Michigan Medicine, Volume 115, No. 4 by Michigan State Medical Society

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July / August 2016 • Volume 115 • No. 4

A NEW L

at the

Revenue Cycle

With patients expecting higher quality health care, physicians are re-evaluating their revenue cycles to adapt to the ever-changing landscape of the health care system.

ALSO IN THIS ISSUE: 08 Protecting Adults – Are You Meeting the

Standards for Adult Immunization Practice?

10 OCR Releases New Guidance on Patient Access to Health Records

18 Heed Those EHR Alerts

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Chief Executive Officer JULIE L. NOVAK

Managing Editor July / August 2016 • Volume 115 • No. 4

COVER STORY

A New Look at the Revenue Cycle By Allie McLary for MSMS

FEATURES

Heed Those EHR Alerts By Jacqueline Ross, PhD, RN, Senior Clinical Analyst, and Susan Shepard, MSN, RN, Director, Department of Patient Safety and Risk Management Education (Contributed by The Doctors Company)

COLUMNS

President’s Perspective By David M. Krhovsky, MD Changes, Challenges and Providing Leadership

Ask Our Lawyer By Daniel J. Schulte, JD Obtaining Credit Reports and Charging Interest

MDHHS Update By Jacklyn Chandler, M.S., Outreach Coordinator, MDHHS Division of Immunization Protecting Adults: Are You Meeting the Standards for Adult Immunization Practice?

HIT Corner OCR Releases New Guidance on Patient Access to Health Records & HIPAA FAQs

MSMS Alliance By Donna Lake, President of MSMSA Join MSMSA Today

22 WealthCare Advisors By Nicole Gopoian, JD, CFP® Navigating Divorce - 5 Steps to Take When You’re in the “Unexpected 50%”

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Postmaster: Address Changes Michigan Medicine Hannah Dingwell 120 West Saginaw Street, East Lansing, MI 48823 Michigan Medicine, the official magazine of the Michigan State Medical Society (MSMS), is dedicated to providing useful information to Michigan physicians about actions of the Michigan State Medical Society and contemporary issues, with special emphasis on socio-economics, legislation and news about medicine in Michigan. The MSMS Committee on Publications is the editorial board of Michigan Medicine and advises the editors in the conduct and policy of the magazine, subject to the policies of the MSMS Board of Directors. Neither the editor nor the state medical society will accept responsibility for statements made or opinions expressed by any contributor in any article or feature published in the pages of the journal. The views expressed are those of the writer and not necessarily official positions of the society. Michigan Medicine reserves the right to accept or reject advertising copy. Products and services advertised in Michigan Medicine are neither endorsed nor warranteed by MSMS, with the exception of a few. Michigan Medicine (ISSN 0026-2293) is the official

magazine of the Michigan State Medical Society,

Committee. In 2016 it is published in January/February,

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published under the direction of the Publications March/April, May/June, July/August, September/October and November/December. Periodical postage paid at East Lansing, Michigan and at additional mailing offices. Yearly subscription rate, $110. Single copies, $10. Printed in USA.

The mission of the Michigan State Medical Society is to promote a health care environment which supports physicians in caring for and enhancing the health of Michigan citizens through science, quality and ethics in the practice of medicine.

P R E S I D E N T ’ S

P E R S P E C T I V E

Changes, Challenges and Providing Leadership BY DAVID KRHOVSKY, MD

his issue of Michigan Medicine highlights the revenue cycle and the challenges many physicians have with the ever-changing world of health care. When I think about how I’ve handled these challenges, I think about the resources and leaders I’ve turned to for guidance and advice.

As members of the Michigan State Medical Society, we have the opportunity to serve as those leaders. With all the changes headed our way, we must continue to promote a health care environment that supports physicians in caring for and enhancing the health of Michigan citizens through science, quality and ethics in the practice of medicine. One of those changes is the transition from volume-based purchasing to value-based purchasing. The health care system used to reward volume and intensity of care, dominated by fee-for-service mentality. Now, the concept of value-based purchasing, linking payment to quality of care, is becoming a reality. But this purchasing concept creates a real danger of interrupted cash flow to physicians’ offices during this transition, causing complications to the revenue cycle. Another challenge in keeping up with the changes in the health care community but still maintaining quality care, is the adequate use of the Electronic Medical Record — a cumbersome and difficult process due to the lack of connectivity between systems. But as mandated by the Affordable Care Act, an EMR is now required in every physician’s office in the country. The real problem is that implementing this requirement can cost a physician’s office more than $50,000, according to the American Medical Association. While an EMR allows instant access, enables physicians to track data over time and identifies patients due for preventive screenings, the skill, maintenance and expense can really serve as a barrier in utilizing this new technology into a physician’s office. 4

Maintenance of Certification is another costly and time consuming process for physicians, and does not guarantee quality. The MOC process could force some patients to leave the physicians they’ve grown to respect and trust, negatively affecting the revenue cycle as well as a patient’s quality of care. Currently there are two Senate and House bills making their way through Michigan’s legislature that, if passed, could provide some relief to physicians in maintaining certification.

Senate Bills 608 and 609 and House Bills 5090 and 5091 will protect and defend: • A patient’s right to the health care and support they need from the physician they choose. • A physician’s right to provide quality care to patients without costly, troublesome “pay to play” requirements. • A state’s right to create a health care system that works for everyone. With so many physicians facing these realities, there’s a greater emphasis on economies of scale. Physicians across the state are choosing to be employed by larger institutions as opposed to joining smaller, more traditional, independent groups. Whether they are employed directly by a hospital, or by a large multispecialty group, the pooling of resources lessens the financial impact for the individual physicians. The cost advantages that the hospitals offer due to size, output and scale of operation, allow more services to be offered on a larger scale. As a direct result of the emphasis on economies of scale. Clinically Integrated NetMICHIGAN MEDICINE

works are rapidly growing. These networks allow physicians to negotiate collectively with payers on reimbursement arrangements in an effort to increase quality health care but reduce costs. A CIN results in the pooling of resources without direct employment. The transition to value-based purchasing, adopting new technological methods like EMR and the process of Maintenance of Certification, are just a few examples of challenges we as physicians will take on moving forward in this profession. In the future, MSMS must continue to support our members by serving as leaders in the development of additional resources aiding physicians in navigating this constantly changing landscape. We should look to management within a physician’s practice to make the development of these additional resources a priority. In looking at the landscape of the health care system, a positive outlook is paramount to providing quality care for our patients — after all, they remain our “why.” Caring for our patients is still an honor and a privilege, and knowing that we are helping people to get and stay healthy is uplifting to us as physicians. The main challenge we will continue to battle in providing that quality care to our patients, is working within the constraints of the revenue cycle while meeting new requirements mandated by state and local governments. Health care is expensive for both those providing the care and those being cared for. It’s our job as physicians to lead in the discussion of this ever-present issue. Doctor Krhovsky, a Grand Rapids anesthesiologist, is president of the Michigan State Medical Society July / August 2016

Patients trust you. You can trust Kerr Russell. A successful practice requires more than talented individuals and a desire to heal. Let Kerr Russell provide the legal insight needed to manage and grow your business. ENTITY FORMATION • BUSINESS MATTERS • EMPLOYMENT CONTRACTS • PURCHASE / SALE OF OWNERSHIP INTERESTS • MALPRACTICE AND ALL OTHER COMMERCIAL LITIGATION • APPEALS • MEDICAL STAFF PRIVILEGE DISPUTES HOSPITAL RELATIONS MATTERS • HEALTHCARE FRAUD DEFENSE •• LICENSING AND AND OTHER OTHER REGULATORY REGULATORY MATTERS MATTERS

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Welcome New MSMS Members! Jason Adams, MD Washtenaw Jan Akervall, MD Oakland Heba Al Butairi, MD Wayne Feda Almallouhi, MD Wayne Kevin Anderson, MD Hillsdale Leigh Apple, DO Wayne Sara Bachman, MD Jackson Joel Barton, MD Ingham Sejal Bennett, MD Kent Nisha Bertucci, MD Kent Katherine Betcher, MD Oakland Rohit Bhave, MD Washtenaw Joelle Boeve, MD Wayne Thomas Bonifer, MD Washtenaw Charles Boyd, MD Oakland Peter Bozeman, MD Washtenaw Manohar Bulagannavar, MD Wayne Dana Busch, DO Oakland Timothy Cahill, MD Washtenaw

Volume 115 • No. 4

Sumner Camisa, MD Oakland Cheryl Canto, MD, CMD St Clair Andrew Caughey, Jr, MD Jackson William Cederquist, MD Washtenaw Jeffrey Chaulk, MD Medical Kalyani Chitale, MD Wayne Traci Coffman, MD Washtenaw Amina Dafalla, MD Wayne Carrie Delbene, MD Wayne James DeMeester, MD Washtenaw Macdonald Dick, II, MD Washtenaw Michael Dorsey, MD Washtenaw Megan Dorsey, MD Wayne Gregory Dwight, DO Wayne Marina Dyment, MD Wayne Anthony Edelman, MD Wayne David Emerson, MD Washtenaw Peter Farrehi, MD Washtenaw Michael Fitzsimmons, MD Washtenaw

Michele Fliss, MD Washtenaw Glenn Gall, DO Wayne Beth Gehan, MD Washtenaw Greg Ghiardi, MD Marquette/Alger Joshua Gitlin, MD Oakland Angel Gomez, MD Washtenaw Zheng-Ping Guo, MD Washtenaw Neal Hall, MD Oakland Anita Hart, MD Washtenaw Thomas Hartzell, MD Wayne Eric Houchin, MD Ottawa Douglas Hoye, MD Washtenaw Antony Hsu, MD Washtenaw Lisa Irwin, MD Wayne Thomas Jeffries, MD Washtenaw Debora Kaczynski, MD Jackson Jonathan Kaper, MD Wayne Michael Kasten , MD Kalamazoo Falih Kazangy, MD Livingston

Joel Kileny, MD Washtenaw Kevin Kiley, MD Muskegon Jonathan Kivela, MD Washtenaw Kevin Klimek, MD Washtenaw Robert Knapp, MD Washtenaw Katheryn Knudson, MD Kent Kent Krach, MD Macomb Mackenzie Kuhl, DO Marquette/Alger Bryan Lin, MD Washtenaw Sean Logan, MD Washtenaw Conrad Maitland, MD Wayne Timothy Matway, MD Oakland Matthew McCord, MD Wayne Suzanne McGoey, MD Wayne Patricia McNally, MD Washtenaw Maureen McNeely, MD Marquette/Alger Dennis Means, MD Kalamazoo Nabil Metwally, MD Wayne Susan Molina, MD Wayne

Harold Moores, MD Mecosta/Lake/Osceola Partha Nandi, MD, FACP Oakland Judy Negele, MD Washtenaw Daniel Nicoli, MD Washtenaw Logan Oney, MD Wayne Nanthini Palanichamy, MD, FACC Oakland Joseph Palazeti, DO Shiawassee Peter Panagopoulos, MD Wayne Anup Patel, MD Marquette/Alger Ashvin Patel, MD Wayne Cheryl Patterson, MD Wayne Elizabeth Pionk, DO Bay Ryan Pirooz, MD Jackson Alan Plona, MD Washtenaw Richard Pollock, MD Jackson Breanna Pond, MD Marquette/Alger Alison Premo, MD Wayne Neeraja Ravikant, MD Washtenaw Kellie Reading, MD Washtenaw

MICHIGAN MEDICINE

Christina Rhee, MD Wayne Jennifer Rhee, MD Wayne John Rivard, MD Wayne LeAnne Roberts, MD Oakland Todd Rosen, MD Genesee Kristen Roy, MD Oakland Marschall Runge, MD, PhD Washtenaw Anupama Shah, MD Monroe Karolina Skrzypek, MD Washtenaw Steven Slack, MD Washtenaw Tom Stathakios, MD Wayne Marek Stawiski, MD Kent Steven Stein, MD Oakland Joshua Stewart, MD Washtenaw Matthew Supron, DO Marquette/Alger David Swastek, MD Washtenaw Jeremy Theiss, MD Washtenaw Kress Townley, MD Kent Marc Tuchman, MD Washtenaw

Brian Turner, MD Marquette/Alger Dmitriy Yefimovich Urman, MD Wayne Carol VanAndel, MD Macomb Jon VanderVliet, MD Washtenaw Katherine Vitale, MD Wayne Catherine Ward, DO Washtenaw Denege Ward-Wright, MD Washtenaw Mark Washnock, MD Marquette/Alger Jeffrey Wesolowski, MD, MHSA Washtenaw Lindsey Whalen, MD Wayne Janet Wilczak, MD Wayne Philip Wolok, MD Wayne Michael Yangouyian, DO Jackson Joshua Yankelove, MD Jackson Kevin Zhao, MD Wayne Melody Zoma, MD Wayne

A S K

O U R

L AW Y E R

Obtaining Credit Reports and Charging Interest BY DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL QUESTIONS:

Due to the prevalence of high deductible plans most of my patients are paying my fees out of pocket. For many this amounts to thousands of dollars of accounts receivable. I want to begin running credit checks, seeing proof of available funds in an HSA, etc. in advance of providing non-critical care. Is there any law that prevents me from doing this without the patient’s consent? Are there other laws I should be aware of prior to doing this? Can I charge interest on these account receivable balances? ANSWER:

Fair Credit Reporting Act

Discrimination Laws

Obtaining a credit report prior to agreeing to make a patient a loan in the amount of the cost of treatment is a prudent business practice. However, there are some laws you should be aware of including:

The federal Fair Credit Reporting Act requires that you notify the patient in writing that you want to obtain a credit report and obtain the patient’s written authorization.

Discrimination laws may also come in to play when obtaining credit reports. You should have a policy requiring that one be obtained on all patients who you have determined will be ultimately responsible for a material account receivable balance (i.e. you should not make individualized decisions to obtain credit reports).

• Fair Credit Reporting Act • Fair and Accurate Credit Transactions Act (FACTA) • Discrimination Laws

Fair and Accurate Credit Transactions Act The federal Fair and Accurate Credit Transactions Act (“FACTA”) amended the Fair Credit Reporting Act by adding provisions to help combat identity theft (by requiring credit reporting agencies to provide free credit reports under some circumstances and requiring that social security numbers, credit card numbers and certain other identifying numbers be truncated). One aspect of FACTA that would apply to a physician obtaining credit reports on patients is the so-called “Disposal Rule”. This rule requires that you have reasonable precautions in place to prevent the unauthorized access to or use of the information contained in credit reports obtained and stored in your office. This includes implementing reasonable measures when disposing of credit reports to maintain the confidentiality of the information they contain. This would require credit reports be shredded incinerated, etc. instead of just being put in the trash. MICHIGAN MEDICINE

The best practice is to have a standard credit report authorization form in your practice that tells patients you will only extend credit in consideration of their agreeing to allow you to obtain a credit report and only if the information contained in the credit report is satisfactory. All patients paying out of pocket for expensive treatments should be required to sign and provide the authorization. Once you have obtained the credit reports you should file them separately limiting the number of staff that have access to them. When it is time to dispose of credit reports do so by shredding or incinerating. Daniel Schulte, JD, MSMS Legal Counsel, is a member of Kerr Russell Attorneys and Counselors

July / August 2016

Volume 115 â&#x20AC;¢ No. 4

MICHIGAN MEDICINE

M D H H S

U P D AT E

Protecting Adults: Are You Meeting the Standards for Adult Immunization Practice? JACKLYN CHANDLER, M.S., OUTREACH COORDINATOR, MDHHS DIVISION OF IMMUNIZATION

aking sure your adult patients are up-to-date on vaccines recommended by the Centers for Disease Control and Prevention (CDC) and the Michigan Department of Health and Human Services (MDHHS) gives them the best protection available from several serious diseases and related complications. In 2013, the National Vaccine Advisory Committee (NVAC) revised the Standards for Adult Immunization Practice to reflect the important role that all healthcare professionals play in ensuring adults are getting the vaccines they need. These new standards were drafted by the National Adult Immunization and Influenza Summit (NAIIS) of over 200 partners, including medical associations, state and local health departments, pharmacists associations, federal agencies, and other immunization stakeholders1.

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July / August 2016

What makes adult immunization a priority for leaders in medicine and public health? Every year, tens of thousands of adult Americans suffer serious health problems, are hospitalized, and even die from diseases that could be prevented by vaccines2. These diseases include shingles, influenza, pneumococcal disease, hepatitis A, hepatitis B-related chronic liver disease and liver cancer, HPV-related cancers and genital warts, pertussis (whooping cough), tetanus and more. Adult vaccination rates are extremely low. For example, coverage rates for Tdap and zoster vaccination are less than 30 percent for adults who are recommended to receive them3. In Michigan, even high risk groups are not getting the vaccines they need – only 30.6 percent of adults younger than 65 years old who are high risk for complications from pneumococcal disease are vaccinated4. Adults trust their healthcare provider to advise them about important preventive measures. Most health insurance plans provide coverage for recommended adult vaccines. Furthermore, research indicates that most patients are willing to get vaccinated if recommended by their provider5, 6. However, many patients report their healthcare providers are not talking with them about vaccines, missing critical opportunities to immunize7. Make it clear to your patients that vaccination is important because it not only protects the person receiving the vaccine, but also helps prevent the spread of certain diseases, especially to those that are most vulnerable to serious complications, such as infants and young children, elderly, and those with weakened immune systems. Immunizing adults creates healthier communities and protects the places in which we live, work, and play.

MDHHS and Michigan State Medical Society are calling on all healthcare professionals to make adult immunizations a standard of routine patient care in their practice by integrating four key steps8: 1. ASSESS immunization status of all your patients at every clinical encounter. This involves staying informed about the latest CDC recommendations for immunization of adults and implementing protocols to ensure that patients’ vaccination needs are routinely reviewed. 2. Strongly RECOMMEND vaccines that patients need. Key components of this include tailoring the recommendation for the patient, explaining the benefits of vaccination and potential costs of getting the diseases they protect against, and addressing patient questions and concerns in clear and understandable language. 3. ADMINISTER needed vaccines or REFER your patients to a provider who can immunize them. It may not be possible to stock all vaccines in your office, so refer your patients to other known immunization providers in the area to ensure that they get the vaccines they need to protect their health. Coordinating a strong immunization referral network will reduce a substantial burden on your adult patients and your practice. If your adult patients do not have insurance, or if their insurance does not cover any of the cost of an immunization, check with your local health department to see if your patient qualifies for the following public vaccines: Td, Tdap, MMR, Hep A, Hep B or Zoster. 4. DOCUMENT vaccines received by your patients. Help your office, your patients, and your patients’ other providers know which vaccines they have had by documenting in the Michigan Care Improvement Registry (MCIR). And for the vaccines you don’t stock, follow up to confirm that patients received recommended vaccines.

RESOURCES 1 2 3 4 5 6 7 8 9

National Adult and Influenza Immunization Summit (NAIIS). Organizations Supporting the NVAC Adult Standards. Accessed May 17, 2016. Centers for Disease Control and Prevention (CDC). Reasons to Vaccinate. Accessed May 17, 2016. Williams WW et al. Surveillance of Vaccination Coverage Among Adult Populations — United States, 2014. MMWR Surveill Summ 2016; 65(No. SS-1):1–36. Centers for Disease Control and Prevention (CDC). Pneumococcal vaccination coverage among adults 18-64 years at increased risk and ≥65 years by State, HHS Region, and the United States, BRFSS, 2008 through 2014. Accessed May 17, 2016. Ding H et al. Influenza Vaccination Coverage Among Pregnant Women — United States, 2014–15 Influenza Season. MMWR Morb Mortal Wkly Rep 2015; 64(36):1000-1005. Malosh R et al. Factors Associated with Influenza Vaccine Receipt in Community Dwelling Adults and Their Children. Vaccine 2014; 32(16): 1841-1847. Ylitalo KR et al. Health Care Provider Recommendation, Human Papillomavirus Vaccination, and Race/Ethnicity in the US National Immunization Survey. Am J Public Health 2013; 103(1): 164-169. Centers for Disease Control and Prevention (CDC). Standards for Adult Immunization Practice. Accessed May 17, 2016. Alliance for Immunization in Michigan (AIM). Education & Training. Accessed May 17, 2016.

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Want to learn more? Live Webinar – August 30, 2016 MSMS is hosting a continuing education opportunity entitled Adult Immunizations in Michigan: Using the Standards to Increase Coverage. This presentation will be offered via live webinar on Tuesday, August 30th from 12:00 p.m. to 1:00 p.m. EST. To register, please visit the following link and enter the passcode “MSMS”: » https://nvite.com/AdultImmz/dylr6w For more information, contact Jacklyn Chandler at ChandlerJ3@michigan.gov.

CME Resources Additional educational resources are available to provider offices, including free immunization education sessions through the, MDHHS Immunization Nurse Education program and the Physician Peer Education Project on Immunization. The sessions through both education programs are approved for continuing medical education credit. For more information, visit the Alliance for Immunization in Michigan9 website and click “Information for Health Care Professionals” and “Education & Training” : » www.aimtoolkit.org

FREE Informational brochures Informational brochures about immunization topics are available free of charge from, MDHHS. A variety of materials is available, and can be ordered online. In spring 2016, the “AIM Packet – Adult” was added. The contents focus on adults and include the immunization schedule, brochures, posters, and other educational flyers and resources for your practice. For more information, visit the following link and click “Enter Site” and “Immunizations” to begin adding resources to your cart: » www.healthymichigan.com

H I T

CO R N E R

OCR Releases New Guidance on Patient Access to Health Records The U.S. Department of Health and Human Services Office for Civil Rights (OCR) released new guidance that gives specific requirements for individuals’ access to their health information under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA’s Privacy Rule generally requires physicians and other health care providers to supply patients, upon their request and in a format requested by the patient, with access to any health records about them that the covered entity maintains. The guidance clarifies the parameters of the patient access rule and includes frequently asked questions that specifically address the following: • The scope of information covered by HIPAA’s access right and the very limited exceptions to this right • The form and format in which information is provided to individuals • The requirement to provide access to patients in a timely manner • The intersection of HIPAA’s right of access with the requirements for patient access under the Health Information Technology for Economic and Clinical Health (HITECH) Act’s electronic health record (EHR) incentive program Many of the FAQs addressed in the new guidance are around the use of electronic methods of transmitting information to the patient. Secure messaging through a portal, direct messaging and unencrypted email are all highlighted. Many physicians are unaware that they may have a Direct Secure Messaging account available through their EHR. As patients begin to use these accounts as well, a physician may be asked to provide the patients information via this secure messaging service. Direct is a secure email-like communications channel that enables providers to communicate with each other—as well as with patients and other caregivers—in a secure, HIPAA-compliant way. All messages are encrypted and require authentication to send and receive. Physicians can access Direct from within most popular EHRs. Direct can facilitate the exchange of patient medical records in a standardized manner, this includes formatted and unformatted data, as well as large files such as radiologic studies and diagnostic images. With the clarification the new guidance provides, it is important to take a close look at how prepared you are to meet some of the requests from patients for their information. Talk with your EHR vendor to see how you will be able to meet these requests in a timely manner, while ensuring all information is kept protected and secure. At right are some FAQs answered by MSMS Legal Counsel, and coming soon, a more in-depth guide on communicating with patients electronically. 10

HIPAA FAQs Q: Are physicians and other health care providers required to have the capability to transmit PHI by email as well as by mail? A: The government expects all HIPAA covered entities, including physicians, to have the capability to transmit PHI not only by mail, but also by email except in the limited case where email cannot accommodate the file size of requested images. Q: Does an individual have the right under HIPAA to require a physician or other health care provider to transmit PHI in a designated record set to the individual or a designated thirdparty by unsecured/unencrypted email? A: Yes, but only if the individual has requested that the PHI is sent by unsecured/unencrypted email and has been warned of and accepts the risks that the PHI in the email could be read by a third-party. Under these circumstances, the individual has the right under HIPAA to have PHI transmitted in an unsecure manner, and the physician or other provider is not responsible under HIPAA for breach notification or liable for disclosures that occur in transmission. Further, the physician or other provider is not liable under HIPAA for what happens to the PHI once the individual or designated third party receives the PHI. As in all instances in which an individual requests access to or copies of PHI, the individual’s request must be in writing, signed and dated. It should state that the individual has requested that the PHI be sent by unsecured/unencrypted email, include the recipient’s email address, warn that the PHI in the email is unsecured and could be read by third-parties, and acknowledge the individual’s acceptance of the risks of the unsecured transmission. Q: Can physicians require patients to accept transmission by unencrypted email? A: No. Under HIPAA, physicians and other health care providers are not permitted to require an individual to accept unsecure methods of transmission of PHI. Q: Does HIPAA permit physicians and other health care providers to exchange PHI between themselves via unsecured/ unencrypted email? A: HIPAA does not per se mandate the use of secured/encrypted email or prohibit the use of unsecured/unencrypted email. As a practical matter, however, physicians and other health care providers will be exposed to violating HIPAA by using unsecured/unencrypted email, except when requested by an authorized individual in the circumstances addressed above or possibly in limited exigent circumstances, such as medical emergencies. Usage of unsecured/ unencrypted email should be addressed in the both the transmitting and receiving providers’ respective HIPAA-required security risk assessments.

MICHIGAN MEDICINE

July / August 2016

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msms.medopps.org For membership information or to schedule a demo of MSMS Medical Opportunities, contact us at 800/479-1666 or recruitment@mhc.org.

Serving healthcare providers for over 30 years

Volume 115 • No. 4

MICHIGAN MEDICINE

A NEW L

at the

Revenue Cycle T

he health care system is in a constant state of transition, with physicians working to keep up on learning new policies, laws, procedures and treatments to bring quality care to patients. Amid those changes are also the expectations from a patient’s perspective, expecting a higher level of care for less money. Adapting to any change is a challenge, especially if that change affects a physician’s revenue cycle. Today’s growing financial pressures on practices will continue to increase as patients bear an amplified financial responsibility for their health care costs.

With patients expecting higher quality health care, physicians are re-evaluating their revenue cycles to adapt to the ever-changing landscape of the health care system.

Revenue cycle phases The revenue cycle includes all administrative and clinical functions that contribute to the capture, management and collection of patient service revenue, or the entire life of a patient account from creation to payment. A healthy revenue cycle should follow collection best practices to ensure bills are submitted and all services provided are billed.

MICHIGAN MEDICINE

July / August 2016

The

11 Phases of the

Revenue Cycle

6 8

THE PHASES OF THE REVENUE C YCLE AND THEIR RECOMMENDED ACTION STEPS INCLUDE:

Scheduling

Pre-registration/ Financial Clearance

Point of service collections

Check in

9 Follow up

10 Payment posting

Develop standards for booking appointments and procedures throughout a physician’s work day.

7 Coding Assign codes for diagnoses and procedures based on supporting medical record documentation.

Volume 115 • No. 4

Standardize the process of collecting all demographic and insurance information including verifying eligibility, benefits and authorizations, prior to the patient’s arrival.

8 Billing

6 Charge Entry/ Change Master

Confirm and verify patient Enter charges from the demographic information is correct At the time of their appointpatient’s visit into the medical and complete, including eligibility ment reminder call, inform billing system. Ensure all checks to secure financial clearance. patients promptly of their charges are loaded in the financial responsibilities to 5 software’s database and pay at the time of service. Ask updated annually. Check out “How would you like to pay for that today—cash, check Collect payment from patient if not performed at check in for any or charge—instead of “Would prior or new balances. you like to pay for that today?”

In a timely manner, send Verify why the claim is not paid, claims to the insurance com- check to verify if the insurance carEnter payments, manage pany and notify patients of any rier received the claims and confirm contractual write-offs, process balance that remains. the claims are in process. Any items insurance rebills or transfers in accounts receivable greater than to patient, resolve credit 90 days old need attention -- staff’s balances. collection actions are measured by the days outstanding in accounts receivable. MICHIGAN MEDICINE

11 Statements/ Collections Bill patients, send collection letters, offer payment plans and analyze productivity of collectors.

Recognize the issues and adapt your process Revenue cycle management is the key to any successful practice. To sustain a medical practice, it is imperative that processes are put in place to enable effective patient registration, insurance and benefit verification, charge capture claims processing and more. These tasks are what keeps a physician’s practice going. Many physicians seek assistance outside of the practice to identify which phase of the revenue cycle they’re struggling with. If you’re struggling, know that you are not alone. Lynn Pepper is a revenue cycle consultant at the Rybar Group, a health care financial consulting firm that works with physicians to maintain their financial viability through compliant and efficient business operations. “We provide guidance to physicians as they’re navigating the revenue cycle,” Pepper says. “Often that means assessing their current financial process and working with them through onsite activities, data analytics, process improvements and more, to develop an action plan moving them forward.” The consultation starts with an assessment, asking the following questions: • Is your practice achieving best practice standards in accounts receivable management? • What percentage of your accounts receivable is more than 90 days old? • What are the processes in place to collect amounts due from insurance companies and patients? Are they providing effective results? How are you monitoring the outcomes? • Do you feel that the practice can be generating more revenue? Why do you feel that way? • Have you completed a reimbursement and payment analysis to know which payors may present opportunities? These questions can help a practice to recognize and address current issues within their revenue cycle. Taking stock of where the practice currently stands will make it easier to determine what changes can improve current processes and policies. “For instance, in a situation where a physician has an outside billing company, it is important for a physician to monitor the billing company’s processes and their own revenue so there aren’t any surprises.” says Pepper. 14

While some physicians prefer to work internally on an action plan addressing issues with the revenue cycle, other practices simply don’t have the staffing to solve the problem alone. “We assist in putting processes and policies in place so a physician can move the practice forward on their own,” says Pepper. “But others recognize they can’t do the work alone due to their current staffing. In those instances, we maintain our support and guidance to keep the practice moving forward.” Often it takes a physician to take notice of a mistake in the revenue cycle, or maybe it’s simply that the physician doesn’t feel right about the practice’s policies, causing the current process to be called into question. “We get a variety of questions that are all dependent on the individual physician or practice,” Pepper says. “Some ask for assistance with staffing assessments, point of collection concerns or other operational needs and struggles. Whatever makes them question their revenue expectations, we address it.”

Identifying the challenges “The biggest revenue cycle challenges physicians are facing are with the charge entry phase,” says Pepper. “It is critical to monitor lag days to ensure charges are entered timely and reconcile daily that charges match the documentation so there are no missing charges.” Missing charges are the low hanging fruit of missed revenue opportunities. By altering internal processes and policies, practices can reduce the chances of patients not getting charged for complete medical care. In addition to reviewing documentation daily, physicians should focus on open communication with patients. By providing the full information, and sharing the cost of treatment and procedures as they’re accrued, patients are better prepared to pay their balance. This is the point of service phase of the revenue cycle. Pepper adds, “Engage in conversation with the patient at the time of their appointment reminder. Share what their cost amount will be and ask them to be prepared to pay that amount at time of service.” With patients paying more out of pocket than ever before, it’s even more important for them to have an idea of what their health care will actually cost. According to a report by the Henry J. Kaiser Family Foundation, more Americans have health insurance coverage, but 25 percent do not have money or liquid assets to cover their deductible. MICHIGAN MEDICINE

“Even if your state has expanded Medicaid, according to the IRS regulation for 2016, high-deductible health plan policies have out-of-pocket maximums as high as $6,550 and family policies as high as $13,100,” Pepper says. “High dollar deductibles will increase as more and more employers shift the cost share amounts to patients. To stay ahead of the curve, it is critical that physicians verify the patient’s insurance is active and collect benefit information prior to their visit.”

More revenue for a physician’s practice With patients navigating the world of unfamiliar health care costs, practices can serve as the guide and communicator for what makes up these costs. But to earn revenue for a practice, the effective processes and policies must be in place. Keep in mind these key revenue points in evaluating a practice’s revenue cycle: • Collect demographic and insurance information at the onset to ensure payment and correct billing. This includes patient name, date of birth, address and phone number, insurance contract and policy numbers. The claim will not pay if the information does not match the payer’s information on file. • Conduct open communication with patients during the point of service so the expectation and level of preparedness is such that a payment is made. • Address aged accounts greater than 90 days old. Identify the root cause as to why claims are not paid by asking: — Was the claim not submitted to the payer and still sitting in house? — Did the claim hit a front-end rejection? — Did the payer receive it? — Did the payer reject it? If so, why? Is it possible the payer made a partial payment and the balance remains in accounts-receivable? These tools can provide a base for building successful processes toward a healthy revenue cycle. For additional resources on revenue cycle management in medical practice, visit stepforward.org/ modules/revenue-cycle-management, provided by the American Medical Association. July / August 2016

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Eliminates Eliminates the the need need for for you you or or your your practice practice to to contact contact insurers insurers for for billing billing purposes; purposes; Has direct access to the insurer’s systems to add, terminate or change Has direct access to the insurer’s systems to add, terminate or change aa subscriber’s subscriber’s information information within within 24 24 hours, hours, which which removes removes the the administrative administrative burden burden from from you you and and your your staff; staff; Will Will research research claims claims inquiries inquiries and and benefit benefit questions questions for for you you or or the the subscriber, subscriber, which which will will eliminate eliminate the the frustration frustration of contacting a complex customer service center; and, of contacting a complex customer service center; and, Handles Handles all all COBRA COBRA administration administration for for groups groups with with more more than than 20 20 employees, employees, free free of of charge, charge, thus thus removing removing another administrative burden. another administrative burden.

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For For more more information information or or to to request request aa quote quote for for affordable, affordable, high-quality high-quality health health insurance, please connect with Beth at 877/742-2758 or belliott@msms.org. insurance, please connect with Beth at 877/742-2758 or belliott@msms.org. Volume 115 • No. 4

MICHIGAN MEDICINE

M S M S

A L L I A N C E

Join MSMSA Today BY DONNA LAKE, PRESIDENT OF MICHIGAN STATE MEDICAL SOCIETY ALLIANCE

he Michigan State Medical Society Alliance (MSMSA) is an organization of physician spouses and partners, working together for the benefit of their communities, families and the profession of medicine. We are dedicated to advancing the health of Michigan through advocacy and action by providing a forum to share information and concerns about the practice of medicine, the quality of health care and the stresses faced by the medical family, I am honored to serve as president of the MSMSA for the 20162017 term. As president, I hope to accomplish three goals to help make this organization grow and continue to effect change in the medical community.

Increase Participation My first goal is to increase our participation in Stop America’s Violence Everywhere, an initiative promoting more than 700 programs covering a broad spectrum of anti-violence activities. These programs include providing support for domestic violence shelters, mentoring programs for the prevention of child abuse, distribution of teen and adult safety cards and mental health screenings at health fairs and schools. I also want to boost the numbers of participation at Doctors and their Families Make a Difference Day. The Michigan State Medical Society Foundation mobilizes hundreds of volunteers once a year to provide basic comforts to those living in Michigan’s domestic violence shelters. Last year volunteers collected more than 12,000 bags, helping approximately 24,000 people. 16

During the June MSMSA board meeting, Karen Begrow, president of the Kent County Medical Society, shared the strategies and ideas that worked for them in getting the rest of the state excited and engaged in both of these events. The goal is to see every county Alliance boost their numbers in both initiatives.

Increase Membership My second goal is to increase MSMSA membership. We must share the values of our organization at every opportunity. The values we plan to share with the community include: SUPPORT – Medical families are different, in a good way. We have unique qualities other families simply do not share. MSMSA, the County Alliances and the American Medical Association Alliance are your family’s support system. Who understands the trials and tribulations of a medical family better than another medical family? Have you ever needed to talk to someone who really understands the unique questions and stresses that come with being a partner to a physician? We, the members of the MSMSA, understand those issues. We can serve as your support system. ADVOCATE – We support the medical community. For example, MSMSA Legislative Chair Karin Maupin and I are compiling informational folders for distribution to our legislators in February. When MSMSA and MSMS visit the Capitol to share views and opinions on matters related to health care and the practice of medicine, our work is to support their efforts. SHARE IDEAS – County leaders are given time during board meetings to fill us in on what is working, what events MSMS has planned, fundraising ideas, fun meetings or gatherings and ways to engage MSMSA members. Other attendees discuss what their counties are struggling with. Sharing ideas may just MICHIGAN MEDICINE

be the answer to a problem or issue that another county is working on as well. Our current membership is strong, but in continuing to grow, MSMSA can truly make an impact in the medical profession and meet the goals of the organization as a whole.

Increase Attendance My third goal is to increase attendance at our MSMSA quarterly meetings. I want physicians to be a part of our discussions. It’s important that our organization understands what physicians hope to gain from our involvement in the medical community. We want physicians to assist in guiding our work, ensuring we’re focusing on the issues that best support them. I want people to understand we are no longer just a group of spouses and partners. The medical community is changing, and so are we. We are a diverse group with one common goal: To strengthen the County Alliances so they are able to improve the health of the Michigan citizens and support the family of medicine. And thanks to MSMS, the MSMSA is prepared to provide a $250 Health Promotions grant to each of its county Alliances to put our ideas in action. It’s time to roll up our sleeves, and get some work done. I ask you to become an active member of the MSMSA. Let’s make a difference together. We all need one another for support to help build healthier communities, making Michigan a healthier place to live and grow. To become a member of MSMSA, fill out the online registration form at msmsa.org/ join-msmsa.

Donna Lake is president of the Michigan State Medical Society Alliance.

July / August 2016

2016 Education Offerings ON-DEMAND WEBINARS

BILLING AND CODING COURSES

EDUCATIONAL CONFERENCES

Visit www.msms.org/eo for complete listing of On-Demand Webinars.

For all billing and coding contact: Stacie Saylor at 517-336-5722 or ssaylor@msms.org

Visit www.msms.org/eo for a complete listing of Educational Conferences.

 Physician Executive Development Programs:

NEW! MSMS/MMBA BILLING WEBINAR SERIES – NOON ON THIRD WEDNESDAY OF EACH MONTH

YOUR PRACTICE, YOUR MONEY – OPTIMIZE YOUR FINANCIAL HEALTH

• Health Care Law for Physicians in ACOs • Medicaid Issues and Trends: Outlook for 2014 and Beyond • In Search of Joy in Practice: Innovations in Patient Centered Care • From Physician to Physician Leader • Inter-Professionalism: Cultivating Collaboration • Financial Information Analysis, Budget Development and Monitoring  Choosing Wisely  Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction  CDL-Medical Examiner Course  Legalities and Practicalities of HIT including: • Cyber Security: Issues & Liability Coverage • Engaging Patients on Their Own Turf: Using Websites and Social Media  Summary of the Affordable Care Act  HIPAA Security Rule  End of Life Concerns and Considerations  What’s New in Labor and Employment Law  Preparing for the Medicare Physician Value-Based Payment Modifier  Understanding and Preventing Identity Theft in Your Practice  Stepping Up to Stage 2  Physician On-line Rating and Reviews: Do’s and Don’ts  Patient Portals as a Tool for Patient Engagement  Health Care Providers’ Role in Screening and Counseling for Interpersonal and Domestic Violence: Dilemmas and Opportunities  Opioids & Michigan Workers’ Compensation

Visit www.msms.org/eo for complete listing of On-Demand Webinars.

• Tips & Trips to Working Rejections – Wednesday, July 20 • Claim Appeals – Wednesday, August 17 • Compliance in the Office – Wednesday, September 21 • ICD-10 for 2017 & Routine Waiver of Co-pays – Wednesday, October 19 • Year-End Wrap Up – Wednesday, November 16 • MSMS Legal Alerts – Wednesday, December 21

PHYSICIAN ASSISTANT AND NURSE PRACTITIONER SERVICES: INCIDENT TO, SPLIT SHARED AND OTHER COMPLIANCE ISSUES

Date: Thurs., October 27 Time: 9:00 am to 4:00 pm Location: Sheraton Detroit, Novi Intended for: Physicians, billers/coders, billing mgrs.

Continental breakfast & lunch provided Date: Wed., September 21 Time: 9:00 am to 4:00 pm Location: Troy Sheraton, Troy Intended for: Physicians, PO Administrators, Practice Consultants, Office Administrators and all other health care professionals. Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

151ST ANNUAL MSMS SCIENTIFIC MEETING

Morning, afternoon and evening clinical courses available. Continental breakfast & lunch provided Date: Tues., October 25 – Sat., October 29 Location: Sheraton, Novi Intended for: Physicians/health care professionals Contact: Marianne Ben-Hamza 517-336-7581 or mbenhamza@msms.org

20TH CONFERENCE ON BIOETHICS

BILLING 101

Date: Wed., October 26 Time: 9:00 am to 4:00 pm Location: Sheraton Detroit, Novi Intended for: Physicians, billers/coders, billing mgrs.

COMPLETE CODING UPDATES FOR 2016

Date: December 8, 2016 Time: 1:00 - 4:00 pm Location: Sheraton Detroit, Novi Intended for: Physicians, billers/coders, billing mgrs.

Continental breakfast & lunch provided Date/Time: Fri., November 13, 5:30 to 8 pm Date/Time: Sat., November 14, 9 to 5 pm Location: Hotel Indigo, Traverse City Intended for: Physicians, bioethicists, residents, students, other health care professionals, and all individuals interested in bioethical issues Contact: Caryl Markzon 517-336-7575 or cmarkzon@msms.org

MSMS LUNCH-N-LEARN — Grab a lunch, click the link, and join us! • HEDIS Best Practices – Wednesday, June 22 • Human Trafficking Overview and CPS Protocols – Wednesday, July 20 • End-of-Life Care – Wednesday, August 31 • Direct Primary Care – Wednesday, September 14 • Heath Information Technology – Wednesday, October 19 • The Importance of Medical Documentation – Wednesday, November 9 • Human Trafficking Part 2: What to look for in Patients and Other Guidelines for Physicians – Wednesday, December 7

For more information and to register for upcoming webinars, follow this link: www.msms.org/Education/UpcomingWebinars.aspx

MICHIGAN MEDICINE

T H E

D O C TO R S

CO M PA N Y

Heed Those EHR Alerts BY JACQUELINE ROSS, PHD, RN, SENIOR CLINICAL ANALYST, AND SUSAN SHEPARD, MSN, RN, DIRECTOR, DEPARTMENT OF PATIENT SAFETY AND RISK MANAGEMENT EDUCATION, THE DOCTORS COMPANY

atient harm caused at least in part by the use of Electronic Health Records (EHRs)—or e-iatrogenesis—emerged as a factor in a closed claims study conducted by The Doctors Company. The study of 71 claims closed by The Doctors Company between 2007 and 2013 revealed that 65 percent involved EHR-related user issues, and 42 percent identified system technology design risk factors. Some claims included both user issues and system technology design risk factors.

The ECRI Institute (formerly Emergency Care Research Institute) recognized alarm hazards as the number one IT-related problem in 2015. Alarm hazards occur not only with physiologic monitoring systems,1 but also with alarm-generating devices, such as EHRs. Unfortunately, human factors may prevent healthcare providers from responding appropriately or using the alarms that are readily available to them. EHRs have multiple benefits—from improved patient outcomes and improved care coordination to practice efficiency and cost savings. However, inappropriate use of or ignoring EHR alarms/alerts has been connected to patient harm. On the issue of over-alerting (systems generating too many alerts), Dr. Tejal K. Gandhi, president and CEO of the National Patient Safety Foundation, noted “most studies have found that only 20 percent of alerts are actually accepted,” so an important alert could be missed. She added that studies have shown that reducing the number of alerts “by streamlining the 18

ones that you decide to alert on, by tiering, to only interrupt for things that have a certain amount of significance, you can actually reduce the number of interruptions significantly.”2 E-health data come from external sources, such as websites or through health information exchanges (hospital charts, consultant reports, and laboratory and radiology reports). Doctors also have access to data through e-prescribing community medication histories—which can expose them to liability for potential interactions with drugs prescribed by other clinicians. For example: Dr. A renews a medication, and his e-prescribing program sends an alert advising him that the medication could interact with another medication the patient is taking. He has not prescribed that drug, so his office staff will have to contact the patient to identify who has prescribed it, and then Dr. A will have to contact Dr. X to “negotiate” which drug will be discontinued or changed. If failure to take action results in patient injury from a drug-drug interaction, Dr. A may be liable.3 Drug-drug interaction lists are often so comprehensive and generate alerts with such frequency that they can become disruptive and annoying. Doctors may develop “alert fatigue” and ignore, override, or disable them. However, if it can be shown that following an alert would have prevented an adverse patient event, the physician may be found liable for failing to respond.4 Optimized, clinically meaningful drug-drug interaction lists that focus on a smaller set of interactions most frequently associated with harm or expert consensus lists may address this problem. However, EHR vendors may resist eliminating the low-risk warnings, fearing that doing so could increase their liability. The two claims outlined at the top of page 21 illustrate some of the issues surrounding alerts and human factors.

MICHIGAN MEDICINE

July / August 2016

Claim One An elderly female saw an otolaryngologist for ear/nose complaints. The physician intended to order Flonase nasal spray. The patient filled the prescription and took it as directed. Ten days later, she went to the ER for dizziness. Two weeks after that, the pharmacy sent a refill to the physician at his request. It was for Flomax—a medication prescribed for enlarged prostate—which has a side effect of hypotension. When ordering the prescription the physician had typed “FLO”, the EHR automatched Flomax, and the physician selected it without realizing the mistake. Flomax is not FDA-approved for females. There was no EHR Drug Alert available for gender. To prevent this type of mistake, the provider should have reviewed the prescription with the patient and read what was ordered. By writing the indication for the medication on the prescription, the pharmacist would have been alerted that the medication was not appropriate to the condition being treated.

Claim Two A dialysis patient was transferred to a skilled nursing facility. There was an active hospital transfer order for Lovenox. A physician evaluated the patient on admission but made no comment about the Lovenox order. During the first dialysis treatment, there was active bleeding at the fistula site. The anti-coagulant heparin had not been given. The nursing staff did not inform the physician of the bleeding. During the second dialysis treatment, there was uncontrolled bleeding from the fistula, and the patient exsanguinated and expired. Experts were critical that there was no EHR high-risk medication alert. Medication reconciliation might have prevented this error.

Strategies for Reducing Alert Hazards n Understand alarm fatigue. When caregivers become overwhelmed, distracted, or desensitized to an alarm or an alert, determine the most important alarms, and work with your vendor to ensure that unnecessary alarms or alerts are not built into your system.5 n Determine if alerts are appropriately configured so that alert conditions are not missed or ignored.6 n Assess your EHR for frequent drug-drug interaction alerts, which have been shown to lead to alert fatigue that can cause the alerts to be disregarded, ignored, or disabled. Work with your EHR vendor to use key data elements to design EHR alerts for high-risk drug-to-drug interactions. The result will be more meaningful alerts that are less likely to be ignored or disabled, thus avoiding a possible error. n Be aware that clicking through drug-to-drug therapeutic duplicates or drug/allergy alerts with little review can be interpreted to mean that the physician ignored the safety alerts. Volume 115 • No. 4

REFERENCES

n Read the alerts. EHRs record how much time is spent reviewing information. If the time is very brief and there is a negative patient outcome, the physician could be perceived as sloppy or hurried. n Don’t turn off alerts. If a hospital-employed physician and hospital turn off alerts that could have avoided a patient problem, the hospital and physician may both be found liable. n Always document why a clinical decision support (CDS) prompt was overridden. CDS may conflict with a medical specialty’s clinical standards of care or practice guidelines or with the information in FDA-approved drug labels.7 n Check your alerts to make sure they provide adequate information and are not overly burdensome to your practice. Alerts are a necessary safety mechanism when used, heeded, and configured appropriately for your practice.

MICHIGAN MEDICINE

1 ECRI Institute. Top 10 health technology hazards for 2015: a report from health devices. November 2014. www.ecri.org/2015hazards. Accessed July 1, 2015. 2 Texas Medical Institute of Technology. Webinar transcript: Ambulatory patient safety issues—opportunities for improvement. http://www.safetyleaders.org/downloads/ WebinarTranscript_August2013.pdf. August 15, 2013. 3 Troxel D. Electronic health record malpractice risks. The Doctors Company. Available at: http://www.thedoctors.com/ KnowledgeCenter/PatientSafety/articles/Electronic-HealthRecord-Malpractice-Risks. Accessed July 1, 2015. 4 Ibid. 5 Lacker C. Physiologic Alarm Management. Pennsylvania Patient Safety Advisory. 2011 Sep;8(3)105-8. 6 ECRI Institute. Top 10 health technology hazards for 2015: a report from health devices. November 2014. www.ecri.org/2015hazards. Accessed July 1, 2015. 7 Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. Prescribers’ interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human-computer interaction. Int J Med Inform. 2012 Apr;81(4):232-243. Reprinted with permission. ©2016 The Doctors Company (www.thedoctors.com). This article originally appeared in The Doctor’s Advocate, fourth quarter 2015. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

T H E

M A R K E T P L A C E

Would You Like To Place A Classified Ad? The rate for classified advertising in Michigan Medicine, including both print and online versions, is $1.60 per word, with a minimum of $65.00. All ads must be prepaid. Text for classified advertisements and advertising fees should be received no later than the first of the month proceeding the month of publication. All submitted ads must be typed. No handwritten or dictated ads will be accepted.

To place an ad, please call Carl Mischka at 888-666-1491 or email carl@mischka.us.

Working Together With You to Maximize the Financial Health of Your Practice Services Tailored to Your Specific Needs: • Full Billing Services • Credentialing Services • Business Planning • Electronic Health Records

• Accounts Receivable Recovery Services • New Practice Start-Up • Flexible Practice Management Software Options

All Medical Specialties Welcome PH: 248-478-5234 • FAX: 248-478-5307 www.elitemedicalbill.com We Are Your Medical Reimbursement Specialists 20

MICHIGAN MEDICINE

July / August 2016

Family Practices n Allen Park: Retired Orthopedic Surgeon offering turn key operation. Full PT Lab, receive patient files, lots of potential for a very low price asking $50,000. n East Pointe Primary Care: Near I94 and Kelly Road. 3 Exam rooms, 2 year old practice. Asking $60,000 includes equipment/goodwill and transition. Real estate available. n Farmington Hills: Long established Internal Medicine Practice, 10 Mile/ Middlebelt area. Free standing building, 5 exam rooms, lab, x-ray. Very close to Botsford, St. Mary’s, and Providence Novi. Asking $175,000 for practice. n Garden City Internal Med Practice: Long established, majority of patients Medicare. Fully equipped, grossing in excess of $200,000 annually. Asking $70,000. n Mexican Town Detroit: 20 year old Primary Care Clinic. Staff is fluent in multiple languages. Seller financing available, priced to sell, work as you pay terms. Never in 25 years have I had the opportunity to offer more flexible terms. Price reduced to $589,000 for everything including real estate. n Lincoln Park: Walk-in clinic. Very visible, long established, seeing approximately 40 patients daily. Approx. gross income $800,000. Asking $250,000 for practice and $350,000 for real estate. n Podiatry Practices Detroit: 2 locations, very successful, grossing in excess of $600,000 annually. Fully equipped. Asking $300,000 for both locations. Real estate available. n Westside Detroit, Primary Care Practice: Established 2005, grossing in excess of $500,000 annually. Fully equipped. Asking $200,000 owner wants to retire.

Medical Buildings For Sale or Lease n Pontiac: Large professional medical building. Three story, suites 5005,000 sq. ft. Across from hospital, acres of parking. VERY REASONABLE rates/terms or buy building for $250,000. n West Side Detroit: 8,000 square feet, multi suites, fully leased. $60,000 positive cash flow excellent. Brick, single story asking $500,000 or lease for $1.00 square foot plus utilities.

For more details contact our practice specialist at Union Realty:

Joe Zrenchik, Broker 248-240-2141 (cell) • 734-808-0147 (eFax) joezrenchik@yahoo.com 248-919-0037 (office) www.michiganmedicalpractices.com Thinking about retirement, relocation or expansion of your medical practice? We have buyers and sellers for primary care, internal medicine and cardiology practices.

Volume 115 • No. 4

MICHIGAN MEDICINE

Navigating Divorce - 5 Steps to Take When You’re in the “Unexpected 50%” BY NICOLE GOPOIAN, JD, CFP®

he tale is tried and true; it’s the stuff fairy tales are made of. Two people fall in love, get married and live happily ever after. Unfortunately, the “happily ever after” only happens about 50 percent of the time according to the American Psychological Association. The other 50 percent of American marriages end in divorce. Divorce can have a profound emotional impact. It can have an equally catastrophic effect on your financial well being. How do you reconcile your old life and the new life ahead of you? Here are five steps you can take if you find yourself in the unexpected 50%.

1. Do Things the Easy Way Wise divorce attorneys know there are two ways to settle a divorce: the easy way and the hard way. Good attorneys promote the easy way, while greedy ones promote the hard way and fill their pockets in the process. The easy way facilitates a non-contentious approach to handle disputes rationally and with compromise. It also generates lower fees for both parties and provides a quicker resolution. If you pick the hard way, compromise is rare and the court often decides the outcome. This path racks up hours of legal work, generates costly bills and often publically displays each party in their worst light. As you look to implement the easy way, interview attorneys that have a great track record, but who also understand the benefits of an amicable agreement.

2. Clearly Define the Division of Assets Once you agree on the terms of the divorce, your attorney will memorialize your agreement in a divorce decree. Be clear on how assets are divided. Assets can be split by specific dollar amount or by percentage. Be aware that if you elected a fixed dollar amount and the market goes up or down before the split, the percentage share you receive could be more or less. Using a percentage method means each party gets the desired allocation regardless of market changes because the values are adjusted proportionally. In addition to investable 22

assets, be sure to consider how personal assets are divided—pictures, antiques, family mementos and even the dog or cat! Sometimes the most meaningful assets are the hardest to split. Additionally, consider your tax bracket in the split. Determine the after tax amount that each party receives and define it as a term in the decree. Keep in mind that a 50/50 pre-tax dollar split might not mean an equal amount goes to each party after taxes. For example, if the assets are held in a taxable account and there are large gains, they might not be worth as much as you hoped after you pay Uncle Sam. Work with your attorney and financial planner to address both of these issues.

3. Update Your Financial Plan Revisit your financial independence goals and determine the best way to achieve them in light of your new situation. A divorce can turn your financial life upside down and any previous planning that you’ve done may not be relevant. Consider current and future sources of income, including alimony and child support. Be mindful of the deductibility or taxability of these benefits depending on whether you’re the giving or receiving party. Determine if you’re eligible for benefits based on your former spouse’s work record. Review and reprioritize your goals and needs. Once you’ve updated your financial plan, use it as the tool to guide your investment management decisions.

4. Analyze New Risks It’s important to reevaluate risk in light of your new situation. Are you moving to a new residence? If so, make sure that your new homeowners insurance is properly coordiMICHIGAN MEDICINE

nated with your automobile and umbrella coverage. If you received health coverage through a former spouse’s plan, determine what private insurance options exist in the marketplace to replace it. If you have dependent children, find out how much of their support you will be responsible for providing. I’ve discovered in the last decade of counseling clients that thinking about new risks can be daunting because you’re facing them alone. But once these risks are addressed, a feeling of relief prevails in knowing that you’re prepared for the unexpected.

5. Update Your Estate Planning It’s necessary to revisit your estate plan after a divorce. This doesn’t just mean updating your will and trust. Medical and Durable Powers of Attorney should also be considered. Think about who you want to make financial or medical decisions on your behalf if you become unable to do so. Be sure to update the beneficiaries on your banking, investment, retirement accounts, life insurance and workplace benefits.. Coordinate with your financial planner and attorney to make sure all accounts and beneficiaries are updated appropriately.

Beginning Your New Life… No one walks down the aisle planning to get divorced. However, if the unexpected should happen, it’s important to get your finances in order as quickly and efficiently as possible so you can focus on living your new life to the fullest. Nicole Gopoian, JD, CFP® is an advisor at WealthCare Advisors, LLC – an MSMS joint venture.

July / August 2016

Volume 115 â&#x20AC;¢ No. 4

MICHIGAN MEDICINE

UNWAVERING

WE ARE UNWAVERING IN OUR MISSION TO DEFEND, PROTECT, AND REWARD THE PRACTICE OF GOOD MEDICINE New healthcare delivery models bring new medical malpractice risks. That’s why you can’t afford to be wrong in your choice of malpractice insurer. The Doctors Company relentlessly defends, protects, and rewards the practice of good medicine. We provide unmatched coverage to 78,000 members nationwide. When your reputation and livelihood are on the line, choose the insurer that stands with doctors. Join your colleagues—become a member of The Doctors Company.

CALL OUR EAST LANSING OFFICE AT 888.896.1868 OR VISIT WWW.THEDOCTORS.COM

MISSION