THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 117 / NO. 4
July / August 2018
SPECIAL EDITION TAKEAWAY INSIDE! msms.org
N O R C A L
G R O U P
O F
CO M PANIES
MEDICAL PROFESSIONAL LIABILITY INSURANCE
PHYSICIANS DESERVE Offering top-tier educational resources essential to reducing risk, providing versatile coverage solutions to safeguard your practice and serving as a staunch advocate on behalf of the medical community.
Talk to an agent/broker about NORCAL Mutual today. NORCALMUTUAL.COM | 844.4NORCAL
© 2016 NORCAL Mutual Insurance Company
nm5001
FEATURES & CONTENTS July / August 2018
08
Use of Herpes Zoster Vaccines JACKLYN CHANDLER, M.S.
12
Meet Your Lawmakers BY MICHIGAN STATE MEDICAL SOCIETY
22
Communication and Resolution Programs Improve Patient Safety, Mitigate Risk BY DAVID B. TROXEL, MD Contributed by The Doctors Company
COLUMNS 04 President's Perspective
BY BETTY S. CHU, MD, MBA
06 Ask Our Lawyer
17
BY DANIEL J. SCHULTE, JD
10 Ask Human Resources
BY JODI SCHAFER, SPHR, SHRM-SCP
14 Health Care Delivery
BY LUANN JENKINS, CPMA, CMRS, CPC, CEMC, CFPC, MEDTRUST, LLC
COVER STORY
Negotiating with Payers BY NICK DELEEUW FOR THE MICHIGAN STATE MEDICAL SOCIETY
Patients have never demanded more from their physicians. Neither have payers. Read more about on page 17.
STAY CONNECTED!
JULY / AUGUST 2018 |
michigan MEDICINE 3
MICHIGAN MEDICINE® VOL. 117 / NO. 4
perspective
Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org Publication Design STACIA LOVE, REZÜBERANT! INC. rezuberant.com Printing FORESIGHT GROUP staceyt@foresightgroup.net Publication Office Michigan Medicine 120 West Street East Lansing, MI 48823 517-337-1351 www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Trisha Keast. Postmaster: Address Changes Michigan Medicine Hannah Dingwell 120 West Street East Lansing, MI 48823
Michigan Medicine®, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine (ISSN 0026-2293) is the official magazine of the Michigan State Medical Society, published under the direction of the Publications Committee. In 2018 it is published in January/February, March/April, May/ June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA. ©2018 Michigan State Medical Society
4 michigan MEDICINE
“…with massive corporations, insurance companies, and new cottage industries fighting for a slice of the health care spending pie, keeping the lights on and your staff adequately compensated requires more skill than ever.”
By Betty S. Chu, MD, MBA, Michigan State Medical Society President
®
Colleagues, Patients have never demanded more from their physicians, and neither have payers. You remain the face of health care, and the access point for patients, but with massive corporations, insurance companies, and new cottage industries fighting for a slice of the health care spending pie, keeping the lights on and your staff adequately compensated requires more skill than ever. Rare is the physician who enrolled in medical school with a lifelong dream of mastering insurance company paperwork and accounting, but those skills (and support staff) become more indispensable by the year. It all begins with contract negotiation.
This edition of Michigan Medicine® highlights the importance of the negotiation process and discusses a few critical steps every physician should take to protect themselves – and their practice – during the process.
BETTY S. CHU, MD, MBA MSMS PRESIDENT
Whether you are considering a new patient pool, courting a new payer network, or re-approaching an existing provider-payer partnership at the end of a contract, negotiating the most favorable financial and non-financial terms with payers can mean the difference between keeping the office staffed and early retirement. It’s hard work, but there’s good news – we are here to help! And this edition will tell you how. You’ll also find in this issue an important insert update on Michigan’s opioid crisis, what physicians and partners like Michigan drug treatment courts are doing to combat it, and what the Michigan State Medical Society is doing in Lansing each and every day to support your important work. You are improving health, saving lives, and changing the face of medical care in Michigan. I am humbled to serve alongside you. Sincerely,
Betty S. Chu, MD, MBA MSMS President
JULY / AUGUST 2018 |
michigan MEDICINE 5
ASK OUR LAWYER
Is a No-Fault Insurer's Determination of ”Reasonable” Fees No Longer Subject to Review? By Daniel J. Schulte, JD, Michigan State Medical Society Legal Counsel
T
he answer is no. Not under the current state of the law, which has been confused by some recent cases.
Historically, Michigan courts have held: Section 3017(a)(1) of Michigan’s No-Fault Act limits what a no-fault insurer must pay a physician or other health care provider to the amount it determines is reasonable; The No-Fault Act does not extinguish the patient’s liability for the balance of a physician’s or other health care provider’s fee in excess of the amount the no-fault insurer has determined to be reasonable; and
I recently received a payment from a no-fault insurer for services provided to a patient injured in an auto accident. This payment was for 55% of charges. This no-fault insurer told me that it was only obligated to pay me what it determines to be the “reasonable” amount for my services and that I cannot challenge its determination or collect the 45% balance from my patient. Is this true?
6 michigan MEDICINE
| JULY / AUGUST 2018
When a no fault insurer determines that a physician’s or other health care provider’s reasonable fee is less than the billed amount the no-fault insurer must defend and indemnity the patient in the event the physician or other health care provider seeks collection of the balance. This state of the law is now being called into question following the Michigan Supreme Court’s 2017 decision in Covenant Medical Center v. State Farm. That case held that the No-Fault Act did not provide physicians and other health care provid-
ers with a cause of action against no-fault insurers. Therefore, physicians and other health care providers cannot dispute reasonableness determinations directly with no-fault insurers. In at least one case (Auto-Owners Insurance Company v. Compass Healthcare) currently pending in the Michigan Court of Appeals, the no-fault insurer and the trial court have extended the Court’s holding in Covenant to mean that physicians and other health care providers cannot seek collection from patients of the balance of their bills in excess of what the no-fault insurer determines to be reasonable (i.e. that the patient is only liable for this amount). If the trial court’s ruling in Auto-Owners is affirmed by the Michigan Court of Appeals and becomes precedent (which has not yet occurred) a no-fault insurer’s determination of what is a reasonable fee will become final, not subject to any review by physicians
and other health care providers and will eliminate their right to collect the balance of their bills in excess of this amount from patients. The Auto-Owners case (and others like it) may be why you were told that you cannot collect the balance of your fees from your patient. However, at this point there is no reason you should not pursue collection of the balance of your fees from your patient. There is Michigan Supreme Court case law holding that physicians and other health care providers have the right to collect the balance of what they are owned from their patients. There is also case law that a no-fault insurer’s determination of reasonableness limits the amount of its insurance obligation only and does not extinguish patients’ liability to their physician and other health care providers.
Michigan Court of Appeals will overturn the trial court in Auto-Owners and that if it does not the Michigan Supreme Court will clarify the state of the law that patients remain liable for the balance of bills in excess of a no-fault insurer’s determined reasonable amount and that physicians and other health care providers have the ability to pursue collection against them for this balance.
DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL
There is good reason to be hopeful that the
JULY / AUGUST 2018 |
michigan MEDICINE 7
MDHHS UPDATE
Use of Herpes Zoster Vaccines Jacklyn Chandler, M.S., Outreach Coordinator, MDHHS Division of Immunization
Herpes zoster, also known as zoster or shingles, is a painful skin rash on one side of the face or body caused by the reactivation of latent varicella zoster virus (the same virus that causes chickenpox).
A
s people get older, they are more likely to develop long-lasting pain, called postherpetic neuralgia (PHN), as a common complication of shingles. PHN is often debilitating and there is no adequate therapy from this pain. Zoster can also produce severe sequelae, including eye or neurologic complications.
About one out of every three people will get shingles in their lifetime, resulting in 1 million new cases each year in the United States. Zoster incidence also increases with age, from five cases per 1,000 in adults aged 50–59 years to 11 cases per 1,000 in adults aged 80 years and older. Some people will experience multiple episodes of shingles in their lifetime. Despite having a licensed vaccine available since 2006, only 33 percent of adults aged 60 years and older in the United States had received a zoster vaccine as of 2016.
Available Vaccines Two licensed zoster vaccines are currently available:
1. Recombinant Zoster Vaccine (RZV) Shingrix, GlaxoSmithKline FDA Approval: 2017 ACIP Recommendation: 2018 2. Zoster Vaccine Live (ZVL) Zostavax, Merck and Co., Inc. FDA Approval: 2006 ACIP Recommendation: 2008
8 michigan MEDICINE
| JULY / AUGUST 2018
Recommendations The Advisory Committee on Immunization Practices (ACIP) Shingrix recommendations are: RZV is recommended for immunocompetent
adults 50 years and older. RZV is recommended for immunocompetent
adults who previously received ZVL. RZV is preferred over ZVL. Furthermore, adults with a history of shingles should receive RZV. Adults with chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease) should also receive RZV. Two doses of RZV provide strong protection against both zoster and PHN. RZV was studied in two pre-licensure clinical trials. Vaccine efficacy against herpes zoster was 97% for persons 50-59 years of age, 97% for persons 60-69 years of age, and 91% for persons 70 years and older. Among persons 70 years and older, vaccine efficacy was 85% four years after vaccination. RZV’s vaccine efficacy against PHN was 91% for persons 50-69 years of age, and 89% for persons 70 years and older. Due to strong vaccine efficacy and the duration of protection, RZV is the preferred vaccine over ZVL. Caution should be taken to avoid vaccine administration errors. History shows that reports of vaccine administration errors are highest shortly after licensure and ACIP recommendation, likely due to lack of knowledge with a new vaccine. There are notable differences in how RZV and ZVL vaccine products are stored, drawn up, given, and recommended. Special attention should be taken not to mistake RZV, which is stored in the refrigerator and administered intramuscularly, with ZVL, which is stored in the freezer and administered subcutaneously. RZV showed increased local side effects in the pre-licensure clinical trials. Be mindful that incorrect vaccine administration of RZV, i.e., subcutaneous injec-
tion, can also increase the likelihood of these local and systemic episodes. In addition to appropriate administration, counsel your patients about local and systemic reactions.
Talking Points The following are suggested talking points for your adults regarding RZV: You can protect yourself against shingles
through vaccination. Shingles is a very painful disease, and
your risk of getting it increases as you age; also, you are more likely to have severe, long-lasting pain if you get shingles when you are older. Shingrix provides strong protection
against shingles and long-lasting pain from the disease. Two doses of Shingrix are more than 90%
effective at preventing shingles. Reactions to the first dose did not strong-
ly predict reactions to the second dose. Pain from shingles can last a lifetime,
and these side effects should only last 2-3 days. Also ensure administered doses of adult vaccine are reported to the Michigan Care Improvement Registry (MCIR). As adults often receive vaccines in a variety of settings, it is critical that every health care provider report all administered and historical vaccine doses in MCIR so that adults are not over-immunized or immunized at invalid intervals. You can use MCIR to determine what vaccines your patients need and when they need them. How will zoster vaccines appear in MCIR?
Vaccine Schedules MCIR assesses and forecasts zoster vaccines according to two schedules. The first zoster schedule is a Shingrix two-dose series. This is when adults who are 50 years of age and older are recommended to receive two doses of Shingrix at least two months apart, and who do not have a dose of Zostavax reported to MCIR. MCIR will display this as: Zoster (RZV) Shingrix 1 Zoster (RZV) Shingrix 2 The second schedule is a Shingrix threedose series. This schedule is applied in MCIR for those adults who have previously received a dose of Zostavax that was reported to MCIR, and are now recommended to receive two doses of Shingrix to complete the zoster vaccine series. MCIR will display this as: Zoster ZVL (Zostavax) 1 Zoster RZV (Shingrix) 2 Zoster RZV (Shingrix) 3 MCIR will forecast the “accelerated”, “recommended”, and “overdue” dose intervals for both zoster schedules. If you have questions, do not hesitate to contact your MCIR region at mcir.org/providers/ contact-regions/. REFERENCES Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018; 67:103–108. DOI: http://dx.doi. org/10.15585/mmwr.mm6703a5. Shimabukuro TT, Miller ER, Strikas RA, et al. Notes from the Field: Vaccine Administration Errors Involving Recombinant Zoster Vaccine — United States, 2017–2018. MMWR Morb Mortal Wkly Rep 2018; 67:585–586. DOI: http://dx.doi.org/10.15585/mmwr.mm6720a4
Get up-to-date on recommendations, procedures, and storage requirements by visiting michigan.gov/immunize. Click “Health Care Professionals/Providers,” and then click on “Quick Looks & Other Resources.” Quick Looks provide a one-page summary of key points an immunizer must know before giving a particular vaccine. JULY / AUGUST 2018 |
michigan MEDICINE 9
ASK HUMAN RESOURCES
A Culture of Respect… Little Things That Can Make a BIG Difference! By Jodi Schafer, SPHR, SHRM-SCP
Q: I run a very busy practice, but it
I’ve heard it said that, “Being busy
wasn’t always this way. It took
is a good problem to have,”and
us several years and a lot of hard work to build to this point and now
while you may agree with this statement,
that we are here I don’t want to do
your staff may feel differently.
anything to jeopardize our success. We are go, go, go all day long (which I love!), but I am worried I might be burning my staff out. Many of them hired in when the pace was much slower and I’ve heard more grumbling lately when we have to work through lunch or stay late for an emergency appointment. Patient care comes first to me, but I’ve been in this industry long enough to know that you can’t provide quality care without good people around you. How can I make my current staff see this increase in business as a good thing rather than a nuisance? I don’t want to lose a good employee, but I don’t want to turn away patients either. 10 michigan MEDICINE
| JULY / AUGUST 2018
W
here you see a full/overbooked schedule and think – revenue, fulfillment, excitement – your staff sees missed lunches, limited bathroom breaks and increased daycare costs for late pick-up times. So it’s not about ‘making staff see an increase in business as a good thing’ as much as it’s about seeing the workload from their point of view and respecting the efforts and sacrifices they make to meet the increased scheduling demands. It’s the small things that can lead to a culture of respect in a busy environment rather than one of resentment and unhappiness.
they are stocking supplies, rooming patients, taking vitals and/or performing procedures, charting, answering patient questions, etc. If you fail to take these other duties into consideration when you set your scheduling expectations, you can inadvertently be eliminating any downtime for bathroom breaks, a quick drink of water or a small bite to eat. Before you know it, staff feel like their basic needs aren’t being met, which leads to feeling taken advantage of. Not good.
Medicine is mentally taxing and at times, physically exhausting work. I don’t have to tell you that. While you are busy running from patient to patient, it is easy to
you desire? Well, you start by asking…
get tunnel vision and think that you are the busiest person in the practice. However, your clinical staff are keeping pace. When they are not in the room with you,
their own hard work. They see themselves
Ask, Don't Tell So, how do you balance the needs of your staff with the busy patient schedule not telling. If your employees have been with you for a while (as yours have), they probably attribute some of your success to as part of the practice and they care about the patients just as much as you do. Your ‘good employees’ are willing to make sacri-
fices when they can, but they want you to ‘ask’ rather than ‘assume’ when a situation requires them to go above and beyond. It comes down to respect. When you show respect for their time, their efforts and their personal commitments, you earn their respect in return. They have to follow you because they want to . . . not because they have to. That’s the difference between bossing and leading. You can show respect for your employees’ efforts in simple ways. For example, when an emergency call comes in and you need to add a patient to the end of your day, try asking your staff if they are able to stay late rather than walking into the room and telling them, “We’re here until 7:00 p.m. tonight”. Asking rather than telling allows your employee to have a stake in the decision. If they are com-
mitted to you and to the practice they will say ‘yes’ more often than she says ‘no’.
Be Mindful of the Time Another way to show respect for your staff’s time is by running ON TIME. Don’t let your love of chatting with patients or staff negatively impact the rest of the day’s schedule. Working through lunches and breaks can be necessary at times, but it shouldn’t become the status quo. Consider staggering lunch hours to give staff a breath of fresh air and a chance to decompress before hopping back into the torrid pace. They will be more effective and everyone (including you) will be happier for it! When you show you care for your employees as much as you care for your patients, you can have the best of both worlds.
“It’s not about ‘making staff see an increase in business as a good thing’ as much as it’s about seeing the workload from their point of view and respecting the efforts and sacrifices they make to meet the increased scheduling demands.”
JULY / AUGUST 2018 |
michigan MEDICINE 11
GOVERNMENT RELATIONS
Meet Your Lawmakers As Senate Majority Leader and Minority Leader respectively, Senators Arlan Meekhoff (R-West Olive) and Jim Ananich (D-Flint) have become well-acquainted with the challenges and opportunities that befall legislative leaders. Senator Meekhoff will close out his second and final term this year while Senator Ananich will close out his first. Before the election season really heats up, Michigan MedicineÂŽ took time to ask the leaders some questions about their experiences in office and what they see as some of the most pressing health care issues facing our state.
12 michigan MEDICINE
| JULY / AUGUST 2018
SENATE MAJORITY LEADER ARLAN MEEKHOFF Senator Arlan Meekhoff represents the 30th Senate District, which includes all of Ottawa county. As Senator Meekhoff has assumed the prestigious position, of State Senate Majority leader, many things have surprised him, including, “how hard I work with my colleagues to create an agenda and it often falls to the wayside because we have to react and respond to unanticipated issues.” However, no matter the obstacles, whether big or small, Majority Leader Meekhoff still has a number of legislative priorities he wants to pass, during his time as State Senate Majority leader. Some of his primary focuses are, “to pass our eighth consecutive balanced budget ahead of schedule. I would also like to work toward a consensus on reform of auto no-fault.” Further, Majority Leader Meekhoff sees the auto no-fault issue as one of the most prevailing issues facing the healthcare “climate” in Michigan. “Auto no-fault insurance is definitely a healthcare issue and a significant cost for so many Michigan families. A solution for reform has evaded the legislature for decades. I would like to begin by addressing the issue on which we can all agree: a creation of a fraud authority, reforming attendant care, changes to assigned claims and some others.” Moreover, Majority Leader Meekhoff acknowledges that, with term limits, his time to understand the complex healthcare structure is finite and something he believes ought to be changed. “Enacting term limits sounds great on paper, but the reality is that just as a legislator becomes educated on an issue and has earned a committee chairmanship, he or she is then barred from serving another term. The result is a lack of institutional knowledge and a lack of bipartisanship. I think term limits are a failed experiment,” he says. Majority Leader Meekhoff openly admits that term limits bar him from completely understanding the healthcare landscape; thus, he believes to understand the healthcare community we must look inward, we must look at the physicians. “Legislators are not experts in every policy issue and with term limits, our ability to become experts is limited. I want to know what the stakeholder groups are concerned about when it comes to issues and proposed legislation. That is why I think it is so important to have groups, like MSMS, to advocate and educate about how an issue will impact their membership.” Majority leader Meekhoff admits that as he has gotten older he now looks through a different lens regarding healthcare; a lens much more personal to him. “As I grow older, healthcare takes on new importance in my life as I take on a greater responsibility in helping to care for my parents and as my health becomes something I can no longer take for granted. As a legislator, that personal experience informs how I look at policy.”
SENATE MINORITY LEADER JIM ANANICH Senator Jim Ananich, represents the 27th Senate District, in Michigan, which encompasses parts of Genesee County, including Burton City, Clio City, Flint City, Flint Township, Forest Township, Genesee Township, Mount Morris City, Mount Morris Township, Richfield Township, Swartz Creek City, Thetford Township, Vienna Township. During his time in the legislature, Senator Ananich has seen the issue of delivering quality health care rise to the top in priority due to the devastating crisis facing his district. The Flint Water Crisis, for him, highlighted those areas where the government must improve. “Four years ago, decisions made by reckless emergency managers poisoned a whole city - the city I represent. At least twelve people died from legionella, and it will be years before we know the full impact the lead exposure will have on kids. I will continue to be an advocate for health services in my community for years to come - including behavioral and mental health - so that every person who was poisoned at the hands of the government has access to the care they need.” In addition, the Senate Minority Leader has concerns at the national level with respect to attempts to dismantle the Affordable Care Act, which has given millions of previously uninsured people access to health care. Minority Leader Ananich also sees the ever-changing health care climate not only affecting his constituents in big ways, but he also stresses the impact on physicians, specifically with respect to the Medicaid work requirements legislation. “I worry about the impact of Medicaid work requirements, not only on Medicaid enrollees, but also physicians. The bill, which is expected to be enacted into law, would create unnecessary burdens on physicians as they’d have to provide written consent each time a Medicaid patient is deemed to have a health condition that impacts their ability to work.” The Minority Leader appreciates the great resource physicians have been to him personally, particularly throughout the Flint Water Crisis, and acknowledges that they will continue to be an important resource on both the state and national levels. “Physicians have been on the front line of the water crisis—Dr. Mona Hanna-Attisha was one of the first to go toe-to-toe with the state and we need that kind of courage across the board when major health issues come up. We need physicians who are willing to stand up to those who are afraid of the reality in order to protect the people of our state.” Moreover, he says, “physicians will be pivotal in combating the opioid epidemic that continues to have a grip on our state and our nation.” Senator Ananich has other aspirations during this time as the Minority Leader that go beyond just focusing on healthcare. “Our immediate attention must be laser-focused on fixing the roads. To be frank, the last seven years of failed leadership on this issue has allowed our roads to buckle and it will require millions more to get them back in working condition”.
JULY / AUGUST 2018 |
michigan MEDICINE 13
HEALTH CARE DELIVERY
Impact of Medical Record Documentation and Coding on Reimbursement By LuAnn Jenkins, CPMA, CMRS, CPC, CEMC, CFPC, MedTrust, LLC
Physicians may not understand the true impact their documentation has on the reimbursement for services they render.
The Impact of Physician Documentation
P
hysician documentation is like a story problem and the codes submitted on the claim form are the answer to the story problem. Documentation must equal the codes submitted.
Health plans may perform routine pre- or post-payment reviews of submitted claims. The medical record documentation is scrutinized to be sure the physician documented what was billed. Some of the important pieces health plans look at are:
Identifying information on the medical record
Documentation is
Patient name and/or ID number
the written record of
Legibility of the medical record if not on EMR
what has occurred. The physician must tell the story of the encounter through the documentation in the
Visit date Documentation of medical necessity Level of care billed is supported by documentation n 1995 or 1997 E&M guidelines Time documented for time-based codes (how this time must be documented could vary by health plan) Specificity of the diagnosis code documented Not using ‘‘unlisted’’ with a confirmed diagnosis Reference to any diagnostic results that impact medical decision making
patient’s medical record.
Legibility of the physician signature (Some payers require credentials along with full signature)
If it isn’t documented,
When the documentation does not support the level of care or diagnosis that was billed, the health plan can recover any reimbursement for that service, or in the case of a pre payment review, will deny a claim. It is important to do self audits to be sure the physician documentation is supporting the services rendered.
it wasn’t done!
With the implementation of ICD-10, it is very important that the biller/coder have a mechanism to query the physician when the documentation isn’t providing enough specificity to select a diagnosis code. Because ICD-10 is so specific, health plans are not going to allow the use of unspecified codes routinely. Open communication between the physician and staff is critical to accurately code what the physician documented. That documentation is the basis for reimbursement of the services rendered.
14 michigan MEDICINE
| JULY / AUGUST 2018
How Can Medical Record Documentation Impact Reimbursement? The medical record is most importantly, documentation of the care and treatment provided to a patient but it also is the basis for the CPT© and Level II HCPCS codes used by insurance carriers to reimburse providers. Understanding what elements in the record will impact CPT© Level II HCPCS codes and reimbursement can be critical to the financial success of a practice. Professional providers need to know CPT© and Level II HCPCS coding at least to the point of understanding what the medical record needs to show and using terminology that aligns with CPT© coding language and guidelines. This includes watching the Level II HCPCS Manual for codes created outside of the CPT© and for Medicare in particular who uses many G codes to describe payable services. Providers also need to stay on top of new codes introduced each year and the possible increased revenue opportunity in particular with E&M services, which have seen significant changes in the last couple years. The CPT© manual and CMS are addressing the significant amount of time that providers spend caring for their patients outside of and in addition to the regular office visits including staff time. CPT© does include E&M codes that not all payers will recognize or consider payable but as it evolves providers and their staff must monitor the changes and keep current resources. The list below will address some examples and tips on E&M coding opportunities.
Evaluation & Management (E&M) Services Time One of the most misunderstood elements of record documentation is the use of time and when it is a factor and should be documented. Not all E&M codes have a time element and documenting time for all visits is not recommended. The ideal documentation of time is start and end time but total time has been accepted by payers. CPT© guidelines indicate that a unit of time is attained when the mid-point is passed, this guideline does not apply to the time associated with all E&M codes and only applies when specifically noted.
Following are examples of CPT© codes that are based on time and in some cases are added on to the E&M service (+) for additional reimbursement. Advanced Care Planning – these CPT© codes cover the time spent face to face with a patient discussing advance directives (Living Will, Durable Power of Attorney, Health Care Proxy or Medical orders for life sustaining treatment). 99497 for the first 30 minutes, +99498 each additional 30 minutes and can be reported with other E&M services on the same day. (*Payable by CMS in 2016) Prolonged Clinical Staff Services – New codes for 2016, these services are provided by clinical staff beyond the typical service time during an evaluation and management service in the office or outpatient setting with direct patient contact under physician supervising. +99415 for the first hour and +99416 for each additional 30 minutes. For example a patient having an acute asthma attack that required the patient to remain in the office for 1.5 hours may support 99215 +99415 (if the clinical staff provided the prolonged care and monitoring; if the provider met the prolonged time +99354 to +99355 would be billed and not +99415) Prolonged Physician Time Codes – are add-on codes used in addition to the primary E&M service when the physician face to face care of the patient required in excess of 30 minutes over the average time for the E&M Service (+99354 to +99355 Office/ +99356 to +99357 Facility). Facility includes Skilled Nursing, inpatient, and observation). For example a patient that was seen face to face by the provider for 60 minutes in the office could be billed in the as 99214 +99354. Chronic Care Services Clinical Staff – 99490 can be billed for clinical staff time under supervision by a physician for at least 20 minutes in a 30 day period. CMS has specific policy guidelines to be followed (2 or more chronic conditions etc.) Billed monthly once 20 minutes has been met. Complex Chronic Care Management – 99487 to +99489 are based on time in a 30 day period (not payable by CMS) Smoking Cessation Counseling – 99406 to 99407 can be billed with an E&M service and based on the first 3-10 minutes (99406) and over 10 minutes (99407). CMS recognizes G0436 to G0437 for smoking cessation counseling Other services – (These are payer contract specific and may not be recognized by all); the time of the visit would need to be documented somewhere in the record. • 99050-Services provided outside normal business hours, days or on holidays • 99051-Services provided during regularly scheduled business hours on weekends, holidays or evenings. • 99058-Services provided on an emergency basis in the office which disrupts other scheduled office services n Care Plan Oversight Services-these codes are based on time spent in a 30 day period providing the supervision of patients in hospice, nursing facility and in home health care. Forms completed are not sufficient to support the time element which must meet the minimum of 15 minutes. • 99374 to 99375 Home Health (CMS G0182) • 99377 to 99378 Hospice (CMS G0181) • 99379 to 99380 Nursing Home ( CMS does not cover) n Levels of E&M can be based on time when the service provided is over 50% counseling/coordination of care • face to face provider/patient in the office • floor time for facilities. The record would need to show the time spent on the same day and can be different en counters. For example 99233 Inpatient Subsequent visit has an average floor time of 35 minutes.
Critical Care Services – 99291 to +99292 are based on total time spent on one calendar day providing care to a patient (in any location) related to a critically ill patient. Diagnosis codes will need to support the critical situation.
JULY / AUGUST 2018 |
michigan MEDICINE 15
Other E&M Services (not time based) Transitional Care Management Services (99495 to 99496) describes services provided to patients discharged from a facility and requiring moderate to high medical decision making during their transition. CPT© and CMS have very specific guidelines on documentation and visit requirements; this service includes one visit in a 29 day period. Initial contact is 2 business days and initial visits are 7 to 14 calendar days. Any additional visits within the 29 days could be billed separately.
Power Mobility Device – G0372 Physician service to determine the need for a power mobility device with the patient present. Home Health Care Certification – G0180 covers the work in the initial implementation of plan of care for a patient’s admission to Home Health Care. G0179 is the recertification and both are per certification period. Patient is not present. DME Determination – G0454 Face to face visit for DME determination performed by a nurse, practitioner, physician assistant or clinical nurse specialist.
Other Documentation Points Levels of E&M codes should reflect the care and work that was appropriate for the presenting problem. Coding improperly can lead to audit but also lost revenue. Monitor levels of E&M services and look for unusual patterns; all providers should have a variety of codes levels and not one code billed for all new patients and one code for all established. CMS has stated “the volume of documentation does not determine medical necessity” so do not assume that every visit while documented the same should equate to the same level of service. Medical Necessity is a term used by payers to assess the validity of levels of coding by looking at the reason for the visit and the history taken to support the level of service billed. Even when there is a comprehensive history and examination the visit may not be considered medically necessary for a high level visit 99204/99205 or 99215 if there is no documentation of a significant problem(s). For example, a new patient 99204 would not be appropriate for a patient with a straightforward problem like otitis media; however the patient’s history could impact even this diagnosis to make
16 michigan MEDICINE
| JULY / AUGUST 2018
it more complex. This stresses the importance of a clear documentation of the presenting problems, review of systems and history. A comprehensive history lays the ground work for the rest of the work at the visit which may not always lead to a high level visit. There are many other factors that impact the documentation of history including PQRS, Meaningful Use, HEDIS and other programs, keep in mind this should not impact the level of the E&M service billed to the insurance. Code based on what work was needed at this visit, not what was documented either because the EMR provides it or other programs are requiring for reporting. n Place of service has a huge impact on coding and reimbursement and the record should clearly indicate where the services was performed. E&M services performed in a facility or site that is not owned/leased by the provider are paid at a lower rate than those in the office. The CPT coding is also impacted by the place of service; if it is at the patient’s home, emergency room, skilled nursing facility, observation or inpatient the CPT© codes will be different. The ICD-10 diagnosis code set is a tool to be more specific and describe in detail the reasons for services. The detail in ICD-10 provides a great deal of information to payers but at this point does not increase reimbursement for professional providers and has in fact probably caused denials as payers adjusted policies and edits. Providers should be documenting more specific details of the problems, conditions and injuries they are treating and should be seeing more inquiries from their coders/ billers to get that specific information. Facilities are paid under a different system that is linked to diagnosis coding but professional coding is linked to the CPT© and Level II HCPCS codes so diagnosis coding alone will not increase reimbursement but can help prove medical necessity and decrease denials. Center for Medicare & Medicaid Services (CMS) programs, Physician Quality Reporting System (PQRS) and Meaningful Use, require specific documentation for reporting and qualifying for these programs. The penalties for not meeting the reporting started in 2015 and increased in 2016. If not using an EMR to meet Meaningful Use the providers can still meet PQRS reporting through a registry and the office can gather the needed information based on the PQRS Measures to be reported. So the provider will need to know what elements are to be documented.
Changes to the Medical Record Documentation
W
ork closely with coding and billing staff and be available and willing to make changes to the medical record if needed. Also be sure to understand the correct way to correct a record which is indicating the date of the correction with the new information. Qualified staff can be your best resource for understanding what needs to be in the record for coding purposes but they should also be able to provide the documentation to support their suggestions and recommendations. Coding and documentation is very complex and the best coders/billers know where to find answers. Don't fall victim to someone's "opinion" but always require proof before making decisions. If you are told "they won't pay that" or a change must be made, ask for something from a payer or other resource to confirm. Payers have different rules, policies and guidelines, what works for one payer may not be true of another and this business changes constantly. What was true last year may no longer be and it is critical that coding and documentation is current with new requirements.
FEATURE STORY
Negotiating with Payers
Patients have never demanded more from their physicians. Neither have payers. Health plans. Private insurers. The state and federal governments. Physicians are being pulled in a thousand directions, with demands for higher quality care and better patient satisfaction rates, all at a lower cost.
A
t the same time, the number of middle men in health care continues to grow, from massive health maintenance organizations with buildings full of prior authorization staffers to pharmacy benefit managers, or PBMs, bigger than Walt Disney, McDonalds, and Ely Lilly combined, each with an army of men and women whose chairs are in fancy office buildings, and fingers in the health spending pie. (continued on page 18)
JULY / AUGUST 2018 |
michigan MEDICINE 17
Physicians remain the face of health care and the access point for patients, but patients’ health care dollars are becoming more and more elusive. Rare is the physician who enrolled in medical school with a lifelong dream of mastering insurance company paperwork and accounting, but those skills (and support staff) become more indispensable by the year. It all beings with contract negotiation.
Getting Started – Do Your Research
I
t’s just good business. In an era of declining reimbursements and growing payer bureaucracy, keeping the lights on means paying attention to the details, especially when it comes to contract language.
“Physicians need to ASK the payer whether or not it is open to negotiations.” PATRICK HADDAD
Whether a physician is considering a new patient pool, courting a new payer network, or reapproaching an existing provider-payer partnership at the end of a contract, negotiating the most favorable financial and non-financial terms with payers can mean the difference between keeping the office staffed and early retirement. Payment terms, compensation rates, using fee-for-service, capitation or financial risk sharing make an immediate impact on the bottom line, but the length of the contract, circumstances under which the relationship can end, and items as far afield as contract security for military reservists who may someday be called to active duty are similarly important, and none of it is easy. So where does a physician start? Patrick Haddad is an attorney and member with Kerr, Russell and Weber, PLC, and an industry leading expert in physician-payer contracts. He says the first step is understanding the playing field.
18 michigan MEDICINE
| JULY / AUGUST 2018
“Physicians need to ask the payer whether or not it is open to negotiations,” says Haddad. “Some payers, like traditional Medicare, have a fee schedules which they will not negotiate. Other payers, such as health maintenance organizations or payer-affiliated provider networks, may be willing to negotiate financial or non-financial terms or both.” Haddad recommends physicians first obtain from the payer its terms of participation, which often are stated in a provider participation agreement. Physicians also need to learn from the payer how it structures its compensation arrangements and its credentialing process, among other things. Then the real business can begin.
Appealing to Payers
W
hether physicians will have the ability to negotiate with payers will depend on various factors, such as the number of physicians in the practice, area of specialty, competition among payers and population demographics. Generally, physicians in smaller practices, or physicians who practice in specialties for which there is no shortage within the payer’s service area, will have less ability to negotiate with payers, than will physicians who are part of a large group practice or other large physician organization or who practice in high demand specialty areas.
A study by researchers at Harvard Medical School and published last year in Health Affairs, bore that out, vividly illustrating what Michigan physicians are up against. Researchers found that a physicians’ reimbursement rate very often depends on one of two factors – the size of his or her physician organization and the size of the payer. According to researchers, small insurers – those with less than five percent of the market by county – reimburse physicians an average of $88 per routine office visit. Large insurers – those with more than 15 percent of the market – reimburse doctors at only $70 per visit – an $18 difference. In other words, the bigger the insurer, the smaller the reimbursement. Larger insurers simply have more clout during contract negotiations. Physicians are, generally, willing to take less to access their patient pools. Interestingly, researchers also found that lower rates of reimbursement do not necessarily filter through to patients in the form of rate reductions or discounts. The rates they offer are a reflection of the payer’s size and power, not a less expensive product for the end user – the patient. Little wonder, that mega mergers between insurance companies have so often dominated headlines. Interestingly though, the same general principle applies when it comes to the size and market share of a provider’s office as well. Larger offices are, on average, reimbursed better for the same services. The Harvard researchers found that small, independent doctor’s offices treating less than five percent of the market by county average $72 in reimbursements per routine patient visit. Large offices, those treating more than 15 percent of the market, see average reimbursements of $86 per visit.
Larger practices have stronger bargaining power, bigger clout, and more robust support staff to assist during the negotiation process. Because of the size of their patient pools, they are also able to be more selective in terms of the payers with whom they negotiate. So while insurers wheel and deal to consolidate and grow, physician groups are bulking up as well. The good news for practices of every size is, experts say that with the right approach, excelling in the exam room and operating suite is a big part of that negotiation process.
“Patients are demanding more value for their health care dollar. Payers represent their customers’ demands.” JACQUELINE B. ROSENBLATT, BSN, PHD
Three Keys to Negotiation 1 Treat your patients well 2 Do your research (and consult the MSMS checklist) 3 Don’t be afraid to ask for help
Treat Your Patients Well
J
acqueline B. Rosenblatt, BSN, Ph.D., is the executive director of GMP Network, a group of more than 600 physicians in Macomb County, and with a presence that reaches into Oakland and Wayne Counties as well. She says negotiating with payers starts with appealing to patients. “Patients are demanding more value for their health care dollar,” she says. “Payers represent their customers’ demands. Under the current model, payers ideally represent the consumers and provide physician networks at both a reasonable cost (continued on page 20)
JULY / AUGUST 2018 |
michigan MEDICINE 19
and the highest possible value. They want the most services with the best outcomes for the lowest cost.” In other words, successfully meeting the healthcare demands of patients makes a practice more attractive to the HMOs and health plans with control over network access. But simply meeting patients’ needs isn’t enough. Physicians have to show their results to payers.
Do your research
“The best advice I would give to any physician is to keep and use data. Data, data, data, data. Know your outcomes. Know your costs. Know your track record and understand it.” JACQUELINE B. ROSENBLATT, BSN, PHD
“T
he best advice I would give to any physician is to keep and use data,” says Rosenblatt. “Data, data, data, data. Know your outcomes. Know your costs. Know your track record and understand it.” Payers may, for example, look at the books and conclude a surgeon has relatively high costs. However, if you take into account recovery time, readmission rates, infections, and the way the treatment is completed, the way that surgeon performs may be significantly less expensive overall. Health plans might attempt to negotiate based on costs related to individual steps and procedures, failing to fully track the lifespan of a treatment. It is incumbent on the practitioner to understand their costs and outcomes, and be ready to present during contract negotiations. Rosenblatt is also an advocate for the negotiating strength in numbers afforded by physician organizations, and has seen firsthand the power physicians have at the negotiating table. “Physicians are well served by being part of a physician organization when it comes to negotiations,” says Rosenblatt. “POs help with best practices, with monitoring quality standards, monitoring costs, and letting members know
20 michigan MEDICINE
| JULY / AUGUST 2018
where they stand in the progression of low cost, high quality care. That pays off when physicians demonstrate the power in group bargaining.” While physician organizations and hospital groups often retain their own fulltime health care attorneys, organizations like the Michigan State Medical Society ensure small and solo practitioners across the state are not left wanting.
Don’t be afraid to ask for help
M
ichigan State Medical Society has long advocated and provided resources for physicians in the midst – or on the precipice – of the negotiating process. The Society in 1998 introduced its first Managed Care Contracting Checklist, a resource it has updated regularly, with the help of the Society’s general counsel, Kerr Russell Attorneys and Counselors, and makes available even today. In the mid-90s, managed care contracts were commonly known as “contracts of adhesion,” and physicians were typically expected to sign on the dotted line without much input or negotiation. Over the last 20 years, state and federal legislation and patient rights lawsuits have put some of the power back in the hands of frontline physicians. The Checklist provides a comprehensive list of issues and terms for physicians to track, including definitions, physician and payer obligations, compensation structures, and other issues. Gone are the days of pressured signatures on unread contracts. The rest of the health care world has learned what physicians knew all along – third party payers need providers every bit as much as providers need third party payers. More. MSMS has gone to great lengths to en-
sure members have access to the expertise they need to take advantage of that. The negotiating process can be tougher on small and independent practices, but they don’t have to go it alone. They shouldn’t. Before contract negotiations, MSMS members are encouraged to contact the Society to request a brief informational discussion with MSMS legal counsel – the firm behind the Managed Care Contracting Checklist – on general payer contracting questions. Kerr Russell responds to these questions as MSMS legal counsel, and the discussion is made available at no cost, as an MSMS membership benefit. “While this does not establish an attorney/client relationship between my firm and the physician, it gives the physician an opportunity to discuss legal representation by my firm for services that cannot be provided per the MSMS benefit,” says Haddad. Once a physician, or his or her office manager, has obtained from the payer its provider participation agreement, determined the compensation structure and credentialing process, and asked to what extent the payer may be willing to negotiate terms, it becomes immediately important to engage a competent health care attorney to review and offer advice on the agreement and related matters. “If the payer is open to negotiating terms, the attorney can provide the physician with guidance, including proposed language revisions when warranted,” says Haddad. “Even if the payer is not open to negotiations, physicians still need to be advised on the terms of the agreement and related matters, including the rights and responsibilities of the physician and payer, the compensation arrangement and the physician’s compliance obligations.”
Key Features to Monitor in Your Contracts Appropriate compensation Demand a “due process” clause Professional allowances for MSMS, AMA dues Leave time and contract security during military deployment Avoid provisions for “termination without cause” Avoid “sole source” contracts
Participate None of this is easy, but it couldn’t be more important. That’s why MSMS and legal experts encourage every physician to be either an active or prospective participant in negotiations with payers, even those in large physician or hospital groups. Pay attention to terms surrounding pay and reimbursement, but don’t stop there. Be sure not to enter into a contract that does not include a due process clause. Avoid termination-without-cause provisions in any contract. Consider pursuing language that provides the allocation of a professional allowance to be spent on county, state, and AMA dues. Stay away from sole source contracts. The list goes on and on. Physicians new to negotiation and those with a wealth of experience can find a great deal of helpful information, tips, guidance, and advice in the Society’s policy manual, and with the Society’s support staff.
The good news? The best thing a physician can do to get a leg up with payers is to be a good physician and put patients first. Treat your patients well. Do your research on payers, on contract language, and on your practice. Don’t be afraid to ask for help. Three steps toward a better contract, and a more rewarding practice.
JULY / AUGUST 2018 |
michigan MEDICINE 21
Communication and Resolution Programs Improve Patient Safety, Mitigate Risk David B. Troxel, MD, Medical Director, The Doctors Company
T
he medical profession is part of the cultural shift happening throughout our society toward greater transparency – and this is benefiting physicians, as well as patients. I like to think that our profession has been a leader in this area with the movement to disclose medical errors, which began about twelve years ago. Because of this movement, many hospital systems are using Communication and Resolution Programs (CRPs) to guide patients, families, physicians, and staff members when adverse events occur.
22 michigan MEDICINE
| JULY / AUGUST 2018
Contributed by The Doctors Company
thedoctors.com
We know now that when a medical error occurs, disclosure and transparency often reduce the patient's anger, and anger often leads to a medical liability claim. And greater transparency may mitigate risk on a larger scale as well: When analyses of adverse events leading to claims are made available to physicians, this often reduces their future occurrence, i.e., it reduces the risk of specific missed diagnoses, thus improving patient safety and reducing physician liability risks.
Transparency and Disclosure: With Individual Patients CRPs teach hospitals, medical practices, and physicians how to respond to an adverse event. For example, medical professionals learn how best to respond when explaining why a wrong diagnosis was made or explaining why a pharmacy released the wrong medication. And CRPs stress the importance of offering to help, such as by reassuring the patient that healthcare costs resulting from the error may be ameliorated by fee reduction or waiver. At The Doctors Company, we encourage our physician members to participate in structured disclosure programs, and we provide resources to educate and assist them.
Transparency and Disclosure: Across the Profession One of my main jobs as medical director of The Doctors Company is to review closed claims, both by specialty and by type of diagnostic error. Since we are the largest physician-owned medical malpractice insurance company in the United States, we have the
largest claims database. By reviewing our closed claims data, we can achieve valuable insights, such as which diseases are most frequently misdiagnosed. By sharing our findings, we alert physicians to the most frequent causes of claims in their specialty, thus increasing patient safety and lowering physicians’ liability risks. I can offer two examples of how studying our data, and distributing the results of our studies, have yielded positive outcomes for patients and physicians. Difficult Diagnosis 1: Spinal Epidural Abscess. When we completed a study several years ago of closed claims in hospital medicine, the most common claim allegations were diagnosis related. Of these, we were surprised to see that there were a significant number of claims for missing a diagnosis of spinal epidural abscess. Spinal epidural abscess is so uncommon that many physicians have never seen one. So we shared our study with the Society of Hospital Medicine, and they agreed to publish our study in their medical journal and present the findings at their national meetings. Meanwhile, I wrote an article on our findings in The Doctor’s Advocate, our quarterly publication. We’ve seen a gradual decline in the incidence of claims related to spinal epidural abscess as a result of sharing this data with physicians. Difficult Diagnosis 2: Malignant Melanoma. Some time ago, after reviewing a large number of pathology claims, I was struck by the fact that the most common reason pathologists got sued was for missing a diagnosis of malignant melanoma. Like spinal epidural abscess, melanoma is well recognized as a difficult diagnosis because there are many variants of melanoma, some of which look benign. Unless you're seeing a large number of melanomas, you may not recognize the subtleties that lead to the correct diagnosis.
I shared this data with pathology specialty societies and published it in pathology journals. Additionally, I spoke on the subject at the societies’ national meetings, and they invited pathology experts to speak at their meetings on melanoma misdiagnosis. About seven years ago, I looked to see if the dissemination of this information and the specialty societies’ educational programs had reduced the incidence of claims against pathologists involving melanoma. I was pleasantly surprised to see that the frequency of such claims had dropped dramatically. Sharing closed claims data is one of the most important things we do at The Doctors Company. This information is available to anyone on our website, and we encourage all physicians to review these studies.
Transparency and Disclosure: Optimism About Our Future Within the medical profession, we’ve achieved positive momentum in terms of education for physicians to learn areas of practice where they need to be more attentive, and also for physicians to learn what to do if an adverse event occurs.
For more patient safety articles and practice tips, visit thedoctors.com/patientsafety. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
JULY / AUGUST 2018 |
michigan MEDICINE 23
www.MSMSInsurance.org
Committed to protecting Michigan physicians, MSMS Physicians Insurance Agency knows it’s your life. Your family. Your dreams. We focus onPhysicians you first Insurance and foremost, Committed to protecting Michigan physicians, MSMS Agency knows it’sthe yournovel life. Your family. dreams. We on you firstMichigan. and foremost, because we have idea thatYour protecting youfocus is protecting because we have the novel idea that protecting you is protecting Michigan.
MS Physicians Insurance Agency is uniquely qualified to offer our insurance portfolio to Michigan physicians, their families MSMS Physicians InsuranceAgency Agency uniquely qualifiedByto toknowing offer our our insurance theirday, families MSMS Physicians Insurance qualified offer portfolio Michigan physicians, families, office staff. We make it our business to knowisisuniquely your business. the unique issuestophysicians face every MSMS and office staff. We make it our business to know your business. By knowing the unique issues physicians face every day, MSMS and office staff. We make it our business to know your business. By knowing the unique issues physicians face every day, MSMS sicians Insurance Agency: Physicians Insurance Agency: • • • •
Physicians Insurance Agency: • Eliminates thefor need foror your practice contact insurers for billing Eliminates you your practice topractice contact forpurposes. billing purposes; •the need Eliminates the need for you ortoyour toinsurers contact insurers for billing purposes; • Hasaccess access the insurer's systems to add, terminate change aasubscriber's information withinwithin 24 hours, which • directHasto direct access to the insurer’s to add, terminate or change a subscriber’s information within 24hours, hours, Has direct thetoinsurer’s systems to systems add, terminate oror change subscriber’s information 24 which removes the administrative burden from you and your staff; removes the administrative burden from you and your staff. which removes the administrative burden from you and your staff; Will research claims and benefit questions forthe yousubscriber, or the subscriber, which will eliminate thefrustration frustration Will research claims inquiries andinquiries benefit questions forforyou the subscriber, which will eliminate the • Will• research claims inquiries and benefit questions you or or which will eliminate the frustration of of contacting a complex customer service center; and, contacting a complex customerservice service center; center. and, of contacting a complex customer • Handles all COBRA administration for groups with more than 20 employees, free of charge, thus removing Handles all COBRA administration forburden. groups with 20employees—free employees, freeofofcharge—thus charge, thusremoving removing all COBRA administration for groups withmore morethan than 20 another • Handles another administrative another administrative administrative burden. burden.
You always get more with MSMS Physicians Insurance Agency because we focus on you. You always getwith moreMSMS with MSMS Physicians Insurance Agency because we focus on YOU. ou always get more Physicians Insurance Agency because we focus on you. For more information or to request a quote for affordable, high-quality health For more information or to request a quote for affordable, high-quality health insurance, please connect with Ty at 877-742-2758 or tliggons@msms.org. insurance, please connect with Ty at 877/742-2758 or tliggons@msms.org.
For more information or to request a quote for affordable, high-quality health MSMSInsurance .org with Ty at 877/742-2758 or tliggons@msms.org. insurance, please connect
Welcome New Members Barry
Lenawee
Saginaw
Natalia Dipaola, MD
Abdul Arshad, MD
Humera Khan, MD
Genesee
Livingston
Tiffany Kim, MD
Gunjal Garg, MD
Diane Howlin, MD
Tolutope Oyasiji, MD
Qurratul Shamim-Uzzaman, MD
St. Clair
Smit Singla, MD
Christopher Lai, MD
Richard Kovar, DO
David Diskin, MD
Michael Romanelli, MD
Ryan Kim, MD
Washtenaw
John Ulrich, DO
Macomb
William Lee, MD
Sherry Cavanagh, MD
Rajika Munasinghe, MD
Mohit Rastogi, MD
Grand Traverse/
Roger Harris, DO
Diane Harper, MD
Benzie/Leelanau
Carolann Kinner, DO
Mark Oberdoerster, MD
John McManus, MD
Jeffrey Yeamans, MD
Heidi Flori, MD
Leah Carlson, MD
Vikram Reddy, MD
Jun Cao, MD
Louis Magagna, MD
Jixian Wu, MD
Corey Dean, MD
Karen Meyer, DO Maria Carroll, MD
Omokayode Osobamiro, MD Ronald Barnett, DO
Wayne Masoud Ahmadmehrabi, MD
Melissa Bibicoff, DO
Manistee
Muhammad Shah, MD
Bruce Evans, MD
Douglas Richley, DO
Farvah Fatima, MD
Marquette/Alger
Sagal Mohamud, MD
Ryan Brang, MD
Pierre Morris, MD
Katrina Brang, MD
Elenn Parrish, MD
Austin Kerndt, MD Meri McNulty, DO Neil Forster, MD
Gratiot Mohammad Kudmani, MD Prakash Sarvepalli, MD
Midland David Nadolski, MD Freda Armah, MD
Ingham
David Austin, MD
Jason Chesney, DO
Naeem Sattar, MD
Kalamazoo
Maria Thomas, MD
Pamela Baron, MD
Newaygo
Saad Shebrain, MD
Katherine Sage, DO
Kent
Northern
Craig Bilbrey, MD
Albert Linehan, IV, MD
Eric Kaminskas, MD
Oakland
Kathleen Blazek, MD
Jennifer Weekes, MD
Stephanie Cunningham, MD
Nazia Munir, MD
Brian Lane, MD
Helene Lacoste, MD
Alexander Stoffan, MD
Rula Mahayni, MD
Margaret Thompson, MD
Ramkrishna Surendran, MD
Munther Alaiwat, MD Albino Gimenez, MD Ajit Singh, MD Sanjukta Sridharan, MD Timothy Knapman, MD Rosalie Turek, MD
JULY / AUGUST 2018 |
michigan MEDICINE 25
Educational Offerings MSMS On-Demand Webinars Webinars Offering CME:
Free CME Webinars:
Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction*
2018 Prescribing Legislation* (part of the Pain and Symptom Management Series)
CDL-Medical Examiner Course
Choosing Wisely Part 1 - Stewards of our Health Care Resources
From Physician to Physician Leader
Choosing Wisely Part 2 - Change Strategies to Implement Choosing Wisely
HEDIS Best Practices
Health Care Providers' Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities
HIPPA Security and Meaningful Use Compliance Human Trafficking*
In Search of Joy in Practice: Innovations in Patient Centered Care
Inter-professionalism: Cultivating Collaboration
Legalities and Practicalities of HIT - Cyber Security: Issues and Liability Coverage
Medical Ethics – Conscientious Objection among Physicians*
Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media
Opioids and Michigan Workers' Compensation Webinar Patient Portals as a Tool for Patient Engagement
MACRA Series
Pain and Symptom Management Series*
Key Things You Should Know About MACRA
Pain and Opioid Management 2017*
Roadmap for Getting Started
The CDC Guidelines*
MACRA: Alignment Strategy
Treatment of Opioid Dependence*
The Role of Documentation
The Role of the Laboratory in Toxicology and Drug Testing*
Technology Survival Tips to Tackle MACRA
Michigan Automated Prescription System (MAPS) Update
Navigating Need to Know Resources
MAPS Update & Opportunities The Current Epidemic and Standards of Care Balancing Pain Treatment and Legal Responsibilities Physician Online Rating and Reviews: Do's and Don'ts Preparing for the Medicare Physician Value-Based Payment Modifier What's New in Labor and Employment Law *Fulfills Board of Medicine Requirement
26 michigan MEDICINE
| JULY / AUGUST 2018
MACRA’s Quality Payment Program: Highlights for 2018
Taking Control of MACRA with a QCDR MAPS Update and Opportunities* (part of the Pain and Symptom Management Series) Michigan Automated Prescription System (MAPS) Update* (part of the Pain and Symptom Management Series) Section 1557: Anti-Discrimination Obligations Understanding and Preventing Identity Theft in Your Practice
*Fulfills Board of Medicine Requirement
Visit msms.org/OnDemand for complete listing of On-Demand Webinars. Register online at msms.org/eo or call the MSMS Registrar at 517-336-7581.
Coding and Billing Webinars
Educational Conferences — REGISTER TODAY!
Billing 101
A Day of Board of Medicine Renewal Requirements
Claim Appeals
Date: Wednesday, October 3
Complete Coding Updates for 2018 Compliance in the Office Credentialing ICD-10 for 2017 & Routine Waiver of Co-pays
Time: 9:00 am – 2:45 pm Location: MSMS Headquarters, East Lansing Note: Continental breakfast and lunch will be provided Intended for: Physicians, resident, students and other health care professionals. Contact: Caryl Markzon at 517/336-5755 or cmarkzon@msms.org
ICD-10 What We Have Learned & What We Need to Know Managing Accounts Receivable Reading Remittance Advice Tips and Tricks on Working Rejections Year-End Wrap Up *Fulfills Board of Medicine Requirement
153rd MSMS Annual Scientific Meeting Morning, afternoon and evening clinical courses available. Date: Wednesday, October 24 - Saturday, October 27 Location: Sheraton Detroit Novi Hotel, Novi Note: Continental breakfast and lunch will be provided. Intended for: Physicians and all other health care professionals Contact: Marianne Ben-Hamza 517/336-7581 or mbenhamza@msms.org
For a complete listing of On-Demand Webinars visit: msms.org/OnDemand
22nd Annual Conference on Bioethics Date: Saturday, November 10 Time: 9:00 am – 4:30 pm Location: Holiday Inn, Ann Arbor Note: Continental breakfast and lunch will be provided Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues Contact: Caryl Markzon at 517/336-5755 or cmarkzon@msms.org
Register online: msms.org/eo Or call the MSMS Registrar at: 517-336-7581
JULY / AUGUST 2018 |
michigan MEDICINE 27
In Memoriam
MEMBERS OF THE MICHIGAN STATE MEDICAL SOCIETY REMEMBER THEIR COLLEAGUES WHO HAVE DIED.
HARVEY J. ROSENBERG, MD OAKLAND COUNTY MEDICAL SOCIETY 4/23/18
NEIL D. VARNER, DO SAGINAW COUNTY MEDICAL SOCIETY 4/9/18
WILLIAM R. ENGELMAN, MD SAGINAW COUNTY MEDICAL SOCIETY 5/11/18
x TO MAKE A GIFT OR BEQUEST: REBECCA BLAKE, DIRECTOR, MSMS FOUNDATION 517-336-5729 OR EMAIL RBLAKE@MSMS.ORG
FOR SOME OF OUR MOST ELITE SOLDIERS, THIS IS THE THEATER OF OPERATIONS. Becoming an emergency physician and officer on the U.S. Army health care team is an opportunity like no other. You can build a distinguished medical career by diagnosing and treating illnesses and injuries that require immediate attention. With this specialized team, you will be a leader – not just of Soldiers, but in critical health care. See the benefits of being an Army medical professional at healthcare.goarmy.com /kd60
For more information, call 313 - 441 - 1673, or visit healthcare.goarmy.com/kd60
©2016. Paid for by the United States Army. All rights reserved.
28 michigan MEDICINE
| JULY / AUGUST 2018
Practices for Sale 1.5 Million Dollar Pediatric Gross Practice to be OFFERED CHEAP! After many years of practice, the doctor is passing on the torch to someone younger. Must be able to see 60 patients/day or have help. Must be Boarded in Pediatrics. The price is less than $100K. In 25 years of practice sales I have never seen a better buy. Building is being offered for less than assessment as well, flexible terms.
Bordering Oakland and Wayne County PRIMARY/URGENT CARE Practice with potential to reach million dollar mark per year (again). Call Joe and find out more about what could be your flag ship or second practice! Highly visible, busy road. Set up for success, just need a Primary Care Doctor and maybe a Mid Level.
OLD WEBSITES
don’t attract
NEW PATIENTS
Fabulous New Medical Space Livonia New concept in medical offices with indoor parking, multi-suite and specialty clinics with room for adult day care !! So much is being done with this building. Located central to Botsford, St Mary's, Providence Park. Offered at competitive rates. Dearborn – General Practice Semi-retired Physician has a 2-3 day practice 20-30 patients per week, $20,000 for practice or free when you lease or buy building. ENT with mostly Allergy Patients, Westland Hearing aid tenant and small general medicine tenant in building. Buy practice (asking $25K) and rent on short or long term agreement, very reasonable rates. Plenty of room and parking. Rochester hills Urgent Care/Walk In For years a big money maker, recently due to losing major Carriers the Gross is way down and Physician Owner wants to retire. If you are Primary care, have no license restrictions so you can boost this place back up to the Million Gross per Year. Offered Cheap! ( UNDER $100K) Flexible with terms. Near M-59 so can be reached by several communities. Joe 248-240-2141. Pediatrics in Westland near Canton 30 years, high volume, yes it does a big gross! A Pediatrician Physician can work into the practice and take over EARN and purchase transaction. Only a Boarded Pediatrician, potential to earn substantial income. Call Joe for details, Cell: 248-240-2141.
Looking for Part time/Full time Work as a Provider? Different locations available. Call Joe Zrenchik.
Joe Zrenchik, Broker 248-240-2141 (cell) • 734-808-0147 (eFax) bestdoctors@yahoo.com 248-919-0037(office) www.michiganmedicalpractices.com
Receive 3 months of free website hosting by calling before 7/31/2018 Call 866-799-6955 Visit MSM.3FreeJuly.com
Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.
JULY / AUGUST 2018 |
michigan MEDICINE 29
MSMS Medical Opportunities msms.medopps.org
msms.medopps.org
MSMS Medical Opportunities has been connecting physicians with employers since 1944. It is a nonprofit program through the Michigan Health Council designed to simplify your job search by posting jobs that match your practice preferences. Learn more at msms.medopps.org
Family Health Care Family or Internal Medicine Physician White Cloud, Michigan Med Op ID #11743
Pediatric Associates of Dearborn Pediatrician Dearborn, Michigan Med Op ID #13524
Overview: Family Health Care was one of the first community health centers in the nation to develop a “one-stop shopping” concept for health care services. We’ve been in the business of taking care of families since 1967 offering medical, dental, behavioral health, lab, radiology, pharmacy and vision services.
Overview:
Key Qualifications: • Graduation from an accredited school of Medicine • State of Michigan Medical License • State of Michigan Controlled Substance License • Federal DEA License • Board Certified
• FT/PT
Compensation Package: • Full Benefits Package including Health, Dental, Vision, STD, LTD, Life, 401(k), PTO • Four or five day work week • Call Rotation (PHONE ONLY) 1:11 • Federal Malpractice Coverage (No Cost to you) • Eligible for Federal and State Loan Repayment Practice Highlights: • Progressive, non-profit, outpatient group practice • Certified as a Patient-Centered Medical Home • White Cloud is an outdoor enthusiast’s dream close to trails, lakes and rivers
Pediatrician needed for a private practice in Dearborn. Excellent opportunity in an established practice offering complete benefit package and track to partnership. Key Qualifications: • BE/BC • State of Michigan Medical License (Pediatrician excellent) Practice Highlights: Newly renewed building, great staff, EMR, proximity to Hospital, great neighborhood, best patients ever!
Center for Preventive Medicine Primary Care Provider Grosse Pointe, Michigan Med Op ID #13560 Overview: Seeking a Primary Care Provider to join our primary care medical practice. We are a well established independent private practice associated with Beaumont hospital. We use EPIC EHR. We offer flexible hours and a supportive work environment. The practice is outpatient only with no weekends or hospital call. The practice participates in quality initiatives such as PCMH and provides innovative patient centric care management options. Key Qualifications: • Board Certified/ Board Eligible • Family Practice, Internal Medicine or Certified Nurse Practitioner Compensation Package: • Generous salary and benefit package • Part time or full time position
Are You An Employer? Add MSMS Med Opps to your list of trusted recruiting resources.
30 michigan MEDICINE
| JULY / AUGUST 2018
• Partnership opportunity available Practice Highlights: Well established primary care practice located in Grosse Pointe, a safe friendly community with superior schools and many community resources.
[=]
SOLID ADVICE.
REAL SOLUTIONS. FOR HEALTH CARE BUSINESS.
At The Health Law Partners, our unparalleled knowledge of the business of health care is coupled with timely, practical solutions designed to maximize value. The HLP attorneys represent clients in substantially all areas of health law, with particular emphasis on: • Licensure & Staff Privilege Matters • Health Care Litigation • Health Care Investigations • Civil & Criminal False Claims Defense • Stark, Anti-Kickback, Fraud & Abuse, and Other Regulatory Analyses • Physician Group Practice Ancillary Services Integration and Contractual Joint Ventures • Appeals of RAC, Medicare, Medicaid and Other Third Party Payor Claim Denials and Overpayment Demands • Health Care Contractual, Corporate, and Transactional Matters • Compliance & HIPAA
TheHLP.com [284.996.8510]
RANKED 6TH IN THE NATION AND 1ST IN MICHIGAN.
• Make appointments • Transfer patients • Consult with physicians • Get patient information
M-LINE: 800-962-3555 24 hours a day, 7 days a week