Laura Lauth Andrews, JD is an attorney with Lauth O’Neill, LLC. Lauth O’Neill works exclusively on behalf of health care providers (physicians, nurse practitioners and physician assistants), specializing in the review, analysis and negotiation of employment agreements.

Laura Lauth Andrews, JD

When examining the big picture of our society, rural America is grossly under-represented in many ways. While areas defined as “rural” comprise 80% of the total US land area, its inhabitants comprise only 20% of the US population 

 In other words, rural communities span vast stretches of land, but there simply aren’t many people living there. The relative lack of population has very real consequences in terms of the healthcare available, and the effects are somewhat disastrous and certainly worrisome.

In rural areas, there are estimated to be only 30 specialists per 100,000 residents – this is compared to approximately 263 specialists for every 100,000 people in urban areas 

. The small number of healthcare providers overall means that they are literally and physically spread very thin, creating logistic impediments for people seeking healthcare. It is not uncommon for rural residents to have 

 healthcare providers within an hour drive of their home. The inevitable result is that people are required to devote significant amounts of time just to visit the doctor. This often means taking off an entire day of work to attend an appointment, or even staying overnight in a different town just to see a specialist. For instance, depending on where you live, you may have to travel over 200 miles to see an OB/GYN (54% of rural counties don’t have a hospital with obstetrics services) 

 These statistics shed some light on why it is that the US has very poor maternal mortality rates, which politicians and healthcare experts have recently qualified as a “crisis.” 

Other specific challenges exist in the rural setting that make the delivery of adequate healthcare even more problematic. Rural populations tend to have lower incomes, fewer adults with postsecondary education, and significantly higher rates of uninsured residents. Rural residents are also still smoking cigarettes at the same rates or higher than 10 years ago (whereas the rest of the country has drastically reduced smoking rates), and opioid use and addiction are rampant. Finally, because healthcare is logistically difficult to receive in these areas, individuals are generally only seeking treatment once disease presentation is much farther along and therefore less treatable. Whereas an urban resident would likely seek treatment at the first sign of disease or ailing health, rural residents significantly delay their first doctor visit because they simply cannot get there.

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While the rural healthcare crisis continues to progress—at least 80 rural hospitals have closed since 2010—healthcare experts are examining ways to combat the situation before it becomes an emergency our nation can no longer ignore

. On the positive side, some providers are taking steps to serve those that have historically been neglected. 

To be clear, it is not just highly trained specialists that are lacking in rural communities. Rather, providers of all kinds and backgrounds are under-represented in rural areas. All areas of care, from dentists to psychiatrists, are grossly under-represented, which is not surprising considering that rural physicians comprise only about 9% of all practicing physicians. Filling these gaps is not only an issue of initial hiring, but also of retention.

Healthcare organizations and experts tend to focus on monetary incentives when considering ways to induce providers to rural areas. These incentives include not only significant regular pay, but also things like loan payoff arrangements and sizeable bonus payments. Essentially, relying on the lure of flashing dollar signs to get providers to even consider joining the hospital or group in the first place. For many physicians with crippling student loan debt and young families to look after, this is a legitimate inducement, even if it means relocating to an area they may have never considered before. However, these beneficial financial arrangements solve only the first conundrum of hiring, and do not generally solve the issue of long-term retention. So how to get providers to not only 

It appears that the most effective strategy lies in pursuing candidates who will appreciate the lifestyle advantages offered by practicing in a rural setting, of which there are many. To begin with, there are many lifestyle factors that simply are not available in urban settings. For individuals who value the activities and opportunities presented by the great outdoors, many of our country’s rural communities offer enticing advantages. Hiking, horseback riding, boating, mountain biking, rafting and countless other activities are typical pastimes available any day of the week in many rural areas. Whereas for most of us, participating in such activities would require a special excursion, residents of many rural areas can partake in those activities any day of the week. A rural setting also might offer an attractive lure for parents of growing children. Children raised in a rural setting may have a completely different outlook on life, community, the importance of spending time outdoors being active, and the comfort, safety and reliability of a close-knit community. These are life lessons that cannot necessarily be taught, but rather must be experienced first-hand. 

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For practitioners who are more concerned with career-focused inducements to residing in rural areas, those exist as well. Physicians in rural communities have greater autonomy in general. Based simply on the fact that there are fewer providers to go around, physicians are often in the position to practice areas of medicine they wouldn’t otherwise see in an urban setting that is swarming with specialists of all types. Whereas in an urban setting a particular case might be sent immediately to a specialist, a physician in a rural setting would likely take on the case herself. This allows (and requires) the physician to use a much greater amount of the broader knowledge and information she’s been taught throughout her career, versus being pigeon-holed into only working on a very specific type of case. Finally, rural physicians generally have the benefit of getting to exercise a more holistic, patient-centered approach to medicine, as they are allowed more time with each patient, thereby enabled to provide more comprehensive care.

The benefits are varied and many, and physicians of all ages, experience levels and specialties are well-advised to consider the career opportunities available in our nation’s rural communities.

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Some providers are taking steps to serve those that have historically been neglected. 

Rural Healthcare Access: The providers and the challenges

As doctors proceed through the many years of education and training prior to their professional careers, very few of them are aware of the many non-clinical aspects of medicine that will eventually come to bear on their lives.

Incidental to any medical career are a variety of business and legal factors that have far-reaching effects. Ironically, virtually no physicians enter their professional career with the slightest bit of knowledge or background on those factors. Accordingly, most physicians unwittingly find themselves entering into legally binding contracts (i.e. employment agreements) with little to no understanding as to what they are agreeing to.

For physician contract attorneys, this is an alarming scenario. We aim to advise physicians as to every aspect of their employment agreement, focusing special attention on the provisions that we know from experience can be structured more favorably for the physician-employee. One such provision inherent in every physician employment agreement is that pertaining to Billing and Collections.

Nearly without exception, every single physician employment agreement addresses the issue of Billing and Collections, as it is an inherent aspect of any practice or hospital’s functioning. Just like any business, a healthcare practice relies on revenue and profits to stay alive, and therefore the process of billing and collecting charges from patients is pivotal to the day-to-day.

Accordingly, most employers feel compelled to address this issue in their physician employment agreements, generally focusing on the fact that while the physician will be providing the applicable services, the onus to actually 

Employers are also eager to clarify that all such collected payments are the exclusive property of the employer (versus collected fees going directly to the physician). This is all well and good and expected, but those more inquiring minds (and certainly those with a legal background) might wonder: “Shouldn’t the contract say 

 about this?” In other words, given what we know about the potential ramifications surrounding billing procedures (e.g. the abundance of coding errors and false claims), perhaps the applicable contract provision should include a promise that the employer will utilize proper billing practices.

Experts estimate that up to 42% of claims are coded incorrectly and the number of False Claims Act cases has been steadily increasing every year. In other words, negligent or fraudulent healthcare charges and claims are somewhat rampant in our country.

While physicians are responsible for the initial documentation of their services, it generally falls on professional coders and billers to officially enter the diagnosis and procedure codes for submission. Sometimes, this is completed by in-house billing staff and other times employers utilize third-party billing companies.

In any case, it is not the physician who ultimately submits a claim. Instead, physicians rely on billing staff to accurately document and submit the claims relevant to their services. Like in any situation, things can get lost in translation and the item communicated by the physician may not be what ultimately comes out on the other end. And even more frighteningly, physicians sometimes find themselves being unwittingly used as false-claim pawns by avaricious practice administrators who are eager to upcharge.

Regardless of whether the wrongful billing practices we’re considering are negligent or intentional, physicians are well advised to seek protection against potential liability. The easiest way to accomplish this protection is to make sure the physician employment agreement places 100% responsibility on the 

 to utilize proper billing and collection processes, in conformity with all government and third-party payor requirements. Further, the employer ideally will agree to indemnify the physician from any liability arising out of the billing and collection services utilized in connection with the physician’s services.

It may seem expected that employers would assume this responsibility at the outset; however, that is unfortunately not the case. In our experience of having reviewed many hundreds of physician employment agreements, there are just a few employers that readily assume this responsibility right off the bat (by including applicable contract language in all their physician employment agreements). For those employers who do not assume this responsibility upfront, we experience mixed results in terms of our success in getting them to amend the relevant contract language. But like anything else when it comes to contract negotiation, you simply never know until you ask.

The avoidance of liability in connection with improper billing and collection procedures is just one of many legal facets that physicians should consider when negotiating their employment contracts.

 is an attorney with Lauth O’Neill, LLC. Lauth O’Neill works exclusively on behalf of health care providers (physicians, nurse practitioners and physician assistants), specializing in the review, analysis and negotiation of employment agreements.

Few employers readily assume responsibility in initial contracts — make sure you read the fine print and negotiate.