MI MEDICINE | July/August 2019

THE OFFICIAL MAGAZINE OF THE MICHIGAN STATE MEDICAL SOCIETY » VOL. 118 / NO. 4

July / August 2019

BETTER PAYER CONTRACTING FOR BETTER OUTCOMES

msms.org

FEATURES & CONTENTS July / August 2019

08

Accounting for Travel Time: To Pay or Not to Pay? JODI SCHAFER, SPHR, SHRM-SCP

10

Protect Your Adolescent Patients Before They Go Back to School!

ALYSSA NOWAK, MPH

12

Legal and Regulatory Resources at Your Fingertips STACEY HETTIGER, MSMS

24

When Treating Children, Avoid These Risks DARRELL RANUM, JD, CPHRM

COLUMNS 04 President's Perspective

16

FEATURE

MOHAMMED A. ARSIWALA, MD

06 Ask Our Lawyer

DANIEL J. SCHULTE, MSMS LEGAL COUNSEL

DEPARTMENTS 15 In Memoriam 22 Welcome New Members 28 MSMS Educational Courses

Better Payer Contracts for Better Outcomes

BY NICK DELEEUW FOR THE MICHIGAN STATE MEDICAL SOCIETY

The better the business of medicine gets done, the better a physician is able to treat patients, build a compassionate staff, and expand quality care and services. Read the article beginning on page 16.

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STAY CONNECTED!

MICHIGAN MEDICINE® VOL. 118 / NO. 4 Chief Executive Officer JULIE L. NOVAK Managing Editor KEVIN MCFATRIDGE KMcFatridge@msms.org Marketing & Sales Manager TRISHA KEAST TKeast@msms.org Publication Design STACIA LOVE, REZÜBERANT! INC. rezuberant.com Printing FORESIGHT GROUP staceyt@foresightgroup.net Publication Office Michigan Medicine® 120 West Saginaw Street East Lansing, MI 48823 517-337-1351 www.msms.org All communications on articles, news, exchanges and advertising should be sent to above address, ATT: Trisha Keast.

Postmaster: Address Changes Michigan Medicine® Trisha Keast 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, published under the direction of the Publications Committee. In 2019 it is published in January/February, 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. ©2019 Michigan State Medical Society

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perspective

By Mohammed A. Arsiwala, MD, MSMS President

®

Colleagues, You went to medical school and persevered through residency and continuing education programs because of your concern for and commitment to your patients.

You do your very best each day and deliver world class care to men, women, and families facing what may be some of the most difficult days of their lives.

Making those connections—helping patients—requires more than your training and your commitment. It requires physicians across the state to master another discipline altogether—payer contracting.

In this edition of Michigan Medicine®, you’ll hear from health care professionals about the risks and benefits of payer contracting, and we’ll deliver a brief primer on what it takes to succeed in negotiations with payers.

MOHAMMED A. ARSIWALA, MD MSMS PRESIDENT

You’ll also learn about services and resources available exclusively to members of the Michigan State Medical Society designed to help you get a leg up on the contracting process to benefit your practice and your patients. You’ll learn about the key terms you need to define in each contract, the steps you should follow to get the best results, and the key contract elements that attorneys who specialize in health law insist every practice, physicians organization, or hospital take the time to get right.

Michigan’s physicians pour their lives into their patients. Getting the most out of your contracts with payers will make that more possible than ever before; and, should ease some administrative burdens, improve physician reimbursement, and decrease the effects of burnout on your wellbeing. The Michigan State Medical Society is here to help every step of the way.

Sincerely,

Mohammed A. Arsiwala Mohammed A. Arsiwala, MD MSMS President

michiganMEDICINE® JANUARY JULY / /AUGUST FEBRUARY 2019 2019 | |michigan MEDICINE®

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ASK OUR LAWYER

Different Fee Schedules and “Most Favored Nation” Provisions

By Daniel J. Schulte, JD, MSMS Legal Counsel

I recently terminated my contract with a health plan. As a result patients enrolled in that health plan may have higher out of pocket costs if they elect to continue treating with me and may have to file claims with the plan themselves to obtain their benefits. In an effort to keep as many of these enrollees as possible, I plan to offer them reduced fees. These lower fees will be different than the fee schedules of other health plans I continue to participate with and the fees I charge patients that are not enrolled in any health plan and have no health insurance coverage.

Is there anything illegal about charging patients differing fees for the same services?

The answer?

“Not necessarily.”

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T

here is no Michigan statute that prohibits a physician from varying the fees charged for services based on whether the patient is enrolled in a health plan, has insurance or the fact that the patient used to have coverage with a health plan that you no longer participate with. However, there are two reasons you should be careful in doing so.

First, you would not want your practice of charging different fees to be construed as a disguise for illegal discrimination.

Technically charging patients differing fees for the same service is discriminating. However, not all discrimination is illegal. For discrimination to be illegal it must affect a protected class of patients. Protected classes are established an antidiscrimination statute (e.g. those of the same gender, race, nationality, etc). It is hard to imagine that what you are contemplating would have the effect of adversely affecting a particular protected class of patients. If somehow it did, you could be subject to discrimination claims.

WE CONNECT PATIENTS TO THE CARE YOU PROVIDE Websites & Digital Marketing for Healthcare Providers.

The second reason is that you may have another participation agreement with a health insurer/plan that imposes adverse consequences should you offer lower fees than that health insurer's/plan's fee schedule amounts. Such adverse consequences may include a “most favored nation” provision providing that if fees are charged to patients not enrolled in that plan that are lower than the plan's fee schedule amounts, the fee schedule amounts are automatically lowered to that level.

This is much less of a concern following the enactment of MCL 500.3405a. That statute generally prohibits the use of most favored nation clauses in the absence of approval by the Michigan Department of Insurance and Financial Services.

You mentioned that you continue to participate with some health plans. You must carefully review those participation agreements (and any uniform participation requirements, rules, terms, etc that are referenced and incorporated into the agreements) to determine whether there are most favored nation provisions or other prohibitions or consequences of varying the fees you charge patients in your practice.

In addition to the legalities of charging patients different fees for the same service you need to consider the practicalities.

Will others understand your decision to incentivize your patients to continue to treat with you following your termination of your participation with this health plan?

Prior to charging patients differing fees for the same service the best practice is to both carefully review all your participation agreements and consider how doing so is going to appear to your patients and, most importantly, how patients will react.

New clients receive $99 design fee in July 2019.

Call 866-744-2212 or Visit MM.OFCJuly.com

Expires 8/31/2019

DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL IS A MEMBER AND MANAGING PARTNER OF KERR RUSSELL

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5/22/19 1:35 PM

ASK HUMAN RESOURCES

Accounting for Travel Time: To Pay or Not to Pay?

By Jodi Schafer, SPHR, SHRM-SCP, Human Resources Management Services, LLC

Q:

I took some of my staff

The proper and appropriate payment of wages is regulated

for specialized training

by the Department of Labor under the Fair Labor Standards

in Chicago. The training was going to

Act (FLSA). This law was passed in 1934 and, although

improve their skills, and I had to make

still relevant, it had not fully addressed how travel time is

it mandatory to assure attendance.

to be compensated. To address these questions Congress

We drove to Chicago, leaving on

passed an amendment to the FLSA to address what is

Thursday afternoon it took me 4 hours

considered compensable time when traveling. It is known

to get to Chicago, I drove the entire

as the Portal to Portal Act.

way. I need to know if I have to pay for the travel time, when they are benefiting from the training. When the employees submitted their time, they all had different amounts of time credited to travel. I need to know what time is compensable and if it will it count towards overtime?

Travel time is compensable if the reason for the travel— the training—is for the benefit of the Practice and/or it is mandatory.

If you mandate it, the appropriate time is compensable and/or…

If you, as the practice owner, benefit from the training (even if the employee also benefits), the time is compensable.

Based upon your question, you declared the training mandatory, so any time that meets the criteria above will be compensable.

Now we have to determine when the clock starts and stops.

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“If the training is mandatory, then any time spent in the training (regardless of when the training takes place) is compensable.”

Travel Time

Training Time

Let’s start with the time spent driving to Chicago. This travel pay will only apply to your hourly (non-exempt) staff. The time that is compensable as a passenger in a vehicle is the time spent traveling during the employee’s normal work hours. That includes not only hours worked on regular working days, but also during corresponding hours on nonworking days. For example, let’s say you have an employee that typically works 9 AM to 5 PM. If you left for Chicago at 1 PM and it took four hours to get to Chicago, you’d arrive at 5 PM. Those four hours should be paid and considered hours worked, regardless of which day of the week you traveled on.

If, let’s say, you were caught in traffic, and did not arrive until 6 PM you would still only pay that employee for four hours, since they work until 5 PM. If you left for Chicago after work, then none of the time spent traveling to the training would be compensable. You would use this same logic to calculate the compensable travel time on the return trip as well. If your employees don’t all work the same hours, then you will have to calculate travel time on an individual basis.

Now let’s look at the time spent in the training. If the training is mandatory, then any time spent in the training (regardless of when the training takes place) is compensable. Going to meals, social events or time spent sleeping does not have to be paid as long as the employee is free from all work responsibilities.

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You need to treat the compensable travel time and training time as hours worked for overtime purposes as well. So, based upon your established work week, add these compensable hours to the other hours worked during that week, and anything over 40 hours will be paid at time and a half.

There are additional rules that address air and train travel, and when the driver is non-exempt. Many of these rules seem odd, but they are the guide we use to assure compliance.

For more information about the proper and appropriate payment of wages, visit https:// www.dol.gov/whd/flsa/

MDHHS UPDATE

Protect Your Adolescent Patients Before They Go Back to School!

Alyssa Nowak, MPH, Adult and Adolescent Immunization Coordinator, MDHHS Division of Immunization

As the summer months come to an end and the back-to-school fury begins, the Centers for Disease Control and Prevention (CDC) and Michigan Department of Health and Human Services (MDHHS) want to remind you to ensure your adolescent patients are fully protected with all of the recommended vaccines before beginning another school year. While busy parents make lists and stock up on back-to-school essentials, take the time to reach out and remind them that vaccines are important back-to-school items too.

P

reteens and teens require several vaccines to keep them healthy and fully protected throughout the upcoming school year. According to CDC, preteens age 11-12 years should receive one dose of meningococcal (MenACWY) vaccine, two doses of human papillomavirus (HPV) vaccine 6 to 12 months apart, one dose of tetanus, diphtheria, and pertussis (Tdap) vaccine, and an influenza vaccine every year.1 According to the Michigan Care Improvement Registry (MCIR) and as of March 31, 2019, only 39 percent of adolescents 13 through 17 years are up to date with the recommended ado-

lescent vaccine series.2 In addition, CDC recommends that all 16-year-olds receive an additional dose of MenACWY. Further, teens 16-18 years of age may be vaccinated with a serogroup B meningococcal (MenB) vaccine in a series of doses.1 Outbreaks of disease can occur in school settings, so it is important to ensure that all your adolescent patients are up to date on all the recommended vaccines.

Meningococcal vaccines protect against the bacteria that cause meningococcal disease, specifically meningitis and bloodstream infections. Meningitis is easily spread through close contact with an in-

of adolescents 13 through 17 years are up to date with the recommended adolescent vaccine series as of March 31, 2019.

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fected person, such as coughing and sharing food and drinks. Meningitis can become serious very quickly and can cause brain damage, severe disabilities, or death.

To learn more about MenACWY, MenB, and the diseases they protect against, visit https:// www.cdc.gov/vaccines/vpd/mening/hcp/ index.html.

The HPV vaccine protects against genital warts and six different types of cancer caused by HPV infection: cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancer. The HPV virus is very common, with approximately 14 million people, including teens, becoming infected with HPV every year.3 HPV is transmitted by skin-to-skin contact. Many HPV infections do not cause symptoms, so a person could easily spread the virus to others without knowing. The best way to protect your patients from HPV-related cancers is with timely HPV vaccination.

To learn more about the HPV vaccine and the diseases and cancers it protects against, visit https://www.cdc.gov/vaccines/vpd/hpv/hcp/ index.html.

The Tdap vaccine is a booster shot that helps protect against the same diseases that DTaP vaccine protects young children from: tetanus, diphtheria, and pertussis. Tetanus is caused by a toxin found in soil and causes painful muscle tightening. Diphtheria can cause shallow breathing, paralysis, and heart failure. Pertussis, also known as whooping cough, is spread very easily from coughing or sneezing and causes severe coughing and choking.

Pertussis can be deadly to babies, who often get pertussis from their older siblings.

To learn more about Tdap and the diseases it protects against, visit https://www.cdc.gov/ vaccines/vpd/dtap-tdap-td/hcp/index.html.

Every year, everyone 6 months of age and older should receive influenza vaccine to protect them from seasonal flu. CDC encourages everyone to get their flu shot by the end of October, if possible. School-

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aged children are more likely to catch the flu, and a typical flu illness can mean missing at least a week of school.4 CDC estimates that from October 1, 2018 – May 4, 2019, there were 37.4 – 42.9 million flu illnesses, 531,000 – 647,000 flu hospitalizations and 36,400 – 61,200 flu deaths in the United States.5 Influenza can be very serious, and the best protection from flu and flu-related illnesses is to get flu vaccine every year. For more information about flu, visit https://www.cdc.gov/ vaccines/vpd/flu/index.html.

For best protection, send reminders to all your adolescent patients who are eligible for vaccination and remind them to schedule a back-to-school appointment!

Make sure your patients are equipped with everything they need, including their vaccines, for a safe, happy, and healthy 2019-2020 school year.

REFERENCES 1 CDC (2019). Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger, United States, 2019. Retrieved from https://www.cdc.gov/vaccines/schedules/hcp/imz/ child-adolescent.html 2 MDHHS (2019). Michigan’s Statewide Quarterly Immunization Report Card. Retrieved from https://www.michigan.gov/documents/mdhhs/ State_Level_ReportCard_621826_7.pdf 3 CDC (2019). Human Papillomavirus (HPV) Vaccination Information for Clinicians.

Retrieved from https://www.cdc.gov/vaccines/ vpd/hpv/hcp/index.html 4 CDC (2019). Flu Vaccine for Preteens and Teens.

Retrieved from https://www.cdc.gov/vaccines/ parents/diseases/teen/flu.html 5 CDC (2019). 2018-2019 U.S. Flu Season: Preliminary Burden Estimates. Retrieved from https://www.cdc.gov/flu/about/burden/ preliminary-in-season-estimates.htm

HEALTH CARE DELIVERY

Legal and Regulatory Resources at Your Fingertips

By Stacey Hettiger, Director Medical and Regulatory Policy, The Michigan State Medical Society

M

embers of the Michigan State Medical Society (MSMS) have access to a variety of supports and services. MSMS Departments cover a range of areas of interest to physicians,

practice managers, and other medical staff including education opportunities, legislative and regulatory advocacy, legal support, payer advocacy and connections, coding advice, representation on federal and statewide panels, and communication on health care hot topics.

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The Health Care Delivery Department at MSMS deals with payer, regulatory, and system issues that impact the practice of medicine. Health Care Delivery team members are available to help members address individual questions and concerns, as well as to monitor and report on global issues of interest.

As health care law becomes increasingly complex, MSMS’ legal resources are relied upon to help members navigate legal and regulatory constraints and obligations related to care delivery. A list of those legal resources begins on page 13.

“As health care law becomes increasingly complex, MSMS’ legal resources are relied upon to help members navigate legal and regulatory constraints and obligations related to care delivery. ”

Legal Services

Legal Alerts and Guides

General legal questions on a variety of issues of concern to physicians statewide (e.g., medical record retention, medical records charges, privacy issues, Stark, etc.) are answered for FREE as a benefit of MSMS membership.

MSMS legal alerts and guides provide a succinct legal analysis of both timely and long-standing issues that impact the practice of medicine. These resources provide members with an informative, on-demand tool to answer questions regarding regulations, processes, etc. to ensure compliance.

Many of the alerts are based on trending inquiries directly from physicians and their staff. Below are excerpts from our most recent and popular documents.

Legal Checklists MSMS checklists provide physicians with a starting point to evaluate key areas that should be addressed in contracts, employee documents, and compliance plans: Managed Care Contracting Employed Physician Contracting Compliance Program Employee Manual HIT/EHR Vendor Contracting

Special Legal Services MSMS members in need of a thorough legal review and consultation pertaining to overpayment audits, bylaws, and contracts are able to receive this benefit for a fixed fee for the following services: Employment Contract Review Service Physician Audit Consultation Service Medical Staff Bylaws Review Service HIT/EHR Vendor Contracting Review Service

Health Law Library The MSMS Health Law Library, assembled by our Legal Counsel, is available digitally so members can access it 24/7.

Information available through the Library is designed to assist physicians in learning about and understanding the many Michigan statutes and regulations which affect the practice of medicine in our state and includes a variety of topics from "AIDS/ HIV" to "Scope of Practice," as well as antitrust regulations, Michigan’s new physician licensure laws, and the latest reporting requirements.

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ASK OUR LAWYER

CONTRACT REVIEWS

MEDICAL RECORDS GUIDE “Neither the HIPAA Privacy Rule nor the MMRAA permits you to withhold medical records until a past due balance is paid.

However, you may insist that the patient prepay the appropriate copying fee and the fee charged for preparation of a summary of the medical record (see CHAPTER 9).”

“For Michigan health professional licensing purposes, MCL §333.16213 requires that you keep your medical records for a minimum of seven years from the date of service to which the record pertains unless a longer period of time is required by another federal or Michigan law or regulation or by generally accepted standards of medical practice. MCL §333.16644, which applies only to dental records and requires them to be maintained for ten years from the date of service, is an example of a statute requiring a longer retention period.”

“The statute of limitations on potential medical malpractice claims should be considered before destroying any medical record. You do not want to be in a position of having to defend a medical malpractice claim without the medical records that are the subject of the claim.”

(CONTINUED ON PAGE 14)

HEALTH LAW LIBRARY

ALERTS, GUIDES & CHECKLISTS

To access any or all of these member resources, visit msms.org/Resources or contact the MSMS Health Care Delivery Department at 517/336-5723 or via email at cwheeler@msms.org.

MEDICAL RECORDS POLICY MODEL AND LICENSURE REQUIREMENT FOR MICHIGAN PHYSICIANS “The Michigan Public Health Code (the "Code"), at MCL § 333.16177(4), requires a physician or other applicant for an initial Michigan health professional license, or a licensee applying to renew a license, to provide the Michigan Department of Licensing and Regulatory Affairs (the "Department"), on the application or the license renewal form, with an affidavit stating that he or she has a written policy for protecting, maintaining, and providing access to his or her medical records in accordance with Section 16213 of the Code.”

“A person who fails to comply with Section 16213 is subject to an administrative fine of not more than $10,000.00 if the failure was the result of gross negligence or willful and wanton misconduct. MCL § 333.16213(5).”

“Sample Medical Records Retention Policy. Instructions: Physicians and their medical practices may use this model policy for

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guidance when drafting a Medical Records Retention and Disposition Policy for Michigan health professional licensing compliance per the requirements of the Michigan Public Health Code § 333.16177 and § 333.16213. Physicians are responsible to modify this model policy to suit the particular needs of their medical practices…”

MANDATORY FLU SHOT FOR EMPLOYEES: POLICY IMPLEMENTATION AND BEST PRACTICES “As a condition of employment, an employer may require that all employees receive a flu shot. However, an employer’s compulsory flu shot policy must provide for exemptions in order to comply with various laws regulating the employer/ employee relationship.”

“It is advisable for an employer that wishes to require flu shots to adopt a written flu shot policy so that all employees have reasonable advance notice that receiving an annual influenza vaccination is a condition of employment.”

“Educating employees about the benefits and importance of the flu shot may help maximize employee participation. Just like frequent hand washing and wearing gloves, the flu shot is an important protective measure for employees and patients. The Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that all U.S. health care workers get vaccinated annually against influenza1.”

LEGAL ISSUES FOR PHYSICIANS TREATING HEARING IMPAIRED OR LIMITED ENGLISH PROFICIENCY PATIENTS “Several methods are commonly used by physicians to ensure effective communication with hearing impaired patients…The method(s) physicians choose to adopt—or may be required by law to provide at the physician’s expense—will vary depending on the

relevant facts and circumstances. The avail-

SERVICE ANIMALS AT PHYSICIAN'S OFFICE

ability and cost of qualified commercial

“The Americans with Disabilities Act ("ADA") requires places of public accommodation, including physicians’ medical practice offices and health-care facilities (individually referred to in this Legal Alert as a “facility” and collectively as “facilities”), to allow service animals to assist persons with disabilities.”

interpreting services, the need for an impartial interpreter, the number of hearing impaired patients in the practice, the patient’s individual wishes, the government’s enforcement practices, and the complexity of the encounter are some of the factors that may influence this decision.”

“Discrimination in the delivery of physician services based on a patient’s disability has been prohibited by federal and Michigan law for quite some time. A hearing impairment is considered a disability.” “…a December 5, 2001 HHS policy guidance document (the “HHS Guidance Document”) applicable to all health care providers receiving federal financial assistance, including physicians, does require that language assistance services be provided to LEP Patients in certain circumstances.”

“Service animals may accompany a patient, employee, or a visitor of a facility. These service animals must be allowed to accompany persons with disabilities in all areas where the public is allowed.”

To access any or all of these member resources, visit msms.org/Resources or contact the MSMS Health Care Delivery Department at 517/336-5723 or via email at cwheeler@msms.org.

“Emotional support animals or comfort animals are often prescribed by a doctor as part of a therapy or treatment plan. This may cause some confusion when determining whether to admit the animal into place of public accommodation. However, service animals and emotional support animals are treated differently under the ADA and Michigan law.”

MEMBERS OF THE MICHIGAN STATE MEDICAL SOCIETY REMEMBER THEIR COLLEAGUES WHO HAVE DIED.

Physician

with independent primary care practice in Grand Rapids, MI

NAZEM ALHUSEIN, MD WAYNE COUNTY MEDICAL SOCIETY – 4/4/19

JERRY L. IRWIN, MD KENT COUNTY MEDICAL SOCIETY – 4/5/19

Opportunity Available Answer Health, a Physician Organization supporting independent physicians in West Michigan, has an opportunity available for a primary care physician within an established, independent Internal Medicine Practice located in Grand Rapids, Michigan. The practice has provided exceptional care to a large patient base for over 50 years.

Currently, five providers provide patient care in a family-oriented, caring, and team-based environment. The team includes physicians, mid-level providers, embedded care manager with CDE, social worker and pharmacist, medical assistant for each physician, and experienced administrative and support staff.

MATTHEW L. BURMAN, MD OAKLAND COUNTY MEDICAL SOCIETY – 4/15/19

HENRY V. GUZZO, MD KENT COUNTY MEDICAL SOCIETY – 4/22/19

GERALD H. MANDELL, MD WAYNE COUNTY MEDICAL SOCIETY – 4/23/19

KENNETH J. VANDERKOLK, MD WAYNE COUNTY MEDICAL SOCIETY – 5/9/19

SEVERO R. ARMADA, MD WAYNE COUNTY MEDICAL SOCIETY – 5/28/19

WILLIAM R. EYLER, MD WAYNE COUNTY MEDICAL SOCIETY – 5/28/19

NATALIA MUZ, MD WAYNE COUNTY MEDICAL SOCIETY – 5/28/19

Eligible candidates are board certified in internal medicine, family

RALPH F. WOODBURY, MD

medicine, or internal medicine/pediatrics and have experience in

WAYNE COUNTY MEDICAL SOCIETY – 5/28/19

providing patient-centered and evidence-based care within the

EDWARD G. LARSEN, MD

primary care setting. This position is full-time with competitive salary

WAYNE COUNTY MEDICAL SOCIETY – 6/5/19

and benefits including 401K, health and life insurance, paid time off,

To make a gift or bequest, contact Rebecca Blake, Executive Director, MSMS Foundation. Call 517-336-5729 or Email rblake@msms.org.

and an ownership opportunity after one-year employment.

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FEATURE

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BETTER PAYER CONTRACTING FOR BETTER OUTCOMES

R

are is the physician who during medical school’s toughest moments and residency’s longest shifts found

the strength to persevere in her deep and abiding passion for completing health plan paperwork, mastering accounting spreadsheets and negotiating fee schedules.

Most physicians pursue medicine with a genuine and purposeful desire to help people during life’s most difficult and challenging moments. No one worked 24-hour residency rotations because they couldn’t wait to do paperwork.

As it turns out, though, it’s the business of medicine that empowers physicians to embrace and master the practice of medicine. The better that business gets done, the better a physician is able to treat patients, build a compassionate staff, and expand quality care and services.

Payer contracting is among the business side’s most important pillars and, like everything else in medicine, the more a physician excels in any one aspect, the more patients benefit. Better contracts mean a better bottom line, sure, but they also mean better HEDIS scores.

That’s true in part because payers are moving more and more to “value-based” metrics. At their simplest, these measures aim to align reimbursements with patient outcomes; one physician staffing firm reported in 2017, for instance, that 43 percent of its clients tied physician bonuses to patient satisfaction and other outcome measures.

In a rapidly developing marketplace of ideas and measures, these newer systems offer physicians the opportunity to define success—and to build those definitions around patients themselves.

In creating economies of scale, especially among physician organizations and hospital groups, contracts may even offer physicians the opportunity to minimize prior authorization demands, simplify the referral process, and improve their patients’ timely access to the care they need.

In other words, there’s a lot riding on the contracting process, and for more than just the contracting physician. But… getting those contracts right? In its own way, it can be as complicated as surgery.

Scott Monteith, M.D., is a Board Certified Psychiatrist treating patients in and around Traverse City. His experience has taught him that taking the time and care to carefully negotiate makes a meaningful difference.

“Recognize that negotiations are among the most important things you will do outside of caring for your patients,” Doctor Monteith said. “Spend the time and money to negotiate. Read every word in the contract, understand it, and make (CONTINUED ON PAGE 18)

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sure you are willing to make the promises spelled out in the contract. Negotiating is not easy, but it is one of the best things you can do for your practice and patients.”

Thankfully, physicians don’t have to go it alone. A variety of allies exist to walk alongside health care providers as they interact with payers, from physician organizations to health care contract law attorneys and professional associations like the Michigan State Medical Society.

Payer Contracting & Risks, Defined

Researchers found personnel and overhead costs related to billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure. That breaks out to anywhere from three percent to 25 percent of professional revenue.

The process has also been linked to the growing trend of physician burnout, a crisis that threatens not only providers’ physical and emotional health, but their patients’ access to care.

Getting the contract right is the first, most important step towards minimizing those personal and financial expenses. Measure twice, cut once.

At their simplest, payer contracts define physicians’ obligations to patients and Debra Roberts is the Executive Director of to the insurance plans that cover them. the Huron Valley Physicians Association, They also detail the payer’s obligations to P.C. Her organization, like the dozens of physicians and their patients, other physician organizations and describe the performance in Michigan, also known as incentives the payer offers to POs, helps member physicians Getting the those who achieve benchnavigate the contracting procontract right is cess. marks designed to improve care and reduce costs. the first, most “Physicians need to underContracting and billing proimportant step. stand their practice’s ability to cesses aren’t cheap. A 2018 meet clinical care metrics and study published in the Jourknow whether their office workflows will nal of the American Medical Association help reduce costs and improve care,” Robexamined the administrative costs associerts said. “This means that physicians need ated with physician billing activities in a to be able to identify and manage their large academic health care system that empatient populations by providing the right ployed certified electronic health records. care at the right time for the right reasons.”

Key Terms Every Contract Should Define Kerr Russell recommends physicians ensure every payer contract they sign first include clear definitions of key terms to avoid conflicting interpretations of the obligations of the physician and the payer. These key terms include: Medical Necessity Required Services Emergency Provider Clean Claims “Plan,” “Policies,” “Procedures,” and / or “Manuals” For more information on these terms, and the importance of definitions, please contact the Michigan State Medical Society at 517-336-5723.

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“Recognize that attorneys can offer legal advice, but often are not qualified to offer advice on the business side of an agreement. The legal and business dimensions of agreements can be very different.”

SCOTT MONTEITH, M.D., BOARD CERTIFIED PSYCHIATRIST

Many physicians find it valuable to join a physician organization, or PO, to help streamline the contracting, performance programs and billing processes—among myriad other reasons.

“Joining a group and becoming more engaged by adopting the Patient-Centered Medical Home principles, if they are in Primary Care, and adopting more broadly used Electronic Medical Record systems increases a physician’s ability to effectively participate in value-based contracts and have an opportunity to earn shared-savings,” said Roberts. “The factor of demonstrating active population management will add value from a payer perspective and achieve the elements of the Triple AIM (improving the patient experience of care, including quality and satisfaction), improving the health of populations, and reducitng the per capita cost of health care.”

POs also minimize the administrative lift for member physicians.

an attorney says that agreement is “acceptable,” remember that opinion may only apply to the legal dimension of the contract, not the business dimension.”

Once a contract is signed, the work has only just begun.

According to McKesson Healthcare Business Consulting Solutions, payers in some parts of the country have moved to reduce fee schedules by five to 12 percent per market. The cuts may come in a variety of ways, including the termination of old contracts and post-signature amendments to new ones. The McKesson consultants warn providers to pay close attention to everything health plans send them. Providers may be given as few as 30 days to respond to proposed amendments, and depending on how they and the contract are written, failure to respond may allow the amendment to go into effect anyway.

“There is annual maintenance of a contract and measurement of physician yearly performance,” said Roberts. “A physician Doctor Monteith, the northern Michigan organization can support the practice with physician, finds value in his own PO, but focused campaigns to target suggests tapping additionbest performance outcomes al outside help. For example, and the corresponding finanhe recommends every prac- Once a contract cial rewards. POs also can help tice work with dedicated legal is signed, the with ‘best practice’ workflows counsel with extensive health to help physicians work smartlaw expertise when negotiating work has only er, not harder, to maximize all a contract, but—he warns— just begun. payer financial outcomes.” don’t expect them to do everything for you.

Of course, not every physician in the state “Recognize that attorneys can offer legal advice, but often are not qualified to offer advice on the business side of an agreement,” Doctor Monteith said. “The legal and business dimensions of agreements can be very different. For example, an agreement can be legally sound (and therefore ‘acceptable’), but it might be an unacceptable business arrangement. When

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is a member of a PO or a hospital group.

Employment agreements and settings are almost as varied as physicians’ specialties.

Thankfully, there are a number of contracting tips and best practices that apply to physicians across geographies, specialties and employment arrangements.

(CONTINUED ON PAGE 20)

“A physician organization can support the practice with focused campaigns to target best performance outcomes and the corresponding financial rewards. POs also can help with ‘best practice’ workflows to help physicians work smarter, not harder, to maximize all payer financial outcomes.”

DEBRA ROBERTS EXECUTIVE DIRECTOR, HURON VALLEY PHYSICIANS ASSOCIATION, P.C.

Key Elements of Every Payer Contract The Michigan State Medical Society in partnership with Kerr Russell has compiled a Managed Care Checklist to assist member physicians during the contracting process. It includes key elements including: Definition of Key Terms

“Begin by asking the question ‘Do the benefits we stand to gain from the contract outweigh the burdens we're taking on by entering into it?’ ” DANIEL J. SCHULTE, JD, MSMS LEGAL COUNSEL

Physician’s Obligations Claim Submission and Payment Compensation Method Utilization and Quality Assurance Term and Termination Dispute Resolution To obtain a copy of the Checklist, or for more information, visit MSMS.org/checklists.

Getting the Contract Right: A Primer With plenty of pitfalls to avoid, where can a physician, hospital group or PO find sure footing? The Michigan State Medical Society and their legal partners at Kerr Russell Attorneys and Counselors have a few suggestions.

Do the early research. Use your voice. Be thorough. (Just to start.)

able positions in audit a year or two after the fact,” said Schulte. “[Is it worth the] special documentation requirements and the other burdens I’m taking on in order to gain new patients and revenue in my practice?”

Doing the research at the beginning— understanding with whom the physician is contracting, what they offer, and what risks might arise after signing on the dotted line—can help physicians avoid a lot of regret right off the bat.

Physicians must understand Dan Schuelte is an attorney who they are as a provider and with Kerr Russell, a full service Do the early the value they or their practice Michigan law firm. Schulte is research. brings to the equation, as well. co-chair of its health care law practice. He advises physicians Use your voice.

“Always recognize the value you entering the contracting probring and focus on the payer Be thorough. cess to begin by asking thempriorities,” said Jack H. Dillon, selves a simple question: do the Executive Director for Anesbenefits they stand to obtain from the conthesia Practice Consultants, PC, in Grand tract outweigh the burdens they’re taking Rapids, Michigan. “Often there is alignon by entering into it? ment. Before you ever meet, evaluate your data and processes and understand if there “In its simplest form the question is: are are any gaps. Come prepared with specific the fees I’ll be paid, the additional patients goals for every meeting.”

I am going to be able to have in my pracA provider or group should also fully know tice… do those economic benefits outwith whom they are contracting. Underweigh the claims filing burdens, or the risk stand whether it is an insurer and a plan, that this payer is going to take unreason-

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or an administrator of other plans as well.

By understanding the patients represented by the payer, a provider can take a good hard look at his or her own practice to determine how much access to new patients—if any—the payer can provide.

for both the payer and the provider. Sound contracts cover claim submission processes, payment requirements, compensation methods, utilization and quality assurances, term and termination, dispute resolution, and much more.

“The tendency is to just sign as many of Another key contract element to address is these agreements as possible, to just increase any language related to “indemnification” the likelihood you’re going to (in all its forms), including get patients you wouldn’t oth“hold harmless” clauses.

There are erwise get into your practice,” There are thousands of “i”s to thousands of said Schulte. “You might only dot and “t”s to cross. Every get a handful of patients, and “i”s to dot and single one of them is critical. could be taking on tremendous “t”s to cross.

Being thorough counts, espeburdens and risks. For what? cially when there are multiple Every single Assess what you stand to get payers on the playing field. one of them is out of the deal, [so you know if Dillon, the anesthesia pracit is] worth entering into it in critical. tice executive director, sugthe first place.” gests no practice overlook the value of orSchulte, who has 25 years of experience ganization. specializing in health care law and physi“A practice should develop a grid for their cian licensing, staffing and contract dispayer contracts,” Dillon said. “Have someputes, urges physicians to find their voices thing to reference that you can build upon early in the contracting process, as well. and contains all the vital information. That “Too few physicians take the time to do way, you are not recreating the process and the due diligence, to not only have the lannegotiation each time you sit down with guage of the contract reviewed and have a a payer.” lawyer’s perspective of what is over the top, Keeping an up-to-date grid can also help but also to take the time to request changes providers replicate best practices and stay [to contract language] and to voice their on top of requested changes and amendconcerns,” he said. “If more of that went ments from payers. on, the insurers and health plans would have to be more receptive to changes.” “…That’s usually when the work begins,” There’s certainly plenty in the average conDillon said. “It’s important after the negotract to discuss. Payer contracting involves tiations are done and everything is signed much more than negotiating a fee schedto have a level-setting meeting with everyule, Schulte and other experts say. The one in your practice. Make sure everyone process—when done right—covers lanunderstands the expectations and what guage spelling out rights and obligations needs to be done.

“A practice should develop a grid for their payer contracts…something to reference that…contains all the vital information. That way, you are not recreating the process and negotiation each time you sit down with a payer.”

JACK H. DILLON, EXECUTIVE DIRECTOR, ANESTHESIA PRACTICE CONSULTANTS, PC

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To help providers, groups, and POs through the entire process, Kerr Russell and MSMS developed a catalogue of tools and resources, including a contracting checklist and a contract review service that brings the carefully trained eye of a health care attorney to bear on behalf of a provider.

To help providers, groups, and POs through the entire process, Kerr Russell and MSMS developed a catalogue of tools and resources, including a contracting checklist and a contract review service that brings the carefully trained eye of a health care attorney to bear on behalf of a provider.

The Michigan State Medical Society offers many of the resources to members at no cost, and has negotiated legal services for members at a discounted rate. With a little bit of help—and a whole lot of elbow grease—physicians in any setting can secure contracts that benefit their practices, and the patients they serve.

Welcome New Members Genesee

Macomb

Angela Joseph, MD

Jimmy Haouilou, MD

Hussein Mazloum, MD

Monroe Houghton/Baraga/Keweenaw

Ewa Hansen, MD

Jeffrey Jacobs, MD

Muskegon Kalamazoo

Gabriel Dunn, MD

Robert Page, MD, FAAP

Oakland

Kathryn Redinger, MD

Mariam Awada, MD, FACS

Kent

Andrew Compton, MD

Fadi Saab, MD

Bryan Gray, DO Mary McBrien, MD

Lapeer

Louis Sobol, MD

Kenneth Jostock, MD

Saginaw

Livingston

Mark Zaki, MD

Neelam Dutt, MD Derek Korte, DO

Washtenaw

Nathan Landesman, DO

Charis Hill, MD

John Macksood, DO

Cheryl Ruble, MD

Justin Miller, DO Mark Minaudo, DO

Wayne

Michael Neumann, DO

Amy McKenzie, MD

Theophilus Ulinfun, DO

Theresa Toledo, MD

www.msms.org/Membership

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When Treating Children, Avoid These Risks Darrell Ranum, JD, CPHRM, Vice President, Patient Safety and Risk Management, The Doctors Company

A

study of malpractice claims against physicians in 52 specialties who treat children reveals that while there are common elements in allegations, the types of problems experienced by pediatric patients—and that lead to malpractice claims— change as they age.

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Contributed by The Doctors Company

thedoctors.com

The Doctors Company studied 1,215 claims (written demands for payment) filed on behalf of pediatric patients that closed from 2008 through 2017.

The study focused on four groups: neonate (less than one month old), first year (one month through 11 months), child (one through nine years), and teenager (10 through 17 years).

It included all claims and lawsuits except dental claims, regardless of how the cases were resolved (denied, settled, or judgment at trial).

Claim and Lawsuit Payments Of the claims, 446 (37 percent) resulted in a payment to the claimant. The mean indemnity payment was $630,456, and the mean expense was $157,592. The median indemnity payment was $250,000, and the median expense to defend these claims was $99,984.

Neonates had the highest mean indemnity ($936,843) and median indemnity payment ($300,000). The mean expense paid to defend these cases was also the highest ($187,117), as was the median expense paid ($119,311).

The median number may be a more accurate representation of the amount of indemnity in paid claims. The median eliminates the impact of very high or very low indemnity amounts, giving a better idea of a typical value.

The patients represented in these claims and lawsuits were treated by a variety of specialties. Obstetricians were most frequently involved with neonatal patients.

Pediatricians, orthopedic surgeons, emergency medicine physicians, and family medicine physicians were most frequent-

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ly named as defendants for children older than one month.

The top 10 physician specialties named as defendants were: obstetrics (24%), pediatrics (15%), orthopedics (7%), emergency medicine (6%), family medicine (6%), radiology (3%), general surgery (3%), anesthesiology (3%), otolaryngology (3%), and psychiatry (2%). These specialties represented 72 percent of all the claims.

Allegations Diagnosis-related allegations were the most common allegation in all but the neonate age group. Patients older than neonates experienced diagnosis-related claims in 34 to 44 percent of all claims and lawsuits.

patient harm. Categories of contributing factors include clinical judgment, technical skill, patient behaviors, communication, clinical symptoms, clinical environments, and documentation. Physician experts identified factors that contributed to patient harm and evaluated each claim to determine whether the standard of care was met.

The most common factor contributing to injury in neonates was selection and management of therapy. This issue refers to decisions about vaginal birth versus cesarean section. Other factors included patient assessment issues and lack of communication among providers.

Factors Contributing to Patient Injury

The most common factors contributing to patient harm for age groups other than neonates were patient assessment issues and communication between the patient or family member and provider. Inadequate patient assessments were closely linked to incorrect diagnoses. Incomplete communication between patients or family members and providers affected clinicians’ ability to make correct diagnoses.

To prevent injuries, it is essential to understand the factors that contributed to

(CONTINUED ON PAGE 26)

The most common allegation for neonates was obstetrics-related treatment for injuries that occurred during labor and delivery (63 percent).

Risk Mitigation Strategies The following strategies can assist physicians in preventing some of the concerns identified in this study:

For Neonates • Become familiar with the National Institute of Child Health and Human Development nomenclature. Physicians and nurses should participate together in regular fetal monitoring learning activities.

• Respond without delay when a nurse requests a physician assessment.

• Conduct drills to ensure 30-minute response times for emergency cesarean section deliveries and carry out simulations of low-frequency/high-severity obstetric emergencies.

• Estimate and document fetal weight when considering vacuum-assisted vaginal delivery. Plan the exit strategy, such as calling the cesarean section team in advance in case the extraction is unsuccessful.

For Children Ages One Month to 17 Years • Ensure quality documentation. Documentation is essential for coordinating quality care and defending a claim that may not be filed until years after the alleged injury.

• Conduct careful reevaluations when patients return with the same or worsening symptoms. If no new information comes to light, consider a second opinion or referral to a specialist.

• Ensure an adequate exchange of information. Utilize translations services if communication is difficult.

• Provide parents with information to help them recognize when a sick child requires emergency care. Train office staff to recognize the types of concerns raised by parents during phone calls that should prompt immediate assessment and treatment.

Conclusion This study showed that neonates and infants in their first year of life were more vulnerable than older children. Children less than one year of age experienced high-severity injuries at almost twice the rate of children older than one year. Neonates may experience complications due to difficult labor and delivery. They also face congenital conditions that may not be readily diagnosed and treated.

Children older than one year experienced more injuries from trauma, communicable disease, and malignancies. Teenagers experienced trauma and illness, and teenaged females may also face the dangers of pregnancy and childbirth.

This wide spectrum of development adds to the challenges of diagnosing and treating pediatric patients and shows that clinicians need the assistance of reliable systems to help prevent these errors.

These issues and additional data are addressed in more detail at thedoctors.com/ childmedmalstudy. ________________________________ The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Reprinted with permission. ©2019 The Doctors Company (thedoctors.com).

STAY CONNECTED!

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Educational Offerings MSMS On-Demand Webinars Webinars Offering CME: Balancing Pain Management and Prescription Medication Abuse: Chronic Pain and Addiction*

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Legalities and Practicalities of HIT - Engaging Patients on Their Own Turf: Using Websites and Social Media MAPS Update and Opportunities* Michigan Automated Prescription System Update* Reading Remittance Advice Section 1557: Anti-Discrimination Obligations Sexual Misconduct – Prevention and Reporting (new in 2019) Update on Chronic Fatigue Syndrome Part 1: Clinical Diagnostic Criteria for Chronic Fatigue Syndrome/CFS now called Myalgic Encephalomyelitis or ME/CFS (new in 2019) Update on Chronic Fatigue Syndrome Part 2: Uniting Compassion, Attention and Innovation to treat ME/CFS (new in 2019) Prescribing Legislation* Tips and Tricks on Working Rejections *Fulfills Board of Medicine Requirement.

Upcoming Educational Conferences – REGISTER TODAY! Medical Necessity – Tips on Documentation to Prove it

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

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