Expanding Access to Care through Telemedicine

Lea Chatham September 16th, 2014

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Tweet this Kareo storyBy Lisa Eramo

When MedPeds, a family medicine practice of eight providers in the D.C. suburb of Laurel, MD, decided to venture into the world of telemedicine, it wasn’t a completely novel idea. The practice, which was named winner of the 2013 Ambulatory HIMSS Davies Award of Excellence for its use of health information technology to improve patient care, had implemented an EHR nearly a decade ago and had also served as a beta site for a patient portal in 2006.

Seth Eaton, MD, adolescent and internal medicine specialist at MedPeds, says the benefits of telemedicine seemed obvious—that is, being able to increase access to patient care and help patients overcome the barriers that may prevent them from being able to physically come to the office. These barriers could include distance, health or physical limitations, lack of transportation, and a variety of other reasons. Telemedicine—the use of electronic and telecommunication technologies to enhance patient care—helps physicians and patients because it fills the gap and enables direct communication without necessitating the need to be in the same room, he explains.

“I see it as a way to expand access to primary care,” says Eaton. This increased access is critical not only for both rural and urban providers but also for patients who continue to enter the healthcare marketplace due to the Affordable Care Act, he adds. The supply of providers must be able to accommodate the increased demand from patients flooding the marketplace.

According to the Deloitte Center for Health Solutions 2013 Survey of U.S. Physicians, 18% of primary care physicians use telemedicine for follow-up or diagnostic visits. Tweet this Kareo story
Rural primary care physicians have also been using the technology to obtain specialty consults in real time. Telemedicine may be particularly beneficial for orthopedic practices or any surgical specialty that requires follow-up visits, says Eaton. With telemedicine, a physician or physician assistant could see a patient postoperatively while the patient recovers from an injury or surgery at home. Not only is this more convenient for patients, but it’s also more efficient for providers who typically aren’t reimbursement separately for these visits after a surgery, he adds.

At MedPeds, patients currently have access to one telemedicine slot per week. This ‘virtual visit’ is typically reserved for urgent issues and follow-up visits. Eaton says he eventually hopes to expand the number of telemedicine slots so that every patient will have the option to either physically come to the office for a face-to-face visit or meet with their provider during a virtual encounter.

“The major benefit that I see for our practice is that if we can hire a nurse practitioner who could essentially work behind a monitor, we could generate visits that don’t require additional staff such as medical assistants,” says Eaton. “This would also add so much access for our patients.”

The New England Journal of Medicine reported in May 2013 that physicians in many specialties are starting to embrace telemedicine as a way to “expand their practice, reach new patients, and potentially improve the care of patients who have historically had poor access to medical services—especially specialty services.” The article, titled “Telemedicine: Changing the Landscape of Rural Physician Practice,” cites various examples of how providers, including a pediatric critical care physician, a psychiatrist, a neurologist who performs telestroke consultations, an OB/GYN, and a family medicine physician, are using the technology to improve care.

Cardiologists and electro-physiologists have embraced telemedicine because it allows them to monitor patients remotely, says Rhonda Bray, RN, BSN, founder and CEO of Rhythm Management Group, a Washington D.C.-based company that provides remote monitoring for patients with a pacemaker or implanted defibrillator. With remote cardiac monitoring, a machine collects data wirelessly and then transmits it to an EHR, or a company such as Rhythm Management Group sends the information to the provider within 24 hours. Bray says her company is in the process of interfacing with various EHR vendors so providers can automatically view the data.

Nearly one million Americans currently use remote cardiac monitoring, according to the American Telemedicine Association. Bray says physicians like the technology because it allows them to intervene more quickly. “If a patient has a new onset of a heart rhythm disturbance or their battery is wearing down or if the wires are failing, we can catch that early and alert the physician,” she says.

Patients like the technology as well because they’re able to stay at home while being monitored 24/7. “These devices are so sophisticated now that they’re on auto pilot. They self-adjust. There’s really no good clinical reason to bring patients in [to the office] every six months,” says Bray.

In addition to enhancing the access to and quality care patient care, telemedicine also enhances patient satisfaction because it gives patients options in terms of how and where they can receive care, says Eaton. Although patients in the Laurel community are slowly embracing the concept of virtual care, Eaton says he hopes they will take advantage of it more frequently over time just as they have gradually accepted the practice’s portal technology.

How to get started with telemedicine
If you’re thinking about offering telemedicine in your practice, consider the following tips:

  • Shop around for a vendor. Eaton says there are an overwhelming number of vendors that offer telemedicine technology, some of which are more geared toward hospitals rather than physician practices. Many vendors charge a monthly fee for an unlimited number of visits. The American Telemedicine Association provides a helpful telemedicine buyer’s guide that practices can use to find a vendor that’s suitable for their particular specialty.
  • Look into reimbursement limitations. According to the American Telehealth Association, almost every state Medicaid plan covers at least some type of telehealth services; however, this coverage varies greatly by state. Medicare covers telehealth only in certain circumstances, such as remote radiology, pathology, and some cardiology. It also covers videoconferencing for beneficiaries living in rural areas. Private insurance coverage for telehealth service also varies by state. Eaton says there is a state mandate in Maryland that requires all insurers to cover telemedicine in all instances. “We’ve never had a single denial,” he adds.
  • Consider legal issues. The National Telehealth Policy Resource Center outlines several legal implications for telehealth that providers must address.
  • Identify a physician champion. As with any technology implementation, practices that succeed are those who identify a physician champion who can help other providers learn how to use the telemedicine technology and incorporate it into their workflow.

Find out more about how the demand for healthcare services will be changing in the coming years on this infographic, Healthcare Demand is Growing: Are You Ready?

Are you using telemedicine or considering it? Share your thoughts in the comments.

About the Author

Lisa A. EramoLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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Free Webinar: Should You Start Your Own Medical Practice?

Lea Chatham September 11th, 2014

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Register NowTaking the Leap: Best Practices to Start Your Own Medical Practice
Wednesday, September 17, 2014
1:00 PM Eastern, 10:00 AM Pacific



Are you ready to take the leap and step out on your own? Whether you are a newly minted physician or looking to leave a group practice, how do you know if going it alone is the right choice? In this webinar, startup practice expert Audrey Christie McLaughlin will walk you through a step-by-step process to help you decide if opening your own medical practice is the right choice.

During this free event, Audrey will offer practical recommendations on:

  1. How to decide if you should open your medical practice
  2. The initial steps to take prior to leaving your current position
  3. Business models, budgets, timelines, marketing and staffing considerations

Find out everything you need to know to decide if independence is right for you and how to start a new practice successfully.Tweet this Kareo story

Register Now

About the Speaker

Audrey MAudrey “Christie” McLaughlin empowers physicians to grow their practices and better the lives of the patients they serve. Audrey is the CEO of McLaughlin Sales Group LLC, creator of the series Customer Service from the HEART, and creator of physicianspracticeexpert.com, a sales and consulting firm that specializes in the business of medicine. Audrey has more than 12 years of experience in helping physicians and hospitals provide the best medical care while growing revenue and keeping costs down. She is an expert, entrepreneur, author, speaker, and is active volunteer in her community.

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6 Common EHR Implementation Challenges and How to Avoid Them

Lea Chatham September 10th, 2014

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Download this guide on successfully implementing an EHRBy Lisa Eramo

The adoption of EHRs in physician practices is definitely on the rise thanks to Meaningful Use incentives. According to the data from the Office of the National Coordinator (ONC), office-based provider adoption of basic EHRs has increased from 17% in 2008 to 40% in 2012.

And although the number continues to grow, actual implementation of EHR technology continues to challenge many practices. Tweet this Kareo story
Only 12% of the 1,442  respondents who completed the Physicians Practice 2014 Annual Technology Survey sponsored by Kareo reported that EHR implementation was ‘smooth sailing.’ Slightly more than 10% characterized the transition as ‘traumatizing.’

Mary P. Griskewicz, MS, FHIMSS, senior director, healthcare information systems at the Healthcare Information and Management Systems Society (HIMSS), says practices can encounter a variety of setbacks during—and even after—implementation, and they need to know how to address those challenges efficiently and effectively in order to achieve success. She provides insight into these challenges as well as advice for how to overcome them.

  1. The EHR implementation is breaking your budget. According to HealthIT.gov, various studies indicate that the cost of purchasing and installing an EHR ranges from $15,000 to $70,000 per provider, depending on whether the practice uses an on-site or Web-based EHR. These costs include hardware, software, implementation assistance, training, and ongoing network fees. The cost of an EHR is the number one reason why practices haven’t purchased one yet, according to the Technology Survey. Griskewicz says practices—particularly solo practitioners and smaller groups for whom these costs are especially high—should contact their Regional Extension Center (REC) to identify ways in which they can work with vendors in an economical way. Practices may find that it’s more economical to partner with the same vendor that provides their practice management software because it’s more seamless from an interoperability standpoint. There are also several free and open source EHR products available on the market that physicians can explore to determine whether they meet the needs of the practice. Essentially, there are options for everyone, and physicians shouldn’t let cost be a deterrent.
  2. The EHR just doesn’t fit into the workflow. Some practices may find that even after a careful implementation, the EHR just doesn’t provide the flexibility or customization that the practice needs. This is the worst scenario in which physicians find themselves because they’ve already invested in the technology and are unable to use it effectively. The 2014 HIMSS Physician Community EHR Usability Pain Point Survey identifies several deficiencies related to clinical data review, documentation, clinical decision support, and more. The best way to avoid this problem is to ensure that each potential vendor provides an in-depth demonstration regarding features and functions. All staff members should be able to ‘test drive’ the software and provide input.
  3. EHR training is difficult and time consuming. Although vendors should be able to provide thorough training for all employees, practices that succeed with EHR implementation are those that identify super-users who really take the time to get to know the EHR and who can serve as a resource for physicians and others, says Griskewicz. Also be sure that your EHR vendor specifies the type and duration of training that employees will receive. This includes training on any software updates or patches. The vendor should also provide an active support line that users can call when they have questions. Again, the vendor should outline all of these details, she adds.
  4. Physicians resist using the EHR. Some physicians simply won’t want to use the technology either because they don’t believe in its efficacy, they feel that it will decrease productivity, or perhaps they are even intimidated by it. Practices must identify a physician champion who can encourage others to adopt the technology and feel more comfortable using it, says Griskewicz, adding that a peer-to-peer approach works best.
  5. Your chosen vendor hasn’t—or doesn’t intend—to meet Meaningful Use Stage 2 requirements. Griskewicz says some practices are frustrated because the certified vendor they chose to meet Stage 1 requirements either isn’t going to meet the more detailed Stage 2 requirements or will be delayed in doing so. Only 40% of respondents stated their vendor was ready for Stage 2, according to the Annual Technology Survey. If practices intend to continue the attestation process, they may need to find a new vendor entirely. For those that choose to ‘wait it out’ with their vendor, keep in mind that time is money, and the longer that practices must wait on their vendor to update software to meet the new requirements, the fewer incentives they’ll receive. Griskewicz says one way to avoid this is to vet your vendor thoroughly to ensure that it intends to invest the time and money to accommodate ever-changing requirements. RECs may be able to help physicians switch vendors in a cost efficient way and help them choose a vendor that meets the needs of the practice.
  6. The practice falls behind in meeting Meaningful Use requirements. There’s no doubt that it’s challenging to keep up with the requirements to comply with Meaningful Use. Even practices whose vendors are ready for Meaningful Use requirements sometimes fall behind because they don’t have the internal processes in place to ensure success. Practices that miss deadlines will unfortunately be subject to penalties. The best way to avoid this is to appoint someone within the practice whose responsibility it is to oversee requirements, deadlines, and ongoing communication with your vendor.

Networking is often the best way to resolve EHR challenges and identify best practices. Many EHR vendors provide user groups, and practices should take advantage of the opportunity to network with other providers and ask questions. Oftentimes, practices face the same challenges and can benefit from best practices and lessons learned, says Griskewicz.

For more strategies to help you successfully implement your EHR, download this guide.

About the Author

Lisa A. EramoLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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Kareo September Newsletter Focuses on Staying Independent and Competitive

Lea Chatham September 9th, 2014

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The September edition of the Kareo Getting Paid Newsletter highlights the steps for launching a new practice and staying competitive with emerging retail clinics. The newsletter also provides a chance to discover upcoming events, news, and resources from Kareo. Plus, you’ll learn about how to register for our upcoming free educational webinar, Taking the Leap: Best Practices for Starting Your Own Medical Practice, presented by Audrey McLaughlin, RN. Read all this and more now!Tweet this Kareo story

September Kareo Getting Paid Newsletter


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The 5 First Steps to Start a New Medical Practice

Lea Chatham September 8th, 2014

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Tweet this Kareo storyBy Audrey Christie McLaughlin, RN

So you’ve decided to open a practice? Now what?

Once you have determined that starting your own new medical practice IS for you, then it’s time to dive in. Sure, you could wait until the timing is perfect, but much like anything else you do in life, there really is no perfect time. You just make up your mind, and go for it.

Here are the first five steps you should take to get started with your new medical practice. Tweet this Kareo story

  1. Hash out a budget and timeline. Starting a practice costs money. In order to spend your money judiciously, you must know what things cost. Your budget document will be a very fluid document. You may choose to have multiple scenarios included in the same document or have multiple budgets outlining different scenarios. You could look at it as plan A, B, and C.The budgetary step will involve some research on your part. Sure you can delegate this to practice start-up specialist, but it will still be more of a collaborative effort. Don’t forget to add the cost of a consultant and marketing for the first year.
  2. Secure tax, legal, and practice start-up advisors. Don’t look at this as a luxury. Taxes are no joke, and the right tax professional and legal advisor can make the difference in choosing and setting up the type of entity that is most beneficial to you financially.Practice start-up advisors can help you finalize your budget, allow you to continue practicing in your current position, train and hire your staff, set up and plan your marketing and prevent you from making common start-up mistakes.
  3. Business Entity Formation and obtain an EIN. Your tax and legal advisors will assist you in securing this information.
  4. Begin insurance credentialing. Yes begin insurance credentialing even if you don’t have a practice location selected. This process is long, and even though it can be a pain to change your address later with the payers, not getting paid for rendering services when you open will hurt worse. You can use your home address temporarily or secure a temporary address.
  5. Location selection. Begin researching options for location and building choices. Determine a timeline for any construction and installation etc.

From step five, we could go on thru step 105. This list is just a starting point. For a more detailed overview of the steps involved in starting a new medical practice, join me for my free webinar, Taking the Leap: Best Practices to Start Your Own Practice on September 17.

About the Author

Audrey MAudrey “Christie” McLaughlin empowers physicians to grow their practices and better the lives of the patients they serve. Audrey is the CEO of McLaughlin Sales Group LLC, creator of the series Customer Service from the HEART, and creator of physicianspracticeexpert.com, a sales and consulting firm that specializes in the business of medicine. Audrey has more than 12 years of experience in helping physicians and hospitals provide the best medical care while growing revenue and keeping costs down. She is an expert, entrepreneur, author, speaker, and is active volunteer in her community.

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6 Steps to Position Your Practice to Accept Urgent Care Patients

Lea Chatham September 8th, 2014

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Tweet This Kareo StoryBy Nathaniel Arana

Noticed a drop in the number of patients coming to you for simple consultations or same-day care—flu vaccines, minor infections, or a sprain? Retail clinics may be to blame.


Retail clinics like those offered by Walgreens, CVS/Caremark, and Walmart have emerged as a solution for patients who need to be seen quickly for relatively minor injuries or illnesses but who can’t get an immediate appointment with their primary care physician (PCP).

It’s a skyrocketing business. A recent study shows that the number of patients using retail clinics for preventive services, screenings, and chronic visits jumped from 4% in 2007 to 17% in 2013. With the backing of multibillion dollar corporations, retail clinics could very well transform the way healthcare is delivered in the United States.

The reason patients turn to these clinics is straightforward: It’s much more convenient. Patients can get a same-day appointment or walk in without one. They are seen quickly—most often in less than 30 minutes. As a general rule, patients trust their PCPs more than retail physicians, and would prefer to see them for urgent care. But the hassle of waiting days or weeks for an appointment makes retail clinics the easier option, especially for patients who aren’t feeling well.

In order for PCPs to regain their patients, they must set up their practices to provide urgent care. The following are relatively simple operational changes that PCPs can make to avoid losing patients—and revenue—to retail clinics.

  1. Make time in your schedule to accommodate same-day appointments. Designate one to three 10-minute time slots for urgent-care appointments. To accommodate patients’ schedules, it is best to spread these throughout the day (9 a.m., 12 p.m. and 3 p.m., for example).
  2. Have your urgent-care patients seen quickly. Most urgent-care visits take less than five minutes. Many of these visits can even be handled by a nurse practitioner or physician assistant if you have one on staff. It is important that these patients don’t wait longer than 30 minutes. Remember, you are competing against retail clinics that offer convenience.
  3. Manage your schedule strategically. If your office typically runs late, set your urgent-care time slots for times of the day when you are least likely to be behind schedule (for example, the first appointment of the day or immediately after lunch).
  4. Market aggressively. Don’t assume that your patients know you offer urgent-care services or that they can book same-day appointments. Post a sign in your waiting room and train your front-office staff to inform patients that you offer urgent-care services. Make a handout with a list of conditions that can be treated. Communicate to your patients that they can typically be seen within 30 minutes. Make sure this information is on your website and posted to your social channels (i.e., Facebook).
  5. Provide 24/7 Online Appointment Scheduling. The benefit of online scheduling is two-fold. First, patients can schedule an appointment with you at 9 pm in the evening for first thing tomorrow morning, which adds another level of accessibility and convenience. Second, if you use a service like ZocDoc you may be able to reach more patients looking for an urgent-care appointment and grow your practice. According to ZocDoc about 85% of the patients who schedule appointment with local physicians through their service are new patients.
  6. Offer to accept cash. For patients without insurance, create a reasonable cash-pay rate that is similar to retail clinics in your area—the typical range is $90 to $125. Communicate to your patients that they can see you, a trusted provider, for a similar rate that they would pay at a retail clinic.

Although retail medicine can help fill a gap, it’s bad medicine to have them replace primary care practices altogether. Tweet this Kareo story
Given their success in offering urgent care, retail clinics have now begun to offer treatment for chronic conditions such as diabetes and hypertension. But for the most effective treatment, chronic conditions require continuity of care, and retail clinics tend to have high turnover among providers. This is just another reason why it is important for PCPs to retain their patients and find ways to meet their changing needs.

It’s not only good business, but also good medicine to accommodate your patients’ urgent-care needs.

Share your thoughts about the impact of retail clinics and solutions for PCPs in the comments below.

About the Author

nathaniel_headshotNathaniel Arana is nationally recognized healthcare business consultant. A physicians’ advocate, he has helped numerous practices become more profitable by allowing his clients to focus on patient care. You can e-mail Nathaniel at nathaniel@ngahealthcare.com or visit his website at www.ngahealthcare.com.



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5 Tips for Marketing Your New Medical Practice

Lea Chatham September 4th, 2014

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Tweet this Kareo storyBy Cheryl Bisera

You’re taking the big leap, you’ve chosen a community, a practice name, location and key staff you hope will help get you from ‘new kid on the block’ to thriving, established medical practice in as little time as possible. But patients aren’t just going to bang down the door; you have to attract them with solid marketing that works.Tweet this Kareo story

Getting off on the right foot can save thousands in wasted dollars for later re-dos and time lost to build your patient base.  Here are five tips for getting it right from the get-go!

  1. Have a Plan: Before you can implement a good marketing plan, you need to make sure there is a market to be had! A thorough analysis of the community you’ve chosen will tell you if the area is under-served and if there is a place for you among the other specialists or PCPs. A strong marketing plan is multi-faceted, meaning it includes different angles to reach the identified target market and strategies to reach out to potential referral sources. Some examples might include developing a social media presence, hosting an event in your new facility, and finding ways to network with local colleagues.
  2. Develop a mission and image: In order to properly promote your practice you must know who you are as a provider and practice. Identify what you uniquely bring to your target market.  For example, are you the sleek, contemporary practice bringing the most technologically advanced offerings to patients or perhaps your practice strength is a warm, casual atmosphere where patients and their families are remembered and engaged by staff.  A strong mission statement will communicate in as few words as possible what you value most and how you deliver that to patients. Your mission and your image should go hand in hand. Pinpoint your strengths and capitalize on them, always being authentic. Don’t try to be all things to all types of patients; there is strength in focusing.
  3. Be Consistent: One of the most common errors new practices make in marketing is inconsistency. If McDonalds suddenly had a hostess waiting to seat you, you’d be confused. If Gieco commercials started starring a giraffe instead of a gecko, you’d wonder what was up. Big brands know that brand recognition is as important as the value customers (patients) assign to it. Hire a professional designer to partner with you in developing a patient-friendly, professional logo and color scheme that won’t scream “last year” next year. Along with strong, concise messaging about your practice, this theme should be carried throughout all your marketing ( i.e. website, social media, ads, etc.), polishing your “brand” and giving marketing efforts a cohesive boost.
  4. Reach Out: We’ve all heard the saying, ‘it’s who you know’. Relationships rule, and it’s no different in the business of medicine. If you’re new to the community you will have to work extra hard to develop relationships as quickly as possible. Take advantage of any opportunities your hospital provides to help you reach patients and meet colleagues while being sensitive not to “step on the toes” of established physicians in your specialty. Consistently work at getting to know and building trust among your potential referral sources. Find ways to let the community know you’re coming and what you offer far in advance to build anticipation. Reach out to supportive colleagues; they can be a gold mine of insight into your local market. Be open minded, respectful and patient while you build relationships – you never know what networking opportunities lie down the road!
  5. Roll it out, and don’t stop! Too often when a new practice begins to taste some success, they decide to try to save money by pulling back on marketing – the very thing that likely got them the success they are enjoying! In order to deepen loyalty among existing patients, consistently grow and maintain credibility with referral sources and reach new patients you must continue to communicate what you do and how well you do it. This requires continuously reaching out and communicating.

Be patient, building community relationships and a good reputation takes time. Potential patients and referral sources need to figure out who you are and the value of choosing you. A well-planned, consistent approach to marketing will expedite that process while building the patient base you want!

Discover more strategies for successfully launching a new practice at the upcoming free webinar Taking the Leap: Best Practices to Start Your Own Medical Practice on September 17.

About the Author

Cheryl BiseraCheryl Bisera is a consultant, author and speaker with extensive experience in marketing and business promotion that spans more than ten years in which she worked with professionals to strengthen their position in the marketplace. She is the founder of Cheryl Bisera Consulting, a California-based image development and marketing company that focuses on the healthcare industry. Cheryl has spoken for regional medical management organizations, conducted customer-service workshops, and written numerous articles for publications such as KevinMD, Physician Magazine, and the Journal of Medical Practice Management.

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5 Legal Considerations with Concierge Medicine

Lea Chatham September 3rd, 2014

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Tweet this Kareo storyBy Lisa A. Eramo

As the Affordable Care Act (ACA) continues to swing into full gear, physicians and patients are both looking for alternatives to the traditional model of care. Tweet this Kareo story
Patients want more attention and time from physicians, yet many physicians are struggling to keep their doors open while also maintaining a work-life balance.

Concierge medicine may be one solution as we discussed in the first post in this series last week. In this arrangement, physicians offer services to patients and bill them directly, or they may bill insurers for covered services while collecting a flat fee from patients for other non-covered services. Physicians see fewer patients, but they’re able to spend more time getting to know the unique health needs of those patients. Today, nearly 5% of providers are using this
model with many more considering the option.

Michael D. Miscoe, founding partner of Miscoe Health Law, LLC, says more and more physicians are starting to consider a concierge arrangement in light of the ACA. “Physicians are seeing exchange plans with higher deductibles. Patients are being required to pay more out of pocket. Because some outpatient providers would never be able to justify expenses beyond the patient’s deductible, more are moving toward concierge models,” he says.

Miscoe frequently assists physicians who want to make the transition from the fee-for-service model to a full-fledged concierge practice. He provides insight into the types of legal questions that concierge physicians must address as they make the move. Consider the following common questions that arise:

  1. Are concierge physicians ever required to bill the insurer? It depends. If the physician is an MD or DO, he or she has the legal right to opt out of Medicare completely, in which case he or she can simply bill Medicare patients directly even when services are covered. No provider is required to bill non-covered services to Medicare. All provider types have the ability to choose not to participate with a commercial insurance plan. Even when providers do participate, most contracts allow them to bill the patient directly for non-covered services. Miscoe says many physicians are moving toward non-covered models of care to avoid the post-payment risk associated with billing of covered services.“Docs are saying it’s not worth it. When you go through an audit, you go through what’s now a three-year appeal process,” he says, adding that he’s currently waiting for a decision on an Administrative Law Judge hearing that took place nine months ago.For physicians and other providers who can’t opt out (e.g., nurse practitioners, podiatrists, chiropractors, therapists, physical therapists, and others) or those who haven’t opted out, there is a legal obligation to bill for covered services, says Miscoe.This is where it gets complicated. An evaluation and management (E/M) service, for example, is covered under Medicare. However, if the E/M service isn’t medically necessary, then it’s not a covered service. Consider a physician who performs an E/M service for the purpose of preparing a patient for a cosmetic Botox injection. This is not a covered E/M service, thus the provider has no obligation to bill the service to Medicare with an appropriate Advanced Beneficiary Notice (ABN) and can bill the patient directly, explains Miscoe.Other examples of non-covered services include weekly maintenance care for physical therapy or chiropractic services, certain routine foot care, certain ongoing wellness and prevention services, and a whole slew of others.“The best way to avoid billing Medicare is to not provide a covered service,” says Miscoe. “If you go through all of the publications and LCDs, you can come up with a million ways as to why a service isn’t covered.”Chiropractors run into non-covered services all the time, he says. For example, manipulation is covered if considered and documented to be restorative care, but maintenance manipulation is not. “Additionally, Chiropractors can treat patients with a wide variety of techniques that don’t constitute manipulation, depending on how it’s defined in a particular state,” he adds.Medicare auditors often impose strict conformance with their interpretation of documentation content guidance as a proxy for determining whether services are necessary, says Miscoe. He recalls one instance in which a provider documented a mechanism of trauma, as instructed in the guidance; however, the auditor denied the care because the trauma was due to an everyday activity.

    “This is the kind of ridiculous audit results commonly seen that trigger an expensive and time-consuming appeal process. 100% error rates are not unusual for that reason” he says. Miscoe continued by stating that where providers apply these same post-payment audit standards, it is easy for them to conclude that care isn’t covered.

  2. Must concierge physicians provide Advanced Beneficiary Notices (ABN)? There’s no requirement to provide an ABN for non-covered services, says Miscoe, except for cases in which the basis for non-coverage is due to a lack of medical necessity. He advises concierge practices to ask patients to sign a document stating that they understand that the services are non-covered and that they will not be billed to Medicare. When non-coverage is based on medical necessity, an ABN is technically required.
  3. Should concierge physicians assign CPT and ICD-9-CM codes if they don’t bill insurers? Miscoe advises against the assignment of these codes. “Using these codes suggests that you’re doing a particular service, and in some cases, it can imply that the service was necessary” he says, adding that he has seen cases in which use of a particular code to record the encounter was scrutinized for its accuracy during a licensure board investigation even though the code was not billed to any third party. Instead, he suggests that cash only practices develop internal codes for tracking.
  4. If a concierge physician isn’t billing insurers, must he or she continue to maintain detailed documentation? The only requirement for these physicians is to adhere to rules set forth by their licensure boards, says Miscoe. However, these rules are often vague and very loose. Miscoe says all providers should maintain detailed documentation regardless of whether it’s required by an insurer or other entity.“I worry about malpractice liability more than compliance with licensure board standards,” he says. “You need to be able to justify what you’re doing any why so if there’s an adverse effect, you have something to rely on. But you don’t need to adhere to a strict LCD documentation content standard. In fact, the more you deviate from that standard, the more you can justify why your service would be considered non-covered by Medicare or a commercial carrier.”
  5. Must concierge physicians abide by HIPAA? Those who transition to a care model that doesn’t require submission of claims to Medicare and other carriers may not be subject to the Privacy and Security provisions of HIPAA to the extent that they don’t meet the definition of a covered entity under the law. Essentially, they don’t engage in electronic transactions (e.g. electronic claims, benefit verifications, or receive electronic an remittance advice), explains Miscoe. However, these physicians must continue to abide by state laws and common law restrictions pertaining to privacy and confidentiality.

For more information on legal issues with concierge medicine, review “Concierge Medicine: Legal Issues, Ethical Dilemmas, and Policy Challenges,” originally published in the Journal of Health & Life Sciences Law. The American Medical Association also provides guidelines regarding retainer practices.

Any physicians interested in the concierge model should definitely consult with a healthcare attorney familiar with these issues throughout the transition process to ensure that all legal obligations are met.

About the Author

Lisa A. EramoLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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4 Meaningful Use Questions Answered

Lea Chatham August 28th, 2014

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Watch Webinar NowAt the recent free webinar, AAA for MU: Roadside Assistance for the EHR Incentive Program, speaker Barbara Drury, FHIMSS, shared the latest updates on Meaningful Use along with some user cases and experiences she has had as a HIT consultant. Participants had many questions, and Barbara and Kareo have answered some of them here.


Q: When will we know whether or not the extension for use of MU 2011 Edition has passed? Tweet this Kareo story
A: We will know whenever CMS publishes the final rule (FR). The government has no obligation to publish a final rule within any specific time and sometimes the FR takes years. However, the pressure of the pending Medicare physician fee schedule 1% penalty is most likely to result in a final rule being available within “months” of the public comment period rather than years. Continue to watch since the October 1st deadline is right around the corner.

Q: If the rule change goes into effect, do we still have to do the patient portal piece of MU?
A: That depends: if the final rule allows you to use a 2011 Edition with the 2013 “tweaks”, then you would not be required to provide the patient with an electronic copy, or electronic access—that was removed from MU1 with the 2013 “changes”. If the rule holds fast that all stages must use a 2014 certified Edition, then the ‘access’ and the VDT requirements are likely to stand.

Q: If the proposal passes and we’re in our 4th year of Medicare MU and we elect to use our 2011 CEHRT for the 2013 measures, what is the reporting period for 2014?
A:  For 2014, no providers, regardless of stage or program year, will be required to report on 365 days. If 2014 is your 4th year of Medicare MU (3 years for MU1 and 1 year for MU2), then you must report on any quarter in 2014.

Q: When the EP begins to attest, who is supposed to register? What is the link to register?
A:  A staff person in the practice may register and attest on behalf of an eligible professional but it is the EP who is registered, attesting, receiving the incentive and being assessed a penalty. So, if you are doing these things on behalf of an EP be sure they are reviewing and signing off on each item. The first thing you need to do is determine eligibility, which you can do on the CMS website.

If you missed the webinar, you can watch the recording or download the slides.

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Can Concierge Medicine Improve Physician Satisfaction and Patient Care?

Lea Chatham August 26th, 2014

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By Lisa A. Eramo

Tweet This Kareo StoryOverworked and underpaid. That is the plight of many of us, including some physicians. As physician reimbursement continues to decrease while regulatory requirements mount, some doctors are turning toward an alternative business model to maintain current practice income levels while ensuring quality care: Concierge medicine. Otherwise known as ‘boutique,’ ‘personalized,’ or ‘private’ medicine, this model allows physicians to limit the number of patients they see and spend more time providing in-depth care. In some cases, they bill patients directly or work with insurers to cover all or a portion of the services rendered.

Although the concept of concierge medicine has been around for a while, it seems to be gaining traction with physicians (and patients) since the Affordable Care Act (ACA) took effect. Tweet this Kareo story
The ACA, which mandates insurance for most patients, has resulted in an influx of new patients into the healthcare marketplace. The appeal of concierge physicians is that they’re often more available, and they provide the individualized care that patients seek. According to the Physicians Practice 2014 Great American Physician Survey, sponsored by Kareo, nearly 5% of physicians are currently in a practice and 30% are or have considered the change.

Concierge models vary and will likely continue to evolve. Tweet this Kareo story
Some concierge physicians choose to opt out of Medicare, Medicaid, and private insurance completely. These physicians typically charge patients directly for treatment and/or a membership that provides access to a menu of services all of which are paid for directly by the patient. Doing so eliminates costly overhead expenses related to billing.

However, other concierge physicians bill insurers for covered services while collecting fees directly from patients for an additional level of service that goes beyond what their insurer would cover. Fees are paid annually, quarterly, or monthly, and can range from as low $600 to as much as $15,000 or more per year, according to the American Academy of Private Physicians (AAPP), a non-profit organization that seeks to spur the growth of practices that provide concierge, personalized, or value-based medical care.

The AAPP estimates that there are currently more than 3,500 concierge physicians and that this number will only continue to grow. According to the physician staffing firm Merritt Hawkins, 9.6% of practice owners plan to convert to concierge practices in the next one to three years. This statistic is based on a national survey of nearly 14,000 physicians that analyzed 2012 practice patterns. According to a Merritt Hawkins analysis, certain states, such as Texas, Florida, and New York, appear to have either a proportionally higher number of entrepreneurial physicians or practice environments likely to motivate doctors to switch to concierge medicine.

“There is a lot of uncertainty in health care now, and the only certainty is there is a lot of talk about cutting physician fees,” Mark Smith, president of Merritt Hawkins told Forbes Magazine. “One way to get out of it is to go off the grid.”

Physicians like going ‘off the grid’ because they don’t need to deal with complicated insurance requirements when they accept cash payments only. For patients, concierge medicine means they’ll often pay a fraction of the cost associated with extremely high deductibles.

Primary care physicians are frequently moving into the concierge realm. Consider Dr. David J. Jones, an internist in McLean, VA. Jones told the Fairfax Times that he transitioned his practice in April so he could spend more time with patients and get to know them better. He charges patients a one-time annual membership fee paid out of pocket in return for more individualized care. Dr. Mark Niedfelt, a family physician in a Milwaukee suburb, told American Medical News that the ACA will help build his already thriving concierge practice.

The New York Times reported that direct primary care is also beneficial for employers looking to cut costs. Direct primary care physicians generally charge $50-$60 per month for adults with lower fees for children. This fee typically covers routine primary care services and certain lab tests, basic x-rays, and minor procedures. Employers combine direct primary care with high-deductible plans that cover more extensive services, such as hospitalizations and specialty care.

MDVIP, a network of private physicians who focus on personal wellness and disease prevention, reports that the interest in concierge medicine continues to grow. MDVIP affiliates with more than 700 physicians in 41 states and the District of Columbia and caters to more than 200,000 patients.

David Barrie, vice president of MDVIP, says physicians enjoy being able to spend more time with patients while also seeking a work-life balance. “You’re more focused on the clinical side of what you want to do as a physician rather than on the transactional side.” he says.

Approximately 75%-85% of an MDVIP’s income comes directly from a $1,500-$1,800 out-of-pocket fee that patients pay in exchange for a comprehensive annual wellness exam that focuses on important health and wellness areas including heart health, emotional well-being, diabetes risk, respiratory health, quality of sleep, hearing and vision, sexual health, nutritional assessment, weight management, bone health, comprehensive risk factor analysis, and face-to-face counseling.

“If patients would go to the open market, it would cost them significantly more,” says Barrie.

All other covered services are billed to the patient’s insurance. Patients also enjoy other benefits, such as 24/7 availability to physicians via email and cell phone, a “no waiting” waiting room, and more. Patient yearly renewal rate is 94%.

MDVIP has evidence that concierge medicine actually does make a difference in patient care. According to a study published in the American Journal of Managed Care, the MDVIP personalized healthcare model resulted in a 79% reduction in hospital admissions for Medicare patients and a reduction in readmission rates for certain diagnoses as compared to the national average.

“This shows that when physicians have the time and can use the tools available to them, patients get better care,” says Barrie.

Share your thoughts about concierge models in the comments section.

About the Author

Lisa A. EramoLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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