Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded

Delivering Physician Services: A Horse of a Different Color.

• When is the right time?• Should we hire, guarantee or other

support?• Should we share our TIN or set up new?• Should we set up RHC, FQHC or practice

model?• How will it affect current medical staff?• Are we “equipped” to handle delivering

physician services?

Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded

The Decision

• Hiring as knee jerk reaction or to bail out.• Hiring when not justified by outmigration.• Hiring when only bad payer mix subject to shift.• Hiring based on gut feelings (without proforma).• Hiring wrong specialty (PCP vs SCP).• Hiring with guarantee without mechanism to promote

proper set up and maximization of volume and reimbursement.

• Hiring under hospital TIN.• Hiring with physician “issues.”• Hiring without executive leadership/oversight.

Bad Practices:

• Review market share analyses:– HERMES data– Outmigration by payer by specialty– Lost cases with financial impact

• Develop proforma– Use market share– Identify specialized equipment, office space, staffing needs– Project both hospital and physician impact

• Determine specifics of purchase– Buying old A/R?

• Review licensure and any “issues.”

Best Practices:Do Your Homework!

• Determine correct legal structure– Separate physician group TIN (make TIN decision and stick

with it – avoid changes!)– All physicians under one (non-hospital) TIN– Establish physician group name (i.e. Evans Family Centered

Medicine)– Establish as physician group practice initially; transition to

RHC.

Best Practices:Legal Set-Up

• Determine correct corporate structure.– Hire good Practice Manager– Hire experienced physician office staff

• Integrate functions that don’t hinder practice effectiveness (i.e. HR).

Best Practices:Corporate Set-Up

The Preparation

• Insufficient lead time for enrollment and office set up.• Failure to assist in practice set up.

– Provider enrollment– Office start-up– Billing– Training

• Establishing too much like hospital.• Attempting to incorporate into hospital business office.• Adjusting corporate structure in middle of process

(changing TINs, adding addresses).

Bad Practices:

• Start early (very early)!• Determine participation strategy.• Identify staff member responsible.• Set up physician credentialing file.• Establish appropriate NPI numbers.• Establish CAQH.• Enroll electronically in Medicare and Medicaid.• Enroll in EDI/EFT.

Best Practices:Provider Enrollment

• Contract as HEALTH SYSTEM!• Obtain PHO or Group contracts whenever possible.• Negotiate language and reimbursement.• Watch for operational implications.• Only Hospital CEO or CFO signs group contracts.• Train physician and office staff NOT to sign anything;

send to you.

Best Practices:Contracting

• Set up as practice initially (if qualifies and beneficial)!• Determine eligibility.• Review financial benefits.• Review operational requirements (NPs, etc).• Review billing components (POS and copay

differences).• Understand time frame for conversion (9-12 months).

Note: Must be primary care with mid-level and at least 4,200 visits annually.

Best Practices:Research RHC Status

• Hire Practice Manager.• Implement processes to support claim payment:

– Patient registration (ABNs, HIPAA notices)– ID card recognition– Referral/preauthorization– Check-out processes (ask for the MONEY!)– Billing

• Know how to handle OON patients (make whole?).• Know what to collect and how to ask for it.• Train, train, and retrain.

Best Practices:Practice Operations

• Set comprehensive charge master (get help with this!).• Select good practice specific software (not a hospital system!).• Set up insurance master accurately (get help with this!).• Load reimbursement schedules into software; analyze against

payments.• Know payer plan participation status (when to take and not to

take contractual adjustments).• Consider outsourcing to billing expert (i.e. PPM).• Provide up-front training (i.e. HTHU and PPM).

Best Practices:Revenue Cycle Set-Up

Best Practices: Insurance and Risk

Management

Charley Malmquist CPCU, ARM, AAI

Potter Holden & Company 888-528-0589

Serving the Insurance Needs of Georgia’s Healthcare Community Since 1918

Best Practices: Insurance and Risk Management

HTH SURVEY RESULTS:HOSPITALS EMPLOYING

PHYSICIANS

How many are employing physicians?

88% currently employ physicians. Of those hospitals… 88% employ 1-5 physicians, 12% employ 11 or more

78% plan to hire new physicians in the next 18 months 57% in primary care, 42% both primary care & specialists

Best Practices: Insurance and Risk Management

Who are you hiring? 67% of the physicians responding hospitals typically recruit have

6 or more years of experience; 22% are new to practice; 11% have 2-5 years experience

How are you hiring?

78% use outside search or recruiting firms56% Recruit from physician practices within their community22% recruit from referral of existing employees

HTH SURVEY RESULTS:PHYSICIAN EMPLOYMENT

Best Practices: Insurance and Risk Management

PRE-EMPLOYMENT CONSIDERATIONS

• Prior practice locations• Prior insurance carrier… compatibility• Prior Acts Coverage / Nose Coverage• Past loss history, open losses, & incidents

not yet reported• Board consent orders or license restrictions• Health issues / drug or alcohol abuse (*as it

relates to licensing)• Prior insurance cancellations of declinations

Best Practices: Insurance and Risk Management

How are you structuring coverage? 89% provide professional liability protection for their employed

physicians.75% under the hospital’s policy: 25% on a separate policy.

33% said the hospital’s deductible applies to their physicians;22% said the hospital’s deductible does NOT apply, and55% said they weren’t sure/didn’t respond.

100% of respondants provide $1 mil/ $3 mil limits of liability for their employed physicians

HTH SURVEY RESULTS:PROGRAM STRUCTURE

Best Practices: Insurance and Risk Management

How are you structuring coverage? “Does your hospital’s umbrella/excess policy

include coverage for employed physicians?”44%- yes22%- no22% - hospital does not carry an umbrella or excess policy11%- aren’t sure

Best Practices: Insurance and Risk Management

PROGRAM STRUCTURE ISSUES

• Ownership of policy

• Policy type— claims made or occurrence

• Individual or group policy

• As an endorsement to the hospital’s policy

• Separate or shared limits

• Application of any retention or deductible

• Retirement options

Best Practices: Insurance and Risk Management

“How do you address employed physician's malpractice exposure prior to joining your hospital? (prior acts coverage)89%- It is the responsibility of the physician to purchase tail coverage0%- hospital assumes the prior acts by maintaining an original retroactive date11%- weren’t sure

“Does the hospital have a clearly defined plan to address the cost of “tail coverage” should the physician leave the employment of the hospital?” 67% said ‘yes’22% said ‘no’

HTH SURVEY RESULTS:EMPLOYMENT CONTRACTS

Best Practices: Insurance and Risk Management

EMPLOYMENT CONTRACTS

Clearly identify insurance responsibilities:

• Who will purchase coverage?• What constitutes an acceptable insurer?• What limits of coverage required or provided?• Who will hold consent to settle? (if available)• Who is entitled to receive dividends or return

premium?• Will moonlighting be allowed?• Mutual hold harmless or indemnification clauses

Best Practices: Insurance and Risk Management

OTHER INSURANCE CONSIDERATIONS

• Workers Compensation

• Business overhead

• Key man life

• Billings Errors & Omissions

• Business Interruption

• Medical Equipment

• Offices Premises Liability

Best Practices: Insurance and Risk Management

BEST PRACTICE- “DO’S”• Do your due diligence on the physician

candidate before you employ

• Do ask for full disclosure on any potential, pending or open claims

• Do consider all potential ramifications associated with insuring the physician before finalizing your approach

Best Practices: Insurance and Risk Management

BEST PRACTICE- “DON’Ts”• Don’t make assumptions regarding each

party’s responsibilities – spell them out clearly in writing

• Don’t assume unknown liabilities

• Don’t assume all insurance policies are the same

• Don’t assume a departing physician will automatically purchase “tail” coverage: get proof

Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded

The Oversight

• Payment addresses; mixed payments.• Mixed physician and hospital posted on general ledger.• Little to no oversight over practice A/R.• Little to no practice reports reviewed.• Reporting GL and A/R/Revenue to hospital center.

Bad Practices:

• Establish lock box for payments (separate from hospital).

• Ensure cash poster is properly trained.• Use payment verification software component.

Best Practices:Practice Payments

• Review routine A/R reports; ask questions.• Review variance reports; require payment

verification/write-off support.• Review Collectability Analyses.• Review routine A/P reports; ask questions.• Establish PM reporting lines; meet regularly.• Set up separate GL department for physician practice.

Best Practices:Reporting

HINDA GREENE,D.O., SR VP, MEDICAL AFFAIRS

HOSPITAL PHYSICIAN PARTNERSAPRIL 30, 2010

Best Practices for Integrating Physician Services into Your

Hospital

Integrating Physician Services

Emergency Department

Great Care Standardization Protocols in triage Quality Review

Shorten LOS Door to admission or

discharge

Patient Satisfaction

Staff satisfaction

Hospitalist Program

Great Care Less “push back” for

admissions Increased Risk Aversion Quality review: inpatient

Shorten LOS By decreasing LOS, increase

reimbursement Patient Satisfaction

Staff satisfaction Less on call Vacation Coverage Protect office time

Win Win

Emergency Department

Initial workup and stabilization

Less resistance for admissions

Standard protocols

Hospitalists

Increased admissionsDecreased length of

stayStandard admission

orders

Coordination

Emergency Physicians and Hospitalists work together

What can I do for you?Expedite exit from EDCover hospitalist for a few hours per night by

bundling admissions and use of standard orders

Patients and hospital both win Happiness is spending less time on a one-inch

mattress

Mike ScribnerStrategic Healthcare Partners

Helen Williams, CPCPrecision Practice Management

Charley Malmquist, CPCU, ARM, AAIPotter-Holden & Company 888-528-0589

Dr Hinda GreeneHospital Physician Partners

What else can I say?