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Practice tip of the week: 3 digital payment trends that healthcare providers need to know

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, 

Marketing Your Medical Practice-Ethically, Effectively, and Economically,

 which has sold over 225,000 copies and has been translated into Spanish. He contributes a weekly video for 

 on practical ideas to enhance productivity and efficiency in medical practices.  His 5–7-minute videos and short articles provide practical ideas that can be easily implemented and incorporated into any medical practice. Dr. Baum can be reached at 

Recently, a digital artwork sold for $69.3 million.

Healthcare primer on NFTs

Justin Tabone is the originations leader for healthcare vendor equipment finance at TIAA Bank in Parsippany, New Jersey.

Rather than expending all your capital up front to buy the equipment, financing allows you to spread payments over time and free up capital for other business expenses.

Equipment financing for your practice

Trish Rivard is CEO and Principal Consultant with 

, an independent healthcare research company

Why providers need to invest more in online scheduling and recommendations on where to start.

Online appointment scheduling: A missed chance to boost patient satisfaction 

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Time to Take Back Control of Healthcare

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Harassment awards can take a bite out of a practice's pocketbook - not to mention reputation.

Drafting an Airtight Sexual Harassment Policy

Part two of our look at abusive tax planning schemes that are heavily promoted doctors at year-end. We examine specific schemes to avoid, including those that the I.R.S. is making a special effort to crack down on.

Specific tax fraud traps physicians should avoid

Asset protection attorney and regular Physicians Practice contributor Ike Devji and Anthony Williams, an investment advisor representative and the founder and president of Mosaic Financial Associates, discuss the impact of COVID-19 on high-earner assets and financial planning, impending tax changes, common asset protection and wealth preservation mistakes high earners make, and more. 

Asset Protection and Financial Planning

Physicians Practice® spoke with Kristina Hutson, a product line developer at Availity, about surprise billing events in independent healthcare practices and what owners and administrators can do to reduce the likelihood of their occurrence. 

How to reduce surprise billing in your practice

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Malpractice Claims and Artificial Intelligence

Physicians Practice® spoke with Michael Parisi, Vice President of assurance strategy and Community Development at high trust Alliance, about how physicians and practice owners can discern whether or not communications technology they are interested in integrating into their practice is certified secure. 

Certifying Your Communications Technology is Secure

 Last year, The American Medical Association released results of their prior authorization survey, which found that physicians were completing an average of 33 prior authorizations per week, waiting an average of two whole business days for approval. The entire approval process had become so burdensome that some respondents reported increasing their staff specifically to deal with the increased burdens of prior authorizations.

We spoke with Paul Joiner, chief operating officer of Availity, to flesh out some of the results from the survey and find out how primary care practices can improve their prior authorization processes.

In case you are new to the concept of prior authorizations, here is a brief explanation from Paul.

 So prior authorization is a process in which providers have to go through on behalf of their patients to get approval from the health plan to provide a service and get paid for it. This process is often reserved for procedures and diagnostics. It's probably the biggest burden in the diagnostic process, just because you're anxious to get to a diagnosis. You'll also hear it referred to as pre certification. And then sometimes there's other confusing topics, like notice of admission sometimes gets called a ‘preauth’, with people technically, because of a common transaction name, but by and large, in general, pre authorization and pre certification is an approval prior to service from the health insurance plan to perform a procedure and get paid for it.

 Paul mentions radiology, but he also said other treatments that typically require prior authorizations are those that require some medical guidelines before administering or performing, including many preventative diagnostic type tests.

Furthermore, they are intertwined with electronic health records, which may present additional hurdles.

 Well, they are because the source of information for supporting the need for the diagnostic test or for that procedure lives within the medical records. So proper documentation and understanding what is needed to attain the authorization is very, very important. It's important from a training perspective. And it's important that this team working on the authorization process is giving that feedback to the physicians, the physician extenders, so the medical assistants, the nurses and the physician assistants, if you will.

 Regarding the report mentioned earlier, Paul says that the average two-day wait time for prior authorization decisions is due to the fact that every health plan handles various authorization types differently.

 Sure, well, every health plan handles various authorization types differently. It takes two days, because one, the sheer volume, and then two, it requires a lot of these requires some type of clinical review and some type of clinical back and forth. And those are limited, expensive, highly skilled, specific resources. And then the back and forth part is, is that many times, there's a level of clinical information that needs to be supplied. And sometimes there's a back and forth conversation that needs to occur before the final disposition of the pre-authorization or the approval or the denial of the authorization can be can be given. And so many times, providers get very frustrated because they're a little confused about the status of the prior authorization, and how plans sometimes struggle to convey that status back to the providers. Obviously the patient's anxious to move on, so it creates a lot of anxiety, but it's a function of resources, the function of the complexity of the process, and in the back and forth conversation sometimes has to occur.

 Also mentioned in the report from the American Medical Association is a reported increase in a sense of burden among respondents. When asked whether or not this burden was perceptual—that it was an incorrect assessment from the physicians—or whether their sense of burden was actually due to requirement changes and increases in complexity, Paul says that it is certainly the latter.

 Requirements are truly been being increased. The level of which, the types of procedures, the variety of procedures, and diagnostic tests that requiring prior authorization is increasing. And then the nature in which these procedures and services are being scrutinized has been ratcheted up.

To the health plans’ credit though, many health plans are trying their best to innovate and improve the process and exchange of clinical information and make it clear to providers on when a prior authorization is required, and information that they need in order to give the prior approval.

You know any recommendation I would give to any provider or any physician especially if they're new to practice or long established, take a second and spend a couple extra moments with your staff and to make sure the process is worked out. And you as a physician know how you can help and how you can provide the proper documentation to facilitate the process or make sure the process is moving. smoothly.

And then the other thing is, is a lot of this misconception going back this 86% of burden increase. There's a lot of misunderstanding between the providers and health plans. And so, if something doesn't make sense, I encourage the providers to reach out to the health plans and have a conversation about it. Because a lot of times, it's a process or a structural issue in terms of how the information is being sent to the health plan, or the way that information is being interpreted creates a lot of confusion, a lot of problem between the providers and health plans, which increases the burden.

I've seen examples where providers have sat down with health plans and worked out and improve the process. And there's always going to be a little friction to the process. But it definitely can be reduced if you just take the time to kind of learn the process, both internally and also engage the health plans.

 Requirements from health plans are not the only way in which requirements, and subsequent physician burden, are increasing. Paul says that there are some legal and regulatory changes that can affect the prior authorization process as well.

 Well, there are in there are different mandates out there trying to improve the process. In fact, I just participated in and testified to Washington organization in relation to the improvement of the process and different operating rules. Core is putting for roles, the AMA is obviously involved. There are other technological advances that will could probably change the authorization process there since the Da Vinci project, which is a clinical information interoperability initiative that's underway. So, there's a lot of pressure from the federal and state governments to improve interoperability to improve the process. Really, where a lot of the technical legal stuff happens is that if you perform a procedure, and the payer denies it, because they don't think proper authorization was in place, that does trigger a formal legal process that does vary from state to state.

 Though some practices said in the American Medical Association report that they were increasing staffing levels to deal with the prior authorization process, Paul says that improvements do not stop at the hiring process.

 Well, yes, staffing. I'm familiar with one practice. You know, a dozen years ago, they had two people working prior authorizations, and now they have eight, it's a practice I'm familiar with. And so, number one thing around when you're increasing staffing is training. So, make sure that you're working hard to evolve your training with the times and staying current corporate policies, and that you're just not perpetuating common myths and workflows that you're constantly improving as you're training your employees.

Number two, invest. Invest in these in these resources that you have in the authorization problem and make sure that are of a high caliber, because there is a valuable payback in terms of them being a sophisticated resource and capable to navigate the system and capital is also capable to, you know, interpret how this process is changing and how the payers are changing.

Next on the process side, you can subdivide the authorization work by payer type, by procedure type, so you can subdivide the work. And that typically helps because then your resources can get more and more specialized and more and more focused in terms of information they're collecting, and who they're communicating with. Because many health plans outsource certain segments of the authorization process to vendors. Radiology benefit managers is a common one, you'll hear where there's an actual health I know speaking with, they're actually speaking a company, who providers provides the UN services or the authorization process to the provider to the health plan. And then providers have to engage the UN vendor. So, from a process perspective, it's about how can you subdivide the work and make sure the work is prioritized and bucket in terms of the most complex the least and make sure the right people working on the right task.

Then from the technology perspective, there's all sorts of opportunity to think through the person trying to attain the authorization and the approval making sure they have all the proper clinical documentation. And then try to understand and engage with that your largest health plans on what tools they have available to you to submit for an authorization or check the status of it. Besides picking up the phone and calling. One thing I want to share that is a common issue that a lot of providers think that they'll go through a solution like you know like Availity has or other vendors have in relation to electronic submission or authorization. I've heard numerous for physician practices say well I also call even if I get an electronic because I want the name and phone number and I want documentation that got called to double check or for an extra level of verification that the authorization is in place because I do not want to denial after treatment. So, despite so what that means is despite electronic channels and technology channels, and integration channels, they're still calling the health plans and trying to write down the name of a call center and the name or name of the time and a reference number for that phone call. So that they have that additional evidence that they did obtain authorization in the event that their claim was denied for that service because prior auth wasn't on file.

Train, hire well, process, constantly review the process, and make sure you're subdividing the work and the technology. Look for all the opportunities you can to pull the practice correct information forward to the process. And that that you're using all the proper available channels to the end of your largest health plans.

 Before we parted, Paul offered some final advice to practices looking to streamline their prior authorization process.

 Well, I hope that they are who are curious, and they go down and try to find the team and staff and they invest a little extra trying time trying to understand how their practice or their facility is managing authorization process and what role they play in that process.

The other thing is that, despite I know, many, many physicians are very frustrated with the authorization process and get upset. And I understand—put those emotions aside and look at it as it is a process it's out there, it's not going away. So with the most open and innovative mine, you can go to the process and see how you can help improve it, or how you can give additional resources or technical resources or integration resources or additional training to make sure your staff is only calling when they have to call and they're using all the best possible tools out there, available to them.

And another thing is, you know, if it is an increasing burden for your organization, keep the Google search up around, you know, authorization tools, because there are some small, innovative companies out there. We're partnering with some and then there are some that we're keeping an eye on that I think are working on trying to come up with little neat little widgets and modules to improve the gathering of the clinical information and the submission of it. And so keep your eyes and ears open because I do think it's a big enough problem that solutions will continue and innovation will continue to evolve the process probably at a more accelerated rate.

Physician's Practice spoke with Paul Joiner, chief operating officer of Availity, to discuss the implications of an American Medical Association survey and find out how you can improve your prior authorization processes.

Improving the prior authorization process

In our last episode, we featured the first part of our Practice Financing discussion with Chris Panebianco, CMO of Bankers Healthcare Group, on loans and credit cards for physician practices.

This week, we continue our practice financing discussion with a focus on patient lending services.

Your ultimate goal as a healthcare provider is to provide the care that you spent years training to perfect.

However, to provide care to all patients rests upon the presumption that patients will be able to pay for services. In an ideal world, this would be the case. But sometimes, some patients present with an ailment that must be treated regardless of the cost; the challenge comes in mitigating the cost responsibility

In these instances, practices can turn to a financial practice called ‘Patient Lending’. It’s similar to loans, except the parties include the patient, the physician or practice, and another third party.

To learn more about this program and how it can help both physicians and patients, we spoke with Banker’s Healthcare Groups President of Patient Lending, Keith Grubele.

What a patient lending program does is it allows patients to have an option—to pay for that-out-of pocket responsibility that in many cases is very affordable for them. So essentially, we provide a specialized financing tool for the patient to be able to afford that deductible coinsurance, whatever that out-of-pocket responsibility is that they may not be able to afford, which unfortunately happens more often than not.

 How patients pay for these services and whom they pay directly varies by vendor or the provider, Grubele says. 

Healthcare providers have taken upon themselves to create some sort of internal payment methods for patients. While it's a very honorable effort, and it's a great idea to do in theory, oftentimes what happens is it divides the practice to where now they have to focus on both being a financial institution and a healthcare provider. That's the last thing we want to do.

I often find that I go into centers and come to realize that there are high paid nurses —their highly skilled nursing staff—which are better suited to obviously provide care to patients. They're now turned into glorified telephone collectors, if you will, where they're calling on patients and saying, “Hey, you know, we gave you a payment plan to be able to afford you out-of-pocket responsibility. You haven't been able to pay it. What can we do here?”

It causes a number of inefficiencies on the back side of the business. The most critical one that we've seen impacting healthcare providers today is larger and larger amounts of patient responsibility or patient AR that sits on their balance sheet. And it goes uncollected oftentimes because our primary goal is to provide care, not to provide a financial lending solution.

So, in many cases, if the provider has internal payment plans, if they've partnered with a vendor, a lot of third party vendors will set up very, very differently. The more successful or the better partner plans for the provider are ones that pay off that patient balance upfront, and that create affordable payment plans through their own platform to the patient.

Essentially, they provide patient with a financing tool through maybe a loan product, that loan proceeds or go directly to the healthcare provider to pay them off, and the patient then engages directly payments with the partner provider.

 Whether or not these programs are right for your practice is dependent upon the typical out-of-pocket cost of your services. The higher the cost of services, the more likely the patient lending programs might be good programs to implement.

Patient balances that are over $500 tend to be the most common ones that want to qualify. The reason why is that realistically at $500, the patients can either find a little bit of a balance on a credit card or some patients actually have up to $500 available in their bank accounts that they may be able to come out-of-pocket with. That tends to be the cutoff.

So, if you are doing some high-level imaging, if you are a specialist in a number of different fields where unfortunately out-of-pocket cost for the procedures or care that's offered amounts to more than $500. Those are generally your best facilities to look into a patient learning option. They're often the facilities that most often have cancellations because patients are scared of affording their or can't afford the responsibility, and they're ones that see large patient AR balances

So for anybody watching this, I normally would say, if you look at your balance sheet and see that you have patient responsibility or patient accounts receivable sitting on your balance sheet, you probably want to start asking questions, it's a great indicator that there's a challenge here. If you're turning away patients because of affordability, or seeing a high level of cancellations, again, great indicator that you should be looking for a patient lending platform to help create a more flexible solution for your patients.

 If you are interested in implementing one of these programs at your practice, you should know that there isn’t necessarily a one-size-fits-all format to patient lending systems. Grubele says that each vendor or practice takes their own little spin on how to solve for patient responsibility. 

Everybody seems to take their own little spin on how to solve for the patient response.

Ability problem, I think ultimately what you have to look at is your demographic of patients and find a solution that applies to as many of your patients as possible. A lot of solutions are not one size fits all their one size fits the very, very credit elite. A lot of them are very specific and the amount of monies they will allow a patient to utilize, or how long they'll allow a patient to make those repayments—which then pushes the affordability issue because if we take the same $500 and spread it over, let's say a full year over a three or four month period—the payment amounts drop very drastically and obviously affordability becomes a challenge.

I normally tell people look for a couple of things. Number one, something that's 

flexible enough to cover every patient demographic

—you want a solution that can provide as close to 100% approval as possible, so that all of your patients get the benefit of the program, not just the few credit elite that will be qualified for it

The second thing I tell people is look for 

solutions that create flexibility for your patients

. Today, most of our patients—and most Americans—have less than $500 in their bank account in the event of a medical emergency. The largest reason that people avoid care is because of the fear of cost.

There was a recent study, I think it was in, in Forbes that said that it's not so much even fear of COVID, it's actually the 

fear of being able to afford their health care during these COVID challenges

, which are keeping people away from providing or receiving the care that they need.

. Look for something that's easily integrated into your practice. The last thing you ever want is to look for something to solve one problem that causes 10 others. And a lot of the 

, a lot of the platforms that are built out there, are built from a technological perspective and they don't realize that we're creating so much more labor and work to be able to implement into a practice to get it up and running. So look for something that's easy and efficient to implement.

You shouldn't have additional reporting additional paperwork, additional management or accounting practices to figure this out. It should seamlessly work into your process flow and create more of an efficient process for you on the back office side as, opposed to create more challenges or another account to balance.

 Of course, with any program and especially one involving large finances, there are risks and liabilities that might be involved. Physicians should consider some of the following if interested in implementing these services at their practice. 

Another wonderful question. Actually, for me, it's interesting because often when I start talking to people, I find that the biggest risk of liability is not implementing anything. You know, I tell people, if we don't change, if we don't evolve, we become extinct. We're in a really kind of very touchy point in healthcare and healthcare is being affected from numerous different factors, not just the clinical aspect because of the COVID challenges that are coming on; the addition of the way that we're screening patients and how we have to provide care; the changes in something as simple as the waiting room area; but you're also facing some transitions and challenges from the financial climate, the economic climate, which is something we haven't seen in a long time. We've had a very strong economy, where a lot of people said, you know, things are going great. There's no really big concern or need to provide a patient financing solution, everybody easily had access to credit or credit card. That is all changing today.

For me, the biggest risk is not doing anything. Because if we do nothing, unfortunately, these patient responsibility balances will continue to go up. If the economy continues on the track it is on, a lot less patients are going to be able to afford those payments. And so that becomes a challenge.

When looking at a program to implement, I go back to a little bit of what we were discussing before: what is the current risk that you're taking right now, if you're offering every patient that comes into your practice and internal payment plan, and you're collecting on them internally? Well, you're bearing 100% of the risk today.

Anything that helps get you ahead and out of that situation is going to be an advantage and it's going to mitigate your risk, if you will, if you're doing nothing. Again, the risk is that unfortunately, other practices in your specialization, maybe offering programs like this, and if they are, are you losing patients to those centers that are making it more affordable for patients?

We often talk about the consumerism aspect of healthcare and how people are now finding it more important to be able to be shoppable for your patients to have a more consumeristic approach to it. Part of the big consumer experiences financing is making things affordable. We see it in every industry across the across the globe, and you're starting to see that now in healthcare where people are actually shopping their health care providers based on cost and affordability.

So, having an option that creates affordability, or I should say not creating an option that has for affordability of costs for patients is the largest risk you could probably take.

In part 2 of our discussion with Banker’s Healthcare Group, hear from the President of Patient Lending, Keith Gruebele, on how these programs can benefit your practice by extending the amount of patients that can receive and finance your services.

Practice Financing Part 2: Patient Lending Programs

. In this podcast, we'll bring you some of the most interesting and influential guests in healthcare. If you have any ideas for podcast guests or topics, email us at 

In terms of a dynasty, the 1990s Dallas Cowboys have nothing on the state of Texas' placement in the Best States to Practice.

For the fifth year in a row, the state was one of 

's Best States to Practice. It placed seventh in malpractice premium average, fourth in residency retention, eighth in physician density, and eighth in cost of living. 

What has made Texas such a consistent choice as a "Best State to Practice"? We spoke to Carlos Cardenas, a gastroenterologist from Edinburg, Texas, and president of the Texas Medical Association (TMA), to give us some insight into the Lone Star State's physician friendly attributes. He says the state has favorable Tort reform laws and lots of underserved areas, which mean there are opportunities to practice in different kinds of environments.

Another positive for physicians is Texas' pro-business attitude, Cardenas says. "There is no state income tax on personal income, which is a benefit. In addition, when you look at business taxes, levied on physicians in particular….physicians have an exclusion if their total [income] is $1.2 million or less, they don't have to pay any tax," he notes. The state also excludes Medicare, Medicaid, and charity work from tax-reported income, so this number is even lower.

Later in the podcast, Cardenas talks about how Texas could be a better place to practice medicine. "Like in a lot of states, we have a significant need in mental health and being able to provide to that population. We still are underserved in different areas of the state…in order to attend to a rapidly growing population. We still have a large uninsured population," he says.

Texas was one of the five Best States to Practice. Dr. Carlos Cardenas talks to us about what makes it so friendly to physicians.

A Physician's Case for Choosing the Lone Star State 

Don't be mistaken - Dr. Robert Wachter, MD doesn't want to go back to the world of paper-based health records.

Indeed, Wachter, the Chair of the Department of Medicine at the University of California at San Francisco School of Medicine and Bestselling Author of the Book, "

," says that health IT has done more good than harm as it relates to patient safety.

"When you look at some of the problems with [EHRs], it's easy to get romantic about the old days [and think], 'Wouldn't it be wonderful if we went back to paper?' No it wouldn’t. There were hundreds and hundreds of errors related to the doctor's handwriting, or forgetting the patient was allergic to medicine, or information that came out of an X-Ray that wasn't transmitted to the primary-care physician," he says.

But Wachter is adamant that there is a lot of room for improvement with current EHR systems. In this episode of the 

, Wachter talks to us about the improvements he'd like to see to make EHR systems safer and user friendly. He says clunky user EHR system interfaces and incessant patient safety alerts that create false positives are part of the problem. He also adds that EHRs are "not designed with real people in mind….That's the fundamental problem."

Later in the podcast, Wachter talks about the impact EHRs have had on malpractice lawsuits. In essence, he says it's too early to see any kind of connection, but predicts that will change soon. One reason why is because EHRs have created voluminous records, making it much harder to find vital information.

Dr. Robert Wachter wrote the book on the failings of health IT and the effect these systems have on patient safety. He joined us for the Pearls podcast.

EHRs Not Designed with Real People in Mind, Expert Opines	

 Podcast. In this podcast, we'll bring you some of the most interesting and influential guests in healthcare. If you have any ideas for podcast guests or topics, email us at 

What will the ascendance of Tom Price, the new secretary of Health and Human Services (HHS), mean for practices across the country?

This question is very much in the air, but Anders Gilberg, the vice president of government affairs for the Medical Group Management Association (MGMA), has an idea. In the most recent edition of the 

 Pearls Podcast, Gilberg said MGMA is hoping Price's previous focus on reducing administrative burdens for practices carries over to his work as HHS administrator. The association 

"He has been instrumental as a member of Congress in stepping in and mitigating various administrative burdens, especially as it relates to the Meaningful Use program," Gilberg said in the podcast. He added that having Price at the helm of HHS will provide a "great opportunity" to reduce administrative burdens that have built up over the past few years.

Later in the podcast, Gilberg explained why it's not entirely realistic to expect Price to make a significant impact in the first year, especially with regards to the Affordable Care Act. "Much of what needs to be done has to be done through the legislative process," he said. Although Gilberg predicts he may try to reduce the administrative complexity surrounding the Medicare program in the first year.

Gilberg also addressed whether those who did not support Price's nomination should be concerned over his controversial opinions on Medicare, Medicaid, and women's health.

Click to play the podcast above for the complete interview.

In what areas will Secretary Tom Price make an impact at the Department of Health and Human Services? MGMA's government affairs expert shares his insight.

Previewing Tom Price's Reign as HHS Secretary  

As if proving meaningful use of an EHR weren't challenging enough, physician satisfaction with the means to getting there is on the decline.

According to new research being unveiled at the HIMSS13 Conference in New Orleans, there was a 12 percent drop in satisfied physician EHR users between 2010 and 2012 and a corresponding increase of 10 percent in dissatisfied users over the same time period. The survey, from Vancouver-based Cientis Technologies, is based on replies from 4,270 clinicians, 70 percent of whom are from practices with 10 or fewer physicians.

Presenting the data at HIMSS13 will be William S. Underwood and Alan Brookstone, CEO of Cientis Technologies. Brookstone is a family physician with 25 years of medical practice experience in rural and urban practice setting. In 2004, he established Cientis, which facilitates the adoption and use of health IT for clinicians.

In this podcast, Brookstone explains some of the survey data and offers advice to physicians about how to avoid transitioning from a satisfied to dissatisfied user of an EHR system.

Brookstone and Underwood's session is scheduled for March 5 from 9:45 to 10:45 a.m.

For more coverage of the HIMSS13 Conference, visit our 

New research indicates that a growing number of physicians are dissatisfied with their current EHR as they strive to meet meaningful use requirements.

Study: Physician EHR Satisfaction Rates on the Decline

Two recent settlements underscore the FTC's status as an enforcement agency with the power to enforce consumers’ rights in relation to their sensitive information.

The new kid on the block: The Federal Trade Commission and data sharing

Cautionary tales ripped from the headlines.

Cybersecurity highlights: The “money mule” and cybercriminals

On March 23, 2010, the 60-Day Rule was enacted as Section 6402 of the Affordable Care Act.

CMS proposes changes to the 60-day rule

HHS Proposed Rule – electronic transactions and privacy rule enforcement action.

HIPAA 2023!

You protect yourself against medical malpractice, but are you protected against medical board complaints?

Most read 2022: What you need to know about medical board complaints

The pandemic has changed so much of everyday life, it should also change the way you think of keeping your assets safe.

Asset protection attorney and regular Physicians Practice contributor 

, an investment advisor representative and the founder and president of 

A pair of experts discuss asset protection as the COVID-19 pandemic continues.

Law & Malpractice

Specific tax fraud traps physicians should avoid

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