Delivering Physician Services: A Horse of a Different Color.

1. Delivering Physician Services: A Horse of a Different Color. Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded

2. When is the right time? • Should we hire, guarantee or other support? • Should we share our TIN or set up new? • Should we set up RHC, FQHC or practice model? • How will it affect current medical staff? • Are we “equipped” to handle delivering physician services?

3. The Decision Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded

4. Bad Practices: • 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 wrong specialty (PCP vs SCP). • Hiring with guarantee without mechanism to promote proper set up and maximization of volume and reimbursement. • Hiring under hospital TIN. • Hiring with physician “issues.” • Hiring without executive leadership/oversight.

5. Best Practices:Do Your Homework! • 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 • Determine specifics of purchase • Buying old A/R? • Review licensure and any “issues.”

6. Best Practices:Legal Set-Up • Determine correct legal structure • Separate physician group TIN (make TIN decision and stick with it – avoid changes!) • All physicians under one (non-hospital) TIN • Establish physician group name (i.e. Evans Family Centered Medicine) • Establish as physician group practice initially; transition to RHC.

7. Best Practices:Corporate Set-Up • Determine correct corporate structure. • Hire good Practice Manager • Hire experienced physician office staff • Integrate functions that don’t hinder practice effectiveness (i.e. HR).

8. The Preparation

9. Bad Practices: • 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. • Attempting to incorporate into hospital business office. • Adjusting corporate structure in middle of process (changing TINs, adding addresses).

10. Best Practices:Provider Enrollment • 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.

11. Best Practices:Contracting • 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.

12. Best Practices:Research RHC Status • Set up as practice initially (if qualifies and beneficial)! • Determine eligibility. • Review financial benefits. • Review operational requirements (NPs, etc). • Review billing components (POS and copay differences). • Understand time frame for conversion (9-12 months). Note: Must be primary care with mid-level and at least 4,200 visits annually.

13. Best Practices:Practice Operations • Hire Practice Manager. • Implement processes to support claim payment: • Patient registration (ABNs, HIPAA notices) • ID card recognition • Referral/preauthorization • Check-out processes (ask for the MONEY!) • Billing • Know how to handle OON patients (make whole?). • Know what to collect and how to ask for it. • Train, train, and retrain.

14. Best Practices:Revenue Cycle Set-Up • Set comprehensive charge master (get help with this!). • Select good practice specific software (not a hospital system!). • Set up insurance master accurately (get help with this!). • Load reimbursement schedules into software; analyze against payments. • Know payer plan participation status (when to take and not to take contractual adjustments). • Consider outsourcing to billing expert (i.e. PPM). • Provide up-front training (i.e. HTHU and PPM).

15. Best Practices: Insurance and Risk Management Serving the Insurance Needs of Georgia’s Healthcare Community Since 1918 Charley Malmquist CPCU, ARM, AAI Potter Holden & Company 888-528-0589

16. Best Practices: Insurance and Risk Management HTH Survey Results:Hospitals employing physicians • How 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

17. Best Practices: Insurance and Risk Management HTH Survey Results:physician employment • Who are you hiring? • 67% of the physicians responding hospitals typically recruit have 6 or more years of experience; 22% are new to practice; 11% have 2-5 years experience • How are you hiring? •  78% use outside search or recruiting firms56% Recruit from physician practices within their community22% recruit from referral of existing employees

18. Best Practices: Insurance and Risk Management Pre-Employment Considerations • Prior practice locations • Prior insurance carrier… compatibility • Prior Acts Coverage / Nose Coverage • Past loss history, open losses, & incidents not yet reported • Board consent orders or license restrictions • Health issues / drug or alcohol abuse (*as it relates to licensing) • Prior insurance cancellations of declinations

19. Best Practices: Insurance and Risk Management HTH Survey Results:Program Structure • How are you structuring coverage? • 89% provide professional liability protection for their employed physicians.75% under the hospital’s policy: 25% on a separate policy. • 33% said the hospital’s deductible applies to their physicians;22% said the hospital’s deductible does NOT apply, and55% said they weren’t sure/didn’t respond. • 100% of respondants provide $1 mil/ $3 mil limits of liability for their employed physicians

20. Best Practices: Insurance and Risk Management • How are you structuring coverage? • “Does your hospital’s umbrella/excess policy include coverage for employed physicians?”44%- yes22%- no22% - hospital does not carry an umbrella or excess policy11%- aren’t sure

21. Best Practices: Insurance and Risk Management Program Structure Issues • Ownership of policy • Policy type— claims made or occurrence • Individual or group policy • As an endorsement to the hospital’s policy • Separate or shared limits • Application of any retention or deductible • Retirement options

22. Best Practices: Insurance and Risk Management HTH Survey Results:Employment Contracts “How do you address employed physician's malpractice exposure prior to joining your hospital? (prior acts coverage)89%- It is the responsibility of the physician to purchase tail coverage0%- hospital assumes the prior acts by maintaining an original retroactive date11%- weren’t sure “Does the hospital have a clearly defined plan to address the cost of “tail coverage” should the physician leave the employment of the hospital?” 67% said ‘yes’22% said ‘no’

23. Best Practices: Insurance and Risk Management Employment Contracts • Clearly identify insurance responsibilities: • Who will purchase coverage? • What constitutes an acceptable insurer? • What limits of coverage required or provided? • Who will hold consent to settle? (if available) • Who is entitled to receive dividends or return premium? • Will moonlighting be allowed? • Mutual hold harmless or indemnification clauses

24. Best Practices: Insurance and Risk Management Other Insurance Considerations • Workers Compensation • Business overhead • Key man life • Billings Errors & Omissions • Business Interruption • Medical Equipment • Offices Premises Liability

25. Best Practices: Insurance and Risk Management Best Practice- “Do’s” • Do your due diligence on the physician candidate before you employ • Do ask for full disclosure on any potential, pending or open claims • Do consider all potential ramifications associated with insuring the physician before finalizing your approach

26. Best Practices: Insurance and Risk Management Best Practice- “Don’ts” • Don’t make assumptions regarding each party’s responsibilities – spell them out clearly in writing • Don’t assume unknown liabilities • Don’t assume all insurance policies are the same • Don’t assume a departing physician will automatically purchase “tail” coverage: get proof

27. The Oversight Source: https://www.hermesdb.net October 2007 to September 2008 data, updated 01/08/2009 ALL OB Services excluded

28. Bad Practices: • Payment addresses; mixed payments. • Mixed physician and hospital posted on general ledger. • Little to no oversight over practice A/R. • Little to no practice reports reviewed. • Reporting GL and A/R/Revenue to hospital center.

29. Best Practices:Practice Payments • Establish lock box for payments (separate from hospital). • Ensure cash poster is properly trained. • Use payment verification software component.

30. Best Practices:Reporting • Review routine A/R reports; ask questions. • Review variance reports; require payment verification/write-off support. • Review Collectability Analyses. • Review routine A/P reports; ask questions. • Establish PM reporting lines; meet regularly. • Set up separate GL department for physician practice.

31. Best Practices for Integrating Physician Services into Your Hospital hinda greene,d.o., sr vp, medical affairs Hospital physician partners April 30, 2010

32. Integrating Physician Services • Emergency Department • Great Care • Standardization • Protocols in triage • Quality Review • Shorten LOS • Door to admission or discharge • Patient Satisfaction • Staff satisfaction • Hospitalist Program • Great Care • Less “push back” for admissions • Increased Risk Aversion • Quality review: inpatient • Shorten LOS • By decreasing LOS, increase reimbursement • Patient Satisfaction • Staff satisfaction • Less on call • Vacation Coverage • Protect office time

33. Win Win • Emergency Department • Initial workup and stabilization • Less resistance for admissions • Standard protocols • Hospitalists • Increased admissions • Decreased length of stay • Standard admission orders

34. Coordination • Emergency Physicians and Hospitalists work together • What can I do for you? • Expedite exit from ED • Cover hospitalist for a few hours per night by bundling admissions and use of standard orders • Patients and hospital both win • Happiness is spending less time on a one-inch mattress

35. Mike Scribner Strategic Healthcare Partners Helen Williams, CPC Precision Practice Management Charley Malmquist, CPCU, ARM, AAIPotter-Holden & Company 888-528-0589 Dr Hinda GreeneHospital Physician Partners

36. What else can I say?