The Way Hospitals Work

[docB]

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Based on the things I see on this board it's clear that many people don't know how hospitals and doctors interact outside of academic instituations. It's not surprising as no one tells you any of this before you experience it on your own so here are a few nuggets of info:

You have to apply to every hospital and surgery center in which you want to see patients. You are applying for priveledges. It's a big application (very similar to a license app) and it usually takes a few months. The fee (in my area) is usually $200 to $500 per hospital.

Different hospitals have different requirements to work there such as years of training and board certification.

Hospitals maintain DOPs (delineation of priveledges) on docs saying what you can and can't do. Eg. as an EP my DOPs include intubation and suturing but not appendectomies and hernia repairs.

The hospital can require various things of you to remain on staff. Examples include taking call, keeping your charts up to date and having coverage for your patients when you are not available.

The hospital can suspend or expel you for violations such as comitting a crime, failing to call back when paged, etc.

This stuff is not covered in school or residency but it's important. Next week (meaning when I get bored again) billing!

 

[DrB]

Thank you docb!

One of the reasons for becoming a phlebotomist was to learn about these little tid bits in the doctors world. Unfortunatly, I only interact with nurses and other hospital techs. I get to see the ER docs sometimes, but they tend to keep to their own world. I know you are an ER doc, so.... be kind to us peons of the hospital staff!!!

BTW docb... I will begin med school in Las Vegas this fall. I also know that you work in the area... tried to pm you, but failed 🙁

Hope to work in one of your hospitals one day!

-Ben
TUN class of 2009

 

[kungfufishing]

Thank you docb!

One of the reasons for becoming a phlebotomist was to learn about these little tid bits in the doctors world. Unfortunatly, I only interact with nurses and other hospital techs. I get to see the ER docs sometimes, but they tend to keep to their own world. I know you are an ER doc, so.... be kind to us peons of the hospital staff!!!

BTW docb... I will begin med school in Las Vegas this fall. I also know that you work in the area... tried to pm you, but failed 🙁

Hope to work in one of your hospitals one day!

-Ben
TUN class of 2009

docB and DrB messaging back and forth? both in vegas? schizophrenia? psychogenic fugue?

 

[DrB]

You know what they say about Vegas...


Excuse me...its time for my Zyprexa

 

[docB]

Thank you docb!

One of the reasons for becoming a phlebotomist was to learn about these little tid bits in the doctors world. Unfortunatly, I only interact with nurses and other hospital techs. I get to see the ER docs sometimes, but they tend to keep to their own world. I know you are an ER doc, so.... be kind to us peons of the hospital staff!!!

BTW docb... I will begin med school in Las Vegas this fall. I also know that you work in the area... tried to pm you, but failed 🙁

Hope to work in one of your hospitals one day!

-Ben
TUN class of 2009

Are you going to be at the new Torou [sp] Osteo school?

 

[DrB]

Touro University College of Osteopathic Medicine Class of 2009!!!!

Any phlebotomy jobs at your hospital?

I work in Santa Cruz, CA at a CHW hospital... Already looked into transfer to St. Rose, but there are no jobs 🙁

-Ben
See you in Vegas

 

[fedor]

Based on the things I see on this board it's clear that many people don't know how hospitals and doctors interact outside of academic instituations. It's not surprising as no one tells you any of this before you experience it on your own so here are a few nuggets of info:

You have to apply to every hospital and surgery center in which you want to see patients. You are applying for priveledges. It's a big application (very similar to a license app) and it usually takes a few months. The fee (in my area) is usually $200 to $500 per hospital.

Different hospitals have different requirements to work there such as years of training and board certification.

Hospitals maintain DOPs (delineation of priveledges) on docs saying what you can and can't do. Eg. as an EP my DOPs include intubation and suturing but not appendectomies and hernia repairs.

The hospital can require various things of you to remain on staff. Examples include taking call, keeping your charts up to date and having coverage for your patients when you are not available.

The hospital can suspend or expel you for violations such as comitting a crime, failing to call back when paged, etc.

This stuff is not covered in school or residency but it's important. Next week (meaning when I get bored again) billing!

This is a great post. I decided to bump it for some of the people who may not have seen it.

 

[docB]

A few more tidbits:

In a private hospital none of the docs are paid by the hospital. The ER docs have a contract with the hospital to work in the ER and they bill the patients for their services. Same with radiology. Primary docs like internists and FPs have priveledges at the hospital and bill their patients directly. The specialists are consulted by the primaries and they bill the patients directly. People don't realize how many different bills a patient can get. If you went to the ER with an appy you'll probably get six seperate doctor bills (ER, Radiologist, Internist, Surgeon, Anesthesia, Pathologist). And that is in addition to all the hospital charges.

The Department Chiefs and the Chief of Staff are not just ceremonial positions. They have to field all the problems that crop up with the docs in their departments. They get called in the middle of the night to settle disputes about admitting and so forth. Painful but true.

Getting a consultant to see your patient depends on their insurance. Let's say you're an internist and you have an indigent patient on your service that you picked up on call. Let's say that guy develops a urologic emergency (priapism, sepisis with a stone that needs a nephrostomy, whatever). The urologists don't have to see your patient. They can refuse, and they will if there is no insurance. You will probably not be able to transfer the patient because an inpatient transfer is much more difficult than an ER transfer. You and the patient may be really screwed.

 

[Gimlet]

A few more tidbits:

In a private hospital none of the docs are paid by the hospital. The ER docs have a contract with the hospital to work in the ER and they bill the patients for their services. Same with radiology. Primary docs like internists and FPs have priveledges at the hospital and bill their patients directly. The specialists are consulted by the primaries and they bill the patients directly. People don't realize how many different bills a patient can get. If you went to the ER with an appy you'll probably get six seperate doctor bills (ER, Radiologist, Internist, Surgeon, Anesthesia, Pathologist). And that is in addition to all the hospital charges.

The Department Chiefs and the Chief of Staff are not just ceremonial positions. They have to field all the problems that crop up with the docs in their departments. They get called in the middle of the night to settle disputes about admitting and so forth. Painful but true.

Getting a consultant to see your patient depends on their insurance. Let's say you're an internist and you have an indigent patient on your service that you picked up on call. Let's say that guy develops a urologic emergency (priapism, sepisis with a stone that needs a nephrostomy, whatever). The urologists don't have to see your patient. They can refuse, and they will if there is no insurance. You will probably not be able to transfer the patient because an inpatient transfer is much more difficult than an ER transfer. You and the patient may be really screwed.

Thanks for the post, docB. You gotta wonder how people can go through medicals school and NOT know this stuff, but if they don't teach it, how the heck else are we supposed to learn it?! I think you should make this a regular "lecture series" and keep the informative topics coming! You could touch on all of the "shortcomings of medical education" that you mentioned in a different post the other day.

 

[docB]

Maybe some of the guys that work in academic centers will chime in. They run a little differently than private houses.

There's also a ton of stuff about setting up a practice or buying into one that is super critical for primary docs and specialists. I don't know so much about that being EM.

 

[RuralMedicine]

A few more tidbits:
Getting a consultant to see your patient depends on their insurance. Let's say you're an internist and you have an indigent patient on your service that you picked up on call. Let's say that guy develops a urologic emergency (priapism, sepisis with a stone that needs a nephrostomy, whatever). The urologists don't have to see your patient. They can refuse, and they will if there is no insurance. You will probably not be able to transfer the patient because an inpatient transfer is much more difficult than an ER transfer. You and the patient may be really screwed.

Fortunately our urologist is nice and will see anyone (and in exchange the hospital buys him some expensive toys like lasers etc) but the last part is definitely true. I spent over 2 hours on the phone trying to find an accepting physician for my patient and I knew I was in trouble when the less than helpful surgical subspecialist I was dealing with suggested I just send the patient through the ED and then maybe the ED would admit it to medicine and he could consult and do his procedure. I tried to point out to him that doing such would violate EMTALA and ended up eventually getting one of the medicine hospitalists at the institution to accept several phone calls later.

 

[fedor]

Getting a consultant to see your patient depends on their insurance. Let's say you're an internist and you have an indigent patient on your service that you picked up on call. Let's say that guy develops a urologic emergency (priapism, sepisis with a stone that needs a nephrostomy, whatever). The urologists don't have to see your patient. They can refuse, and they will if there is no insurance. You will probably not be able to transfer the patient because an inpatient transfer is much more difficult than an ER transfer. You and the patient may be really screwed.

I imagine this wouldn't apply to consultants such as radiologists or pathologists. Aren't they contractually required to do what the clinician requests?

Also, I thought that doctors were allowed to turn down patients except in the case of an emergency. Wouldn't the urologist in question be forced to operate regardless of potential reimbursement because 1) it's an emergency 2) he's contractually bound to the hospital in practice. The law requiring care to be provided to emergency patients is the reason they're seen in the ED in the first place.

 

[docB]

These are excellent questions that get right to the heart of some of the misconceptions that people develop in academic institutions.

I imagine this wouldn't apply to consultants such as radiologists or pathologists. Aren't they contractually required to do what the clinician requests?

For radiology I have never had a problem getting a study for an uninsured patient from the ER. I that the clinic docs have trouble getting studies done on an outpatient basis (the reason I know this is that these patients often get turfed into the ED to get their studies). I don't know about path because I almost never send stuff to path.

Also, I thought that doctors were allowed to turn down patients except in the case of an emergency. Wouldn't the urologist in question be forced to operate regardless of potential reimbursement because 1) it's an emergency

Just because it's an emergency does not mean a doctor can be compelled to act. It's a very complex issue. If the patient is an inpatient they can refuse any consult they want. This leaves the admitting doc in a bad spot. If the needed specialty is not on staff then the doc could transfer to a higher level of care which is not terribly difficult. If the needed specialist is on staff but is just refusing that means any transfer would be a lateral transfer (a transfer between two hospitals of equal ability) and is very difficult to accomplish. In my experience when that happens the hospital administration has to get involved. It gets very ugly.
It's a little simpler in the ER but not much. In the ER it comes down to who is on call. If the needed specialist is on call he has to see the patient and he can't refuse. If he does refuse he will lose his hospital priveledges and I am mandated by federal law to report him for failing in his EMTALA obligations. If the needed specialty is not on call then I transfer the patient. It gets ugly when the needed specialty is not on call to the ER but does exist at the hospital. EMTALA is not totally clear on that situation (or on anything else really) and it basically gets dealt with case by case.

2) he's contractually bound to the hospital in practice. The law requiring care to be provided to emergency patients is the reason they're seen in the ED in the first place.

The consulting docs are not contractually bound to the hospital. They just have privelidges. If they are on call they are obligated but if they are not on call they have no obligation.
The nasty truth is that it is not that uncommon for patients to be in need of specialty care that they can't get due to being uninsured. I get stuck with this all the time. I do sympathize with the consultants. Why does an ENT for example want to get up at 2 am to operate on a guy who can't pay his bill. The ENT is still liable for any lawsuits brought by the patient. This is the driving force behind those who advocate for tort reform that restricts people from suing over care they were given for free.

 

[fedor]

The nasty truth is that it is not that uncommon for patients to be in need of specialty care that they can't get due to being uninsured. I get stuck with this all the time. I do sympathize with the consultants. Why does an ENT for example want to get up at 2 am to operate on a guy who can't pay his bill. The ENT is still liable for any lawsuits brought by the patient. This is the driving force behind those who advocate for tort reform that restricts people from suing over care they were given for free.

Is malpractice coverage paid per annum or is it based on the number and types of cases? If per case, I could see that as an additional disincentive for physicians to render care to indigent patients.

I can forsee one problem with restricting patients to sue for care if they were provided the care for free: how do you know which patients are rendered care for free and which will eventually pay? In practice is it common to 1) draw the dividing line between who will pay and who won't according to whether they are insured or not. 2) render a different standard of care for patients which will reimburse higher. Or in different words, just how much do consultants keep in mind the potential for reimbursement when they are actually rendering care (not deciding to render care)?

I mention the first since for a decade or so I was without insurance, showed up at the ED, and wound up paying a huge sum out of pocket. At the time did the ED staff most likely think they would receive nothing? Or in addition to the insured/uninsured criterion, are factors such as employment and means taken into consideration. If a well to do uninsured patient comes into the ED, will they also have trouble receiving care from consultants?

 

[docB]

Again excellent questions.

Is malpractice coverage paid per annum or is it based on the number and types of cases? If per case, I could see that as an additional disincentive for physicians to render care to indigent patients.

For most non EM physicians malpractice is based on an annual payment although it is usually divided monthly. The actual cost of your malpractice is based on a hodgepodge of your specialty, your volume, your personal record and your region. You won't necessarily incur more malpractice insurance cost for seeing that individual patient but they can sue you.

I work for an EM staffing corporation that is self insured (this set up has risks and benefits, lower cost but might not cover you in a pinch, for more info search PhyAmerica and check out the AAEM site). They siphon a percentage of every patient bill to go into the pot to pay the lawyers and the payouts.

I can forsee one problem with restricting patients to sue for care if they were provided the care for free: how do you know which patients are rendered care for free and which will eventually pay? In practice is it common to 1) draw the dividing line between who will pay and who won't according to whether they are insured or not.

In general the assumption is that if a patient is uninsured they won't pay. That's not always true but that's the assumption, particularly by consultants I call in the middle of the night.

2) render a different standard of care for patients which will reimburse higher. Or in different words, just how much do consultants keep in mind the potential for reimbursement when they are actually rendering care (not deciding to render care)?

I would like to say that everyone is treated exactly the same but it's not true. I have run into docs that ask about insurance and then decide on care. For example a cardiologist who will take the insured to the cath lab but becomes "unavailable" and want TNK given for the uninsured. I'm sure this attitude exists in EM too but I've never run into it.

It's also not true that the insured get more care than the uninsured. I frequently admit the uninsured for borderline stuff like cellulitis or pneumonia because I know they have no follow up and won't be able to fill their prescriptions. I also try give the uninsured lower cost drugs like doxy instead of a Zpack or Bactrim instead of Cipro, phenergan instead of Zofran. I also give the uninsured doses of stuff before they leave like a shot of bicillin rather than a course of po PCN. Also, you should always tell your poor patients to go to big pharmacies like WalMart because their bulk buying lowers the prices.

One good thing about the way that my group's compensation works is that we divide the cost of treating the uninsured evenly over the whole group. If you spend a whole shift seeing the indigent you don't get a tiny check that month. We all suck up the cost but we bear it evenly. The danger in groups that have a strict fee for service or "eat what you kill" system create a disincentive to see the uninsured and even an incentiv to do unecessary workups on the insured.

I mention the first since for a decade or so I was without insurance, showed up at the ED, and wound up paying a huge sum out of pocket. At the time did the ED staff most likely think they would receive nothing? Or in addition to the insured/uninsured criterion, are factors such as employment and means taken into consideration. If a well to do uninsured patient comes into the ED, will they also have trouble receiving care from consultants?

Yes, the usual assumption is no insurance, no money. This kind of illustrates how the main group of people that get screwed by the system on a regular basis is the working poor. The bums don't care because they've got nothing to lose and the insured are insured. It's the people who incur a big bill and then try to pay it but don't benefit from the sweetheart deals that the insurance companies get who are really in trouble. They are the ones who wind up getting their car repossessed or their wages garnished and often go bankrupt. I'd like to see the system shifted so that the safety net catches the working poor rather than the addicted indigent but then I'm a fascist.

 

[f_w]

> For radiology I have never had a problem getting a study for an
> uninsured patient from the ER.

Radiology groups commonly have a contract with the hospital. In one way or another, it gives the group the exclusive right to interpret all imaging studies (sans cards, sans OB) at a given hospital in exchange for the obligation to interpret all studies in a timely manner. These contracts also oblige the rads group to some level of overnight and weekend coverage.

As a result, you will rarely see a problem getting an imaging study done. 99% of the time, the radiologist doesn't know the insurance status on a patient before the study is approved (if there is an approval process at all). If the patient is 'self-pay/no-pay' the hospital eats the charge for the technical component, the radiology group eats the charge for the professional component. For radiology groups covering inner-city hospitals, this typically means that the collection rate on the 10pm to 8am ER related work hovers somewhere in the single digits. In the end you make it up with the paid outpatient daytime work and in the mix it works out allright (similar to the ED docs. In order to make a living, they have to see 3 'BC/BS centennial' insured runny noses in the afternoon to make up for the 2am drunk with chest pain.)

EMTALA mostly applies to the ED and the hospital, less so to the consulting physician. They can often maintain the position that the immediate emergency threatening this patient is well taken care of by the ED and that the underlying problem can be handled on an outpatient basis.

The behaviour of consultants regarding the uninsured is also a function of local practice patterns and the specialties involved. In my experience general surgeons tend to be more ethical in their dealings with indingent patients than subspecialists. Rural and urban hospitals tend to have a more hospitable climate than snooty suburban private hospitals.

 

[Annette]

If the hospital accepts medicare/medicaid, they have to treat all patients the same regardless of the ability to pay, or the payor source. That is why most rooms are semi-private instead of wards, and there has to be reason for a private room. The same in general applies to physicians, but there is more wiggle room. If a consultant leaves the primary in a lerch too often, the consultant can find themselves in some hot water with the hospital and the feds.

 

[GoPistons]

What I don't think is fair about this whole mess is that Doctors are the ones that are screwed in this system... it's not like a nurse who is working an ED shift gets paid nothing if a patient is uninsured... nor does the radiology tech, the phlebotomist, the security guard, the phone operator, etc.

Why is it the responsibility of the doctor to collect the bills when all others in the system are getting compensated for their work?

Also, are there any good books that you recommend on this subject? I have read Medical Economic books but they mostly cover how medicine is a "special" good that needs to be treated with its own set of principles and analysis... any good books on just the practical ways hospitals are run?...

 

[fedor]

For most non EM physicians malpractice is based on an annual payment although it is usually divided monthly. The actual cost of your malpractice is based on a hodgepodge of your specialty, your volume, your personal record and your region. You won't necessarily incur more malpractice insurance cost for seeing that individual patient but they can sue you.

What do you consider to be the advantages and disadvantages of the two main types of malpractice coverage: 1) Occurence 2) Claims Made

(For those following along, occurence coverage is a type of coverage where you are covered regardless of when a malpractice claim against you is filed as long as you were covered by the policy during the time the alleged malpractice occured. Meanwhile, a claims made policy covers you only if the claim is made during a set time period and you were covered by the policy when the alleged malpractice occured.)

Personally I lean towards occurence coverage because it seems much simpler. There are no headaches with reporting endorsement (tail) and prior acts (nose) coverage.

Also, could you explain the workings of malpractice a little more fully. From what I understand, the rates are set in some cases by the state legislature (ie, NY State) so doctors pay the same amount regardless of whether they have had previous claims filed against them or not. Thus you can have a doctor with 5 settlements paying the same rates as one with a clear record. If this is the case, how do insurance companies deal with this? If the rates can't be lowered, will insurance companies eventually refuse to insure a high risk doctor?

 

[f_w]

Good luck finding occurance coverage. In most states you are limited to claims made these days. After 9/11 the big companies in the business decided that medmal is too uncertain a business for them to make the committment involved in occurence coverage (and they make more money on the claims made policies).

 

[docB]

If the hospital accepts medicare/medicaid, they have to treat all patients the same regardless of the ability to pay, or the payor source. That is why most rooms are semi-private instead of wards, and there has to be reason for a private room. The same in general applies to physicians, but there is more wiggle room. If a consultant leaves the primary in a lerch too often, the consultant can find themselves in some hot water with the hospital and the feds.

Yes, that is how it is supposed to be. In reality the wiggle room you talk about becomes a huge amount of space. I already talked about the cardios who will come in and cath a patient with insurance but call for TNK on an uninsured patient. You can write all kinds of stuff in the chart, "patient was a poor cath candidate, EKG suspicious for diffuse disease, patient improving clinically needs stabilization prior to cath." Blah, blah, blah. The hospital doesn't want to annoy a consultant who brings in a lot of paying business with their elective procedures. The government via EMTALA has been LOOSENING the requirements of hospitals to provide specialty services. All too often the primary or the ER doc are stuck trying to beg consultants to do thier thing or making dubious transfers.

 

[docB]

What do you consider to be the advantages and disadvantages of the two main types of malpractice coverage: 1) Occurence 2) Claims Made

(For those following along, occurence coverage is a type of coverage where you are covered regardless of when a malpractice claim against you is filed as long as you were covered by the policy during the time the alleged malpractice occured. Meanwhile, a claims made policy covers you only if the claim is made during a set time period and you were covered by the policy when the alleged malpractice occured.)

Personally I lean towards occurence coverage because it seems much simpler. There are no headaches with reporting endorsement (tail) and prior acts (nose) coverage.

Also, could you explain the workings of malpractice a little more fully. From what I understand, the rates are set in some cases by the state legislature (ie, NY State) so doctors pay the same amount regardless of whether they have had previous claims filed against them or not. Thus you can have a doctor with 5 settlements paying the same rates as one with a clear record. If this is the case, how do insurance companies deal with this? If the rates can't be lowered, will insurance companies eventually refuse to insure a high risk doctor?

Occurence is definitely better but as f_w noted it's very tough to get now. The rule is claims made then buying a tail which is not cheap (usually in the tens of thousands). For those who don't know a tail is an insurance policy you (or your employer) buys to cover you if you get sued for something you did while covered under a claims made policy. I am covered under a claims made policy but I will still be covered as long as the company I work for exists. I shouldn't have to buy a tail unless the company goes under. Again this is not unheard of as with the PhyAmerica debacle (check out AAEM).

As for the way malpractice insurance premiums are set you are right that different states have tried various things to deal with the problems. The problem is that the med mal system as currently incarnated has 4 goals: to compensate victims of negligence, to punish bad doctors, to provide money to unlucky people who have had bad outcomes and to enrich lawyers. The problem is that because of the last two goals the system doesn't accomplish the first two.
Insurance runs off a basic business model of collecting more in premiums than they pay out in claims. The states that capped the premiums instead of the damages disturbed this arrangement so the insurers, like any other business, started to close their med mal division. The states, who were trying to sweep the problem under the rug in the first place then made laws mandating that the insurance companies provide med mal if they wanted to keep selling other types of insurance like car and life in that state. This destabilizes the system even more because it essentially passes the cost of malpractice on to other totally unrelated consumers. The NY model, that artificailly equalizes risk among physicians, distributes the higher cost of insuring risky doctors to all the doctors practicing in the state.

 

[fedor]

Could you please explain a little about the hospital hierarchies and the political workings of hospitals? Unfortunately this is something that one often won't learn about until one is already an attending.

From the little I know, various departments in the hospital have more or less power primarily based on their importance to the administration. Thus, any high revenue department will usually have more power and often times respect (ie, CT surgery, radiology (huge monetary windfall for hospitals), ENT, etc.) compared to the low-revenue departments (ie., dermatology).

Another factor would be the ability of a department (really a specific group which is contracted to run that department) to leave the hospital and start up a competing center. Thus, in areas where imaging centers aren't already on every block, a hospital based radiology group has enormous bargaining power because of the potential for it to open a center across the street. I imagine another specialty group which would have the ability to gain added bargaining power is nephrology which could establish a free-standing dialysis center.

 

[f_w]

> Thus, in areas where imaging centers aren't already on every block,
> a hospital based radiology group has enormous bargaining power
> because of the potential for it to open a center across the street.

Typically the 'exclusive contract' in radiology contains a non-compete clause to rule this out. Often, the radiology group will operate an outside imaging center as a joint-venture with the hospital. This is the single most contentious issue in contract negotiations between radiology groups and hospitals. At times, groups will just allow their contract to expire in order to open their own imaging center. This can lead to nasty fights with the hospital which usually threatens to kick the radiology group out (just to find out later that it is close to impossible to hire any significant number of rads in todays market).

The politics of hospitals are very different in community vs academic vs HMO places. Outside of rads, path,ED and anesthesia, physicians typically have no contractual relationship with the hospital itself. They are members of the medical staff association which is an entity separate from the hospital itself. Whoever brings lots of revenue for the hospital in the form of patient referrals and admissions has political pull. Typically ortho, GS, NS and cards are the big players in community hospitals. Rads in most hospitals contributes 50-60% of the hospitals revenue, but due to the fact that all the patients are brought in by other specialists we usually don't have a lot of political pull (the other factor is the chronic envy and contempt of our colleagues).

 

[docB]

f_w is right on. On point of interest with regard to EM people is that the "non-compete" clause that he is talking aobut involves the radiology group saying they won't try to open an imaging center and undercut the hospital's business. It's an agreement between the group and the hospital. The "non-compete" clause that some EM docs have to sign (the ones that AAEM hate so much) are the physician saying that he won't compete with his group for the hospital contract to staff the ED. It's an agreement between the physician and his group, not the hospital.

Another thing that affects the hospital hierarchy is the committee system in most hospitals. For example, in my hospitals, the big ones are the Medical Executive Committee, the Credentials Committee and the Continuous Quality Improvement (CQI) committee. If you land a spot on one of these you can guarantee more power for your department. You can shield your dept. from trouble and rain hellfire on others. It's hospital politics at its most distilled.

 

[f_w]

> For example, in my hospitals, the big ones are the Medical
> Executive Committee, the Credentials Committee and the
> Continuous Quality Improvement (CQI) committee.

And then there are real powerhouses such as the 'medical records committee' or even better 'planning and facilities'. Nothing is more fun than introducing a new form that every admitting physician has to fill out on each patient. Or, in the hospitals where 'planning and facilities' has actual power, move someone to the 'trailer park' because his prime 1st floor space is needed for a new 'signature program' 🙂))))))

 

[fedor]

Could you clarify reimbursement a little?

From what I understand is that physicians charge a cash rate which can vary greatly between different physicians.

Let's use a simple physical exam as an example. One doctor in Beverly hills may charge $100 for a physical while a doctor in East Los Angeles may charge $50 for the same physical. If the patient pays in cash, then it's pretty clear cut.

However, the government decides on a rate for the procedure which is state dependent. This would be the medicare rate. Thus, let's say for the sake of argument, that the medicare rate is $30 for a patient in California. The above patients both come in for their physical, the doctor bills medicare for $30, and that's that. Because medicare reimburses very little, is it likely some doctors will say that they will not accept medicare patients? Or are there laws against that?

Now for the third type of patient - the one with insurance - the amount billed and reimbursed varies according the insurance company. The doctor approaches three insurance companies. The first says that they will reimburse 90% of medicare, and the doctor says he isn't interested. The second says 120% of medicare (if I am not mistaken, usually insurance companies do not list specific fees, but instead offer percentages of what medicare reimburses for the specific area and procedure). The third says 150% of medicare. The doctor only accepts the third insurance company's reimbursement, and thus when patients with insurance from company 1 and 2 call, the receptionist says that the doctor doesn't accept that insurance and if they still choose to come, they will have to pay cash ($100).

Am I correct so far?

Now onto the billing itself. If it's cash, it's fee for service. If a patient shows up for a physical ($100), the doctor may do a CXray ($100), bloodwork ($100), and a stool sample ($150). Thus the patient would pay $450 for the visit.

If an insurance patient shows up, the same method of reimbursement (fee for service) would be used except that the insurance company reimburses at different rates (150% of medicare's $30 = $45) plus a % of medicare for the rest of the tests. Let's say for the sake of argument that it comes out to $220. Now, for a simple physical, this is a lot of tests and the insurance company may 1) let is slide and pay the $220 2) challenge some of the tests (ie, not pay for them) 3) throw the doctor off the plan.

For the third, medicare patients, reimbursement is entirely different in that it isn't fee for service. Instead it is based on prospective payment. Thus regardless of how many or how few tests you do, you will be reimbursed the same amount. In our case, $30.

Is this an accurate picture of billing/reimbursement or am I off the mark?

 

[f_w]

> Let's use a simple physical exam as an example. One doctor in Beverly
> hills may charge $100 for a physical while a doctor in East Los Angeles
> may charge $50 for the same physical. If the patient pays in cash,
> then it's pretty clear cut.

Chances are, they both will charge about the same. Just the guy in East LA will often 'code down' a visit to a lower level because he knows that his cash paying customer won't be able to afford the full charge.

> However, the government decides on a rate for the procedure
> which is state dependent. This would be the medicare rate.
> Thus, let's say for the sake of argument, that the medicare rate
> is $30 for a patient in California.

The medicare rates vary by state and sometimes county. The goverment factors cost such as office rental and malpractice rates into the equation (as a result, taking out a hangnail is $178 in NY,NY and $104 in Dickinson,ND. You can look this up on the CMS website).

> The above patients both come in for their physical, the doctor
> bills medicare for $30, and that's that. Because medicare reimburses
> very little, is it likely some doctors will say that they will not
> accept medicare patients? Or are there laws against that?

Participation in medicare is 'voluntary'. But as >60% of medical care in this country is rendered to people over 65, pretty much every physician with a 'normal' practice (not some chi-chi boutique practice in florida) will accept medicare assignments. Also, some insureres only take you on their roster if you are a medicare provider (They know, the threat of 3-7 in a minimal security facility levied by the feds keeps your billing practices honest).
If you participate in medicare, you can't charge the patient anything beyond what medicare gives you for a given service (exception: stuff medicare doesn't pay for e.g. prevention. If you get consent from the patient beforehand you can charge them cash rate).

> Now for the third type of patient - the one with insurance -
> the amount billed and reimbursed varies according the insurance
> company.

The amount billed is allways the same: the cash rate. The amount paid by various insurance companies will be different. The difference between amount paid by the insurance + deductible and your cash bill is written off as 'negotiated discounts'.
(As a result of this perverse billing system, the only person liable to pay the entire bill is a poor sucker who doesn't have health insurance but owns a house which would be threatened by collection action).

> and thus when patients with insurance from company 1 and 2 call,
> the receptionist says that the doctor doesn't accept that
> insurance and if they still choose to come, they will have to
> pay cash ($100).

Sort of. Depends on the type of health insurance plan. The patient will have the choice to pay you out of pocket and can attempt to get the money back from his insurance as an 'out of network' visit. An HMO typically won't pay any charges from out of network physicians. A PPO will sometimes pay, but with a huge deductible. Only a classic 'fee for service' insurance or sometimes workmans comp will pay the entire bill at cash rate (only very rarely encountered today).

> Thus the patient would pay $450 for the visit.

Except that the patient rarely pays if he doesn't have insurance. More commonly, the bill will remain unpaid for 90 days. The billing manager will call up the patient and ask: 'So, how do you want to settle this ? You can either make payment arrangements with us, or we give it to collections'.
Many physician practices will opt to accept some fraction or installments on the outstanding debt and write off the rest as bad debt. Sending collections after your patients doesn't make you popular in your community.

> Is this an accurate picture of billing/reimbursement or am I off the mark?

You lost me at the end there.

 

[docB]

Could you clarify reimbursement a little?

From what I understand...

Everything you said is pretty accurate. To answer some of your questions yes a doc can opt out of Medicare but it's tough because then you can't have any patient's over 65 and they are the biggest consumers of healthcare. If you opt out of medicare you do it totally. You can't see any Medicare patients at all.
You are right about what the third party payor (jargon for Medicare, Medicaid or insurance) and what happens to the leftover balance? For the insured they get a bill from the doc for whatever the insurer didn't pay. I think you're right about the M&Ms prohibiting billing the patient for the leftover but I could be wrong on this (anyone?).
Since CMS has set prices for everything you can't increase you pay by charging more. I do it by working more shifts, primaries do it by seeing more patients. Some docs get into big, big trouble by doing unecessary procedures. Medical economics is a bizarre thing because there is no relationship between supply and demand.
All in all if every resident would read your description the amount of knowledge about this would double from the average. Most residents don't know what CMS is.

 

[docB]

Oops. I didn't see f_w's reply there. f_w is right about what he said. And he confirmed about the prohibition against overbilling Medicare.

 

[f_w]

> yes a doc can opt out of Medicare but it's tough because

Well, you actually have to 'opt into' medicare. It is an active act requiring a 20 page form to be filled out.

> then you can't have any patient's over 65 and they are the biggest
> consumers of healthcare. If you opt out of medicare you do it totally.

If you are not a medicare provider, you are free to see any patient you want, including mediciare 'beneficiaries'. You can also bill them cash rate and have them pay out of pocket. Some 'take no insurance' surgeons still do this. People will spring 8k vor a cataract done by one of these guys rather than having the local guy do it on medicare for $600. But the market for this type of boutique practice is very slim.


> You are right about what the third party payor (jargon for
> Medicare, Medicaid or insurance) and what happens to the
> leftover balance? For the insured they get a bill from the doc
> for whatever the insurer didn't pay.

It depends. If you are an enrolled provider with big HMO/PPO plans, your contract specifies what you are allowed to bill the patient and what not. Typically, all you get is the co-pay + whatever the insurance pays you. Your contract typically won't allow you to bill anything beyond that to the patient. In 'fee for service' insurance, the company will pay you cash rate or a little bit below that. Usually they pay way better than the HMOs so you would be a fool if you drove that patient away by billing the balance out.

> Some docs get into big, big trouble by doing unecessary
> procedures.

One thing you want to make sure is that you know how to get paid for the work you do. As long as you document your work properly and bill what the guidelines allow, you are fine (doing unneccessary procedures is not only fraud by also highly unethical).

 

[curious1]

What do you people think the future holds in store for private practices? A lot of people talk about efficient practice models, but then physicians never seem to be able to implement them well (e.g. they have too many secretaries, feel too bad to fire unnecessary people, don't schedule visits well...). And Kaiser's style of practice doesn't seem to be catching on anywhere else in the same way it did in California. Is 50% overhead for private practices here to stay?

Btw contrary to what many people think, I have heard from my family members that medicare can actually one of the best insurance plans... at least they pay on time!

 

[fedor]

Btw contrary to what many people think, I have heard from my family members that medicare can actually one of the best insurance plans... at least they pay on time!

This is contrary to what I have heard. I heard that it takes up to 12 months for medicare to reimburse. Can anyone chime in on this issue?

I would imagine it's a question of perspective. A hospital with a largely uninsured indigent patient base I imagine would relish their medicare patients.

On the other hand, an Ob/Gyn I know had such a busy practice that she decided not to accept any medicare but also any other insured patients. All patients had to pay cash. Yet her office was still packed.

 

[fedor]

The medicare rates vary by state and sometimes county. The goverment factors cost such as office rental and malpractice rates into the equation (as a result, taking out a hangnail is $178 in NY,NY and $104 in Dickinson,ND. You can look this up on the CMS website).

Looking at the CMS website was the most mind-numbing experience I have faced in the last 10 years. I believe there are thousands of diagnostic codes (DRG's) with all sorts of extra variables. The site is absolutely not user friendly with no tutorials. And the gaudy color scheme! Hah!

Is there a good way to get familiar with the issue of coding? I was considering picking up a few books on medical billing and coding that the secretaries use. I believe that they even have a certification exam of some sort for this. Do any of you have any experience with this sort of thing?

 

[f_w]

> Is 50% overhead for private practices here to stay?

Unless the US medical system through some act of god goes to a single payor system, the answer is unfortunately yes.

> This is contrary to what I have heard. I heard that it
> takes up to 12 months for medicare to reimburse. Can
> anyone chime in on this issue?

HMOs have a tendency to drag their feet. Medicare actually pays within a few weeks of you submitting your bills electronically (at least aroun here).

> an Ob/Gyn I know had such a busy practice that she decided not
> to accept any medicare but also any other insured patients.
> All patients had to pay cash. Yet her office was still packed.

You will rarely find this type of practice outside of California, NYC and Florida. In primary care, you need a thick 'cream layer' of worried well to sustain such a practice.

> Looking at the CMS website was the most mind-numbing experience
> I have faced in the last 10 years.

 

[fedor]

Radiology groups commonly have a contract with the hospital. In one way or another, it gives the group the exclusive right to interpret all imaging studies (sans cards, sans OB) at a given hospital in exchange for the obligation to interpret all studies in a timely manner. These contracts also oblige the rads group to some level of overnight and weekend coverage.

How is it possible for night and weekend telerad locums to be desirable? If radiologists bill their patients directly, and night and weekend reads are usually emergency cases while daytime cases are mostly elective, then the overnight/weekend locum would get a terrible reimbursement because of the worse payor mix.

What is the incentive for this individual to accept their outsourcing and read at night or on the weekends since collections will be lower per scan because of the worse payor mix. Do these groups provide additional compensation beyond the normal percentage of collections?

 

[f_w]

The telerad company bills the RADIOLOGY group a fixed amount per prelimnary read (maybe $50 for a CT). The rads group gives the final read the next day and bills the patient or his insurance. In the mix, the group will typically loose money on it, but the comfort of not getting up at 2 am on sunday to read the 25th kidney stone CT on the same patient in the past 6 months is priceless (also they can usually save about 1 FTE they usually have to use for on call coverage and in the end it is a wash).

 

[fedor]

Can internists accept patients who are not adults and can pediatricians treat non-handicapped adult patients?

An American physician's medical license is very broad, and even a pediatrician could legally perform a hemispherectomy if he were so inclined, but certain obstacles would prevent that from happening in reality:

1) difficulty of finding a hospital to provide privileges
2) invitation to lawsuits
3) medmal insurance won't cover it
4) difficult to find patients who would put themselves in your hands
5) patient's insurance won't cover it

Now back to the original question about ped's treating adult patients. Do the same non-legal constraints hold? If a mother presents her children and also asks the pediatrician to take a look at her, would the ped do it? Would a pediatrician continue treating a patient once a patient turns 18 and specifically requests continued care?

While peds wouldn't be interested in performing a hemispherectomy, I can see many peds wouldn't mind treating the patient for a few years past adulthood. Likewise, I could see internists willing to treat patients just shy of adulthood. While turf wars seem common in medicine, I have yet to hear any complaints about turf from peds and internists. Is it just because there are firmly entrenched rules and regulations on this particular issue?

 

[fedor]

Another question that hopefully one of our more experienced posters can shed some light on.

Are a physician's prescription records accessible by the public? The reason I ask is that pharmaceutical reps are often able to obtain this information and thus reward the physicians accordingly. From what I have heard, pharmaceutical reps are often able to obtain lists of everything the doctor has prescribed, not just the drugs the pharmaceutical company in question sells.

 

[f_w]

> Now back to the original question about ped's treating adult
> patients. Do the same non-legal constraints hold? If a mother
> presents her children and also asks the pediatrician to take a look
> at her, would the ped do it?

Most likely he would send her to her PCP, but that would be based on the pedis preference, not on any of the legal constraints you mentioned before. As long as you are in your own office, hospital priviledges have no bearing, I don't think malpractice carriers restrict pedis to <18 patients. Reimbursement shouldn't be a problem either if the pedi is provider for the moms insurer (which is often the same as for the kids).

> Would a pediatrician continue treating a patient once a patient
> turns 18 and specifically requests continued care?

Some do, some don't. Most 18-25 year old rarely ever see a doctor anyway (unless they have some chronic health issue such as asthma or diabetes). There is a 'gap' that these patients fall into. Internists are so used to their geriatric clientele that young patients often don't feel comfortable with them. Pediatricians on the other hand are often in such a teddybear mode that it doesn't fit the bill either (and adolescent medicine is the specialty dealing with substance abuse and promiscuity, often not a place where normal teenagers and young adults fit in either).

 

[docB]

Another question that hopefully one of our more experienced posters can shed some light on.

Are a physician's prescription records accessible by the public? The reason I ask is that pharmaceutical reps are often able to obtain this information and thus reward the physicians accordingly. From what I have heard, pharmaceutical reps are often able to obtain lists of everything the doctor has prescribed, not just the drugs the pharmaceutical company in question sells.

That's a good question. I don't really know the answer. I don't think that just anyone can get those records but that being said I'm not sure what mechanism allows the drug reps to get it. I know that in NV there is a state board of pharmacy that we have to pay every year. They track everyone's rx habits. One thing that is cool about them is that they will send you a letter when they think you got hit by a doctor shopper. They'll send you a printout of all the narcs that patient has gotten recently. It usually looks like a who's who of EM in town. You can also call the pharm board's enforcement division if you think you are getting played by a seeker.

 

[fedor]

That's a good question. I don't really know the answer. I don't think that just anyone can get those records but that being said I'm not sure what mechanism allows the drug reps to get it. I know that in NV there is a state board of pharmacy that we have to pay every year. They track everyone's rx habits. One thing that is cool about them is that they will send you a letter when they think you got hit by a doctor shopper. They'll send you a printout of all the narcs that patient has gotten recently. It usually looks like a who's who of EM in town. You can also call the pharm board's enforcement division if you think you are getting played by a seeker.

Welcome back docB. Here is the answer to the question (I researched it pretty thoroughly over the weekend):

Most of the information on prescribing habits comes from the large pharmacy chains which sell the prescription records of the physicians to intermediate companies. As long as the patient names are not sent, it is legal. These intermediate companies (such as IMS Health, Verispan, Dentrite International) then correlate the prescription records with doctor information they receive from physician databases such as the AMA's physician database.

These intermediate companies are very sophisticated and they're often able to provide data on prescribing habits within a few days of the prescription. They sell this information to the pharmaceutical reps who use this to target doctors more efficiently.

When a pharmaceutical rep comes to your office, they almost certainly have detailed knowledge of your prescription habits. If you respond well to their visit (aka: dinner, gifts, etc.) they will continue to reward you. If your prescription habits don't change (and they now know within a week how their "visit" effected your prescriptions) then you can expect them not to reward you in the future.

NPR had a piece about this where they mentioned that few physicians were aware that pharmaceutical reps had such information, let alone how detailed it was, and that pharmaceutical reps were discouraged from revealing this to physicians who would rightly become infuriated.

 

[docB]

Welcome back docB.

Thanks. It's fun to go away but it's always good to be back.

You know, my ignorance of this (the pharma rep stuff) speaks to a difference between EM and other specialties. In EM we just don't have as much interaction with the pharm reps. We don't get a lot of stuff and I'd say they have relatively less pull with us. It's not like we're better or untouchable or anything. I'm sure willing to be bought 😉 but the nature of EM makes us less interesting to the reps. We don't prescribe long term. We like cheap, generic drugs that your typical uninsured ER pt might be able to afford. We are more pressured by hospital formularies than anything.

 

[fedor]

How about state disciplinary boards? If I am not mistaken, a physician is licensed by each individual state and must abide by the medical code of that state. If a physician were suspended or otherwise disciplined (ie, can only function under the supervision of another physician) in a single state, would he be able to continue practice in another state? Or do states uphold the suspensions of other states (much like in professional boxing) without the ability to look into the details of the case?

 

[docB]

I don't think that they work like the boxing boards. I have heard of people moving to get away from restrictions on their licenses. Every state I've ever looked at has a rule that you have to tell them about any discplinary actions against you but then they can decide if they want to do something about it or not.

 

[f_w]

a physician is licensed by each individual state and must abide by the medical code of that state. If a physician were suspended or otherwise disciplined (ie, can only function under the supervision of another physician) in a single state, would he be able to continue practice in another state?

Yes and no.
There are two databases. The 'national practioner database' and the 'board action database'. If you have disciplinary action or a malpractice issue in one state, it gets broadcast to all the other states you have licenses in. Many of the cases of license suspensions that you can see on state medical board websites are just 'the state of xx has revoked Dr YYs license to practice due to medical neglegience/chemical dependency/sexual misconduct. In keeping with this states medical code, we hereby suspend Dr YYs license'. They do know what the other state suspended the license for (you signe away your right to privacy on the medical license application).

The system is not perfect as many states don't check on other states board actions until your license comes up for renewal. But particularly if you apply for a new license, all your prior misdeeds will come up.

 

[fedor]

How about mortality statistics and other statistics such as the # of procedures done at each hospital?

Is this information proprietary? Are there any agencies which oversee these statistics?

I have heard before that some hospitals refused to provide patients information about mortality statistics for certain procedures (in this case, CABG's). If anything, I would imagine that there is a federal agency of some sort which would demand these statistics for medicare patients.