ACG PRACTICE MANAGEMENT
s t h g i l h g i H x o b l Too Brought to you by the
ACG Practice Management Committee
Accessible. Relevant. Practical.
The information you need to improve your practice. The ACG Practice Management Committee’s mission is to equip College members with accessible tools to overcome management challenges, improve operations, enhance productivity, and support physician leadership in their private and physician-lead clinical practices. Learn from practicing colleagues through monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.
Toolbox topics include • Policy and Procedures
• Revenue and Reimbursement
• Professional Relations
• Patient Engagement
• National Affairs
• Quality Enhancement
• Public Relations
• Human Resources
Start Building Success Today.
CONTRIBUTORS & PRACTICE MANAGEMENT COMMITTEE...................................................................2 LETTER FROM THE CHAIR.................................................................................................................3 PRACTICE MANAGEMENT TOOLBOX ARTICLES.................................................................................. 4 Negotiation 101: How to Get What You Want In A Negotiation.................................................................................... 4 Essential Guide to Telemedicine in Clinical Practice: Easy Steps to Rapid Deployment..............................................7 Answering the Call: Improving Telephone Management in Your Practice.................................................................. 13 The Graceful Exit........................................................................................................................................................... 17
LAW MIND ARTICLES..................................................................................................................... 20 Professional Service Agreements: Perfect Solutions to Affiliations? Key Situations Every PSA Should Address.... 20 What Androcles and the Lion Has To Do With GI Practices During a Pandemic.........................................................23
GI.ORG/TOOLBOX | 1
CONTRIBUTORS Stephen T. Amann, MD, FACG
Dr. Amann is Chair of ACG’s Practice Management Committee and a partner at Digestive Health Specialists, PA, in Tupelo, MS.
Ann M. Bittinger, Esquire
Ms. Bittinger is health law expert at Bittinger Law Firm in Jacksonville, FL. She regularly contributes to ACG's publications on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups (bittingerlaw.com).
PRACTICE MANAGEMENT COMMITTEE Chair Stephen T. Amann, MD, FACG Board of Trustees Liaison John R. Saltzman, MD, FACG Nitin Aggarwal, MD Nitin K. Ahuja, MD, MS
Samer S. El-Dika, MD
Dr. El-Dika is Clinical Associate Professor at Stanford University School of Medicine and served on ACG's Practice Management Committee.
Joseph C. Anderson, MD, MHCDS, FACG Brian B. Baggott, MD, FACG Sophie M. Balzora, MD, FACG Ahmed A. Bolkhir, MD
Syed M. Hussain, MD
Dr. Hussain is a gastroenterologist at GI Associates in Kenosha, WI, and is a member of ACG’s Practice Management Committee.
Arkady Broder, MD, FACG Sumanth R. Daram, MD Ihab I. El Hajj, MD, MPH Andrew C. Elden, MD
R. Sameer Islam, MD, MBA, FACG
Dr. Islam practices at University Medical Center Southwest Gastroenterology in Lubbock, TX, and is a member of ACG’s Practice Management Committee.
Christopher J. Fyock, MD, FACG Deepinder Goyal, MD Neil R. Greenspan, MD, FACG David J. Hass, MD, FACG
Jordan J. Karlitz, MD, FACG
Dr. Karlitz is Assistant Clinical Professor of Medicine and Director, GI Hereditary Cancer and Genetics Program at Tulane University. He serves as Chief Medical Officer for Gastro Girl, Inc. and Director of Clinical Operations for GI OnDEMAND, a new telehealth solution for GI clinicians from ACG and Gastro Girl.
Pierre Hindy, MD, FACG Michelle L. Hughes, MD Syed M. Hussain, MD R. Sameer Islam, MD, MBA, FACG Srinivas Kalala, MD, FACG Ashwani Kapoor, MD
Dave Limauro, MD, FACG
Dr. Limauro is a gastroenterologist at Pittsburgh Gastroenterology Associates and served on ACG's Practice Management Committee.
Vonda G. Reeves, MD, MBA, FACP, FACG
Dr. Reeves is a gastroenterologist at GI Associates Endoscopy Center in Flowood, MS, serves as ACG's Governor for Mississippi, and is a member of ACG’s Practice Management Committee.
Whitfield L. Knapple, MD, FACG Akash Kumar, MD Melissa Latorre, MD, MS Manoj K. Mehta, MD Paresh P. Mehta, MD Jeffry L. Nestler, MD, FACG Mindie H. Nguyen, MD, MAS Shireen A. Pais, MD, FACG
Eric D. Shah, MD, MBA
Dr. Shah is Assistant Professor of Medicine at Dartmouth-Hitchcock Medical Center and Director of the Center for Gastrointestinal Motility. He is a member of ACG’s FDA-Related Matters Committee and served on ACG's Practice Management Committee.
Swati Pawa, MD, FACG Shajan Peter, MD Dany A. Raad, MD Tarun Rai, MD Nipun B. Reddy, MD
Sapna V. Thomas, MD, FACG
Dr. Thomas is Medical Director of Gastroenterology at University Hospitals Cleveland Medical Center, Westlake, and Assistant Professor of Medicine at Case Western Reserve University School of Medicine. She is a member of ACG's Practice Management Committee, Co-Director of the ACG 2020 Practice Management Summit, and served as ACG Governor for Northern Ohio.
Vonda G. Reeves, MD, MBA, FACP, FACG Brian J. So, MD Manish Tandon, MD Raja Taunk, MD Sapna V. Thomas, MD, FACG Bennie R. Upchurch, MD, FACG
Louis J. Wilson, MD, FACG
Dr. Wilson practices at Wichita Falls Gastroenterology Associates in Texas, and served as Chair of ACG's Practice Management Committee.
2 | GI.ORG/TOOLBOX
Rajeev Vasudeva, MD, FACG
THE CHAIR Dear ACG Colleagues,
Welcome to ACG Magazineâ€™s special issue on improving your GI practice. These articles were authored by fellow ACG colleagues and other contributors and have been published in ACG Magazine.
What is the ACG Practice Management Toolbox? The ACG Practice Management Toolbox is a series of short articles, written by practicing gastroenterologists and GI clinicians, that provide members with easily accessible information to improve their practices. Each article covers an issue important to those in private practice, as well as physician-lead clinical practices. They include a brief introduction, a topic overview, specific suggestions, helpful examples and a list of resources or references. Each month, a new edition of the Toolbox is released, and remains available on the ACG website along with all previous editions. The Practice Management Committee is confident this series will a provide valuable resource for members striving to optimize their practices. Please let us know if you have any ideas for future ACG Practice Management Committee articles and guidance. The ACG Practice Management Committee continues to strive to help you prepare for and succeed in this ever-changing environment of our profession, for all forms and sizes of the GI practice.
Stephen T. Amann, MD, FACG Chair, Practice Management Committee
GI.ORG/TOOLBOX | 3
GETTING it Right
// BUILDING SUCCESS
NEGOTIATION 101: GET WHAT YOU WANT
By Sameer Islam, MD, MBA, FACG, and Vonda Reeves, MD, MBA, FACG
In A Negotiation
This article is part of a series sponsored by the ACG Practice Management Committee. See more: gi.org/toolbox
ď‚Š NEGOTIATION IS AN ESSENTIAL SKILL for every gastroenterologist in business and in life. Physicians are often required to negotiate with hospitals, third-party vendors, and insurance companies over critical issues. They even find themselves negotiating with their patients over care! Negotiation can be intimidating and confusing, even for experienced business executives. Unfortunately, most health professionals have never been trained in negotiation skills and are uncomfortable when it is required. The results can be devastating. This toolbox article is a brief introduction to the subject of negotiation and provides a few essential tips and tricks to help gastroenterologists negotiate in the ever-changing climate of medicine. The authors encourage additional reading and practice to improve results. 4 | GI.ORG/TOOLBOX
PREP, PREP, PREP Preparation is vital. Knowing your numbers, your strengths, your weaknesses, and what the other party wants is crucial. Knowledge is power and the more you know, the better your negotiating power. Questions to ask: 1. What knowledge is necessary to negotiate effectively? 2. What knowledge does the other party need from you? 3. What are some areas of common ground? 4. What are some areas of potential conflict?
BRINGING PARTIES TOGETHER When negotiating, it is not always just about winning or losing, or haggling over scarce resources. Successful negotiation is a process of exploring underlying interests and positions. It is a conversation that should bring parties together in a manner that is constructive and complementary. It is about investing in what is behind each position to identify the essential issues that must be resolved. By understanding these issues, the parties may arrive at a complementary agreement that meets the needs of both parties. Relationships are key to the process. Relationships need to be established BEFORE the actual negotiation is started. Don’t expect to get what you want without first establishing a relationship with the other side. Success in a negotiation may depend on your relationship with the opposing party before the process began. Lasting relationships are important now and in the future. If you do not have the luxury of a previous relationship, focus on establishing rapport from the outset.
INSIST ON OBJECTIVE CRITERIA This is about making sure that the conversation stays on topic—remove any emotional or subjective components. The parties involved should be making deals based on objective and practical criteria. Connecting in advance can help facilitate this by agreeing on the process and who is involved. Additionally, plan how you will work and communicate with the other party.
Specific suggestions: 1. Establish a rapport. 2. Identify the other party’s intentions or objectives. 3. Keep an open mind—you may need to continually adapt your approach. Be prepared to change course. 4. Avoid becoming emotional when facing pressure or threats. 5. Create and refine your options— make the most of your time together. 6. “Fairness” is hard to define. Instead, determine objective criteria to measure success. Consider what criteria may be applied: acceptable prices, reasonable volumes, payment conditions, quality standards, terms of cancellation, or other stipulations of your agreement.
KNOW YOUR VALUE Gastroenterologists provide a tremendous amount of value to the health care system. However, many do not know the value they may bring and may even minimize this value. Answers to know: 1. What are your “numbers”? a. Number of procedures per annum b. Payer mix c. Discount rates per payer d. Quality metrics 2. Who is your market competition and your degree of market penetration? This may be organized by zip code if available. 3. What viable options does the other party have if you do not come to an agreement? 4. What are your options if the negotiation breaks down? Remember that preserving a relationship is vital in any negotiation, regardless of the outcome.
ZONE OF AGREEMENT Negotiated settlements occur when the common interests of the parties are identified and agreed upon. This common ground is known as the “zone of agreement.” Reaching the
“zone of agreement” depends upon each party’s alternatives to the agreement and the negotiation skills of the people at the table. An example of a “zone of agreement” between a gastroenterology group and a healthcare system would be the need to provide an affordable, jointly-owned endoscopy center. Failure is not always the worst outcome. Avoiding a bad deal is a success. Reaching a destructive agreement in which one or both parties cannot achieve their basic needs is often worse than no agreement at all. Recognizing this reality is as critical to the process as finding creative solutions in a negotiation. At the outset of the negotiation, seek to determine whether a zone of agreement exists between the two parties. This is a key principle of negotiation and if this cannot be identified, then success is unlikely. A skilled gastroenterologist should be able to identify what the major points of agreement will be and whether the parties are likely to find solutions. Key Questions for Zone of Agreement: 1. What are your key interests and why? 2. What are the other party’s interests and how might they be considered? 3. Are there any third parties whose interests should be considered? 4. Which interests are shared, which are different, and which create conflict? 5. What trade-offs can you negotiate? For example, management contracts, control of scheduling, anesthesia or pathology ancillaries are potential trade-offs.
DETERMINE YOUR "BATNA" Every negotiation has limits. You need to determine what is “off the table” in the negotiation. The next step is to clearly define the best outcomes you could expect without undertaking the negotiation. This is called the “BATNA” (Best Alternative to Negotiated Agreement.) Assessing the gastroenterologist’s BATNA: 1. What are my alternatives to an agreement? What are theirs? 2. What are our alternatives if we fail to reach an agreement? 3. How can I improve my alternatives? 4. How can I weaken the other party’s alternatives? If the best alternative to negotiation is unclear or undesirable, it is more important
GI.ORG/TOOLBOX | 5
to search for common ground and to do what is necessary to reach an agreement than to agree to a poor agreement.
ESSENTIAL SUGGESTIONS 1. Relationships are vital. 2. Prepare before you come to the table. 3. Know the value that you bring to the negotiation. 4. Know what the Zone of Agreement is. 5. Determine BATNA—for you and the other party.
RESOURCES: 1. HBR Guide to Negotiation by Jeff Weiss 2. Getting to Yes! By Roger Fischer 3. Never Split the Difference by Chris Voss and Tahl Roz 4. Harvard Business Review: The Most Overused Negotiation Tactic is Threatening to Walk Away by Jay A. Hewling, September 18, 2017.
Reference for Specific Situations: 1. Harvard Business Review: How to negotiation with someone more powerful than you by Carolyn O’Hara, June 06, 2014. 2. New York Times: Teaching Doctors the Art of Negotiation by Dhruv Khullar, MD, January 23, 2014. 3. Medium: Mind the Gap: Negotiations Tips for Women by Roi Ben-Yehuda, August 25, 2017
Sameer Islam, MD, MBA, FACG, Lubbock, TX
Vonda Reeves, MD, MBA, FACG, Flowood, MS
A NEGOTIATION OUTLINE Related Parties
Interests Our interests Other party interests Third party interests
Our alternative to a negotiated agreement with this party (highlight the best one)
Elements of a framework for agreement
What authority do we have?
Possible diagnoses for any gap
What authority does our counterpart have?
Possible ways to bridge the gap
Ways to improve our best alternative Other party’s alternatives (highlight the best one) Ways to weaken their best alternative
Communication Meeting purpose
Questions to ask/things to listen for
Information to disclose
Who should be there?
Assumptions to test
How to handle conflict?
6 | GI.ORG/TOOLBOX
IN THIS TOOLBOX ARTICLE, WE OUTLINE A FIVE-STEP PLAN FOR GASTROENTEROLOGY PRACTICES to transition rapidly and successfully to telehealth during the novel coronavirus disease (COVID-19) crisis while recognizing important clinical, technology, legal, regulatory, and reimbursement aspects of this service. It is important to recognize that telehealth requirements during this public health crisis are significantly broader than before this crisis, and will likely change significantly when the national emergency period ends.
// BUILDING SUCCESS
Essential Guide to
TELEMEDICINE in Clinical Practice: EASY STEPS TO RAPID DEPLOYMENT Eric D. Shah, MD, MBA, Stephen T. Amann, MD, FACG, and Jordan Karlitz, MD, FACG
TOPIC OVERVIEW Despite COVID-19, our patients still have gastrointestinal (GI) conditions including inflammatory bowel disease, cirrhosis, chronic pancreatitis, eosinophilic esophagitis, and others which require ongoing and careful treatment. Faced with concerns about exposure to this virus, there has never been a better time to harness the strengths of telemedicine. By adapting to changing times, gastroenterology practices can leverage telemedicine to maintain patient access to GI healthcare through this crisis. Telehealth supports “social distancing” efforts and eliminates patients’ travel costs, missed time from work, and childcare barriers to care. Recognizing the natural history of all pandemics, GI.ORG/TOOLBOX | 7
telehealth is strategic toward ensuring financial practice viability and maintaining employment for highlyskilled staff during a severe economic crisis. To ensure that patients can still receive the best possible care, regulatory agencies, and insurers are temporarily reducing barriers to telehealth, which we will outline in this article. Practices should continue to pay close attention to evolving requirements and nuanced differences among Medicare, Medicaid, and commercial insurers, and also stay up-to-date with state regulations and licensing requirements for telehealth as this crisis evolves.
GETTING STARTED: COMMON LICENSURE AND MALPRACTICE QUESTIONS Where can I access detailed information on telehealth policy in all 50 states? The following website has detailed information listed by state and by insurance type. Importantly, there is also information on parity laws detailing in which states private payers are required to reimburse for telehealth services. In light of the pandemic, however, this information will be constantly evolving. Resources (link below) • COVID-19 related state actions • Telehealth in your state prior to COVID-19 bit.ly/PM-Toolbox-Telemedicine-Links Does my medical license allow me to practice telehealth? In most states, no special licensing is required beyond your existing professional medical license. Does my malpractice policy cover telehealth? This is determined by your individual coverage policy. Some carriers already include coverage, while others may require an additional rider or premium. It is strongly encouraged to review covered services with your malpractice carrier to ensure your practice and you are covered fully.
8 | GI.ORG/TOOLBOX
Resource (link below) Federation of State Medical Boards (FSMB) Statement on Supporting States in Verifying Licenses for Physicians Responding to COVID-19 Virus (March 13, 2020) bit.ly/PM-Toolbox-Telemedicine-Links
STEP 1 – DEVELOP A PRACTICE POLICY ABOUT TELEHEALTH Patients at risk for death or serious complications from COVID-19 should be prioritized for telehealth • Age > 65 • Chronic health problems • Patients with acute gastrointestinal symptoms (nausea, diarrhea, abdominal pain) often preceding the respiratory illness. These patients often lack a history of GI illness. Resource (link below) Pan L, Mu M, Ren HG, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. Am J Gastroenterol. Read Pan, et al.: bit.ly/PM-Toolbox-Telemedicine-Links
Can I schedule Medicare, Medicaid, and commercially insured patients using telehealth? • New and established Medicare patients can use telehealth under the current national emergency (this includes all patients, not just services to help diagnosis/treat COVID-19) • At least 41 states and the District of Columbia have parity laws in place requiring commercial insurers to reimburse for telehealth • More states are allowing new and established Medicaid patients to be scheduled using telehealth under the current national emergency • To encourage “social distancing,” several states are allowing real-time audio-only to replace videoconferencing requirements for telehealth visits • It is important to stay up-to-date on this rapidly evolving area My practice’s catchment area includes multiple states. What if the patient is physically located in another state? Am I allowed to see my patients who live in another state without a license in that state? It is very important to review information relevant to your state and payer mix in this rapidly evolving area. From an insurance
standpoint, CMS has temporarily waived requirements for Medicare that out-of-state providers be licensed in the state where patients are physically present. Many state Medicaid programs and commercial insurance plans are following suit. The Interstate Medical Licensure Compact already expedites state licensing to practice telemedicine in several states. Several state medical boards are allowing out-of-state physicians to continue to care for their patients who reside out-of-state. What if I encounter licensing or insurance barriers to seeing out-of-state telehealth patients in my catchment area? If commercial payers do not allow reimbursement for in-state licensed providers to care for out-of-state patients, or if out-of-state licensing boards do not allow you to continue caring for your out-of-state patients in your catchment area, or if you are unsure: 1. Check the latest requirements in your state from the Center for Connected Health Policy. (link below) 2. Contact your state’s ACG Governor, the corresponding state licensing board, or state medical association to learn about ongoing work to address licensing and coverage barriers to appropriate medical care during this crisis. 3. Contact your state Governor’s office so they can ensure that you maintain the ability to meet the clinical needs of patients in your catchment area during this health crisis (reference: ACG Practice Management Toolbox: Advocacy and Resources for Effective Political Action in Gastroenterology). bit.ly/PM-Toolbox-TelemedicineLinks
STEP 2 – BUILD A SCHEDULING PROCESS How do I build a telehealth schedule? Most integrated electronic health record (EHR) platforms already offer the ability to accurately capture telehealth charges. Work with your practice manager to build a new “place-of-service” to enable telehealth, and pay attention to billing code modifiers described later in this document. How do I transition my scheduling grid to telehealth? Start your telehealth program at the
end-of-day, with longer visits, and with gaps between patients to accommodate technology issues. You can also consider opening up a session on a weekend or after hours when you have more time. “Start small.” Expect some technology hiccups—both for you and your patients—as you rapidly learn how to use a new healthcare delivery platform. What types of visits should I build into the schedule? In designing your telehealth schedule, realize that telehealth uses the E/M codes you already know, but their use is billed on time, not on E/M service, because of the lack of a physical exam. 1. Schedule telehealth visits using realtime videoconferencing technology to replace new and established patient office/ outpatient appointments. 2. Schedule extended telephone calls in lieu of telehealth visits for patients who lack sufficient technical knowledge or equipment to allow real-time videoconferencing. Note, however, that a recent ACG pilot study utilizing the ACG-specific telehealth platform, GI OnDEMAND, found that most patients, regardless of age, were comfortable using the platform. Note that several mechanisms may be useful for charge capture of a telephone call; an increasing number of states are allowing telehealth visit codes to be applied to audio-only phone calls for both new and established patients. 3. Block off time for e-visits to answer patient questions on your patient portal to avoid unnecessary visits. How do I convince my patients to move to telehealth instead of canceling their appointment? Consider scripting videoconferencing telehealth as a default option for your scheduling secretaries and encourage your patients that they will still receive outstanding care, rather than offering several choices among videoconferencing, a phone call, or canceling outright. There is a national shortage of videoconferencing cameras which many patients don’t have. Screen for hardware during the scheduling process. Recognize that some platforms will allow patients to access telemedicine services by smartphone and tablet, which can minimize barriers to entry. For patients who lack the necessary hardware, schedule phone
calls. Alternatively, you as the physician can consider switching to audio-only if needed during a telehealth visit for patients who encounter difficulty setting up. States are increasingly allowing real-time audio-only telehealth using telehealth visit codes during this crisis, but this area remains rapidly evolving and highly variable. My patients will probably have difficulty installing and testing the software. How can I help them? The most important step is to send clear and concise instructions through the patient portal so that patients can install and test the technology on their own before their visit. You can also consider assigning a tech-savvy scheduling secretary or assistant to help patients with difficulties and to identify patients who truly need audio-only telehealth. Some telehealth options (for example, doxy. me) are fully web-based and require no downloading or installing at all; patients using these options just log-in on a website, and many patients have found that process much simpler. Do patients have to consent to using telehealth? Best practices recommend that patients consent to using telehealth services, so it is important to consider this as a part of your scheduling workflow. State laws and licensing boards govern this process: some states do not require consent at all, while others require a signed consent form for the initial telehealth visit (which can often be signed electronically, but not always). Ensure that your practice manager helps you to review and build the legally required consent process (electronic signature, paper signature, or provider documentation only) into your scheduling workflow. View example telehealth consent forms: bit.ly/PM-Toolbox-TelemedicineLinks
How do I create a process to schedule patients for telehealth? 1. Identify – Assign staff to identify priority patients for telehealth according to your practice policy. 2. Educate – Assign staff to contact identified patients, discuss telehealth
using a script, and ensure they have the technology they will need to complete the telehealth visit (smartphone or computer with camera, patientside software based on your chosen telehealth platform). 3. Convert – Change patients from inperson to the appropriate telehealth visit type (telehealth visit, telephone call, in-person, or cancel). 4. Visit – See the patient! Are telehealth requirements different among Medicare, Medicaid, and commercial insurance plans? YES. The “telehealth visit,” which serves as a replacement for the office consultation, is the most commonly covered visit type and should be the primary focus of your efforts. While covered by Medicare and Medicaid, it is important to stay up-to-date with coverage policies for your individual commercial payer mix (as well as telehealth coverage requirements enacted by state action) as this crisis evolves. Are there other types of telemedicine to cover audio-only phone calls and portal messages? First, consider whether your state temporarily allows you to conduct realtime audio-only telehealth visits (using the same E/M codes as a full in-person office visit). Otherwise, Medicare has two prime options: “e-visits” and “virtual checkins.” These mechanisms are intended for physicians and advanced practice providers to help patients avoid unnecessary follow-up visits. In addition, Medicare has long offered a “prolonged non-face-to-face encounter” mechanism which exists outside of telehealth. Coverage for these mechanisms is variable outside of Medicare, but we include them here as payer coverage (or dictates on coverage enacted by state action) evolves with this crisis. It is important for you and your practice manager to consider (1) your local Medicaid and commercial payer policies and (2) your state’s requirements for telehealth coverage by commercial insurance, as you consider how to leverage these several options to meet your patients’ needs.
GI.ORG/TOOLBOX | 9
Table 1: Mechanisms for your practice manager to consider as you build your telehealth program
MECHANISM OF CARE (Insurance considerations in italics)
ELIGIBLE PROVIDER TYPES
Telehealth visit Broader coverage
Replaces the office/ outpatient visit
Physicians, advanced practice providers, clinical psychologists, clinical social workers, registered dietitians, nutrition professionals
Real-time videoconferencing (some states including California are allowing real-time audio-only phone calls during this crisis)
Covers new* and established patients Blocked time for provider to answer the patient portal
E-visit Likely Medicare-specific
Responding to established patients on a patient portal
Providers who are eligible to bill using E/M codes (physicians, advanced practice providers)
Scheduled telephone visits and unscheduled phone calls responding to patients
Virtual check-in Likely Medicare-specific
Answering questions from patients who initiate contact with the provider
Providers who are eligible to bill using E/M codes (physicians, advanced practice providers)
Telephone or other audio, video, secure text messaging applications, or patient portal
Providers who are eligible to bill using E/M codes (physicians, advanced practice providers)
ANY! In fact, this mechanism does not even require any communication with patients and should NOT be billed as a telehealth appointment. This mechanism also does not require a specific place-of-service.
Prolonged non-face-toface care Possibly broader coverage
Communicating with established patients OR Communicating with new patients with an upcoming scheduled appointment OR Conducting other non face-to-face work between visits without patient communication
Real-time communication not required
Resources (link below) • Top Five Things Gastroenterologists Should Know About Telehealth • About virtual check-ins • About e-visits • Medicare Telemedicine Health Care Provider Fact Sheet bit.ly/PM-ToolboxTelemedicine-Links
*“The Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act. To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.” (Reference: https:// www.cms.gov/newsroom/fact-sheets/medicare-telehealth-health-care-provider-fact-sheet)
STEP 3 – CHOOSE A TELEHEALTH PLATFORM TO REACH YOUR PATIENTS Several important factors drive practice choices among various telehealth platforms. Does your EHR already allow you to do these things, or do you need more functionality? If your EHR already provides most of these tools, then a simpler platform may be best. • HIPAA-compliant (required outside of the current national emergency) • Appointment reminders • Scheduling capabilities • E-prescribing • Billing support • Single- or multi-provider support • Messaging capabilities • Access or use of online forms (virtual check-ins, consents for example) • Revenue cycle management • Real-time videoconferencing ability
10 | GI.ORG/TOOLBOX
Table 2: GI practices are successfully transitioning using one of the three products below: NAME
• An ACG-endorsed member benefit • HIPAA-compliant • Includes secure video, and end-toend practice management tools like scheduling, document sharing, EHR integration, and billing • Can be used by providers and patients on computers, laptops, tablets, and smartphones • Dedicated to practice of gastroenterology
Waived subscription fee, $1 per session fee only. No threshold of use limits.
• HIPAA-compliant • Includes secure video • Patient consent (being added)
Free, or subscription model
FaceTime, Skype with your own EHR (such as Epic)
• NOT HIPAA-compliant, however, the Office for Civil Rights will “exercise enforcement discretion and waive penalties” for providers acting in good faith during public health emergencies*
*GI OnDEMAND is a joint venture between the American College of Gastroenterology and Gastro Girl, Inc.**Reference: https:// www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
STEP 4 – HOW TO DOCUMENT TELEHEALTH ENCOUNTERS DURING VISITS VISIT TYPE
• Requires the same documentation as an office visit, absent the physical examination or vital signs • Requires a time-based billing statement with a stated time for counseling and coordination-of-care exceeding at least 50% of the total visit time • Can be done in most EMR/EHR platforms
practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.”
Examples: 1) New consultation for dyspepsia and diarrhea 2) Follow-up visit for Crohn’s disease
Resource (link below) Medicare Telemedicine Health Care Provider Fact Sheet bit.ly/PM-Toolbox-
Virtual check-in (i.e. a telephone call mechanism)
• Requires that “the patient provides verbal consent to receive virtual check-in services”
Examples: 1) Returning a phone call to a patient to update the care plan. 2) Writing back to the patient with your interpretation of a drug rash, based on a picture of a rash sent by the patient to you over the portal.
• Requires that “the patient provides verbal consent to receive e-visit services”
Telehealth visits Uses office-based codes billed on face-to-face time (of which a documented number of minutes exceeding 50% of total time must be spent on counseling and coordination of care) as follows:
Example: Responding to several messages back and forth with a patient spanning three days. Prolonged nonface-to-face services (i.e. a telephone call mechanism)
• Start and end times for this overall service should be documented and need not be continuous, but all billed time must occur within the same calendar day • Documentation and a brief summary of eligible activities which were provided (i.e. chart review, coordination of care, calling a patient and/or provider, and documentation and summarization of the care plan in a note) • You must attest to the total time spent on this service (which must be at least 31 minutes) • You must reference the scheduled date of a prior or upcoming office or telehealth visit • Review specific documentation requirements with your practice manager Examples: 1) Calling a patient to update the care plan after extensive testing. 2) Calling a patient to discuss care in detail to avoid an unnecessary in-office visit. 3) Performing extended chart review on the patient. 4) Documenting an updated care plan for the patient. 5) Speaking with colleagues in other specialties about the patient.
NEW PATIENT OFFICE/ OUTPATIENT VISIT Code
OFFICE CONSULTATION (new patient)
STEP 5 – CHARGE CAPTURE Many of my patients are financially devastated. Are regular co-pays and deductibles waived for patients during the COVID-19 crisis? CMS is allowing practices to waive co-pays and deductibles for Medicare patients during this national emergency. Several commercial insurers and state Medicaid programs are following suit, but this is a rapidly evolving area that you should continue to monitor. These co-pays and deductibles may likely return after the current national emergency ends. Resource (link below) OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak. Read at the link below. bit.ly/PM-Toolbox-Telemedicine-Links
What was telemedicine like before the COVID-19 crisis? Medicare only covered telehealth under limited circumstances: when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. Several Medicaid programs and commercial insurance had variable coverage or no coverage for telemedicine. It is likely that many of these changes will revert once the current national emergency ends, so it is important for you and your practice manager to stay up-to-date with telemedicine licensing rules and payer coverage policies through this crisis. What changed after the COVID-19 crisis started? “The Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act. To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular
ESTABLISHED PATIENT OFFICE/ OUTPATIENT VISIT Code
Reference: 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule
GI.ORG/TOOLBOX | 11
Virtual check-in This service should not be billed if it occurs within seven days following a visit and is covered by Medicare Part B. Appropriate codes are listed to the right but may not be recognized by all payers.
HCPCS code G2012
Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
HCPCS code G2010
Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
Reference: CMS Fact Sheet.
E-visits Physicians, nurse practitioners, and physician assistants can use 99421 (510 minutes), 99422 (11-20 minutes), and 99423 (21 or more minutes) to capture the total time spent by the provider over a seven-day period over the patient portal to answer a patientinitiated message for Medicare Part B enrollees. Appropriate codes are listed below but may not be recognized by all payers. Non-face-to-face prolonged care Physicians, nurse practitioners, and physician assistants can use 99358 (first 31 to 74 minutes), add-on code 99359 (for 75 to 104 minutes total time), second add-on code 99359 (for 105-134 minutes total time) for Medicare Part B enrollees but these codes might not be recognized by all payers. It is important to recognize that these codes exist outside the spectrum of the telehealth place-of-service, are already covered by Medicare for you to use in your practice as part of prolonged non-face-to-face care, and have not changed during this national emergency as of this writing. More information on these codes can be found at the link below. Resource (link below) Christopher Y. Kim, Braden Kuo, Glenn D. Littenberg. 2017 Coding Updates. Gastroenterology CPT Advisors. bit.ly/PM-Toolbox-Telemedicine-
SUMMARY: IMPORTANT DETAILS FOR YOUR PRACTICE MANAGERS • Consultation codes are not recognized by Medicare, but can be billed to some commercial insurers. These are generally automatically downcoded to “new patient office” codes when not recognized. • Place of service (POS) “02 – Telehealth” must be on the claim for Medicare. Some commercial insurers may require a different POS (such as 11) so that they recognize the visit in their existing system. • Modifier GQ (asynchronous telecommunications system) is required if the provider is affiliated with a federal telemedicine demonstration in Alaska or Hawaii. • Modifier 95 indicates “Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System” and is relevant to telehealth visits meeting this criterion but should not be used for virtual check-in, e-visit, or a prolonged non-faceto-face encounter. Use this modifier for commercial insurance claims. At this time, this modifier is optional for Medicare. (Please note the difference between the POC code and a modifier.) • These codes cannot be billed on E/M services and must be billed on time, as a physical examination cannot be performed. • The facility fee cannot be billed, unless the patient is physically located at the referring physician’s office (which is not recommended during the COVID-19 crisis).
Resources (link below) • Top Five Things Gastroenterologists Should Know About Telehealth • American College of Physicians Telehealth Coding Tips • American Medical Association (AMA) Quick Guide to Telemedicine in Practice • AMA: Special telehealth coding advice during COVID-19 public health emergency bit.ly/PM-Toolbox-Telemedicine-Links
Eric D. Shah, MD, MBA, Dartmouth-Hitchcock Medical Center, Lebanon, NH
12 | GI.ORG/TOOLBOX
Stephen T. Amann, MD, FACG, Digestive Health Specialists, Tupelo, MS
Jordan Karlitz, MD, FACG, Tulane University, New Orleans, LA
GETTING it Right
SO MUCH DEPENDS UPON THE PHONE. Even in this age of social media, mobile devices, and portals and websites, telephones remain the backbone of communication with our patients. Although search engines and the internet have become the first â€œcontact,â€? phone calls remain the most common first two-way interaction between a medical practice and patients. Well-managed phone processes will improve practice operations and strengthen the patient-provider relationship. This toolbox article seeks to provide a practical guide to optimize telephone management in your practice.
Answering the Call: Improving Telephone Management
in Your Practice
By Syed Hussain, MD, GI Associates LLC, Kenosha, Wisconsin and Sapna Thomas, MD, FACG, University Hospitals, North Ridgeville, Ohio
Phone Calls Bring A Staggering Variety of Issues Phone calls reveal or create important issues for a practice to act upon and resolve. Unfortunately, attempts to simplify telephone management are often frustrated by several realities. First, medical practices receive calls from a great variety of sources. These include patients and their family members, the practice's own staff, other medical professionals, various medical facilities, vendors, payors, and many others. Second, the variety of reasons for these calls is extensive. Major categories include scheduling and cancellations, care coordination, follow-up on results, prescription medication issues, and patient satisfaction. Even inside these categories, the situations and requirements for a successful resolution of the issues vary tremendously. Simple automated phone-tree solutions will never fully account for this variety. A comprehensive strategy is required. GI.ORG/TOOLBOX | 13
Phones—A Vital Hub for the Entire Operation How telephone calls are handled, routed, and categorized is a major contributor to a successful operation. Clinical personnel must often give full attention to patients currently in the office. Intermittent or continuous interruption of those duties results in poor care, reduced patient satisfaction, and staff frustration or burn out. Phone calls are often a major source of those frustrations. The phone hub or “call center” in your practice must function to resolve issues as quickly as possible and route calls and messages to appropriate personnel. If many questions and issues are resolved immediately, the rest of the operation will benefit. Phone Management: Open Access, Call Centers, and IVR Systems Some practices continue to rely on open phone lines answered by the first available employee. This may be called “open access.” The result of this approach, however, can be highly inconsistent and cause significant operational difficulty. Not only does this approach fail to account for factors such as call volume variation throughout the work day and staff availability, staff members will almost certainly vary in their talent in answering calls and questions. For these reasons, the open access model is usually replaced by one of two approaches: automated systems using Interactive Voice Response Systems (IVR) or dedicated call centers (phone hubs) with staff specifically trained and dedicated to appropriately answer calls, take messages, answer questions, and route messages to appropriate locations. Goals of the Phone Hub To resolve call issues as quickly and effectively as possible To limit distraction to patient care by clinical staff and physicians To improve office operations To satisfy patients
14 | GI.ORG/TOOLBOX
Automated versus Human Generally, practices attempt to resolve telephone management with either one or more staff members to directly answer calls (phone hub) or an automated system to receive and route calls to the appropriate people. The phone hub should be a more effective dynamic in dealing with the tremendous variety of calls, but requires trained and dedicated staff. If the people answering calls are simultaneously expected to carry out other duties, such as with the open-access model, the results will
hub model works best for practices of at least four to five providers and requires two or more operators. The hub may be expanded based on call volume or as the number of providers increases. Many phone systems can now help track volume, wait times, and other metrics to help organize your plan and staffing needs. Solo-practice physicians and very small practices are more likely to use an open-access structure, but automated systems are usually still
ADVANTAGES AND DISADVANTAGES OF PHONE MANAGEMENT TYPES ADVANTAGES Open-Access Phones
• No Specialized Staff
• No Specialized Staff
• No Automated systems
• No Special Technology
• Immediate access to automated answering
• Immediate access to human staff
• Immediate access to human staff
• Superior routing • Accounts for variation in call types DISADVANTAGES
Open-Access Phones • Variation in staff availability • Potential interruption in clinical duties • Inefficient • Variation in staff training and ability
• Menus may confuse patients
• Requires specialized staff
• Voice prompts may be difficult to understand • Inappropriate routing • Delays in issue resolution
usually be inefficient. Dedicated phone staff may not be realistic for very small practices. Automated systems have the benefit of continuous availability but leave incoming callers to navigate imperfect options and wait for issue resolution later. Improperly routed calls reduce office efficiency and frustrate callers. It is critical to recognize that automated systems cannot work alone. Most issues raised by calls will eventually be resolved by providers or staff. Phone Management and Practice Size Phone management solutions can vary based on your practice size and structure. A trained phone specialist (operator) can handle and rout ebetween 75 and 100 calls per day, but phone hubs that completely depend on one individual are susceptible to significant disruption if that employee becomes unavailable. Therefore, the phone
an advantage for them. Since most calls must eventually be handled by staff, the difference in staffing may be nominal. Even small practices that have a receptionist receiving all initial calls usually benefit from an automated system that uses prompts to route calls and triage issues. Most larger practices with separate departments also use automated triage capabilities. It is recommended that the merits of each model be evaluated carefully, considering the practices needs and resources. Disadvantages of Automated Systems The greatest disadvantage of IVR systems is that people do not like talking to machines. Many patients have a hard time following menus and instructions. Patients may become frustrated with the slow process of
rise of Internet communication and social media is also undeniable. Details on these best practices are outlined in the ACG toolbox article ‘Marketing Your Practice in the
working through menus and choosing Certain 'soft skills' need to be taught, Setting Patient Expectations options and choose options that such as handling an upset patient and A great deal of stress and hassle is promise fastest access. Long menus of diffusing a crisis. Newly hired staff potentially avoidable when customers options are usually counterproductive, should be trained by an experienced know what to expect when they call. With and we recommend a menu of no manager who orients them to the every new patient and established patient, more than four choices. As previously practice telephone policy and carefully the practice should provide a summary of discussed, many issues do not fit neatly supervises the process. Script options the telephone policy with hours, expected into one of those options and voice for common questions and situations time required for returned calls, and prompts can be difficult to choose. are especially valuable. These scripts frequency of voicemail checks. A summary Practices will need to be prepared for must be written to streamline answers of the policy can be included in the posta high percentage of incorrect choices and minimize hold time. Training visit clinical summary and on the practice and inappropriate routing. The quality should be ongoing, and coaching website. Patients should be encouraged of voice prompts is also important. and follow-up supervision are critical. to use other methods of contacting the Professional voice talent may help 1: CHOICE Structured metrics such as FOR wait-times, practice as well. Patient portals provide Figure ARCHITECTURE AUTOMATED PHONE MANAGEMENT craft and read more effective prompts. issue-resolution, and patient experience a convenient method of contact for nonPoorly managed IVR systems will result can be measured and used for process urgent medical questions and concerns. in improper routing of calls, frustrated patients, failure to resolve important FIGURE 1: CHOICE ARCHITECTURE FOR AUTOMATED PHONE MANAGEMENT issues, poor patient satisfaction, and can even have negative impact on your medical care.
Despite the advances in technology, the telephone call remains a vital line of c for any medical practice. A “one size fits all” approach is not practical and eac develop a system that works for their team members and patients. Internal au measurable metrics can be useful for annual staff reviews, recognition, or bon and efficient telephone management can strengthen the entire practice by m frustration of all involved.
Initial Call Structure Automated IVR systems use a choice architecture driven by recorded prompts. We recommend the use of a simple decision tree, with an early option to reach the physician representative (MA, RN) to address medical questions and concerns. Staff members with clinical responsibility must have the training to recognize significant issues and the ability to triage the call and contact the physician or another appropriate provider throughout the work day. The other prompt choices such as scheduling, billing issues, and prescriptions will route calls to their respective departments. It is important that the automated triage connects the caller to a live person within a few minutes. See Sample Choice Architecture: Figure 1
The IMPORTANCE of Training Answering phone calls properly in a medical practice is a critical task. It is vital for staff to be trained in active listening and be equipped with the tools necessary to handle the most common types of phone calls. They must also be familiar with practice operations, call schedules, clinic schedules, and organizational structure.
improvement. We also recommend the physicians (yes, doctors) remain involved in the process and participate when appropriate. Providers must be alert to call-related complaints and communicate them to administrators. Finally, value an excellent telephone employee highly! Customer service by phone is a valuable skill that practices must not underestimate.
Providers may also benefit by a policy that differentiates medical concerns that will require office visits. Since patients will also use websites and social media to contact practices, access to the practice through these methods must be carefully monitored. In the end, patients will choose the pathway of least resistance to get access to your practice. Considering the notion that 90% of calls are made by
GI.ORG/TOOLBOX | 15
10% of the patients, it is important to manage a patient’s expectation and support our multi-tasking staff. Managing Physician Referrals A direct prompt should be available to address physician referrals and consultation requests so as not to inconvenience referring providers. Minimize friction on these important calls. We recommend requiring only minimal information such as patient identifiers, location, reason for consultation, and urgency (same day, within 24 hours). Easy access to a practice is a major marketing strength, especially in highly competitive environments. Practice Improvement for Phone Management Like any aspect of your practice, telephone management should be audited internally by an assigned manager. There are several measurable metrics that can used for constant and ongoing quality improvement. 1. On-hold times and the time taken to either call patient back or connect with a scheduler or provider 2. Evaluate staffing ratios by performing a ‘traffic study’ to evaluate the average call volume at certain times of the day 3. Seek feedback from referring providers to assess ease of consult calls and urgent office visits 4. Incorporate patient feedback and allow comments regarding the telephone system
interactions are being routed to telemedicine as a better way for providers to resolve issues and directly provide care. We strongly encourage readers to refer to ACG Practice Management Committee Toolbox article ‘Essential Guide to Telemedicine in Clinical Practice: EASY STEPS TO RAPID DEPLOYMENT.’ The rise of internet communication and social media is also undeniable. Details on these opportunities and best practices are outlined in the ACG Toolbox article ‘Marketing Your Practice in the Digital Era.’ Summary Despite the advances in technology, the telephone call remains a vital line of communication for any medical practice. A “one size fits all” approach is not practical and each practice should develop a system that works for their team members and patients. Internal audits with measurable metrics can be useful for annual staff reviews, recognition, or bonuses. Prompt and efficient telephone management can strengthen the entire practice by minimizing frustration of all involved. References 1. www.physicianspractice.com/managersadministrators/telephone-etiquette-tipsmedical-practice-staff 2. Elnicki D, Ogden P, Flannery M. Telephone Medicine for Internists. J Gen Intern Med. 2000; May; 15(5): 337-343 3. AAFP Guide for Improving Telephone Management in Your Practice: www.aafp.org/ fpm/2005/0500/p49.pdf 4. AHRQ Toolkit for Telephone Quality Improvement: www.ahrq.gov/sites/default/ files/wysiwyg/professionals/quality-patientsafety/quality-resources/tools/literacy-toolkit/ healthlittoolkit2_tool7.pdf
New Opportunities to Supplement Telephone Access Recent events have rapidly pushed telemedicine to the forefront in medical practice. Many patient
Syed Hussain, MD, GI Associates LLC, Kenosha, Wisconsin
16 | GI.ORG/TOOLBOX
Sapna Thomas, MD, FACG, University Hospitals, North Ridgeville, Ohio
The Graceful Exit The Graceful Exit Building Success
By Samer El-Dika, MD, Dave Limauro, MD, FACG, Eric Shah, MD, FACG, Louis J Wilson, MD, FACG
By Samer El-Dika, MD, Dave Limauro, MD, FACG, Eric Shah, MD, FACG, Louis J. Wilson, MD, FACG
THE CHALLENGE OF CHANGE Few things require more long-term commitment than working in a medical practice. Moving from one practice setting to another, or retirement from practice can be a daunting task. Nevertheless, such moves are a frequent occurrence. As many as 40% of newly practicing physicians choose to leave their initial practice within two years of joining. (1) Even if the move is for an exciting new opportunity or a much-needed change, leaving a medical practice is both complex and stressful. Physicians who have been colleagues and partners may find themselves forced to sit on opposite ends of a negotiating table to define exit strategy and financial terms. Achieving a “graceful exit” requires careful preparations. In this article, we will highlight important items that gastroenterologists need to consider before making a move towards retirement or practice change.
STEP 1: PRE-ANNOUNCEMENT CONTRACTUAL REVIEWS Before announcing your intention to leave a practice, it is critical that you to review all relevant contractual arrangements. These include: your employment contract, managed care contracts, partnership agreements, operating agreements, purchase agreements, non-compete/nonsolicitation clauses, and stock-purchase agreements. It is also important to revisit practice policies as they might be set to override your current employment contract if they differ in certain aspect.(2) Review the precedents set by the departure of previous partners in the practice in order to avoid potential pitfalls. The abiding agreements, policies, and clauses must be weighed carefully into your decision to announce your departure. Carefully consider the best timing for your departure. Considerations to keep in mind are listed in Table 1.
TABLE 1. CONSIDERATIONS FOR OPTIMAL TIMING FOR DEPARTURE OR RETIREMENT 1. How will you departure affect the value of your ownership and the ownership of other partners? 2. How will purchase of your ownership interest be financed? 3. Does your departure violate any legal commitments to the practice? 4. Does your departure violate any financial obligations such as bank loans, real estate loans, or lease agreements? 5. Does the manner of the departure violate any non-compete agreements? 6. Does the practice have the capacity to assume your clinical responsibilities, or will you need to help patients find new providers?
It is also important to inquire about the type of malpractice insurance policy that you carried through your employment. If it is a “claim made” malpractice insurance policy, it means that you are insured for claims made while you are employed. In that case, you should procure a supplemental endorsement policy known as “tail coverage.” The latter usually costs 1.5 to 2 times the annual premium.(2) Once the above questions and issues are carefully evaluated, note the pros and cons of leaving with consideration of the impact of your decision on your family, finances, and career. While it is often considered prudent to keep any active job searches discreet until you are sure of your final decision, you may benefit from having an open dialogue with your current colleagues about the issues and considerations driving the change. It is best to announce retirement plans with plenty of time for your partners to make any necessary arrangements, especially if they will need financing to purchase your ownership interest.
GI.ORG/TOOLBOX | 17
STEP 2: ANNOUNCEMENTS When it comes to announcing your departure, your current partners should come first. It is important to have your partners notified about your intention to leave the practice before they hear it from others. It may be considered disrespectful and will likely leave a bitter taste if they learn of your plans from others. Discuss with them the “when” and “how” to announce your departure. It is essential to give plenty of notice. The required notice may also be stated in your contract. It should be enough time for you to take care of business, and for them to work on finding a replacement as well as manage any ramifications of your departure. Do not forget to show gratitude and appreciation for the opportunity to be part of the team. Acknowledge mentorships and the various support you received. Give constructive criticism while highlighting the positive impact the job had on your life and career. Next you will need to notify professional societies, specialty boards, state licensing boards, malpractice carriers, and contracted health plans. It is recommended to notify health plans at least 60–90 days from your departure to allow them to update their network.(1) If you are moving to another state, similar agencies must be contacted, and licensing and professional liability requirements must be met. After notifying your partners, you should provide enough notice to institutions or locations where you treat patients. The notification can be achieved with a telephone call followed by a confirming letter a few weeks in advance of your departure. For legal reasons, the letter should clearly state the contact information of the physician(s) picking up patients’ care.
STEP 3: THE CLINICAL EXIT Finish your assignments while gradually retreating from your responsibilities as part of a clear transition plan. Do not hesitate to recommend a qualified colleague for your replacement, offer to help recruit and or train your replacement, and check with the state authorities regarding the recommended timeline for patient notification. Many states require notifying patients when a physician is leaving the practice. The timeline of notification can
18 | GI.ORG/TOOLBOX
vary from one state to another. A letter formulated in conjunction with your former partners is the most commonly used notification form. In general, patient charts belong to the practice and cannot be taken by the departing physician, unless your contract and the state-mandated responsibilities regarding patient transfer and recordkeeping state otherwise. It is worth noting that most states permit patients to request that their charts be transferred to the departing physician(2).
STEP 4: THE FINANCIAL EXIT While every practice is unique, in gastroenterology there are valuable assets such as ambulatory surgical centers (ASCs), ancillary businesses, and real estate. Understanding the buy/sell agreements for these entities should begin years before you retire or depart. This may allow you to identify and make important amendments long before your departure. Consider reviewing these governing documents every few years, perhaps when new associates are joining your practice. While ownership agreements come in all shapes and sizes, it is important to review them carefully again as you plan a departure. Make sure these agreements adequately compensate you for your assets without crippling your practice financially when you do leave. One important item that must be addressed is the treatment of accounts receivable for the departing physician. Defining exactly what is owed to the departing physician, clearly stating when and how she/he will be paid. If it is not clearly stated in the practice agreement(s), an “exit agreement addendum” should be drafted to address those details. Verbiage stating that there would be access to the practice financial records granted to the retiree should also be included.(1)
VALUING YOUR PRACTICE Valuation of assets, particularly those of an ASC, equipment and real estate are likely to be key issues in the
departure of a GI physician. Decide both who will be assigned the task of determining the valuation as well as what method will be used. Reviewing historical valuations when bringing in new partners could be helpful. If a certain “multiple of EBITDA” was previously used for a buy or sell events, it may be easiest to use the same multiple again. If there is a high degree of trust for a cooperative departure, then it may be appropriate for the practice’s accountant to perform the valuation. If, however, there is a likelihood of conflict, or if you and your partners disagree about the valuation method, an independent firm should be retained. Be sure to also stipulate how these valuation-services will be paid for. We recommend an equally shared payment for this service. Methodologies for valuation of a business can be complex, but a general review is appropriate. According to Matt Sobieralski, former senior business analyst for Physicians Endoscopy, most ASCs rely on historical multiples of cash flow as a basis for valuation.(3) There are two critical components for this approach, the EBITDA and the valuation multiple. The valuation multiple would usually be clearly spelled out in the exit agreement and may be based on factors such as size, risk, liquidity and competition in the marketplace. The EBITDA stands for “earnings before interest, taxes, depreciation and amortization.” It is used as a proxy for actual cash flow and accurately captures the earning potential of the ASC or other asset that is being sold. EBITDA is generally an annual value, but carefully consider whether the EBITDA will be an average of just the immediate previous year, or of several previous years. This can have profound implications. Obviously, it is important for physicians to carefully consult with their business accountant to understand their own unique tax and debt status before and during their anticipated exit.
SUCCESSION PLANNING: THE BENEFITS OF A PRE-DETERMINED EXIT PATHWAY Succession planning is best done in an open, proactive, and transparent way. Important questions such as whether the retiring physician may continue to work part-time may also be addressed long before a retirement event begins. As an example, does the practice allow the retiring physician to cut back hours or stop taking call, but remain in the practice? Does your group allow you to do this and also take your exit-distribution? Some agreements state that a physician must die, be disabled, or exit completely to take any final distribution. This creates a counterincentive to a smooth and mutually beneficial succession. A clearly defined process for a smooth departure is critical for medical practices seeking to recruit new members. A professional services agreement (PSA) for partners approaching retirement can be an excellent option for practices seeking to ease the transition both clinically and financially.(4) A PSA should include a formula for compensation for the semi-retiring physician based on collections, minus the overhead rate of the practice and the expenses allocable to the â€œcontractor.â€? Other items to clearly define include the treatment of compensation and expenses, malpractice insurance requirements, duration of the agreement, terms for renewal, and provisions for early termination.
Samer El-Dika, MD, Stanford University, Redwood City, CA
A GRACEFUL EXIT FOR A BRIGHTER FUTURE Change is part of every career and cannot be avoided. Likewise, physician retirement/exit is an inevitable event and is part of the normal career cycle of every gastroenterologist. Achieving a graceful exit requires open communication, careful planning, and consideration of important details that can save you and your former partner(s) preventable legal headaches and financial losses. Leaving properly helps ensure a positive outcome for the departing physician and the long-term success of the practice.
REFERENCES: 1. https://www.nejmcareercenter.org/article. Moving on issues to consider when making a career move. 2. A Must Do List for the Departing Physician. James D. Wall, Esq, Family Practice Management. www.aafp.or/fpm/Octover 2005. 3. Retirement Ahead. TJ Berdzik. Endoeconomics. Winter 2019, p. 6-7. Understanding Business Valuation. Matt Sobieralski. Endoeconomics. Winter 2016. P. 11-12. 4. Alignment but not Employment: Professional Service Agreement with a Hospital System. Stephen T. Amann, James C. Dilorenzo. ACG GI Practice Toolbox.
Dave Limauro, MD, FACG, Pittsburg Gastroenterology Associates, Pittsburg, PA
Eric Shah, MD, FACG, Dartmouth-Hitchcock Medical Center, Hanover, NH
Louis J. Wilson, MD, FACG, Wichita Falls Gastroenterology Associates, Wichita Falls, TX
GI.ORG/TOOLBOX | 19
// LAW MIND
PROFESSIONAL SERVICE AGREEMENTS: PERFECT SOLUTIONS to AFFILIATIONS? Key Situations Every PSA Should Address The College commissioned Ann Bittinger, Esq., to draft a white paper on Professional Services Agreements (PSA) as a resource for our members. In addition to guidance and perspective, Ms. Bittinger also provides template legal contract language that will be helpful to ACG members negotiating a PSA with a health system. • As you read the white paper, the legal template language can be viewed online by scanning this QR code with your smartphone • View and download the template language: bit.ly/ACG-PSA-LegalTemplates
20 | GI.ORG/TOOLBOX
By Ann Bittinger, Esq.
THE RAINSTORM THAT STARTED AROUND 2010 IN FAVOR OF CONSOLIDATION IN THE HEALTHCARE INDUSTRY CONTINUES TO FLOOD THE MARKET, with creative, mutuallybeneficial arrangements between hospitals and physicians taking the form of every color of the post-storm rainbow. One form, Professional Services Agreements (“PSAs”), continue to be quite common among hospitals and gastroenterology groups where the system has not yet employed the gastroenterologists. Background. A PSA is simply a contract by which physicians in a physician group provide services to a hospital or health system. They take many shapes and sizes. One physician can enter into a PSA with a system for a few hours of defined work. Or, on the other end of the spectrum, a GI group with dozens
of gastroenterologists can contract through a PSA to manage the GI service line at a system, much like what we used to call a co-management agreement. There is no one-size-fits-all PSA, but there are key terms that should appear in any PSA, and those terms should be tailored to the specific facts and circumstances following negotiation of a robust letter of intent. When a group sells its practice to a system, the group’s company is usually dissolved. The physicians no longer own the company for which they work, and they become W-2 employees of the hospital system, usually of its physician enterprise subsidiary. The closeness of the affiliation in a PSA, however, is one or more steps shy of full employment; how close is up to the terms of the PSA. For most PSAs, the gastroenterologists typically still bill and collect for clinical services. As such, the health system is paying the group for administrative and management services only. In other PSAs, however, all of
the gastroenterologists work under the tax ID number and payer contracts of the health system. (In other words, the GI group still employs all the physicians and assigns all of them via a PSA to work under the hospital system’s payer contracts). In those situations, the payment to the group compensates it not only for administrative services but also for the costs of salaries the group incurs in providing a full spectrum of gastroenterologists to provide services to the hospital. Because the hospital bills and collects for physician services, the hospital pays the group to pay the physicians’ salaries and benefits. The Law. It is illegal for a hospital to pay a physician group other than fair market value. The hospital can only pay physicians rates that do not vary based on the volume or value of referrals, for commercially reasonable services. Payments above fair market value or for work that is not commercially reasonable can be construed by prosecutors as kickbacks that violate the Federal AntiKickback Statute. This is a criminal law, so if violated, the physicians and system executives who offered, solicited, paid, or received payment can face prison time. Fair market value is a range, not a number. And the range should not be based solely on third-party data. To use third party data properly, the facts surrounding the proposed relationship have to be shared with the consultant. That way, the consultant can ensure that he or she is comparing the industry information correctly to the facts at hand. Although it’s not advisable to blatantly negotiate what is considered fair market value, there is absolutely nothing wrong with providing supporting documentation about the facts at hand in response to a draft report from a valuation consultant. Typically, in a fair process, the consultant will interview both the physician group and the hospital and ask for non-biased, fair information relating to the valuation job. A consultant may share the draft report with both parties, soliciting feedback, before finalizing it, to insure the integrity of the assumptions and conclusions the consultant makes.
Sample Agreement Terms. Although every PSA must be tailored to the specific facts and circumstances, groups should pay particular attention to these terms: 1. Duties 2. Term 3. Exclusivity 4. Non-compete (Confidentiality)
DUTIES What are you doing? Because the most important compliance issue in a PSA is to demonstrate commercial reasonableness and fair market value, it is essential that the contract accurately and robustly describe the work that is being performed by the physician group for the benefit of the system. Is it specifically for call coverage, for example, or only for endoscopy coverage for the hospital? Valuation consultants, not lawyers, opine on fair market value, but before you call a valuation consultant you need an accurate description of services that will be provided. Sometimes PSAs are casually referred to as “medical director agreements on steroids.” Some level of medical direction or administrative oversight is part of all PSAs (other than agreements for call coverage only), but what else are you doing? Need more help? View and download examples of contract language when negotiating duties related to your PSA: bit.ly/ACG-PSA-Legal-Templates
it is finalized? Metrics should be flexible or provide multiple options. The practice will change over time, so the effectiveness of the measures needs to change in tandem. As to physician recruitment, consider including in the PSA that if the staffing of the group falls below X number of physicians, then the hospital will agree to subsidize the income of a new hire subject to a recruiting agreement that complies with the Stark Law and Anti-Kickback Statute. This agreement typically mandates that the recruit stay in the community for 2–3 years in addition to a subsidy paid to the group to allow the group to pay him regardless of his collections or productivity. The recruiting agreement is separate from the PSA, but a provision in the PSA that would mandate a subsidy, under to-be-determined terms, is helpful to physician groups. Another option is to mandate a needs assessment periodically, so that at a minimum a discussion about recruiting is built in to the PSA. As to call coverage obligations, be wary of how heavy the beeper is. By this, I mean incorporate a cap or some other limit on the extend of your call obligations per shift. It’s not reasonable for a gastroenterologist to have to manage 30 inpatient and emergency department patients a night. Also, as to call obligations, explore the medical staff bylaws and PSA terms to ascertain whether an extender can be used in addition to, or in lieu of, a physician on call. For example, a call coverage provision might say that the group will provide call coverage 10 nights a month for $1000 a night, but in the event that the census for patients seen by the group on call in the hospital (inpatient and ED)
As to the schedule containing the metrics and targets, a model is beyond the scope of this paper, but be sure that the targets and metrics are tailored to your service. Do they make sense from a cooperative standpoint as items that both the hospital and group want to improve upon? Is there a fair way to track and document progress on those targets? Does the group get to review the documentation before
GI.ORG/TOOLBOX | 21
in the last six weeks exceeds 20, then the fee will increase going forward to $1750 a night to support a second provider on the shift or an extender. The heaviness of the beeper should definitely be considered by the valuation consultant to determine the fair market value of the pay for call coverage.
TERM One of the pros of a PSA as opposed to an acquisition/employment model is that PSAs are easy to unwind, as the physician group entity remains in place. (That being said, an unwind can be difficult if the PSA includes the hospital hiring the non-physician staff and administration. In those cases, the PSA should allow for the re-hire of staff upon an unwind). But easy termination can also be one of the cons. It is not uncommon for a PSA to have a longerthan-normal term, of three to five years for example, with no without-cause termination provision by either party. They are, in a way, a short-term marriage between group and hospital. Locking in a longer term may be more valuable than negotiating higher compensation. It’s hard to get things done if you know the agreement is subject to expire in year term. If you negotiate favorable control rights and exclusivity, you want to lock that in for a while. Additionally, PSAs usually have minimal for-cause termination provisions. Need more help? View and download contract language examples related to terminations: bit.ly/ACG-PSA-Legal-Templates
22 | GI.ORG/TOOLBOX
EXCLUSIVITY When negotiating PSAs with hospitals, groups sometimes focus on the compensation and duties without paying attention to the value of intangibles, like exclusivity. An exclusive agreement means that you are the only entity or person providing the services defined in the agreement. If your group has an exclusive contract to handle call coverage, then only your group can take call (so long as there’s no conflict with the medical staff bylaws). If your group has an exclusive contract to manage the GI service line at the hospital and to oversee GI quality assurance and utilization review, then your group and your group alone maintains control of that. Having this intangible in your pocket prevents other groups from taking control of the department. An exclusivity term also makes clear the line of demarcation between what the hospital’s administrators do and what the physician group does. Need more help? View and download sample contract provisions related to exclusivity: bit.ly/ACG-PSA-Legal-Templates
NON-COMPETE (CONFIDENTIALITY) One remnant topic from employment agreement drafting that hospital systems like to make a part of a PSA is a noncompete. Hospital counsel argues that if the hospital is going to associate so closely with the GI Group, sharing information and collaborating so closely and perhaps exclusively, then the group has to agree not to take that information and use it competitively. Non-competes lock groups in, preventing them from leaving and associating with a system that competes with the system. Agreeing to a non-compete sacrifices significant leverage. The point of pursuing a PSA rather than an employment model is to
allow for an easy out if the Group is not happy. That easy out isn’t much of an out if the PSA includes a non-compete. If the hospital system is sincerely worried about a group taking the system’s confidential information and using it elsewhere, then the group should argue that a Non-Disclosure or Confidentiality Agreement (not a non-compete) is the more appropriate contractual tool to protect the hospital’s interests. After all, the physician group has its own intellectual property and experience that it is bringing to the PSA. Any restrictions on use of information should be mutual. It’s not like the group is an employee who is being trained to work for an employer and who should, therefore, be subject to a non-compete post-termination. Need more help? If the system suggests a non-compete in its letter of intent or PSA, view and download suggested language that you can counter with during your negotiation: bit.ly/ACG-PSA-Legal-Templates
When negotiating your letter of intent before entering into the PSA, don’t focus on compensation to the detriment of other important provisions. Be sure to keep in mind topics that could carry great intangible value: termination and term, confidentiality-versus-non-compete, and exclusivity. Doing so could help your group more strategically align its future course and help it survive well into the 2020s. Spend significant time outlining exactly what duties the group will provide, as there’s no better way to assure a group’s demise than to come under the scrutiny of a United States Attorney who things a hospital is paying a group a kickback for referrals. Careful counsel and detail-oriented executives for the group and hospital system should negotiate at arm’s length a PSA that reflects the true nature of services and protects what is important to each side.
By Ann M. Bittinger, Esq., a health care attorney with physician group clients across the country. Questions? Email firstname.lastname@example.org
while maintaining legal protections— acted with compassion and composure.
What Androcles and the Lion has to do with GI Practices During a Pandemic By Ann Bittinger, Esquire
IN TODAY’S CLIMATE OF UNCERTAINTY, legal protections and considerations relating to ensuring that physicians, health care workers, and patients are safe while operations remain solvent are critical. Physicians have been facing extraordinary challenges while evolving their GI practices with agility. Continuing to address unique legal liabilities of operating a medical practice in the pandemic is of upmost importance. But in doing so, physicians may be best served by reflecting on the folk tale of Androcles and the Lion. In that story, Androcles, a shepherd, follows his flock into a high mountain forest. As it grows dark, he seeks refuge in a cave. As he lights his lantern, he
sees that the cave is also inhabited by a lion in obvious distress. As scared Androcles tries to maintain his composure and decide whether to fight or flee, he sees that the source of the lion’s distress is a massive thorn in his paw. With utmost bravery and compassion, Androcles removes the thorn from the paw. Years later, Androcles is imprisoned, taken to the Colosseum in Rome and thrown before a lion for the pleasure of the audience. But the lion was the one from the cave. When he saw Androcles, he bowed his head in gratitude. While it goes without saying that the healthcare delivery system—and society as a whole—will be fundamentally changed long term by the pandemic, some things will return to normal. Your colleagues and patients will remember those who—even
HOW YOU PAY YOUR PHYSICIANS. Lockdowns followed by patient fear have resulted in decreased volume in many practices, resulting in lower revenue and, therefore, decreased pay. In “eat what you kill” models, in which physician pay is tied to their collections minus their expenses, collections may have dropped below expenses for many months now, triggering obligations of employed physicians to repay the difference to their employer. I’ve even heard of this happening in health systems that received hundreds of thousands of dollars in paycheck protection program loans—they are keeping the government-sponsored PPP money but still holding employed physicians to their contractual obligations to repay the employer if their expenses exceed their collections. Sure, that’s legal, and it’s what the contract says, but is it the right thing to do? Employers may be able to forgive the debt or collaborate with the employee to develop a compromise or longer-term plan for repayment. Perhaps there are other ways that a physician can contribute to the practice to make up for the loss that does not involve writing a check to the employer. After all, the pandemic is not your employed physician’s fault. For example, could the physician use the time due to the decreased patient volume to help implement the telemedicine or remote patient monitoring program? Could the practice help the physician organize Zoom calls with patients to promote trust in returning to the practice? There are legal steps that can be taken that protect the practice while showing compassion to the physician employee in the “eat what you kill” compensation model. A simple internet search allows people to see who received CARES Act and Paycheck Protection Plan money, and the amount received. The hypocrisy of taking the money while holding employed physicians to their contracts will be apparent.
GI.ORG/TOOLBOX | 23
WHAT IF A COLLEAGUE GETS COVID-19? One of my consultations recently involved a situation in which one of the practice’s physician owners has been in the ICU with COVID for the last month. If the practice applied its shareholders agreement’s disability provision to the situation, right around Christmas they would be able to terminate the physician’s employment and ownership in the company, as he would be “disabled” according to the shareholders agreement for the requisite contractual period. Is that the right thing to do? Just end his employment and buy back his shares, sending the payments to the physician’s husband at home with their kids while the former partner battles for his life in the ICU? Perhaps, instead, the other partners could agree to an amendment to the shareholders agreement to address this situation in a way that reflects the fact that the physician is not generating revenue for the group but that provides the support that he needs. After all, the pandemic is not that sick physician’s fault. There are legal steps that can be taken that protect the practice while showing compassion to the sick physician. One of my first COVID-related consultations this spring (during the “all hands on deck” phase of the early outbreak) was with an asthmatic physician employed in one of the hospitals in the epicenter of the outbreak. In a high risk group as an asthmatic, she ended up quitting because the system would not or could not find a place for her to provide services to the employer that did not potentially expose her to the virus. She had to choose between sacrificing her health or sacrificing her job. PATIENT TRUST. One principle of basic risk management is that the best approach to reducing legal risk is to promote patient trust and communication. Physician practices would be well served by implementing robust cleaning, screening and testing programs and explaining them in detail to their patients and the public. Of course, subject to the severity of
24 | GI.ORG/TOOLBOX
the outbreaks in your area, consider taking everyone’s temperature and having them complete a screening questionnaire before they enter the office. Make family members wait in the car during patient visits but give them a “curb side” service. Get drivers’ phone numbers so you can text them when the patient is done and ready to be assisted into the car after a procedure. Limit the number of people in your office (pharma reps, vendors, etc.) Increase use of disposables and tailor your procedure “kits” to include everything you need per procedure in one disposable kit. Check the disinfectant aerosols and whether they are activated in 5 or 15 minutes—that matters as you revolve patients in and out of the endoscopy center procedure bays. Limit the number of people allowed to scrub in. And let your patients and the public know what you are doing. Put it on your website. Not only does that promote trust in your clients, it documents your risk management efforts so that if you are ever questioned about them, you can easily show what you were doing to protect patients and staff. This will also produce the benefit of increased trust from staff, many of whom are also scared of infection. It is neither difficult nor horribly expensive for an employer to contract with a lab that can send a phlebotomist to the workplace each day to swab staff for COVID and run tests that are turned around same day or within 48 hours. Fortune 500 companies are doing it for their CEOs, executives and board members so as to promote continuity and avoid disruption of the company if a key employee gets sick. Tulane University is testing students daily in two of their dorms where there has been an outbreak, at no cost to the students. I speculate that in the new presidential administration that we
will see an increased importance placed on rapid COVID testing, and perhaps some government subsidies for those. A prudent practice will be ahead of the curve in implementing testing of its team members, and maybe even use that program to get better rates as it negotiates with its health and other insurance companies. We clearly have a long winter ahead of us, but this too shall come to pass. Will your practice be eaten by the lion in the cave or in the Colosseum, or will the lion bow its head in gratitude, loyalty and respect?
Ann Bittinger, Esq., is the owner of The Bittinger Law Firm, dedicated solely to advising physicians, physician groups and healthcare entities on their compliance and legal challenges and opportunities. Questions? Email email@example.com