Enhancing Your Practice's Revenue - California Orthopaedic ...
Enhancing Your Practice's Revenue - California Orthopaedic ... Enhancing Your Practice's Revenue - California Orthopaedic ...
QualificationsAs a minimum, you must be Board-eligible or Boardcertifiedin orthopaedic surgery in order to testify inorthopaedic cases. However, just because you are Boardcertifieddoes not mean that you are qualified to testify inevery case. If you do not perform spine surgery on a regularbasis, you cannot testify on spine surgery or any other areawhich is not a part of your training and/or regular practice.Beyond your years of practice, a fellowship or an academicappointment, publications and presentations improve yourvalue in the medical-legal process.The American Board of Independent Medical Examiners(www.abime.org) was established with the intent ofraising the level of knowledge and standards and providinga national mechanism of certification of physicianswho have undergone additional training in impairmentand disability evaluation and who have pledged to provideindependent and unbiased evaluations. A candidate must(a) be in practice in the area of orthopaedic surgery, neurology,physiatry, neurosurgery, occupational medicine, or a“related field”; (b) take prescribed CME regarding impairmentevaluations and the American Medical Association’sGuide to the Evaluation of Functional Impairment, and (c)take a Board examination. If the candidate passes, he orshe becomes a Certified Independent Medical Examiner(CIME). ABIME runs multiple courses throughout theyear regarding issues involved in case management, workerscompensation, injury and impairment evaluations, the useof the Dictionary of Occupational Titles, national clinicalalgorithms for the treatment of various injuries, and ofcourse, the Guide I made reference to above.How Do I Get Started in Forensic Medicine?It is actually more difficult to avoid medical-legal cases thanto participate. By the very nature of orthopaedics, almostevery orthopaedic surgeon will be involved in a secondopinion, a personal injury, or with case managers for avariety of reasons. Even if you studiously attempt to avoidworkers’ compensation cases, if you take emergency roomcall, you will become involved eventually. The easiest wayis to treat case workers with respect and realize that theytoo, are just doing their job as a representative for the onewho is paying the bills. Ask them what they need. Providetimely, detailed and accurate (evidence-based) reports.Make them aware that you are available for their clients.Eventually, some of these cases will be adjudicated and youwill be involved with attorneys.Provide the same high-quality services to the attorneysand make them aware that you are available for additionalcases. Word of mouth is your best advertisement. However,there are numerous companies that provide attorneys withnames of physicians who are willing to provide legal evaluations.Some services are free, some charge a fee. Theseinclude:36• The SEAK directory (www.seak.com)• Corvel (www.corvel.com) Coventry(www.coventryhealthcare.com)• Medical Communications Network (www.mcn.com)• Evalumed (www.evalumed.com)• Medical Evaluation Specialists (www.mesgroup.com)• Concentra (www.concentra.com)• Gallagher-Bassett (www.gallagherbassett.com).Most of these companies are actively looking for interestedphysicians. There always seems to be a greater demandthan willing physicians.Finances: The “Good” Part of “the Good,the Bad and the Ugly”Every attorney will ask the loaded question, “Doctor,how much are you being paid for your testimony?” Theappropriate answer is, “I am being paid for my time awayfrom my practice of orthopaedic surgery.” This is a simplestatement of fact and avoids the pejorative impression thatyou are a “hired gun” who is willing to say anything formoney. You are spending your time and sharing your hardearnedexpertise; you deserve to be paid for this.Certainly, the attorneys are not providing their servicesfor free. They expect to be paid for their time and expertiseand so should you. Obviously, there are physicians whodo make their entire living testifying. However, for mostreputable attorneys, you are not valuable unless you are afull-time practicing physician. In fact, this is a statutoryrequirement in many states.While you can set your rates at whatever you feel yourtime is worth, you should remain within your community’sstandards. A fair and defensible rate is based uponyour yearly gross income divided by +/- 2000 hours (i.e.,40 hours times 50 weeks). The following is an example toclarify the preceding sentence, not a recommendation.• If your gross yearly receipts are $1,000,000, then yourfee would be $500/hour. Yes, you may appear to billmore than that for a single surgical procedure. However,that procedure involves preoperative time in the office,indirect operating room time (i.e., waiting time betweencases), postoperative or office follow-up, and whateverpaperwork that is associated with the surgical procedurethat is included in the global payment.• While an IME requires you to physically examine thepatient in the office, all of the paperwork can be done onyour schedule and still billed at an hourly rate. Becauseyou are using office staff and resources and this doeshave medical legal risk, it is only fair that this activitycontribute its share to your malpractice and otherexpenses. As an example, you might receive a total of$1,500 for a total hip arthroplasty from Medicare.© 2011 American Academy of Orthopaedic Surgeons
• You could easily spend 3 hours in toto earning thatsurgical fee. A record review, examination, and report at$500 per hour would probably generate exactly the samefee, most of which you could complete at home on anevening or weekend.SummaryThere is no need to perceive forensic medicine as “takingaway from the regular practice of orthopaedic surgery.” Inmy opinion, it does not detract - - it actually complementsand supplements my own clinical practice.Contact: G. Klaud Miller M.D.: doc@jockdoc.netChapter 11Real EstateBy Adam Soyer, DOIntroductionPhysicians typically rely on the practice of medicineto generate revenue. The fee-for-service model is theprimary source of income for most of us and funds mostinvestments. This type of income is finite and ends once wecease practicing medicine. Ideally, we would like to workless and make more, while having investments that generaterevenue with little direct involvement.Types of IncomeThere are several types of income. Active or “linear”income (in which time is traded for money) is incomegenerated by direct involvement. Once the service iscompleted, the income ends. A subset of active incomeis recurring income. Recurring income is a regular,consistent source of income, such as a weekly nursing homeconsultation. Recurring income is stable but is limited inearning capacity since it is based on volume.Passive income is income that does not require yourdirect involvement. There are two types of passive income:residual and leveraged. Residual income is income thatoccurs over time from work done once. In medicine, thiscould be from the sale of a book or royalties on surgical implantsyou may have designed. Leveraged income is incomethat leverages the work of other people to create income foryou. For a physician, this could be ownership of ancillaryservices run by other professionals such as physical therapy.Being familiar with the different types of income will giveyou a better idea of ways to generate additional revenue.Having multiple streams of income is the key to earningmore and working less.Utilizing your real estate investment via rent is a goodway to start recognizing an additional source of income.Rental income is considered passive residual income. Thereare several ways to make your real estate work for you,including space sharing, subleasing and real estate development.Anti-Kickback Safe HarborWhen considering any financial venture that involvesother physicians, it is imperative that the arrangementcomplies with the federal Anti-kickback law. The initiallaw adopted in 1972 is broad; it states basically that anyonewho knowingly or willfully receives or pays anything ofvalue to influence the referral of federal health care programbusiness, including Medicare and Medicaid, can be heldaccountable for a felony. In 1987 the law was amendedto include specific “safe harbors” for various paymentand business practices that, while potentially prohibitedby the law, would not be prosecuted. In 1991 and 1992,13 regulatory safe harbors were established. In 1999, thenumber was expanded to 23 safe harbors.Space Rental Safe HarborSpace rental has a safe harbor. In section 1128B of theFederal Anti-kickback Act, “remuneration” does notinclude any payment made by a lessee to a lessor for the useof the premises as long as all of the following standards aremet:1. The lease agreement to set out in writing and signed bythe parties.2. The lease covers all of the premises leased betweenthe parties for the term of the lease and specifies thepremises covered by the lease.3. If the lease is intended to provide the lessee with accessto the premises for periodic intervals of time (ratherthan on a full-time basis) for the term of the lease, thelease specifies exactly the schedule of such intervals,their precise length and the exact rent for such intervals.4. The term of the lease is not for less than one year;5. The aggregate rental charge is (a) set in advance, (b)consistent with fair market value in arms- lengthtransactions and is not determined a manner that takesinto account the volume or the value of any referralsor business otherwise generated between the partiesfor which payment may be made in whole or in partunder Medicare, Medicaid or other Federal health careprograms.Any lease arrangement, whether it be space-sharing or asublease, should be scrutinized. A well-written lease, whichclearly identifies the space and its proposed use as well as afair market value offering, is essential to compliance withthe anti-kickback law. Referrals that are generated as aresult of the lease arrangement should be well-documentedand clinically appropriate. Consultation with a healthprofessions attorney is recommended before any real estateventure is considered.© 2011 American Academy of Orthopaedic Surgeons37
- Page 3 and 4: Enhancing Your Practice’s Revenue
- Page 9 and 10: Section 1PersonnelChapter 1Non-Phys
- Page 11 and 12: Difficult cases can lead to diagnos
- Page 13 and 14: enefits from an “image” standpo
- Page 15 and 16: • Have we met all current regulat
- Page 17 and 18: OperationsRegardless of organizatio
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- Page 21 and 22: expenses for the ASC for a period o
- Page 24 and 25: have to be replaced periodically. T
- Page 26 and 27: Section 3The HospitalChapter 7On-Ca
- Page 28 and 29: coverage on specified holidays. Whi
- Page 30 and 31: • Partners must recognize that th
- Page 32 and 33: careful planning, creation of a rea
- Page 34 and 35: When physicians are compensated by
- Page 38 and 39: Space-sharing ArrangementsWhether y
- Page 40 and 41: Section 5MarketingChapter 12Marketi
- Page 42 and 43: Wise practices first perform market
- Page 44 and 45: Appendix:Ten Top TipsBy Steven E. F
- Page 46 and 47: Resource List (On-line Links effect
- Page 48: Product No. 05247ISBN: 978-0-89203-
• You could easily spend 3 hours in toto earning thatsurgical fee. A record review, examination, and report at$500 per hour would probably generate exactly the samefee, most of which you could complete at home on anevening or weekend.SummaryThere is no need to perceive forensic medicine as “takingaway from the regular practice of orthopaedic surgery.” Inmy opinion, it does not detract - - it actually complementsand supplements my own clinical practice.Contact: G. Klaud Miller M.D.: doc@jockdoc.netChapter 11Real EstateBy Adam Soyer, DOIntroductionPhysicians typically rely on the practice of medicineto generate revenue. The fee-for-service model is theprimary source of income for most of us and funds mostinvestments. This type of income is finite and ends once wecease practicing medicine. Ideally, we would like to workless and make more, while having investments that generaterevenue with little direct involvement.Types of IncomeThere are several types of income. Active or “linear”income (in which time is traded for money) is incomegenerated by direct involvement. Once the service iscompleted, the income ends. A subset of active incomeis recurring income. Recurring income is a regular,consistent source of income, such as a weekly nursing homeconsultation. Recurring income is stable but is limited inearning capacity since it is based on volume.Passive income is income that does not require yourdirect involvement. There are two types of passive income:residual and leveraged. Residual income is income thatoccurs over time from work done once. In medicine, thiscould be from the sale of a book or royalties on surgical implantsyou may have designed. Leveraged income is incomethat leverages the work of other people to create income foryou. For a physician, this could be ownership of ancillaryservices run by other professionals such as physical therapy.Being familiar with the different types of income will giveyou a better idea of ways to generate additional revenue.Having multiple streams of income is the key to earningmore and working less.Utilizing your real estate investment via rent is a goodway to start recognizing an additional source of income.Rental income is considered passive residual income. Thereare several ways to make your real estate work for you,including space sharing, subleasing and real estate development.Anti-Kickback Safe HarborWhen considering any financial venture that involvesother physicians, it is imperative that the arrangementcomplies with the federal Anti-kickback law. The initiallaw adopted in 1972 is broad; it states basically that anyonewho knowingly or willfully receives or pays anything ofvalue to influence the referral of federal health care programbusiness, including Medicare and Medicaid, can be heldaccountable for a felony. In 1987 the law was amendedto include specific “safe harbors” for various paymentand business practices that, while potentially prohibitedby the law, would not be prosecuted. In 1991 and 1992,13 regulatory safe harbors were established. In 1999, thenumber was expanded to 23 safe harbors.Space Rental Safe HarborSpace rental has a safe harbor. In section 1128B of theFederal Anti-kickback Act, “remuneration” does notinclude any payment made by a lessee to a lessor for the useof the premises as long as all of the following standards aremet:1. The lease agreement to set out in writing and signed bythe parties.2. The lease covers all of the premises leased betweenthe parties for the term of the lease and specifies thepremises covered by the lease.3. If the lease is intended to provide the lessee with accessto the premises for periodic intervals of time (ratherthan on a full-time basis) for the term of the lease, thelease specifies exactly the schedule of such intervals,their precise length and the exact rent for such intervals.4. The term of the lease is not for less than one year;5. The aggregate rental charge is (a) set in advance, (b)consistent with fair market value in arms- lengthtransactions and is not determined a manner that takesinto account the volume or the value of any referralsor business otherwise generated between the partiesfor which payment may be made in whole or in partunder Medicare, Medicaid or other Federal health careprograms.Any lease arrangement, whether it be space-sharing or asublease, should be scrutinized. A well-written lease, whichclearly identifies the space and its proposed use as well as afair market value offering, is essential to compliance withthe anti-kickback law. Referrals that are generated as aresult of the lease arrangement should be well-documentedand clinically appropriate. Consultation with a healthprofessions attorney is recommended before any real estateventure is considered.© 2011 American Academy of <strong>Orthopaedic</strong> Surgeons37
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