I am not sure how I feel about this new niche being carved out on the business side medicine. I am told that it is not the same as a doctor creating a boutique practice, one in which insurance is not accepted. The company courting my client is currently reviewing various aspects of the practice not the least of which are the demographic, insurance and age factors. Through use of marketing tools as well as I guess some quantitative and qualitative analysis, the company will decide which patients should be invited to stay with the practice for an annual fee (I have heard these fees to be between $1500 and $2000 payable over four installments).

As a billing service, I will not lose this client because insurance will still be billed. The annual fee is a private contract between doctor and patient. I will make less money probably because my earnings are based on the doctor’s receipts and he will see less patients every week This is NOT why I am unsure how I feel about this relatively new idea.

My concern is for the 1400-1600 patients in his practice who will not be asked to “rejoin” the practice. Where will they go to find another primary care physician who isn’t already overloaded? Where will the patients who have no insurance go (as I don’t think they have an additional $1500 to pay for an annual fee?) Where will patients who have a Medicaid plan go as fewer and fewer doctors are participating in those plans?

So you can see why I am conflicted. For the 400-600 patients who will have more access to the doctor, this could be a way to decrease what sometimes is a stressful experience. And for the doctor who can and will spend more time with each patient there will also be a decrease in stress on all aspects of the practice. But my conflict continues.

There are now stacks of balance bills for patients who are unable to pay. Many of these patients have been seeing the same doctor for years (primary care or a specialist for a chronic condition). Some patients doctor hop to spread the debt around.

Some patients come in with expired insurance and if eligibility is not checked, the patient gets a free ride at least for a while. Some patients might give a check that will be returned for insufficient funds while others may think twice about using a credit card should your office accept that form of payment. Some people will simply ignore the bill because they are overwhelmed with all the other bills, so what is one more?

Now is the time to set policies for patients who have no insurance. Certainly checking eligibility makes sense even in better times. A partial payment can be advised while making the appointment and if you take credit cards, ask the patient if you can expect him/her to use it. Set up a payment plan at the end of the visit and keep one employee or your billing service informed of the arrangement. Make notes in the computer as to what was discussed. Consider a courtesy on a case by case basis especially if you can obtain payment in full at the visit. This saves time, creates loyalty, and a good feeling among the staff who collected the money.

You know your patients best and when they hopefully obtain insurance again, do you want them going to another doctor who might have been more flexible during this rough patch? Is a collection agency really the answer that may take a portion that is larger than the courtesy you may give? Most people want to pay their bills; be clear on what you are billing them for and communicate your policy with your patients

To be clear, it can be very frustrating to deal with the bureaucracy of Medicare, (translates as the government) but from a billing standpoint, this is not the case in my experience.

I find customer service very knowledgeable, the remits are easy to read with even denial codes explaining what is wrong with a claim. The phone numbers to contact either a person or an automatic information system are very clear. The website is cumbersome, but someone will walk you through it while they remain on the line with you. There are forms for everything if you cannot accomplish something by phone and while it is true the every “I” has to be dotted and “T” has to be crossed, the work I put in yields results. I cannot always say that about the other plans. Sometimes I wonder where the other plan’s rules come from – like a 90 day timely filing limit with NO room for appeal, explanation, or human error. Medicare’s timely filing deadline is one full year! And even after the year, there is another level of payment available with only 10% taken off the top; that seems fair to me in assigning mutual responsibility instead of simply throwing out the claim and forcing me to write an appeal usually in vain.

I know that a major argument against Medicare is the fee schedule, but if you examine your others plans closely, you will find there are non-Medicaid plans that pay the same or LESS than Medicare. And some of those plans make you jump through hoops to get certain procedures authorized, most of which do not require authorizations by Medicare. And there are also many codes that are bundled with non-Medicare plans but the proper use of modifiers can get you paid for each code with Medicare. Even when Medicare sends you a request for information, they have a standard system in place to process your response.

Finally, Medicare replacement plans have become popular of late mostly because it eliminates people from having to carry a secondary insurance. I am very opposed to them not only for the reasons that I like Medicare, but because these plans have wreaked havoc with beneficiaries. The replacement plans are not properly explained to retirees. So not only are doctors having more plans for which they have to obtain authorizations, I have been the bearer of bad news to patients when I have had to tell them that they must have signed some paper that transferred their health insurance to a replacement plan when that was not their intention.

The bottom line is that if you work within the process of Medicare you can spend more time caring for your patients and less time arguing with their insurance.

Fran Glucroft
Medical Office Manager
Fairfield, CT

Most other industries are already there: financial, communications, and entertainment to name a few. Hospitals are way ahead of private practice physicians with their digital initiatives. All documentation about our patient’s hospitalization, from lab results to discharge summaries, must be printed out on paper to be included in their medical record in the office. All information sitting in the chart in the office is inaccessible to the Emergency Room doctors who see the patient presenting at night or on the weekends. We know this to be true. Traditional paper-based medical records can impede delivery of excellent medical care.

Doctors are resisting the change to EMRs, however, because there are currently just as many problems with the computer “solutions” proposed to be the panacea of all problems paper.

Patient data still needs to be input. Different medical charting systems don’t sync easily with others; a standard for data sharing between all hospitals and doctors’ offices is lacking. A private practice will need ready access to IT support, just like what’s available at most hospitals so patient care can continue when the system goes down. This change is going to require monumental energy, time, money and other resources. These are assets that most doctors have in limited supply now as they struggle to keep up with their current workload.

If the government and insurance companies and the fear of losing money can’t motivate doctors to update their practice methodology, then their patients will most likely force the change. Patients will go to doctors keeping up with the times. They will seek doctors able to communicate with them like they communicate with their family and friends, and who have systems established to help them get what they need easily, efficiently and accurately. Doctors need to know about the social web, iPhone applications, Facebook and Twitter and begin to think how these technologies will someday fit in their practice. My mother won’t be one of those patients, but I know my children will be. Read the article, “Doctor of the Future” in the May 2009 issue of Fast Company magazine for some real-life examples of medicine tomorrow happening right now, today. Whether we doctors like it or not, the future is upon us. Time to get with the program! RB