJM) (D.N.J. Aug 20, 2013) the District Court for the State of New Jersey held 

which are configured to be private are indeed covered under the SCA

transmitted via an electronic communication service;

Although the court recognized and applied the “authorized user” exception – one of two exceptions in the SCA, caution should be taken regarding if the person providing authorization has the authority or right to do so. Also, if a person’s Facebook or other social media is linked to an email, separate permission is needed for each application. Also, as lawyers appreciate potential clients may reach out through private social media or a colleague may send a link to an article and reference a case that is been worked on. Regardless of whether the person gave the roommate or spouse permission, professional rules and other laws dictate otherwise.

The HIPAA Security Rule has Security Standards (45 CFR § 164.306(b)). As 

, “[t]he Security Rule is clear that reasonable and appropriate security measures must be implemented, see 45 CFR 164.306(b), and that the General Requirements of § 164.306(a) must be met.” The task of addressing the changing cybersecurity landscape on both a professional and a personal level may seem daunting and, in some ways, it is. Here are some compliance tips, which can be used in healthcare, a variety of other industries, and personally:

NIST is a great resource and utilizing its standards may mitigate liability. I always recommend 

SP 800-53 (rev. 5 is the current version)

Implementing the Health Insurance Portability and Accountability Act (HIPAA) Security Rule: A Cybersecurity Resource Guide

 is designed to help the industry maintain the confidentiality, integrity and availability of electronic protected health information, or ePHI. The term covers a wide range of patient data, including prescriptions, lab results, and records of hospital visits and vaccinations.”

Adopt a Remote Worker checklist for working from home and traveling. Some fundamental items are: (1) secure WiFi at home and when traveling (use a hotspot); (2) ensure that if you are 

 your Apple products (or other devices and software) that your private messages are not connected to another person’s account – whether family, friend, or colleague; (3) educate yourself and understand how your private messages on social media may end up being looked at by a spouse, roommate, or child (hint: if you get alerts know where the alerts are going and who has access to your phone, tablet, or email account); (4) set policies and procedures and have workforce members and contractors review and sign off on them, so they understand the potential legal liability that may come with sharing information; and (5) if you are a small business (or even a one person physician practice or law firm), have your disaster recovery plan as well as incapacity plan in place and pick a trusted person and have the information in a safe deposit box to be accessed only when needed.

. Workforce members should also be educated as part of cybersecurity and HIPAA training on social engineering, phishing, and wrongful disclosure of both PHI and personally identifiable information.

In sum, there is a lot to digest. Approaching one’s business and personal life from a risk mitigation standpoint can help avoid significant liability, especially during an unforeseen change in circumstances, just as the recent indictment referenced herein substantiates.

Rachel V. Rose, JD, MBA, advises clients on compliance, transactions, government administrative actions, and litigation involving healthcare, cybersecurity, corporate and securities law, as well as False Claims Act and Dodd-Frank whistleblower cases. She also teaches bioethics at Baylor College of Medicine in Houston. Rachel can be reached through her website, 

If a person works in a sensitive field such as healthcare, law, accounting, or finance then setting boundaries that adhere to a plethora of laws and professional obligations should be implemented. 

Utilizing NIST Safeguards to reduce liability under the Stored Communications Act

Editor's note: The information is this story was taken from a recent Medical Economics Bootcamp session. You can find the full video of the session 

Taxes are inevitable, but that’s no reason they must unduly lighten your bank account. Proper tax planning can keep Uncle Sam from taking an outsized portion of your income. With recent changes to the tax code, some of the strategies of the past have become outdated, whereas new possibilities have become available. With inflation at the highest it has been in four decades, the need for physicians to utilize these strategies has gained outsized importance.


Understand top tax planning ideas for physicians to reduce their tax burden

Gain insights into how to achieve financial independence

Learn about effective financial decisions physicians have made in their lives and how it affected their future.


President and Founder, Physician Tax Solutions

The first part of developing an effective tax strategy is finding out which tax bracket you fall into and how much more you can earn before you move up to the next bracket. Most doctors will find themselves paying around 35% and possibly up to 37%, according to David Auer, CPA, MS, PFS, CGMA, president and founder of Physician Tax Solutions. If you have a C-corporation, the tax is a flat 21%, whereas self-employed physicians have a 12.4% and employed physicians have a 6.2% Social Security tax. Physicians should also factor in their capital gains taxes, as well as state income and corporate tax liability.

President Joe Biden has proposed increasing taxes, but legislators are running out of time to make the changes into law before the end of this year. Auer doesn’t believe taxes on the highest earners will rise to the historical high of 94%. “Depending on what state you live in and what other taxes you might be subject to, (your tax rate) could very well be into the 60% to 70% range, and that becomes very important when it comes to tax planning,” he said.

Auer recommends that doctors maximize their retirement plan contributions, which lowers their taxable income and moves them to a lower tax bracket. He also recommends considering a Roth conversion, which involves rolling over transferring funds from a traditional IRA or plan funds to a Roth IRA. This maneuver can be done by individuals who own a traditional IRA, a SEP IRA or those who’ve had a SIMPLE IRA for at least two years. It is also available to those with a 401(k), 403(b) or a government 457(b) plan eligible for distribution.

Roth IRA funds can be withdrawn tax-free so long as the funds have been held for at least five years and the holder is 59.5 years or older. There is also no lifetime required minimum distributions for Roth IRA owners.

Auer also recommends considering funding a “back door” Roth IRA and a Mega Roth 401(k) to further lower your taxable income. If properly utilized, these can enable physicians to put away an additional $66,000 and lower their taxable income.

When it comes to investments, Auer recommends harvesting capital losses, which can offset current and future capital, plus an addition $3,000 a year. However, beware of the capital wash rules that say you can’t buy the same assets, which leads to the initial loss for 30 days.

Physicians should also consider converting W-2 income to 1099 income either in part or entirety. This is helpful, especially if the physician has locum tenens income in addition to their regular job. This also adds the ability to claim business expenses as deductibles.

To those physicians who already have Schedule C/1099 income, Auer recommends considering converting that income to an S-Corporation LLC. This will lower self-employment taxes and reduce the risk of an audit. “Based on the most recent published statistics the IRS has provided, generally speaking, if you have a Schedule C income of over $250,000, you currently have about a 2.5% chance of an IRS audit,” he said. “If you have that same income going through an S-Corporation, statistically, that drops your audit risk down to 0.7% — a fairly significant drop in the risk of an audit, everything else being the same.”

With an S-Corporation in place, Auer recommends considering employing family members by putting them on the payroll and assigning responsibilities. This shifts income from being subject to your tax bracket to being subject to their tax bracket.

A physician can also maximize their home office and automobile deductions. There are acceptable ways to do this, so it’s best to work with a tax planner to ensure you’re getting the most out of your vehicle and workspace. Physicians should also consider the per diem allowances for lodging and meals as opposed to the actual expenses.

Finally, physicians should consider making a pass-through entity (PTE), such as an S-Corporation or partnership, to pay individual state income taxes at the PTE level. You would be able to deduct the cost of that tax dollar for dollar. This is available in 40 states.

With recent changes to the tax code, some of the strategies of the past have become outdated, whereas new possibilities have become available. With inflation at the highest it has been in four decades, the need for physicians to utilize these strategies has gained outsized importance.

Summer Bootcamp: Top 10 tax planning ideas for physicians in 2022

is a partner at Hall Booth Smith. She can be reached at (406) 317-0077 or jquinlan@hallboothsmith.com. 

is an associate at Hall Booth Smith, where their practice focuses on medical malpractice and healthcare matters. She can be reached at (406) 317-0074 or jswajkoski@hallboothsmith.com.

Annabelle Smith is a summer aassociate at Hall Booth Smith and a law student at the Alexander Blewett III School of Law at the University of Montana.

The peer review privilege refers to laws that protect the records and proceedings of peer review committees from disclosure outside the peer review process. Peer review privileges can apply to multiple credentialing, privileging and quality assurance and improvement processes; however, this article focuses on the peer review privilege as it relates to the evaluation of adverse outcomes.

Most states want to encourage the use of peer review panels to improve patient healthcare

 and have passed legislation providing broad privileges to documents generated for peer review, such as peer review evaluation forms, claims review reports, root cause analysis reports, notes relating to root cause analysis, and other quality management documents, as well as associated proceedings.

 Granting privilege helps foster an environment where physicians feel safe to speak openly and candidly about adverse outcomes and the quality of patient care.

This article will explain what practices generally increase the likelihood that communications or documents will be deemed privileged. Notably, physicians can conduct peer review without a formalized committee. Generally, ad hoc committees receive the same peer review privilege as formal review committees in larger hospitals. However, there are certain steps that all physicians should take to maximize the likelihood a court will find a document falls under the definition of peer review materials and therefore privileged.

Courts do not want to overextend evidentiary privileges, so keeping peer review material separate from other nonprivileged business is essential. Physicians should ensure that all discussions, files, documents and communications regarding quality assurance and adverse outcomes are separate from other business and committees. Most states require peer review committees meet for the specific purpose of peer review, which includes evaluating areas to improve the quality of healthcare, determining a healthcare provider’s adherence to the standard of care, and even examining whether the cost of care was determined within the standard of care.

 If the purpose of a particular committee is something other than peer review but the discussion becomes about to quality assurance, a court may find the committee is not a peer review committee and is therefore ineligible for privilege protections, waiving any protections that may have been appropriate. A peer review committee can be comprised of the same members as another committee and may even take place in the same location; however, it should be obvious when one committee’s business ends and the peer review committee’s business begins.

Most states only grant privileges to documents generated by, within or for a peer review committee. Therefore, making it obvious when a committee begins and ends an investigation is imperative.

 If a physician begins doing quality assurance research and discussion 

 of a peer review committee, it is unlikely any material generated will be privileged.

The more regimented and routine a peer review committee becomes, the more likely the committee's documents and communications will receive privileges. Thus, it is important to develop procedures to alert a committee when an adverse outcome is being reviewed, and to obtain and develop information expressly for the committee. Physicians can do this by using a submission form created exclusively for the peer review committee, or even a verbal request to the committee chair. Another way to ensure privilege protections is by keeping clear minutes of the peer review committee meeting to document the intent of the meeting as peer review and the members of the committee in attendance. The development of procedures is not to discourage the use of ad hoc committees; however, it is safer to have more formalized procedures than less, as it indicates to a court that the materials and discussions are explicitly for quality assurance.

Documents describing how a peer review committee operates and quality assurance documents are typically privileged.

” will not alone create privilege but will demonstrate to an outside observer the documents purpose and the legitimacy of the peer review committee. In addition to labeling documents as confidential, it is important to make sure the document’s title clearly identifies its nature. Documents created and kept as a regular course of business and not created for or by the committee’s direction, such as medical records or incident reports, are generally discoverable, and thus not subject to peer review protections.

 will make it more likely a court will determine the document is privileged.

Like all privileges, peer review privilege can be waived. This can be done deliberately through a waiver or accidentally by revealing confidential peer review information to a person or entity who was not party to the peer review committee. Because of this, it is vital committee members keep control over information that was revealed through the peer review process. This can be facilitated by incorporating the foregoing tips. First, keep peer review material separate from other business. Second, require the committee meeting be closed, and acknowledge the proceedings are confidential. Third, do not discuss peer review issues outside of the committee. Finally, label confidential materials as such to alert others to the nature of the material and remind committee members of the importance of confidentiality. These steps will decrease the chances of accidentally breaching confidentiality and waiving privilege.

Although these tips are generally applicable, the extent of the privilege depends entirely upon the laws of the jurisdiction where a patient is receiving care.

 Physicians treating patients through telehealth may then have to navigate the laws of multiple states to determine what information is privileged. These laws can vary significantly. For example, Iowa protects all information, files and reports that 

a peer review committee to be privileged.

 Distinguish this from federal law, which does not recognize 

 peer review privilege. Because of these differences, it is crucial to reach out to a local healthcare attorney or professional liability insurance provider for state-specific guidance on what steps you should take to protect your privileged information.

 is an associate at Hall Booth Smith, where their practice focuses on medical malpractice and healthcare matters. Annabelle Smith is a summer associate at Hall Booth Smith and a law student at the Alexander Blewett III School of Law at the University of Montana. Jori Quinlan can be reached at (406) 317-0077 or jquinlan@hallboothsmith.com. Jennifer Swajkoski can be reached at (406) 317-0074 or jswajkoski@hallboothsmith.com. 

Wigmore on Evidence § 7.8.2, Privilege for Medical Peer Review.

Cleveland Clinic Health System­—East Region v. Innovative Placements, Inc.

, 2018 IL App (1st) 171107, 109 N.E.3d 353.

Scope and Extent of Protection From Disclosure of Medical Peer Review Proceedings Relating to Claim in Medical Malpractice Action

, 69 A.L.R. 5th 559, § 2 (Westlaw through July 13, 2022).

 Mass. Gen. Laws Ann. ch. 111, § 1 (West 2021).

State Variability in Peer Review Protections Heightens Liability Risks

, 5(2) Mayo Clin. Proc. Innov. Qual Outcomes 476–79, Feb. 2021.

,769 N.W.2d 898 (Iowa 2009); Iowa Code Ann. § 147.135(2) (West 2022).

 Tex. Occ. Code Ann. § 160.007 (West 2021).

Peer review privileges can apply to multiple credentialing, privileging and quality assurance and improvement processes.