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questions from physicians, office managers, office administrators
and others. Have a question about the operation of your practice?
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Q
How do I apply for a Medicare provider number?
A
To apply for a Medicare provider number, go to www.cms.gov
and download an enrollment form (also called the HCFA 855)
for providers.
Q
How do I know when to fire an employee? What issues
should I be aware of?
A
Firing an employee won’t get any easier if you put it
off. If an employee is costing you time and money, act. First,
though, make sure you’ve clearly communicated what you
expect from the employee and give him or her a chance to improve.
The following are some steps to take:
- Document problems and
all conversations with the employee. Be completely honest
in evaluations and discussions with the employee.
- Explain practice standards
and policies; review and discuss the employee’s job
description. Does he know what’s expected? Are the
job requirements fair?
- Set a time limit for
improvement. Be clear that this conversation constitutes
a warning and that termination is being considered. During
this period, point out when expectations are being met and
when they are not. If there is no improvement in the time
set, fire the employee.
These tips should help protect you from accusations of wrongful
discharge. Be aware that such laws simply mean that employees:
• have the right to be treated fairly;
• are not arbitrarily dismissed; and
• are evaluated with a sound review process.
Also consider adding “employment-at-will”
language to your employee policy manual or hiring letter.
That means there is neither a promise that the employee will
be employed for a certain amount of time, nor is “good
cause” needed to end the relationship.
Q
Is ours the only practice left
that still arranges call by seniority? The practice founders
take very little call, but the new recruits cover a lot of
hours. This used to be common, but now we are having a hard
time recruiting, apparently because of this policy.
A
Actually, quite a few practices still use
the seniority model — and you are absolutely right that
it is a barrier to recruitment. In repeated surveys, fellows
and residents say they are more likely to choose a practice
based on lifestyle issues than even compensation. Note that
this is partly about wanting more free or family time than
constant call allows, but it’s also about not wanting
to work in a job where one is seen like a serf bullied about
by omniscient masters. Partners — even “partner-someday”
employees — want to be treated like partners.
Some practices do manage to recruit more naive young physicians,
but within a few months, those recruits are writing to us
asking how to get out of their contracts with these obnoxious
senior physicians.
I understand how the senior physicians feel — they put
in their long hours when they were young, expecting more time
off when their time came. It is not unfair of them, per se,
to expect the payoff they worked for.
But the fact remains that the rules have changed.
Together, groups need to work out a compromise that everyone
can live with.
Q We are
in the process of building a new clinic that will have an
electronic medical record (EMR). We are interested in designs
for exam rooms, in particular, the work surface for the PC.
Have you seen any changes that practices have made as they
go to an EMR?
A
The changes you’ll need to make depend
entirely on how you plan to use your EMR.
Ideally, if physicians will use the EMR in the exam room —
whether on a tablet, laptop or desktop — they should
have room to set down their PC with sufficient space around
it for paperwork. It’s great if patients can be positioned
so that the physician can sit next to them while using the
EMR. Try to avoid forcing the physician to use the EMR with
his back turned to the patient.
If the EMR will be used between visits, some practices use
standing-room only “dictation pods.” This is a
space off the main exam room hallway with a small counter
— positioned high enough to use a PC on it while standing.
Physicians can pop in there between visits for some privacy
to create a chart without leaving the exam room area.
Q
Our senior physician is retiring
from our OB/GYN practice and the rest of us want to buy out
his share of the practice. No one here wants to do a formal
practice appraisal, but would simply be happy with a number
we could all agree was reasonably fair. Where do we start?
A
The historic median market value of OB/GYN
practices is approximately 28 percent of the previous year’s
collections for goodwill and intangibles, plus tangible assets
(furnishings, equipment, instruments, and supplies); plus
accounts receivable discounted to current value (and perhaps
adjusted for OB prenatals and deliveries booked but not collected,
depending on your global-fee accounting methods).
This historic figure is usually adjusted for variables of
income above/below norm, location and your state’s current
malpractice-premium environment for OB/GYN. Appraisers usually
look at value using at least three methods, then weigh the
results for a final opinion.
Keep in mind the possible need to recruit a new substitute
OB to replace the exiting one. It is currently very hard to
recruit OBs, especially in some regions, so goodwill value
may be depressed, especially if income is not above what the
market compensation is for employed OBs. This needs to be
considered if you plan to recover the purchase costs from
the recruit’s buy-in.
Q
We have a long-time employee who
was just diagnosed with a serious illness and has used up
all of her time off to date. According to our employee manual,
she doesn’t qualify to take the time off that she would
like to take, so she feels she needs to quit. I’d like
to keep her, but how can I change the rules for one employee
out of 100?
A
There’s no reason you can’t
work a special deal with a long-term employee.
Write something similar to an offer of employment letter with
the new terms and conditions. Or grant the paid time off (PTO)
as a discretionary bonus. You may want to set it up so that
it does not accrue as a benefit. If she doesn’t use
it before she leaves the practice or within a specified period
of time, like a calendar year, then the PTO benefit is lost.
Q
I am starting a solo pediatric
practice and hoping to take commercial insurance. Do I need
a license from the Department of Health and Human Services
even though I am not seeing Medicare patients? Do I need a
business license?
A
There are some overlapping issues in your
question: business structure and contracting.
Most practices structure themselves as a formal entity, such
as a limited liability corporation or professional corporation.
The consequences of each vary by state, so you’ll want
to work with an experienced accountant or other professional
to get some help on that.
You must also apply for federal, state and sometimes local
tax identification numbers so everyone knows where to find
you at tax time.
You must also register your business with the state.
Any business would have to take those steps. As a medical
practice, you also need to have your credentials ready, including
a state medical license, Drug Enforcement Administration number,
board certification and an up-to-date resume. You then contact
the payers in your area for applications and submit all the
paperwork for their credentialing process. Meanwhile, you’ll
also, presumably, apply for hospital privileges.
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