Mari Edlin

Here are 10 Ways to Add 30 Minutes to Your Day

Just what you didn't need: an allegation of misconduct from your state medical board, which has the power to revoke your medical license, among other possible sanctions. Unfortunately, thousands are sent out every year by boards around the country, originating from patients, peers, hospitals, insurers, or directly from the state. 

No more than 20 percent of complaints go beyond an informal settlement conference. Still, the 70 medical boards in the United States and its territories took 6,265 disciplinary actions last year - a 20 percent increase over 2003 - according to the Federation of State Medical Boards. Some 88 percent of those actions directly affected physicians' licenses to practice medicine. 

How to keep in your medical board's good graces?

Edward Dauer, a radiologist who served on Florida's medical board for 11 years, says the most obvious advice is the best: "Be aware of what can get you into trouble. It just takes common sense. Don't write prescriptions for family members; document all controlled substances that are prescribed; know your limitations; and if you are going to perform surgery, mark the 'wrong' side with an 'X.'" 

Physician misconduct: boards' primary concern

That's fair enough. But sometimes a complaint is unavoidable, even when the care you provided was good. So what do you do if it happens?

"You have to remember it's not a civil case but a violation of the Medical Practice Act (which defines unprofessional conduct in each state)," says Joan Jerzak, chief of enforcement for the California state medical board. "A physician either did something or he didn't. It is not an emotionally-driven case." 

As David Slawkowski, an attorney with the Chicago-based law firm of Anderson, Razor and Partners LLC says, "The process is not to punish physicians but to demonstrate compliance by licensed professionals." 

But not unlike the preparations for a malpractice case in civil court, responding to a medical board complaint demands detailed documentation, legal counsel, open communication and level-headedness, says Bill Spratt, a health lawyer with Kirkpatrick & Lockhart Nicholson Graham LLP in Miami. 

"Most physicians are surprised when a complaint is filed," Spratt says. "If there are any adverse outcomes, they expect to hear directly from patients, their families, or an attorney first."

State board actions, though, are often prompted by allegations of professional misconduct, rather than a mere adverse medical outcome that so often triggers a malpractice lawsuit. With the boards, unconventional financial arrangements among physicians, sexual misconduct, unfair billing, and fraud can raise eyebrows, as can a pattern of questionable behavior. 

Failure to maintain patient records, falsifying information for a hospital reappointment application, prescribing drugs without conducting a patient exam, sexual abuse of patients, and gross medical inadequacy are some of the behaviors that, according to public records, are likely to result in board actions. Settlements run the gamut from license revocation or suspension, to supervision by a colleague and community service, to five years of probation. 

If you're like most physicians, you probably don't have any formal contingency plans should you be summoned by a state medical board; complaints from the state seem to come out of the blue. It never hurts to take some preventive measures that will stand you in good stead throughout your careers.


Dale Austin, senior vice president and chief operating officer for the Federation of State Medical Boards in Dallas, says it's important to know how to practice within your state's laws. "Become familiar with the medical practice act in your state; pay attention to deadlines for license renewal; stay up to date on CME-required content and how many courses [you must take] over what period of time - and read state medical board newsletters, which often offer guidance on policy matters."

Develop a compliance and risk management program in your office so you stay abreast of regulations and requirements outlined by the state board of medicine.

Recognize the significant relationship between physician and patient. Be above-board and honest in your communications with patients and their families so there will be no misunderstanding about care delivery and anticipated outcomes. Show compassion, but don't step over the physician/patient line. Maintain professionalism in the face of an adverse patient outcome.

Conduct internal audits periodically to ensure nothing slips through the cracks.

And finally, remember the physician mantra: document, document, document.

Boards' processes for dealing with complaints vary from state to state, but in general, it begins with a board's receipt of a complaint from any of a number of sources, including patients, families, managed-care organizations, hospitals, and other physicians. The complaint is reviewed by an investigative and medical staff. The physician receives notice of this investigation, and has an opportunity to respond to the allegations within a specific time frame.

Spratt recommends that physicians work closely with an attorney to hammer out a response and forward any necessary information, such as evidence-based information supporting the physician's actions, a supplemental letter from a respected colleague, and patient records; other information may be solicited by the investigator. The key is cooperation, Spratt says. 

"Don't bang your fists and say, 'I didn't do anything wrong,' but also don't admit wrongdoing," notes Fletcher Brown, president of the Health Law Section of the Austin (Texas) Bar Association and a partner with Davis and Wilkerson PC. "Boards are interested in compliance, so the complaint may be resolved by just taking a specific CME course."

Linda Stimmel, a partner with the law firm of Stewart & Stimmel LLP in Dallas, recommends that even if you have made a mistake - which may be due to a "system failure," a confusing drug label, or a colleague's prior error - you should explain the circumstances and indicate ways that they can improve the process in the future. "You should not fold, give up, and plea bargain unless you have no explanation or reasonable defense for a mistake. By offering an explanation, the plea bargain will be less severe," she says.

Once the investigators have all of the information and documentation in hand, they typically will submit the materials to a probable cause panel for review. If substandard medical care is alleged, a physician peer in the same discipline as the licensee might be asked for an opinion. 

The probable cause panel has several options: it may simply dismiss the case and close the file; issue a letter of guidance to the physician; initiate an informal settlement conference; or if the physician's actions appear to be a violation of licensure, the panel may issue a formal complaint, which may be heard by an administrative law judge. 

In the informal settlement conference, the physician is usually in attendance and may present her case to a panel composed of medical board members, board attorneys, and the lead investigator. That panel's decision must be approved, rejected, or modified by the state board. The physician must also accept the settlement; if she doesn't, a formal hearing is held before an administrative law judge. 

Yet even decisions reached at formal hearing must be approved by the state board. If a physician remains unhappy after the board's final decision, she may appeal to the circuit court. 

Again, the processes vary by state. Make sure you know your state's rules.


Disciplinary actions and summary suspensions are reported to the Federation of State Medical Boards, local and regional medical societies, the American Medical Association and other agencies, and are often posted on state medical board Web sites in the public domain. Closed claims, dismissed actions, and ongoing investigations remain confidential. 

In the face of an allegation that could tarnish - or wreck - your career, you should seek counsel - not just any lawyer but one experienced in administrative law and healthcare. "Many physicians think they can handle the complaints on their own because they make critical decisions every day," Spratt says, "but they are too busy and are not thinking like an investigator or lawyer. They may make inconsistent and incorrect statements, providing less credibility to the case."

"Medical boards have their own counsel, so why shouldn't physicians?" asks Brown. "We don't have to act as attorneys but rather help doctors tailor their response to an allegation and better understand the perspective of the board. Physicians may never have to read a statement, but the preparation helps them focus on critical issues so that they can speak on their own behalf if necessary. Physicians are not in their comfort level in the regulatory environment. Success rests on believability, likeability, and trustworthiness."

Just as processes differ by state, so do standard-of-evidence requirements. In California and Florida, the medical boards require "clear and convincing" evidence to prove a physician's wrongdoing, evidence that produces a firm belief or conviction that the allegations are true. Other boards, though, such as those in Texas, Colorado, and Michigan, require only a "preponderance of the evidence" - that is, evidence of greater weight or that is more convincing than the opposing evidence. 

Rules of evidence, such as those governing the admissibility of hearsay, only apply to formal administrative hearings, not informal settlement conferences. If physicians are suspected of impaired ability to practice due to alcohol or drug abuse or mental illness, this information is confidential and cannot be used as evidence if they voluntarily participate in a supervised treatment program. 

Physicians often select character witnesses and professional experts to support them and their actions. Brown recommends no more than one to two witnesses so that it is affordable for the defendant and does not become a "battle of experts." 

Attorneys and physicians with experience in the medical board complaint process offer a consensus of opinion for responding to an initial complaint, weathering the review, and avoiding a formal hearing: 

Provide a concise, logical, and clear description of what occurred (usually chronologically), your rationale for what happened, and what you have learned from the experience.

Be honest. Fudging the truth could come back to bite you.

Explain extenuating circumstances, if they are relevant to what occurred. 

Don't ignore requests for information by an investigator. 

Ask questions during the investigation period if you don't understand something.

Take the complaint seriously; state medical boards certainly do.

Slawkowski says that poor documentation is often at the root of complaints that progress into a formal hearing; on the other hand, good patient records are also your best evidence.

The first line of defense is good charting. Record facts; stay objective.

Consider the potential audience of your charts.

Ensure the documentation is legible. Don't try to recount patient visits if they are not properly documented; making up information or altering records will only compound the problem.

Document good practices - especially as they relate to end-of-life issues and prescribing controlled substances.

This article originally appeared in the October 2005 issue of

Articles

Disciplinary actions against physicians are up. Avoiding one is pretty straightforward, but it's still wise to have a plan for dealing with a complaint - and salvaging your career.

Surviving a Medical Board Review

Brett Segal, MD, is living in paradise. For the past three years, he has served as a physician aboard Carnival Cruise lines. His backyard stretches from New Orleans to Martinique and Antigua, with Jamaica, Bermuda, and Aruba in between. It's not a bad gig if you can get it, but the life of a solo physician catering to 1,000 crew members and as many as 3,400 guests is not always as luxurious as it seems. 

"It can be very daunting to work on a ship," says Segal. "This is a serious job on the cutting edge of modern medicine. One of the main challenges is being isolated in the middle of the sea with the potential for anything to happen, sometimes a life-threatening situation which we are not prepared to treat on board."

Although Segal is supported by a medical staff of three nurses and a nurse practitioner, a comprehensive on-board medical library, access to the U.S. Coast Guard during medical emergencies, and a fully equipped, high-tech infirmary that would put any clinic to shame, he is basically on call 24/7 for four to six months at a time. "You are not called every night to attend to an emergency, but the potential exists," he says. "It can be very tiring working every day without a break. That doesn't leave much personal time."

Still, for Segal, like many physicians who practice in nontraditional settings, it's worthwhile to give up certain consistencies of a regular practice in exchange for something a little bit different. Whether they're treating the injuries of major league athletes, volunteering in developing countries, or mingling with Mickey Mouse and Donald Duck, these physicians agree that variety spices up their practices.

Segal, who is trained in emergency medicine, not only treats ailing guests, but also coordinates emergency patient evacuations, negotiates with insurance companies, serves as a primary and occupational physician for a multicultural crew, pacifies family members of sick passengers, and is an expert in guest relations. 

For Segal, life as a shipboard physician has been a great financial opportunity -- he's got free living expenses and a good salary (although a cruise line physician generally earns less than a physician in a traditional setting, and has the same responsibilities). 

And, not unlike physicians working in a regular medical office, "You really need a sense of humor and a thick skin; otherwise, you will never make it on this job," Segal says. "Guests can be very demanding and rude but you have to understand that they are guests first and not patients. They are on vacation and do not expect to get sick, so they often have unreasonable demands."

Ben Shore, DO, a fleet physician for Norwegian Cruise Line (NCL) and Orient Lines, has been on the other end of the phone during on-board medical emergencies and evacuations, giving shore-side advice to ships' physicians about stabilizing sick guests and instructing them how and where to transport them if additional care is warranted. With a background in emergency medicine, he is well suited to providing immediate feedback to NCL physicians facing a life-threatening medical episode. 

Like Segal, Shore is basically on call 24/7, during which time he performs legal, medical, policy-making, purchasing, and human relations duties in an office in Miami. He enjoys the freedom of setting his own schedule, serving as a consultant, and working in a state-of-the-art communication and technology environment. The only thing missing is hands-on patient care, from which he retired in 2002. 

His advice for physicians looking for a change? Use your medical degree to expand your opportunities, not limit them.

James Yu, MD, a staff anesthesiologist with Southern California Permanente Medical Group, takes his medical expertise to remote parts of the world through a nearly two-decade association with Operation Smile, a private, not-for-profit volunteer medical services organization providing reconstructive surgery and related healthcare to indigent children and young adults in developing countries and the United States. Yu recently visited Foraleaza, Brazil, where a team of reconstructive plastic surgeons, anesthesiologists, and nurses performed 155 surgeries in five days, including correcting cleft lips, cleft palates, and other facial deformities.

As a visiting physician, Yu shares modern medical techniques and adds a jolt of confidence to the native physicians and the rest of the local healthcare team, allowing them to eventually assume responsibility for patients. In turn, Yu has benefited from the ingenuity of his Brazilian peers, who create operating rooms with primitive equipment and minimal supplies. 

"Volunteering for an organization such as Operation Smile is a very humbling experience," Yu says. "You have to be able to size up what you can offer by doing a little homework, corresponding with the local staff abroad, and doing everything you can to achieve it. There is no room for a superior attitude or for focusing on one's own goals. You can't successfully collaborate with others unless you have a keen interest in helping and a big heart."


He also finds satisfaction in bringing his patients out from under the stigma associated with facial deformities. "Many of these people are outcast by their communities and cover their faces with sheets when in public," he says. "It is a mighty cross to bear. You should see what happens after we perform surgery: mothers become nearly hysterical with appreciation at the physical change in their children." 

For four years, Ted Palen, MD, an internist with the Colorado Permanente Medical Group, has been affiliated with Medical Ambassadors International (MAI), a missionary group that combines spirituality and physical healthcare. His recent destination was Quezaltenango, a town in the northwest highlands of Guatemala, occupied by native Mayans. It is not unusual for Palen and his co-workers over a two-day period to treat 150 
residents in a cinderblock schoolhouse with a dirt floor. Many of his patients suffer from diarrhea and musculoskeletal aches -- not unusual for women who balance heavy loads on their heads while carrying their children.

He says that helping the less fortunate has changed his priorities. 
"This kind of volunteering takes the willingness to step out and do something that may be a bit uncomfortable at first but becomes easier once you forget yourself," Palen says. "In the United States, we are very time-oriented and focused on completing tasks. In many third-world countries, time is a very relative thing and people and relationships are more important than tasks. These cultural differences are important to understand and account for before and during a trip. [You need to] be prepared for rudimentary conditions, often with a lack of supplies, and be able to rely on clinical skills rather than diagnostic equipment."

For physicians who are looking for this kind of practice experience, Palen suggests first volunteering, for example, at a clinic for the uninsured.

If Disney World is indeed the happiest place on earth, then Gary Clonts, MD, may just be the happiest physician. He is medical director for the Orlando, Fla., entertainment complex housing four theme parks and two water parks. A two-week occupational medical residency rotation at Disney World gave him the in, and he has been there since 1988, with no immediate plans to move on.

His responsibilities include overseeing nurses who provide first aid to Disney World guests, treating routine illnesses and injuries and offering preventive care to 51,000 employees, monitoring OSHA requirements, processing family medical leaves, and confirming return-to-work requests. Clonts, along with four full-time physicians and nurses, staffs the 15,000-square-foot medical clinic serving all six Disney World park sites. It's open 14 hours a day, seven days a week. 

Clonts' biggest challenge is merging the worlds of business and medicine, which he says is a continual learning process. "When you transition to occupational medicine," he says, "you have to adopt a global perspective -- decisions affect more than one person -- enhance and develop your leadership skills and financial competencies, and accept more ownership in the public health model. All of this requires a shorter learning curve than in a regular healthcare environment." 

Clonts admits that occupational medicine is not the route to go for physicians who have high financial goals. You do it because you want to, he says, and because you crave flexibility, want to continue learning, and have a desire to develop leadership and communication skills. He suggests physicians explore their local communities for these kinds of opportunities.

Although Jay LaCour, MD, is an ophthalmologist in private practice, he or his partner Scott Lanoux, MD, can be found on the sidelines of every New Orleans Saints and Hornets game -- a role they inherited from their late partner. The two physicians are paid a stipend by the teams to treat eye injuries that may occur during football and basketball games. Recently, LaCour treated four Saints when contact with a newly laid surface at the Super Dome sprayed an irritant into players' eyes. 

Working with both teams is a bonus for the two physicians, who are avid sports fans. "The affiliation adds a different flavor to our practice," LaCour says. The partners also offer surgical services to the indigent population in New Orleans, who LaCour says are treated with the same amount of respect and care as the physicians' better-known clients. 

"The athletes are not asking for any special treatment except to get back on the field as soon as possible. They are appreciative of the time and care," he says.

This article originally appeared in the March 2004 issue of 

These physician found career satisfaction outside the office

Work Outside the Box

These days, practices have to focus on physician productivity, not managing staff crises or worrying about violating some regulation. Having a complete, written, and well-thumbed policies and procedures manual can help. Word-of-mouth policymaking or holding onto an outdated manual that no one reads only hampers smooth operations. The new trend is to use written protocols as a tool for efficient practice management.

"When policies and procedures are 'living and breathing' documents for employees, there is a reduction in variation in work processes, which leads to increased efficiency and a way to measure and monitor performance," explains Deborah Walker, a principal with Boehm/Walker Associates, a medical group management consulting firm in Surfside, Calif.  

"Many practices lack an infrastructure for achieving efficiency," says Bette Warn, practice administrator for Woodridge Orthopaedic and Spine Center, a nine-physician practice based in Denver. "But by putting policies and procedures in writing, you avoid saying things in multiple ways." 

Warn ought to know. She is co-author, with Elizabeth Woodcock, of 

Operating Policies and Procedures Manual for Medical Practices

, a 443-page "bible" on developing and updating operating procedures, complete with a CD containing content boilerplate practices can customize (visit 

, the Web site for the Medical Group Management Association, to buy a copy). 

Warn and Woodcock's book has 17 sections encompassing everything from sexual harassment to storing and retrieving medical records, greeting patients on the telephone, authorizing referrals, and coding. Such a broad reach may be too burdensome for some practices, but others flourish by having everything covered.

Jo Anne Kroener, office manager for Dallas Asthma and Allergy Center, a three-physician practice, doesn't waste time reinventing the wheel. She relies on the book to provide basic policies and procedures and then adds others that reflect the practice's operations and philosophy. The practice's manual received an overhaul last September, when a new computer system was introduced. Many tasks once accomplished manually are now handled electronically, such as scanning insurance cards into the computer instead of using a copy machine.

Kroener warns against getting too detailed, though. Some older policies and procedures in her office had gotten so outdated or exhaustive that "if we had to tell you that, you shouldn't be working here," she says. One even told employees to keep pencils in pencil holders.

What could develop into a monster -- hundreds of pages of detailed policies and procedures dictating every process in a medical practice -- can be designed to be much more user-friendly. "You have to look at what's significant or employees will get bogged down and not read any of the policies and procedures," Warn says.

Kroener's manual gives standardized directions for making patient appointments so any staff person can handle the task. The manual also provides a quick ruling on whether an employee on unpaid sick leave can receive her salary for the holidays that coincided with her absence. (She cannot.)

Use common sense when deciding what to include in a manual, warns Alex Fernandez, executive administrator for Gastroenterology Care Center, an 11-physician practice in Miami. His practice uses a series of manuals addressing corporate compliance, employee issues, medical records, and HIPAA. He likes how the manuals train employees to do things "our way" and add a touch of professionalism to the group.

Jayne Oliva with Croes/Oliva Group, a medical group management consulting firm in Burlington, Mass., further suggests separating administrative and clinical protocols when deciding what to include in a manual. That makes for easier reading and helps physicians stay clinically focused instead of worrying about answering phones. But when it comes to issues that directly affect them -- such as triage, traffic flow, and patient preparation -- physicians should jump right in.

Pinehurst Surgical Center in Pinehurst, N.C., maintains a separate Physician Owners' Manual which fleshes out 140 different clinic policies and procedures, including income distribution, physician recruitment, use of physician assistants, expenses, contributions to charitable organizations, malpractice insurance coverage, and dispensing controlled substances. When a physician comes on board, he or she receives a copy so there are no gray areas, says William M. Edsel, CEO.

It's one thing to decide you need a manual, another thing to actually get it written.


For best results, Oliva suggests that an office administrator take the first crack at drafting administrative policies and procedures, supported by input from employees, while a medical director tackles the clinical side. Ultimately, though, the two sides need to work cooperatively. It does no good, for example, for physicians to create such complex scheduling protocols that schedulers can't possibly follow them.

No matter who crafts the rules, it's important that physician leaders approve them. That boosts physician and employee compliance and eliminates bickering later on about a policy's validity. 

Pinehurst Surgical Center has more than 100 policies and procedures affecting employees, issues that have bubbled up from the organization. The rules face a rigorous review process by a committee of physician owners and the human resources manager, who make recommendations to an executive committee comprised of clinic officers and committee chairs. If the vote is unanimous, the motion passes; however, even one dissenting vote kicks the idea up to the board of directors for final approval. 

Once approved, no policy should stagnate. Industry regulations and even physician preferences change over time and so should the manual. Pinehurst Surgical Center reviews its manual every two years.

New policies, such as HIPAA, may make faster review necessary. Although 

 does not contain much information on HIPAA, Warn says it is necessary to cross-reference patient information protection rules with personnel and medical records policies to ensure privacy and confidentiality. 

Pinehurst has been readying itself for HIPAA over the last year and a half. Confidentiality and security policies are incorporated into the employee handbook and intranet and describe how to appropriately safeguard patient  information. 

Similarly, the manual for Medical Consultants in Muncie, Ind., is a work in progress, especially those aspects related to security and privacy, says Wayne Winney, CEO of the 40-physician multispecialty practice. The practice includes HIPAA requirements in its policies and procedures manual, but Winney's primary objective is to find efficient ways to comply. For example, HIPAA requires patients to sign a variety of different forms. Medical Consultants developed a policy to consolidate the forms so patients could deal with them all at one time. 

Developing a policies and procedures manual is only half the battle; getting staff and physicians to use it is like winning the war. Joseph Zumpano, managing partner of Ferrell, Schultz, Carter, Zumpano and Fertel, a law firm in Miami, has a few ideas for ensuring compliance: 

acknowledgement by staff and physicians that they have read and understand policies and procedures;

appointment of a compliance officer to monitor and audit compliance; 

objective and specific methodology for enforcing penalties for non-compliance; and 

educating staff and physicians to avoid potential violations.

"Senior physicians must set the tone by establishing a code of conduct which everyone is expected to follow," says William Spratt, Jr., a partner with Kirkpatrick & Lockhart, a law firm based in Miami. "There must be orientation for new employees and training at all levels as to those expectations. And the practice must commit to addressing each issue in a fair and objective way consistent with its code of conduct."

It can also help to make sure the manual is very clear and well-suited to the real world. Arcane, misunderstood rules are the most likely to be broken. Here are some ways to stay relevant:

Make sure the policy or procedure can be supported by the facility, reflects what the practice is doing, and how that relates to what is expected of employees. Back up each policy with a rationale.

Use a team approach so no one person is responsible for developing policies and procedures; checks and balances are key.

Ensure everyone is interpreting a policy in the same way to avoid potential business risk.

Incorporate policies and procedures into everyday activities.

Keep the format easy-to-read and brief; no one will use the manual if they can't locate what they need. If the information is in a binder, use tabs with section names, or icons for online versions. 

Include flowcharts in policies and procedures manuals outlining steps for a particular work process, Walker recommends.

Review one policy at each staff meeting to ensure its currency, relevance, and understanding.  

Get physician and employee buy-in. Most people are reasonable and will accept policies if they understand them; if policies are imposed by edict, buy-in is unlikely, Edsel says.

A policy that gets off the shelf and into the heads of staff and physicians can help eliminate redundancies and distracting bickering. 

This article originally appeared in the July 2003 issue of 

How to create and use a complete and well-thumbed policies and procedures manual

Put Policies in Writing

Julio Garcia, a plastic surgeon in Las Vegas, has taken his practice to a new level. He is no longer just making his patients beautiful on the outside -- he has also established an anti-aging clinic to help them improve memory, reduce stress, and manage the symptoms of menopause. 

Garcia is among a growing number of physicians who have expanded their traditional practices to include additional services, from alternative medicine to MRIs to executive physicals. While the primary motive for some physicians is to produce more revenue to compensate for dropping reimbursement rates, others see their expanded service lines as a natural extension of their practices, an opportunity to provide one-stop shopping as well as to give their incomes a shot in the arm.

"Adding services helps physicians increase productivity," says Mike Fleischman, a consultant with Gates, Moore & Co. in Atlanta, a firm that provides practice management, tax, and accounting services to physicians. "There are only so many hours in the day; so if you can do a procedure next door to your office, you can improve efficiency." 

"Physicians can't make money practicing medicine like they used to, so they have become more entrepreneurial and bigger risk-takers," says Marshall Baker, of Physician Advisory Services in Boise, Idaho. He notes that physicians are turning to wellness product lines, ambulatory surgical suites, women's centers, and diagnostic tests to boost their bottom lines, and estimates that some practices may earn as much as 15 percent of their income from added services.

Garcia's anti-aging clinic, started in 1998, definitely fills a niche considering that the average age of his patients is mid-40s, and most of them visit him at least three times a year. He offers nutritional counseling, hormone replacement therapy, blood and saliva testing to check for vitamin and hormone levels, "smart drugs" to prevent memory loss, bone density screenings, body fat measurements, lung capacity evaluations, and a relaxation capsule heated to 104 degrees. 

For a fee of $600, Garcia meets with patients for 20 minutes before the diagnostic tests and an hour afterwards, and provides a 25-page assessment with recommendations. Garcia attributes 20 percent of his revenue to the anti-aging clinic, and expects that it will climb to 50 percent in the next two years. 

Deborah Harding, MD, splits her time between her own internal medicine practice in Orlando, Fla., and Rippe Health Assessment (RHA), founded in 1998 by cardiologist James Rippe. RHA offers a comprehensive medical, diagnostic, fitness, nutrition, and lifestyle evaluation geared specifically toward executives. Its client base in 2001 numbered 600, a growth rate of 67 percent since RHA's inception.

RHA offers four assessment levels, ranging in price from $1,400 to $3,400, each incorporating increasingly lengthy and specialized evaluations and personalized services. Patients also may request full body scans for $1,000 and lung and heart scans for $600 each. The exams and assessments are not covered by insurance but are often paid for by executives' employers.

"Our primary goal is to prevent disease before it happens, and if a problem already exists, we can pick it up more quickly," Harding says. "It is important to look at the whole person, but when you have to see more and more patients to compensate for lower reimbursement, that becomes difficult. I am fed up with insurance telling me how to practice medicine."

When patients visit their OB/GYNs at Louisiana Women's Healthcare Associates (LWHA), an 18-physician practice in Baton Rouge, they can also take advantage of onsite lab tests, such as bone marrow density screenings, mammograms, hormone analyses, DNA testing, hepatitis and HIV screenings, and lipid profiles. When the lab expanded its test offerings in 2000, there was an 80 percent increase in production over its first year, 1998. 

"The full-service lab brings tests closer and results more quickly to patients," says Thomas Schmidt, the practice's CEO. 

LWHA also has an ambulatory surgical suite and a separate suite for performing ultrasounds. While Schmidt says the motivation to offer additional services is not revenue-driven, the surgical suite and sonography, mammography, and osteoporosis screenings account for 22 percent of all revenue.

Sandy Eckard, vice president of operations for KDV Orthopedics and Rehabilitation in York, Pa., calls that practice's ancillary services, which include MRIs, physical therapy, and physical medicine and rehabilitation, "a natural extension of orthopedic surgery. We wanted to offer a broader continuum of care -- diagnostic and therapeutic procedures -- to help our six surgeons decide what treatment to choose," she says. 


"Having to refer patients for tests and screenings causes delays and prevents immediate attention to problems that require it. In addition, as we work harder for less reimbursement, our blend of services enhances our orthopedic surgery and our revenue."

David Edelberg, an internist with Whole Health Chicago, has blended his knowledge of internal and alternative medicine techniques by joining forces with a chiropractor, homeopath, psychologist, acupuncturist, massage therapist, and nutritionist, all of whom practice under one roof. As the group's solo physician, Edelberg became an alternative medicine convert after listening to patients tout its virtues. 

"I was the medical director for a large group and became disenchanted with managed care," he says. Edelberg spends lots of time with each patient, seeing only 13 a day, all of whom pay on a fee-for-service basis.

The providers in the practice generate their compensation based on the number of patients they see, and 50 percent of that revenue supports office overhead. "We didn't initiate alternative medicine for the revenue; we're adding value by making many disciplines available in one place under the supervision of a physician," Edelberg says.

Promoting expanded services has remained low-key for most practices. Mark DeFrancesco, MD, chief medical officer of Women's Health Connecticut, an OB/GYN practice in Avon that sells nutritional supplements, says physicians hand out product brochures, but "patients don't have to buy from us; we just make recommendations and get them to think about good nutrition," he says. "We tone down the promotional aspect." In addition, the practice conducts FDA-approved clinical trials that bring in about $40,000 a year.

Page Sturgill, manager of client services and clinical research for RHA, says that the company's marketing budget is small, but that they do advertise in a few top-end magazines, produce promotional marketing materials and videos, and rely on testimonials and word-of-mouth. "I have a strong handle on the local community and have developed relationships with our clients' colleagues," she says.

Physicians agree that staffing is another critical component to the success of expanded practices. Many have either hired experienced staff members who share their expertise or train staff to manage the new services. "It's worth paying extra for staff who can teach you," says KDV's Eckard. "Our MRI chief technician knew more than the doctors, so he educated us." 

Garcia, who is certified by the American Academy of Anti-Aging Medicine, praises his assistant, who formerly worked with an endocrinologist -- a boon for his anti-aging clinic. 

LWHA has set minimum training and educational requirements for its staff. Its sonographers are registered and have an OB/GYN specialty, while staff attend courses to become certified to perform bone density screening and laser procedures.

According to Baker, offering additional products and services presents many of the same challenges of any new venture -- namely, ensuring the new initiative will make money and add value to the business. 

Fleischman warns practitioners to adequately plan and calculate costs of adding new services before jumping in. "It may seem like a good idea until you realize that MRI equipment may cost as much as $2 million and that it requires qualified technicians. If there isn't steady use, it might not be worth it."

"We emphasize services that support our core competencies so that we are not perceived as entrepreneurial and it's not necessary to retool our offices," DeFrancesco says. He suggests adding services that make sense medically before anything else.

Perception is something Garcia also takes very seriously. "Many of my peers believe you should not slow the aging process and are not convinced my services are worthwhile," he says. "This forces me to back up my work with credible research and prove its value to both patients and other physicians."


Schmidt stresses the importance of meeting patient expectations. "You can't do it halfway; you have to dedicate yourself and be committed to incorporating new methodologies into daily practice patterns." Then the extra income that is generated from expanded service is just icing on the cake.

This article originally appeared in the January/February 2002 issue of 

Ancillary services boost revenue and customer service

Boost Your Bottom Line


"We're not a bank. Take out a loan or charge it," says Diane Colton, office manager for Family Medicine Associates of Texas, when asked about extending credit to patients. It's not that Colton is heartless, but her eight-physician practice in Carrollton, Texas, has established a set of rules for collecting payments from its 30,000 patients.

While most physicians prefer to concentrate on their clinical expertise rather than their business acumen, many are savvy enough to hire people like Colton to help them establish and oversee policies ranging from collecting copayments, charging for no-shows, adding finance charges to late payments, and using credit cards. At the same time, office financial gurus should be aware of regulations that may affect these collection practices to ensure that their payment plans follow the rule of law and result in prompt payment to the practice.

What every physician practice strives for is collecting payments at the time of service. Copayments are easiest - not only are patients conditioned to paying them at the time of the visit, but managed-care contracts require them to be remitted up-front; otherwise, contract terms with insurers may be violated. Colton says it makes no sense to bill for them because statements cost nearly as much as the copayment. More important, physicians have a legal obligation to collect them.

Waiving copayments for Medicare patients, for example, violates federal law; it may be construed as an inducement to see a specific doctor and is considered fraud by the CMS (Centers for Medicare and Medicaid Services, formerly HCFA). "If you routinely give courtesy, someone is going to question it. You are under obligation to charge the full fee unless you can show financial hardship for the patient," says Mark DeFrancesco, chief medical officer at Women's Health Connecticut, a 140-physician practice in Avon.

Similarly, professional courtesy may be considered an incentive to physicians to refer patients, another potentially fraudulent practice. Scott Williams, director of billing and collections at Duke University in Durham, N.C., says it's a big challenge to ask patients for money, but educating patients and practice staff can help smooth the process. At Duke, staff members are given scripts customized for each specialty to assist in dealing with patients about financial matters.

"When patients call for an appointment, we let them know we expect payment at time of service and remind them of outstanding balances," Williams explains. "And we discuss it again during appointment reminder calls so requests for payment won't come as a surprise." He encourages practices to design their infrastructures so that patients pass a business office or desk before they leave - and have access to an office or alcove for discussing financial issues in private. 

"You really can't ask for much more than a copayment up-front," says Victoria Jackson, CEO of Southern Orange County Pediatric Associates in Lake Forest, Calif. "You have to wait to see what insurance covers before you can bill someone." Her practice gives patients envelopes for copayments if they can't pay at time of service, and gives them a week to pay; she will, however, charge $5 if she has to send a billing statement. 

While the majority of physician offices accept credit cards to allow patients to pay larger balances over time, some smaller practices - and those striving for that extra degree of customer service - may decide to handle their own payment plans. In that case, disclosure of certain information is required before a "closed-end credit transaction," in which the borrower is required to pay off an established amount by a particular time, is completed.

The Truth in Lending Act outlines several items that must be included in disclosure statements for closed-end credit plans, to protect the creditors (in this case, physicians). These required items include: the institution name, annual percentage rate, finance charge, itemization of amount financed, the payment schedule, the total number of payments and total amount, security interest (whether the loan is secured and if so, by what collateral), prepayment statement (if one exists), late payment (and whether there is a penalty), contract reference, the required deposit, a demand feature (creditors may demand full payment if a patient defaults on payment terms), and insurance disclosures. Any items that are not applicable, such as collateral, may be deleted from the disclosure statement. Be aware, too, that some items may have negative public relations and administrative ramifications.

Inga Ellzey, who runs a physician consulting and billing firm in Casselbury, Fla., recommends that physicians think long and hard about charging a finance fee, for example. "It becomes a bookkeeping hassle. You have to keep separate books - one for medical care and one for administrative charges. If someone can't pay in the first place, how are they going to pay extra fees?" she asks. DeFrancesco agrees that charging interest is not a good idea. "It makes physicians look greedy and gives us a bad image," he notes.

Although the American Medical Association (AMA) discourages commercial collection practices, it supports interest charges if physicians continually experience delinquent accounts. The organization emphasizes that physicians must not only comply with state and federal laws and regulations related to finance charges, but that they also must tell patients their policies in advance by posting signs in the office waiting area, distributing brochures describing billing practices, and including notification in billing statements. If there is a change in terms, patients must be notified within 15 days.

Williams agrees that extended payment plans are a better incentive to encourage prompt payment than adding finance charges to late payments, but he is in favor of doing a little due diligence through financial screenings of the patients to ensure they can eventually pay. Family Medicine Associates of Texas is willing to develop payment plans, but with reasonable terms, Colton says - although that doesn't mean $10 a month for a $3,000 invoice. Patients are required to sign a financial agreement, and if they fail to pay on time, the account is moved to a collection agency.


Practices that handle overdue accounts themselves should be aware of the Fair Debt Collection Practices Act. That act outlines when it is appropriate to contact a person (not before 8 a.m. or after 9 p.m.), what constitutes harassment or unfair practices (threats of violence or harm), and what is considered false or misleading representation (misstating the amount owed).

"It's just putting good money after bad," Williams says, when it comes to charging for no-shows. "It's self-defeating because you won't collect money anyway." Family Medicine Associates of Texas is one of those practices that charges for missed appointments, but only after the third time. Colton sends a letter informing patients that they will be billed for an office visit.

Ellzey considers charging for no-shows another bookkeeping nightmare. She believes that chronic no-shows will eventually move on to another provider. As a preventive measure, she recommends that physicians or their administrators track when missed appointments occur most often - during the summer vacation time, for instance - and overbook the average number of no-shows for those periods. "Use software to automatically trigger appointment reminder calls and don't book appointments too far in advance," she recommends.

DeFrancesco holds a practical view of the no-show dilemma. "We realize that as doctors, we have similar transgressions, making patients wait or sometimes even canceling," he says. "Not charging makes for more satisfaction and better doctor-patient relationships."

Although Mike DiDonato doesn't typically bill for no-shows, there are two elective surgical procedures offered by his urology practice in Voorhees, N.J., that make it necessary because the procedures involve time-consuming microsurgery. Administrator DiDonato says patients must put half down once they decide to undergo these surgeries, half of which the practice keeps if the patient backs out.

"Billing has become so complex," he says, "with so many different regulations and insurers that billing staffs have to be experts, not just data entry people."

This article originally appeared in the November/December 2001 issue of 

What you can and can't do when it comes to collections

A Fair Trade?


Early in his career, healthcare policy guru Paul Ellwood, MD, began noticing that the healthcare system rewarded episodes of care, rather than management of care. In other words, recalls the founder of the Jackson Hole Group, treatment of acute problems was at the forefront, and prevention and long-term management of chronic conditions - which would ultimately improve quality and reduce costs -  lagged behind.

Now, a decade after a group of erstwhile healthcare reformers began meeting at Ellwood's Wyoming retreat, quality of care -  including a healthy dose of preventive measures and disease management -  is emerging as the basis of physician incentive plans across the country.

Michael Barrow, MD, who practices with Samaritan North Family Physicians in Dayton, Ohio, is a supporter of -  and a participant in - a quality-based incentive program. "It is a refreshing change to work with payers in this unusual collaboration. Usually payers just act as insurers," says Barrow, who serves on the coordinating council of the Tri-River Healthcare Initiative, an alliance of health plans, purchasers, and physician groups; at the core of the initiative is a quality-based physician incentive plan, funded by a $2 per member/per month fee paid by participating purchasers.

"We wanted to reengineer the delivery system and engage the community in designing a plan," says Sam Shalaby, regional director of healthcare initiatives for General Motors' southwest region - one of several major healthcare purchasers that form the Tri-River Initiative. "Quality reduces costs, inappropriate utilization, and variation in treatment patterns. If you focus on cost, you deprive people of needed services."

The Tri-River group engaged the Permanente Co. to conduct an assessment of the Dayton community. The results showed that physicians and plans were not structured to drive quality improvement - the care they provided focused on treatment, not wellness, and there was a lack of coordinated care and disease management programs. The Permanente Co. recommended community-wide initiatives, supporting physician leadership programs, a community health information network, and prevention programs.

Once purchasers were on board, the Tri-River Initiative pulled in Medical Mutual of Ohio, which supplies patient data, as the plan administrator, and Premier Health Partners, which includes two primary-care physician (PCP) groups of 125 providers paid fee-for-service -  including Barrow's practice. Physician incentive markers include

conducting health risk assessments and developing written action plans for at least 50 percent of patients; 

developing disease management programs for diabetes, post-coronary events, hypertension, and tobacco use, enrolling at least 80 percent of at-risk patients; 

establishing personalized Web sites; achieving patient satisfaction goals; and 

meeting efficiency indicator goals based on global targets for per member/per month costs. 

Each measure is weighted, and incentives are paid to the group, not to individuals. Physicians are eligible to receive some bonus even if they don't accomplish all five goals, and are not subject to a withholding.

In addition, physicians are paid extra - slightly higher than the IDC-9 code for a preventive counseling visit -  for conducting the health risk appraisal, a time-consuming activity they do not undertake on a regular basis.

"The employer/plan/physician relationship is often adversarial, so the partnership represents a new way of looking at healthcare," says Evan Steffens, director of clinical and quality services for Premier Health Partners. Although she says it has taken a hands-on effort to get physician buy-in, "we are all at the same table trying to problem-solve."

Premier's Meenakshi Patel, MD, believes quality-based incentives are a step in the right direction. "Traditionally, [health plans] have pushed physicians to perform excellent preventive and chronic care but have not always reimbursed us appropriately," he says. "By placing money in an incentive pool, it delivers the message that they are 'putting their money where their mouth is,' so to speak. That message is as important as the actual amount in the incentive pool."

Employers, too, are taking a more proactive role in the quality act. When The Everett Clinic (TEC), a 180-physician multispecialty group in Everett, Wash., found itself bogged down in health plan negotiations, a large employer in the market, Verizon, stepped in to avoid disrupted coverage for its employees.

Thomas Davies, Verizon's regional healthcare manager, brokered a compromise between the clinic and payer, resulting in a bonus arrangement - an unusual move for a purchaser.

"Doctors liked that idea since they thought of themselves as part of a high-quality organization," Davies says. "There has always been a business case for quality but nothing had been done about it, even though plans have said they would be willing to pay for it."

In TEC's case, quality benchmarks are based on Health Plan Employer Data and Information Set (HEDIS) measures, such as breast and cervical cancer screenings, childhood immunization rates, pre-natal and post-partum care, diabetes management, and smoking cessation. Each area is weighted, and when the medical group falls into the top percentile compared to all plans reporting to the National Committee for Quality Assurance (NCQA), TEC receives 50 percent of the bonus; if it reaches the 90th percentile, it receives the entire bonus from participating plans. TEC has the potential to receive up to $2.1 million in bonuses this year.

In keeping with its history as an early adopter of healthcare trends, there is a movement in California by the Integrated Healthcare Association (IHA), headquartered in Walnut Creek, to create a statewide initiative to pay physician groups for achieving documented performance.

To pay for the incentives in its "Pay for Performance" effort, participating plans would set aside 2 percent of the premium associated with professional capitation payments each year for at least three years, building up to a 6 percent pool. If all plans in the state participated, that 2 percent pool would equal $100 million to $150 million.

Measures under consideration combine patient satisfaction, information technology infrastructure improvement, disease management quality initiatives, preventive screenings, immunizations, and use of antibiotics. "Medical groups will get rewards for improvement, not just for reaching benchmarks," says Beau Carter, IHA executive director. "The bonuses have to serve as an incentive, not just be money given to a medical group for what it's already doing."

Blue Cross of California introduced a quality financial bonus six years ago to help improve their quality scorecard rating. The incentives are based on a variety of satisfaction indicators including rate of appeals and grievances, preventive health and onsite quality management audits, and voluntary member transfers from medical groups.

Bonuses for the 170 participating medical groups/independent practice associations (IPAs) come from Blue Cross and are not only based on performance, but also on the number of patients. "These incentives are more in line with what consumers are seeking from the HMO world - rewarding doctors for performance, not for withholding care," says Michael Belman, MD, medical director of Blue Cross of California.

The 130-physician, multispecialty Beaver Medical Group in Redlands, Calif., participates in the Blue Cross program. Ron Bangasser, MD, medical director, says that although his group is already achieving many of the clinical measures, attention to the data provided by the plan has enabled the group to do an even better job.

Beaver also gives individual physicians small incentives -  movie passes and gift certificates -  for accomplishing clinical objectives such as monitoring and calculating the right dose of Coumadin for patients with atrial fibrillation.

While quality-based incentive plans remain the exception rather than the rule, they reflect increasing attention to quality as a means of improving healthcare delivery, as espoused by organizations such as the Institute of Medicine, which encourages development of "payment policies that reward quality," and physicians who have long resisted the emphasis on cost savings over appropriate and thorough care.

This article originally appeared in the September/October 2001 issue of 

Finally, get paid more for providing better care