8 Must-Do Ways to Lift Your Income Up

Leigh Page

Disclosures

March 15, 2017

Reasons to Worry About Income

There's plenty of concern among physicians about how to maintain their income in the coming year. Between turbulence, uncertainty, and the announcement by the Centers for Medicare & Medicaid Services (CMS) last November of a scant 0.24% rise in the fee schedule in 2017, it's not surprising that doctors are anxious.[1]

In 2017, no specialty will see an increase of more than 1%, and such specialties as ophthalmology and urology will actually see decreases, predicts Elizabeth Woodcock,[2] a practice management expert based in Atlanta. The 2017 payment rise is "paltry—and disappointing," she wrote.

In a Medscape interview, Woodcock acknowledged that the gloomy 2017 outlook means it's a good time for physicians to look for savings and reach out for new opportunities—including several new Medicare payments introduced in the final rule. Woodcock and several other experts provided eight strategies to use in 2017.

1. Adapt to the High-Deductible Trend: Collect Before the Appointment

With the recent growth of high-deductible insurance policies, practices are now forced to collect large sums of money from patients on a regular basis. But many of them still don't have the skills to do it well, says Patti Jo Moulds, a billing and collections expert in Encinitas, California.

"You have to rework your collection policies to deal with this phenomenon," she says.

She notes that the highest deductibles have now reached a limit that many people can no longer afford. The Affordable Care Act sets limits on out-of-pocket limits, including deductibles, for health plans. The 2017 limits are $7150 for individuals and $14,300 for families—up from $6850 and $13,700, respectively, in 2016, according to a report[3] by the US Department of Health and Human Services.

A growing number of Americans are in high-deductible plans—defined as those with a deductible of at least $1300 for an individual and $2600 for a family. The percentage of non-Medicare adults enrolled in a high-deductible plan climbed from 25% in 2010 to 40% in the first quarter of 2016, according to a report[4] from the National Center for Health Statistics.

The failure of large groups of patients to pay out-of-pocket charges is starting to affect the bottom lines of large hospital systems. Community Health Systems, the second-biggest for-profit hospital system in the United States, raised its projection for bad debt by $169 million in the fourth quarter of 2015, in part because of patients with high deductibles and copayments, according to a news report[5] in February.

Physician practices are under similar pressures, Moulds says. For this reason, she says, it is essential to collect payments from the patient before the appointment, whenever the payer allows it. "If you wait until after they've had the care, they are less likely to pay," Moulds says. "And when they get back home, even less likelier."

Practices should verify patients' coverage with the insurer before the appointment. Then, when patients arrive, tell them the amount that will be expected from them, she says.

Front-office staff should be totally involved in the patient payment process, Moulds says. She advises assessing each staff member's collection record and paying a small percentage of the collection to those who meet a certain level of collections.

Make sure patients understand their obligations under a high deductible. "Often, the patient signs up for a plan that has a lower-cost premium, not realizing that the trade-off is a high deductible," she says. "When they find out what they have to pay, they can get very angry. It's not a fun job to deal with upset patients. But if you face it directly, it will go a lot easier."

Ask patients to pay by credit card, and get their permission to put the credit card on file for future visits. "Before each visit, we call the patient and ask whether we can run the care for the visit," Moulds says. "I've found that almost all patients agree to this."

Patients who can't immediately pay a bill can be put on a payment plan. Moulds says payment plans are very effective, as long as the patient has the means to pay. She advises asking for at least $50 at the time of service, and then at least $100 a month afterwards. A successful payment plan requires active oversight. "Work with patients so that they keep paying regularly," she says.

When patients fail to pay bills, the only thing left to do is to write them a letter stating that the next step will be sending the bill to a collection agency. "The letter is very effective," she says. "We get calls from about 80% of those who receive the letter, including people who haven't talked to us for months."

2. Avoid the 2017 Medicare Reporting Penalty -- and Maybe Get a Bonus

Next year will be first of reporting for the Merit-Based Incentive Payment System (MIPS), and a lot of physicians are dreading it. But 2017 reporting will actually be quite easy, owing to last-minute changes that CMS announced in October in its final rule[6] for MIPS.

The MIPS program, which applies to most physicians participating in Medicare, was authorized by the Medicare Access and CHIP Reauthorization Act (MACRA), takes the place of three current reporting programs—the Physician Quality Reporting System, value-based modifier program, and the meaningful use program for electronic health records (EHRs)—and adds a fourth category on reporting practice improvement activities.

Physicians who don't report MIPS measures in 2017 will lose 4% of their Medicare reimbursements in 2019, and the percentage rises to 9% by 2022. The penalties are still in place, but in its final rule, CMS announced that it would substantially roll back requirements.

All physicians have to do is report on one quality measure, one activity in the improvement activities category, or the required measures of the EHR category. Also, physicians can wait until the last 3 months to report, and don't have to continuously report. These requirements apply just to 2017 reporting.

Will MACRA go away under the new administration? Republican US Rep Tom Price, MD (R, Georgia), the nominee for Secretary of the Department of Health and Human Services, which oversees CMS, voted for MACRA but has been critical[7] of the way that CMS has rolled it out.

If Dr Price decides to make big changes in the MACRA final rules, such as revising MIPS reporting, CMS would probably have to issue a new rule-making process, which could take the better part of a year, according to Woodcock.

For this reason, "MACRA is likely to remain intact in 2017," she says. "It takes a great deal of planning to make changes in a law."

Meanwhile, physicians who are adept with gathering and reporting MIPS quality measures have the opportunity to earn substantial bonuses in the new program. In 2019, the bonus for the highest performers could be as high as 12% of their Medicare reimbursement, according to CMS.[8] And those in the top 25% would get an additional bonus of as much as 10%.

The final rule also provides a middle way for practices that would be satisfied with a more modest bonus. Physicians who engage in "partial reporting"—reporting one quality measure, more than one improvement activity, or more than the required measures in the EHR category—would not pay a penalty and might win a modest bonus in 2019.

3. Give Your Billing Operation a Tune-up

Rather than looking for new forms of revenue, the best way to find extra income is to recover lost income in your billing operations, according to Kathryn I. Moghadas, RN, a practice management advisor in Winter Springs, Florida.

Some physicians try to sell new products or services on the side, but they often fail because "doctors aren't salesmen," Moghadas says. "You have to deal with middlemen who want you to buy the product up front. When it doesn't sell, it ends up in the corner somewhere."

She thinks physicians would be better off working on billing and practice efficiency. "Control your costs, and work on your revenue cycle," she says. "Those are about the only ways you're going to see extra money."

Many practices have a lot of room for improvement, according to a 2015 study by NextGen Healthcare,[9] a company that helps practices transition to value-based care.

In the survey, only a little over one third of practices enter charges into the system within 1 day of patient visits, and only 35% have implemented a credit card program as an option for patients to pay. And only 15% rated their practices' denial follow-up and resolution abilities as excellent.

Moghadas says that billing staff need to closely review insurance payments. "Review the report from the insurer to make sure it's accurate," she says. "So that there are fresh eyes, someone other than the biller should be reviewing the report."

Billing staff must be not so overwhelmed that they can't be vigilant. "Make sure you send a clean claim," she says. "Claims scrubbing does not replace intelligent inputters of data." She advises to compile reports on inputters' error rates and share the results with each staff member.

If your denial rates with payers are high, consider an internal audit using an outside expert, says Suzanne Quinton, a certified coding consultant in Broken Arrow, Oklahoma.

"An audit can be costly, but it is well worth the losses from denied claims," she says, adding that the auditor needs to be a certified coder who is familiar with your specialty. 

Physicians have a role in improving billing, she adds.

"Many physicians aren't documenting well," Quinton says. "As a result, the value of evaluation and management services may be reduced a level when doctors don't document what they've done. Make sure you capture everything in the medical record."

Doctors also have to learn to be more specific with the new diagnosis codes in the International Classification of Diseases, 10th edition, which are now fully phased in. "At the start of the phase-in, doctors were allowed to use unspecified codes, but now payers are demanding specific codes," she says.

4. Earn Extra Pay by Managing Patients With Chronic Conditions

Since 2015, practices have been able to bill Medicare for chronic care management (CCM), which involves doctors and their staffs closely following patients who have multiple chronic health problems. A report by CMS[10] estimates that about two thirds of Medicare beneficiaries would be eligible for these services, but use of CCM has been disappointingly low.

The low utilization has blamed on administrative burdens for physicians and low reimbursements. In its final rule for the 2017 Medicare Physician Fee Schedule, CMS has eased the administrative burdens and provided higher reimbursement for patients with more complex problems.

Specifically, CMS will no longer require a consent form for the patient to sign, and it will cover two new Current Procedural Terminology (CPT) codes, according to an analysis[11] by the law firm McDonald Hopkins.

The original 99490 code paid $41 a month and covers 20 minutes of clinical staff time per month. But in 2017, Medicare will starting paying $85 per month for CPT code 99487 for services that take 60 minutes of staff time. Moreover, the new add-on code 99489 covers additional 30-minute increments, with a payment of $30 each, for services that exceed 60 minutes.

CCM patients must have two or more of a wide array of chronic conditions, including osteoarthritis and rheumatoid arthritis, asthma, atrial fibrillation, dementia, autism, cancer, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, ischemic heart disease, and osteoporosis, the CMS report said.

The work involves "non–face-to-face" contacts by staff, including a phone call to the patient to collect such information as whether they are taking their meds or continuing to abstain from smoking, and then exploring the issue with them.

Meeting CMS guidelines involves recording patient's health information in a structured form, creating an extensive care plan, ensuring 24/7 access to care management services, and providing "enhanced opportunities" for the patients and caregivers to communicate, the CMS report said.

5. Earn Extra for Assisting Patients Discharged From the Hospital

Medicare's transitional care management (TCM) program pays doctors for work they have been doing already—following their patients after discharge from the hospital, nursing home, or other facilities.

The program, however, is only for patients who have complex medical needs. These patients require moderate or high-complexity medical decision-making at discharge.

The reimbursement is higher than what is paid for an office visit. According to a report[12] by the American Academy of Family Physicians, TCM paid almost $60 more than an office visit in 2013. It involves CPT code 99495 for moderate complexity, which paid $125-$144 in 2013, and code 99496 for high complexity, which paid $150-$203 in 2013.

However, TCM requires more intensive staff involvement than an office visit. A CMS learning module[13] identifies three TCM components: contacting the patient promptly after discharge, providing "non–face-to-face" services by staff, and a face-to-face office visit soon after discharge with a doctor or advanced caregiver, such as a nurse practitioner or physician assistant.

The staff member contacts patients within two business days of discharge, educating them on self-management and connecting them with community health resources. Doctors or advanced health professionals then see patients within seven days of discharge for high complexity cases or 14 days for medium complexity cases. Doctors then review the discharge information, perform medication reconciliation and interact with other clinicians that have been involved in the patient's care.

A 2016 change in TCP rules has speeded up payment, according to a report[14] by the American Academy of Professional Coders. The visit can now be billed on the day of the office visit, rather than waiting 30 days from the date of discharge.

6. Provide Annual Wellness Check-ups for Medicare Patients

Quinton reports that a lot of doctors aren't offering Medicare patients the wellness visits they are entitled to each year. "They may not even realize they can do this," she says.

New Medicare beneficiaries are given a check-up, called the "Welcome to Medicare" visit, when they join Medicare, and yearly wellness visits after that. They do not have to pay a cost share for these visits, and the physician gets $172 for the initial checkup and $111 for the annual wellness visits, according to a 2014[15] report by the American Cancer Society.

To earn the reimbursement, practices must collect a specific set of information and follow certain steps in interacting with patients, according to a 2012 report[16] in Family Practice Management by Arnold E. Cuenca, DO, a family physician in San Diego.

"It can be challenging and frustrating for physicians to provide and document the extensive list of required elements in a 20- or 30-minute visit," Dr Cuenca wrote.

The only way you can break even for these services, he wrote, is by creating an efficient system that relies on licensed vocational nurses (LVNs) or medical assistants (MAs) to gather information for the patient.

Dr Cienca wrote that he expanded the role of his LVNs to include obtaining and documenting information required in a "previsit" with patients before they see the doctor or advanced caregiver. Cross-trained MAs fill in when our LVN is unavailable, he added.

"The nurse previsit enables the physician to focus on the aspects of the visit that require a physician's knowledge and skills," Dr Cuenca wrote.

The staff must create an extensive list of the patient's current risk factors, and the clinician must provide personalized health advice and making referrals to wellness programs for such issues as tobacco cessation, fall prevention, nutrition, and weight loss, the American Cancer Society report stated.

The practice can also couple the visit with other services. "This additional service will be billed separately and, therefore, is subject to the Medicare deductible/coinsurance co-pay," Dr Cuenca wrote.

It's important to make it clear to patients that they will have to pay the Medicare cost share for these extra services. There have been a number of articles[17] in the press about patients who expected to pay nothing for the visit and were furious when they got billed.

The Medicare wellness visit is authorized by the Affordable Care Act, and it could conceivably disappear if the law is repealed. Health system researchers have found[18] that the wellness benefit produces few health benefits that could justify Medicare expenditures for the visit. Taking away the benefit, however, might be very unpopular with patients.

7. Get Paid for Coordinating Behavioral Health Services for Patients

In 2017, Medicare will begin paying primary care physicians (PCPs) separately to provide behavioral health services to their patients under a team-based care model called "behavioral health integration" (BHI).

"This is a huge win for behavioral health, which has had to deal with spotty payment," Woodcock says, adding that commercial payers are expected to offer the same coverage eventually.

The new Medicare benefit was featured in a December 15 article[19] in the New England Journal of Medicine, lead-authored by Mathew J. Press, MD, an internist in New York City.

Until this new reimbursement, Dr Press wrote, physicians lacked "a clear business model" for incorporating behavioral health services into their practices.

The payment is based on a team-care approach, called the psychiatric collaborative care model. A PCP or advanced practitioner works with a behavioral health care manager, such as a psychologist, social worker, or nurse with behavioral health training.

When one of the PCP's patients comes forward with a behavioral health concern, the doctor and the behavioral healthcare manager conduct an initial clinical assessment and work with the patient to develop an initial care plan, which may involve a psychiatrist prescribing drugs or a psychotherapist or other caregiver offering psychotherapy.

Even as the patient starts therapy, the team remains involved, monitoring the patient's outcomes and staying into contact with the outside provider. The team must follow a list of collaborative care model protocols that have been shown to be effective in studies, Dr Press and colleagues wrote.

The PCP uses three new codes to bill for the team's services on a monthly basis. Code G0502 covers 70 minutes of care, at a reimbursement of $140 for the first month of care; code G0503 covers 60 minutes of care, at a $125 reimbursement; and code G0504 covers 30 minutes of care a month after that, at a $65 reimbursement.

A fourth code (G0507) for general BHI allows the PCP to work outside the collaborative care model, charging $48 for 20 minutes of services per month. The PCP must assess the patient, monitor symptoms, facilitate care, and assure continuity.

Dr Press and colleagues wrote that physicians who are already coordinating behavioral health care for their patients would welcome the new program. "But the biggest potential effect will be increasing the number of Medicare beneficiaries with access to effective BHI services," he added.

8. Assign More Work to Medical Assistants

Physicians looking for practice efficiencies should consider expanding the duties of MAs, according to Jaan Sidorov, MD, an internist by training who works as a practice management consultant in Harrisburg, Pennsylvania.

Dr Sidorov says that MAs are particularly useful in team-based care needed value-based arrangements, such as accountable care organizations (ACOs).

"There are revenue opportunities when you down-job routine monitoring from doctors to nurses and MAs," he says. "This gives doctors the opportunity to backfill the practice with more complex patients who need more care that may be attached to higher payments. In this way, the practice can actually increase volume and revenue."

Kevin D. Hopkins, MD, a family physician at Cleveland Clinic, described his successful transfer to an MA-based care model in a 2014 article[20] in Family Practice Management.

Assigning two MAs to each doctor in his seven-physician practice within the Cleveland Clinic resulted in a 23% increase in gross patient revenue, or almost $2 million a year. He said this increase was almost as much as that from hiring two new full-time physicians.

This arrangement also reduces the doctors' stress. "I love my job," Dr Hopkins wrote. "I feel less bogged down by details and busy work, and my MAs do a better job taking care of forms and paperwork than I ever did. They help me navigate through my day and address issues sooner than I might have otherwise gotten to them."

Dr Hopkins was unavailable to comment on his model, but its success may have something to do with Cleveland Clinic being an integrated system that includes hospitals. Money saved by reducing hospital admissions, for example, might be included in the savings. Indeed, a study at Group Health Cooperative in Seattle, also an integrated system, found that the medical home model of team-based care saved an estimated $10.30 per patient.

On the other hand, several studies of medical practices that are not in integrated models do not show heightened income or savings. For example, a study[21] released this August found that using a team approach to treat patients with coronary heart disease in primary care practices actually resulted in a 2.5% loss in revenue.

The authors concluded that the losses came from the practices' continued reliance on fee-for-service payments, which don't reward use of nonphysicians. "Payment for care must be restructured if patients are expected to enjoy the benefits of team-based primary care," they concluded.

That restructuring is already beginning, although it might not be robust enough yet to support full-fledged team-based care. For example, both CCM and TCM under Medicare reward the use of nonphysician teams.

The authors of the 2016 study also urged practices wishing to start team care to join ACOs. However, only 30% of ACOs in the Medicare shared savings program actually produced shared savings in 2015, the latest measured year, according to an analysis[22] this September published on the Health Affairs blog.

Still, that percentage was up from 25.8% in 2014 and 23.6 % in 2013, and the average payment to ACOs that did achieve shared savings was $429 million in 2015, the report said. Sidorov added that some studies suggest that doctor-run ACOs are more successful than ones run by hospitals, because "doctors have no interest in generating inpatient revenue," he noted.

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