February 2015 | Physician Magazine by Los Angeles County Medical Association

THREE IPAs COMBINE RESOURCES TO FORM THE NEW ALLIED PACIFIC IPA

REPORTING ON THE ECONOMICS OF HEALTHCARE DELIVERY

A PUBLICATION OF PNN www.PhysiciansNewsNetwork.com

Billing, Cash Flow & ICD-10 PLUS:

Smart Ways to Cut Your Income Taxes in 2015

FEBRUARY 2015 L I A

M A G

L I A

M A G

The piece that makes a difference. Todayâ&#x20AC;&#x2122;s turbulent healthcare environment places a premium on fundamental analysis and innovative management. Get the analytical, financial, business, and leadership tools you need to move your practice forward.

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FEB R UA RY 2015 | TA B LE OF CONT ENT S

Volume 146 Issue 2

6 Independent Practice Associations Combine Resources to Form the New Allied Pacific IPA 8 Prescription for Home Ownership 20 Five Smart Ways to Cut Your Income Taxes in 2015

COVER STORY CASH 10 BILLING, FLOW & ICD-10

ICD-10 implementation is at the top of

the list of physician concerns for 2015. For many physicians, especially for

those working out-of-network, knowing

FROM YOUR ASSOCIATION 4 President’s Letter | Pedram Salimpour, MD 22 United We Stand | At Work for You 24 CEO’s Letter | Rocky Delgadillo

how to maximize recovery of pay will be

a key consideration. In this article, we will address how you can prepare now

to improve collections, and we will pro-

vide helpful tips and resources for getting on track to maximize your revenue.

Physician Magazine (ISSN 1533-9254) is published monthly by LACMA Services Inc. (a subsidiary of the Los Angeles County Medical Association) at 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. Periodicals Postage Paid at Los Angeles, California, and at additional mailing offices. Volume 143, No. 04 Copyright ©2012 by LACMA Services Inc. All rights reserved. Reproduction in whole or in part without written permission is prohibited. POSTMASTER: Send address changes to Physician Magazine, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 9001 7. Advertising rates and information sent upon request.

F EB RUA RY 2015 | W W W. P H Y S I C I A N S N E W S N E T W O R K .C O M 1

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as well as medical students, interns and residents. For more

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Pedram Salimpour, MD Peter Richman, MD Vito Imbasciani, MD William Averill, MD Marshall Morgan, MD

than 100 years, LACMA has been at the forefront of current medicine, ensuring that its members are represented in the areas of public policy, govern-

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County and with the statewide

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your physician leaders and staff

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strive toward a common goal– that you might spend more time treating your patients and less time worrying about the challenges of managing a practice.

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LACMA’s Board of Directors consists of a group of 30 dedicated physicians who are working hard to uphold your rights and the rights of your patients. They always welcome hearing your comments and concerns. You can contact them by emailing or calling Lisa Le, Director of Governance, at lisa@lacmanet.org or 213-226-0304.

SUBSCRIPTIONS Members of the Los Angeles County Medical Association: Physician Magazine is a benefit of your membership. Additional copies and back issues: $3 each. Nonmember subscriptions: $39 per year. Single copies: $5. To order or renew a subscription, make your check payable to Physician Magazine, 707 Wilshire Boulevard, Suite 3800, Los Angeles, CA 90017. To inform us of a delivery problem, call 213-683-9900. Acceptance of advertising in Physician Magazine in no way constitutes approval or endorsement by LACMA Services Inc. The Los Angeles County Medical Association reserves the right to reject any advertising. Opinions expressed by authors are their own and not necessarily those of Physician Magazine, LACMA Services Inc. or the Los Angeles County Medical Association. Physician Magazine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. PM is not responsible for unsolicited manuscripts.

A Successful Medical Practice It’s what California’s finest physicians strive for... and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT).

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P RES IDEN T ’S LET T ER | P EDRAM S ALIM P OU R, M D

F O R T H E F O R E S E E A B L E FU TU R E , the Affordable Care Act has laid the groundwork for the changes in how healthcare is delivered and, just as importantly to patients and their access to doctors and hospitals, how that healthcare is paid for. Within the last year about 6.8 million Americans who did not previously have access to health insurance got that through the mandates of this new law. And whether each of us was in favor of the specifics of this concept or cautiously wary of its mandates, today we know that with all the good that it will bring many families, there will be serious challenges. Among those challenges is a shortage of physicians due to an aging population and a sudden increase in the number of patients who would like access to their doctors. Kaiser Health News reported that approximately 10,000 baby boomers are becoming eligible for Medicare each day. This immediate heavy increase of new patients now qualifying for healthcare is challenging a primary care system already struggling to keep up with demand, overall contributing to an already present physician shortage. California today ranks 24th in the country in the number of doctors per 100,000 residents. And there are parts of Southern California that have fewer doctors per 100,000 people than the state ranked 49th in the union. A survey completed in late 2014 by the Physicians Foundation found that 81 percent of

4 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2015

doctors described themselves as overextended or at full capacity—even before this sudden increase in workload. Another 44 percent of physicians said they planned to cut back on the amount of patients they see, retire from their practice or close their practice to any new patients. And the challenges get still more pervasive. While the ACA’s overarching goal was to make healthcare more accessible, some insurance companies are limiting the number of doctors into their physician panels as a way to cut costs. Consequently, patients are finding it difficult to find doctors within their insurance networks, and when they do find a doctor affiliated with their insurance plan they often find it difficult to get appointments to see their doctor in a timely manner. Today, nearly one in five Americans lives in a region designated as having a shortage in primary care. The Association of American Medical Colleges projects the shortage will grow to about 66,000 in little more than a decade as fewer residency slots are available and more medical students choose higher-paying specialty areas—by choice but often by necessity because of their educational debt burden. This is not just a stress on individual doctors, who we can argue are accustomed to stress, this is a stress on the healthcare system. Los Angeles County physicians are dedicated to working through the physician shortage in order to keep the ACA a benefit and not a burden. We have to stay active, vigilant and engaged. We all are busy. And by the measures stated above, we will get busier. But if we do not engage with policy makers and others to come up with solutions for the issues facing us and our patients, others will do that for us. Every profession and every professional ought to remain master of their own destiny. Doctors are no exception.

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INDEPENDENT PRACTICE ASSOCIATIONS COMBINE RESOURCES TO FORM THE NEW

ALLIED PACIFIC IPA

A L H A M B R A - B A S E D A L L I E D P H Y S I C I A N S I PA (Independent Practice Association) com-

pleted a merger with two other groups, Physicians’ Healthways IPA and Pacific IPA, which resulted in a new entity under the name of Allied Pacific IPA that has 2,000 physicians serving over 250,000 members in San Gabriel Valley. There are 500,000 members in seven counties in Southern and Central California.

“Instead of competing we decided to come together and collaborate so we can survive together.”

Kenneth Sim, MD, chairman, Board of Directors Allied Pacific IPA and co-chairman, Board of Directors, Network Medical Management, told PNN that in October 2014, Allied Physicians merged with Pacific IPA and now all three IPAs have come together. The goal is to consolidate resources and create a viable entity that will enable independent physicians to remain in private medicine and be competitive in the market where economies of scale and access to new technologies are the key. “The market is changing so fast that every time you look around something new is happening. Business models are evolving, there are mergers, acquisitions, everything is changing so quickly,” Dr. Sim said. The government is driving the changes and this is nothing new, according to Dr. Sim, but the willingness of physicians to come out of their individual silos and work together to survive is new. From the Health Maintenance Organization Act that President Richard Nixon signed into law in 1973, to the Affordable Care Act of today, the pressure is to contain costs while encouraging better management of care for the patients. But you can no longer do it without having the resources to take advantage of the new technologies that will bring healthcare to the level consumers expect in all other industries, Dr. Sim said. In the past Allied Physicians IPA, Pacific Physi-

6 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2015

cians IPA and Physicians’ Healthways IPA competed with each other for patients. No one wanted to talk to each other, Dr. Sim noted. This is no longer a viable model going forward. “Instead of competing we decided to come together and collaborate so we can survive together.” New technology and innovation will be key, but individual doctors do not have resources or even time to learn about them, let alone implement them. Yet it is technology that will be the biggest game changer and differentiator. Information technology implementation, population health management and home monitoring are the biggest challenges, Dr. Sim said. There are ideas and products out in the market, but most physicians don’t know about them and don’t have time to find out. As a group, he said, there will be opportunities and resources to address that lack. “Patient care in the future will require greater investments in technology and other innovations. Consolidation is a way to free up economic resources that can be better invested in doctors and in the clinical management systems that take better care of patients. This is smart. This is the future: Dr. Sim’s is a novel and innovative model of exceptional clinical care that has proved scalable,” Pedram Salimpour, MD, president of the Los Angeles County Medical Association, told PNN.

Los Angeles County Medical Association Activate your free membership by visiting www.lacmanet.org/StudentsandResidents Calling all Students, Residents & Fellows! Shape your future as a physician-in-training. Students, Residents, and Fellows have the opportunity to shape healthcare policy as they train to become the future leaders of medicine in California.

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Prescription for Home Ownership BY ARMEN LEONARDO KARAPETIAN, SENIOR LOAN ADVISOR, RPM MORTGAGE INC.

IND E E D, TH E R E ’S N O PL AC E LI K E H OM E .

For some first-time homebuyers, though, the

process of buying a home can be downright overwhelming. However, when these same first-time homebuyers are educated in the advantages of purchasing a home, they may decide that the risk and effort involved are minimal when compared to the benefits of home ownership. Let’s examine some of the key benefits in detail and see if the prescription of homeownership is right for you.

Five main benefits of home ownership: • TAX BREAKS | Mortgage interest and property tax

deductions can translate into some impressive tax savings for homeowners. These expenses are usually completely tax-deductible on both the federal and state income tax returns, as are several closing costs. This is of particular benefit to new homeowners, as the bulk of the monthly payments in the first few years goes toward paying down the interest on the new loan. Of course, it is best to consult your tax professional for specifics based on individual income bracket and other deductions.

• BUDGET STABILITY | Home ownership is a great way to hedge against inflation. While rental rates increase year after year based on current market conditions, buying a home allows homeowners to fix their payments for up to 30 years. This means that monthly housing expenses will be capped even when inflation takes hold and price for rent, gasoline, and other consumer goods increase.

• BUILT-IN INVESTMENT | Owning a home can be a wise financial decision. Over time, real estate has proven to be a sound investment, particularly as the mortgage principal is paid down and both equity and home values increase. Oftentimes, homeowners can sell their current homes and

8 P H Y S I C I A N M A G A Z I N E | F EB RUA RY 2015

“roll over” the equity as a down payment for an upgraded home.

• CAPITAL GAINS INCENTIVES | Homeowners who have lived in their homes as their primary residence for two of the past five years have added benefits when they decide to sell. Single taxpayers can exclude up to $250,000 profit and married taxpayers can exclude up to $500,000 profit from capital gains tax. There is no need to buy a replacement home, nor any age restriction.

• AUTONOMY | It is not economically advantageous for renters to upgrade their homes, either cosmetically or structurally. Homeowners, on the other hand, have both the freedom and the incentive to upgrade their living environments. These improvements can result in increased equity and, as any home owner can attest, they help to turn a house into a home.

Homeowners who missed the last refinancing boom have been given another chance. Interest rates are the lowest the country has seen since mid-2013, and remain close to their lowest level in 50 years. Whether you’re a first-time home buyer or current homeowner it’s a good idea to speak with an experienced mortgage professional to determine if the prescription of homeownership is right for you.

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BILLING, CASH FLOW & ICD-10 BY MARION WEBB

With its October deadline approaching, ICD-10 implementation is at the top of the list of physician concerns for 2015. For many physicians, especially for those working out-of-network, knowing how to maximize recovery of pay will be a key consideration. In this article, we will address how you can prepare now to improve collections, and we will provide helpful tips and resources for getting on track to maximize your revenue.

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LAYING THE GROUNDWORK FOR A SUCCESSFUL TRANSITION Current ICD-9-CM diagnosis codes do not provide sufficient clinical specificity to describe the severity or complexity of various diseases, according to Physicians Practice. ICD-10 will add more than 68,000 codes, compared to ICD-9â&#x20AC;&#x2122;s maximum of 13,000 codes. The new codes will be different in their organization, structure, detail and composition and seek to improve operational capabilities of clinics and practices.

ICD-9

Physicians will be able to better determine the severity of illnesses and therefore quantify the level of care more accurately. The codes will also create an electronic trail of documentation, which will help doctors receive proper payment and ensure that their reputation remains in good standing, wrote Mike Patel, CEO of Meditab Software, in an article published on the Advance Healthcare Network website. With the importance and significance of this transition, Patel said, itâ&#x20AC;&#x2122;s crucial that providers are amply prepared.

vs.

ICD-10

3-4 characters in length

3-7 characters in length

14,025 diagnosis codes

68,000+ diagnosis codes

3,824 procedure codes

71,924 procedure codes

3-5 characters

3-7 characters

Outdated technology

Current technology

Generic, non-specific codes

Specificity improves accuracy and depth of data

Not used by other countries

Allows data exchange

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TIPS TO ENSURE ICD-10 READINESS AND MAXIMIZE INCOME Here is a checklist of 14 tips from the experts to get on track with ICD-10 compliance and maximize revenue along the way. Experts include Patel as well as Robert Tennant, Health IT policy director for the Medical Group Management Association, and such online sources as Physicians Practice and Peoriamagazines.com.

CREATE AN IMPACT CHART: Practices should create an impact assessment chart and capture key information in a spreadsheet including the area impacted, needed changes in workflow, how the new system will impact assigning of code, vendor information and contingency plans.

TRAINING: To maintain their certifications, all medical coders must take a minimum number of ICD-10-specific CEUs before the compliance date. To ensure that your staff is adequately trained, the experts suggest conducting a gap analysis to determine your team’s knowledge of medical terminology, pharmacology, pathophysiology, anatomy and physiology and review samples from different types of medical records to see whether the current level of documentation contains enough detail for ICD-10 coding. Physicians also have a learning curve, and those with specialty tools will be in the best position to make sure they aren’t negatively impacted financially.

COMMUNICATE: Ensure clear communications with payers and clearinghouses to ensure that the system is ready to go, and ask if they are ready for the transition as well.

PAYERS: Find out if payers have adopted contractual changes regarding coding specificity that could affect how you process claims.

EXTRA EXPENDITURES: Plan for unforeseen expenses in time and resources such as training of staff, IT upgrade costs, business process analysis of health plan contracts and documentation, and cash flow disruptions due to the ICD-10 transition.

CLEAR DOCUMENTATION: Ensure that your patient records are clear and complete in order to submit accurate claims and avoid delays in payment.

OUTSOURCING VS. IN-HOUSE BILLING: If billing is handled in-house, the cost of keeping employees on staff may be higher than the cost of hiring a third-party biller. Here are some questions to consider in making the decision: What are some of the financial benefits in hiring a third-party biller that your practice currently does not get? How will your practice pay for the third-party biller and what hidden expenses will come up (postage or processing fees)? Also, ask yourself how will billing services be affected as your practice continues to grow, given that many revenue cycle management firms are paid a percentage of collections?

TEST, TEST, TEST: Make sure your staff is up to speed and practices with active claims by coding them in the old system and the new to see if they are getting the right information.

COST-EFFECTIVE RESOURCES: Visit the Centers for Medicare and Medicaid Services website as a resource. cms.gov/Medicare/Coding/ ICD10/index.html?redirect=/icd10

SOFTWARE: In addition to impacting practice systems and electronic health record software, the move to ICD-10 may require that practice software needs to be updated or replaced. To do this takes time and resources.

REGULATIONS: Know and identify all other regulations and changes so you won’t get behind as you approach ICD-10 implementation.

FILTERING: Filter out the codes you will be using the most for greater efficiency.

TURNOVER: Ask yourself if your billing department has a high turnover rate. If the answer is 20% or more, you may have inefficiencies that either need to be addressed in-house or may lead you to consider outsourcing.

ICD-10 codes will create an electronic trail of documentation, which will help doctors receive proper payment and ensure that their reputation remains in good standing.

HIRE COUNSEL: Because payment disputes are possible, providers should proactively address ICD-10 issues in their current negotiations. The attorneys at Epstein Becker & Green suggest that any provisions addressing group changes that address ICD-10, and those referencing “revenue neutral” requirements and provisions dealing with policy and manual compliance, should be carefully considered in contract reviews. Finally, the attorneys also recommend a clear, fair dispute resolution provision for ICD-10 conversion.

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INCREASING YOUR CASH FLOW EARLY While some organizations continue to wait to see if the compliance date of Oct. 1 will truly stand, some experts caution that waiting for the final date could put your revenue at risk. Robert Wergin, MD, president of the American Academy of Family Physicians, expressed confidence that the Oct. 1 deadline will stick. “This time, it looks like the real thing,” Dr. Wergin told Medscape. He agrees that doctors’ anxiety

remains high over what it will take to implement the new coding system and what it will mean for doctors in terms of income. “There is concern that the technology won’t work when the systems start up,” he said. He also noted that providers might not get paid right away. The best way to prepare for any delays, the experts say, is to increase your cash flow early.

Five Ways to Increase Cash Flow Now:

CLEAR EXISTING BLOCKAGES: With the move by health plans to increase deductibles, more patients face higher out-of-pocket costs. Rather than waiting to be reimbursed, by tapping into the payers’ systems, practices can assess the status of a patient’s deductible and accurately predict out-of-pocket expenses at the time of their visit. They then can obtain authorization right away to charge a patient’s credit card once the insurance claim is settled.

USE NEW TECHNOLOGIES: Using new technologies such as lockbox services, remote deposit, electronic funds transfer, sweep accounts and online bill payments for all expenses allows practices to get payments into their accounts faster. Combining claims into one outsourcing solution and a single electronic database rather than tracking them separately also helps improve cash flow.

COORDINATE CARE IN YOUR PRACTICE: In the old days, long wait times were seen as a sign of a physician’s popularity, but today any obstructions in a practice’s scheduling process will likely leave patients to seek care elsewhere. To keep your clients coming back and keep your reputation as an efficient and effective practice intact, you want to optimize care, which will ultimately translate into optimized cash flow.

IDENTIFY ERRORS EARLY: Post-service revenue cycle management opportunities abound, giving you tools to identify and correct errors before you submit a claim to your insurer. Also, training your staff to monitor claim denials to spot trends and fix problems at their source is key. Common preventable causes of claim denials include lack of insurance company-required referrals or prior authorization, inaccurate demographic or insurance information, claims that weren’t filed in a timely manner, and incorrect modifier, procedure and diagnosis codes.

RULE OUT FRAUD: With large sums of cash coming in, it’s critical that you hire honest employees. It takes only one dishonest worker to disrupt your cash flow. Consider paying vendors with a business credit card instead of checks. Banks offer business credit cards to medical practices for internal use as well as credit card merchant processing for payments. Segregate banking duties among staff so no one person has access to all bank accounts. Ask your bank to send account statements directly to your accountant and limit online banking access. Put strong cash controls in place and log all funds collected on site and total them at the end of each work shift. Invest in periodic audits of internal controls performed by an accountant or an auditor who specializes in detecting fraud.

Consultants advise doctors to keep three months of cash flow in reserve to prepare for any delays in pay as ICD-10 implementation gets closer. While some groups continue to push for additional delays, saying the mandate comes at a time when physicians are already dealing with several other technology requirements and risk penalties, several experts recommend that physicians who aren’t ready to comply put themselves at a financial risk.

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EFFECTIVE REVENUE RECOVERY TECHNIQUES BY SHANA NISSANOFF, CHIEF EXECUTIVE OFFICER OF ECURE (EMERGENCY CARE UNDERPAYMENT RECOVERY EXPERTS)

TH E NUM B E R O N E M I S TA K E

made by medical practices is to fail to implement a claims auditing process. Even if the practice sends out a perfectly scrubbed bill, health insurers will still inappropriately deny, delay and significantly reduce payments. They may even request refunds for claims they have overpaid. By implementing claims auditing processes, a physician’s practice can ensure that health insurances pay appropriately. It’s a two-step process. Appropriate documentation for patients to sign must be front-loaded, and denial letters to health insurers should contain a legal framework rebutting the specific denial at hand. This protects your rights for claims being underpaid. (continued)

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The first step in ensuring proper payment is to dure typically bills out, what specific circumstances make sure that you understand as a physician or are involved, the physician’s experience and specialty and many other factors that are non-tangible. Hence, healthcare provider if you are a contracted provider. Often a healthcare provider thinks they are not if at any time a commercial carrier such as an HMO contracted and find out later, unbeknownst to them, or a PPO does not pay a provider his usual, customthat their contract was assumed or sold to another ary and reasonable reimbursement and reduces it to a different number called the “allowable,” then the carrier, or a “Silent PPO.” If you happen to be contracted, then you are provider has the ability to seek further payment. Once the physician figures out if he is bound by bound by the terms of your contract. If you are not, then you are not bound by any terms of anyone’s con- the participating plan’s contract or not, then the next tract; rather, the carriers are actually bound by the step is to streamline the claims management revenue terms of the law in the state of California. Those legal cycle — your practice’s internally designated work rules differ for elective cases and for emergent/urgent flow that includes the steps you take to prepare, submit and collect the claim cases. correctly. In a nutshell, if you are The documentation in contracted, then based on your notes needs to be allthe benefits that are allowed Often a healthcare provider encompassing. It needs to to the patient in the patient’s thinks they are not contractspecify exactly what was benefits contract, you will done in the text of the note. collect only the amount ed and find out later, unbeFurthermore, you cannot that has been agreed on beknownst to them, that their rely on billers to read the tween you and the carrier. contract was assumed or note and make a decision Because there are so sold to another carrier, or a on your behalf as to what many insurance companies the CPT code should be. It and so many different plans “Silent PPO.” is incumbent on you to figwithin each insurance comure out what you did and pany, this is almost imposlook up the CPT code that sible to follow except on a clearly reflects the evaluation, management or procecase-by-case basis. If you are not contracted with a carrier for an elec- dure that you performed in order to be able to submit tive case, then the patient is ultimately responsible for appropriate claims and not receive a denial. The carriers are always looking at the CPT codes the care they received, unless you verified benefits with the carrier and they told you otherwise. The car- and then comparing it to actual documentation. If the rier, as a general rule, needs to pay for only the ben- documentation itself does not reflect the description efits documented in the patient’s benefit plan. How- in the CPT code, they will deny the bill, or worse, ever, when a physician goes into the emergency room consider it fraudulent billing and request a refund if or consults on a patient in the hospital, and he is not they have already paid it. Again, you cannot rely on a participating provider in that particular healthcare any biller to code for you. The next step is to streamline your claims audit plan, then that healthcare plan’s benefits do not preand appeals procedures, i.e., your practice’s internal vail. What does prevail is called “usual, customary and controls that detect health insurance payment errors reasonable” (UCR) reimbursement. If the payment and manage submitted claims, and perform the apisn’t paid in full by the carrier (minus the co-pay and propriate collection efforts to ensure that the health deductible), then you, as a non-contracted provider, insurer’s processes adjudicate and pay your claims can have a claim directly against the carrier for your accurately. In other words, the first time an EOB (explanation of benefits) comes back to the biller with an underpaid balances. The UCR reimbursements are based on a very explanation as to how the carrier paid that claim, if specific law that entails many factors, including what it was not paid in full, then it needs to be evaluated other physicians in the geographical area bill out, and deciphered as to why it was not paid in full. Was what that specific provider who performed the proce- the entire bill offset because of the patient’s deduct-

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We start where your billing and collection company stops. We work to recover your money from insurance plans. We put YOUR money back in your pocket at no cost to you!

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F EAT U RE | B ILLIN G, C AS H F LOW & IC D- 1 0

ible? Did the patient meet their out-of-pocket maxi- would make far less at the same percentage rate than mum allowable for the year, in which case the carrier he would just finding more clients to keep on billing should have paid 100 percent of the claim? Did the out initial billings. For example, if a doctor has a $1,000 bill and the carrier just indiscriminately decide to pay you as a non-contracted provider the contracted rates that they biller takes 5%, it will take him about five minutes usually contract with other providers who otherwise to bill out the $1,000. If only $100 was collected, get volume discounts for signing those contracts that he will collect $5, which is 5% of 100. Five dollars for five minutes equates to $60 an hour. If he now you are not entitled to? tries to collect the balance Until you can deterof the billings that he has mine why the bill was not done, which is now $900 paid appropriately, you ($1,000 minus the $100 will not know how to apMost providers think that the collected) with no guaranpeal it correctly. This docubiller is incentivized to collect tee that he will ever see a ment will explain how to penny of that $900 from simplify your claims audit as much as he possibly can as that insurance carrier, he and appeals process and he is on a percentage basis, may spend two to three reduce the administraand the more that he collects hours trying to collect it. tive burden, demystify the for you, the provider, the more Even if he collects the health insurance claims full amount, which is rare, appeal process and exhe will keep in his pocket. This then he would have spent plain what to do when the is far from the truth. three hours of his time — insurance carrier flat out at $60 an hour, or $180 — denies the appeal. but he is only making 5% Physician practices are of the $900, which equates entitled to fair reimbursement and appropriate payment for the procedures to $45. This is not economically advantageous to a and services they provide when they have coded and biller to try to even collect your monies. Therefore documented the procedure or services appropriately. you must understand that there is significant difference between a biller and biller’s incentives and a collector and a collector’s incentives. A collector usually charges anywhere from 30% A BILLER IS NOT A COLLECTOR to 50% of what he collects. There is a reason for his OR AN APPEALS SPECIALIST Most practices either hire billers internally or send high percentage: It takes so much more time, effort the billing to an outsourced company. Most provid- and energy with higher risks of not collecting from ers pay a percentage of claims, on an average 5% to the carriers, as the bills have already been billed out 10% of what is collected. Most providers think that correctly, and initial payments have been made. A practice needs to understand that after the billthe biller is incentivized to collect as much as he possibly can as he is on a percentage basis, and the more ing is done, the next step is to either send it to an that he collects for you, the provider, the more he will in-house collector or outsource it to a collector that is separate from the biller. keep in his pocket. The provider will have to expect that the percentThis is far from the truth. A biller’s job is to bill. His job is not to collect. age he will give to this collector will be substantially The more claims he bills out correctly, the more bills higher than the biller would be getting because othwill eventually be paid. His job, and his incentive, is erwise there would be no reasonable incentive for to bill correctly as many claims as possible one time the collector to collect these monies and spend long hours on the phone, sending letters of appeals, etc. for each claim. Even after the collectors have pursued claims If the bills go out correctly and they get paid inappropriately, he still gets his percentage of those pay- against the carriers, they too fail in many ways. The ments. If he spent time, effort and energy trying to carriers understand that for out-of-network emergencollect monies that were underpaid or not paid, he cy services, they are obligated by law to pay the usu-

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ics actually makes sense. They create a mini class action lawsuit against the carrier, and the attorney fees and costs now are economically beneficial and reasonable to the litigated case at hand. One of these companies is ECURE out of California. They will purchase and take assignment of claims and consolidate them with other providers in order to create an economically beneficial case against the carrier. Once this actually happens and the company that purchased the accounts receivables is successful in either settling or winning a case in the courts of California, the carriers usually will start paying those providers appropriately, understanding that their legal fees are going to exceed the cost of paying the providers appropriately from the get-go. This is the only way to turn the tables on the carriers and have them follow the rules and force them to follow the rules of the law. For more information contact ECURE at (844) 834-8141.

WHAT TO DO WHEN YOU ARE NOT PAID YOUR FULL BILL So what is a physician/provider to do when the carrier underpays the biller, does not pay or continues to underpay the collector? The first answer is to complain to the Department of Managed Care, which has an ombudsman who reviews these billings with appropriate documentation and makes a determination that is binding on the carrier. Over the past several years of reviewing the percentages of the Department of Managed Careâ&#x20AC;&#x2122;s decisions, it appears that about 50% of the time they do find in favor of the provider. They too are not always correct, but this is an avenue that needs to be addressed by the provider and by the collector. An alternative to the Department of Managed Care, which can take up to 18 months to get a response, is to sell the outstanding accounts receivable to companies that actually purchase them at a somewhat discounted rate, or purchase them based on a percentage of what they collect in the future. By doing this, the physician has absolved himself of any and all costs associated with collections and has monetized his zeroed-out balances and dead accounts receivable. These companies consolidate claims from multiple providers, and as an example, they take a thousand providers that have $900 balances, and now have a case that they litigate against the carrier for $900,000. In this situation the econom-

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al, customary and reasonable rates for these services. They rarely ever do. They understand the economics. They understand that most practices have billers that just bill and never appeal. For those practices, there is a statute of limitations as to how long before those claims can never be pursued again by law. There is a small percent of practices that actually send their claims that were not paid on the initial billing out to collectors who then appeal those decisions appropriately citing case law and attaching supportive documentation to their appeal for the appropriate payments. There are times when the insurance companies will pay these, but again, most of the time they will not pay the bill in full as they realize that, as the example above, the $900 underpaid claim will never be taken to court. Therefore they effectively have nothing to worry about. A lawyer will cost a physician anywhere from $250 to $500 an hour, and it will take anywhere from 10 to 100 hours to try to collect and litigate for $900. The math here does not work either.

Cut Your Income Taxes in 2015 FIVE SMART WAYS TO

BY DAVID DENNISTON, CFA

TO DAY ’ S W O R L D I S an incredibly tax-unfriendly environment for physicians. And

by increasing your taxes due to the provisions of the Affordable Care Act, Uncle Sam is out to get even more! The good news is that there are several steps that you can take to be proactive and keep more money in your pocket. Here’s how you can minimize your tax burden and improve your specific situation.

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Pay Yourself First | Start contributing to your 401(k)

plan (or 403(b) plan if you work for a nonprofit) as well as a 457(b) and a Health Savings Account (HSA) if they are available. Contributing boosts your retirement savings and lowers your income taxes as well. This money comes right out of your paycheck, withheld by your employer. By contributing to your 401(k), every dollar you put in gives you a discount on your federal income taxes. For example, if you are in the 35% bracket, and you contribute $10,000, you have just lowered your taxes by $3,500. That’s like a 35% rate of return on your money today that can grow tax-free until you withdraw it someday, when it will be taxed likely at a lower rate. Be sure to contribute at least up to the maximum match your employer provides. If your employer matches dollar-for-dollar, this is like an automatic 100% return. Even if your employer matches 50 cents or 25 cents on the dollar, that is still a 50% or 25% return just for contributing. Get close as you can to maxing out your contribution. If you are under 50 years old, the maximum you can put in the 401(k) is $18,000 in 2015. If you are over 50 years old, you may do an additional catch-up contribution of $5,500 for a total of $23,500.

Set Up a Business or Moonlight as a Consultant |

The American tax code is set up to benefit one person: the business owner. There are many potential writeoffs, including using a home office, which allows for many deductions. For instance, you could remodel your basement as a tax-deductible home office, and deduct 100% of all costs, such as utilities, insurance and depreciation, related to the office. Keep in mind, you don’t have to be the business owner; it can be your spouse.

Avoid Tax-Inefficient Funds | You can control capital

gains and dividends when you own individual stocks and exchange-traded funds,, because you can sell them anytime. Unfortunately, it is much more difficult to control them with mutual funds. Mutual funds will distribute capital gains even when you haven’t sold anything, a phenomenon called “phantom capital gains.” As assets come into a fund, the portfolio manager will buy stocks or other securities. Then, when investors redeem their money, the manager will have to sell stocks or other securities, creating taxable distributions. This can be bad news for tax efficiency. If you are in a “hot fund” that had capital gains from unsold positions that the manager bought years earlier (before you invested in the fund), and investors start pulling out dough, you could be left with a big tax bill. You could actually lose money in a mutual fund and still get caught with a big capital-gain distribution. Be very careful which mutual

funds you invest in. Some managers are incredibly taxefficient, but many are not.

Harvest Capital Losses | The idea of tax harvesting

is to purposely create capital gains or capital losses to maximize your tax advantages. Of course, the government has no ceiling on the amount it can tax you for capital gains. However, it does it have a floor on capital losses: $3,000 per year. Net losses above $3,000 must be carried over into the following year. Perhaps you have no carry-forward losses and you have realized some capital gains. Instead, you may have some capital losses that you can harvest to offset the gains and perhaps even create a loss for the year. It’s simply a matter of selling one or more losers while holding onto your winners.

Be Charitable | By donating to charity, you can get a tax deduction by unleashing your giving spirit. If you can get your itemized deductions above the amount of the standard deduction, you can have a higher tax write-off than many Americans. Remember your state income taxes are counted towards your itemized deductions, as well as mortgage interest. By adding some charitable giving to the mix, most of us can easily exceed the standard deduction limits and be able to itemize instead. There’s no minimum to the amount of charitable gifts you can report. However, if your contribution entitles you to merchandise, goods, or services, including admission to a charity ball, banquet, theatrical performance, or sporting event, you can deduct only the amount that exceeds the fair market value of the benefit received. For a contribution of cash, check, or other monetary gift (regardless of amount), you must maintain as a record of the contribution a bank or credit-card record or a written communication from the qualified charity containing the name of the organization, date of the contribution, and the amount. As a physician, you’ve made a commitment to helping others and your community. Now you need to make a similar commitment to your finances. You can fight back at Uncle Sam through focusing on reducing your taxes by contributing to your retirement, setting up your own business, harvesting losses, avoiding tax-inefficient funds, and being charitable. By being proactive with your tax situation, you can then do the things you’ve long dreamed of doing and be well down the road to financial independence. About the Author: Dave Denniston, Chartered Financial Analyst (CFA), is a professional wealth manager and financial advisor located in Bloomington, MN. He is also the author of 5 Steps to Get out of Debt for Physicians, The Insurance Guide for Doctors, The Tax Reduction Prescription, and his upcoming book The Freedom Formula for Physicians. You can contact him at (800) 548-1820, at dave@daviddenniston.com, or visit his website at www.DoctorFreedomBook.com to get a copy of The Freedom Formula for Physicians.

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U N IT ED WE S TAND | AT WORK F OR Y OU

CMA Elects New Chair for Board of Trustees

The California Medical Association (CMA) has elected David H. Aizuss, MD, David H. Aizuss, M.D. as the new Chair of the Board of Trustees. This is the first time in twenty years a Los Angeles County Medical Association (LACMA) member has been elected CMA chair. A board-certified ophthalmologist who practices in Los Angeles, Dr. Aizuss exclusively places focus on direct patient care. He has served as vice chair of the CMA board since 2011 and was a former president of the LACMA and the California Academy of Eye Physicians and Surgeons. “I am honored to have been elected. The association is dedicated to serving its members and advancing the public health of the citizens of California,” said Dr. Aizuss. “CMA is the single most effective voice for physician advocacy in our state Legislature and before state regulatory bodies.” Pedram Salimpour, MD, president of LACMA, applauded the electoral results. “We are proud to have one of our own serving on such a highly regarded board,” Dr. Salimpour said. “Dr. Aizuss is one of the most highly respected clinicians and physician leaders in California, and I take very personal pride in that he has been a close associate of my family’s for many years.” “I am proud of the physicians who put their reputations and pocketbooks on the line in the interest of their patients. To have such a compassionate and dedicated physician as the new chair of CMA strengthens our voice in our advocacy for the patients our physicians serve,” stated Rocky Delgadillo, chief executive officer of LACMA, after hearing of the electoral results.

AMA Asks Feds to Decouple EHR Certification from Meaningful Use

The American Medical Association (AMA) has sent a letter to the National Coordinator for Health Information Technology, Karen B. DeSalvo, MD, urging that the certification of electronic health records (EHR) be decoupled from meaningful use certification requirements. “Unfortunately, we believe the meaningful use certification requirements are contributing to EHR system problems, and we are worried about the downstream effects on patient safety,” the letter said. “Many physicians find these systems cumbersome, do not meet their workflow needs, decrease efficiency, and have a limited, if any, interoperability,” the letter said. ”Most importantly, certified EHR technology can present safety concerns for patients.” AMA believes there is an urgent need to change the current certification program to better align end-to-end testing to focus on EHR usability, interoperability and safety. The letter was also signed by 35 medical societies and specialty societies.

CMA TELLS DHCS

Medi-Cal Payments Must Be Raised

BEFORE IMPLEMENTING ANY NEW REFORMS

The California Medical Association (CMA) recently submitted comments to the California Department of Health Care Services (DHCS) on the state’s next 1115 Section Medicaid Waiver, telling DHCS that increasing reimbursement rates is absolutely imperative prior to implementation of any new program reforms. California’s current Medi-Cal rates often do not even come close to the cost of providing care. California is in the last year of its current Section 1115 waiver, which was approved by the federal government so California could expand Medi-Cal coverage in accordance with the Affordable Care Act in 2010 and implement a variety of delivery reform projects like the duals demonstration project. The state’s current five-year waiver is set to expire October 2015. CMA has participated in a number of work groups designed by DHCS to receive feedback on what new projects the state would implement in the next waiver. The state convened work groups in order to explore ways to implement incentive payments to providers participating in the Medi-Cal program and how to increase and maintain the physician workforce in the state of California.

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CMA commented that the 10 percent provider reimbursement cut authorized by AB 97, on top of California’s already abysmally low provider reimbursement rates, which have not been adjusted for increasing costs in two decades, and the discontinuation of the Affordable Care Act’s pay bump for primary care providers, makes it very difficult for physicians to accept new Medi-Cal patients—placing roadblocks for patient access to care. CMA made it clear that increasing rates is a prerequisite to implementing incentive payment reforms. CMA called for the state to conduct an independent, third-party assessment on reimbursement rates, stating that such an assessment is a critical component in determining both the baseline rates and the level of incentive payments required. CMA also commented on workforce development, calling for the funding of new residency programs and the expansion of Song-Brown and Steven M. Thompson Physician Corps Loan Repayment Programs. DHCS is expected to enter into negotiations with the Center for Medicare and Medicaid Services on the new waiver in the spring of 2015.

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AS S OC IAT ION H AP P ENINGS | LAC M A NEWS

CEO’s LETTER

THIS FEBRUARY, L ACM A is excited to continue to serve, expand and provide new offerings to its rising numbers of distinguished physician members. As part of our ongoing outstanding series of events and efforts to keep physicians on the cutting edge of knowledge and learning during this time of change in the health sector, we are thrilled to highlight three programs you don’t want to miss this February. Kicking off our February series on Feb. 7 is a seminar on “Disruptive Behavior and the Medical Staff’s Response” presented by the California Public Protection and Physician Health Inc. Speakers Tom Curtis, an attorney with Nossaman LLP, and Karen Miotto, MD, chair of the UCLA Medical Staff Health Committee, will discuss key issues every member and staff of physician health committees in hospitals, medical groups, county medical societies and specialty societies need to be aware of when addressing disruptive behavior. Curtis has more than 35 years of experience representing clients in the healthcare sector on a wide range of issues. Dr. Miotto is an expert on issues pertaining to well-being and emotional health of physicians. She frequently talks about the rising stress of practicing in the changing health environment and the alarming rise of physician burnout to physician leaders and groups. On Feb. 11, LACMA is proud to present another event, the “Ambulatory Care Centers Committee Panel Discussion,” which will focus on such topics as accreditation of surgery centers, reimbursement of claims and physician intimidation. This event will take place from 7-9 p.m. in Beverly Hills at a location that will soon be announced on the LACMA events website. Our distinguished Women Physicians Action Committee is proud to present a topic that is near and dear to every woman’s heart—namely how to best manage finances and plan for the now and the future to ensure financial stability and security. The experts on money issues will delve into accounting, financial planning and contract negotiation issues specifically as they pertain to female physicians. Whether you’re a female physician working in your own practice, are employed or have employees, this seminar will pave the way to your successful financial planning for 2015. As always, you will find more information and registration details on LACMA’s website in the events section. In our efforts to continually serve you better, we are currently researching a new address in the downtown area of LA as our lease expires. I look forward to seeing many of you during an upcoming event and am excited about the many opportunities as well as challenges that will present themselves during this new year.

Rocky Delgadillo Chief Executive Officer

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75th Diamond Anniversary BY HALAINE ROSE

THE DISTRICT 2 ALLIANCE celebrated its

75th anniversary in style with an event held in a doctor’s beautiful garden and a delicious catered dinner and wonderful entertainment enjoyed by 115 physicians, spouses and friends of medicine. Success in achieving camaraderie across the full medical specialty spectrum and turf lines was dramatically evident. The Pasadena Symphony Quartet performance was a special bonus. California Assemblyman Chris Holden and California Representatives in the U.S. Congress Adam Schiff and Judy Chu provided congratulatory certificates. A hand-painted scroll from LA Supervisor Mike Antonovich wowed the crowd as it was presented by Helen Chen, MD, radiologist at City of Hope Cancer Center in Southern Pasadena and a former intern with Holt Rose, MD, cho-emcee of the event. Lois Matthews, Huntington Hospital Board, praised District 2 president Halaine Rose and her active all-volunteer organization. At the party, the D2 Alliance in honor of its diamond anniversary, raised $5,000 for HMRI migraine research led by Mike Harrington, MD, and $3,200 for the District 2 Alliance MD student scholarship fund. Co-emcee Dr. Holt Rose commended D2 Alliance—greater Pasadena region—for working vigorously to educate colleagues and other voters to preserve the Medical Injury Compensation Reform Act by voting “No on 46.” A presentation by Gordon Sasaki, MD, and Halaine Rose, plus Halaine’s archival photo books, gave insight into the stellar record of Alliance D2 in health education, legislative advocacy, physician and patient support. Special thanks to Joanne and Gordon Sasaki, MD, Cathy and William Caton, MD, Halaine and Holt Rose, MD, for financial and diamond input, Team 75 -- hosts Nancy and Dave Rhodes, MD, co-emcee Vivien and Willaim Foran, MD, Marilyn and Eden Henderson, Georgiana Wu, Sara Gaspard, MD, Jan and Dave Moritz, MD, and Debra Fallon.

Dr. Helen Chen (second from right) presents painted scroll from LA County Board of Supervisors honoring 75 years of health, education and community service of D2 Alliance to current president Halaine Rose (center) and former presidents (left to right) Betty Falk, Joan Dietrick and Carole Roback.

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Benefits & Discounts

Aimed at meeting both your professional and personal needs, LACMA offers you additional discounts and savings on Auto & Home Insurance, UPS services, Staples office supplies, Financial Planning, HIPAA Compliance Kits, and more!

TOP REASONS

FREE CME & Educational Resources

Unlimited Access to Legal Experts

LACMA/CMA IS THE VOICE OF PHYSICIANS score

Legislative Advocacy

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LACMA and CMA are distinguished by their successes. Dual membership provides for unparalleled legislative advocacy to end abusive practices. In addition, LACMA has sued health care plans on behalf of members to stop intimidation tactics.

• Socialize and network with members of the medical community • Find or create opportunities for your practice • Engage with legislators and policymakers

9 State-of-the-Art Communication

Tired of fighting with payors? CMA’s Economic Services experts have recovered nearly $8 million for members since 2010!

Information is power. LACMA and CMA produce several publications full of valuable information including the award-winning Physician Magazine, Physicians’ News Network, and CMA Practice Resources, full of tips and tools for your practice.

FREE Jury Duty Assistance

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Access to your Physician Advocates

Through an exclusive partnership with Medline, LACMA saves members a guaranteed minimum of 10% on their medical supplies and equipment. Find out how one member saved $31,000 for his practice!

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27% in AVERAGE SAVINGS

Save time and money by consulting with a CMA legal expert before hiring a lawyer. Services include HIPAA Compliance, ACOs, Buying and selling a practice, Upkeep of medical records, and much more!

FREE Networking & Referral Events

FREE Reimbursement Assistance

LACMA can help you: • Reschedule your date • Relocate for your convenience • Reduce number of call-in days from 5 to 1!

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Working together, the Los Angeles County Medical Association and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining LACMA and CMA, 10 stand out.

CMA develops toolkits, guides, webinars, and resources on all things related to today’s changing healthcare landscape—all FREE with membership. In addition, LACMA provides access to important and local CME-accredited events.

FOR JOINING LACMA AND CMA

When you join LACMA and CMA, you hire a professional staff that serves as an extension of your practice. We are here to help you reach your goals and connect to the resources you need most. Whatever you need—be it help with a problematic payor, or details about your member discounts—just call the member helpline at (800) 786-4262 or visit www.lacmanet.org

RIGHT NOW

is the best time to join LACMA and CMA For more information on member benefits and resources, visit www.lacmanet.org/Membership LOS ANGELES COUNTY MEDICAL ASSOCIATION 707 WILSHIRE BLVD, SUITE 3800 LOS ANGELES, CA 90017 PHONE: (213) 683-9900 FAX: (213) 226-0353

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Group

Health Insurance Are you aware that small groups can change their health insurance at any time throughout the year? Mercer provides a wide range of health insurance options and guidance to members of the Los Angeles County Medical Association. We connect you with the top group insurance carriers and help you choose the coverage that best fits your needs and budget. We offer flexibility and value so you can provide quality health, dental, life and disability plans to your employees. Small Group (2 to 50 employees) coverage is available for all business forms that include at least one non-spouse W-2 employee in addition to the owner(s). Tax form verification of your status as a small group is required. We can help you to determine whether your business structure and enrollment will qualify for small group coverage if you are not sure. Plus, members who purchase their group health insurance through Mercer, the Association’s sponsored insurance program broker and administrator, are eligible to receive Mercer Select H&B KnowHow. Developed by Mercer, a leader in human resource consulting, outsourcing and investments, Mercer Select H&B KnowHow is a tool that helps provide employers with important human resources information such as the latest health and benefit requirements for California, and it provides the forms needed for compliance. For more information, contact a Mercer Client Advisor at 800-842-3761, or visit www.CountyCMAMemberInsurance.com.