delivering physician services: the good, the bad and the ugly!
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Delivering Physician Services: the Good, the Bad and the Ugly!. Trend in Hospital Physician Employment. 2009 first year in which more graduating physicians entered practice as an employed vs. independent. - PowerPoint PPT PresentationTRANSCRIPT
Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded
Delivering Physician Services: the Good, the Bad
and the Ugly!
• 2009 first year in which more graduating physicians entered practice as an employed vs. independent.
• Studies show large decrease in independent and two-physician practices from 1996 to 2007.
• Nearly 70% of rural hospitals surveyed were currently recruiting physicians for employment. Nearly 40% suggested that the only way to bring a physician to the local market was to employ.
Trend in Hospital Physician Employment
• Hospital employment drivers in the 90’s:– Rural rationale- Initial push to utlize cost-based reimbursed rural
health clinics transferring risk of physician employment to federal government.
– Urban rationale- Attempt by hospital systems to control and expand their market share. Vertical and horizontal integration in response to “managed care” threat.
• Typical losses in excess of $100k per year per physician due to large salaries and bonuses not supported by productivity.
Our experience from the 90’s
• Physician Drivers– Reimbursement- Decreasing for commercial payers; stagnant
with governmental with prospects for large decreases.– Curbing ancillary revenue/expansion of Stark Law limitations.– Rising practice expenses- Practice costs up 4-5% per year while
reimbursement increasing only .5% per year.– Higher expectations for EMR without financial or personnel
resources to implement.
Why this time is different
• Hospital Drivers– Keep up with demand. No shortage of patients, just shortage of
reimbursement.– Desire to have physicians with invested interest in financial
performance of hospital.– Need for more specialists in local markets.– Desire to improve ability to control quality/cost control.
• Average loss per physician has dropped from approximately $100k per year to roughly $30k per year.
Why this time is different (con’t)
Best Practices: Insurance and Risk Management
HTH SURVEY RESULTS: HOSPITALS EMPLOYING PHYSICIANSHow many are employing physicians?
88% currently employ physicians. Of those hospitals… 88% employ 1-5 physicians, 12% employ 11 or more
78% plan to hire new physicians in the next 18 months 57% in primary care, 42% both primary care & specialists
Information provided by Potter Holden & Company
Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded
The Decision
• Hiring as knee jerk reaction or to bail out.• Hiring when not justified by outmigration.• Hiring when only bad payer mix subject to shift.• Hiring based on gut feelings (without proforma).• Hiring with financial guarantee without mechanism to
promote proper set up and maximization of volume and reimbursement.
• Hiring under hospital TIN.• Hiring physician with “issues.”
Bad Practices:
• Review market share analyses:– HERMES data– Outmigration by payer by specialty– Lost cases with financial impact
• Develop proforma– Use market share– Identify specialized equipment, office space, staffing needs– Project both hospital and physician impact
• Review licensure and determine any “issues.”– Behavioral issues (drugs, alcohol, etc)– Malpractice history
Best Practices:Do Your Homework!
• Determine correct legal structure– Separate physician group TIN (make TIN decision and stick
with it – avoid changes!)– All physicians under one (non-hospital) TIN
• Determine operational and financial structure: Practice or RHC?
Best Practices:Legal Set-Up
Benefits of a Practice
• Easy to establish.• Concept easily understood by public and
patients.• Does require enrollment and contracting with
health plans.• No requirement to staff with NP, PA.
Benefits of an RHC
• Possible Increased Reimbursement– Medicare visits are reimbursed based on allowable costs– Medicaid visits are reimbursed under the cost-based method– Insulations against Medicare and Medicaid rate cuts. Since
reimbursed based upon costs the RHC is unaffected by the proposed Medicare or Medicaid rate cuts.
• Potential Cost Savings on Utilization– RHCs may see improved patient flow through the utilization of NPs,
PAs and CNMs, as well as more efficient clinic operations. The clinic must be staffed at least 50% of the time with a midlevel practitioner.
Be Clear…
• It is a very lengthy process – up to 12 months or more!• An action plan is necessary for successful establishment or conversion.• Any changes to application will either delay the approval process or cause
the application process to be restarted (i.e change of address, name change, etc)
• RHC designation does not improve Commercial reimbursement.• CMO contracting must be included in the process to ensure appropriate
amendments are obtained.• Billing processes must coordinate with conversion activities.• It will be a frustrating process! (but often worthwhile in $$s)
The Preparation
• Insufficient lead time for enrollment and office set up.• Failure to assist in practice set up.
– Provider enrollment– Office start-up– Billing– Training
• Establishing too much like hospital operationally.• Attempting to incorporate into hospital business office.• Adjusting corporate structure in middle of process
(changing TINs, adding addresses).
Bad Practices:
• Start early (very early)!• Determine participation strategy.• Identify staff member responsible.• Set up physician credentialing file.• Establish appropriate NPI numbers.• Establish CAQH.• Enroll electronically in Medicare and Medicaid.• Enroll in EDI/EFT.• Keep copies of everything (applications and approval letters,
etc)• Follow up, follow up, follow up
Best Practices:Provider Enrollment
• Apply contracting strategy to your physician entities.• Contract as HEALTH SYSTEM!• Obtain PHO or Group contracts whenever possible.• Negotiate language and reimbursement.• Watch for operational implications.• Only Hospital CEO or CFO signs group contracts.• Train physician and office staff NOT to sign anything;
send to you.
Best Practices:Contracting
Provider Credentialing: A Technology Solution
Steve Cherry CPHIMS
President
(615) 424 2489 [email protected]
www.ionitgroup.com
Providing IT Solutions for the Healthcare Community
Provider Credentialing Technology
Ion IT Group’s PrivilegePortal application is designed to help providers of all sizes meet their Credentialing requirements.
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PrivilegePortal is a single solution for credentialing of physicians, allied health and other staff/providers.
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Provider Credentialing Technology
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• On line application process• Expiration worklist• Automated reappointment alerts• Verification letters populated with entered data• Import and storage of scanned/email/fax documents• Email reminders of expiring data• Auto population of CMS-855• Provider and Procedure view only search
Provider Credentialing Technology
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Provider Credentialing Technology
Provider Credentialing Technology
Provider Credentialing Technology
Provider Credentialing Technology
Provider Credentialing Technology
Provider Credentialing Technology
Mike ScribnerStrategic Healthcare Partners
Helen Williams, CPCPrecision Practice Management
Steve CherryIon IT Group