Karen Appold

Need more hours in a day? You’re not alone.

A physician with a panel of 2,500 patients could spend nearly 22 hours per day providing the recommended acute, chronic, and preventive care as well as conducting effective care management and outreach, according to research findings in 

And that’s not taking into account the national shortage of primary care physicians (PCPs), the rise in non-direct patient care, and clerical workload or the more than half of physicians who 

 feelings of burnout in 2017, up from 40 percent in 2013. 

“With these new demands, the ability for physicians to see patients has decreased,” says Joseph Behn, MD, family medicine provider at Mayo Clinic Health System in Onalaska, Wis. “The amount of time physicians actually spend doing what they are trained to do-such as interacting with patients, examining them, and formulating diagnoses and treatment plans-has markedly declined. By delegating tasks, PCPs can alleviate this aspect of the work burden and allow physicians to reacquire the ability to practice again.”

Physician assistants (PAs), nurse practitioners (NPs), pharmacists, and other support providers are valuable members of care teams at primary care physician (PCP) practices. These non-physician providers can make practices more efficient and effective, allowing all team members to work at the top of their licensure.

“Treating patients as a team helps to meet their diverse needs, including physical, mental, social, and spiritual,” says Cheristi Cognetta-Rieke, DNP, a nurse administrator at Mayo Clinic Health System in La Crosse, Wis. “A team-based approach allows a care team to collectively manage larger, more complex panels of patients and achieve wellness and health more effectively than any provider can do as an individual.”

By having several healthcare professionals coordinate a patient’s care, teams are more likely to identify all potential issues-which might otherwise fall outside of their individual scope of care-and improve outcomes.

A collaborative team of clinicians affords patients access to a team member they know faster than their PCP or when their PCP is not available, such as after patients are discharged from a hospital or care facility. “This allows for a timely response from a team member who is familiar with a patient’s condition,” says Arnold DoRosario, MD, primary care physician and chief population health officer at Northeast Medical Group/Yale New Haven Health in New Haven, Conn. “In turn, patients are comforted by personalized care.”

Molling’s practice has both NPs and PAs who alleviate the clinical burden by seeing both walk-in and scheduled patients. They help with patient management by relaying patient results and plans of care, coordinating care if results necessitate additional communication with other providers, and having discussions with consulting physicians, insurance companies, and ancillary staff as needed. They can also see complicated patients or those who take more time along with a PCP.

PAs can also bring different skill sets to a practice, such as expertise in nutrition or the ability to perform a less common procedure, says L. Gail Curtis, MPAS, PA-C, DFAAPA, president and chair of American Academy of Physician Assistants’ board of directors. She previously practiced in otolaryngology, where she learned how to do a nasopharyngoscopy, a procedure that uses a fiber optic tube to look at the larynx. That’s a procedure not all PCPs do and an example of how PAs can add to a practice. Those skills also benefit patients, who could avoid having to make a second appointment and the potential wait to see a specialist.

Clinical pharmacists, another type of support provider, can see hypertensive patients and patients on anticoagulation therapy or on chronic opioid therapy, especially if they are tapering off such a drug, says Richard Furlong, MD, section head at Virginia Mason Kirkland Medical Center in Kirkland, Wash. They can also provide direct and indirect follow-up care for patients who are on antidepressant therapy.

Oftentimes, a pharmacist has the most in-depth knowledge of drug interactions, over-the-counter medications, and timing of administration and can collaborate with a PCP to provide medication-related support directly to a discharged patient, says Ken Goldblum, MD, chief medical officer of Tandigm Health in West Conshohocken, Pa.

Before employing a care team, PCPs should analyze their patient population, conduct budget and staff forecasting to make sure they are allocating resources appropriately and develop workflows to ensure clear delineation of responsibilities. This daily clinical workflow should build on team members’ strengths to maximize efficiency. As an added bonus, spreading clinical and administrative responsibilities across a care team might also reduce the risk of PCP burnout, says Erin Mastagni, senior manager at ECG Management Consultants, a healthcare consultancy that helps providers through transformational initiatives in New Orleans.

Clinical team member huddles to identify optimal task allocation for the day and/or week can be quick but high-value moments. If feasible, co-location such as shared office space or working in the same hallway can help improve communication, too.

For some physicians, it can be difficult to delegate duties to others and relinquish control. “PCPs need to change their mindset: By having the right person doing the right task at the right time, they can optimize and improve their ability to care for their patients,” Behn says.

Karen Appold is a freelance medical writer based in Lehigh Valley, Pa.

Articles

Non-physician providers can help lighten the load for physicians while improving patient care, practice efficiency, and overall effectiveness.

How to deliver team-based care

The amount of money physicians will pay for medical malpractice insurance and the likelihood of being sued are largely determined by where they choose to practice. For instance, malpractice insurance rates are based on how much is paid out in each state territory (most states have multiple territories) for each medical specialty.

“The more likely there are to be malpractice payouts in a territory, the higher the cost of medical malpractice insurance in that state territory,” says Mike Matray, editor, 

, based in Chicago. “A physician’s malpractice insurance rate will increase depending on the number of claims against him or her. The (rate) amount can decrease if a physician is claim free and has taken risk management courses that medical malpractice insurers offer.”

Malpractice insurance rates are also heavily based upon a state’s tort reform laws, which vary among states and generally make it more difficult for a patient to sue a doctor. For example, before going to court states such as Pennsylvania, New Jersey, Delaware, and Michigan, among others, require a certificate of merit, whereby a doctor in the same specialty as the physician being sued indicates what the physician did as grounds for malpractice. “If the patient can’t get a doctor to write a certificate of merit, the court case can’t proceed,” Matray says. 

Another example of tort reform involves medical review panels that are used in some states, such as Massachusetts, Hawaii, Indiana, and Kentucky. Before patients can access the legal system, a panel that is usually comprised of two doctors and an attorney will evaluate their claim. The panel will review the case and give their opinion on whether or not malpractice occurred. If they believe the case has merit, it will proceed to court. If not, the suit can still proceed, but the panel’s opinion is admissible as evidence for the defense at trial.

Statutes of limitation, which state the timeframe that a suit can be filed, also play a role in how likely physicians are to get sued. “The longer the statute of limitation, the more likely a claim will be made,” Matray says. States with shorter statutes of limitations will generally have lower malpractice insurance costs.

Damage caps set by states are yet another factor that come into play. They refer to the amount patients can win for damages. The lower the cap, the more difficult it will be for patients to find an attorney to take their case because attorneys mostly take medical lawsuits on contingency. Attorneys will front the money to file the case, and if the attorney wins, she will split the amount of the winnings with the patient. “This is a big gamble, because more than 80 percent of defendant physicians win their cases,” Matray says.

Peter Carrazzone, MD, FAAFP, a family physician in Haledon, N.J. and president of the New Jersey Academy of Family Physicians, says 38 percent of states don’t have damage caps on malpractice lawsuits.

A state’s regulations and related complexities are just one more reason why physicians should implement policies and procedures that can help them from getting sued in the first place.

Regardless of what state you practice in, here are some tips from experts on how to avoid malpractice suits:

Build a strong physician-patient rapport through open communication and mutual trust. Studies have shown that how physicians communicate can determine whether patients will sue, especially after an adverse event, says Rich Cahill, JD, vice president and associate general counsel for medical malpractice insurer The Doctors Company in Napa, Calif.

Adds Carrazzone, “Take the time to explain in layman’s terms the patient’s diagnosis and plan of care.”

When taking on new patients, Cahill advises having patients sign a statement outlining the conditions of treatment and setting forth the practice’s expectations regarding the patients’ responsibilities on proper decorum (e.g., respectful treatment to staff, physicians, patients, and other visitors), payment of fees, cancelling appointments, continuity of care, and follow-up instructions.

In addition, when performing a procedure, get informed consent orally and in writing from patients. By having it in writing, many patients will not sue if an adverse event occurs because they don’t think that they can.

“Make sure you write or type out all possible complications from a procedure and make sure the patient signs it, because it will make it easier for defense counsel to later argue that this was a potential complication the patient consented to before undergoing the procedure,” says Marc A. Brown, partner in the law firm LeClairRyan, based in Alexandria, Va.

“Plaintiffs always take the position that if something wasn’t written down in the records, then it did not occur,” Brown says. “The opposite is also true. If something is written down, defense counsel will argue successfully that it did take place because otherwise why would it be recorded in the records. Careful documentation has ended a lot of malpractice suits before they have even been filed.”

Brown says medical malpractice plaintiff’s attorneys have told him they often decline to take cases when the doctor’s documentation is good because it is unlikely that the attorney will win the case, even if the damages are huge.

Refer patients when warranted-and follow up

“When you encounter a medical condition that you don’t see frequently, spend time making sure you are current on the condition’s diagnosis and treatment,” Brown says. “Or, refer the patient to a specialist to treat it-especially if it is something serious.”

If you employ physician assistants or nurse practitioners, outline the conditions when these advanced practice providers should refer patients to physicians or seek a second opinion, Cahill adds.

If a condition has the potential for a serious or life-threatening outcome, follow the patient closely and document your actions, Carrazzone says. If a patient does not follow up, send certified letters explaining the risk and potential problems of not doing so.

Physicians should select a medical malpractice insurer with a track record for winning cases, focuses on the interest of physicians over stockholders, is financially sound, and provides advice on how to avoid risks, Cahill says.

In addition, Cahill advises choosing an insurer that can provide an aggressive defense for physicians at all stages of litigation, including both the trial and appellate processes.

Karen Appold is a medical writer based in Pennsylvania.

Five strategies to avoid a malpractice suit no matter where a physician practices medicine.

Simple steps to avoid medical malpractice suits

After several years of not giving raises, things have turned around for Bender Medical Group, Inc., in Fort Collins, Colo.

John L. Bender, MD, MBA, the CEO of the physician-owned group, says his practice reviews physician salaries at the end of each year. It has given physicians raises since 2014, after several years of being flat. The average salary increase over the three-year period was around 16 percent for a full-time employed family physician. 

Production was up, mostly as a result of implementing medical scribes to take notes while the physician talks with and treats the patient. “This boosted provider bonus payouts as revenues increased from team productivity,” Bender says.

But not all physicians in the group received raises. “Raises are still about recognizing what value a physician brings to the table and what they can negotiate,” Bender says. “It’s important for a physician to know their revenue numbers, and to also understand how he or she contributes to the organization’s overall efforts.”

Similarly, Shannon Davis, the office manager for Littlerock Family Medicine, a private practice in Tumwater, Wash., was able to give the entire team raises this year after a few years of not being able to due to limited resources.

“Staff members in our billing department worked hard to recoup as many outstanding payments as possible and chased denials from insurance companies, making raises possible,” she says.

These two practices reflect data from the 2018 

 Staff Salary Survey, indicating that more practices plan to give raises beyond cost of living this year. According to the data, 42 percent said they plan on increasing annual salaries, up from 34 percent in 2017.

Phillip Miller, a vice president, with physician job search and staffing firm Merritt Hawkins and Staff Care can certainly attest to the competitive market for physicians.

“Over the past 30 years, a multi-billion dollar industry has grown up around physician recruitment and staffing,” he says. “Just about every hospital as well as larger medical groups have their own in-house physician recruiters and may also use outside recruiting firms.”

Bender can attest to this. “We saw increased marketplace pressures from two local health systems that heavily recruit family physicians, as well as a downturn in the availability of resident physicians to rotate through our clinic,” he says. “That compelled us to bargain harder to retain our current staff.”

Merritt Hawkins’ 2017 Survey of Final-Year Medical Residents indicates that 76 percent of physicians about to finish residency receive 50 or more recruitment offers during their training; 55percent receive more than 100 recruitment offers.

For this reason, paying higher salaries to retain physicians has become a priority for practices.

About 13 percent of primary care physicians relocate every year, according to the data firm SK&A. “Offering competitive compensation is one way to prevent physicians from exploring greener pastures,” Miller says.

Furthermore, a growing number of sites of service are vying for the same physicians-including hospitals and hospital systems, medical groups, urgent care centers, Federally Qualified Health Centers, retail clinics, and insurance companies.

There are many other reasons why more practices are giving physicians raises, such as a growing need for care. “Demand continues to be strong for primary care physicians,” says Miller. For 11 consecutive years, family medicine has been Merritt Hawkins’ most requested search assignment, which is unprecedented in its 31-year history. Internal medicine has consistently been its second or third most requested specialty.

Demand is driven in part by U.S. population growth, which grew by 28 percent from 1987 to 2010 when it reached 310 million. The U.S. Census Bureau projects it will to grow to 383 million by 2040. An aging population is also a contributing factor-approximately 10,000 baby boomers turn 65 every day, and people in that cohort visit a physician at three times the rate of younger individuals.

In addition, emerging value-based delivery models that feature team-based care are primary care driven, with these physicians being both gatekeepers and the key coordinators of care who help ensure quality and cost effectiveness. “These models typically are implemented by large, integrated health systems that may require dozens of primary care physicians to be effective,” Miller says.

Another reason why demand for care has increased is because about 91 percent of Americans now have health insurance-the highest rate ever. “The robust employment outlook across the nation and the Affordable Care Act have created an environment in which a lot of people have access to insurance,” Miller says.

When the individual mandate goes away in 2019, he expects premiums to increase and more people to be uninsured. Nonetheless, demand for doctors will remain high because it is mostly driven by older Medicare patients.

In light of increasing demands, physician shortages are growing. The Association of American Medical Colleges (AAMC) predicts a shortage of up to 104,900 physicians by 2030, with about 43,000 of them in primary care.

“Shortages are driven in part by rising demand, but also in part by a constrained supply of physicians,” Miller says. “Supply is inhibited by the long-standing cap on what the federal government pays for graduate medical education, but also by changing physician practice patterns. Younger physicians prefer a controllable lifestyle with set hours and vacations, reducing overall physician full-time equivalents.”

The AAMC projects that physicians who are 35 years old or younger today will work 13 percent fewer hours than previous cohorts as a result.

In addition to increased salaries, physicians are receiving other financial benefits. Miller says signing bonuses are common and are offered in 76 percent of Merritt Hawkins’ search assignments. Continuing medical education, moving allowances, health insurance, and malpractice and disability insurance are also common. Educational loan forgiveness is offered in nearly one-quarter of searches.

As a small independent clinic, Davis says the practice can’t compete with the big health powerhouses in terms of salary. “So we compensate with offering scheduling flexibility and maximizing the number of patients primary care physicians see to two per hour,” she says. “If [physicians] are motivated solely by money, they will seek work at a bigger outfit. By sharing the additional income we recover with staff members, it shows that we appreciate them.”

With so much competition, a conspicuously low salary can lead to turnover. “It should be stressed, however, that compensation alone cannot buy physician engagement or long-term commitment,” Miller says. A practice’s quality, including schedules, numbers of patients seen, group governance, quality of the clinical staff, and level of communication are more important.

The risk of not giving raises can result in losing a physician, and sometimes staff will follow them.

“Non-compete clauses are becoming harder to enforce, because courts tend to rule them as restraint of trade, so it is not just about losing the physician, it’s about losing the patient base as well, and perhaps even the entire care team,” Bender says.

Greater competition for services and other factors are resulting in pay raises-and other benefits-to physicians at many practices.

Why more practices are giving physicians raises

More and more final-year medical residents are flocking to employment.

 of 935 final-year medical residents by Merritt Hawkins, a healthcare recruiting company, the majority (94 percent) prefer employment with a salary in their first practice rather than an independent practice income guarantee or loan. A major reason for this is significant student loans. The survey reported that more than 50 percent of final-year medical residents owed more than $150,000 in student debt. Residency directors, healthcare recruiters, and financial experts cite a myriad of other reasons for physicians preferring employed positions, including reducing student debt and obtaining financial security; a lack of training during residency on how to run a practice; the upfront costs to start a practice coupled with complex government regulations; the ease of getting an employed position; and a desire for work-life balance.

Most graduating physicians want to get rid of significant student loan debt, not add to it by starting a practice. According to the Merritt Hawkins' survey. Employers' loan forgiveness programs allow young clinicians to reduce debt burdens in a tax-advantaged manner, explains Tom Davis, MD, principal of St. Louis, Mo.-based Tom Davis Consulting, which provides clinician career mentoring. These organizations typically make the loan payments directly, pay the clinician additional monies to cover the tax liability and then, at the end of the employment agreement, pay off a large balance (i.e., $100,000 to $200,000) with an additional bonus to cover income taxes.

An employed position also ensures a steady paycheck, as well as benefits such as health insurance, paid time off, retirement plans, profit sharing, and typically a steady stream of patients, says Jake Serfas, lead financial strategist at O'Dell, Winkfield, Roseman, and Shipp, a financial advisory group in Washington, D.C.

"Many physicians want to focus on seeing patients and providing treatments, not running a business and dealing with the stress that comes with it," Serfas says. "Unless you have a great practice manager, for many physicians it makes the most sense to collect a paycheck and receive employee benefits without having to worry about whether the practice can afford to make payroll next month."

The cost to open a small internal medicine practice can easily exceed $100,000. It includes staff labor costs, paying rent or a mortgage on the medical facility, insurance (medical malpractice and health insurance), and purchasing an EHR system, furniture, equipment, and other items, says Joe Thomas, senior vice president with SunTrust Private Wealth Management's Medical Specialty Group, a financial advisory firm. Existing debt can impede a physician with little-to-no work or credit history to take on additional debt that may be needed to get a practice off the ground.

As a new physician gets a practice up and running, he will have to spend time building a patient base and addressing the business side of the practice. "Many new physicians feel overwhelmed at the thought of doing this, so they gravitate toward an employed setting," says Travis Singleton, senior vice president of Merritt Hawkins.

On top of this, dealing with governmental regulations can be daunting. "New practice owners have to know how to navigate the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS), and Meaningful Use criteria, and have an EHR system that is compliant per CMS," says Singleton "They will also need coding expertise because CPT codes are complex, as well as a legal team for general business purposes, such as compliance with employment regulations."

Not knowing how to start and operate a practice is also a deterrent. About half of residents (49 percent) in the Merritt Hawkins' survey said they didn't receive any formal instruction during their medical training regarding medical business issues such as contracts, compensation arrangements, and reimbursement methods. Furthermore, over one-third of residents (38 percent) said they felt unprepared to handle the business side of medicine.

"Over the last couple of decades, there has been a clear shift from being self-employed [or joining a small physician-owned group] to being employed by a hospital system," says Rick Kellerman, MD, professor and chair, Department of Family and Community Medicine, University of Kansas School of Medicine - Wichita. As a result, family medicine residency programs, including the program at University of Kansas, have modified their practice management curricula from "how to start your practice" to "how to review a contract."

Due to a physician shortage, jobs are plentiful. In fact, more than 55 percent of primary-care residents received over 100 specific job solicitations during their residency training, the Merritt Hawkins survey reported. "We have never seen this category so high since we began conducting the survey in 1991," says Singleton.

"Highly sought-after residents can have an offer in their desired location fairly quickly, sometimes in as short as one month," says Jamie Thomas, executive vice president of recruiting, The Medicus Firm, a national physician search firm based in Dallas, Texas.

Unlike their Gen X predecessors who were more focused on how much money they could garner as physicians, today's younger physicians are more concerned about their vacation packages. "Work/life balance is an even a bigger motivator than financial compensation today," Thomas says. In a hospital-employed practice, he says physicians are more likely to work 8 a.m. to 5 p.m.

Although many say that an employed position offers more work-life balance than being a practice owner, it depends upon whom you ask. Emily Briggs, MD, family physician, Briggs Family Medicine, New Braunfels, Texas, who started a private practice right out of residency, says autonomy and being able to set her own schedule was key in her decision. "When I started my practice, my children had extra-curricular activities on Wednesday afternoons. I didn't schedule office hours during that time so I could attend," she says. "If I worked for a large group or hospital, scheduling flexibility might not be available." 

Thirty-five year old James Pinckney II, MD, founder and CEO of a family medicine practice, Diamond Physicians, Dallas, Texas, says he wanted control over his life as he began his career. "As an employed physician, you have production requirements; I didn't want to follow that model," he says. Like Briggs, he started his practice upon graduation. He has found that 

 (i.e., an alternative payment model requiring a flat, membership fee) makes billing very simple. The model allows him to spend more time with patients compared to employed physicians who accept traditional insurance.

Owning your own practice has other perks as well. "I decide how many patients I see and how to provide the best care for them," says Briggs, who has practiced for eight years. "I am in charge of office protocols, hiring, and firing. I am not subject to the actions of a non-medical administrative board when caring for patients."

Experts say one component to getting more physicians interested in starting their own practices is education. "More needs to be taught about the business of medicine at the medical school level and through residency," Singleton says. "A top complaint among providers was that they didn't get an adequate education in this area."

However, Stratos Christianakis, MD, program director, Internal Medicine Residency, Huntington Hospital, Pasadena, Calif., says altering curriculum would be a difficult task considering the variability in regional job markets and public policy changes regarding healthcare. Plus, "adding another dimension to medical education may encroach into valuable time training residents," he adds.

Davis, who finished residency in the 1990s, points out that some residencies have been trying to incorporate business training into their curriculum for decades. "Although well intended, it is almost always inadequate, at least in part because most faculty have limited private practice experience. I only learned myself through mentoring from my former partners," he says.

Davis notes that the economic opportunities for young primary-care providers just out of training are greater and more diverse than ever before, and include direct primary care, micro practices, telehealth, and online locum tenens matching sites - which could play a role in reversing the trend.

"The 'gig economy' is hitting medicine in a big way - and with much lower overhead per opportunity than I ever enjoyed," he says. "Intentionally or not, training doesn't provide exposure to these employment alternatives. With a medical license and a reasonable business plan, banks are more than happy to advance the capital needed to finance student loan payments as individual clinicians' ramp up these low-overhead options."

Fewer regulations could also entice physicians to open their own practices. “Compliance takes time and money,” Dr. Davis says. “The fewer the regulations, the more money a physician has to work with and the more time he or she has for patient care. And the more money a physician can generate, the fewer patients they will need to see to reach their financial goals.”

The bottom line is that much of the stress physicians face today stems from payment systems that force them to take care of far too many patients. “Fewer regulations would allow physicians to take better care of fewer patients,” Dr. Davis concludes.

While there are lots of reasons why physicians aren’t pursuing independent practice nowadays, doing so still has some advantages and new practice models exist. Consider the options as you make your next career move.

A recent survey indicated 94 percent of final-year medical residents prefer employment over independent practice. Can this be reversed?

Bringing Young Docs to Independent Practice

In order to have its coding needs fulfilled, a practice could hire a part-time or full-time coder, or it could outsource the work.

When trying to decide which avenue to go, Richard J. Lucibella, CEO of Accountable Care Options, LLC in Boynton Beach, Fla., a direct risk contractor with CMS for Medicare patients, advises practices to base it on panel size and composition. "Consider the number of patients you see per day, the mix of insurance payers, and your involvement in pay-for-performance programs," he says.

If you have a single specialty practice only involved in fee-for-service reimbursement, it is quite possible that periodic training of internal staff, combined with a random chart audit will render external and perhaps even internal coders superfluous, Lucibella says. Existing staff members are oftentimes looking for advancement opportunities and there are plenty of resources available.

"Contracted accountable care organizations (ACOs) and HMOs will often provide extensive coding training and support," he says. "Therefore, [ACOs] generally look to our office administrators, medical assistants, and billing staff and offer them the resources necessary to obtain certified coder status. In this manner, the practice can grow into coding functions in a more fluid ramp up - adding staff only as [it] identifies needs."

If a practice requires coding expertise only for reporting CPT and G-codes (codes that report functional status such as mobility, cognitive ability, and self-care), then an external coder might be a good option. For larger practices, including those reliant on Medicare Advantage, commercial HMOs, or commercial and Medicare ACO programs, the importance of knowledgeable and experienced coders increases, Lucibella says.

Physicians should also consider the effects of value-based care and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) when deciding whether to use an in-house coder or outsource coding needs.

Maxine Lewis, president of Medical Coding Reimbursement Management, a company specializing in coding, reimbursement analysis, auditing, and compliance, and a member of the National Society of Healthcare Business Consultants, says MACRA will initiate the cost component to the Merit-based Incentive Payment System - which eventually will become 60 percent of the total MIPS score. This component will be based not only on bundled payments and the hierarchy of codes, but also episodes of care.

"A coder must understand the initial, subsequent, or sequel of the encounter, adding to that any referrals or additional treatment that will contribute to the diagnosis' cost," she says. "Providers will be responsible not only for the cost of their services, but also for others that are associated with the specific diagnosis. Keeping coding needs in-house will provide greater access to the referrals and any additional cost factors that may relate to the practice."

There are both advantages and disadvantages to having coders on staff at a medical practice. Barbara L. Hays, CPC, coding and compliance strategist at Leawood, Kansas-based American Academy of Family Physicians (AAFP), points out that in-house coders allow for improved communication and education between the physician and the coder, as well as staff such as the front office and back office.

"By having a coder in-house and accessible in person, the communication loop is typically condensed," Hays says. "An in-house coder allows for communication barriers to be broken, particularly when dealing with the often misunderstood topic of coding."

Hays also says that an in-house coder may be privy to physical actions not properly documented in a medical chart that an outsourced coder wouldn't know are occurring. There are a couple of reasons for this. When interacting with staff, coders may see activities that are billable that staff may not know about. In addition, coders can physically observe physician encounters to verify if actions are occurring in the exam room that perhaps are being overlooked in documentation. For example, a physician may not be documenting a full history in an evaluation and management (E&M) encounter. However, during occasional observation, the coder may witness the actual exchange and help the physician see where he is missing recording information that was actually gathered.

But good coders are typically not cheap to employ. The AAPC, the nation's largest medical coding training and certification association for medical coders and medical coding jobs, reports that a coder's average salary is $49,872 annually. Other downsides of having coders in-house is the cost of employee benefits, service gaps during vacations and sick leave, turnover, and space requirements, Lucibella says.

As healthcare moves further into value-based reimbursement models and pay-for-performance, prospective chart review becomes increasingly important in order to catch gaps in care and identify treatment/coding opportunities.

"Programs frequently increase reimbursement based on a provider's recognition, treatment of chronic conditions, and specificity of coding - moving the focus from billing codes to diagnosis codes," Lucibella says. In these circumstances, in-house coding staff can be an invaluable resource in terms of reviewing charts prior to the patient being seen, alerting the physician to potential opportunities and diagnoses about to expire, and providing ongoing training to the physician or other providers.

For those looking to employ a team of coders in their practice, Hays recommends maintaining individuals with credentials, such as those who have earned the certified professional coder (CPC) title. Depending on the type of practice, different credentials may be applicable. For a family medicine practice, Hays advises not only seeking out a CPC, but also someone who is certified in E&M for family practice or a certified biller. Experience is not always mandatory if someone on your team can act as a mentor, she says.

Lewis says a basic understanding of anatomy and physiology is a plus - depending upon the specialty. "I frequently see a physician hire a coder who has worked in all types of specialty practices. There are nuances with all specialties, and having experience in a specific specialty may not be helpful in one diametrically opposite to it. For a physician practice, I would recommend a CPC or [certified coding specialist-physician]. While this may not definitely indicate the expertise of an individual, it is a level of competence and one which requires continuous learning."

"Familiarity with medical terminology and a working knowledge of primary care are extremely important," adds Lucibella. "Experience as a medical assistant is preferred because familiarity with medical terminology and a working knowledge of primary care are extremely important."

Coders should also have great interpersonal skills and be capable of navigating the roadblocks encountered at busy offices, he says.

Having a substantial budget for ongoing training is not necessary - time is the major investment. Certified coders are required to maintain continuing education units and coding associations such as AAPC provide ongoing seminars and webinars, mail lists, and blogs for this purpose. CMS and other government entities also offer a number of resources and mail lists that provide up-to-date information and are typically free.

Another area to look for continuous coding education are professional societies and academies for physicians and other providers. "These entities devote a great deal of time and effort to interpret and clarify rules and regulations regarding procedure and diagnosis coding," Hays says.

Outsourced coders also have benefits of their own. Lucibella points out that an external agency or motivated independent contractor might be more current on changing rules and guidelines regarding coding. External agencies provide service during non-business hours and offer part-time assistance when required.

For short-term assignments, such as medical leaves or searching for a permanent coder, Hays says outsourcing may be a viable option. Or, if a physician is providing a specialized medical service and coding staff does not know how to appropriately bill it, then outsourcing may be a good option.

If you decide to outsource your coding needs, Lucibella advises asking an agency about its training and turnover. Find out who specifically will be assigned to your practice and what their background is - including length of time with the agency. Also, what is the background of their immediate manager? Do they specialize in specific medical disciplines or specific programs such as hierarchical condition category coding?

Ask for references and take the time to call them, Hays adds. Find out if others are happy with the services they receive. Make sure revenues have not dipped prior to outsourcing. "If you do choose to outsource, monitor the submitted codes," Hays cautions. "It might be beneficial to hire a consultant periodically to review charts to make sure claims are being coded and submitted compliantly."
 

Should you hire an in-house coder or outsource? Do you need to hire one at all? Answers to these questions and more. 

Building a Medical Coding Team: In-house vs. Outsourced

The "bad guys" are no longer limited to gangs that roam the streets with chains and backward baseball caps. These days, they may wear thick glasses and are likely to be part of an organized cybercrime group featuring a team of hackers, coders, con artists, and sophisticated networks of money launderers.  And recently, they've gone after healthcare providers.

The main reason these criminals target medical practices is to gain access to credit card numbers, Social Security numbers, email addresses, bank account information, and birth dates, experts say. "With all of this information available, they can take over a patient's existing financial accounts or open new accounts and make charges," explains Robert Siciliano, CEO, IDTheftSecurity.com, Boston, Mass. "With an email address alone, these criminals can phish patients to obtain additional information."

Diana L. Burley, PhD, executive director of the Institute for Information Infrastructure Protection, a national consortium that analyzes complex cybersecurity problems, and professor of human and organizational learning, The George Washington University, Washington, D.C., says small businesses such as medical practices are prime targets because they are often less secure than their larger counterparts. This may be due to their technical defenses not being as robust and personnel being unaware of threats.

In light of this, Chris Richter, senior vice president, Global Security Services Level 3 Communications, a healthcare network service provider in Broomfield, Colo., says humans are the weakest link when it comes to cybersecurity. He points to the most recent 

Benchmark Study on Privacy & Security of Healthcare Data

 by the Ponemon Institute, which found that the health industry remains "negligent in the handling of patient information." Ponemon notes that external threats are the leading cause of security incidents specifically, and reports that healthcare organizations find dealing with data breaches challenging because there are many possible root causes. Fifty percent of healthcare organizations reported the root cause of a breach was a criminal attack, 41 percent of respondents said it was caused by a third-party snafu, and 39 percent of respondents said it was due to a stolen computing device.

So how can practices protect themselves from these thieves? Here are six tips from cybersecurity experts.

At minimum, an IT security framework should include deploying technical controls - which may include firewalls, desktop antivirus software, antivirus software on email servers, antivirus and anti-malware protection on employee inboxes, and content filtering for the Internet and email. "An IT team should update software as appropriate, patch all devices as often as possible, and perform vulnerability scans that can detect potential weaknesses," says Jorge Rey, chief information security officer and director of information security and compliance at Kaufman Rossin, a certified public accounting and advisory firm in Miami, Fla.

, a healthcare and privacy attorney with the law firm Bradley Arant Boult Cummings LLP, in Nashville, Tenn., explains that a firewall protects against intrusions and threats from outside sources. A software firewall (as opposed to a hardware firewall - which usually requires technical expertise to configure) is typically more appropriate for small physician practices. Experts say a hardware firewall is a physical piece of hardware that protects a computer on the corporate network for which it is installed. Software firewalls are included with some popular operating systems and are also available from computer security vendors, including most suppliers of anti-virus software. They are installed on an individual's computer or workgroup server, and usually come with technical support and guidance on how to successfully configure it without technical expertise.

Don't be lazy when it comes to creating passwords and have your staff follow this rule. Do not use the same password for work and personal accounts. Strong passwords should not include personal information such as your birth date, name, family member or pet names, Social Security number, or anything else that thieves could easily acquire. If a piece of information is on a social networking site, don't use it for a password. Staff should not log into Facebook, Gmail or other personal accounts from a work computer. In addition, don't write down passwords and leave them where someone else can see them, experts say.

Gaurav Jain, vice president, Information Systems, IKS Health, New York, N.Y., advises changing passwords every 90 days. Strong passwords have eight characters or more and use a combination of letters, numbers, and symbols. If you notice anything suspicious, the first precaution to take is to reset the password.

Not all employees need access to sensitive information. As a healthcare organization, you need to think about not only protecting your practice's financial and operational data, but also any patient data that is considered protected health information (PHI) under HIPAA, Rey says. Penalties for violating HIPAA can be severe, such as fines exceeding $1 million. The more employees who have access to PHI, the greater the risk that it could be compromised. Assign user account access for your IT systems based on a least-privilege model. In other words, grant each employee access to information only on an as-needed basis. For example, a receptionist most likely does not need the same level of access as a physician.

If it is not feasible for your practice to have encrypted email, which Stivers highly recommends, you could password protect documents containing PHI or prohibit the transmission of PHI via unsecured email, using mail or fax instead. Use spam and malware filters to help block phishing and other attacks.

Many risks exist with mobile devices that store or transmit PHI, such as laptops or smartphones on which you may access work email or other information, says Stivers. “Any PHI on a mobile device should be encrypted,” she says. “Install personal firewall software on all laptops that store or access electronic PHI (ePHI) or connect to networks on which ePHI is accessible. Also install, use, and regularly update virus-protection software on all portable or remote devices that access ePHI. Password protect all mobile devices, and if feasible, implement two-factor authentication (i.e., where you have to answer security questions or another step in addition to entering a password).”

A practice can implement sophisticated technological defenses and develop robust security policies, but if employees are not trained to avoid risky behavior, their efforts will be in vain, Burley says. Common risky employee behaviors include accessing public Wi-Fi, sharing passwords, using generic thumb drives to transfer confidential information, leaving password protected files unlocked, leaving devices unattended, and failing to notify managers about lost or stolen devices.

Small businesses must prepare their personnel through cybersecurity awareness programs that not only introduce them to the threat environment, but also help them understand the risks of different decisions and motivate behavioral changes, says Burley. Employee education should span all levels and positions in the practice.

Oli Thordarson, CEO and founder, Alvaka Networks, Irvine, Calif., points out that it's important to regularly cover safe user practices. "If you set the culture that security is important, employees will behave like it is important. If you ignore the topic, they will too," he says.

Cybercrime is a threat to even the smallest of practices, here are six ways to prevent criminals from accessing your patients' data.