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CME Practice Management

Negotiating a Physician Employee Contract and a Contract with a Third Party Payor

Sev Hrywnak, DPM, MD

Sev Hrywnak, DPM, MD will review common terminology and factors to consider when reviewing an employment contract as well as accepting an insurance company contract.

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Goals and Objectives
  1. Understand the definition of the different types of law
  2. Understand the key elements to an employment contract
  3. Understand malpractice insurance and how it relates to the environment you are working in
  4. Understand Insurance company contracts and how to better negotatiate reimbursement
  • Accreditation and Designation of Credits
  • CPME (Credits: 0.75)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.75 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Sev Hrywnak, DPM, MD

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  • It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

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    Sev Hrywnak has nothing to disclose.

  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker: Our next speaker, I believe is here, Sev Hrywnak, I hope I pronounce that right, I didn’t kill it. Doctor of podiatric medicine and a medical physician who’s going to be talking about negotiating a physician employee contract and a contract with a third-party payor. So please welcome Dr. Hrywnak.

    Dr. Sev Hrywnak: Good afternoon, and thank you for inviting me to ePresence to present this lecture. We’re going to be covering in the next 25 minutes two aspects of law, major components of law which is contract law which sooner or later you’re going to be involved with and I know you’re residents now. We’re going to go through this fast but we’re going to hit on all the major points. In my experience, the past 25 years, I can create a contract museum from all the different contracts former students have sent me. And contracts are always evolving. The rules of the game are always changing and it’s something you should be aware of but you got to have a basic foundation. So to start off, we have to make a little bit of a little bit of a background here on what law is. And the term law has a lot of acceptable meanings. Law in general is any rule that has been established and must be obeyed. And again, there’s about 15 different definitions for law, I’ll just give you the top two or three that we’re going to go by here in the United States. The term law is also used to describe a system of principles, rules of conduct, rules of human conduct that people have to abide by. In addition, law could mean a rule or other enactment of a governmental law making body. And last but not the least, a law can mean the principles, rules and standards that apply to a particular field, be it business law, contract law, tort law. The US legal system in the United States these days if somebody asked you to define it, it would be very hard to define. I would likely say that nobody really knows what’s going on. Law in and of itself has been evolving since the year 1066 after the Norman conquest when the king’s court started to make decisions based on precedent. It started to get more defined in the 13th Century when these rules were being written down and the precedents were being looked at to make decisions. You have to remember, by the 13th Century, only about 18% of the population could read or write and they depended on the kings and what they called yearbooks to look at the precedents and to see what they should do to somebody who broke the law. Currently, this is our sources of law in the United States. There’s basically five aspects of law that you have to consider. And that supreme law of the land is the United States Constitution. The US Constitution is number one at the top. Any law that contradicts the US constitution is null and void. Number two, we have statutes that are enacted by governmental bodies. Both federal and state governments have legislative branches that establish numerous laws. These laws are known as statutes. So that’s two. The third way is states. Each state has their own constitution. These constitutions run the state, but again, they cannot supersede the United States Constitution. On the lower level, we have what’s called ordinances. They’re enacted by the governments at the local level. And last but not the least, we have governmental agencies that have administrative laws, like, the National Labor Relations Board, the IRS. Those are legal bodies that have their own rules and laws and you have to follow them or you’re in trouble. We have to learn how to classify. I’m going to, just a short introduction until we start talking about contract law. A common way to classify law is to distinguish between substantive law from procedural law. Substantive law deals with creation, definition, and the regulation of legal rights and obligations. And some examples of substantive law are contract law, tort law, property law. Then we have another classification called procedural law. And procedural law is the enforcement of the rights existing by reason of substantive law. So procedural law broken down would the civil procedure, criminal procedure, administrative procedure, that’s one way the lawyers look at it. To simplify it, I like to classify it as public law from private law. So public law, by definition, would deal with the rights and the powers of the state – constitutional law, criminal law, administrative law. Private law deals with individuals and their relationships with each other. Again, going back to contract law, tort law, property law. What we’re going to be talking about today is basically going to deal with contract law because you’re all going to be dealing with contracts. So by definition, a contract is a basically a promise or more precisely what kinds of promises are enforceable by law. So a promise is enforceable by law is a contract. By legal definition, a contract is a promise or a set of promises for a breach of the law against the remedy.

    [05:01]

    That’s what we’re looking for. To have a valid contract in the United States of America, you have to have four components, a valid offer and acceptance. Number two, consideration. Consideration, 90% of the time being money. Number three, legally competent parties. And number four, a lawful purpose. These four aspects must be in the contract or the contract is deemed null and void. And sometimes you need to go to court for a judge to decide if the contract is legal enough. When you’re going to be involved in doing contract negotiations and you might be involved in contract negotiations, you might be involved hopefully not in a legal lawsuit or a tort violation and a malpractice. One thing I need to mention here, a lot of times students ask me in residences, if I get sued or if I have contract I don’t like, why do I need a deposition? A deposition is part of the legal process called discovery. Discovery is when you’re involved in a lawsuit, be it for contract law or for tort law, when you’re involved in discovery in a lawsuit; discovery means each side gets to find out what they know. And parts of a discovery are interrogatories which is a set of questions that the lawyer sent to each other. And the second part being a deposition where they have the right to sit you down and ask you questions. One thing I always stress and emphasize in a deposition is, a deposition, if you haven’t gone to one and you might in the future, a deposition strictly is when lawyers use a deposition to evaluate the plaintiff or the defendant. When I mean evaluate, I’m talking about evaluating from the standpoint, how would they appear and look in front of a jury. Because a plaintiff or a defendant can lose your case. And the way I evaluate them is at a deposition and the way I can get to unnerve them or make them look upset or make them look angry is by asking them questions. And one of the major rules of thumb in law is you never ask a question of somebody that you don’t know the answer to. All right. No lawyer will do that ever. They always know the answer. And a lot of times, what doctors have a problem with is they assume that the attorney does not know anything about medicine, all right, that the attorney does not know anything about biomechanics or surgery. And that’s the wrong assumption to go by. All right. If an attorney is involved in contract law, they’re going to know A through Z if they’re involved in malpractice. They’re going to know everything from an anatomic standpoint, the procedural standpoint, preoperative care, post-operative care, maybe sometimes better than a physician would. So don’t underestimate an attorney, they’re there to trip you up and it’s a very important point I bring up here when we’re talking about contracts. When we start talking about contracts, all right, and I’ve seen so many over hundreds, maybe thousands in the past 25 years, the basic aspect of a physician employment contract [indiscernible] [7:46] when you’re an associate and you’re signing an associate contract, the first thing I always tell everybody is try to remember what the initials in front of your name stand for. Either DR is going to stand for you’re a doctor and it’s an abbreviation or DR is going to stand for delaying reality. And you’re going to be a permanent associate and you’re not going to make the jump to have your own practice or be involved as a partner in a group. So you have to decide which DR you are, hopefully you’re a DR doctor. But everybody needs to know what their compensation is going to be. Today, and things could change next month as things have changed a year ago, compensation changes. If I had to draw a scale now or a graph now, the compensation for associates is slowly diminishing year by year. It’s down 8% from 2014 to 2015 in what doctors are getting. The average associate contract that I’ve seen enough in the survey is between 45 to 75,000 for an associate. All right, I’ve seen some higher, I’ve seen some lower. So what you’re going to have is establish as a base. You’re going to have a base salary. Along with that base salary, there might be some clauses or incentives or bonuses put in there for you to make money for the senior partner or for the practice, one of them being productivity. A contract for employment can tie your productivity into how much you’re going to be receiving. How many surgeries you do, how many orthotics you prescribe, et cetera, et cetera. Those are legitimate items that can be put into an associate contract. Incentives, same thing. If you work an extra day, if you do health fares, if you do home visits, there might be incentives put in there that you receive some remuneration for doing that. And the last but not the least is bonuses. That’s the one we always have a problem with on employment contracts is the bonus clause. A lot of times, you have a standard salary base, let’s say for example, it’s 50,000 a year. The bonus clause is usually tied in – the bonus clause is usually a percentage of the patients that you have seen and what you have collected. The usual percentage range as of 2015 because I’m a year behind in getting statistics is about 20% to 25%.

    [10:04]

    So your contract will read that you’ll have a base pay of a thousand dollars per week plus you will make 20% to 25% of what you collect from the patients that you’ve seen. But here’s the caveat, it’s going to be based on your base. Meaning, after you’ve achieved $50,000 of collection, anything up and above the 50,000, then you’ll get your 20% or 25% of what you’ve collected. Now, a lot of physicians like to use two times the base, one and a half times the base. All you’re doing in that practice is you’re paying for yourself. So once you achieve that $50,000 ceiling, anything after that, you’re going to get 20% to 25% of. What I always stress at when you negotiate a contract is you must have in that contract. You must have in that contract the ability to look at the EOMBs, the explanation of medical benefits. All right. You need to know what was billed on your behalf. Number one or actually number two, that’s your money; and number one, legally, you want to make sure that what’s been billed on your behalf is correct. Because the last thing you want to do is wind up in Medicare jail. Okay. These things do happen. So if you’re going to take anything away from the last five minutes, you need to look at the explanation of medical benefits, the payment should be to you quarterly and you have to monitor it. Any future partner or associate, a contract to get into that does not want to provide you the EOMBs, that’s a red flag, that’s only putting your license and your livelihood at stake. Next, terms, a lot of people get this wrong. I always ask everybody, they send me a contract and the contract says I’m going to be an associate from July 1st 2016 to June 30th 2018. I have a two-year contract. And I say, okay, now look at the termination clause. And they’ll flip to the back page and I’ll say, “Read me the termination clause and termination clause for any cause”. This relationship can be terminated in 30 days. So then I’ll ask you again how long is this contract. The contract is 30 days. All right. Termination, so the date you started and the date you finish, okay, are usurped by your termination clause. All right. And we’re going to talk about with cause and without cause, you’ll always want to have termination for cause. All right. You lost your license, you lost your malpractice, you got arrested. All right. You lost your DEA privileges. That’s four cause. Without cause, the doctor might see you one day and say, “You know what, I’m just sick of having this associate, I’m giving you notice and you have to go”. And guess what, based on your contract, you have to go. So that 30 days is your actual length of your contract. It’s not the two years. It’s not the one year. Also, I bring up that a lot of contracts don’t have for employment is hopefully you’re looking to get into a practice. So you understand that you’re going to be an associate the first year or the first two years. Another vital part of an employment contract with a physician, with another doctor, is during the course of employment, sometimes halfway through the course of employment you will sit down and have meaningful negotiations to buy into the practice. That’s very, very important. And a lot of times lawyers miss that. Because if you start negotiating two months before your contract is over, you have no legal standing to try to buy into that practice. You want to do it halfway through. You might not want to buy into that practice. But you want to have that ability. And that ability is if it’s a two year contract, 12 months into it, do I have the opportunity, doctor? Yes or no to buy in and you do. The doctor should provide three years of the income tax returns of the corporation and be able to send that person, the associate to the bank or whatever or that group, give the tax returns and you have the ability to buy in. The ability to buy in doesn’t happen overnight. That’s a long-term process. And again, banks these days are not as willing to give money as they were years ago. But still, you want to have that opportunity. The only way to have that opportunity is it has to be in writing in your employment contract. So that’s a caveat you should take away. The doctor can tell you, sign this contract and yes, in two years halfway through this or whatever, I’ll talk to you about buying in but it’s not in writing. If it’s not in writing, it didn’t happen. All right. We’re talking contract law here. We’re not talking of verbal contracts; we’re talking actual employment contracts. But what else are you going to be looking for? You’re going to look for benefits. Are the benefits just health and dental? Is it life insurance? Are you looking for CME credits? Are you looking for reimbursement for those CME credits? Travel, lodging. Those are part of the benefits package you’re going to need to look at. And I don’t care if you’re going into in with one doctor, three doctors, or a group of twelve, that’s going to impinge on your base salary. So for example, I’ve seen a contract for 90,000 a year. First year podiatric surgeon, 90,000, 15% bonus clause. No benefits. You subtract out health insurance, dental insurance, life insurance, CME credits, you’re down from 90 to 70 to 68.

    [15:06]

    All right. It’s time to think about money because it’s all about economics here. If it’s not in the contract, you’re not going to get it. So that’s what I throw in the business expense. Same thing. Malpractice insurance. Of course, the senior doctors are going to provide you malpractice insurance. And the malpractice insurance is usually 1 million, 3 million. One million per incident, that’s what the first number means. The second number, the 3 million is aggregate. Meaning, if you got served five times and it equals 3 million dollars, you’re still covered. That’s the important part. The more important part is who’s going to provide the tail if you leave the practice? So if your malpractice is 15,000 a year, for example, you’re there the one year, you’re there the second year, it’s 15 and 15 but you leave the practice. All right. You’re going to need to buy a tail. A tail is 30% to 50% of the year premium. So for you to be covered on prior x, you’re going to have to come up with 7,000 or does the practice that you left come up with a tail coverage. Very important, a lot of contracts don’t have it in there. And the young doctor who’s leaving the practice go on their own or go someplace else is stuck with a big malpractice bill. Second thing is to take into consideration; this is more practice management than law. With the changes going out in medicine out there and macro, et cetera, which if you’re going to the IPA meaning in September, I got a two hour lecture on macro. Things are changing. More doctors are turning toward their office or toward a surgical center to do procedures. Now remember from a legal standpoint, the reason a hospital wants you to have 1 million, 3 million dollar coverage is what? Is to spread the liability. Okay. Because as an attorney, if I go in and sue, all right, I’m not just suing you, I’m suing the nurses, the janitors, the hospital, anybody those within a mile of that case. And hopefully, we’ll have a lot of co-negligence going around there because everybody has a million, three. The hospital requires a million, three to spread their liability. If you turn to surgery centers depending on some states or if you turn to doing office-based surgery, whichever off you’re going to do, your malpractice insurance can be 200,000, 600,000. It could be 100,000, 300,000. Okay. From a legal standpoint, two things happen, you’re still going to get sued, that’s right. Number one, financially, you’re saving yourself a lot of money. The lower your malpractice is, the cheaper it is. Okay. And number two, it’s very hard for attorneys to collect up and above your malpractice. So if you’ll get sued for $5 million, chances are the attorneys will sue and take up to 3 million. All right. That will be the judgment for 3, anything after that will be dismissed. Now there are some cases now that the attorneys are going up and beyond malpractice coverage. You got to be careful. You got to see what state you’re in. Malpractice rates are adjusted by the county you are working in. That’s why the rates vary from Cook County in Chicago to Poughkeepsie, New York County where there’s only 60,000 people in the county. Malpractice insurance rates change all the time. The more you want to do, the higher the malpractice insurance rate is. The more you wanted to sports medicine, the higher the malpractice rate is. The more you want to work on pediatric population, the higher your malpractice rate is going to be. So now doctors, GI, ophthalmologists, plastic surgeons, they’re doing a lot in their office. They have lowered their malpractice from 1 million, 3 million to 500,000, 1 million. They’ve saved a lot of more money by not paying exorbitant malpractice fees. Another important issue on your employment contract, the scope of duties. And trust me, I bring this up because I’ve had one contract from Boston a few years back where a podiatric resident got a job after they finished their residency. I went through it the first time and I blinked. And I had to go back and read again. Besides providing podiatric medicine and surgery at the location, the associate had to come and run the snow plow for the senior doctors’ driveway. That was in the contract. Okay. That’s fine. Let me back up a little bit here just mentioning that. You’re educated enough and you’re going to be physicians that before you even go to an attorney to review your contract, you have to take that contract, label each paragraph one, two, three, four, five, six, seven, eight, ten, whatever. There’s 30, 40 paragraphs, you have to decide what you’re comfortable with. Because if you come to me with your contract made by another attorney, I’m going to find 15 things wrong with it and I’m going to convince you that I can’t live with this paragraph. You have to decide what you wanted to live with.

    [20:00]

    The attorney can give you the advice legally, you make the decision, otherwise, it’s turned to what they call a pissing contest between two attorneys. And guess who pays for that pissing contest? You do. All right. The $300 an hour to negotiate your contract, it could take 15 hours. So again, you’re adults, you’re physicians, you’re educated, don’t let the attorneys decide what’s good for you. You decide what’s good for you, let them explain the contract, that paragraph and you say, I’m fine with that counselor, let’s go onto the next paragraph. Oh, I can live with that. Are you sure you can live with that? I wouldn’t live with that. Well, don’t worry about it, I’ll live with it. I know what the risks are; you just told me the risks and benefits in the contract. So the scope was one issue, you have to identify the locations and areas that you’re going to be practicing at. This comes up every so often, I’ll take a look at a contract and they’ll say the associate will be working at 123 East Main Street. And then six months into the contract, well, guess what, I forgot to tell you, but about 40 miles away, I got to satellite office, you have to go to Tuesday and Thursday. Well, that’s your gas and tolls and time. So location should be identified in the contract. Equitable allocation of time, a tough one. I got an associate now so, you know, it’s a great day, I was going to see all these patients but my buddies just called me to play so I’ll see two patients and I’m out at the office by 10:00. Now you got to see your patients and my patients. That’s what equitable allocation means. Moonlighting. There are some contracts that say, any financial reimbursement during the course of being an associate goes to the practice. So if you get a nursing home, if you’re doing school exams, or taping and padding, athletes and stuff and you’re getting paid for it, the doctor has a right to grab your income. So it’s very important that what can I do outside this practice that’s 100% my income. And I’m mentioning that because I see it more times than not in the contracts. Last but not least is the catch-all phrase of integrative medicine and this is the new term the last three, four years since Obama Care came out and all these changes. Integrative medicine more applies to if you get a job with a hospital to run a wound care clinic or to provide podiatry services. Integrative medicine is just a clause to put in it to make sure that you’re working with other healthcare providers. I’ve only seen one bad clause, one bad clause in the past year, that clause was written that the podiatric physician can see the wound care patient three times and after that, the wound care patient has to be turned over to, anybody have a guess? To…

    [Crosstalk]

    The nurse practitioner. Correct. Who said that? Somebody is on top of things. All right. Turned over to the nurse practitioner after three visits. Well, wait a minute, I’m the doctor, I’m taking care of the patient. That’s justifiable enough, we’ll talk about that later on. That’s justifiable enough to have you dismissed from your contract because you’re not practicing integrative medicine. Or vice versa, the nurse practitioner saw the sub second diabetic ulceration and referred to you, but guess what, based on their metrics and standards, it’s seven visits later, nothing has changed. You’re not doing quality measures; you’re not meeting the metrics; that gives me a reason to dismiss you from this practice. Little things like that add up and are important in contracts. We mentioned it briefly before about termination, the termination goal is for cause or without cause, you have to be very careful how it’s worded like termination for cause, material breaches. Again, if you get caught with a DUI or if there’s things going on here, they have a right to dismiss you. Unilateral termination, you’d like that in there, sometimes the attorneys will fight that. That’s your decision. You want a unilateral from your part. You know what, I got another offer, I’m out of here, I’m going, I’m giving you my 30-day notice. All right. But I still would want some severance pay. And if I don’t become a partner, you can put that in that if I don’t become partner or there’s no chance of me coming a partner, why should I stay here another eight months? I have the right to leave now because somebody else is giving a better offer. So these are the little things that should be in your contract. A lot of times even good contract attorneys in healthcare don’t pick up at it because things change so much. The one thing that you should take away from this whole weekend seminar is medicine is changing not month by month, not day by day, it’s changing minute by minute. And everybody is scrambling to get to a position, get their hold in the healthcare world that is rapidly changing. Restricted covenants. Tricky subject but very important. With restricted covenants nowadays and the Federal Trade Commission has ruled that even two years and two miles maybe too much because when you sign this contract as an associate, there’s going to be a restricted covenant clause. Restricted covenant clause has the following, when you leave that practice for the next two years and two miles, you cannot practice within the location of that office. A restricted covenant that’s been challenged in Tennessee and in North Carolina because we need more doctors everywhere, we can’t exclude them.

    [25:01]

    If your contract for restrictive covenant clause says ten miles, five years, that will never hold up in court, okay? There’s ones that I’ve seen where it says, once you leave this practice, you can’t practice for two years, two miles and you have to resign all your privileges at the hospital. Again, the Federal Trade Commission is looking down on that very hard the past year and a half because areas are losing doctors and they don’t want that to happen. The trick on that one is what I’ve seen is there’s a restricted covenant and it says one year one mile. So far so good, are we on the right page? One year one mile, that’s not bad. But then the rest of the senses of any existing location that the doctor or the company has, well, there’s four satellite offices. The four satellite offices are scattered throughout the county so one mile could took a compass and circle that you’re outside the county. All right. So you have to be careful and you have to be very specific on what location, it should be the main location where the restricted covenant takes effect. You can always agree to two years two miles, you can negotiate that but you should never agree to the part where you have to give up and resign your hospital privileges. And that’s still an old trick that’s in lot of employment contracts when you’re an associate. Confidentiality, there’s always a clause in there that you cannot approach any of the help. You cannot approach any of the patients that if you’re leaving to set up on your own here. I’m leaving next week, here’s my business card, can’t do that. Oh, this assistant was great, he or she were great. I want you to come. I’m starting a practice or I’m joining another practice. There will be a confidentiality. There will be a restriction on approaching any employees and any patients of the current practice. If the patients decide on their own and they find out you’re someplace else, there’s nothing the senior doctor can do about that. So we’re just talking about confidentiality and restriction approaching patients and employees. Next one is even better. We’re going to talk about negotiating. Negotiating with health insurance companies. This was the easy part doing an employment contract for being an associate with a group or a senior doctor. That’s the easy one. This is the hard one. This is the one that changes week to week, month to month, as different hospitals merge, as different corporations change their rules as they go by different guidelines of how much they want to pay any type of specialty and we’re going to talk about that for a few minutes. This is basic in any employment contract with a third-party career. I don’t care if it’s Blue Cross, Aetna, Humana, it doesn’t matter. This will always be the top of page and I underlined what’s important because these are the things they will catch you on in law if there’s a problem. The intent of this contract is to provide access to enhanced quality in healthcare, utilizing managed care components at an affordable, competitive cost to members of this health plan. And the health plan being Blue Cross, Aetna, whatever. Very important because each one of those words are catches, okay, where they can dismiss you from the health plan. They’re looking for reasons to dismiss you, that’s the first paragraph on any contract that you’re going to sign with the carrier. By definition, you’re going to have all these catch-all phrases in there and you better know what they mean, all right, because these are the things you will get trapped on, well, what do you mean you’re not allowing me to see these patients anymore? Well, doctor, you’ve just exceeded the medical necessity, we’ve done a scan, we’ve done a study. What’s happened to medicine and I’ve told all my friends that we talked about it is computers have changed how insurance companies operate. Insurance companies need data. They never had access to data. Data was always regional. It was actually by ZIP code 20 years ago. You know, Downtown Chicago paid higher than outside of Chicago and the fringes, all that has changed. Okay. So with data, insurance companies have learned how they can control the cost they reimburse back to you. So for example, an allowable fee by definition, maximum charge, a third party will reimburse a provider for a given charge. Okay. Medical necessity, another one. Healthcare services are supplied, needed to prevent, diagnose or treat an injury condition, diseases or symptoms that need the acceptable standards of this health plan. Okay. Maybe it doesn’t mean anything to you, established doctors out there know what these means, these are catch-all phrases of this health plan. Metrics which we just talked about. A method of measuring the quality or quantity of something. Metrics is the big catch-all phrase, analytics is the second big catch-all phrase. That’s what they’re using to drive doctor’s fees down. Well, you don’t meet the metrics. The local coverage determination, you don’t meet that. All right. “If you don’t meet that, we’re not going to keep you on the plan. If you’re in this ACO and you don’t meet the metrics, you’re costing the ACO money.” Meaning, let me simplify it, I’m a family practitioner, all right, I see somebody with strep throat, I give them an antibiotic, they come back the second time, they’re cured. All right.

    [30:02]

    The guy down the street sees another patient with strep throat. Does a rapid strep test, culture sensitivity, sees them four times. Well, they’ve exceeded the metrics for that area. The average is 2.2 visits to get rid of strep throat. So visit three and four will not get paid by that, for that doctor. These are things that are going on here. That’s why you have to change how you’re thinking because all health plans are all going that way and we’re going to get to more other things. Precertification, prior authorization, all these things are going to be seen in the contracts, prior approval, that’s a big one. Physician responsibilities, these are all standard from health insurance contracts. Services that are medical necessary under this plan, you refer to members, you refer the members to physicians in the network, okay, big one, prescribed medications adapted in the health plan formulary, have patient records on EMR within 24 hours that they could access. Very important. Participated and abided by decisions from reviews of medical care by the physician, return payments, over payments in 30 days, and participate in all patient audits. By having electronic medical records, the insurance company has the right to go into your records while you’re sleeping and pull out all the data of how you’ve treated your patients, how many times they’ve come, what kind of treatment you provided for them. That’s what they look for. These are standard clauses, I don’t care if it’s Humana, Blue Cross, Aetna, this is what you’re going to find. And these things only get tighter and tighter as they try to reign in of how much they spend for healthcare, meaning, how much they spend to pay their practitioner. Even more important is compensation in these plans. The plan agrees to pay the physician’s bill charge for each procedure or office visit a set fee established by the plan. Physicians must collect all deductibles, co-insurance copayments, reimbursement payments by a plan member in 30 days. Again, two year contract that you’re going to get from Aetna, Blue Cross, or whatever, there’s going to be an addendum or exhibits and the exhibits will tell you this is what we pay. Now, we don’t have an hour here to talk about but trust me, they’re going to bait and switch by showing you certain CPT codes that pay great and then the other 20 or 30 that they don’t show you, they’re not going to be on there. What doctors are advised to do since 2015 is you have got to provide the 30 top CPT codes you use in your office that you provide for your patients and you send that to them and they should send you a fee schedule that’s negotiable. I’ll go, I’m finishing up. Using the plans, EMR forms, billing and appropriate modifiers, again, if you don’t code right, you don’t put things down right in your computer, you’re not going to get paid for. The last one is very, very important because this gives you a guide of how you’re going to get reimbursed. Third party carriers now use Medicare as a basis. For those of you who are residents, I know you’re busy all day long treating patients, take five minutes and see what insurance company this patient has. Try to go to billing and collections in the hospital, see how much do you get reimbursed, what kind of plan are we under. A sample of fee schedules, attachments, reimbursement is set at a 120%. 120% of the prevailing Medicare reimbursement and maybe subject to change during this contract. All right. Maybe subject to change. 120% is not a lot of money, all right. But it depends on the value of patients you’re having so that’s an economic decision you would have to make. Prior authorization list have increased fivefold since just January 2016. Ask any of your doctors, need an MRI prior authorization, CAT scan prior authorization. I just listed a few at the top there all the way down to stem cell 38. So between there, every move you make, you better get somebody that sits at a computer that really doesn’t know anything about medicine but they’re going to give you the okay, yes or no based on a list of criteria on a template that’s in the computer. You know what you need for your patient but if you don’t meet the criteria, it’s going to come back from the computer from the insurance company. I’m sorry, it’s not allowed. We’re not going to allow you to order this test or that test. You got to take a look and see if you’re happy with that in your contract. Liability insurance. Insurance companies make sure that they are not liable. Remember, well, you didn’t allow me to order that test, that’s why that patient is suing me. No. We just told you we’re not paying for it. All right. You’re the doctor, if you think that patients still need the test, you should make sure that they go get it. Understand where they’re coming from. Again, termination, standard in all health insurance contracts for reimbursement. If you lose your license, you know, termination, et cetera, nothing that you should be surprised with. Any questions? How does that for law in 20 minutes? Yes?

    Male Speaker: Now, any default referrals referring to foot screening or treatment in advance or contracts related to that, not to include...

    [35:00]

    Dr. Hrywnak: It should not be in there. And I’ll tell you why, you’re negotiating with Aetna to get reimbursed. The last thing you want to put in that contract is you’re offering free services. Okay. Do not do that. It has nothing to do, you want to see patients, when you go do a foot screening, you don’t know what insurance they have until they fill out the release form, et cetera, et cetera. I wouldn’t go back and tell them I’m going to do free care for your Aetna patients. Never. All right. And again, we don’t have time for this time here but they’re going to take RVUs, they take Medicare, they do these averages, they try to bring the numbers down so you get less for your patient visits, less for the extra you take, et cetera, et cetera. Don’t let them factor free into whatever you’re doing, whatever work you’re doing. That’s a big no, no. You’re fighting an uphill battle trying to get reimbursed as it is. It’s good to do free care, again you’re doing a free foot screening, you don’t know what insurance companies they have until they fill out the form, then they come to your office for service that you’ll charge them for, et cetera. The other thing you keep in mind here is deductibles. When you go back to your hospitals, look what the deductibles are for the patients you’re treating. Three years ago, the average deductible in the United States was $275 in 2014, excuse me, 2013. All right. Guess what, there’s 2,500 now, there’s 4,000 now, there’s 5,000. They say by 2020, the average deductible at 2020 in the United States will be 10,000. Okay. The average premium for a family of four will be 12.81 a month. Okay, that’s a mortgage payment. The average, average coming up. These are the things to consider. So there’s a lot of work here to do. You’re a doctor but you got to be a businesswoman, a business person. Any other questions? Thank you very much.


    TAPE ENDS - [36:46]