Download Launching Your Career in Pediatrics American Academy

Launching Your Career in
Pediatrics
American Academy of
Pediatrics
04/10
Launching Your Career in Pediatrics: Getting Started
Thinking of a location to practice medicine or open a practice is an important decision.
There are a number of considerations that any pediatrician will need to examine before
making a final decision.
Pediatricians often choose their jobs based on several factors—family needs, spousal
considerations, recreational and cultural opportunities, friends, size of the community,
lifestyle, income guarantees, and benefit plans. This section will look at the most
important things to consider when joining or opening a practice.
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Personal and Family Needs
Physician Salaries and Financial Considerations
Assessing the Community
Practice Types
Current Trends in Malpractice
Professional Relationships and Opportunities
Personal and Family Needs
Family needs and wants are often at the top of the list when considering where to
practice. Many pediatricians who have young children often choose to move closer to
family and relatives for support. The location of where a spouse can work is an important
factor when determining a location, as well. Also important are the availability of
educational, cultural, and recreational activities. If you love outdoor activities, you may
wish to move to regions that offer those advantages.
As more women enter the field of pediatrics, there has been an increase in demand for
careers that offer a work/life balance. This demand has prompted many pediatricians to
seek careers that offer job sharing and part-time and flexible work schedules. The
American Academy of Pediatrics (AAP) Women in Pediatrics Web site
(http://www.aap.org/womenpeds/) has more information about issues facing women in
pediatrics. The same dynamics hold true for those on the opposite end of the spectrum—
retiring pediatricians (Shrier DK, Shrier LA, Rich M, Greenberg L. Pediatricians leading
the way: integrating a career and a family/personal life over the life cycle. Pediatrics.
2006; 117:519–522) (http://pediatrics.aappublications.org/cgi/content/extract/117/2/519)
To make a decision about where to practice, it is important to assess your goals.
Clarify your career objectives.
• Do you want to practice a specific style or philosophy of pediatrics?
• Are you a team player or someone who likes to go it alone?
• What type of location would you like to be in—rural, suburban, or urban?
• What kinds of patients do you want to serve?
• What are your future goals?
• Do you enjoy working shifts?
• Do you prefer inpatient or outpatient care?
Do you like the idea of hospital or academic practice, a clinic practice, or a private office?
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How many hours do you want to work?
Do you mind working a lot of evenings and weekends?
How often do you want to be on call?
Is the practice committed to being a medical home for its families?
What kind of lifestyle do you want outside the office?
• Exposure to urban life opportunities
• Outside adventures
Physician Salaries and Loan Repayment Options
Salary
The region of the country where you practice will likely determine your lifestyle and
practice income. Surveys of pediatric salaries show that incomes are highest in the
Midwest and Southeast, with the lowest salaries in the Northeast and on the West Coast.
US Department of Labor Bureau of Labor Statistics
http://www.bls.gov/oes/current/oes291065.htm (Based on 2009 Data)
For general pediatricians—annual mean wage: $161,410; annual median wage: $152,240.
The following chart lists state/commonwealth annual mean wage and annual median
wage:
STATE/COMMONWEALTH
STATE/COMMONWEALTH
ANNUAL MEAN WAGE ANNUAL MEDIAN WAGE
Alabama
$171,320
$161,330
Alaska
$178,660
$164,970
Arizona
$156,360
$152,600
Arkansas
$196,360
(5)-
California
$165,270
$155,960
Colorado
$165,220
$156,740
Connecticut
$148,280
$137,830
Delaware
$120,610
114,980
Florida
$161,800
$145,590
Georgia
$169,730
$158,290
Hawaii
$187,760
(5)-
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Illinois
$134,190
$104,860
Indiana
$154,950
$141,090
Iowa
$206,390
(5)-
Kansas
$190,390
(5)-
Kentucky
$196,210
(5)-
Louisiana
$140,860
$116,640
Maine
$161,530
$156,030
Maryland
$139,530
$132,770
Massachusetts
$159,390
$151,270
Michigan
$151,870
$134,080
Minnesota
$199,440
$(5)-
Mississippi
$174,540
(5)-
Missouri
$155,350
$137,090
Montana
$189,780
$(5)-
Nebraska
$200,280
$(5)-
Nevada
$178,820
$163,520
New Hampshire
$149,460
$140,660
New Jersey
$156,360
$139,840
New Mexico
$170,130
$160,520
New York
$154,070
$146,840
North Carolina
$169,530
$162,750
North Dakota
$155,450
$150,830
Ohio
$144,670
$134,630
Oklahoma
$186,040
$(5)-
Oregon
$193,090
(5)-
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Pennsylvania
$146,260
$135,620
Puerto Rico
$82,310
$62,730
Rhode Island
$169,770
$158,290
South Carolina
$166,030
$151,430
Tennessee
$163,650
$159,900
Texas
$153,470
$148,070
Utah
$192,530
(5)-
Vermont
$115,980
$112,200
Virginia
$166,800
$156,560
Washington
$175,780
$163,240
West Virginia
$145,880
$136,080
Wisconsin
$181,960
(5)-
Wyoming
$146,870
$148,310
Annual wages have been calculated by multiplying the hourly mean wage by 2,080 hours;
where an hourly mean wage is not published, the annual wage has been directly calculated
from the reported survey data.
(5) This wage is equal to or greater than $80.00 per hour or $166,400 per year.
Data extracted on July 6, 2010.
According to the Medical Group Management Association (MGMA) Physician
Compensation and Production Survey: 2008 Report Based on 2007 Data, the national
mean for general pediatricians was $196,936 and the national median was $183,265.
Salary References and Additional Resources
• AAP Socioeconomic Survey of Pediatric Practices
(https://www.nfaap.org/netFORUM/eweb/DynamicPage.aspx?webcode=aapbks_pro
ductdetail&key=3ecfa4df-0177-4650-b1e0-7c53c4733d5d)
• "Pediatricians Leading the Way: Integrating A Career and a
Family/Personal Life Over the Life Cycle,"
(http://pediatrics.aappublications.org/cgi/content/extract/117/2/519) February 2006
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• "Pediatrician Workforce Statement,"
(http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/1/263)
Pediatrics, July 2005
• "The Pediatrician Workforce: Current Status and Future Prospects,"
(http://pediatrics.aappublications.org/cgi/content/full/116/1/e156) Pediatrics, July
2005
• Physician Placement Starting Salary Survey
http://www5.mgma.com/ecom/Default.aspx?tabid=138&action=INVProductDetails
&args=2300&kc=ECN) Report: 2006 Report Based on 2005 Data, MGMA
• Merritt Hawkins & Associates® 2007 Survey of Primary Care Physicians
(http://www.merritthawkins.com/pdf/2007_survey_primarycare.pdf)
• Physician’s Search Physician Compensation Survey—In Practice Three Plus
Years (http://www.physicianssearch.com/physician/salary2.html)
Additional information can be found on AAP PedJobs.
Loan Repayment Options
As the cost of higher education continues to rise, so does the amount of loan debt. Many
members of the AAP emerge from medical school or pediatric residency with a balance
of more than $125,000 in student loans.
It is important to obtain qualified advice before entering into any loan repayment or
employment agreement. There are many state and federal government programs that offer
repayment programs. It is essential to learn about the commitments and expectations before
entering into any formal agreement. Examine the source of funding and the fine print, and
consult mentors on your faculty and in your student affairs office before entering into any
commitments (Pediatrics 101: A Resource Guide from the American Academy of
Pediatrics)( http://www.aap.org/profed/Peds101book.pdf)
The following links provide general information as a starting point for research. Consult
with your college financial aid officer and other qualified advisors before committing to
any financial arrangement.
Loan Repayment Resources
National Health Service Corps: Loan Repayment Program
As part of the American Recovery and Reinvestment Act of 2009 (ARRA), $200 million
has been allocated to support loan repayment programs as part of the Health Resources
and Services Administration National Health Service Corps (NHSC) program. In
exchange for 2 years of service at an NHSC site, clinicians are provided with $50,000 to
repay their educational loans.
Pediatricians can take advantage of this opportunity in 2 primary ways.
1. Apply for the loan repayment program if you are already working at an NHSCapproved service site or are interested in doing so.
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2. Apply to have your clinic considered as an NHSC service site.
Applying for the National Health Service Corps Loan Repayment Program
Allopathic and osteopathic physicians are eligible to apply for this program. Application
materials can be found at http://nhsc.hrsa.gov/loanrepayment/apply.htm. Important facts
about the program include
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National Health Service Corps loan repayers are committed to serve 2 years at an
approved site in a health professional shortage area.
Loan repayers fulfill their service commitments by providing full-time clinical care
(at least 40 hours each week), with at least 32 of those hours in the ambulatory care
setting.
Loan repayers negotiate their salaries with the employing site, but the NHSC requires
that they be paid at least as much as they would in an equivalent federal civil service
position.
All NHSC-approved sites accept Medicare and Medicaid and provide services on a
sliding fee scale or other method that enables patients who are poor or uninsured to
receive care whether or not they are insured or able to pay.
You will be notified whether you were selected to receive an award approximately 8
weeks following submission of your application. If you are selected to receive an
award, you will need to become employed at an approved site within 30 days.
The NHSC Web site has a database that currently lists more than 7,000 job openings.
Applying to Become a National Health Service Corps Service Site
To become an approved NHSC site and recruit clinicians who have received an NHSC
scholarship or are eligible for NHSC loan repayment, you must be a community-based
primary medical, dental, or mental health care practice or facility that meets NHSC
eligibility requirements. These requirements include
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Located in a health professional shortage area, as designated by the federal
government using several criteria including population-to-clinician ratios (usually
3,500:1 for primary care).
Provides services on a discount fee schedule.
Accepts patients covered by Medicare, Medicaid, and the Children’s Health
Insurance Program.
Can document sound fiscal management.
Has capacity to maintain a competitive salary, benefits, and malpractice coverage
package for clinicians.
Before you begin your application to become an NHSC service site, it is recommended that
you contact your state primary care office (http://bhpr.hrsa.gov/Shortage/pcos.htm). It can
make sure you are eligible, help you prepare and submit your application, and connect you
with other resources in your state. Additional information and application materials can be
found at http://nhsc.hrsa.gov/communities/apply.htm.
State Loan Repayment/Forgiveness Programs
• Review the Association of American Medical Colleges database of state and other
loan repayment/forgiveness scholarship programs with an interactive guide to
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information from state health departments, medical schools, federal programs, and
military agencies
Association of American Medical Colleges (http://www.aamc.org/)
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(MD)2: Monetary Decisions for Medical Doctors
(http://www.aamc.org/programs/first/students/start.htm)
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A chart
(https://services.aamc.org/dsportal2/index.cfm?fuseaction=login.login&thre
ad=jump.VOVICI_TSF&appname=VOVICI_TSF&frompermissionscheck
=true) showing tuition and student fees for first-year medical students (login required)
National Institutes of Health (http://www.nih.gov/)
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Pediatric Research Loan Repayment Program
(http://www.lrp.nih.gov/about_the_programs/pediatric.aspx) in return for a 2year commitment to your research career, the National Institutes of
Health will repay up to $35,000 per year of your qualified repayable
education debt plus an additional 39% of the repayments to cover your
federal taxes, and may reimburse state taxes that may result from these
payments.
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Student Loan Consolidation
Indian Health Service Loan Repayment Program Service Center
(http://www.ihs.gov/JobscareerDevelop/DHPS/LRP/lrpsc.asp)
Applicants sign a 2-year agreement and provide full-time clinical practice at the Indian
Health Service facilities or approved Indian health programs. In exchange, a portion to all
of their educational loans will be repaid.
Assessing the Community
Whether you are considering opening a practice, joining a practice, or relocating, there
are a number of things to consider before making the final decision. In real estate, the 3
most important considerations when buying a house are location, location, and location!
The same is true of a pediatric practice. Many of the decisions about practices and
lifestyles will be determined by your preferences about where you would like to live and
work.
Following are some tips on selecting a community in which to practice:
• The most basic approach to assess the requirements for pediatricians is to
determine the employment opportunities and competition for patients.
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Consider trends in the local obstetrician demographics.
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Contact the local chamber of commerce to find migration trends and the opening
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of schools, homes, and hospitals. This is often a good predictor of whether the
location will be viable.
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It is important to know if the community in which you plan to practice is a
younger community with new families emerging or an aging retirement
community.
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Identify where patients live. The rule of thumb is that patients will drive 20
minutes to see a doctor. Any farther, patients will look for a doctor closer to
where they live. However, this rule may not apply to rural physicians.
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Consider the number of retail-based clinics (RBCs) in your area. If there are no
RBCs, this is a good time to establish your pediatric office in a central location
near a major retail location to get ahead of the competition in the future. If RBCs
do exist, make sure the practice you are starting or joining is providing
competitive hours and values customer service. Families are using RBCs mainly
out of convenience. If your practice can compete by providing the same or better
level of convenience, your expertise as a pediatrician will far outweigh the
services provided at an RBC. It’s a win-win situation for you and your patients.
More resources on RBCs (http://practice.aap.org/content.aspx?aID=1511) can be
found on the AAP Practice Management Online Web site.
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Consider the number of pediatric care professionals in the area.
Urban Versus Rural Locations
There are many differences between practicing in a rural versus an urban location. Those
who choose to practice in a rural area usually prefer to do so in an effort to use all skills
learned during residency. It is common for practicing pediatricians in rural areas to
perform resuscitations, intubations, and lumbar punctures. It is often their responsibility
to stabilize and care for children who are chronically ill. See Table 1
(http://pediatrics.aappublications.org/cgi/content/full/107/2/e18/T1) in “Trends in the
Rural-Urban Distribution of General Pediatricians”
(http://pediatrics.aappublications.org/cgi/content/abstract/107/2/e18 ) (Pediatrics.
2001;107:e18) for more information.
Practicing in an Urban or Rural Population
Urban
Rural
More technology
Less technology
More networking opportunities
Independent practitioner with less networking
opportunities
Less on-call and weekend hours
Need to be available more (on call, after hours,
and weekends)
More commuting time
Larger salaries
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More physicians = more competition
Greater need = less competition
Access to subspecialists and
children’s hospitals
Often will need to contract with subspecialists
Where Children and Their Families Go for Health Care
The American Academy of Pediatrics (AAP) partnered with Dartmouth Medical School,
Center for the Evaluative Clinical Sciences, to develop Mapping Health Care
Delivery for America's Children (http://www.aap.org/mapping/). This Web site
provides the status of current available national, state, and city data on the following:
• Children younger than 18 years per clinically active pediatrician Percent of
clinically active pediatricians who are female
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Median household income
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Percent of Hispanic children younger than 18 years
• Percent of children 5 to 17 years old in linguistically isolated households
It is important to note that while some areas in the United States appear to have a large
number of pediatricians, these pediatricians are still employed and working.
Practice Types
There are a variety of practice options and structures available to pediatricians.
Following is an overview of the various structures.
Solo Versus Group Practice
Solo Practice
Group Practice
More individual freedom
Less individual
practice freedom
Longer work hours—
clinical and business
Shorter work hours
Complete responsibility
for the business
Hospital
Owned
Not as much
physician
autonomy
Federally
Qualified
Health Center
Not as much
physician autonomy
Academic
Health
Center
Not as much
physician
autonomy
Work on a
schedule
Work on a
schedule
Work on a
schedule
Less need to be involved
in business aspects
Subject to
employee
constraints
Subject to
employee
constraints
Subject to
employee
constraints
High public/patient
visibility
Less personal visibility
with public and patients
Marketing
department
Marketing
department
Marketing
department
Extremes of financial
return
Built-in on-call coverage Centralized patient
record keeping
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Centralized patient
record keeping
Centralized
patient record
keeping
Business risk
Low to no
legal/business risk
Low to no
legal/business risk
Required
referral patterns
Required referral
patterns
Cost allocation to
physicians
Limitations
due to federal
fund ing regulations
Access to
larger amounts
of working
capital.
Possible
administrative
limitations
Less opportunity
for involvement in
business concerns
Greater chances to be
involved in high-tech
practice
Systemdetermined
decisions
Better access to
equipment and
better equipment
System- determined
decisions
Systemdetermined
decisions
Better access
to equipment
and better
equipment
Set growth pattern
More limits on rapid
income growth
Steady flow of
income
Determine benefit
structure
Established benefit
structure
Established
benefit
structure
Less opportunity for
informal professional
consultations
More limited working
capital
Total
involvement in
business concerns
High-tech practice
will depend on
expenses
Lower
medicolegal/business
risk
More opportunity for
informal professional
consultations
Access to larger
amounts of working
capital
Better access to
equipment and better
equipment
Steady flow of income
Established benefit
structure
Low to no
legal/business
risk
Required
referral
patterns
Steady flow of
income
Established
benefit
structure
Source: American Academy of Pediatrics, Committee on Practice and Ambulatory
Medicine. Management of Pediatric Practice. 2nd ed. Elk Grove Villlage, IL:
American Academy of Pediatrics; 1991 and American Academy of Pediatrics. A
Guide to Starting a Medical Office. Elk Grove Village, IL: American Academy of
Pediatrics; 1997
Solo Practice
Solo practices are for pediatricians who want to own and manage their own practice. This
physician is responsible for all aspects of the practice, including establishing policies and
guidelines, staffing, office hours, finances, and legal.
Expense Sharing
This type of practice may be as simple as 2 pediatricians sharing office space and staff
but operating as independent practices. This provides some relief from the financial
burden of overhead and office operations and provides some relief from finding night-call
coverage. Patients should be made well aware that the 2 physicians have separate
practices. If there is no written agreement and patients assume that the physicians are
partners, both physicians may be implicated in malpractice litigation.
Partnership
A partnership is an association of 2 or more persons for the purpose of carrying on as coowners of a business for profit. The partners in this arrangement invest together to make a
profit. In this structure, each partner has equal rights and management and also shares the
risks and responsibilities. New partners are usually brought in after acquiring the consent
of all existing partners. Like marriages, there needs to be compatibility in medical
practice and management philosophies among partners. Partners can also expect to
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receive a formal accounting of all partnership affairs. On the other hand, all partners may
be liable for each individual partner’s wrong acts or acts of commission or omission
assumed by the partnership as a whole, inviting individual liability for any legal action
against the partnership. Also, in much the same way partnership gains are shared equally,
so may losses be expected to be shared.
Single and Multi-specialty (Large and Small)
Single-specialty groups pool the resources of several pediatricians. The legal arrangement
becomes important and is essential to define the roles and responsibilities of the partners.
Multi-specialty groups provide a pool of other medical and management skills, but with
significantly less personal autonomy.
Corporate Practice
Working for a large corporate health care provider is another option. Corporate practice
reduces the personal and financial risk to the individual physician, while also providing
opportunities to shelter income through a qualified retirement program. A large health
maintenance organization (HMO) office allows pediatricians to practice without business
or administrative concerns. This provides a great deal of security in terms of salary and
benefits and eliminates the need to be concerned about administrative and business
aspects of practice. Government and federal health care facilities provide another practice
outlet. Academic practices provide many of the same benefits. Lastly, niche practices
such as emergency department or delivery room coverage, working with specific disease
entities like obesity, or substance abuse centers provide yet another practice outlet.
Advantages include limited liability to the individual practitioner; centralized
management; continuity of life beyond the career trajectories of existing physicians;
pension and profit-sharing plans that may be superior to solo practice or partnerships; tax
incentives; and presence of other benefits that are more cost-efficient because of scale
(eg, health benefit, life insurance, disability, malpractice discount). Disadvantages
include need for an extensive organization to manage personnel, legal paperwork, tax,
and accounting; need for higher start-up costs; and potential tax consequences (eg,
corporate versus income tax). Corporate practices may exist in several forms—HMO
groups, government or federal health care centers, hospital-based practices (eg, academic
groups, hospitalist groups, emergency department physicians), and boutique practices
(eg, substance abuse, surgical centers). These may all be structured very differently
depending on local standards, community and state laws, and preferences of organizing
groups. Each may have various arrangements for a physician’s role and responsibility
within the group, including profit sharing, vesting time, amount of call, and academic
partnerships.
Academic and Hospital-Based Practices
With the growing demands of outpatient practices, hospital-based practices are growing
in almost every community. They may develop as an initiative of local physicians, or
hospitals may choose to contract with them. They may offer around-the-clock care that
primary physicians find difficult to provide. Having hospitalists has been shown to
improve quality measures—including length of stay, mortality, and 30-day readmission
rate—in several common inpatient diagnoses. Evidence also shows that hospitalists
reduce costs and length of stay while achieving the same or better patient outcomes
achieved by non-hospitalists. Hospitalists often practice in group-type structures; they
may be simple informal arrangements among a group of physicians within a community
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who share hospital calls with or without teaching responsibilities, or they may be more
elaborate corporate organizations that employ individual physicians. Some may even be
organized on a national scale, with local “franchises” that operate within a community but
are answerable to corporate headquarters. They may cover one or multiple hospitals
depending on the demand and the particular relationships that exist between the group
and hospital administration. In much the same way corporations offer benefits of scale in
terms of sharing expenses, employee benefits, and tax advantage, groups that are more
organized offer the advantage of monitoring the quality of care provided by their
physicians. These groups may have methods in place to assess outcomes, lengths of stay,
patient satisfaction, and reimbursement values.
Physicians who practice within such a setting report the following advantages:
• Satisfaction of working within a team
• Satisfaction of contributing to the improvement of inpatient care or hospital
processes
• Flexibility of work hours (i.e., not necessarily 9:00 am–5:00 pm)
• Opportunities for various educational interactions (eg, with other specialists,
residents, medical students)
• Opportunity to have nonmedical responsibilities (eg, administration, quality
assurance) as much or as little as one wants
• Large variety of clinical cases, which are often acute and whose successful
outcomes provide enormous satisfaction
• Being kept on one’s toes
Most physicians who work in this setting will report difficulty and even boredom with the
daily grind of an office practice, which often seems to involve the same medical
problems over and over. These physicians also perceive the business side of keeping a
practice afloat not to their liking. They express a high comfort level with a hospital
setting and the pace that such work involves. On the other hand, depending on the level
of specialty required, length of training time, and challenge of working in a high-pressure
field that may be dominated by males, some women may not find this to be a suitable
practice alternative. Furthermore, practice turnover may turn the work hours from an
advantage to a disadvantage, since regardless of the number of covering physicians, the
group will still be committed to providing 24/7 care.
Physicians in practice transitioning to or new graduates contemplating a hospitalist
position should ask themselves a number of questions.
What is the nature of the organization? Is it a corporation, a partnership among
physicians, or a hospital-based group? Will a physician be an employee of the
corporation or of the hospital? What is the basis of the corporation’s relationship
to the hospital?
What is the organizational structure? Who will serve as my direct supervisor(s)
and what are his or her responsibilities?
What is the group’s composition? Are they all general pediatricians? Are there
family or nurse practitioners? Who are the actual physicians participating in the
call rotation? What are the responsibilities of each physician who takes calls?
What is the call rotation schedule?
Are there outpatient responsibilities or emergency department coverage apart
from inpatient calls? Where will these be conducted?
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Which hospitals does the group cover? If more than one, are there different
responsibilities or expectations with each hospital setting? Are the patient load
and population different with each hospital? If one is relocating, what is the
approximate distance between each hospital and one’s residence? Is there a
central office location for the group?
What are other physician responsibilities apart from direct patient care? Are there
administrative duties or teaching responsibilities? Are these expected, required, or
optional? If one were to supervise or teach, does this involve nurse practitioners,
physician assistants, other nursing personnel, residents, or medical students?
Does the group have subspecialty or surgical support? If so, who and where?
Does it require transferring patients from a primary hospital to a tertiary one?
What is the rate of physician reimbursement? What is the basis of this scale (eg,
seniority, productivity, patient load, call load)? How is one’s productivity
calculated and what factors go into this calculation? How does one’s productivity
affect compensation and future raises?
What benefits are offered to physicians? Do these include health coverage,
malpractice liability, other insurance coverage, and retirement funds? If
transferring from another practice, will the group offer tail coverage?
What constitutes terms of separation, termination, and contractual breach? Are
there any restrictive covenants (eg, geographic practice restrictions)?
What are the laws of the state governing all of this and what are the
responsibilities and liabilities if one assumes this position? You may need to
consult your state medical board or a local lawyer.
Concierge Medicine Models
Members of the American Academy of Pediatrics Committee on Child Health Financing
and Private Payer Advocacy Advisory Committee considered the implications of
concierge medicine to pediatrics and pediatric practices. Following is a general
description of concierge medicine and the various types of models and considerations for
pediatric practices.
Members of the American Academy of Pediatrics Committee on Child Health Financing and
Private Payer Advocacy Advisory Committee considered the implications of concierge
medicine to pediatrics and pediatric practices. Following is a general description of concierge
medicine and the various types of models and considerations for pediatric practices.
Concierge medicine (aka, boutique medicine, retainer-based medicine, innovative
medical practice design) describes medical practices that charge an annual retainer or
monthly service fee instead of, or in addition to, a fee for each medical service. In return
for the fee, the patient obtains enhanced access to the physician including, but not limited
to, decreased waiting periods, priority scheduling, telephone care, online consultation,
and after-hours and house calls. Concierge practices may continue to take third-party
payments, as well as an additional fee from the patient for services that are generally not
covered by insurance plans. This annual fee is not a substitute for medical insurance and
does not cover other medical services outside of the practice from other health care
providers such as laboratory tests, pharmaceuticals, hospitalizations, or therapies.
According to Concierge Medicine Today
(http://conciergemedicinetoday.com/indexhome.html), there are typically 2 to 3 types of
concierge medicine business models practiced today. Other variations with substantially
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higher fees than $1,500 per year also exist but can usually fall into one of the following
categories:
• Fee-for-care model: An annual fee is paid for an annual evaluation or other
identified services.
• Fee-for-service model: Patients pay a set fee directly to physicians for visits or
other services. Often, these fees can be based on age and paid monthly, quarterly,
or annually.
• Fee-for-non-covered-services model: Considered a hybrid concierge medicine
practice in which physicians charge access fees for services that Medicare and
insurers won’t pay for, such as e-mail access, phone consultations, and
newsletters, and bill Medicare and insurance companies for patient visits.
A new variation is direct primary care, which charges the patient a relatively low, flat rate
for defined primary care services.
04/10
In the following Table, primary variations of
concierge medicine are reviewed on the basis
of implementation factors for the physician
practice and access to primary care.
- 16 -
- 17 -
Retail-Based Clinics
While the AAP does not support the RBC model of care for children, families are using
these types of clinics. Located in retail settings (eg, pharmacies, supermarkets), these
clinics provide families with a convenient location and the ability to multitask. While this
may seem like a benefit to the family, the care provided at an RBC is very limited and
only fragments the medical home. Practices must educate their patients on the importance of
the medical home, but also provide a practice setting that meets the needs of busy families
today. Practices must acknowledge the changing health care market and respond to remain
competitive. Providing a medical home for patients can be challenging financially and
administratively, but it is the best model of care for children.
More resources on RBCs (http://practice.aap.org/content.aspx?aID=1511) can be found
here.
Current Trends in Malpractice
Pediatricians are sued less than other specialties—approximately 33% of pediatricians are
sued in their career. However, the indemnities are 25% higher. (Donn SM. Is there really
a relationship between medical liability, risk management and quality improvement?
Pediatricians and the Law. AAP News. 2007;2:1 1)
(http://practice.aap.org/content.aspx?aid=1788&nodeID=1020)
Malpractice coverage is necessary. There are 2 main options to choose from when
deciding on malpractice coverage claims-made or occurrence-made policies. It is very
important to understand the differences.
- 18 -
Claims-made policies will only cover you during the time you hold the insurance policy;
thus, once you leave the policy you will not be covered for any claims. For instance, if
you were in practice from January 2008 and left your job and policy in January 2009,
after January 2009 you will not be covered for any claim made, even if it is regarding an
incident that occurred between January 2008 and January 2009. However, you maybe
able to purchase a tail, which can cover any claims filed about incidents during the time
you had claims-made policy.
Occurrence-made policy, on the other hand, covers all claims regardless of when the
incident in dispute occurred. In other words, even after the policy expires, it still protects
you from any claims filed for incidents that occurred while the policy was in force. This
policy tends to be more expensive.
For additional information, visit Buying Professional Liability Insurance 101
http://practice.aap.org/content.aspx?aid=1636.
Resources
“Malpractice Insurance,” American College of Physicians
Medical Liability for Pediatricians- 6th Edition
(http://www.acponline.org/residents_fellows/career_counseling/malpractice_insurance.ht
m)
“Evaluating an Insurance Policy,” American Medical Association (http://www.amaassn.org/ama/pub/category/print/4584.html)
“Exclusive Survey—Malpractice Premiums: Starting to Level Off,”
(http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=476096
) Medical Economics
“Is There Really A Relationship Between Medical Liability, Risk Management and
Quality Improvement?”
(http://practice.aap.org/content.aspx?aid=1788&nodeID=1020) AAP News.
- 19 -
Professional Relationships and Opportunities
Nearly 50% of physicians who practice in towns with a population of fewer than 2,500
grew up in a town with similar statistics. Studies show that there is a strong correlation
between where a pediatrician went to post-training studies and where he or she chooses to
practice.
You will also want to consider the professional relationships and networking
opportunities that you have had. Often, your mentors and professors can serve as
references and resources as you locate a place to practice.
Your State AAP and Medical Society Contacts
AAP chapters are organized groups of pediatricians and other health care professionals
working to achieve AAP goals in their communities. There are 59 chapters in the United
States and 7 chapters in Canada. The US chapters generally are drawn along state lines,
but 2 states with large populations (New York and California) constitute more than 1
chapter. In addition, 2 chapters serve pediatricians in the uniformed services (east and
west, divided by the Mississippi River), and Puerto Rico and the District of Columbia are
also separate chapters.
I Already Belong to the National AAP; Why Should I Become a Member of My
Chapter?
Advocacy
• Increase your knowledge of and participation in legislative and advocacy
activities at a local level.
• Increase involvement in the legislative arena to positively influence the quality of
pediatric practice and the welfare of children in your state.
• Build coalitions with other organizations working toward improving children’s
health and well-being.
• Promote the interests of pediatricians in the AAP.
Leadership
• Participate in chapter committees in areas of interest.
• Serve as part of the chapter leadership team in an official officer capacity.
Networking
• Network with other pediatricians with similar interests.
• Improve chapter membership participation on national AAP affairs.
Education
• Receive regular chapter newsletter and other informative mailings.
• Attend local continuing medical education meetings and chapter annual meetings
to further necessary educational requirements.
- 20 -
To learn more about your state chapter, visit
www.aap.org/member/chapters/chapfacts.htm.
Launching Your Career in Pediatrics: Finding the Job
For many, choosing a location to open or join a practice is the first step in searching for a
job. Once a location has been determined, the job search begins. This next section will
provide tips on the following:
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Searching for a job
Researching the practice and community
Recent graduates
Identifying goals
Timeline summary
Working with recruiters
Preparing a curriculum vitae and cover letter
The interview
Negotiating an agreement
Searching for a Job
There are many ways to look for a job, from headhunters to posting your résumé on the
Web to looking in journals, but one very important way is through networking. A personal
recommendation and interaction go a long way. Some of the key people to network with
include
•
•
•
•
Residency director and faculty. Contact the residency or training director and
faculty at the institution where you trained. Many local pediatricians provide
residency directors with job openings.
Local agencies. Contact the local medical society or American Academy of
Pediatrics (AAP) chapter (http://www.aap.org/member/chapters/chapserv.htm).
Many times these groups are aware of pediatricians looking for new associates.
PedJobs. Visit and register with PedJobs at www.pedjobs.org.
Hospital. Many hospitals will assist with practice setup if they have a need for a
new pediatrician in the community. Additionally, many hospitals, local health
centers, and urgent care centers are building primary care networks and are
looking for physicians to staff them. You may want to consider contacting a
hospital that delivers newborns because there may be opportunities to cover the
nursery and delivery room. Additionally, some hospitals hire hospitalists to care
for newborns, inpatients, and patients in the emergency department.
- 21 -
•
•
•
•
•
Local pediatricians. Once you have decided on a location, get a list of the
pediatricians in that area. Contact them expressing interest in working for them. If
they are not hiring, they may be aware of other colleagues who might be looking
for an associate.
Events. By attending events, you can meet other physicians in the area.
Colleagues. Your former and present colleagues are a great resource. They are the
ones who have worked alongside you and know you well. Colleagues can be
helpful if an opening becomes available at their practice or if they hear of another
opportunity. Colleagues can include people you have interacted with in high
school, college, and medical school.
Ask. The best advice is “Ask, ask, ask!” If people are not aware of jobs, many
times, they will refer you to someone who is aware.
Recruiters. The use of recruiters can be very beneficial to a new job seeker. The
recruiter’s primary goal is to fill a position for the clients they represent, whether
hospitals, health systems, or clinics. Following is additional information on
working with recruiters.
Remember to tell everyone you know that you are looking for a job because you never
know what opportunities may arise. Having a curriculum vitae (CV) or résumé ready to
distribute can help make the most of a time-sensitive opportunity.
If you are a physician who is re-entering the workplace, visit
http://www.physicianreentry.org/ for tips and information.
Resources
Medical Economics: “Finding a Job: Step 1: What Do You Want?”
(http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=12891
1).
Medical Economics: “Finding a Job: Step 2: Start Looking”
(http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=13152
0)
Researching the Practice and Community
When you have narrowed down the search to a few practices, it is important to research
the practice and staff working at that location to determine if it would be a good fit for
you. The following are guidelines to assist in this process:
•
•
Talk with other pediatricians about the reputation of the group that you are
considering. Are they respected as good doctors? Look at the CVs of the partners
in the practice as well.
Do they have a Web site and what can you learn about them from it?
- 22 -
•
•
•
Who is the local competition?
Talk with the medical society about local medical issues.
Call the chamber of commerce and learn what the community has to offer. Is the
hospital open to new physicians or closed? Who would be your collaborator and
competition?
Recent Graduates
The obstacles facing recent graduates and current residents looking for a position in
pediatrics are different from those who have previously undertaken this process.
Recent graduates are often individuals who have pursued a career path without any
experience in job searches. These individuals transitioned from one level of training to
another since high school. With this perspective, the foundational skills of a job search
need to be reviewed. Specifically, recent graduates are often at a loss as to when to look
for a job and how to design a CV and cover letter.
Identifying Goals
In the first year of residency, residents should identify their career goals and attempt to
tailor their training appropriately. If this entails further subspecialty training, activities that
strengthen the resident’s interest such as research and appropriate mentorship should be
started. However, for those interested in general pediatrics, exploring different practice
types while under the umbrella of training can offer much insight. Look to shadow and
work in various practice locations. Residents should explore an academic practice, a rural
practice, an urban practice, and all the variations in between. Discussions with program
directors about career goals can be very fruitful during the later aspects of the intern year.
For those looking for general practice, the second and third years give residents time to
hone in on the location and types of practice that they are suited for. This is important
because various locations may have different requirements for licensing and skill sets. For
instance, an academic position may not require in-hospital coverage and thus
documentation for procedural skills and staff privileges within a hospital may not be as
important. Those looking in a different state may also need to start working on how to
obtain a medical license and credentialing in that state.
For those interested in further subspecialty training, the second and third years involve
further research and applying to the specialty of choice. Currently, pediatric subspecialty
match involves the National Resident Matching Program on a subspecialty-bysubspecialty basis. There has been a recent move to involve all subspecialties in the match
program, but some continue outside of the match. As the specialty of choice is identified,
the application process must be identified early to avoid missing the appropriate
application cycle.
- 23 -
Timeline Summary
Postgraduate year (PGY)-1
• Focus on surviving the intern year.
• Assess fit with possible careers during various rotations.
• Explore career goals by establishing a mentoring relationship.
PGY-2
• Pursue electives to explore career opportunities.
• Decide between general versus subspecialty practice.
• Initiate research as needed to strengthen career choices.
• Create CV and identify programs for fellowship.
• Identify timing for various subspecialty fellowship applications.
• Match for fellowship programs.
PGY-3
• Identify suitable primary care positions and send out cover letters and CV during
the early part of the year.
• Interview during the middle portion of the year for primary care positions.
• Solidify primary care positions and negotiate contracts and benefits during the
second half of the year.
• Match for fellowship programs.
Fellowship Application Schedule as of Spring 2008
Specialty
Admission
Cardiology
Spring to summer PGY-2
Gastroenterology
Spring to summer PGY-2
Rheumatology
Spring to summer PGY-2
Allergy and
Spring to summer PGY-2
immunology
Nephrology
Winter to summer PGY-2
Pulmonary
Rolling PGY-2
Endocrinology
Rolling PGY-2
Neonatology
Winter to summer PGY-2
Hematology/oncology Spring to summer PGY-2
Critical care
Fall PGY-3
Emergency medicine Fall PGY-3
Sports medicine
Winter PGY-3
- 24 -
Participates in Match
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Resources
Association of American Medical Colleges Electronic Residency Application Service
(http://www.aamc.org/students/eras/)
National Institutes of Health: “Preparing the Curriculum Vitae”
(http://www.training.nih.gov/careers/careercenter/cv.html)
National Resident Matching Program (http://www.nrmp.org/)
New England Journal of Medicine: “Writing Compelling Physician Cover Letters”
(http://www.nejmjobs.org/career-resources/physician-cover-letters.aspx)
New England Journal of Medicine: “Working With In-House Physician Recruiters”
(http://www.nejmjobs.org/career-resources/physician-recruiters.aspx)
University of Chicago: Department of Pediatrics Career Planning
(http://pediatrics.uchicago.edu/res_careerPlan0405.html)
Working With Recruiters
In transitioning from training into the workforce, residents commonly receive solicitation
from physician recruiters. In approaching recruiters, the job seeker needs to understand
the market that the recruiter serves. Although there are national recruiters, frequently
recruiting firms operate in a specific geographic area. In addition, keep in mind that the
recruiter’s primary goal is to find physicians for their clients. Thus, the job seeker should
always be mindful that the recruiter is an extension of the position and approach
interactions carefully and professionally. The use of recruiters can be very helpful to
streamline the search process but does not eliminate all of the hard work. The networking
that may result from this relationship can be very beneficial to a new job seeker. The
following are some helpful guides in working with recruiters:
• Know thyself. Because opportunities can be endless, it is important to have a
specific picture in mind of your ideal practice before working with a recruiter. Is it
in a city or suburban town? Is it a partnership or salaried employee position? Will
there be hospital-based work or clinics only? By focusing your goals, the recruiter
can better work with you to identify the practices that would be a good fit for you.
• Recruiters work for the companies for which they recruit. More importantly,
they do not work for you. Recruiters’ job is to find suitable candidates to fill the
positions for which they are hiring. In a November 5, 2004, Medical Economics
article, “Finding a Job: Step 2: Start Looking,”
- 25 -
(http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=
131520) Gail Weiss states that the use of recruiters may limit your bargaining power
because the cost of using the recruiting firm may curb the employer’s appetite for
working with you on compensation such as moving expenses.
• Know who you are working with. You should be comfortable with recruiters’ style
and approach. Before starting a relationship, you should check out credentials such
as the history of the business, duration of stay for previous placements, companies
that they have worked with, and their areas of specialty geographically and
medically.
• Confidentiality. Finally, one of the common mistakes in working with recruiters
involves not protecting your confidentiality. The key is to work with a couple of
recruiters (some have suggested 2-3) and work with them closely in identifying
opportunities. Prior to starting any relationship, you should insist that you maintain
control as to where your CV goes. If you lose control of the relationship and fail to
establish confidentiality, your CV may get out to the same employer many times
over from different recruiters and thus give the employer the impression that you
may be desperate to find a job.
As residents and new job seekers, your time is limited and the use of a recruiter allows for
additional networking opportunities. However, knowing what you want ahead of time,
understanding the recruiter relationship, trusting the recruiter, and protecting your
confidentiality will make sure that this is a positive experience for all parties.
Preparing a Curriculum Vitae and Cover Letter
Writing a CV sounds easier than it may be despite its importance to applying to general
pediatrician positions and subspecialty fellowships. Although the Electronic Residency
Application Service of the Association of American Medical Colleges has composed a
CV for all medical students applying for residency, the components of a job-specific CV
differ. There are many online resources available for help in writing a CV, but what is
frequently most helpful is to look at a mentor’s CV and use that as a guide in creating
your own. The PedJobs CV Builder (http://www.pedjobs.org/cv.asp) is available to assist
in constructing a CV.
Once a CV is created, cover letters are needed to submit applications for positions. In
general, the cover letter expresses the interest in a position, summarizes the qualifications
of an applicant, and ties those skill sets to the needs of an employer. All this is
accomplished in a direct, well-written letter. Finally, cover letters should always be
targeted to a specific position and employer. (Example cover letters are included.)
The CV and cover letter are often the deciding factors on whether you will be called for
an interview. The person hiring for the job will look at these documents to gain an
- 26 -
understanding of your training, experience, volunteerism, and most importantly, what you
can bring to the position. Therefore, it is important that these documents look professional
and accurately relay the pertinent information about yourself to the reader. Following are
some tips on creating a CV and cover letter:
•
•
•
•
•
•
Be sure that the CV and cover letter provide an accurate description of the work
that you have done over the course of your training.
Include titles, names, and dates for each job that you have had since school.
List all job duties for each position or training experience. The positions should be
listed in chronologic order.
The cover letter should specify why you are a good fit with the practice and
position.
Check all grammar and punctuation.
Be sure that your contact information is included and up to date.
Sample Cover Letter 1
DATE
NAME, TITLE
STREET ADDRESS
CITY, STATE ZIP
Dear Ms Smith:
I am writing in response to your recent classified ad for a full-time pediatrician. I am in
my final year of pediatric residency and will be graduating in June 2008. I will be boardeligible and intend to sit for the pediatric board examination later this fall. I am interested
in starting with a practice this summer.
During my pediatric residency, careful listening, vigilance, compassion, and enthusiasm
enabled me to excel during my outpatient and inpatient rotations. Although it is a
challenge to provide treatment for children who are more acutely ill or sometimes
chronically ill, the true reward is in watching them heal and improve. Working as a
primary care pediatrician will allow me the chance to continue to play a major role in this
process.
I also look forward to teaching and supervising students and residents if the opportunity
arises. I am organized and hardworking, and work excellently as a team player. I hope to
join a practice where I can use my current skills and continue to grow and develop new
- 27 -
ones as I gain experience.
My pediatric training at <name of pediatric hospital> has given me diverse exposure to
primary, secondary, and tertiary care pediatric medicine. Because this is a large children’s
hospital, I have become comfortable with working in an environment where one may have
to see 20 to 30 patients a day.
I have an interest in asthma management as it pertains to primary care pediatrics. I also
love the continuity and the preventive care aspects of this field. I am fluent in German and
can speak conversational Spanish as it pertains to medical history taking. I am excited
about joining a practice and feel that I would a great addition to your team.
Enclosed you will find my CV. Please call me at 888/333-3333 or e-mail me at
[email protected] if you are interested in talking to me further. Thank you for
considering me.
Sincerely,
NAME, Resident
Sample Cover Letter 2
DATE
NAME, TITLE
STREET ADDRESS
CITY, STATE ZIP
Dear Mr Smith:
I am writing to express my sincere interest in a job opportunity that your practice recently
posted on www.PedJobs.org. I am currently a board-certified pediatrician at a large
private practice clinic in southern Washington. I have 4 years of experience in private
practice. I am looking to relocate to your area so that I can be closer to my family.
My primary goal is to join a group practice that will provide me with the opportunity to
practice the best standard of care in pediatrics. I am interested in a practice that will allow
me to focus on outpatient pediatric care, especially preventive medicine. I have
experience in inpatient primary care pediatrics as well and look forward to continuing
those skills if the opportunity allows. As a former chief resident, I have a passion for
teaching and would welcome the chance to interact with medical students and residents as
well.
- 28 -
I feel it is essential to be a strong advocate for my patients and an active participant in
their care. I have served in various leadership roles at my current practice and hospital and
would like to continue to do so in my career. I feel that by becoming a part of the
decision-making process in my practice and hospital, I can make a difference in my local
medical community.
I currently work 4 days per week and 1 weekend per month, seeing an average of 25
patients per day. I have an on-call schedule of 1 in 7. Our calls typically include
emergency department consultations, phone triage, admitting patients into the hospital,
and attending high-risk and cesarean deliveries. I am fluent in English and skilled in
conversational Spanish.
I strongly believe that your practice has the potential to enable me to achieve all of my
goals. I would welcome the opportunity to speak with you directly. Please contact me if
you are interested in setting up an interview. I have attached a copy of my CV. Please call
me at 888/555-5555 or e-mail me at [email protected]. I look forward to hearing
from you. Thank you in advance for your time and consideration.
Sincerely,
NAME, MD, FAAP
The Interview
Once you have identified a practice opportunity, you will start the interviewing process. It
is important to know that the interview is for the person hiring for the position and the
person seeking the position. The interviewer will use this meeting as a way to determine if
you are a good fit with the practice’s mission, staff, and position. The interview is also an
opportunity for you to examine the practice to determine if it is a good fit for you.
Therefore, it is important to prepare for the interview beforehand and come with questions
about the practice and community that can help you make this decision.
Five Steps of the Interview
1. Get acquainted. Are you compatible?
2. Find out about the practice goals, philosophy, lifestyle, and working
relationships.
3. Ask questions about the practice.
• Number of patients seen (per year, per day)
• Staffing ratios
• Income and financial stability
• Partnership opportunities and procedure
- 29 -
• Marketing techniques to gain patients
• Comfort with technology
• Payer mix
• Others
4. Assess practice and candidate attributes.
5. Negotiate a deal.
Depending on your location and the location of the interview, the first encounter will be
by phone, by e-mail, or in person. When arranging an interview, determine who you will
be interviewing with, if your expenses for travel will be covered, and what the expectation
is from you.
Tips for the Interview
• Dress professionally for this interview. Business attire is most appropriate, even in
a casual practice.
• Bring your CV along as well as any other information about yourself which you
feel would be helpful.
• Make eye contact with your interviewer and listen carefully to the questions. Be
sure that you answer all of the questions completely.
• Talk with the partners and also the staff. If possible, speak with some of the
patients about what they like about the practice.
• As you begin your questions, do not start by discussing salary. It is better to
understand the practice structure and responsibilities before getting into financial
questions.
• If the interview will occur by phone, be sure you schedule this at a time when
there are no disturbances. Be sure that there is no background noise.
Following are some questions that you may wish to ask the interviewer about the position
or practice.
Interview Questions
Following is a useful checklist to take when going in for an interview with a prospective
practice. Keep in mind that most interviews proceed from the informal (eg, getting to
know each other, seeing if the new physician is a good fit) to the more formal (eg,
contract negotiations). Keep the checklist in the back of your mind, but avoid coming
across as too forward or pushy. Remember that the group may have a set of criteria by
which you are being evaluated as well.
• How is the practice organized? Is it a partnership or corporation, or are the
physicians all employed?
- 30 -
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Who makes up the group? Are they all general pediatricians? Are there family or
nurse practitioners? Is everyone working full time? Who are the actual physicians
participating in the call rotation? What are the responsibilities of each physician
who takes calls? What is the call rotation schedule?
Are there hospital responsibilities? Do these involve nursery calls or inpatient
admissions? Does the group use area hospitalists?
What kind of nursing support does each physician have? Will each doctor have a
medical assistant, licensed practical nurse, or registered nurse, or do they share a
pool of nurses?
How does the office flow? Will each physician have a set of examination rooms or
does everyone use a common set of rooms? How are patients checked in and out?
What is a typical workday for each physician? How do they schedule well and
follow-up visits versus acute visits?
Who triages patient phone calls? What is expected of physicians with regard to
returning patient calls?
What laboratory or radiology support does the group have? If laboratory tests or
radiographs are done within the facility, how does the practice bill for these?
What kind of medical record system does the practice have (electronic versus
paper)? Are there plans to convert to an electronic medical record if paper is still
being used? How user-friendly is the system?
What is the physician payment rate? What is the basis of this scale (eg, salary,
seniority, productivity, patient load, call load, combination)?
What benefits are offered to physicians? Do these include health coverage,
malpractice liability, other insurance coverage, and retirement funds? If
transferring from another practice, will the group offer tail coverage?
What constitutes terms of separation, termination, and contractual breach? Are
there any restrictive covenants (eg, geographic practice restrictions)?
Does the practice have any relationship with area hospitals or universities?
Will you be responsible for any administrative or management responsibilities?
What will be your clinical duties (eg, calls, coverage)?
What will your office schedule be? Hospital rounding?
Will you need to attend deliveries? Cover the emergency department?
Will your schedule include weekends, evenings, or holiday coverage?
Is there a phone triage or answering service at night?
What office space is available? Staff-provider ratios?
What expenses are covered by the practice and what are your personal expenses
(eg, licenses, phones or pagers, subscriptions, automobile)?
What is the policy on vacations and sick leave?
What is the policy on personal days and pregnancy or paternity leave?
Is there a retirement plan? When can you participate?
- 31 -
•
•
•
•
•
•
What is the arrangement for continuing medical education (CME)? Time?
Expenses?
What is the philosophy of the practice?
What is the length of the contract? Are there renewal options?
What privileges or affiliations are required? Board certification? Hospital
privileges? Licenses? Will the practice pay for these?
How will patients be assigned to you? Do you share patients with other providers
or do you have your own patients?
Will the practice assist with moving expenses?
Additional Tips on Interviewing (http://practice.aap.org/content.aspx?aid=2237)
Behavior-based interviews have become popular recently, replacing loosely structured,
traditional interviews. This type of interview allows employers to ask candidates
questions about how they have handled previous situations in an effort to predict future
behavior. Behavioral interviewing is used to assist employers in finding a good match,
lower turnover rates, and increase job satisfaction and performance. Behavioral
interviewing focuses on asking about a situation in the past, the action taken to address the
situation, and the outcome.
Tips for Preparing for an Interview
• Be prepared. Questions will be based on your past experience. Therefore, have
specific examples and situations prepared to share. If this job will be based on
seeing patients, be prepared to answer questions such as, “Tell me about a time
when you encountered a difficult patient who was unhappy with his or her
service.”
• Beware of questions that ask for your mistakes or personal failings. Don’t answer
them in a way that will make the employer doubt your abilities. You can discuss
something that was difficult, but end on a positive note by relating how you
managed it.
• Allow time to think of an appropriate answer, even if it requires a few moments of
silence.
• Answer each question concisely, with one example. Let interviewers ask if they
want elaboration or another example.
• Rehearse answers to potential questions ahead of time.
Here are some examples of interview questions using the behavioral interviewing model.
•
Tell me about a project or an idea that was successful mostly because of your
efforts.
- 32 -
•
Think of a time when you had to make an important decision without enough
information. Explain your decision-making process.
• Tell me about a time when you encountered a difficult patient who was unhappy
with his or her service.
• Tell me about a time when something unexpected happened that changed the way
you planned your day.
• Tell me about a situation in which you had to overcome or manage an obstacle to
accomplish your objectives.
• Give me an example of a situation in which you found a new or an improved way
of doing something significant.
• Tell me about a time when you had to work with a colleague who has a different
work style or ethic. How did you handle a situation in which you disagreed with
that colleague?
After the interview, it is important to send a personal note of thanks for the time the
practice spent with you. Also, follow up with appropriate questions and requests for
further information in a timely manner. If the practice offers you a job, you are ready to
move to the next level—reviewing the contract.
Negotiating an Agreement
Once a position has been offered to you, it is time to negotiate an agreement. Following
are points to consider when negotiating an agreement:
1. Status
a. Will you be a salaried physician or full partner?
b. If you will not be a full partner, will the opportunity be offered to you at a
future date? If so, at what cost?
c. How will expenses, profits, and losses be divided or managed? Know what
your limits will be concerning openness relating to financial accounting of
the firm, even if you are not a partner or an owner.
2. Involvement
a. Will you have a voice in the administration and management of the
practice? If so, to what extent, and with what limitations (eg, staffing,
purchases, additional of new physicians, policy changes, site changes)?
3. Insurance
a. Does the practice cover your malpractice insurance? What type of policy?
Are health, life, and disability insurance included? Who will pay for these?
What is the amount?
b. Will tail insurance for malpractice be provided?
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4. Duties and assignments
a. What will your duties be?
b. What will your on-call, referral, coverage, and house call schedules be?
c. What will your office schedule be?
d. How are weekends, evenings, and holidays rotated?
e. How many hours per week and per year will you be required to work?
f. Is there additional compensation for hours worked beyond the required
amount?
g. Will you be required to take emergency department or hospital calls?
h. Will you be attending deliveries?
i. How will hospital rounds be rotated?
5. Office space
a. Will you have your own office space?
b. Will staff be shared within the offices or will specific staff be assigned to
you?
c. Will you be required to furnish your own office space?
6. Business-related expenses
a. What expenses will you be personally responsible for?
b. What expenses will you be expected to pay and in what proportion?
c. Who pays for licenses, dues, pagers, journal subscriptions, and automobile
expenses?
7. Office supplies, marketing, and advertising
a. Will the group pay for the expenses of adding you to the practice such as
announcement cards, business cards, door plaques, stationary, advertising,
and changing of indoor or outdoor signage?
8. Leaves, vacations, and paid time off
a. What are the vacation and sick leave plans?
b. Are personal days allowed? In what quantity? Are these paid?
c. Is there pregnancy leave or paternity leave, and is this time paid?
d. Will the number of days off or vacation weeks increase after the first year
of the contract?
9. Retirement/death planning
a. Is there a retirement plan and how does it function?
b. Is there a contingency plan in the event of your death or the death or
incapacity of a member of this group?
c. Is there a 401(k) plan, and how soon can you participate?
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10. Continuing education
a. Are time or funds allotted for CME?
b. Will travel expenses be paid?
c. Can time be taken off without penalty for CME or to be involved in
speaking?
d. Is involvement in professional organizations encouraged?
11. Practice philosophy
a. What are the philosophies of the existing group about medical care,
employee relations, expenses, and the like?
b. Are you in agreement with these philosophies?
12. Salary and compensation calculations and payment
a. How are salaries computed and when are they paid?
b. Is there a percentage of the fees that you will be paid over and above a
certain amount?
c. Are there bonuses given, and under what circumstances are they given?
d. Do you receive a share of income from income-producing assets (eg,
laboratory)? If compensation is based on productivity, what is the formula
used, and are there minimum (base) guarantees and maximum ceilings?
e. If you are required to submit reports to justify the payment due you, what
information must you submit? Who must have access to this information?
f. If a hospital is subsidizing your first year of practice or your practice setup,
is repayment expected, and if so, on what schedule and at what percent
interest?
13. Termination/withdrawal
a. What is the termination or withdrawal policy? How much notice must be
given once you decide to leave? Can you be fired or dismissed from the
group, and under what circumstances? What rights do you have to dispute
your termination or rectify the situation?
14. Restrictive covenants
a. What is the noncompetition policy of the group (restrictive covenant)
should you decided to leave? Would there be a certain radius from the
office within which you could not practice and for what period? What
would the penalties be for a breach of contract? Look for these 4 parts:
geographic area, time restriction, monetary penalty, and schedule of
penalty payments.
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15. Moonlighting and other outside activities
a. What is the policy addressing moonlighting and other outside activities?
b. Are you permitted to keep funds received from outside sources?
16. Length of contract and renewal clauses
a. What is the length of the contract?
b. What are the renewal stipulations?
17. Privileges, affiliations, and certifications
a. What privileges or affiliations will be required?
b. Is board certification required within a certain period after beginning
work?
c. Are there any obligations, implied or specified, to admit to certain
hospitals or use certain medical facilities?
d. Will you need to have licensure in more than one state?
18. Practice location
a. At what site will you be required to work (if there are satellite offices)?
b. Does the group do contract work at a well-child clinic, hospital nursery
coverage, or group home coverage?
19. Disability
a. What is the policy should you become ill or disabled and unable to practice
for a length of time?
20. Moving expenses
a. How much, if any, of your moving or relocation expenses will be paid, for
what specific expenses, and how will these expenses be paid (prepaid or by
a specific date)?
21. Accounts receivable and patients
a. Who retains ownership (property) or fees that are charged or collected by
the practice—you, the practice, or your employer?
b. Who will be doing the billing—an outside party, the practice, or perhaps
the hospital?
22. Patient base
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a. How will patients be assigned to you (ie, how will you get your fair share
of patients)? Are patients considered your patients or patients of the
practice?
b. Where will referrals come from?
Note: It is very important for a lawyer to review any contract before signing.
Resources
AAP News: “Pediatricians and the Law: Careful Review of Employment Contract Sets
Graduates Off on Right
Foot” (http://aapnews.aappublications.org/cgi/content/full/26/5/17)
Employment Contracts: A Practice Management FAQ
(http://practice.aap.org/content.aspx?aid=2107)
Sample Employment Contract (http://practice.aap.org/content.aspx?aid=2100)
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Launching Your Career in Pediatrics: Opening a New Practice
Opening a new practice involves many steps including business decisions, community
networking, credentialing, obtaining proper insurance, working with various consultants,
and deciding on an implementation of a computer system for practice management and
electronic records. This next section will provide tips on the following:
ƒ Making Business Decisions
ƒ Writing a Business Plan
ƒ Getting a Loan
ƒ Credentialing
ƒ Working With Consultants and Advisors
ƒ Obtaining Insurance Coverage
ƒ Setting Up a Computer System
ƒ Tips From the Experienced
ƒ Template/Timeline for Opening a New Office
Making Business Decisions
Health Insurance Plans/Payer Mix
Questions You Need to Ask and Answer
What payer mix might you expect in the community? If the area has a high percentage of
children on Medicaid, are the state’s rates reasonable and profitable? Similarly, are the
State Children’s Health Insurance Program (SCHIP) payments acceptable? What are the
major private insurers, and how well do they pay? Ask other pediatricians if they have had
particular difficulties dealing with certain programs or insurers. The American Academy
of Pediatrics (AAP) Section on Administration and Practice Management (SOAPM)
(http://www.aap.org/sections/soapm/soapm_home.cfm) and Practice Management Online
(http://practice.aap.org/) (PMO) can be superb sources for information and feedback. If
you are considering a cash-only or concierge practice, are there enough families to
support your venture? Are there many military families in the community, and will there
be any issues contracting with Tricare? (Tricare will usually not allow private
pediatricians to be primary care physicians if there is a military base nearby.) Contact
your state medical society for information on payer mix and the business climate within
your area.
Working With a Hospital System
If you will be contracting with a local hospital for financial assistance, how much control
will they have in the decision of where to locate your office? How much input do they
require on your practice style or hospital admissions? What kind of reputation does the
hospital have in the community—will patients avoid your practice if you are associated
with that hospital? Are there local pediatricians who do not have privileges at the
hospital—and if so, why? If the community is served by more than one hospital, do the
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other hospitals have expansion plans of their own? Do the hospitals have different payer
mixes and birth rates that might affect your growth and patient demographics? Will the
hospital’s emergency department be a source of desirable referrals? Do contractual or
distance issues preclude you from obtaining privileges at another hospital? Will you be
willing or required to take unassigned patient calls, inpatient coverage, or delivery or
newborn coverage?
Working Near State Borders
Communities near borders with other states deserve special consideration. You will need
to research Medicaid, SCHIP, and private insurers for the nearby states; in addition, some
state Medicaid programs may not cross state lines, and you may not be able to participate.
Will you need or want privileges in another state’s hospital? Will you need another state
license and state-controlled substance privileges?
Writing a Business Plan
Writing a business plan is a useful exercise for several reasons. For your practice to
succeed, you need to know where you’re going and how you’ll get there. Creating a
business plan forces you to set goals, determine the resources you will need to carry out
your goals, and foresee problems that might otherwise broadside you.
If your business plan is not being used to solicit financing, you can create an informal plan
that serves primarily as a planning tool and a device to keep you on track. An informal
plan can also be used to show to potential partners when you are ready to recruit.
There are several online resources and software that can help you formulate and write a
business plan. The key elements usually include
1. Introduction: provides an outline of the business plan and an executive summary,
which is a snapshot of the practice setup, philosophy, and viability.
2. Business description: provides your practice vision and includes who you are,
what you will offer, what market needs you will address, and why your business
idea is viable.
3. Market description: provides your interpretation and research of the existing trends
and conditions in the area in which you plan to practice; this will form the basis of
the succeeding marketing and financial plans you wish to propose.
4. Development and production: provides a description of the current state of your
practice and your plan for continuing or completing its development (eg, hiring
staff, buying equipment, leasing space).
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5. Sales and marketing: provides a road map of the strategies and resources you will
employ to generate practice growth.
6. Management: describes the team you will gather to manage the practice, including
specific strengths, qualifications, and responsibilities of each team member.
7. Financials: documents the viability of your business idea and its soundness as an
investment, using specific financial information and risk assessment.
Getting a Loan
How Much?
The biggest factor in determining when you will break even is the amount of money you
have to borrow to start up the practice. When determining a loan amount, it is important to
consider the cost of equipment, rent, malpractice, and other insurances (eg, worker's
compensation, liability). Also, during the first few months, you will be paid on what you
borrow or have set aside, as you will have little to no income for 30 to 90 days, depending
on how well you did your homework with the local managed care organizations (MCOs).
You will need to borrow or use capital for your income over the first 90 to 180 days; if
you borrow more, you will have to pay back more. In addition, check the sample supply
and equipment checklist (http://practice.aap.org/content.aspx?aID=2395) to get an idea of
how much money you will need to borrow to stock and furnish your practice. For
information on obtaining loans, check with various bank Web sites. For additional
information, visit the US Small Business Administration
(http://www.sba.gov/mostrequesteditems/CON_FAQ1.html).
Credentialing
The process of becoming credentialed to open a medical practice is time consuming and
laborious, and involves lag time in terms of completion. When beginning, be aware of
which processes take the longest and which are more rapid and straightforward, and
prioritize accordingly. Although universal applications exist for some issues, they are rare,
and there is little way around the busywork to be done. However, many applications ask
for the same information, and keeping essential data handy and organized can save time.
Be prepared to budget at least a few thousand dollars for the process. Some entities do not
charge a fee; others do. Additionally, unanticipated expenses may be incurred, such as
getting duplicates of appropriately sized diplomas. At times you may have to depend on
organizations and individuals to send the necessary information. Check with your state
medical society for state-specific information.
American Board of Pediatrics
The American Board of Pediatrics (ABP) offers certification in general pediatrics as well
as pediatric specialties. This information will be needed when going through the
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credentialing process. The ABP also maintains Maintenance of Certification. Visit
https://www.abp.org for more information.
Obtaining Hospital Privileges
Hospital credentialing committees meet periodically, usually monthly. It can take several
months to be approved, so start early. Fortunately, many hospitals accept that privileges
are applied for and do not require the process to be complete before processing
applications. Also, many hospitals will grant temporary privileges, if needed before the
credentialing process is complete.
Credentialing With Health Insurers
Most large insurers and all MCOs will require credentialing for participation as a provider
in their plans. It is necessary to start this credentialing process as soon as you have enough
of the required information to do so; many insurers take 3 to 6 months, and at times, a preapplication step is required as well. Some hospitals offer credentialing services for a fee,
which may save considerable time. These services often are able to negotiate contracts
with insurers. For information on universal credentialing, visit
http://practice.aap.org/content.aspx?aid=2196. Another solution is to access Council on
Affordable Quality Healthcare online at www.CAQH.org, which provides a single
application for many payers.
Occupational Safety and Health Administration
All practices must be in compliance with Occupational Safety and Health Administration
standards. These encompass a large number of requirements including employee dress,
waste disposal, and universal precautions. While meeting some of these requirements is
straightforward and intuitive, some may entail a process that takes several weeks.
Biohazard removal, for example, may require a scheduled educational session before the
office can be set up to handle biomedical waste. Thus, it is worthwhile to address this at
least several weeks before anticipated opening. For additional information, visit
www.osha.gov.
Employer Identification Number
(http://www.irs.gov/businesses/small/article/0,,id=98350,00.html)
All businesses require an employer identification number, also known as a federal tax
identification number. Your practice attorney or accountant can obtain one for you. It is
also possible to obtain one online. Plan on a few weeks for this process.
State Tax Identification Number
Check with your state to see if a separate state tax identification number is required. A
link to state agencies, as well as information on obtaining a federal tax identification
number, can be found at www.irs.gov.
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State Medical License
Whether you are starting your own practice or entering private practice as a physician
employee, it is extremely important to start your license application early. States differ in
their approach, but it is not unheard of for a license to take a year or more to obtain. It is
not unreasonable to begin the license application process before deciding on an ultimate
location.
Begin to gather information from all colleges and universities, as well as your medical
school, residency, and places of employment on the forwarding of all of your records.
Most will want copies of diplomas, residency certificates, and board certification. Be
prepared to explain any breaks in the educational process and don’t forget courses taken
elsewhere. When in doubt, it is best to be thorough, honest, and complete with any
explanations.
Some states have extra requirements, such as a special examination or letters of
recommendation. Read the application early so none of these requirements is missed;
notification from state boards on missing material is often slow and can waste valuable
time. Most states have an online information system that informs you of the process,
needed materials, and contact information specific to that state.
Drug Enforcement Administration
An application should be filed with the Drug Enforcement Administration (DEA) for a
DEA number, which is required to prescribe any medication. This is usually a fairly rapid
process. Individuals who already have a DEA number should keep the agency informed of
any address changes. For more information, visit www.deadiversion.usdoj.gov.
State Narcotics License
Check with the state medical board to see if a separate state-controlled substance license
or permit is required. It is usually less involved to obtain this than the medical license
itself.
National Physician Identifier
In 2008, a requirement was initiated for all physicians to have a unique National Physician
Identifier (NPI) number. Among other uses, it is the number recognized by most insurance
payers and is necessary for payment for services. This is usually a fairly straightforward
process. Apply at www.cms.hhs.gov/NationalProvidentstand.
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Business License
In addition to federal and state licensing, be sure to check with your city and county about
the possible need for obtaining a business license. If needed, this is usually an
inexpensive, routine process and in most cases can be done after some of the more
involved tasks are completed. Be aware of specific requirements—most will want a copy
of your medical license, and many will want information about your location, including
access and trash removal.
Laboratory License
Decide if you would like to have an in-house laboratory and if so, what tests you will be
performing. Any testing at all—even a rapid test for blood in the stool—requires an
application with Clinical Laboratory Improvement Amendments (CLIA)
(http://www.cms.hhs.gov/CLIA/). This is a process that may take several months and is
worth starting earlier rather than later. Some states charge additional fees and have an
additional application process for in-house laboratories. A CLIA license is not required if
all testing is to be sent out. Visit www.cms.hhs.gov/clia for a listing of waived tests,
guidelines for laboratories, CLIA brochures, information on applying for a CLIA
certificate, categorization of tests, and more
Working with Consultants and Advisors
Why Hire Consultants?
As one can see from this discussion, there are myriad processes the new practice must set
up across a broad range of disciplines, including medical, legal, technologic, insurance,
business, and management. While many physicians have tried to save money by doing all
of this themselves, it may not be the best way to proceed. While doing it alone may be
possible depending on the skill set of the physician(s) in the new practice, it is absolutely
critical to establish all of these systems correctly the first time out. Given the increasing
complexity of these matters and the total lack of physician training and experience with
any of them, failure to do so can be very, very expensive to you and your practice in the
long run.
Herein lies the dilemma of consultants and advisors. Doctors are notoriously averse to
paying others to do tasks that they somehow feel they ought to be able to do for
themselves. After all, how hard could it be for the bright individuals who go into
medicine? Unfortunately, it is considerably harder than it looks. Choosing the proper help
is vital to a new practice. Such help includes a health care accountant (not only
bookkeeper), a health care lawyer (not a general practitioner), and a practice management
consultant. All of these consultants can entail significant expense in the short run. Doctors
are again notorious for viewing such expenses as overpriced and unnecessary. However,
when used properly, they will pay for themselves many times over.
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Legal Counsel
The most expensive will generally be legal counsel. Some practices choose to have
everything set up by their legal advisor. While this may be possible with an experienced
health care attorney, their time is the most expensive of all consultants. They may be good
at what is legal but may not appreciate the day-to-day dynamics of medical practice
management and administration. A good legal mind to advise you on partnership
agreements, corporate structure, leases, contract negotiations, and contracts is absolutely
vital. Yet many of these tasks can be accomplished just as effectively with lower cost
consultants, with only a final legal review at the end.
Health Care Accountant
A good health care accountant is someone who does more than keep your books. This
accountant will help you with budgeting, help you with contacts at local financial
institutions, supply you with advice in financing business practices, and provide you with
frequent reports based on benchmarking your performance against other practices in the
field using national norms and local experience.
Practice Management Consultant
Lastly, hiring an experienced practice management consultant is a good idea. It is
important to begin working with a consultant during your third year of residency. Lay and
physician consultants are available. Consultants can provide the overview you need to
coordinate and get the most out of your other consultants. They can review your practice’s
processes from a functional end-user point of view and can assist you in assessing
whether your plan will work in a real-world setting. Consultants are also available to
assist you with coding and physician profit distribution, staffing, salaries, and marketing.
Often, they can assist you with drafting documents for later legal review. Consultants are
available to help you compare electronic health records (EHRs) and practice management
software (PMS), negotiate with payers, and construct an office policy manual. Finally,
consultants can even help run your practice until you are able to hire your own
management team.
Please realize that none of this advice comes cheap, but it is a worthy long-term
investment to make sure your new practice is primed for success.
Obtaining Insurance Coverage
When opening a practice, it is vital that you obtain insurance. If an employee slips on a
wet floor and breaks a leg, you need insurance. If a burglar steals your computer
equipment, you need insurance. If a hurricane destroys everything in your office and
you’re out of practice for the next 6 weeks, you need insurance. But there are many kinds,
and no one-size-fits-all exists.
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The first step is to find an insurance agent. Ask around, get recommendations, and make
an appointment. Keep in mind that some agents work for specific companies, whereas
others are independent and deal with a few different companies. Regardless, a good agent
will be able to compare quotes, process paperwork, help you get the best coverage for the
best cost, and generally make your life much easier. You will need the following
coverage:
Malpractice Insurance
Professional liability insurance is one of the most important and expensive features of
practice today. Pediatricians need to make sure that they are adequately and continuously
insured throughout their careers, but making informed decisions on professional liability
insurance is not effortless. It requires time, attention, and a willingness to learn about
some rather dry information. Even so, most pediatricians agree that protecting their
careers from ruin is worth the effort.
It’s best to shop around and ask peers about malpractice insurance. This is an activity to
accomplish early because many other entities will want proof of coverage. Be ready to
forward information on previous insurers, if any, as well as any explanations of claims.
Your state medical society can be an excellent source of information. The AAP also has a
member benefit affinity program, the Members Liability Insurance Program. The
Members Liability Insurance Program includes a 2% premium credit exclusively for AAP
members; competitive rates; new-to-practice credits; part-time practice credits (includes
locum tenens arrangements, retirees, and special circumstances); claim-free credits; group
practice discount; consent-to-settle; free tail coverage; and claims-made and occurrence
coverage options. Visit http://practice.aap.org/content.aspx?aid=2836&nodeID=1121 for
more information.
The AAP cannot recommend a particular insurance company or kind of policy simply
because there is no "one size fits all" for pediatricians. Following are tips to give you the
information you need to make an informed decision. The most thorough source of this
information can be found in the AAP manual, Medical Liability for Pediatricians, 6th
edition. It is available from the AAP bookstore.
Ways to find a professional liability insurance company:
1. Ask colleagues.
2. Call your state or county medical society.
3. Contact the Physician Insurers Association of America (PIAA) at 301/947-9000 or
www.thepiaa.org.
- 45 -
4. Visit the National Association of Insurance Commissioners website and click on
your state to be taken to the website of your state insurance department for
information on company and agent licensing requirements, as well as available
insurance products. http://www.naic.org/state_web_map.htm
5. Contact a local independent insurance agent and ask to speak to someone familiar
with medical malpractice insurance.
6. Check a company's rating with A.M. Best at www.ambest.com and record with the
Better Business Bureau at www.bbb.com before you make any final decisions.
Warning! Do not just look for the company that offers the lowest premiums; look for one
that is financially sound and able to pay claims. Before purchasing any professional
liability policy, check with the hospital(s) where you have privileges to make sure that a
policy from that particular carrier is acceptable as proof of insurance. Other important
factors include the insurer's financial stability, protections against insolvency,
performance record, and claims-handling procedures.
Worker’s Compensation
This is mandatory in nearly all states and is needed to cover your employees in the event
they get injured on the job. This coverage can be obtained, in most states, from private
insurers. However, some state agencies or state funds offer this as well. As you set up a
practice, a certified public accountant can help you through the maze of local, state, and
federal tax and employment regulations and be an invaluable resource, especially if you
consult with one early in the process.
Commercial Property
This is your standard general business insurance and covers property loss and business
liability, as well as other business-related risks (eg, loss of income, employee theft,
employee dishonesty, employees’ personal property, electronic data). Take the time to
investigate the coverage limits and exclusions. Most businesses don’t fail directly from a
material loss, but rather from the subsequent loss of operations and inability to recover.
Make sure your policy covers the total value of your business property and will provide
enough money to get you back on your feet. There may be specially delineated coverage
for items such as computer equipment, papers and records, exterior signs, glass (which
some landlords specifically require), and building damage; understand the limits and
ensure they are adequate to cover all potential losses. Unique to pediatric offices, vaccines
will need special additional coverage in case of power failures; some policies may contain
a specific vaccine rider, while others may include these under “spoilage.” Again, make
sure the policy limit is high enough to cover a total loss of inventory. Carefully review
what situations might be excluded, and if you are at risk for these instances. Common
examples are earthquake and flooding. If there is any confusion over the policy, talk to
- 46 -
your agent to help clarify. You don’t want to learn of any gaps in your coverage after a
disaster strikes.
Liability
Most general business insurance policies also offer coverage for slips and falls, defense
costs, and judgments against the business owner and employees. Employment practices
liability insurance provides limited coverage for claims resulting from employmentrelated wrongful termination, discrimination, sexual harassment, and other workplace
torts (eg, retaliation, defamation, emotional distress, invasion of privacy, negligent
evaluation, wrongful discipline, wrongful failure to employ or promote, wrongful
demotion). Auto liability protects against vicarious liability in case an employee gets into
an accident while running an errand at your request (eg, a trip to the bank or post office).
Specific Hazard
If you are in a flood or earthquake zone, you can purchase coverage for these hazards
separately within the context of your general business insurance. Flood coverage is
available from the federal government. Earthquake insurance is usually either an
additional endorsement or a separate policy from a private insurer. Keep in mind that
these special policies usually cover physical losses only, not loss of business income or
related recovery expenses. Immunizations are an expensive “stock item” for practices,
unless you are in an all–Vaccines for Children state (universal purchase state), and can be
a major source of loss in the case of power failure or theft. Be sure to have coverage
clearly spelled out. The typical practice may have an inventory of $150,000 per physician
or more.
Umbrella Coverage
An umbrella policy provides additional coverage above the usual commercial policy
limits, in case of liability. As a doctor, you and your business have the potential to be an
attractive target in a lawsuit, and an umbrella policy can offset that risk. Consider how
much you will need to protect the value and earning potential of your practice. A standard
policy might supply coverage up to $1 million. Expect to pay a premium of a few hundred
dollars annually if you elect this coverage. Be absolutely sure the insurance contract spells
out all coverage as well as noncoverage, and what your responsibilities are as the insured.
Disability Insurance
A disability insurance policy covers you in the event that you cannot perform the work
you want to perform. Own-occupation coverage may cost significantly more but only
requires that you can no longer function as a pediatrician (as opposed to being completely
incapacitated from any work). Most plans offer different options for waiting and benefit
periods. For example, a plan may not pay until after 30, 60, or 90 days of disability.
- 47 -
Benefit periods may last for 1 year, 3 years, 5 years, or up to age 65 years. Make sure your
disability plan offers the ability to increase coverage limits each year, to grow with your
practice’s success and your ever-increasing income. Also, rates for this coverage are
generally lower when you are healthier and younger.
Life Insurance
Life insurance should be purchased to cover any liabilities or debts of the practice, or to
replace your income for your family. If married, consider a policy for your spouse to
offset the loss of the numerous ways he or she helps you (eg, providing a second income,
caring for children, helping manage the practice).
Health Insurance
Don’t forget this for you and your family, and consider if and how to offer coverage to
employees. The local chamber of commerce can be a valuable source of information in
this regard.
The AAP offers a discounted rate for group insurance plans covering term life, disability
income, office overhead expense, dental, and long-term care. Visit
www.aap.org/moc/memberservices/affinity.cfm or www.aapinsurance.com/index.html to
learn more.
Record Your Property
Once you have obtained insurance, keep a copy of the policy (or policies) safe and away
from the office. Take an inventory of the office, whether written, photographed, or
videotaped. Keep purchase receipts to assist in determining the amounts of any potential
loss. It is usually a good policy to have a second copy of all the inventory, photographs, or
videotapes in the hands, or files, of your insurance agent. If so, make sure you update
them regularly as you acquire equipment or materials.
Using Your Policy
In the unfortunate event that you have to use your policy, consider the cost of your
deductible(s) against the amount of loss. Coverage and exclusions that seem
straightforward may be subject to debate after the fact. As an example, after a hurricane,
insurers may debate “wind versus water,” where water damage related to wind—such as a
breached roof and subsequent rain damage—is covered, whereas water damage related to
storm surge is excluded. Conflicts can arise in determining what portion of equipment or
structures were damaged from which cause. The delineation may be even more important
because straightforward property loss usually has a flat dollar-amount deductible, whereas
wind or earthquake damage usually has a deductible based on a percentage of the value of
the property. Loss of business income may be denied because of flood damage, but could
instead be claimed from loss of power and infrastructure, or civil disturbance. If you are
- 48 -
not satisfied with your insurer’s settlement offer, consider appealing to your state
insurance department. It is always critical to involve your agent’s help from the outset.
Check with your state medical society for additional information about insurance policies.
Special thanks to Jeff Bogan of Jeff Bogan Insurance Agency, Naples, FL, for assistance
with this article.
Setting Up a Computer System
As you set up your practice, an integral part of your business operations may involve
purchasing and implementing a computer system. Even if you are not very comfortable
with computer systems, many are easy enough to use with adequate training. Consider
that more and more practices are adopting EHRs and with more regulations such as
Health Insurance Portability and Accountability Act (HIPAA) and electronic prescribing,
a computer system may be inevitable in the future of health care.
There are several levels of how a computer system can be integrated into your practice.
The cost is determined by what level of involvement you desire. If you are just setting up
your practice, it may be easier to start with an EHR rather than trying to convert your
practice at a later time. However, it is significantly more expensive and time consuming to
implement an EHR system as you start your practice. Some hospital systems are helping
practices by offsetting expenses with a system that is compatible with the hospital’s
system. This would be worth investigating if it is true in your area.
Steps for Choosing a Computer System
1. Determine to what extent you would like to use a computer in your practice.
2. Perform a financial analysis to see what is affordable and what your return on
investment (ROI) would be. Investigate options such as hospital system financial
support. Contact banks or lenders in your area if financing will be needed.
3. Research vendors and systems.
4. Meet with several vendors for product demonstrations. If possible, visit pediatric
practices that are currently using the system.
5. Contact SOAPM (http://www.aap.org/sections/soapm/soapm_home.cfm) and the
AAP Council on Clinical Information Technology (COCIT)
(http://www.aap.org/visit/medinfo.htm), and review the publications and
advisories on PMO (http://practice.aap.org/) and the COCIT review of available
systems (additional information follows).
6. As you refine your search, make sure you understand the initial costs of
acquisition and implementation, as well as any ongoing maintenance costs.
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7. Once a decision is made, define an implementation and a transition strategy.
Information is available through SOAPM, COCIT, and PMO to help you plan
these processes (additional information follows).
8. Schedule installation of required wiring, networks, telephony, hardware, and
software. This is especially important if you are constructing a new office and can
install the necessary wiring during the building process.
9. Plan and carry out implementation of products with all necessary training and
customization.
How Will the System Be Used?
When looking to purchase a computer system for your practice, the first question that you
must answer is, “For what will I be using the system?” The answer will determine the type
of system you need, the investment that will be required, and the timeline for installation.
The simplest use of computers in an office is like what you would do at home—word
processing, spreadsheets, simple accounting, and possibly Internet access.
The next step would be to use a computer system to run PMS. This software typically
would allow you to use a computer for appointment scheduling, billing, and storing
patient demographics.
The final step for using a computer in a pediatric office is for EHRs. This is essentially
patient charting completely on the computer.
The cost of and time for installation increases as you proceed from stand-alone computer
to full-scale PMS and EHR. Sample costs are listed in the Table.
Electronic Cost Comparison
Single-User
Computer
$500–$1,000
Software cost
Hardware cost
Implementation cost
Time frame
PMS
PMS and EHR
$1,000–
$1,000–
$5,000/FTE
$50,000/FTE
$2,000 desktop
$1,000–$2,500 per
desktop/laptop/tablet
$2,000–$4,000 per server
Additional for printers, scanners,
modems, networking equipment
$75–$150 per hour of training/implementation (usually some
hours included in purchase price)
Average 35 h for implementation for EHR
2 wk–1 mo
3 mo
3–6 mo
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Simple
Moderate
Complex
Implementation
difficulty
$500–$1,000/FTE $1,000–
Maintenance/support None–$100
$4,000/FTE
(yearly)
PMS, practice management software; EHR, electronic health record; FTE, full-time
equivalent.
Financial Analysis
Dependent on which system you buy, there is usually a significant up-front expense.
However, it is extremely important to investigate what the recurrent expenses include.
Hardware and software maintenance can be very costly and are a necessary burden to
keep your business running. Additionally, hidden expenses for upgrades, support, and
additional training should be outlined before you sign any contracts.
Benefits of an Electronic Health Record
Why go electronic if it costs so much? There are many benefits to being on a computer
system. You gain accuracy, efficiency of charge capture and billing, legibility, and
accessibility. Improvement of coding is more easily achievable with electronic capture.
Increased legibility and better documentation result in improved patient care and
decreased medical liability. Depending on your practice, you may see improved work
flow. Locating and pulling charts are no longer an issue with EHRs. This results in more
rapid processing of refills and forms. There are no longer concerns about lost charts. If
you do internal billing, you can take advantage of electronic filing and posting, which can
significantly reduce your accounts receivable. These are some of the most tangible
benefits to being electronic. While not helpful for most pediatricians, there are also
significant savings of transcription costs. With these benefits, it generally takes 2 to 3
years to get an ROI. The other important point is that it is far easier and less costly to start
a practice with information technology (IT) in place than to implement at a later date.
The AAP SOAPM e-mail list provides pros and cons from various members. Visit
http://practice.aap.org/content.aspx?aID=1971 to view comments. Also see the article
titled “Electronic Health Records: Should I Convert My Office to Paperless?”
(http://practice.aap.org/content.aspx?aid=1969).
There are many resources to help you to calculate your ROI available from Physicians
Practice (http://www.physicianspractice.com/) and the Medical Group Management
Association (http://www.mgma.com/). Because you are just starting in practice, you may
need to talk to other practitioners to get a better feel for work flow, time costs, and
expenses.
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Evaluating Software
Once you’ve determined the computer needs of your practice, the next step is to evaluate
vendors of PMS and EHR software. One of the best ways to evaluate software is to ask
around in your local community or the AAP to see what other pediatric practices are
using. The Certification Commission for Healthcare Information Technology
(http://www.cchit.org/) is an organization that certifies health care software that meets
certain standards. The AAP COCIT Web site (www.aapcocit.org) also has many valuable
resources.
The AAP offers answers to some frequently asked questions as well as reviews from
fellow AAP members.
•
•
•
“Electronic Medical Record FAQ” (www.aapcocit.org/EHRfaqs.pdf)
EHR reviews (www.aapcocit.org/EHR/readreviews.php)
“Implementing an Electronic Health Record” (www.practice.aap.org/ehr.aspx)
There are some features of the PMS and EHR that you should investigate that are unique
to pediatrics.
Practice Management Software
• Is it capable of family billing using head of household?
• How are siblings linked in the system? If you update one child’s address, will all
the siblings be updated?
• Can you put alerts on the account for special situations (eg, child with special
needs requires extra time for appointments)?
• Can you design appointment templates that can specify different types of
appointments (eg, well-child appointments vs sick-child appointments)?
• Can you easily move appointments from one physician’s schedule to another?
• Is it capable of running queries so that you can do studies or single out patients
within certain demographics (eg, to determine your payer mix or how you are
being paid for certain procedure codes)?
Electronic Health Records
• Does it have growth charts? Does it have specialized growth charts (eg, preemie
charts, Down syndrome charts)?
• Can you create forms (eg, school)?
• How well does it handle immunization records? Can you add new ones (as
vaccines are developed)? How does it handle reminders if a child is due for
vaccines? Can it communicate with statewide immunization registries?
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•
•
•
•
•
•
•
•
•
•
•
•
How do you enter notes? Via templates? Can you type free text also? Can you
customize the templates?
How does it handle documenting a sick visit in addition to a well check?
Does it have coding assistance?
Does it offer electronic prescribing? Does it have a weight-based prescribing
system for calculating pediatric dosing?
Does it have laboratory report integration and ordering? Can you set pediatric
norms for laboratories? Can you interface with local hospital laboratories and
major laboratories? For how much?
Can you use images or photos (eg, drawing of lesions)?
Can you capture signatures (eg, for waivers)?
Is there an online interface available where parents can request refills, schedule
appointments, or preregister online?
Are there pediatric-specific educational handouts?
Can you integrate a spirometer, electrocardiogram machine, or vitals machine?
Is it capable of sending charges electronically?
Will it support patient self–check-in?
General
• What is your support turnaround (including after hours and weekends)?
• How frequent do you have upgrades? Who does those upgrades?
• Are upgrades included in the maintenance cost?
• Who performs support for your system? Is there someone local who will come
onsite? Or is it done remotely?
• Is there a resource for users of the same specialty to network and share ideas for
using the system?
• How long has the company been in business? What is the company’s business
plan? Does it give you a feeling of confidence in that it will be there for the
duration of your practice?
• How do you store backups for patient data? Is it done locally? Is there off-site
storage?
• What are the security features? HIPAA compliance features?
Once you have chosen several vendors, schedule demonstrations. Make sure that the
vendors demonstrate a pediatric scenario for you. For such an expensive capital purchase,
it is wise to meet with at least 3 different vendors. When you have decided which ones
you like the most, visit practices that are using these systems in real life. These practices
can give you a much better feel for how the system works in everyday pediatric practice.
It is also a good idea to get information about obstacles they encountered, how they would
do things differently if they could, and whether they would purchase the system again
- 53 -
knowing what they do now. The implementation of an EHR in an existing practice can be
a very painful process. Depending on what stage they are in the implementation process,
you could take their advice accordingly. In general, once you are 2 to 3 years into a
system, you will find that the EHR was a good choice and that you wouldn’t go back.
However, those first years can be very strenuous as you make the transition!
Technical Support
There are many ways to implement a computer system. The larger your practice and the
more features you make electronic, the more likely you are to need technical support. This
may take the form of a staff member who is technically savvy and a local engineer from
your vendor. It may be a local computer support business or your local “geek squad.” If
your system is large enough, you may need to hire an IT specialist. Regardless of the
system, you are likely to encounter needs for upgrades and maintenance (eg, backups), as
well as troubleshooting problems. The problems will range from simple (eg, the mouse
doesn’t work) to complex (the network is down for your satellite office). In general, it is
wise to have someone you can call for help when these issues arise.
Data Storage, Backups, Power Outages, and Disaster Plan
Lastly, it is important to consider how you will protect your data. There are frequently
news reports of patient data being stolen by employees. Once you are electronic this issue
should be examined carefully. It is much more difficult to steal 1,000 paper charts than to
steal a computer containing that same information. Investigate your vendor’s capacity for
security and virus protection. EHRs must be compliant with specific HIPAA rules.
Backup for your data can be done many ways depending on your system. Investigate
options with your vendor. If your system is on site, certain precautions should be taken to
have some form of off-site storage for your data.
You should also have a disaster plan in place. This will be important in case of extreme
disaster to your practice (eg, fire, water damage), but also in other cases when something
as simple as the power goes out to your building. For power outage or when the system is
down for some reason, a common plan is to go onto paper. The data is scanned into the
computer when power is restored. Design a plan that works for you and your practice.
For information on implementing an EHR, visit http://practice.aap.org/ehr.aspx.
For additional information on PMO about EHRs, visit here
(http://practice.aap.org/topicBrowse.aspx?nodeID=3000.3038.3039). This section of PMO
also provides articles provided by those practices who switched to EHRs.
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Tips From the Experienced
Before opening your doors, here are some important points to keep in mind.
1. You must be credentialed with any and all MCOs and Medicaid before you
open your doors. You are not credentialed until you hold a piece of paper in
your hand saying you are, regardless of who tells you what. If you are not
credentialed, you may not be paid at all, or your payments will be held until
you are. Delays in payments over the first 6 months of opening a practice can
be lethal.
2. Establish what your hours are going to be, and be there. If you have office
hours on evenings or weekends when you are starting up to increase your
revenue, you will also be creating an expectation among all your patients that
you will always be open during those times. When you are first open, you need
to be available. SOAPM and PMO have excellent advisories in this area.
3. Keep in mind that hospital work provides income without adding to practice
overhead, even at Medicaid rates.
4. Be sure that your payer mix is incorporated into your business plan. Also,
decide ahead of time what percentage of Medicaid patients you are willing to
accept.
5. It is important to create a financial policy and share it with your patients when
they join the practice. Visit (http://practice.aap.org/content.aspx?aID=2184)
for a sample financial policy. Also, create a patient payment agreement and
enforce it from day one. Establish your ground rules early and enforce them
consistently.
Recruiting Patients for New Practices
Effective and efficient marketing is a very important part of running a successful practice.
Marketing is not just advertising. It is making your practice attractive to patients, and
letting them know about your practice and its uniqueness.
How Can You Distinguish Your Practice From the Current Marketplace?
The most common answer might be availability. If many of the other local practices limit
their hours to daytime appointments only, you may consider also having evening or
weekend hours. Other tips and creative ideas on setting hours can be found at
http://practice.aap.org/content.aspx?aid=2800.
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•
If you are opening your practice as a solo practitioner, you will likely
invest a lot of time in the office to establish a patient base. As you recruit more
patients and your practice schedule warrants the need for an additional
practitioner, consider hiring another pediatrician or physician extender.
•
If you are located near a retail-based clinic, availability will be critically
important. Visit http://practice.aap.org/content.aspx?aid=1516 for tips on how to
compete with retail-based clinics.
•
If it is important for you to be centrally located, consider leasing a retail
storefront space where the population shops. This will make your practice easily
accessible and highly visible, with an abundance of parking. However, if you
choose this type of location, be sure to have access to nearby laboratories and
imaging facilities.
How Will You Manage Inpatient Care?
Many pediatricians new to practice will have time to see newborns and hospitalized
patients during daily rounds. As your practice grows, if time does not permit, consider the
option to have all inpatients seen by hospitalists, if that option is available. Some
pediatricians fear that because newborns are the lifeblood of general pediatrics, allowing
them to be seen by hospitalists may mean that they will not become patients in your
practice. If this is a concern to you, consider allowing hospitalists to see newborns while
you provide a home visit for the first newborn visit. Parents will love this, especially in
the middle of winter! An added bonus for the quality of practice is to see the environment
in which newborns live. It is very important, however, to at least make a personal phone
call to the home of new patients (especially newborns) just to “see how things are going.”
If you are joining an existing practice, learn about what the existing practice offers and
what patients want that is not offered. You might learn that there is a need for increasing
evening or weekend hours, or for offering walk-in appointments, group appointments,
breastfeeding support, or educational classes. Once you have identified the needs and
obtained approval from your associates, implement and promote new services. Other tips
and creative ideas on setting hours can be found at
http://practice.aap.org/content.aspx?aid=2800.
A sample marketing plan is available at
http://practice.aap.org/content.aspx?aid=2853&nodeID=1081.
Get the Word Out!
• Create a Web site (visit
http://practice.aap.org/content.aspx?aid=2335&nodeID=1081 for tips).
• Use social networking sites.
• Develop a logo.
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• Create a brochure discussing the business and availability of the practice.
• Provide brochures and business cards to area pharmacies and child care centers
and schools.
• Attend community events—set up a table to inform the community about your
practice or volunteer to speak at local events, as appropriate.
• Advertise through printing on prescription bags used at local pharmacies.
• Other media to consider using
o Brochures
o Newspaper ads
o TV ads
o Personal appearances
Visit http://practice.aap.org/content.aspx?aid=2631&nodeID=1081 for additional
marketing ideas.
In summary, the most important step in marketing a new practice is to develop a clear idea
of what you are offering patients. Only then can a new practice owner think about ways to
spread the word.
Template/Timeline for Opening a New Office
Task
Details/Notes
Obtain/submit the following:
Open a bank account.
State medical license
DEA certificate
Tax ID number
Business license
Malpractice insurance
Medicare application
UPIN/NPI number
Health plan credentialing
Hospital credentialing
(allow 3 months)
Insurance credentialing
(allow 3 months)
State payroll tax number
Unemployment payroll tax
number
- 57 -
Completed
Determine a business plan.
Create a budget.
Meet with consultants (eg,
legal, practice
management).
Locate space to lease or
purchase.
Choose a corporate
structure (eg, partnerships,
corporations, limited
liability corporation).
If leasing, review, negotiate,
and sign contract.
If building or modifying
existing building, choose
architectural firm.
Negotiate and sign
architectural agreement.
Select carpeting, wall
coverings, paint, tiles,
cabinets, furniture.
Choose a contractor.
Complete construction
contract.
Consider parking, access,
build-out costs, terms, and
rent rates.
Consider legal review.
If leasing, contact landlord.
Consider legal review.
Consult with landlord first.
Consider legal review. Also
determine who will be
responsible for fire
extinguishers during
construction.
Plan for opening day
Usual construction time is
considering, staff hires,
12 weeks for 3,000 square
holidays.
feet.
Create staff job descriptions Determine how you will
and pay scales. Begin hiring screen new hires.
process.
Create staff training plan.
Determine how medical
record transfers will occur
(eg, new registration,
consents, privacy policy,
medical records).
- 58 -
DEA, Drug Enforcement Administration; ID, identification; UPIN, unique physician
identifier number; NPI, National Physician Identifier.
- 59 -
12 to 16 Weeks Prior to Opening Day
Task
Details/Notes
Arrange for Web site.
Design, address, content
Recruit and hire practice
Be aware of appropriate
manager.
interviewing questions.
Train practice manager.
Apply for business credit
cards.
Assess telephone and
Arrange for installation 2
computer needs. Plan 2
weeks before opening day.
lines and a private line for
each of the first 3 MDs.
Select vendors and obtain
quotes.
Confirm phone and fax
numbers for advertising.
Set up cost center.
Set up accounts payable and
payroll.
Create a central purchasing Store in a place for staff to
log.
find.
Order exterior signage.
May need landlord
approval.
Order examination room
furniture (eg, examination
tables, cabinets, stools;
consider one table capable
of pelvic examinations).
Order lobby and modular
furniture for office space,
break rooms, nursing areas.
Begin recruitment process;
set start date for reception
staff 2 to 3 weeks prior.
Nursing staff can start 1 to 2
weeks before opening day.
Train employees (eg,
scheduling, charge entry).
Review cabling plan with
- 60 -
Completed
contractor and vendor.
Include examination rooms,
MD offices, practice
manager space, reception
areas, nursing stations,
laboratory, printer locations,
and copier locations.
10 to 12 Weeks Prior to Opening Day
Task
Details/Notes
Completed
Order furniture for MD
offices. Set delivery date.
Determine the laboratory
If moderate complexity,
procedures that will be
request CLIA number.
performed in the office.
Order necessary forms to
support laboratory
functions.
Determine fax and copier
needs. Obtain quotes and
place orders.
Develop appointment
templates.
If using paper charts, order
materials.
Set up accounts with the following:
Laboratories—order forms
and drawing supplies
Medical equipment and
office suppliers
Pharmaceutical companies
Set up Internet access
accounts for online
ordering.
VFC program
Place VFC order as
appropriate.
CLIA, Clinical Laboratory Improvement Amendments; VFC, Vaccines for Children.
- 61 -
8 to 10 Weeks Prior to Opening Day
Task
Details/Notes
Completed
Order interior signage.
Restroom doors,
examination room numbers,
physician names, wording
about co-payments expected
at time of service.
Plan advertising/marketing
strategy.
Post MD pictures in
advertising and on Web
site.
Contact local yellow pages.
Order letterhead, envelopes,
script pads, tablet paper,
and business cards.
6 to 8 Weeks Prior to Opening Day
Task
Details/Notes
Confirm malpractice
coverage (nose or tail
coverage?).
Order medical record
shelving.
Determine equipment needs
(eg, audiology, vision
screening, otoscope,
ophthalmoscope heads,
transformers, blood
pressure aneroid (wall or
movable), nebulizer, pulse
oximeter, thermometers,
adult and infant scales).
Order the following:
Medical equipment
Credit card machine
Toys, books, magazines for
lobby
Appliances for office
including laboratory and
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Completed
immunization refrigerator
with separate freezer door,
separate staff food
refrigerator, microwave,
and coffee pot.
4 to 6 Weeks Prior to Opening Day
Task
Details/Notes
Order check endorsement
with stamp and account
number.
Arrange for cleaning
service.
Arrange for medical waste
pickup.
Arrange for garbage
collection, if not provided
by the city or building.
Determine list of medical
supplies needed and price
shop.
Set up Web site.
Include MD pictures,
biographies, and driving
directions.
Make sure that the
wall/door charts are part of
the construction plan.
Determine MD-RN
communication system (eg,
colored clips, flags). Order
materials as needed.
Determine which office
forms and educational
materials will be used.
Order, if necessary.
Order examination and
restroom soap, paper towel
dispensers, sharp
containers, and gloves.
- 63 -
Completed
2 to 4 Weeks Prior to Opening Day
Task
Details/Notes
Arrange for moving
company, if needed.
Mount room flags, chart
pockets, brochure holders,
calendars, bulletin boards,
diplomas.
Determine artwork
selection.
Prepare “Patients Rights
and Responsibilities”
posting at the front desk.
Obtain governmentrequired employee
notification posters.
Plan OSHA-required
training and documentation.
Train nurses on stocking
examination rooms.
Contract with answering
service.
Obtain computer access for
all employees, including
network drives, e-mail, and
Internet.
Be sure HMOs have
provided forms, network
books, and referral access
numbers to the new
physicians.
Have phone system
installed after the new
phone lines are in. Train
staff on use and
maintenance.
Order the following:
Medical supplies
Office supplies
Remembers shredder, coat
hanger for lobby, 3-ply
- 64 -
Completed
receipt paper, wastebaskets,
and garbage bags.
Patient registration forms,
release of information, and
other forms to be used
OSHA, Occupational Safety and Health Administration; HMO, health maintenance organization.
Within Last 2 Weeks Prior to Opening Day
Task
Details/Notes
Moderate/minimize patient
loads during the first week
to allow for a smooth start.
Place pharmaceutical order.
Start cell phone and pager
service for MDs.
Train MDs in coding and
billing.
Obtain cash for petty cash.
Develop fire safety plan.
Develop site security plan,
install security system, and
provide training.
Establish procedures for
check-in and co-payment
collection.
Pre-build patient folders.
Train staff on completing
time sheets appropriately.
After Opening Day
Task
Have outside photo taken of
location once sign is up.
Have internal pictures taken
as soon as site is complete
with furniture and artwork.
Take pictures of staff and
MDs.
Arrange open house, if
desired.
Details/Notes
- 65 -
Completed
Completed
Update Web site with
pictures.
This document was adapted from forms provided by Tom Dunigan, MD, FAAP, and Tom
Barela, MD, FAAP.
- 66 -
Launching Your Career in Pediatrics: Practice Work Flow and Policies
There are many things to consider when designing the infrastructure of your pediatric
practice. This section will provide tips on the following:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Selecting an Office Location and Space
Setting Office Hours and Staff Schedules
Making the Best Use of Your Office Hours
Creating Customized Schedules
Using Patient Flow Patterns
Creating Office Policies
The Employee Handbook
Health Insurance Portability and Accountability Act Policies and Procedures
Red Flag Rules
Occupational Safety and Health Administration
Other Policies
Purchasing Techniques: Controlling Purchase Costs of Supplies and Vaccines
Vaccines
Telephone Triage
After-hours Phone Care
Coverage and Referrals
Selecting an Office Location and Space
For information and tips on designing an efficient office, visit
http://practice.aap.org/content.aspx?aid=1982&nodeID=1077.
Additional Resource
“Do I Need Separate Waiting Rooms for Sick and Well Children? A Practice
Management FAQ” (http://practice.aap.org/content.aspx?aid=2226&nodeID=1072)
Setting Office Hours and Staff Schedules
If you are joining an established practice, your hours are set for you by the practice, based
on your negotiations at the time of contracting. If you are taking over an established
practice, the community will likely expect you to continue the prior practice’s hours or to
expand them—reducing them from the outset would likely have a negative marketing
effect.
Most pediatricians go into practice with the idea of balancing work and family time.
Ideally speaking, the decision of office hours should be part of your market analysis, done
- 67 -
as the first step in assessing and selecting the community and location in which you wish
to practice, not after you have made the selection, picked space, ordered supplies, and
made commitments. Your care, your demeanor, and your availability are the major
determinants of the practices success.
Here are some things to consider.
1) The style of practice you want, and if you have a family, what your family can
accept. It is critical that the family unit have appropriate expectations, a full
understanding of what is being undertaken, and a realistic estimate of the effort
needed to succeed.
2) The practice competitiveness of an area or community. If you are the only
pediatrician in town, you can tilt the balance toward your own needs. On the other
hand, if you select a highly competitive area, you will need to find ways to attract
patients. That might mean expanded hours or night, evening, and weekend hours,
which would require more work time.
3) The coverage you might be able to expect, and what responsibilities as well as
benefits accrue through any coverage arrangement.
4) What are the community resources? Are there local retail-based clinics, urgent
care centers, or after-hours centers? If so, this could enhance your practice if you
achieve a cooperative working agreement. However, they can also be competitive
facilities drawing patients away.
5) Understand the community needs—socioeconomic, prior health care availability,
customs, and traditions.
Options to consider making your hours more effective include
1. Early bird hours (eg, walk-in, first-come first-served, minor problems and quick
fixes designed to get children into school and parents off to work). You might be
able to see 5 to 10 patients quickly, relieving the crowding in the morning and
afternoon schedules. Parents look positively on the quick-in-and-quick-out as a
benefit, and enjoy the consideration shown by not making them take a half day off
from work or have the child miss school. Early bird hours could begin at 7:30 or
8:00 am, depending on when school starts in your community. Caveat: For early
bird hours beginning at 8:00 am, set the walk-in registration time from 7:45 to
8:15 am. Do not set the early bird time from 8:00 to 9:00 am. If you do, you might
find 5 to 10 people walking in at 8:55 am, expecting to be seen by 9:00 am.
2. Teen time (ie, evening hours for adolescents). They appreciate it when they come
into a true adolescent practice and not to see a “baby doctor.” Office décor is also
important!
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3. Talk time (ie, certain hours set aside in advance for parents who need extended talk
time for chronic diseases, educational issues such as learning disorders or
attention-deficit/hyperactivity disorder, or behavioral issues). By having a specific
period set aside, you meet the needs of the parents and patient and avoid having
the staff schedule a standard appointment time that is not adequate, causing you to
inevitably run late and disconcerting all the following scheduled appointments.
4. Specialty time (ie, focus on your individual interest in practice). This can be done
one patient at a time or in groups, depending on the subspecialty.
5. Group baby care. Some practices set aside an hour and schedule 5 to 6 similaraged infants for the same time. The nurses begin the visit by obtaining a history of
each infant. The physician examines the infants in sequence, expanding on history
issues. Next, all of the families sit down as a group with the physician for
question-and-answer time and anticipatory guidance time. Many parents ask the
same questions; many forget what to ask but hear another parent ask it for them.
This format also allows for group support as the parents develop social
relationships with other parents with similar-aged children. Consider this option as
an elective solution—parents can opt in or out at any time; however, it is common
for many groups to continue this format into the early school years.
These solutions are attempts to take patient needs into account, which is difficult if you
have set 10- or 15-minute, or modified wave appointments. They compartmentalize your
chosen hours. Remember—marketing quality of service is just as important to a practice’s
success as quality of care.
Sample Office Schedule
Solutions
Days of Week Hours
Early bird time Monday–Friday 8:00 am (parents to arrive no
later than 8:15 am)
Regular
Monday,
9:00 am–4:30 pm
appointments
Wednesday,
Friday
Regular
Tuesday,
1:00–4:00 pm
appointments
Thursday
Talk time
Tuesday
9:00 am–12:00 pm
Teen time
Tuesday
4:00–7:00 pm
Baby groups
Thursday
9:00–11:00 am
Toddler groups Thursday
11:00 am–12:00 noon
In this sample schedule, your hours would essentially be Monday through Friday from
8:00 am until 5:00 pm (last appointment, 4:30 pm). As the practice develops, you can
modify the schedule. As you potentially add on partners, nurse practitioners, or physician
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assistants (PAs), you can continue to modify your schedule.
Scheduling Staff and Physicians
When creating schedules for staff and physicians, it is most important to have a mix of
full-time and part-time staff. Part-time employees might have a fixed schedule with little
flexibility, but malpractice insurance for a part-time physician might be significantly
cheaper—and usually is for physicians who work fewer than 21 hours.
Full-time employees generally offer a lot more flexibility because they are there for 4 or 5
days a week to work as needed. Most states require employers to pay overtime if an
employee works more than 40 hours in any week; therefore, you might want to set fulltime employees’ schedules to 36 or 37.5 hours a week, which gives the practice
flexibility. If employees need to stay late 1 or 2 days, the practice will not be required to
pay overtime.
Staff scheduling can be done by an office manager or a coordinator and should be done on
a monthly basis and presented to the staff at least 2 weeks before the start of the new
month.
It is important to have very clear guidelines for vacation and requested days off. A lack of
clear expectations in this area will result in the person responsible for scheduling having
to address staffing situations daily, which is very time consuming. Remember, the rules
established for one person will set precedence for the entire staff. Do not allow one person
to do something that would not be desirable for all staff to do.
Physician scheduling should be done by a nonphysician. It is very difficult to be
completely unbiased if a person is in control of his own schedule. Try to offer physicians
a set day off during the week, but never guarantee anything. Things can change on a
moment’s notice and no one should be faced with the situation of not having enough
physicians to provide care to all patients. Once a practice starts canceling patients, it is
very difficult to rebuild those patients’ trust in the practice. Patients need to know that the
practice is there for them.
Physician schedules should be finalized at least 2 but preferably 3 months in advance so
parents can schedule their child’s next appointment before they leave the office. Practices
should not be continually changing a physician’s schedule, resulting in having to
reschedule patients. Once the schedule is posted, it should be understood by all that it is
set in stone, except for extreme emergencies (illness or death, not a child’s school
function).
Decrease in Patient Census
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As long as practice employees are not contracted, they can be sent home at any time
because of decreased patient volume. The first staff to be sent home should be overtime
staff, per diem staff, part-time staff, then full-time staff. Be sure to send home a different
person each time and not pick on any one individual unless it is a per diem or someone
who has volunteered to go home early. If a practice staff person is contracted for a certain
number of hours or salaried, use that staff to do something rather than sending that staff
home. There is almost always some type of paperwork to be done and because the staff
person is being paid regardless, it is important to use her scheduled time to the practice’s
advantage. This is where cross-training can be very effective.
Additional Scheduling Resources Currently on Practice Management Online
• “Creating Customized Schedules”
• Sample Employee Handbook
Making the Best Use of Your Office Hours
The most common scheduling methodologies are fixed appointments and wave or
modified wave scheduling. These formats apply to the timing of appointment scheduling.
There are also open access and modified open access—these apply to the style of
scheduling.
1. Fixed (ie, the time and length are preformatted). For example, appointments
are offered every 10, 15, or 20 minutes. When you first start in practice, it
would be better to allow more time as you get to know patients and they get to
know you. Then, as you get used to your routine and patients become familiar
through repeated visits, you can change the time slots.
2. Wave (ie, schedule all the patients for a given segment, usually a half hour or
an hour). In this scheduling method, instead of scheduling 4 patients 15
minutes apart, all 4 are set for on-the-hour, and the physician sees each one in
sequence of arrival. The first gets seen immediately; the fourth gets seen after
the first 3. The advantage is that some patients arrive on time and some are
late. The wave takes this into account. The disadvantage is if they all arrive on
time, and the fourth has to wait 45 minutes or more to be seen. Caveat: You
must also be very careful to select the type of patients your staff schedules. If
they schedule 4 adolescent well-care visits, you might have difficulty
completing the work.
3. Modified wave (ie, same 4 patients, same hour; however, the first 2 are told to
be there on the hour, and the second 2 are told to be there in a “second wave,”
15, 20, or 30 minutes after the first 2). This method gains (for the most part)
the benefits of wave, but lessens the disadvantages of long waits for later
appointments. For additional information on wave scheduling, see “Wave
Scheduling” (http://practice.aap.org/content.aspx?aid=1920).
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4. Open access (ie, offering same-day scheduling for all visits, preventive or
illness/injury). While it does not rule out parent-choice, in-the-future
appointments, the goal is to take care of today’s work today and minimize
future appointments, so as not to have a full schedule before you open the
doors. Most practices can estimate the daily patient flow and schedule
providers’ work times to accommodate the need. For established practices,
there might be a conversion time because they may already have appointments
well in advance. For new practices, starting with a clean slate, it is much easier
to implement. Logic says you will do a certain number of preventive care and
interval visits over the span of a month—whether you do it in a standard
prebooking “first available appointment” or open access “any available
appointment today,” you will likely see the same number of patients of both
types over a month. The one disadvantage is that parents may not always be
available, primarily for preventive care visits, at the time you have open that
day. For additional information on open access scheduling, visit
http://practice.aap.org/content.aspx?aid=384&nodeID=3014 and
http://practice.aap.org/content.aspx?aid=1108&nodeID=3027.
5. Modified open access (ie, booking preventive care and long consultations at
the convenience of the parent with the traditional “first, or later, available
appointment basis” but using typical open access style for illness/injury or
interval visits). This is the style the vast majority of small practices use
because it takes care of today’s work today, especially for those issues parents
feel are urgent (ie, illness/injury), yet allows the parent to select a preventive
care appointment that is convenient for themselves and their child. It also
allows the practice to set aside additional time if it is apparent that the child
has multiple or in-depth problems the parent expects to discuss.
Final Considerations in Setting Hours
Setting hours is critically important because parents consider availability and accessibility
just as important as care quality and health care insurance participation. It needs to be part
of your marketing plan to build your practice. Decide which you wish to do before you
select where you will open a practice. The greatest mistake is to pick a location without
understanding what will be needed to be successful in that location.
One lesson learned after many years of practice is that if you take care of your
community, they will take care of you. If you are considerate of your community, they
will be considerate of you, and they are your greatest support in practice.
The other lesson is to make use of Practice Management Online (PMO) as your major
referral for suggestions and information, built on the experiences of thousands of
pediatricians who have already gone through the same processes you are about to
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encounter.
PMO has additional resources for reducing no-shows.
• Cost-effective Ways to Reduce No-shows
(http://practice.aap.org/content.aspx?aid=2098)
• “Missed Appointment Policy”
(http://practice.aap.org/content.aspx?aid=2024&nodeID=3017)
• Sample missed appointment letters (First and second letters
(http://practice.aap.org/content.aspx?aid=2093&nodeID=3017), and third [and final]
letter) (http://practice.aap.org/content.aspx?aid=2095&nodeID=3017).
Creating Customized Schedules
The most highly efficient practices use this labor-intensive method. It is unlikely that a
new practice will have the experience and data to implement it fully, but some basic
techniques can be used and more complex management developed as the practice matures.
The base template is the modified open access system described previously. One person in
the practice, preferably a physician with business skills, takes responsibility for
maximizing the number of visits that can be handled by the practice. This can only be
done if the scheduling doctor has several attributes.
1. An understanding of the practice’s seasonal variations in demand for certain
types of visit. For example, each schedule should be customized with more
slots assigned to well visits in the summer season and more acute care visits
assigned in the winter season.
2. An understanding of how each provider works. There are clear differences in
provider styles and they cannot all have the same schedule. Some work very
quickly, some less so. Some take on more complex specialized patients and
need a schedule that reflects this. If there are multiple locations, they may have
different characteristics. All of this must be meshed with your productivity
schema so that everyone has the opportunity to be rewarded for their own
productivity.
3. The time and compensation to monitor how the practice is booking on a daily
basis and to make requisite modifications to the system on an ongoing basis.
There must be an extra salary for this person over and above their patient
productivity compensation.
4. The authority to totally control the schedule of the providers. No one but the
scheduling doctor has the authority to alter the schedule. If other providers
need to make changes, they must be authorized by the scheduling physician
prior to being implemented. This goes for vacations, days off, and other
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commitments. If schedules need to be changed, even with short notice,
providers must cooperate with these changes as much as possible.
5. The data systems needed to figure all of this out and the ability to try to get
patients to move their well visits to low-demand periods such as April and
May to even out the summer crunch of such visits. This may require active
calls to patients to solicit such visit times.
6. The ability to customize the schedule with certain types of visits at certain
times, with rules about changing such job stream templates for appointment
staff to follow. These job streams may vary by season, office, and individual
provider.
7.
As is obvious, this type of system is not for everyone. However, if fully implemented, this
type of schedule can earn a practice far more revenue than nearly any other single
management technique of handling patient care.
Using Patient Flow Patterns
Employers and families are looking at their health care costs closely. The pediatric
services that your practice provides are increasingly being rated for value and quality by
insurance companies and your patients.
Pediatricians, as primary care providers and pediatric specialists, are dealing with fixed
insurance payments that do not allow them to routinely pass on increased costs to payers.
Perception of patient flow through the practice provides the base to adapt and manage
patient visits to the advantage of the providers and patients. Here are some tips to ensure
patient flow.
1. Assess how a patient encounter progresses from the patient’s point of view. This
can be done by shadowing a patient through the visit, using a kitchen timer
attached to a clipboard or notepad where the staff notes encounter times.
2. Start from the initial scheduling, the chart pull, or electronic medical record
(EMR) review. Identify the points of care where your staff engages with the
patient and preps for the visit. You can then review as a team (providers and front
desk, clinical, and billing staff) to identify areas that catch patients in time delays.
3. Gridlock in patient flow can be found during the check-in process, provider
appointment times, interruptions in providers’ work flow, documentation
practices, examination room setups, clinical processes, scheduling, and checkout.
4. Prioritize changes based on staff, provider, and patient survey information. Initiate
one change per area at a time; ensure that adaptation and evaluation is complete
before going on to the next one. A sample patient survey can be found on PMO at
http://practice.aap.org/content.aspx?aID=2374.
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Goals of change should be to increase provider, patient, and staff satisfaction while
increasing revenue and cutting expenses.
Identifying the flow of patients may also have an immediate effect on revenue. The
location of the checkout or collections desk can have a significant effect on co-payment
collection. As the patient checks out after the visit, a properly placed desk can improve
contact with the patient and increase chances for collection. Co-payments are often given
less attention in the world of collections because of the small amounts, but these dollars
can quickly add up. By making sure that all patients pass by the checkout desk before
leaving the office, optimizing patient flow can provide another opportunity to collect the
co-payment as the patient schedules the next appointment.
Creating Office Policies
Because of the multiple regulatory agencies that monitor the health care industry,
physician offices must have policies and procedures established, in addition to those
required by employment and labor laws. When first beginning this process, the alphabet
soup of regulatory bodies can be overwhelming. However, there are key policies and
procedures that every physician’s office should have, and PMO
(http://practice.aap.org/sampleofficedocs.aspx) has many examples to get you started.
Some labor law policies are required only if you have a certain number of employees and
may not apply to a practice that is just starting up. It is especially important to review your
policies with legal counsel because the wording of your policies may have significant
legal ramifications.
The Employee Handbook
The bulk of office policies are included in the employee handbook. This handbook is
given to every employee on hire. You should keep documentation that each employee has
received, understood, and agreed to its terms.
Employee handbooks are often called policy and procedure manuals. The purpose of the
handbook is to provide a written statement of the policies of the business and how the
business is to be conducted. The company employee handbook is one of the most
important communication tools between your company and your employees. It presents
your expectations for your employees, and it also describes what they can expect from the
business. It needs to be as clear and unambiguous as possible. Misunderstandings or
misstatements can create legal liabilities for your business. In legal disputes courts have
considered an employee handbook to be a contractual obligation, so word it carefully and
with professional legal assistance. The handbook provides an objective reference for you
and your employee in the case of disputes over behavior or performance.
This handbook should contain enough detail to avoid confusion, but not so much as to
overwhelm—for instance, there may be other documents (eg, group insurance, retirement
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plan) that more appropriately provide details. In the handbook, you are providing a clear
summary and stating the most importance points of each issue addressed. It is important
to be familiar with the myriad of laws and regulations for employment. Your local
medical society may be a good source of information about human resource laws and
requirements. Additionally, it is a good idea to consult with your business attorney about
any laws on which you are unclear.
The following is a list of potential sections for your employee handbook:
•
•
•
•
•
•
Introduction
Mission Statement
Equal Employment Opportunity Statement
Accommodating Disabled Workers (Americans With Disabilities Act)
General Policies
o Personal Information
o Attendance
o Use of Company Property
o Dress Code
o Safety and Accident Rules
o Fire Prevention
o Smoking
o Illegal Drug and Alcohol Use and Abuse
o Sexual Harassment
o Employee Conduct Guidelines
o Conflict of Interest
o Performance Reviews
o Personal Telephone Use
o Inclement Weather
o Employment Referrals
o Employment of Relatives
o Personnel Record
Compensation and Benefits
o Payroll
o Work Hours and Reporting and Attendance Policy
o New Employee Orientation Period
o Holidays
o Vacation
o Sick Leave
o Family and Medical Leave
o Maternity Leave
o Funeral Leave
o Jury Duty
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•
•
o Military Service
o Leave Without Pay
o Overtime
o Break Periods
o Group Insurance Benefits
o Short-term Disability
o Continuation of Medical/Consolidated Omnibus Budget Reconciliation Act
o Worker Compensation
o Retirement Plans
o Tuition Assistance
o Employee Assistance Program
o Medical Services Provided to Employees and Their Immediate Families
o Employment Separation/Termination
Closing Statement
o This states that the most recent version of the handbook supersedes all
previous versions of the handbook.
Employee Acknowledgment Form
o To be signed by each employee. When you create new policies and update
your employee handbook, you should get new acknowledgment forms
signed.
For more details on each of the policies, there are several Web sites and books that can
assist you. For employee handbooks for medical practices, check with Medical Group
Management Association (MGMA).
PMO has a sample employee handbook available at
http://practice.aap.org/content.aspx?aID=2091.
Health Insurance Portability and Accountability Act Policies and Procedures
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was created to
ensure that patient privacy was protected. It required that businesses who deal with
protected health information follow certain policies to protect patient privacy. In addition,
it required that procedures were in place to deal with violations of these policies. If an
investigation by the Department of Health and Human Services determines that a person
or entity has violated these policies, significant civil and criminal penalties can be
incurred.
There are 3 major sections of HIPAA and all covered entities were required to be
compliant with all of these standards after 2005. The 3 sections are the Privacy Standards,
the Transactions and Code Set Standards, and the Security Standards.
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The HIPAA Privacy Standards require physicians to protect the privacy of patients’
medical information. Physicians are required to regulate the ways in which they use and
disclose patients’ protected health information. Physicians are required to offer patients
certain rights with respect to their information, such as the right to access and copy, the
right to request amendments, and the right to request an accounting. Lastly, physicians
must have certain administrative protections in place (eg, a privacy officer, staff training,
implementation of appropriate policies and procedures, disciplinary actions and recourse)
to further protect the privacy of patients’ information.
The HIPAA Transactions and Code Set Standards govern the format for electronic
transactions between physicians and health plans and other entities. For example, the
claims that physicians submit to payers must be in a specific format.
The HIPAA Security Standards further require physicians to protect the security of
patients’ electronic medical information through the use of procedures and mechanisms
that protect the confidentiality, integrity, and availability of information. Physicians must
have in place administrative, physical, and technical safeguards that will protect electronic
health information that the physician collects, maintains, uses, and transmits. The
standards cover all electronic forms of patient medical information, including faxes, email, and EMR/electronic health records.
The full HIPAA law is complex and arduous to read. The US Department of Health and
Human Services provides a comprehensive guide to covered entities (eg, doctor’s offices)
at www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html.
The American Academy of Pediatrics (AAP) has HIPAA Online: A “How-To” Guide for
Your Medical Practice available at http://practice.aap.org/hipaa.aspx.
You may also find additional assistance in creating policies from the American Medical
Association and MGMA.
Red Flag Rules
Starting in 2009, medical practices are considered creditors and must abide by the red flag
rules as set forth by the Federal Trade Commission. These rules protect against identity
theft. Because nearly all medical practices file insurance claims and wait to bill patients
the remainder of the fee, or have some patients on some type of payment plan, they are
“lending” money to patients and are therefore considered creditors.
If a provider is considered a creditor, the covered account is a consumer account designed
to permit multiple payments or transactions, or any other account for which there is a
reasonably foreseeable risk of identity theft. For a medical practice, this would be patient
billing records.
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Medical practices would be required to develop an identity theft program that contains
reasonable policies and procedures to
•
Identify relevant patterns, practices, and specific forms of activity that are red
flags, signaling possible identify theft.
•
Detect these patterns or red flags.
•
Respond to those detected to prevent and mitigate identity theft.
•
Ensure the program is updated periodically to reflect changes in risks.
In administering such a program, a creditor would need to
•
Obtain approval of the program from its board or board committee.
•
Involve the board or senior management designee(s).
•
Train staff.
•
Exercise oversight of service provider arrangements.
For additional information about the red flag rules and for a sample policy, see
http://practice.aap.org/content.aspx?aid=2687.
Additional information is available at http://www.ftc.gov/bcp/edu/pubs/articles/art11.shtm
and http://www.aha.org/aha/advocacy/compliance/redflags.html.
Occupational and Safety Health Administration
Occupational Safety and Health Administration (OSHA) regulations were created to
provide a safe and healthful workplace to employees. All medical offices are required to
be in compliance with OSHA standards.
There are several key hazards that need to be addressed in a medical office. However,
please see the OSHA official Web site for the complete list of regulations.
The following information comes from the OSHA publication, Medical & Dental Offices:
A Guide to Compliance with OSHA Standards. These are the most common standards that
apply to medical offices.
Bloodborne Pathogens Standard (29 CFR §1910.1030)
This is the most frequently requested and referenced OSHA standard affecting medical
and dental offices. Some basic requirements of the OSHA bloodborne pathogens standard
include
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•
A written exposure control plan, to be updated annually
•
Use of universal precautions
•
Consideration, implementation, and use of safer, engineered needles and sharps
•
Use of engineering and work practice controls and appropriate personal protective
equipment (gloves, face and eye protection, gowns)
•
Hepatitis B vaccine provided to exposed employees at no cost
•
Medical follow-up in the event of an exposure incident
•
Use of labels or color-coding for items such as sharp disposal boxes and
containers for regulated waste, contaminated laundry, and certain specimens
•
Employee training
•
Proper containment of all regulated waste
Hazard Communication (29 CFR §1910.1200)
The hazard communication standard is sometimes called the “employee right-to-know”
standard. It requires employee access to hazard information. The basic requirements
include
•
A written hazard communication program
•
A list of hazardous chemicals (eg, alcohol, disinfectants, anesthetic agents,
sterilants, mercury) used or stored in the office
•
A copy of the material safety data sheet for each chemical (obtained from the
manufacturer) used or stored in the office
•
Employee training
Ionizing Radiation (29 CFR §1910.1096)
This standard applies to facilities that have an x-ray machine and requires the following:
•
A survey of the types of radiation used in the facility, including x-rays.
•
Restricted areas to limit employee exposures.
•
Employees working in restricted areas must wear personal radiation monitors such
as film badges or pocket dosimeters.
•
Rooms and equipment may need to be labeled and equipped with caution signs.
Exit Routes (29 CFR Subpart E §1910.35, §1910.36, §1910.37, §1910.38, and §1910.39)
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These standards include the requirements for providing safe and accessible building exits
in case of fire or other emergency. It is important to become familiar with the full text of
these standards because they provide details about signage and other issues. OSHA
consultation services can help, or your insurance company or local fire and police service
may be able to assist you. The basic responsibilities include
•
Exit routes sufficient for the number of employees in any occupied space
•
A diagram of evacuation routes posted in a visible location
Electrical (Subpart S-Electrical 29 CFR §1010.301 to 29 CFR §1910.399)
These standards address electrical safety requirements to safeguard employees. OSHA
electrical standards apply to electrical equipment and wiring in hazardous locations. If you
use flammable gases, you may need special wiring and equipment installation. In addition
to reading the full text of the OSHA standard, you should check with your insurance
company or local fire department, or request an OSHA consultation for help.
Poster
Every workplace must display the OSHA poster (OSHA publication 3165) or the state
plan equivalent. The poster explains worker rights to a safe workplace and how to file a
complaint. The poster must be placed where employees will see it. You can download a
copy or order one free copy at www.osha.gov or by calling 800/321-OSHA (321-6742).
Reporting Occupational Injuries and Illnesses (29 CFR §1904)
Medical and dental offices are currently exempt from maintaining an official log of
reportable injuries and illnesses (OSHA form 300) under the federal OSHA recordkeeping rule, although they may be required to maintain records in some state plans. If
you are in a state plan, contact your state plan directly for more information. All
employers, including medical and dental offices, must report any work-related fatality or
the hospitalization of 3 or more employees in a single incident to the nearest OSHA
office. Call 800/321-OSHA or your state plan for assistance.
Resources
• www.osha.gov/Publications/OSHA3187/osha3187.html (Medical & Dental
Offices: A Guide to Compliance with OSHA Standards)
• www.osha.gov/dcsp/compliance_assistance/index.html#Resources
Other Policies
Clinical Laboratory Improvement Amendments/COLA Accreditation
The Centers for Medicare & Medicaid Services regulates all laboratory testing performed
on humans in the United States through the Clinical Laboratory Improvement
Amendments (CLIA). If you plan on having an in-office laboratory that performs CLIA
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tests that are not waived, then you must be in compliance with CLIA. COLA is an
organization that provides accreditation to CLIA-compliant laboratories. Visit
www.cms.hhs.gov/clia for a listing of waived tests, guidelines for laboratories, CLIA
brochures, information on applying for a CLIA certificate, categorization of tests, and
more.
Resources
• www.cms.hhs.gov/clia
• www.cola.org
Medical Assistants
Many states allow medical assistants (MAs) to administer vaccinations or medications
under the supervision of a physician. However, most require some sort of training. It is a
good idea to have formal written policies and procedures addressing the type of training
program that you will use and how the MAs will be supervised. In several states, MAs are
not allowed to give injectables, so be sure to check to see what laws apply to you. Your
state board of medicine or equivalent should be able to assist you.
Reconstituting Medications
If you plan to give injectable medications that require reconstitution, such as ceftriaxone,
you may have to develop policies and procedures for this process. Some states require
practices that reconstitute medications to follow US Pharmacopeia guidelines for sterile
mixing techniques. Some states only allow registered nurses (RNs), PAs, or physicians to
do the mixing. Check with your state board of medicine for rules for your state.
Dispensing Medications
As a convenience to your patients, you may choose to dispense some commonly used
medications (eg, amoxicillin, albuterol) for patients to purchase. This can be done in a
variety of ways, including using prepackaged medications through commercial services.
However, each state will have its own legal requirements for the dispensing of
medications in a non-pharmacy. Again, check with your local agency for legal
requirements.
Preparing Your Office for a Disaster
For information about how to prepare your office for an emergency or disaster, visit
Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care
Providers (http://practice.aap.org/content.aspx?aid=2057).
Additional Resources on Policies
PMO has several sample policies available. Visit
http://practice.aap.org/topicBrowse.aspx?nodeID=4000.4033 for additional information.
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Purchasing Techniques: Controlling Purchase Costs of Supplies and Vaccines
Medical supplies and vaccines account for a large percentage of pediatric practice
overhead. Vaccine costs in nonuniversal states can be 20% to 25% of your expenditures.
Controlling purchasing costs allows you to manage one element of overhead expenses in
your business.
Group Purchasing Organizations
A group purchasing organization (GPO) helps physician practices minimize costs of
medical supplies and vaccines by collectively joining practices with other physicians in
volume purchasing. Large-volume purchasing power gives a group of physicians the clout
to bargain for price reductions on medical supplies and vaccines. You can belong to
multiple GPOs for individual supplies and use the price lists to build the best purchasing
plan for your practice.
Develop a spreadsheet with the supply item listed in the first column, and in subsequent
columns enter the price taken from each GPO price list. This makes it easy to compare
your cost for an item when ordering. You can go the additional step of developing your
own shopping list for each GPO, but don’t forget to compare prices with the original
spreadsheet at least quarterly. Generally, GPOs only provide price lists to those interested
in becoming members.
Another cost assurance responsibility is to compare the invoice with your contracted
price. Delegate this to a staff member in billing who is used to dealing with the dollars
and has the time to do the comparison.
PMO has a list of GPOs available at http://practice.aap.org/content.aspx?aid=2381. If
your area is not serviced, consider joining together with other practices to negotiate a
buying contract with manufacturers. AAP chapters and pediatric councils are a great place
to look for partners.
Discounts and Rebates
Always inquire about rebates and discount ordering. Be alert to the end of the financial
quarters when the companies are trying to improve their numbers. Advantage should be
taken of online ordering discounts (about 2%), prompt pay discounts, and manufacturer’s
promotions (most often 2%–3%). These promotions frequently are combined with 90-day
invoice dating. This gives the practice a few months to provide the vaccine and obtain
payment.
Payments
Practice payments made with a credit card can provide a financial advantage to the
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practice in 2 ways. A credit card payment can be scheduled for payment just prior to the
date of the prompt pay cutoff date. This adds the credit card billing cycle time to the time
between purchase and payment. Choose a credit card that offers additional perks, such as
frequent flyer miles, that can be used for attending conferences or continuing medical
education (CME) meetings, reducing other expense line items.
Inventory
Inventory is a cost-saving measure that is often overlooked in a practice. Knowing what
you own and when it expires can save you money by preventing duplication of items, loss
of product by expiration dates being overlooked, and performance of procedures more
tediously when you had purchased a clever product that was going to make your job
easier! A sample list of supplies needed to start a practice can be viewed at
http://practice.aap.org/content.aspx?aid=2395.
Delegate
Staff members need to be accountable for the supplies and usage in their area. Lists and
computer prompts are helpful tools to give them to make it easier to remain compliant.
Remember that your goal is to provide the best pediatric care for the least cost.
Vaccines
The following information about administering vaccines in the office is available on
PMO.
Cost of Giving Vaccines in Your Office
To calculate your total vaccine costs, enter your information into all 3 calculators at
http://practice.aap.org/vaccinecalculator.aspx and click the Calculate Total Cost button at
the bottom of the page. You can also use the individual calculators to calculate partial
vaccine costs. These calculators give the practice cost of administering 1 dose of vaccine
over a 3-month time frame.
Liability Insurance
• “Improve Vaccine Liability Protection”
(http://practice.aap.org/content.aspx?aid=1602)
• “Reducing Vaccine Liability: Strategies for Pediatricians”
(http://practice.aap.org/content.aspx?aid=545)
• “Insurance Coverage for Vaccine Loss”
(http://practice.aap.org/content.aspx?aid=2228)
Storage and Handling
• “Safe Storage of Vaccines” (http://practice.aap.org/content.aspx?aid=2205)
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•
“Lessons Learned From Hurricane Katrina: Ensuring Proper Vaccine Management
Handling and Administration During a Disaster”
(http://practice.aap.org/content.aspx?aid=1979)
Coding for Vaccines
• “Coding for Pediatric Preventive Care”
(http://practice.aap.org/content.aspx?aid=2052)
• “When Is It Appropriate to Report 99211 During Immunization Administration?”
(http://practice.aap.org/content.aspx?aid=2119)
• “Vaccine Coding Table” (http://practice.aap.org/content.aspx?aid=2334)
Managing Vaccine Refusal
• Parental Refusal to Vaccinate Form
(http://practice.aap.org/content.aspx?aid=1605)
• “Responding to 7 Common Parental Concerns About Vaccines & Vaccine Safety”
(http://practice.aap.org/content.aspx?aid=106)
Purchasing Vaccines
• “Vaccine Purchasing Groups” (http://practice.aap.org/content.aspx?aid=2381)
Reminder/Recall
• “Vaccine Reminder Recall Systems: A Practical Guide for Pediatric Practices”
(http://practice.aap.org/content.aspx?aid=2674)
Telephone Triage
An essential function of a pediatrician is to provide advice and guidance to parents.
However, not every issue requires a doctor’s appointment. Therefore, a pediatric practice
will need someone to provide advice to parents over the telephone. This serves to help the
families, as well as to triage patients to determine when and if a child needs to be seen in
the office.
During the workday, most offices will have an experienced pediatric nurse (usually an
RN) provide advice as determined by the physicians of the practice. Many will use
nationally recognized pediatric telephone advice protocols such as those created by Barton
D. Schmitt, MD, FAAP.
The number of advice nurses to staff depends very much on the volume of phone calls
handled. When you are first starting your practice, the volume may not be enough to
warrant a full advice nurse full-time equivalent (FTE). You may have a cross-trained
nurse who helps in the clinical area and with handling phone calls between patients. As
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the practice grows, additional staff may be needed. A fully established practice will
usually require 1 full advice nurse FTE for every 4 providers.
In the past, most pediatric offices provided phone call triage and advice services at no
additional cost. However, recently there has been a great deal of interest in charging
parents for telephone care, particularly after office hours. There are very specific
guidelines for billing insurance for telephone care, and payment varies greatly based on
insurance companies and your individual contracts. The AAP has guidelines for
pediatricians on charging for telephone care at http://practice.aap.org/telecarepmt.aspx.
Additional Resources
• Developing a Telephone Triage and Advice System for a Pediatric Office Practice
(https://www.nfaap.org/netforum/eweb/DynamicPage.aspx?webcode=aapbks_pro
ductdetail&key=4eb96a9a-4b6b-4158-b75c-c8a711a3d98e)
• Pediatric Telephone Protocols: Office Version, 12th Edition, binder
(https://www.nfaap.org/netforum/eweb/DynamicPage.aspx?webcode=aapbks_pro
ductdetail&key=a42632a6-3128-48dd-af32-3787dde346c0)
After-hours Phone Care
After-hours phone calls can be handled by the physician on call. However, many practices
use after-hours triage services to provide frontline phone care. There are many after-hours
triage services across the country and it is important to select one that is experience in
handling pediatric phone calls. Some practices use their own advice nurses to take afterhours calls. For additional guidance, visit “Weigh Costs and Benefits When Selecting
After-hours Triage Service” at
http://aapnews.aappublications.org/cgi/content/full/25/4/182.
Additional information can be found at
• “After Hours Calls: Evaluating Options”
(http://practice.aap.org/content.aspx?aid=386)
• “Finding an After Hours Call Center”
(http://practice.aap.org/content.aspx?aid=390)
Coverage and Referrals
Tips on Finding Coverage From Other Pediatricians
• Join the local AAP and attend meetings.
• Join your local hospital’s medical staff and attend meetings.
• Be willing to be in hospital or organization committees; they force you to go out
and talk to your peers.
• As few and far between as they are now, attend drug dinners and socialize.
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• Advertise in the local AAP magazine or bulletin.
• Be willing to provide coverage to others as well.
• Check with your community hospital or emergency department to see if it has
coverage pools.
• Attend newborn deliveries and form a relationship with local obstetriciansgynecologists; they can point you to other providers in the area.
Tips on Finding Referrals
• Attend CME seminars or conferences provided by your closest tertiary or
children’s hospital.
• Ask other providers in your area who they refer to.
• When you get a referral from a specialist, call and ask about the practice.
• Ask neonatologists at your community nursery for leads.
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Launching Your Career in Pediatrics: Human Resources and Staff Management
Appropriate staffing of an office can help the practice run efficiently, increase patient
satisfaction, and help with your workload. This section will provide tips on the following:
•
•
•
•
•
•
•
•
Creating Job Descriptions
Establishing Staff Salaries
Hiring Quality Staff and Staffing Needs
Recruiting, Interviewing, and Hiring
Managing Staff
Training and Evaluating Staff
Physician/Provider Annual Assessments: Evaluating Partners
Handling Conflict and Difficult Situations
Creating Job Descriptions
Having a strong, cohesive team of committed professionals can make a pediatric practice
incredibly successful and a rewarding place to work. Unfortunately, it can be very
difficult to attain. Many difficulties can be prevented, however, by developing job
descriptions and employment contracts that clearly communicate expectations for each
individual.
Each pediatric practice needs competent staff to ensure that the office runs smoothly and
efficiently. As a pediatrician, it is important to know when it is appropriate to delegate
work so that the work and the practice are successful.
A job description is essential in providing employees a basic understanding of what is
expected of them. These written job descriptions establish lines of authority and define the
duties of each position. Pediatric offices typically employ 2 types of staff, front office and
back office. Front office staff are generally responsible for managing the business aspect
of the practice. Jobs may include a sign-in receptionist, file clerk, bookkeeper, insurance
clerk, and sign-out clerk. Back office staff customarily handle the clinical aspects of the
practice. Frequently, these are nurses (various levels), medical assistants, and laboratory
personnel.
Although the jobs and responsibilities vary, the job descriptions should be in a similar
format. Each job description should include the following sections:
1. Position and Title—including supervisory responsibilities
2. Basic Functions—overview of job content and the nature of position
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3. Duties and Responsibilities—major activities associated with the job
4. Qualifications—education and experience
5. Principal Working Relations—working alone or with others
6. Standards of Performance—qualitative and quantitative
7. Physical Requirements of a job description —physical requirements to perform the
job effectively (eg, must be able to stand/sit for X hours, must have adequate
vision for viewing computer screen or to be able to use assistance software)
8. Overview of the work environment —conditions in which the employee will work
(eg, office setting, with patients and the public)
Job descriptions are also instrumental in recruitment, selection of qualified candidates,
training, and reducing conflicts. While it is important to adhere to job descriptions, it is
also important to be flexible about the basic functions because too much detail inhibits
flexibility and creativity. Job descriptions should be evaluated periodically and changed as
the conditions and needs of the practice change.
The following is an example of physical requirements in a job description:
The physical demands described here are representative of those that must be met by an
employee to successfully perform the functions of this job. Reasonable accommodations
may be made to enable individuals with disabilities to perform the essential functions.
Work may require sitting for long periods; also stooping, bending, and stretching for files
and supplies, and occasionally lifting files or paper weighing up to 40 pounds. Requires
manual dexterity sufficient to operate a keyboard, calculator, telephone, copier, and other
such office equipment. Vision must be correctable to 20/20 and hearing must be in the
normal range for telephone contacts. It is necessary to view and type on a computer
screens for prolonged periods.
The following is an example of work environment:
The work environment characteristics described here are representative of those an
employee encounters while performing the essential functions of this job. Reasonable
accommodations may be made to enable individuals with disabilities to perform the
essential functions. Work is performed in an office environment. Involves frequent
interaction with staff, patients, and
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the public.
Any changes in office practice and work flows (eg, adoption of an electronic health record
system) call for job description review and possible modification. In general, job
descriptions for all staff should be reviewed on an annual basis to ensure that the
responsibilities listed within are still appropriate for each staff member’s position.
Reviewing expectations encourages the employee and manager to develop a comfort zone
where job position changes can be easily discussed. By identifying problem areas early
on, practices will increase staff satisfaction, improve retention rates for valuable staff, and
generally function more efficiently.
Employee and pediatrician salaries and benefits are the largest expense in a pediatric
practice. Staff are also your most valuable assets. Employees who are satisfied with their
job duties, responsibilities, and position on the office team will in turn help to provide
quality pediatric care and generate revenue. When staff are certain that they are receiving
fair compensation for a job done well, the job is well done.
Employees with similar job responsibilities should have detailed job descriptions that
allow assessment of quality of work and productivity. Everyone in the practice feels that
they know who the good employees are, yet often a detailed job description will point
differently. Accomplishments that happened early in the year are sometimes forgotten.
Quantity of work often shines when jobs are line listed. Job duties that are vague and do
not clearly define the work being done allow for personal leanings and unnecessary
conflicts. Detailed job descriptions allow employees to be recognized for their successes
and compensated adequately for their contribution to quality care and the practice’s
bottom line.
This information was taken from the following resources:
American Academy of Pediatrics. Management of Pediatric Practice. 2nd ed. Elk Grove
Village, IL: American Academy of Pediatrics; 1991:47–53
American Academy of Pediatrics. A Guide to Starting a Medical Office. Norcross, GA:
Coker Publishing, LLC; 1997:76–86
Additional Resources
“An Employment Contract Model for Joining a Medical Practice,”
(https://profreg.medscape.com/px/getlogin.do;meddomainjsession=7xncLpjJ85hBwmdG
VD5RYGmNxGWmvpxnyF0WRJJl1XF2xGl91p3T!820347218?urlCache=aHR0cDovL3
d3dy5tZWRzY2FwZS5jb20vdmlld2FydGljbGUvNTYxOTU4) Robert I. Freedman, Esq;
Medscape; September 18, 2007 (Need to register to access article)
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For PedJobs, the official employment resource for the American Academy of Pediatrics,
visit www.pedjobs.org.
A variety of front and back office sample job descriptions can be found on Practice
Management Online (PMO) (http://practice.aap.org/samplepersonneldocs.aspx).
Establishing Staff Salaries
Determining Pay Structure: Hourly Versus Salary
In pediatric offices, employees fall into 1 of 2 categories.
1) Hourly personnel, who are paid by the hour and who must receive overtime pay.
In a pediatric office, hourly staff typically include receptionists, billing staff,
medical assistants, secretaries, licensed practical nurses, and some registered
nurses.
2) Salaried personnel, who get a flat salary regardless of hours worked per week.
These include administrators and managers (including nurse managers), employed
physicians, mid-level providers (eg, physician assistants, nurse practitioners),
registered certified medical technologists, and some registered nurses.
Hourly personnel must receive overtime pay for all overtime worked. This is usually 1½
times usual wages for every hour worked more than 40 in a period of 7 consecutive days.
(Some states calculate overtime pay more strictly; see What About My State’s Laws?
for additional information.) Salaried personnel are exempt from the Fair Labor Standards
Act (FLSA) (http://www.dol.gov/whd/flsa/index.htm) requirements and do not need
calculation of overtime.
How Do I Know if a Staff Member Should Be Classified as Exempt?
Most office personnel in a small pediatric office should be classified as hourly personnel,
but there are some exceptions. To be overtime exempt, the employee must be at least one
of the following:
a) An executive employee, such as a practice administrator or nurse supervisor. These
individuals perform management work such as “supervising other employees of
the employer; interviewing, selecting and training employees; setting and
adjusting their pay rates and work hours; directing their work; conducting
employee performance appraisals; handling employee complaints and grievances;
and disciplining employees. It also includes other functions, such as planning the
work; determining the merchandise to be bought, stocked and sold; planning and
controlling the budget; and monitoring or implementing legal compliance
measures.” www.dol.gov/esa/whd/regs/compliance/fairpay/fs17b_executive.htm
b) An administrative employee such as an office manager or a payroll supervisor.
This individual “has authority to formulate, affect, interpret or implement
management policies or operating practices; has the authority to waive or deviate
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from established policies or procedures without prior approval; has authority to
negotiate and bind the company on significant matters; and provides consultation
or expert advice to management.”
www.dol.gov/esa/whd/regs/compliance/fairpay/fs17c_administrative.htm.
c) A professional employee such as a physician, nurse practitioner, or physician
assistant. These individuals have university degrees and use “advanced knowledge
to analyze, interpret or make deductions from varying facts or
circumstances.”www.dol.gov/esa/whd/regs/compliance/fairpay/fs17d_professional
.htm.
d) Certain types of computer/information technology (IT) personnel, whose wage
when computed hourly would be at least $27.63/hour.
Please note that it is the kind of work done, not the job title, that determines whether a
position is overtime exempt. Calling a receptionist by a fancy title like Patient Reception
Executive does not change the FLSA obligation.
The US Department of Labor decision tool at
www.dol.gov/elaws/esa/flsa/overtime/menu.htm helps determine an employee’s eligibility
for overtime exemption and explains the common exemptions in more detail.
What if My Hourly Employee Agrees to Be Paid on a Flat Salary for Simplicity’s Sake?
While this would do away with a lot of painstaking record keeping, hourly employees
cannot waive their hourly status, even if the employee and the company mutually agree on
it in writing. Employees can sue their employers for back wages, and the employer can be
fined for not keeping records of hours worked or not calculating overtime pay properly.
What About Employees Who Do Exempt and Nonexempt Work?
Some of this depends on what the employee’s primary duty is, and for how long. Be
aware, however, that exempt employees who do a nontrivial amount of nonexempt work
in a given period may be entitled to overtime pay during that period. For example, if your
receptionist (a nonexempt position) is on vacation for a week and your office manager (an
exempt position) fills in, your office manager should be considered hourly for that week
and should get overtime pay (if applicable).
What About My State’s Laws?
Your state may have stricter laws about employee classification, hours worked, and the
computation of overtime. Check your state’s Department of Labor information at
www.dol.gov/esa/contacts/state_of.htm.
Benefits
When you are hiring staff, you need to consider what benefits you will offer your staff.
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Some options include health insurance, life insurance, dental insurance, tuition
reimbursement, paid time off, and continuing medical education. You might consider
checking with your colleagues in the area to see what they offer their employees to get an
idea of what your potential staff might expect.
Additional Resources
Staff Salaries (http://practice.aap.org/content.aspx?aid=2713)
Hiring Quality Staff and Staffing Needs
Using Benchmarks
Many factors affect staffing, including the types of professional and ancillary services
provided, physician preference, and the financial status of the practice. Analysis of
Medical Group Management Association (MGMA) data on staffing numbers and
financial ratios shows that medical practices have decreased financial performance at the
lowest and highest levels of staffing. If a practice has too few employees, it isn’t
maximizing provider productivity and revenue is reduced. If there are too many
employees, salary and benefit expenses outweigh the benefits of increased productivity.
Group practice averages for staff-to-physician ratios are tracked in the annual MGMA
Cost Survey Report and Performance and Practices of Successful Medical Groups as well
as within the American Academy of Pediatrics (AAP) Socioeconomic Survey of Pediatric
Practices. In the AAP survey, a median practice size is defined as 3.5 full-time equivalent
(FTE) physicians and 8 nonphysician staff including nurses. Staff-to-physician ratio
increases with practice size, averaging 3.4 staff per physician in solo and 2-physician
practices to 3.8 in pediatric group practices with more than 5 physicians. In the MGMA
Performance & Practices of Successful Medical Groups: 2008 Report Based on 2007
Data, total support staff per FTE physician was 4.81 FTE for single-specialty primary
care better performing groups versus 4.19 FTE for others. Medicine single specialty
showed 6.18 FTE staff per FTE physician for better performing groups versus 4.16 FTEs
for others.
Deborah Walker Keegan, MBA, FACMPE, coauthor of Rightsizing: Appropriate Staffing
for Your Medical Practice, recommends a 3-step process for evaluating your staffing
levels.
1. Benchmark your clinical and administrative staffing levels, staffing costs per
physician, and salary and benefit costs as a percentage offset medical revenue.
If you use data from Performance and Practices of Successful Medical
Groups, you will compare your practice with better performing groups, rather
than the general group practice population reported in the MGMA Cost Survey
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Report. Better performers tend to have higher staff costs per physician but
lower expenses as a percent of net medical revenue.
2. Analyze your staffing deployment model. Do you have a care team for each
physician, or do the clinical and administrative staff serve several different
physicians? Do you feel that the staffing model best serves the physicians?
Your physicians’ preferences will affect their productivity and, therefore, the
total practice revenue.
3. Assess your business operations. Are they streamlined and efficient? Are there
delays due to overloaded positions? Are there means of combining steps? Is
there an emphasis on patient service that will also decrease the number of
patient phone calls and delays in payment?
Practice managers should apply the concept of rightsizing to determine staffing levels for
the practice. Rightsizing is the systematic process of reviewing employee numbers, tasks,
and work processes to determine the appropriate numbers and mix of staff needed to meet
medical practice goals and operate in an efficient manner. Simply comparing staff
numbers with another practice’s doesn’t provide the understanding needed to maximize
practice performance. According to David N. Gans, MSHA, FACMPE, coauthor of
Rightsizing: Appropriate Staffing for Your Medical Practice, rightsizing is “the right
number of staff, in the right place, with the right skills, at the right cost, with the right
behavior, the right rewards, and the right outcomes—no more, no less.”
The key element of hiring staff is hiring well. It is important to be thoughtful in the hiring
process and not panic hire. Sometimes going without a staff person for a period can be a
better alternative than grabbing a warm body. Following are some tips to help you when
hiring staff:
•
•
•
•
Hire people that have the right chemistry for you and the practice. Think about the
team as you hire. Everyone can’t be the same—you need a good mixture of
introverts and extroverts, some people persons and some number crunchers, but
think how they will fit together. Can you see them getting along?
Hire the person, train the job. Some of the best staff have been formally employed
in fields other than medicine. Learn to be directive and decisive in deciding that
some staff won’t make it, but everyone has to learn something.
Insist on maturity when you hire and tell the candidates up front. Inform them that
the practice does not tolerate such things as cliques and racial segregation in the
office. Instead, tell them that the practice expects staff to be up front, loyal, honest,
and cooperative.
Test potential staff on basic skills such as adding and subtracting, alphabetizing,
and other skills.
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•
•
Allow trusted staff members to be part of the interviewing process. This can
empower the incumbents and give you good perspective.
Accept that only a percentage of your hires will be good ones; some will be
mistakes.
Front Office
The front office staff is likely the first point of contact that your patients have with your
office. In the long term, it pays to make sure that interaction with your front office is a
positive experience. It can be challenging, but not impossible, to find exceptional staff.
While there is no perfect method for hiring front desk staff, these 3 guidelines can help to
find the best person for the job.
• When placing an ad, ask the applicant to send a résumé and cover letter explaining
what makes him a good candidate for the position. Failure to include a cover letter
means that the applicant doesn’t follow directions and is an easy way to weed
some out.
• During the interview process, ask open-ended, behavioral questions that can reveal
a lot about the candidate’s maturity level (Who was your least favorite boss and
why? What could you have done to change the relationship?), work habits (Tell
me about a time you saw room for improvement and what you did to change the
status quo?), and attendance (What would your last boss tell me about your record
of absences and tardiness?). Avoid yes/no questions (Are you a team player?)
because the desired answer is obvious to the candidate and requires little thought.
Visit http://practice.aap.org/content.aspx?aid=2235 for additional tips and sample
questions.
• Don’t automatically disqualify a candidate for lack of medical office experience. It
can be easier to teach basic front desk responsibilities such as collecting copayments and scanning insurance cards than to teach positive attitude and
customer service skills. Oftentimes, the best employees have come not from
medical practices but from fields that require the ability to provide excellent
customer service.
Nursing Staff
Equally important is hiring the appropriate nursing staff for your office. Nursing staff can
consist of registered nurses, licensed practical nurses, medical assistants, and certified
nursing assistants. Whichever you choose to employ, it is important that the nursing staff
is adequately trained, personable, and knows their limitations. Be sure to check with your
state laws on the roles and job responsibilities of each position.
When interviewing nursing staff, some practices request that the candidate job shadow
other nursing staff to ensure that the candidate is a good fit for the practice and with the
other staff. This provides the candidate with the opportunity to learn about the practice
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work flow, job responsibilities, and what is expected if he is offered the position. This
opportunity can be especially important for those nurses who might not have experience
with pediatric patients or are recent graduates.
Additionally, job shadowing provides your current staff the opportunity to provide
feedback and input on potential colleagues. It can help build morale because it allows
them to feel like part of the process. However, because job shadowing is part of the
interview process, it is important to train your current staff on appropriate and
inappropriate questions to ask of the candidate. Only questions related to job
responsibilities should be asked.
Finally, if job shadowing will be incorporated into your practice, be sure that candidates
sign a confidentiality agreement.
Benefits and Implications of Hiring Registered Nurses, Licensed Practical Nurses,
Certified Medical Assistants, and Certified Nursing Assistants
Using the following background, practices can get a better sense of what might work best
for their particular situation.
Registered nurses (RNs), regardless of specialty or work setting, treat and educate
patients and the public about various medical conditions, and provide advice and
emotional support to patients and family members. Registered nurses record patients’
medical histories and symptoms, help perform diagnostic tests and analyze results, operate
medical machinery, administer treatment and medications, and help with patient followup. Registered nurses teach patients and their families how to manage their illnesses or
injuries, explaining posttreatment home care needs such as diet and nutrition, exercise
programs, and self-administration of medication. Some RNs provide direction to licensed
practical nurses (LPNs) and nursing aides concerning patient care.
The 3 typical educational paths to registered nursing are a bachelor degree (BSN), an
associate degree (ADN), and a diploma from an approved nursing program. Nurses most
commonly enter the occupation by completing an ADN or BSN program. Individuals then
must complete a national licensing examination to obtain a nursing license. Sample job
descriptions for RNs, clinical nurses, clinical nurse supervisors, and staff nurses can be
found on Practice Management Online (PMO) at
http://practice.aap.org/content.aspx?aID=2042.
Licensed practical nurses care for people who are sick, injured, convalescent, or
disabled under the direction of physicians and RNs. Licensed practical nurses measure
and record patients’ vital signs such as height, weight, temperature, blood pressure, pulse,
and respiration. As part of their work, LPNs collect samples for testing, and record food
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and fluid intake and output. They clean and monitor equipment. Sometimes they help
physicians and RNs perform procedures. Experienced LPNs may supervise nursing
assistants.
LPNs must complete a state-approved training program in practical nursing eligible for
licensure as well as pass an examination. Most training programs are available from
technical and vocational or community and junior colleges.
Medical assistants perform administrative and clinical tasks to keep the offices of
physicians running smoothly. The duties of medical assistants vary from office to office,
depending on the location and size of the practice and the practitioner’s specialty. In small
practices, medical assistants usually perform many different kinds of tasks, handling
administrative and clinical duties and reporting directly to an office manager, a physician,
or another health practitioner. Those in large practices tend to specialize in a particular
area, under the supervision of department administrators. Medical assistants should not be
confused with physician assistants (PAs) who examine, diagnose, and treat patients under
the direct supervision of a physician.
Clinical medical assistants have various duties, depending on state law. Some common
tasks include taking medical histories and recording vital signs, explaining treatment
procedures to patients, preparing patients for examination, and assist physicians during
examinations. Medical assistants collect and prepare laboratory specimens and sometimes
perform basic laboratory tests, dispose of contaminated supplies, and sterilize medical
instruments. As directed by a physician, they might instruct patients about medications
and special diets, prepare and administer medications, authorize drug refills, telephone
prescriptions to a pharmacy, draw blood, prepare patients for radiographs, take
electrocardiograms, remove sutures, and change dressings. Medical assistants also may
arrange examining room instruments and equipment, purchase and maintain supplies and
equipment, and keep waiting and examining rooms neat and clean.
Medical assisting programs are offered in vocational-technical high schools,
postsecondary vocational schools, and community and junior colleges. Postsecondary
programs usually last 1 year and result in a certificate or diploma, or 2 years and result in
an ADN. Accredited programs often include an internship that provides practical
experience in physicians’ offices or other health care facilities. Formal training in medical
assisting, while generally preferred, is not required. Many medical assistants are trained
on the job and usually only need a high school diploma or the equivalent.
Additional information on using medical assistants can be found in “The Certified
Medical Assistant (American Association of Medical Assistants): An Invaluable Asset for
the Pediatric Office” (http://practice.aap.org/content.aspx?aid=2815)
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Certified nursing assistants provide hands-on care and perform routine tasks under the
supervision of nursing and medical staff. Certified nursing assistants may be responsible
for taking a patient’s vital signs such as temperature, pulse rate, respiration rate, and blood
pressure. Some aides help other medical staff by setting up equipment, storing and
moving supplies, and assisting with some procedures. Nursing aide training is offered in
high schools, vocational-technical centers, some nursing care facilities, and some
community colleges. Federal government requirements exist for nursing aides who work
in nursing care facilities. These aides must complete a minimum of 75 hours of stateapproved training and pass a competency evaluation. Certified nursing assistants are
placed on the state registry of nurse aides.
The practice will have to consider issues such as physician preference, work flow
requirements, and state-based scope of practice limitations before making any hiring
decisions. States, for example, may limit vaccine administration to RNs only. The
physicians in the practice may want RNs to handle the nurse triage calls from parents or
triage a patient who “drops in” to the office without an appointment. Experienced LPNs
also may be able to handle triage calls, however, so the practice manager will need to
examine the pros and cons for each choice.
When hiring staff, it is important that the staff have skills to provide good customer
service. Patients may leave your practice if staff are difficult, even if they love the
pediatrician. All staff should be understanding and dependable, enjoy working with
people and children, be able to work as a team, and have good communication and
decision-making skills. While these traits might be difficult to assess, behavior-based
interviewing allows employers to ask the candidate questions about how they have
handled previous situations in an effort to predict their future behavior. More on behaviorbased interviewing and sample questions can be found at
http://practice.aap.org/content.aspx?aid=2235.
Additional hiring tips can be found on PMO at
http://practice.aap.org/content.aspx?aid=2865
Additional Resources
To learn about staffing ratios, read “Median practice size, patient caseloads highlighted in
AAP report” (http://practice.aap.org/content.aspx?aid=2822).
For information on using medical assistants, read “The Certified Medical Assistant
(American Association of Medical Assistants): An Invaluable Asset for the Pediatric
Office” (http://practice.aap.org/content.aspx?aid=2815).
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Considerations for Nurse Practitioners/Physician Assistants
When hiring a nurse practitioner (NP) or PA, it is important to clearly outline the
practice’s expectations. While one practice may allow more independence, others are very
clear that in no way will the NP or PA function in the same capacity as a physician. Also,
many insurance companies will not pay at nearly the same level for an NP or PA as they
would a physician. It’s important to determine that the type of clinician hired is financially
profitable for the practice. Of course, state and federal laws addressing scope of practice
must always be followed. For additional information, visit
http://practice.aap.org/content.aspx?aid=2176.
Nurse practitioners can be important assets to your practice and can help you carry out
your mission. In the case of expanding a practice, certified pediatric nurse practitioners or
certified nurse practitioners can be employed as physician extenders. Each should have a
collaborating physician at the primary practice site; however, all pediatricians should be
scheduled and work collaboratively with them.
Nurse practitioners and pediatricians should work together as a team. They should not be
asked to carry an individual patient panel, but rather work together with all of the
pediatricians to improve access to well care and illnesses. Some practices might use them
extensively for well-child care and to see those sick-visit patients who want or need to be
seen urgently. Using nurse practitioners can help keep patients coming to your office,
rather than seeking alternative options for non-pediatric medical care.
It is important to have a practice that does not allow or foster competition between
pediatricians and nurse practitioners. Patient care should be in collaboration, open
questioning and discussion, and working together on ideas stressing best practices for
each patient.
It is also important to use the strengths that nurse practitioners bring to your practice.
Some may have additional education and training on specifics topics or health
conditions. If this is the case, encourage this nurse practitioner to receive referrals from
physicians at all locations to do topic-specific counseling and create individualized patient
plans.
Nurse practitioners can be used to assist with elevating the level of care and knowledge in
the practice and, more importantly, can help to standardize care among your offices and
providers by actively auditing practice policies and coding and clinical management. They
can be asked to take on specific tasks to benefit the practice such as championing issues
like introducing fluoride varnish activities, immunization registry usage, or new
equipment.
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Nurse practitioners can bring a different perspective to the practice that may attract a
broader patient population. Some practices use their nurse practitioners to represent the
practice at schools, community events, and even serving on child advocacy organization
boards. They can help in carrying out important messages on nutrition, exercise,
adolescent care, immunizations, and breastfeeding. Utilizing these skills may result in
better care, communication, and patient and parent education. An additional task might be
to serve as the clinical research coordinator for those practices engaging in clinical
research.
To provide optimal care for your patients, increase comfort level among the physicians,
and increase job satisfaction for the nurse practitioner, the following are tips to a
successful working relationship:
• Respect each other.
• Listen to one another.
• Be open and approachable.
• Always keep the patient as the focus.
• Provide on-site oversight.
• Allow nurse practitioners to see patients independently, but be directly available
for consultations.
• Limit the complexity of patients.
When hiring nurse practitioners, it is important to consider candidates’ background,
training, and experience. Some practices require that nurse practitioners specialize in
pediatrics. Be sure that the candidate’s background matches your expectations. Also,
when hiring a nurse practitioner, consider which benefits you will offer. Some practices
offer the same benefits that are offered to physicians, including pay for continuing
medical education, professional liability insurance, and health benefits.
Finally, as stated in Section 4, “Launching Your Career in Pediatrics: Practice Work Flow
and Policies,” (http://practice.aap.org/content.aspx?aID=2797) creating an employee
handbook is essential. This assists the practice with providing employment expectations.
Part-time and Full-time Staff
In addition to general skills and scope of practice issues, practices should consider that
some states (eg, New Jersey) have a per capita licensed professional fee that must be paid
every year for the number of licensed professionals (eg, nurse, laboratory technician). If
the practice has several part-time or per diem staff, it may not be financially beneficial to
keep that large number of employees on the payroll who do not work as often (increasing
visits and revenue) but for whom the practice is paying annually to keep them employed.
How to Most Effectively Use Staff
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Cross-training administrative and clinical staff can greatly ease the burden on the practice
in the event of vacations or other employee absence. Front desk personnel can be crosstrained for switchboard and medical records. Staff members who primarily work with
insurance companies can be cross-trained to help at the front desk and with medical
records. Certain nursing staff can be cross-trained in simple laboratory procedures.
Each practice may have different opportunities for cross-training. Setting time aside to
speak with staff and get their ideas on logical cross-training arrangements can benefit the
practice and increase buy-in from staff when the time comes to use their new skills.
When to Hire Staff
New Positions
As the practice grows, new positions may become necessary. Partners may decide to
pursue additional clinical services, medical home activities may require additional staff
(eg, care coordinator), or grant opportunities through government entities like departments
of public health may present the need to develop new positions.
Practice managers will need to assess the full ramifications of any new position. Issues to
be considered include
• Market need and sustainability
• Break-even requirements (eg, time, revenue)
• Position duration (permanent or time-limited)
• Job description (see Creating and Maintaining Job Descriptions and
Employment Contracts) http://practice.aap.org/content.aspx?aid=2863
Managers should consider whether a new position is needed or if the new activities being
proposed could be assumed by another staff person, perhaps resulting in advancement
opportunities for experienced staff. This can help with staff retention as well as
maintaining or improving general staff morale.
If the new position is being considered simply because of increased volume, managers
must carefully consider the revenue required to support a new position. When factoring in
benefits, the salary for the new position may put the practice at financial risk if the
manager is not aware of how many new patients or new activities are required to support
it. The manager can consider phasing in the new position in increments and then slowly
building to a complete FTE.
Open Positions
When a position opens up because of an employee leaving voluntarily or otherwise, it
presents an opportunity to reevaluate whether that employee needs to be replaced or
whether the job responsibilities could be distributed among remaining staff. As practices
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grow and employees’ skill sets improve, fewer employees may be able to accomplish
more and the open position does not need to be filled.
More general tips on hiring can be found on PMO at
http://practice.aap.org/content.aspx?aid=2865.
Implementing Layoffs
The decision to implement layoffs is a serious one and should be made only after
considering all other options. In addition to the effect the decision will have on the
individual(s) being laid off, those who are left will likely experience an increase in
workload as well as lingering concerns as to how long they will remain employed
themselves. When staff morale is affected like this, it can easily be transferred to the
patient families. Despite whatever financial difficulties the practice may be facing, it is,
above all, still a business with customers who will require a certain level of customer
satisfaction. With increased tension or employee dissatisfaction, patient families may be
inclined to complain about services or seek services elsewhere, causing additional
financial strain on the practice.
Before making decisions, talk with your staff. Present the basic financial picture for the
practice, indicating the need for reducing expenses. Staff may see opportunities in the
day-to-day activities to increase revenue or significantly reduce other expenses before
reducing staff. For example, they may be willing to each take an unpaid day to avoid an
entire position being eliminated. You may have staff interested in cutting back hours or
working part-time instead of full-time. Other areas to consider reducing expenses to avoid
layoffs include
• Discontinuing retirement plan funding for 1 year, potentially saving 12 FTEs
• Eliminating bonuses temporarily
• Reducing medical insurance premiums or increasing cost sharing with employees
• Forfeiting paid holidays
• Temporarily freezing pay increases
Additional ideas to reduce expenses or increase revenue can be found in these articles.
•
•
•
“Decrease Overhead While Protecting Your Most Valuable Assets: A Large Practice’s
Efforts to Cut Costs in an Economic Crisis”
(http://practice.aap.org/content.aspx?aid=2847)
“Practice Overhead” (http://practice.aap.org/content.aspx?aid=2388)
“Effect of Economic Recession on Pediatric Practices”
(http://practice.aap.org/content.aspx?aID=2871)
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Additional Resources
Sample Employee Handbook (http://practice.aap.org/content.aspx?aid=2091)
You Want Me to Write What? (http://practice.aap.org/content.aspx?aid=1056)
Hiring for a Position: Tips on Interviewing
(http://practice.aap.org/content.aspx?aid=2235)
Recruiting, Interviewing, and Hiring
Recruiting
There are a variety of ways to recruit new employees. Word of mouth can be the best and
least expensive way for staff and physicians. Generally, people will recommend
competent individuals because they may end up working alongside them or having them
care for their children. Contacting local residency directors is another great, inexpensive
way to get the word out that you are looking for a new physician.
In addition to word of mouth, PMO has tips on recruiting physicians
(http://practice.aap.org/content.aspx?aID=2866) that may be helpful. Also, consider using
bulletin boards or job posting pages with state AAP chapters
(www.aap.org/member/chapters/chapters.htm), state medical societies, state and national
MGMA chapters, and other organizations with whom members of the practice are
involved. PedJobs (www.pedjobs.org) is another resource for employers and seekers.
Interviewing
When hiring, always have more than one person interview a candidate—different people
will see different sides of a person and can identify potential future problems.
Interviewers do not necessarily need to be from the same area in which the new employee
would work. At times, it is helpful to get perspective from other areas in the practice to
help improve the efficacy of the position in the area that is hiring.
Traditional interviews are necessary, but job shadowing is also a very helpful technique. It
allows the individual to know exactly what he is getting into before accepting the
position. Not all positions require past experience in pediatrics, but they do require the
employee to be flexible and willing to work in a pediatric environment. Unlike working
with adults, pediatric practices have the added challenge of working with children as well
as their adult caregivers. Not all potential employees realize how difficult that can be. Job
shadowing will help the potential employee ask better questions as well as provide
interviewers more insight into the personality of the potential new hire—things that are
more difficult to find out in a direct interview.
Behavior-based interviews have become popular recently, replacing loosely structured,
traditional interviews. This type of interview allows employers to ask the candidate
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questions about how he has handled previous situations in an effort to predict future
behavior. Behavioral interviewing is used to help ensure that there is a good match
between the employer and employee, lower turnover rates, and increase job satisfaction
and performance. Behavioral interviewing focuses on asking about a situation in the past,
the action taken to address the situation, and the outcome. Visit
http://practice.aap.org/content.aspx?aid=2235 for details and sample questions.
Additional Resources for Hiring Currently on Practice Management Online
• “Hiring Quality Staff” (http://practice.aap.org/content.aspx?aID=2865)
• “Recruiting and Hiring Physicians”
(http://practice.aap.org/content.aspx?aID=2866)
Physician Contracts
If you are responsible for establishing and maintaining employment contracts with the
physicians in the practice, there are numerous items the contract should address, such as
• Dates
• Duties
• Time of work (particularly now with significantly more part-time employees)
• Paid time off (eg, vacation, sick leave, continuing medical education [CME])
• Methods of compensation
• Malpractice specifications, including tail coverage when the employee leaves
• Other benefits and expectations (eg, dues payment, medical coverage)
• Buy-in options for partnership
The contract should also address representations, warrants, and covenants, as well as
indemnity clauses and provisions addressing termination. The contract must discuss the
effect on successors (heirs), amendment provisions, and governing laws (of the state), as
well as a severability clause and the provision for attorneys’ fees in the case of legal
action or dispute.
A sample contract can be found at http://practice.aap.org/content.aspx?aID=2100.
Additional information is available at http://practice.aap.org/content.aspx?aid=2107.
Contracts for Physician Extenders
Physician extenders can have contracts function as standard employees of the practice.
Depending on each state’s regulations, a practice that uses a contract with its physician
extenders should consider most of the same features that are considered in a physician
contract. While nonphysician partners are rare, the arrangement does occur. So any
potential for partnership status with a physician extender should be explicitly outlined in
the contract.
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Legal Review of Contracts
While a standard contract can be used as a starting point, generally all contracts should go
for final legal review prior to signing. Having legal counsel that is familiar with changing
state and federal regulations related to practice can be invaluable. With regard to contracts
for physicians and physician extenders, even local circumstances can influence what can
or cannot be included, and thorough legal review can prevent significant complications
when personnel need to be terminated or leave willingly.
Each state’s medical society may have legal resources available for its members.
Information on state medical societies can be found on the American Medical Association
(AMA) Web site (www.ama-assn.org/ama/pub/about-ama/our-people/the-federationmedicine/state-medical-society-websites.shtml)
Using Sample Job Descriptions or Contracts
Practices don’t need to start from scratch with job descriptions or contracts. Practice
Management Online has a number of sample job descriptions and contracts that can be
modified and used for each individual situation. These resources are located in “Sample
Personnel Documents” in the Practice Toolbox
(http://practice.aap.org/samplepersonneldocs.aspx).
If you are considering adding another physician to your practice, visit
http://practice.aap.org/content.aspx?aid=2257 for things to consider. Practice
Management Online also has several other resources that can be used to assist with hiring
a new physician for the practice.
Locum Tenens
Locum tenens positions are one way to practice medicine without the responsibility of
owning or managing a practice. Visit PMO (http://practice.aap.org/) for additional
information.
Additional Resources
Physician Salaries and Financial Considerations
(http://practice.aap.org/content.aspx?aid=2339)
Employment Contracts: A Practice Management FAQ
(http://practice.aap.org/content.aspx?aid=2107)
Hiring Generation Xers and Millennials: What Do They Really Want?
(http://practice.aap.org/content.aspx?aid=2702)
The Pediatric Workforce: What to Expect
(http://practice.aap.org/content.aspx?aid=2699)
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Physician Recruitment in Pediatric Practice
(http://practice.aap.org/content.aspx?aid=2194)
PedJobs: The AAP Employment Resource
(http://practice.aap.org/content.aspx?aid=1659)
Hiring for a Position: Tips on Interviewing
(http://practice.aap.org/content.aspx?aid=2235)
Managing Staff
Once employees have been hired, you must manage them. You don’t want loose cannons,
but you also don’t want unimaginative drones. You don’t want to micromanage, dotting
their i’s and crossing their t’s, but you also don’t want them going forward with a blank
slate. So how do you keep in touch, guide, and trust, but verify?
First of all, determine if you should be doing the job of practice administration. The
debilitating conceit of practicing physicians is thinking that administration is only pushing
paper and that practicing medicine directly with patients is the only respectable pursuit of
a physician. If this is your belief, and you don’t find running a practice or practicing
administration to be challenging and rewarding, you should not be the one doing it. If you
find yourself constantly practicing medicine and not tending to your administrative job,
consider hiring a practice administrator. Read “Factors to Consider When Hiring an
Administrator: A Practice Management FAQ”
(http://practice.aap.org/content.aspx?aid=2122) for more information.
To run a practice, you need to have regularly scheduled meetings with key staff. Be sure
to take them seriously. Don’t be late for them—that is disrespectful—and don’t be
hurrying off to do your “real job” of taking care of patients. When conducing the meeting,
follow an agenda that includes discussions continuing from meeting to meeting. Each
topic should have an action item with progress documented. Try to distinguish what is
urgent from what is important. Urgent tasks tend to drive out important ones. However, it
is crucial to remain aware of the important tasks; otherwise they will languish and you
will not make real progress.
How Do You Keep Track Without Micromanaging?
Although much contact between levels of management will inevitably be oral, important
things need to be written down and saved. Some practices have many different practice
locations, each one with an office manager. Consider requesting that the office manager
complete a weekly report due on the same day each week. Use a standard template for the
report with standard items to complete. Color code each week’s comments so that it is
easy to see new editions. Leadership can then respond to these reports with comments
within 24 hours. The comments may or may not be substantive, but the reports always
need to be acknowledged. The templates also need to be simple enough so that they are
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not oppressive. Besides helping the upper levels of administration keep track of local
events, these reports can serve as a to-do list and help the office manager think about
goals and priorities. Click here (http://practice.aap.org/startinginpractice.aspx) for a
sample.
A second type of report is called a management action plan. This report can be used by a
business manager, clinical office manager, IT manager, and others. It is similar to the
office manager report but more variable and detailed. This is used as a guide for meetings
to track progress and keep objectives in mind. Click here
(http://practice.aap.org/startinginpractice.aspx) for a sample.
Setting Office Policies
The importance of having clear policies in place for the practice cannot be emphasized
enough. Just as with patients, documentation is critical. For example, if the practice does
not have a written policy and procedure for addressing tardiness, supervisors can become
increasingly frustrated with no guidance or support to address an employee who
consistently arrives late for work.
Practices should have policies that address a variety of different areas. Policies should
address not only the functional issue but also the consequences and procedures in the
event the policy is not followed. Each policy should identify the appropriate staff person
to address questions or concerns related to a policy. Ironically, there should also be a
policy about the process for creating policies and procedures. It should delineate who has
the authority to write, approve, and terminate policies. A standard format for policies can
also be helpful, if appropriate.
Some common policies and procedures found in the pediatric practice setting are
• General employee handbook (http://practice.aap.org/content.aspx?aid=2805) that
address personnel issues and office operations (eg, time off, schedules)
• Privacy manuals (eg, HIPAA: A How-To Guide for Your Medical Practice
(http://practice.aap.org/hipaa.aspx), “Preparing Your Practice for the ‘Red Flag
Rules’” http://practice.aap.org/content.aspx?aid=2687)
• Occupational Safety and Health Administration
http://practice.aap.org/content.aspx?aid=2808 (compliance
http://practice.aap.org/content.aspx?aid=2151 and preparing for inspection
http://practice.aap.org/content.aspx?aid=2832)
Staff should be alerted immediately if policies are changed or introduced. To keep staff
familiar with existing policy, consider reviewing a policy at each staff meeting or
regularly posting one policy in a common area (eg, lunchroom, locker area) for staff to
review. Consider requiring all staff to have received and reviewed the employee handbook
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to ensure that they are aware of the policies.
Additional Resources
Duties of a Pediatric Office Manager (http://practice.aap.org/content.aspx?aid=2123)
Job Description: Practice Administrator (http://practice.aap.org/content.aspx?aid=2115)
Factors to Consider When Hiring an Administrator: A Practice Management FAQ
(http://practice.aap.org/content.aspx?aid=2122)
Salaries: Medical Office Administrators and Office Managers
(http://practice.aap.org/content.aspx?aid=2014)
Hiring for a Position: Tips on Interviewing
(http://practice.aap.org/content.aspx?aid=2235)
Training and Evaluating Staff
Hiring a new employee requires significant investment for any practice in terms of time,
money, and energy. The practice needs to develop the skills and attitude in the new hire
that will match and enhance the practice culture. The employee, current staff, and practice
as a whole will benefit from the initial time and effort spent to effect a positive
introductory period. A well-planned and thorough orientation program provides specific
goals and defines the practice’s expectations of the new employee.
Be sure to check with your state laws on appropriate training (eg, Occupational Safety and
Health Administration). Practice Management Online has several sample training
templates, policies, procedures, and more available at
http://practice.aap.org/samplepersonneldocs.aspx.
Orientation
Create a customized orientation program for each job type. Each program should serve as
a welcome to new employees and inform them of the practice’s mission and values.
Meeting Staff
Provide everyone in the practice an opportunity to meet the new employee in a less formal
setting than a staff meeting. This can be done using an introductory breakfast or luncheon,
or just a short meet and greet with snacks. If the practice doesn’t use them already,
consider having name tags to make it a little easier on the new employee that first day.
Review the Employee Manual
Review the employee manual, highlighting key areas related to policies, procedures,
benefits, and other daily issues for which standards have been set. Past experiences,
positive and negative, can help inform the decision as to which areas of the manual are
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most important to highlight.
Direct the new employee to the employee manual and practice policies and procedures.
Allow solitary time for reading and review time daily. Encourage questions about policies
and why the practice does things in a prescribed way.
Observation Time
Schedule observation times of 1 to 3 hours with employees in other positions to expose
the new staff member to all jobs. This encourages one-on-one conversation and may
provide insight into the job duties in which this staff member is best suited to be crosstrained.
Assign a Mentor
Assign a mentor to the new employee for the introductory period. This person should not
be a direct supervisor but should instead be someone who functions as a leader in the
practice (regardless of actual job title). The mentor should have experience and judgment
that has proved trustworthy, and have enough knowledge of the employee’s new area of
work to support him effectively. Provide the mentor with a defined orientation plan to
guide the mentor and employee through the introductory period. The mentor should be
allowed space to continue doing his own job effectively. The new employee should be
encouraged to develop relationships with other coworkers as well as his supervisor.
During the introductory period, the practice manager should visit with the new employee
and mentor separately on a regular basis. This could be weekly or every 2 weeks,
depending on the individual situation.
General Guidance for the Orientation Period
An employee who has a good understanding of the work environment and is comfortable
with the expectations of the practice is far more likely to be productive and effective.
Particularly in the start of a new work relationship, the fear of failure is common. A
thorough and well-developed orientation schedule can alleviate fears and anxieties during
the introductory period and encourage better performance.
Orientation takes time, of which most practice staff have precious little to spare. Using
different media such as online or DVD trainings, or even external training resources (eg,
training through a software company), can provide some relief about time commitment on
current staff while still providing the new employee the orientation needed to ensure a
successful transition into the practice setting. Be creative and open to new ways of
conducting the orientation, and don’t be afraid to modify the format as needed.
Each orientation session is a good opportunity to obtain feedback from a new employee
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who has a fresh perspective. Remember to ask the new employee how she feels the
process is going and what you can do to help improve the quality of the orientation. This
is an opportune time to begin modeling the style of communication that is expected,
which will hopefully allow for a trusting, open rapport between the new employee and all
colleagues that will continue to grow during their time at the practice. Extra time spent
during this initial period is an investment that will hopefully pay off in a stronger new
employee and a more effective pediatric practice team.
Orientation Resources on Practice Management Online
• “Back Office Training Guide”
• “The Employee Handbook”
• Office Managers Clinical Orientation http://practice.aap.org/content.aspx?aID=2036
From HIPAA: A How-To Guide for Your Medical Practice
• Training Documentation Form
• Security Policy Training Checklist
• Workforce Confidentiality Agreement
• Sample Security Incident Policies and Procedures
Compensation Resources on Practice Management Online
• “Staff Salaries” (http://practice.aap.org/content.aspx?aid=2713)
• “Establishing Staff Salaries” (http://practice.aap.org/content.aspx?aid=2864)
• “Physician Salaries and Loan Repayment Options”
(http://practice.aap.org/content.aspx?aid=2339)
• “Salaries: Medical Office Administrators and Office Managers”
(http://practice.aap.org/content.aspx?aid=2014)
External Compensation Resources
• American Academy of Pediatrics Socioeconomic Survey of Pediatric Practices
(http://tinyurl.aap.org/pub75856)
• US Department of Labor Bureau of Labor Statistics Occupational Employment
Statistics List of SOC Occupations (www.bls.gov/oes/current/oes_stru.htm#290000)
• MGMA Physician Compensation and Production Survey (purchase at
www5.mgma.com/ecom/Default.aspx?tabid=138&action=INVProductDetails&ar
gs=5438&kc=PHY11WE00)
Performance Objectives
Performance objectives should be considered for each employee, as well. Performance
objectives should be
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•
•
•
Measurable
Attainable
Beneficial to the employee and practice
Performance objectives should not be simply a restatement of the employee’s current job
responsibilities. They should be evaluated every year, as well, and their status or outcome
included as a portion of the performance review itself.
Encouraging staff to participate in professional development activities will encourage
professional growth and keep the employee’s interest. The employee’s sharpened skills
will help improve job performance and also provide fresh perspective on practice
operations that can be improved.
Frequency of Reviews
The official performance review should occur at least annually. For new employees,
practices should consider reviews at the 90-day or 6-month marks to ensure that the
arrangement is still appropriate between employee and practice, and to ensure that the
employee has a firm grasp on the responsibilities associated with the position.
While the formal review may occur only annually, supervisors and employees often find it
beneficial to meet regularly to monitor progress on any areas of concern as well as on any
performance objectives that were set during the review process.
Legal Review of Performance Review Templates
As with all things related to personnel issues, it may be helpful to have a legal review of
all standard templates to ensure that they comply with state and federal laws that may
apply.
Each state’s medical society may have legal resources available for its members.
Information on state medical societies can be found on the AMA Web site (www.amaassn.org/ama/pub/about-ama/our-people/the-federation-medicine/state-medical-societywebsites.shtml
Conducting and Reviewing Staff Evaluations
The performance review process can be viewed as a 3-step process—prereview, review,
and post-review.
During the pre-review phase, the supervisor will complete the performance review based
on the template used by the practice. The supervisor may opt to obtain feedback from
other staff members who work closely with the employee. This can be done simply by
asking for feedback in an unstructured way, or practices can create a template form for
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this. The supervisor can ask the employee to complete a self-assessment. This selfevaluation can be used by the supervisor to highlight areas of concern or interest to the
employee and will help alert the supervisor to any potential differences in how the
employee and supervisor view the employee’s performance over the past year.
The review phase will include an in-person meeting between the supervisor and
employee. Together, they will review the performance review itself. Ideally, the employee
should have the opportunity to see the review prior to the meeting so questions and
comments can be developed and addressed during the meeting rather than after it.
Once the meeting has occurred to discuss the performance review, the post-review phase
begins. The employee will be given a defined period during which the following will
occur:
• The employee will sign and return the performance review to the supervisor.
• The employee will develop a draft set of performance objectives for review and
approval by the supervisor.
• If necessary, action plans will be developed to address any areas of concern (not
areas of general professional development possibilities, but significant problems
that are identified through the review process). The action plan should be clear,
concise, measurable, and have a definite timeline for each item being addressed so
progress can be reviewed appropriately.
Reviews for Clinical Versus Nonclinical Positions
While many of the issues addressed in the performance review template will be applicable
to any employee, there will be some differences for clinical versus nonclinical employees.
The duties outlined in the job descriptions for each type should guide the supervisor in
terms of evaluating the employee’s performance. Supervisors should also consider the
following:
For clinical positions
• What are the quality improvement initiatives currently underway within the
practice? How do these affect clinical outcomes and to what extent is this
employee responsible for ensuring certain outcomes are attained?
• What data does the practice have to more accurately measure this employee’s
clinical performance (eg, data from electronic medical record or practice
management software)?
• To the extent permitted by state and federal law, how independently does the
employee function? Is this within the guidelines of the practice? Should the
employee be functioning more independently?
• Is this employee’s documentation of work sufficient for coding audits and
effective billing to payers?
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For nonclinical positions
• Are procedures in place to effectively measure employee performance (eg, for
front desk staff, how long are incoming calls placed on hold)?
• Is this employee effectively cross-trained?
• How does this employee’s performance affect the overall efficiency of practice
operations?
Connecting Performance Reviews With Pay Increases
Employers will often connect the results of an employee’s annual performance review
with pay increase for the year. It is important to clearly outline the procedure for this in
the personnel manual and ensure that all employees understand the policy. The practice
may decide that, at minimum, each employee will receive a cost of living adjustment
(COLA) each year, regardless of performance review scores. The COLA that will be used
should be determined prior to the start of the fiscal year and applied throughout the year.
The practice can create a tiered system associated with performance for any additional
increases it chooses to give. For example, if the practice uses a rating scale of 5 for its
review process (ie, 1, unacceptable performance; 5, exemplary performance), it may
choose a percentage increase associated with each rating level. The employee will receive
an overall rating and the increase will be associated with that overall score.
Resources Related to Staff Evaluation Currently Found on Practice Management
Online
It is always easier to start with a template and modify it to meet your needs. Practice
Management Online has a number of resources related to evaluating employees. Most of
them can be found in the Practice Toolbox on PMO (http://practice.aap.org/toolbox.aspx)
direct links follow:
•
•
•
•
•
•
•
“Staff Evaluations: Guidelines and Instructions”
“Staff Performance Evaluation”
“Clinician Evaluation and Progress Criteria”
“Staff Evaluations: Template”
“Performance Review—Self-Review Form”
“Employee Evaluation of Physician Performance”
“Laboratory Testing Personnel Performance Appraisal”
Additionally, continuously monitoring staff performance is integral to success. Sample
performance appraisals are available on PMO at
http://practice.aap.org/samplepersonneldocs.aspx.
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Physician/Provider Annual Assessments: Evaluating Partners
It is always a tricky business to evaluate yourself and your colleagues, but it is essential.
Ideally it is done on a regular and timely basis, and many people in the practice participate
in the evaluation—other clinicians and managers, for instance—although the actual
conference will usually be between the head of the practice and the clinician.
What Needs to Be Evaluated?
Hard and soft data. Hard data include productivity, however your practice decides to
measure it. Absences, lateness (the managers need to keep track), and other behavioral
data also need to be addressed.
It is very hard to evaluate how good a clinician is because reliable hard data addressing
quality of care and medical outcomes information are not readily available. Feedback
from peers who frequently work with the clinician and thus see his patients and charts can
provide subjective quality assessment. Any chart reviews that have been done, cases that
have come to the attention of the group, or hospital events that have been reported or are
known about should be mentioned in the review. Getting the clinician to focus on selfperceived strengths and weaknesses can be helpful as a guide to future action.
Marketing behaviors are very important. External marketing includes giving talks,
befriending obstetricians and other referral sources, and other activities that bring in
patients. Internal marketing would be measured by the popularity of the clinician with
patients, how satisfied the patients are, how timely the clinician is in seeing patients, and
how willing he or she is to stay late to see late callers.
Attitudes and behaviors are also crucial. Examples include cooperation with others,
collegiality, and general mood and kindliness to staff and others within the practice.
Leadership in the office and willingness to serve on committees or do other positive
things need to be recognized. Rather impressionistic, but important, is how much the
clinician has internalized the practice. How much has the clinician concentrated on what
the practice can do for her, and how much she can do for the practice? Does the clinician
care about the practice as a whole? Are the clinician and practice goals and mission
consonant?
A provider evaluation should provide an overview of assessing the skills listed here
(http://practice.aap.org/startinginpractice.aspx). Ask the clinician to complete this form
prior to the meeting—self-rating—and discuss it together at the meeting. Whatever the
results of the discussion, the act that the form covers all these areas is educational for the
clinician just in itself.
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Employee Evaluation of Physicians or Supervisors
Some organizations have started to use a process called 360-degree evaluation. This
process entails obtaining feedback from employees about their supervisor’s performance.
This can be done in a number of different ways. It can be part of the supervisor’s own
review process, during which the next level supervisor may request feedback from the
supervisor’s direct reports. It can also be done more informally to simply help improve
communication between supervisors and employees, practice operations, or any other
areas that have somehow been identified as needing attention.
Practices have also used this process to help evaluate their physician’s performance from
a nonclinical standpoint. While the employee may not directly report to the physician, she
can provide feedback on observed patient interactions, administrative skills,
documentation, relationships with staff, and other areas the practice has identified as
priority. While this may seem challenging to a practice that has never used this technique,
when done appropriately, it can increase staff leadership skills and staff and physician
morale, and ultimately improve practice operations and patient care.
Additional Resources
PedJobs: The AAP Employment Resource
(http://practice.aap.org/content.aspx?aid=1659)
The Pediatric Workforce: What to Expect
(http://practice.aap.org/content.aspx?aid=2699)
Hiring Generation Xers and Millennials: What Do They Really Want?
(http://practice.aap.org/content.aspx?aid=2702)
Physician Salaries and Financial Considerations
(http://practice.aap.org/content.aspx?aid=2339)
Sample Employment Contract (http://practice.aap.org/content.aspx?aid=2100)
Hiring for a Position: Tips on Interviewing
(http://practice.aap.org/content.aspx?aid=2235)
Handling Conflict and Difficult Situations
Employee Discipline and Warnings
Unfortunately, the performance of employees may not always be what you need it to be to
run a successful practice. Some of the most difficult tasks to do effectively as a supervisor
or owner include disciplining and firing employees. Disciplinary actions may consist of
verbal counseling, written warnings, performance improvement plans, and termination of
employment. As mentioned throughout this handbook, the Employee Handbook and your
written office policies and procedures should guide you and your employees on what
types of behaviors warrant disciplinary action or termination.
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Managing conflict is likely one of the most difficult aspects of a job. Creating a practice
culture that fosters open, clear communication can help reduce conflict and increase
practice efficiency and efficacy.
Practices should have clear policies as to how employees and supervisors should proceed
when resolving conflicts. Practice Management Online has a sample employee handbook
(http://practice.aap.org/content.aspx?aid=2805) that can be modified to meet each
practice’s needs. Having a comprehensive employee handbook and clear expectations
listed in the job description can prevent conflicts as well as provide the practice protection
if an employee chooses to act in an unprofessional manner that warrants disciplinary
action or termination.
If the conflict involves employee behavior, there is a sample management action plan
(http://practice.aap.org/content.aspx?aID=2877) that can be used if the employee is not
being terminated. Information on how to handle terminations and unemployment, along
with other tips on this issue, are on PMO (http://practice.aap.org/content.aspx?aID=2870).
If you are considering termination of an employee, it is important to document
progressive warning and disciplinary measures leading up to the point of termination. The
exception to this would be behaviors that would warrant immediate termination, such as
stealing or violent behavior.
Warnings or disciplinary sessions should be done in face-to-face meetings. During these
meetings, you should aim to accomplish the following:
1. Make sure that expectations of job performance are clear. Policies or performance
descriptions should be in a written format and should be reviewed with the
employee.
2. State the performance or behavior that needs to be improved; the more specific
you can be, the better.
3. Review the level of work performance expectation and that it must be performed
on a consistent basis. Define a target date for improvement.
4. If relevant, identify the support and resources you will provide to assist the
employee.
5. Specify the measurements you will consider in evaluating progress, and over what
time frame you will be evaluating for progress.
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6. State specific consequences if performance standards are not met.
7. Have a form on which all of this is clearly stated. You and the employee should
sign it as well as any other management staff that may be involved in the session.
In a legal confrontation, this documentation will help to support your actions.
Employee Termination Decision
If you have taken steps to help an employee improve his performance and there is not
acceptable improvement, it may be time to terminate the employment. While termination
should be a last resort, do not allow a nonperforming employee to remain employed and
be a detriment to your business. It is important to be familiar with laws addressing firing
an employee in your state. As these may vary from region to region, consult your attorney
or your human resource reference to learn what needs to be done to fire an employee
ethically and legally in your state.
Terminating a person’s employment may allow an employee to claim breach of contract
or wrongful discharge. If you are in state that allows at-will employment in which the
employer reserves the right to terminate an employee without cause, this may not be an
issue. However, other claims may be still be brought against the employer.
In addition to the effect that termination has on the individual employee, it will also affect
the rest of your staff. How you fire an employee may have negative or positive
consequences toward the morale and performance of the rest of your staff. It is important
to decide whether termination is appropriate.
Before deciding to terminate an employee, you should ask yourself the following
questions:
1. Is there a legitimate reason for the employee’s poor performance? Make sure you
have both sides of the story.
2. Is termination reasonable and fair for the nature and level of the grievance(s)?
3. Would this termination be consistent with what the employee has been told thus
far? If the employee has always had favorable performance reviews and recently
received a raise, termination would be hard to justify.
4. Are there alternatives to termination? Should the employee be put on a
performance improvement plan or be given a “last chance”?
5. Has the practice disciplined employees in a consistent manner? Ensure that those
in protected classes have been disciplined in the same manner as those not in
protected classes under similar circumstances.
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You may also choose to offer the employee the opportunity to voluntarily quit rather than
go through disciplinary actions and firing. This should be done within a certain timeline,
during which the employee has the chance to give notice. You may also choose to provide
severance pay for a period. If you choose to pay severance, consult your attorney for laws.
Termination Meeting
When you are ready to fire an employee, there are several steps that you should take prior
to sitting down with that employee. These include such measures as discontinuing
computer access (especially if your patient or business information is in an electronic
format) and notification of human resources (if applicable).
Next, schedule the termination meeting with the employee as well as the employee’s
supervisor and your human resource officer or office administrator. During this meeting,
be straightforward and tell the employee why she is being terminated from employment.
Be concise, clear, and compassionate. The employee may become very emotional or
angry. Allow her to speak and state her case. However, at no point allow her to think that
you will change your mind. Remember that you may have been thinking about this for
some time and have had time to prepare for and confront any personal emotions that may
be involved. The employee is hearing about the termination for the very first time. She
will need to go through the emotional process of being terminated. Do not allow yourself
to react strongly or get angry back at the employee if she lashes out at you.
At the time of the meeting,
1. Request return of practice property, such as door keys and ID badges.
2. Request all passwords (if applicable).
3. Review status of benefits.
- Any unused, accrued vacation or sick time is due to the employee. If she has
used time that she has not yet accrued, the pay for this time is subtracted from the
last paycheck.
- Any payroll advances will be subtracted from the last paycheck.
- Any unpaid expenses will be paid in the final paycheck.
- Health insurance—if you have 20 or more employees, your employee has a right
to continue her health care insurance at her own cost for a period. The
Consolidated Omnibus Budget Reconciliation Act
(http://www.dol.gov/ebsa/newsroom/fscobra.html) is the federal law that requires
group health plans to offer extended coverage to their employees who lose
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coverage under the employer’s group health plan as a result of a qualifying event
(eg, termination of employment).
4. Review any non-compete or confidentiality agreements. In your Employee Handbook,
you should have a code-of-conduct paragraph that states that company information is
considered confidential. This should be reviewed with the employee and stated that a
breech of this would be cause for legal intervention.
5. If possible, conduct an exit interview. This is confidential and provides valuable
information about the working environment in your practice.
6. Obtain written permission from the employee to provide reference information when
potential future employers call.
7. Verify the employee’s address and contact information so that you can send W-2s.
8. Give the employee the option of packing up her belongings immediately or after hours.
Post-termination Issues
Legal Claims
As a business owner, you need to be aware of the possibility of discrimination claims
arising from firing an employee. The employee must prove that he was terminated at least
in part because of his protected class. Protected classes include gender, religion, race,
national origin, age, and disability. Other legal claims may be that the employee was
defamed by the act of an employer making false or disparaging comments about him to
coworkers or other parties, that he was treated in a manner intended to cause emotional
distress, that his privacy was violated by improperly disclosing the reason for termination,
or that he was terminated while protected by federal law (eg, taking leave under the
Family and Medical Leave Act http://www.dol.gov/whd/fmla/index.htm or military leave
http://www.opm.gov/oca/leave/HTML/military.asp).
Confidentiality
Only those who need to know why an employee was fired should be informed. They
should be instructed to keep this information confidential.
State Unemployment
Depending on your state unemployment laws, your former employee may be able to file
for unemployment benefits. Generally, the state unemployment office will contact you
about the situation surrounding the termination to determine if the person is eligible for
benefits. Your statements to the unemployment office should be consistent with your
discussions with the employee and any documentation on file.
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Relevant Documents
Secure the employee’s file and keep all documents that support the decision to terminate
the employee.
Finding Employment
Helping the employee find another job may not be possible or desirable in some cases.
However, providing a neutral reference may be a good idea so that the person can find
employment. In general, a terminated employee who is able to find employment
elsewhere quickly is less likely to bring suit against you.
Employee Resignation
At some point, you are likely to encounter an employee resignation. When this occurs,
make sure that you receive a written letter of resignation. Typically, a 2-week notice is
given in this letter.
If the staff who is resigning is a valued and trusted employee, you should consider
retaining her for those 2 weeks. During that time, the goal would be to transition that
person’s workload to another employee. The employee could train someone else to do the
tasks that are unique to the job. However, if the employee who is resigning cannot be
trusted to do her duties during those 2 weeks and would pose a threat to the morale of the
staff or function of the practice, you may want to tell the employee that her services are
not required and that you will compensate her for the 2-week period. You should then
follow procedures that you would normally follow if you were terminating an employee.
Regardless of the reason for resignation, you or the employee should notify your staff
about the resignation. If you are sending out an e-mail notice, you may say that the
employee has moved on and that (if appropriate) you wish her well in her future
opportunities. The remaining staff may be concerned about working short a staff member.
It is helpful to the rest of the staff if you address the plan for a replacement employee and
when a replacement employee may be hired to give them peace of mind about the
increased workload left behind.
Additional Resource
Access to employee records
(http://findarticles.com/p/articles/mi_m3495/is_6_52/ai_n19311781)
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Launching Your Career in Pediatrics: Charging for Your Services and Billing
This section will provide tips on the following:
•
•
•
•
•
•
•
Determining the Break-even Point for Your Practice
Setting Appropriate Fees for Services: Establishing a Fee Schedule
Billing for Services
Handling Accounts Payable and Collections
Managing Private Payer Contracts and Denials
Coding for Visits
Revenue-Generating Services
Determining the Break-even Point for Your Practice
When first starting out in practice, there are many things to consider about finances and
how you will obtain a salary as well as run a practice. Your start-up costs will affect how
long it takes for your practice to break even. First, consider ways to decrease overhead in
the beginning—you may only need one employee; some manage to do well without any.
Next, look carefully at the price of outsourcing things such as billing versus doing your
own billing or hiring someone to do it in-house. Salaries are the biggest expense. Is there
a family member who can help? Some clinicians will even do their own cleaning and
maintenance in the beginning.
Following are some additional tips on breaking even:
• Consider signing a contract with an income guarantee and about $300,000 in startup costs with the local hospital. There may be Stark implications associated with such
arrangements. Be sure to have legal counsel review any such agreements.
• Consider working for the first X months for another physician who may be
leaving the area or retiring; you may be able to “inherit” those patients during this
time.
• Start early with credentialing! You don’t want to be paying people early on only to
have an insurance credentialing problem undermine the practice. Other things that
take longer than expected are getting examination tables and getting certified for
waste disposal (which affects the ability to give immunizations).
• Use early downtime for low-cost marketing opportunities—lectures, support
groups, even extracurricular activities.
• Most hospitals and clinicians would be happy to have you take more emergency
department (ED) calls; although hospital work in pediatrics pays poorly, relatively
speaking, it does produce some income and lots of referrals. Going further, one could
do ED moonlighting if the skill set allows it.
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Breaking even can take 1 to 2 years, sometimes more, sometimes less. Some factors that
would alter this include percentage of Medicaid, number and market share of managed
care contracts and their payment, and amount of competition from pediatricians and other
practitioners. Look carefully where you set up; if it’s in a competitive area, be prepared to
have a niche idea.
Finally, consider opening with a fully functional and complete electronic health record
system in the beginning; it may be onerous to convert to one.
Setting Appropriate Fees for Services: Establishing a Fee Schedule
It is very important for any practice, new or established, to set and monitor its fee
schedule. These fees should not be set at random, by what others charge, or by gut feeling.
A practice must have a rational system for setting fees and a structured system for
periodic review.
In today’s payer environment, unless you do not participate with any insurance plans or
government programs (ie, a cash-only, concierge, or boutique practice), the amount you
charge for various services is often irrelevant, as your contracts with various payers
dictate what you are actually paid. Having such a system allows you to review a contract
and analyze the effect its fee schedule has on your practice, and can be a valid target to
work toward in the event of negotiations.
If you decide to participate in government programs (eg, Medicaid), unless they are
managed by a private insurance company, you must accept their fee schedule as payment
in full. You are generally not allowed to bill the balance for any medical services to these
patients. Because Medicaid is independently administered by each agency, there are more
than 50 different sets of rules, and you must become familiar with those of your particular
location.
Because most private payers typically pay less than the prevailing local “usual and
customary” level, the key factor in setting your fee schedule is to set it based on what you
think is appropriate to get paid for each procedure, not to underestimate or under-set
values in anticipation of what a payer will offer. This means that all of your fees will
likely be set at a level that exceeds the highest-allowable fees for your best payer; this will
give you a realistic benchmark for any negotiation. This process must be approached
systematically, as payer contracts can prohibit a practice from having different fee
schedules for different payers.
The optimal methodology is to obtain the regionally adjusted fee schedule for Medicare
for your area, which can be found at “Overview Fee Schedule”
(www.cms.hhs.gov/FeeScheduleGenInfo). You then should charge a percentage at or
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above that rate; for example, 120% or 150% of regionally adjusted Medicare fees. The
actual amount you charge is your individual decision. As part of the suggested process, it
should be reviewed at least annually to be sure it is appropriate for your practice.
Additionally, we suggest that this methodology be set uniformly across all Current
Procedural Terminology (CPT®) codes used.
Review the current and immediate past year’s Medicare Resource-Based Relative Value
Scale (RBRVS) conversion factor and relative value units (RVUs). Lock your contract
into a “good” year, such as 2008. This will avoid the fluctuation in the contracted fee
schedule from year to year that will occur if you contract with the current year’s fee
schedule. You do not want your negotiated fees to go down. If the rate goes up,
renegotiate. Visit “2010 RBRVS-What Is It and How Does It Affect Pediatrics?”
(http://practice.aap.org/content.aspx?aID=2310).
Additional resources include
•
•
History of Medicare Conversion Factors (http://www.amaassn.org/ama1/pub/upload/mm/380/cfhistory.pdf)
Sustainable Growth Rates & Conversion Factors
(http://www.cms.gov/sustainableGRatesConFact/)
Clearly, this methodology may seem patently unfair to those patients who are uninsured
or who self-pay. While you may not charge them a different fee schedule, you may give
discounts for cash payment, preferably at the time of service, so as to make the playing
field more level.
The Centers for Medicare & Medicaid Services implemented the Medicare RBRVS
physician fee schedule in 1992. The current Medicare RBRVS physician fee schedule is
derived from the relative value of services provided and based on the resources they
consume. The relative value of each service is quantifiable and is based on the concept
that there are 3 components of each service—the amount of physician work that goes into
the service, the practice expense associated with the service, and the professional liability
expense for the provision of the service. The relative value of each service is multiplied
by Geographic Practice Cost Indices (GPCIs) for each Medicare locality and then
translated into a dollar amount by an annually adjusted conversion factor. For additional
information and to view the current GPCIs by Medicare locality, visit “2010 RBRVSWhat Is It and How Does It Affect Pediatrics?”
(http://practice.aap.org/content.aspx?aID=2310). A hands-on tool for calculating 2010
Medicare payment rates for services in your geographic locality is available at “2010
RBRVS Conversion Spreadsheet” http://practice.aap.org/content.aspx?aid=2011.
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Another critical issue is the fact that you are free to negotiate any fee schedule with any
individual private payer, even those administering government programs. If you do not try
to negotiate, you are guaranteeing yourself the lowest possible payments from insurers. If
you have a separately negotiated contract, it can specify any fee structure, methodology,
and carve-outs on which you can agree. Negotiating contracts is always the preferred way
to set your fees with specific payers when those fees differ from their standard fee
schedule, as they should if you follow the process outlined previously.
In addition to negotiating individually, there are several other types of contracting and
negotiating organizations in many regions of the country. These include entities such as
independent physician associations (IPAs) that encompass multiple specialties, pediatricspecific IPAs and health alliances, and physician hospital organizations (PHOs). All of
these entities have various pros and cons. As a general rule, pediatric-specific
organizations will do the best job for pediatricians. Many multispecialty IPAs are
dominated by procedural and specialty adult physicians, and the interests of pediatricians
are not given as much weight as they deserve. PHOs are almost universally dominated and
controlled by hospitals whose interests often diverge from physicians in general and
pediatricians in particular. It must be said, however, that joining any such organization is
likely preferable to just signing any insurance contract without an effort to negotiate.
No one is going to care about your fee schedule more than you. It is not a job you should
delegate. You must review and adjust your fee schedule, working with your
administrative staff (as applicable) on a regular basis to insure the economic health of
your practice.
Billing for Services
In-house Versus Contracting Out
Practices need to decide whether they wish to handle billing and collections in-house or
contract out to a billing and collections company. There are a few schools of thought on
this issue. Some practices feel that no one cares about the financial health of the practice
more than the staff and owners of the practice. Others feel that it is not worth the time of
the staff or owners; therefore, it makes more financial sense to outsource this service.
Whatever your thoughts or concerns, a process needs to be established.
Whether hiring billing staff or outsourcing for these services, the practice needs to make
sure that the individual or company being used has not been excluded from participation
in federal health insurance programs. This can be done by checking the list of excluded
individuals/entities with the Office of Inspector General, US Department of Health &
Human Services (http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp).
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Transactions
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and Code Sets rules apply to billing services. There are standardized transactions that are
required for checking eligibility and billing. The proposed meaningful use requirements
include the use of those standardized transactions. Visit HIPAA
(http://practice.aap.org/hipaa.aspx) for information on HIPAA.
Alert Patients of Your Policy
Regardless of the model that you follow, it is essential that you have a financial policy in
place so that patients know what is expected of them. Sample policies are available on the
American Academy of Pediatrics (AAP) Practice Management Online (PMO)
(http://practice.aap.org/content.aspx?aid=2184). If your practice decides to charge for
completion of school, camp, or other forms, be sure that you have a policy for this as well.
A sample (http://practice.aap.org/content.aspx?aid=2044) is available on PMO. Often,
patients may not be aware of how insurance works. Be sure that they know that additional
payment or co-payments might be expected of them. Click here
(http://practice.aap.org/content.aspx?aid=2398) for a sample handout.
Offering Discounts for Cash Payment
Because cash-paying customers do not require billing costs, some practices may choose to
provide a discount to those patients who provide complete payment at the time of service.
Practices vary in the discount amount. Some practices offer an across-the-board discount
of X% off of the bill. Others provide different varying discounts. If you choose to allow
this in your practice, be sure to check laws to be sure that you are in compliance.
Waivers (Advance Beneficiary Notices)
Waivers should be considered as a financial policy component for pediatric practices. A
waiver is a statement that the responsible party signs accepting financial responsibility for
a requested medical service that is not or may not be covered by health insurance. Visit
PMO (http://practice.aap.org/content.aspx?aid=378) for additional information on waivers
as well as sample waivers.
Check your insurance contracts as well as state laws to see if waivers are legal and
appropriate for your practice.
Handling Accounts Payable and Collections
Collecting co-payments and balances is fiscally important to any practice. Payers often
require that co-payments are collected. As mentioned previously, an office financial
policy will help keep families informed of your expectations. It is equally important that
job descriptions clearly indicate who is responsible for collecting payment, co-payments,
and past-due balances. Sample job descriptions can be found at
http://practice.aap.org/samplepersonneldocs.aspx.
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While some practices may choose to review charts each morning and write balances or
co-payments next to each name, others prefer a different method. Following are some
examples of what practices do to collect payment:
Co-payments
• Create an office policy for co-payments for those who are unable to make a copayment at time of visit. A sample
(http://practice.aap.org/content.aspx?aid=2182) is available on PMO.
Pediatricians should be aware that forgiveness or waiver of co-payments may
violate the policies of some insurers, public and private; some insurers may
permit forgiveness or waiver if they are aware of the reasons for the forgiveness
or waiver. Routine forgiveness or waiver of co-payments may constitute fraud
under state and federal law. Pediatricians should ensure that their policies on copayments are consistent with applicable law and with the requirements of their
agreements with insurers.
• Call each patient or parent the day before the appointment and ask that he or she
bring an updated insurance card as well as any co-payments to the visit.
• Verify insurance information prior to check-in.
• Having a health savings account does not automatically mean that the practice can
bill the patient the amount due at the time of service. This is dependent on the
physician’s contract with the health plan carrier, state regulations, and the amount
of money in the account. To find out if you can bill at the time of service, visit the
“Health Savings Account Algorithm”
(http://practice.aap.org/content.aspx?aid=2364).
• Visit PMO (http://practice.aap.org/content.aspx?aid=465) for effective strategies
for asking patients to pay at the time of service.
For information on professional courtesy, visit
http://practice.aap.org/content.aspx?aid=2926.
Past-Due Balances
• Flag the account and schedule a meeting between the patient or parent and billing
staff prior to being seen by the pediatrician.
• Assign billing staff in contacting all future scheduled appointments for which a
balance is due. Alert the patient or parent of the balance, ask if there are any
questions, and offer to take payment over the phone. Also, request that the patient
or parent bring a current insurance card.
• If a same-day sick appointment is scheduled, inform the patient or parent of the
balance (verify insurance on check-in).
• If patients cannot pay a balance in full, consider setting up a payment schedule.
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•
•
•
•
•
Send a letter that informs parents or patients of their balance. Because sending
letters creates additional costs (eg, postage, staff time), some practices wait until a
certain dollar amount is due to send a letter, while others send statements on a
regular basis (eg, monthly, quarterly, biannually). Still others use e-mail to alert
patients of balances. A template letter is available on PMO
(http://practice.aap.org/content.aspx?aid=2622). For tips on mailing statements,
visit http://practice.aap.org/content.aspx?aid=287.
Save patient or parent credit card information on file. Inform patients of this policy
and tell them that the credit card will be on file and billed for the remaining
balance not covered by the insurance company, which is considered the patient’s
responsibility.
If you have a Web site, consider allowing patients or parents to pay their balance
online.
For tips on how to respond to patients who are unable to pay at the time of the
visit, visit http://practice.aap.org/content.aspx?aid=833.
There may be times when a noncustodial adult brings the child to the office for a
visit and is informed of co-payments and past-due balances. Visit PMO
http://practice.aap.org/content.aspx?aid=835 for tips on how to handle these
situations.
A set of questions found on PMO (http://practice.aap.org/content.aspx?aid=2104) can be
used to assist practices in better understanding their internal processes for submitting and
tracking claims, and in discovering opportunities for improving those processes for the
purpose of improving payment and accounts receivable.
Credit Cards
Credit and debit cards are commonly used by patients. While they may be convenient for
the patient, the practice can incur additional expenses. The AAP offers an affinity
program with 1st Health Care Payment Systems. Members have access to low credit card
processing rates. Visit the AAP Member Center at
www.aap.org/moc/memberservices/affinity.cfm for more information.
Options for Online Bill Pay
As the use of credit and debit cards increases, many practices might be interested in
offering an option for patients to pay their bills online. Several companies offer an online
billing option for practices. When selecting a company, it is important that the company
treats information confidentiality and has a secure server (HIPAA compliant). Also,
before investing in this service, consider the costs versus how much the service will be
used. It may not be financially viable.
Managing Private Payer Contracts and Denials
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The AAP has increased its advocacy efforts in response to the growing frustration of its
membership with inequities in the public and private sectors. The AAP Private Payer
Advocacy Advisory Committee was formed to advance AAP private payer advocacy
initiatives. The committee works in tandem with the AAP Committee on Child Health
Financing (COCHF) in setting the course for continued AAP efforts to improve the level
of payment received from private payers for its member pediatricians.
Based on this, the charge to the Private Payer Advocacy Advisory Committee is to
•
•
•
•
•
•
•
Examine the effect of payment and health plan coverage policies in the private
market on access to quality care and identify strategies to enhance access through
improved payment and health care coverage for children and pediatric services.
Advise the AAP and its leadership on a payment strategy, including specific goals
and action steps, to improve pediatricians’ economic and organizational positions
in the private marketplace.
Collaborate with other AAP committees, sections, councils, and task forces in
advancing the payment and benefit coverage issues germane to their
constituencies.
Refine and monitor criteria for prioritizing payment issues and strategies to engage
private health plans.
Recommend practical and innovative payment education programs and tools to
assist pediatricians in strengthening their strategies and techniques in negotiating
their contracts with health plans.
Develop strategies to ensure consistent and effective communication and
coordinated activities with AAP members, committees, councils, sections,
chapters, and staff as it pertains to payment.
Assist COCHF in its efforts to improve the financing of children’s health care by
examining issues and developing policy relevant to private sector payment.
There are several things to consider when negotiating contracts with insurance companies.
The following resources provide excellent background and important information to
prepare you for your negotiations:
• Questions Pediatricians Should Ask Before Signing a Managed Care Contract
(http://practice.aap.org/content.aspx?aid=1620)
• Checklist to Assess Carrier Contracts
(http://practice.aap.org/content.aspx?aid=1634)
• PediaLink Module Contract Negotiation With Payers
(http://practice.aap.org/content.aspx?aid=1924)
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Appealing Private Payer Denials
The online Hassle Factor Form (www.aap.org/moc/reimburse/hasslefactor) can be
completed to report insurance administrative and claim processing concerns. The
information provided will be used to assist the AAP and chapters in identifying trends and
facilitating public and private sector advocacy related to health plans. The information
collected via the Hassle Factor Form is for data collection purposes only and the user will
not receive a direct reply to the reported hassle.
Know Your Contract Terms
Multiple payers could be taking advantage of your lowest contracted payment rate
through the use of a rental network preferred provider organization (PPO). This is also
known as a silent PPO. The American Medical Association (AMA) developed the “Read
your contracts: Is your practice losing revenue through rental network PPOs?”
(https://ssl3.ama-assn.org/apps/ldap/login.cgi/id/members-staff?URL=http://www.amaassn.org/ama1/x-ama/upload/mm/368/network_ppo_layout.pdf&M=GET) booklet to
educate physicians on how to identify and protect their practices from inappropriate
discounts. AMA members can download this informative practice management resource
at the AMA Web site (http://www.ama-assn.org/) free of charge.
Several AAP chapters have developed pediatric councils that meet with regional payers.
Pediatric councils serve as a forum to discuss pediatric issues related to coverage, access,
and quality. Due to antitrust laws, pediatric councils are not to be used for discussions of
fees or to negotiate payments. However, by educating payers on the costs of pediatric
services and the effect on quality and access, chapters have reported that these discussions
facilitate communication with payers and lay the groundwork for successful problem
resolution. Information on pediatric councils can be accessed in the Pediatric Council
Start-Up Kit (http://practice.aap.org/content.aspx?aid=382).
To assist pediatric practices in appealing carrier denials, the AAP has developed
“Template Letter: Appeal to Payers for Payment”
(http://practice.aap.org/content.aspx?aid=2344&nodeID=2018).
Coding for Visits
Learning how to code properly is essential for every pediatrician. This is how
pediatricians get paid. If it is not coded, payment will not be received—it’s that simple.
Unfortunately, coding itself is not simple and can be rather confusing to learn. Coders for
hospitals and coding auditors for insurance companies generally have to attend several
training courses and have years of experience to master coding guidelines.
For pediatricians, there are many conferences available throughout the year that teach the
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basic essentials of coding as they relate to pediatrics. There are also several other
resources available, including Coding for Pediatrics and the AAP Pediatric Coding
Newsletter™. In addition, PMO has several links online that provide guidance on coding
basics as well as disease-specific coding on PMO
(http://practice.aap.org/topicBrowse.aspx?nodeID=2000.2002).
What Are the Codes?
To code for work that you have done, you will need to understand what codes are being
used. There are 3 sets of codes to bill with—International Classification of Diseases
(ICD), CPT, and Healthcare Common Procedure Coding System (HCPCS). These sets of
codes are used together to build an insurance claim for payment.
International Classification of Diseases, Ninth Revision, Clinical Modification Codes
ICD codes are published by the World Health Organization. These codes identify the
disease being treated or why the patient was seen in the office. These codes may identify
diagnoses, such as diabetes, or symptoms, such as cough. At the time of this article,
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM) is in use; however, International Classification of Diseases, 10th Revision, Clinical
Modification will be implemented in 2013.
Examples of ICD-9-CM codes include
•
•
V20.2, routine infant or child health check
493.30, asthma, unspecified
Insurance companies use these codes to assess whether a visit or procedure is appropriate
by seeing whether they “match” the procedures that are being charged. Therefore, it is
important to make sure that the ICD-9-CM codes go with the procedures being billed. For
instance, if a patient was seen for a well-child visit, ICD-9-CM code V20.2 should be on
the claim. If billing for an inhalation treatment, use a code that relates to wheezing or
asthma on the claim.
ICD-9-CM codes are also a way to let the insurance company know that the patient has
underlying chronic issues that added to the complexity of the visit (thus justifying the
higher level of services). For example, for a child with pneumonia who also has Down
syndrome and chronic asthma, the ICD-9-CM codes on the claim would include
pneumonia, Down syndrome, and asthma to let the insurance company know that this
child was more complex than a healthy child with simple pneumonia.
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Current Procedural Terminology Codes
CPT codes are owned by the AMA and identify the type of work done at the visit. These
are 5-digit codes that have work RVUs assigned to them. Generally, the higher the work
RVUs assigned to a code, the higher the payment.
The first CPT codes that are important to learn are the level of service or evaluation and
management (E/M) codes. The E/M code for each visit is derived from the level of
documentation and medical decision-making involved. It is meant to reflect the amount of
work needed for the visit, level of service provided, or time required. If the visit was more
complex, the relative work involved is higher and payment should be more.
The E/M code level is based on very specific documentation criteria. It is critical to
understand the criteria to document correctly and be successful if ever audited by an
insurance company.
Three components are considered—history, physical examination, and medical decisionmaking. There are a set of 5 codes for new patients and a similar set of 5 codes for
established patients. New patients are considered patients who have not been seen by that
physician or practice in the last 3 years.
The 5 E/M codes for new patients are as follows:
99201 Usually the presenting problem(s) are self-limited or minor and the physician
typically spends 10 minutes face-to-face with the patient or family. E/M requires the
following 3 key components:
•
•
•
Problem-focused history
Problem-focused examination
Straightforward medical decision-making
99202 Usually the presenting problem(s) are of low to moderate severity and the
physician typically spends 20 minutes face-to-face with the patient or family. E/M
requires the following 3 key components:
•
•
•
Expanded problem-focused history
Expanded problem-focused examination
Straightforward medical decision-making
99203 Usually the presenting problem(s) are of moderate severity and the physician
typically spends 30 minutes face-to-face with the patient or family. E/M requires the
following 3 key components:
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•
•
•
Detailed history
Detailed examination
Medical decision-making of low complexity
99204 Usually the presenting problem(s) are of moderate to high severity and the
physician typically spends 45 minutes face-to-face with the patient or family. E/M
requires the following 3 key components:
•
•
•
Comprehensive history
Comprehensive examination
Medical decision-making of moderate complexity
99205 Usually the presenting problem(s) are of moderate to high severity and the
physician typically spends 60 minutes face-to-face with the patient or family. E/M
requires the following 3 key components:
•
•
•
Comprehensive history
Comprehensive examination
Medical decision-making of high complexity
Additional resources include
•
•
•
•
•
•
Anatomy of a New Code: The CPT and RUC Survey Processes
(http://practice.aap.org/content.aspx?aid=876)
Practice Management Online Coding Video Series
(http://practice.aap.org/content.aspx?aid=2792)
Centers for Medicare & Medicaid Services Evaluation & Management Services Guide
(http://www.cms.gov/MLNProducts/Downloads/eval_mgmt_serv_guide.pdf)
Coding for Pediatrics
AAP Pediatric Coding Newsletter
Care Plan Oversight (CPO) Billing Sheet Form
(http://practice.aap.org/content.aspx?aid=922)
Non–Evaluation and Management CPT Codes
Besides E/M codes, CPT codes are used to identify vaccines given, laboratory tests
performed, and procedures done at each visit. Again, it is important to have matching
ICD-9-CM codes to go with the CPT codes that are claimed.
Many insurance companies will bundle certain procedures into a type of visit. They will
claim that certain procedures are included in a visit. It is worth appealing any
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inappropriate denial with your payers, including bundling. You are also encouraged to
report any carrier bundling through the AAP Hassle Factor Form
(www.aap.org/moc/reimburse/hasslefactor/index.cfm). Be sure to examine your
explanation of benefits carefully to see whether unfair bundling or denials are occurring.
While there is no legal mandate requiring private carriers to adhere to CPT guidelines, it
is considered a good-faith gesture to do so, given that the guidelines are the current
standard within organized medicine. Those separately reportable services that are not
recognized by a carrier should be designated non-covered benefits and billed to the
patient.
There are several tips for using CPT codes on the PMO Web site.
• Pediatric Coding Basics (http://practice.aap.org/content.aspx?aid=2427)
• Disease-specific coding advice
(http://practice.aap.org/topicBrowse.aspx?nodeID=2000.2002)
Also, letters to payers about inappropriate bundling can be found on PMO
(http://practice.aap.org/templateletters.aspx#carriers).
There are a variety of important pediatric CPT codes that are currently used.
•
•
•
•
•
•
•
Outside normal operating hours, such as holiday or Sunday visits, after-hours
visits, and emergency visits (http://practice.aap.org/content.aspx?aid=1904)
Vaccine administration (http://practice.aap.org/content.aspx?aid=2334)
Preventive medicine counseling (http://practice.aap.org/content.aspx?aid=2052)
Developmental screening (http://practice.aap.org/content.aspx?aid=2714)
Hearing and vision screening (http://practice.aap.org/content.aspx?aid=2839)
Coordination of care, prolonged services
(http://practice.aap.org/content.aspx?aid=2560)
Telephone care codes (http://practice.aap.org/content.aspx?aid=2267)
Healthcare Common Procedure Coding System Codes
HCPCS Level II codes (commonly referred to as “hick-picks” codes) are used for
identifying medications, supplies, and services that are not identified in CPT codes. These
are billable to insurance companies. (Note: CPT codes are categorized as HCPCS Level I
codes but referred to as CPT codes, not as HCPCS codes.)
In pediatrics, commonly used HCPCS codes include those for oral, nebulizer, and
injectable medications used in the office; splints; and supplies for breathing treatments.
Payment for these codes is variable and should be negotiated with your payers.
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Modifiers
An important coding tool to be aware of is a group of accessory codes called modifiers.
Insurance computer claim systems have certain rules or edits that only allow a payment
for a certain combination of codes. For example, normally only one E/M code or
nebulizer treatment would be paid in a single day. However, often you need to override
these rules; this can be done by using a modifier.
Modifiers can be used for multiple instances of the same procedure at a single visit. They
can be used to get payment for attempted procedures that could not be completed. Another
common use of modifiers is to receive payment for a sick visit done on the same day as a
preventive visit for the same patient.
To use these, list the CPT code that you want to modify as well as the modifier.
Case Study
A pediatrician attempted a urinary catheterization on a baby but was unsuccessful. In this
case, bill the catheterization code (51701) and attach modifier 52 for reduced services,
which would result in partial payment of the procedure that was attempted but not
completed. This would hopefully compensate for the time and supplies used in the
attempt.
Unfortunately, insurance companies may use a particular modifier in different ways and
request that they are attached to codes differently. It is important to learn how each payer
requests these codes.
Learn How to Code Accurately to Get Paid Appropriately for the Actual Service
You Provide
Too often, pediatricians miss out on payment because of under-coding or missed codes.
Often a visit seems so simple and routine that they feel guilty charging a higher code. Or
it is too much of a bother to learn all the details of coding, so everything is a mediumlevel visit (99213). Many fear an audit, so they feel that 99213 is the safest code to use so
that one is not triggered.
Just as it is important not to under-code, it is equally important not to over-code because
this can open you to charges of fraud.
It is important to code for work that has been done and documented. Only by becoming
familiar with the ins and outs of coding can you become an effective coder and receive
payment that is appropriate for the work you did.
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Additional resources include
•
•
•
•
Coding Calculator (http://practice.aap.org/content.aspx?aid=1680)
Top Ten Underutilized CPT Codes in Pediatrics
(http://practice.aap.org/content.aspx?aid=1904)
Mastering Modifiers: Unlock the Revenue
(http://practice.aap.org/content.aspx?aid=1118)
Practice Management Online Coding Video Series
(http://practice.aap.org/content.aspx?aid=2792)
Revenue-Generating Services
Nontraditional services can increase practice revenue. Pediatric care is best known for
pediatric preventive care, chronic disease management, and the care of children with acute
illness.
There are a wide range of services that can be provided in the pediatric office. This
section will look at services that may be considered for your office. The following are
options to consider:
•
•
•
•
•
Diagnostics. Diagnostic services can be brought in-house.
Laboratory tests such as lead testing, lipid testing, and transcutaneous bilirubin.
If your practice will do laboratory tests, your office requires an application with
Clinical Laboratory Improvement Amendments
(http://wwwn.cdc.gov/clia/default.aspx).
Pulmonary function testing with and without bronchodilator.
Vision testing such as vision evoked potential testing and auto-refraction.
Hearing testing such as otoacoustic emissions testing.
Prior to offering these services, it is important to consult potential antikickback or safe
harbor laws.
Colocating Other Professional Services
Housing other professionals within your office or next door encourages families to see your
practice as the place to go for their care.
Pediatricians often set up agreements with lactation consultants, nutritional consultants, and
behavioral therapists. Evaluation of insurance contracts will tell you whether it is best to
employ the professional in the practice or to provide space within the office under agreement
and allow the practitioner to bill for services autonomously.
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Vaccines
Pediatricians may wish to consider administering vaccines (eg, tetanus, diphtheria,
acellular pertussis; influenza) to the parents or caregivers of patients. By vaccinating
parents, additional protection is granted to the child and the community. Vaccines could be
provided to families in the office and at community flu clinics. Before choosing to
provide this service, however, it is important to check with the clinician’s medical liability
insurer to ascertain whether treating adults would be considered a covered activity.
Various groups within the AAP have differing views on the practice of administering
vaccines to adults. An article in AAP News
(http://aapnews.aappublications.org/cgi/content/full/30/1/8) includes concerns expressed
by the AAP Committee on Medical Liability and Risk Management about vaccinating
adults in a pediatric office.
Dental Services
Fluoride Varnish
Consider providing fluoride varnish. Some state Medicaid programs are now providing
payment for this service. Check with your state Medicaid program to determine coverage
for fluoride varnish. Generally, most private health plans consider fluoride varnish to be a
dental benefit, not a medical benefit, and therefore it is not covered under the medical plan.
If it is not a covered benefit, the parent would need to be responsible for payment. Patients
usually get dental varnish 6 times, usually at 9, 12, 15, and 18 months and 2 and 3 years.
Additional resources include
•
•
•
AAP Oral Health Initiative Web site
(http://www.aap.org/commpeds/dochs/oralhealth/)
Oral Health Risk Assessment: Training for Pediatricians and Other Child Health
Professionals (http://www.aap.org/oralhealth/ohra-cme.cfm)
Fluoride Varnish Reimbursement Table
(http://www.aap.org/commpeds/dochs/oralhealth/pdf/OH-Reimbursement-Chart.pdf)
Products
Pediatric offices also may want to provide products for sale to patients. The sale of
products in the office can require a durable medical equipment registration in some states.
State laws for sales tax collection also need to be addressed.
Medications
Medication dispensing machines
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Durable Medical Equipment Supplies
• Spacers and masks
• Nebulizers
• Splints
Cosmetic
Other services such as ear piercing are provided by pediatricians in the office.
Functioning as a Host Provider for an Electronic Health Record/Practice
Management System
A computer server in your office has the capacity to service multiple offices and providers.
Practices have found that they can expand the function of their in-house information
technology staff by reaching out to support other local physicians. This earns additional
income for the owners of the server and supports the salary of the staff while allowing
other practices to have computer services without purchasing a server or employing
technical staff.
There are state laws and regulations related to privacy; contact your chapter or state
medical society for information. Following are steps that can be taken to begin
implementation of a new service:
1. Identify the target population.
What is the number of active patients in that age group or population (eg, total number of 6month-olds and younger)?
2. Estimate the number that you feel would participate (eg, 31% will request the influenza
vaccine).
3. Determine the expected expenses and revenue.
•
•
•
•
How much does the machine or product cost?
How much does the procedure cost (eg, cost of transcutaneous bilirubin tips plus
the cost of the nurse time)?
Check fee schedules for payments (eg, what is the average payment of 99211 and
transcutaneous bilirubin?).
Determine the revenue per service (eg, payment – cost = revenue).
4. Determine overhead and practice costs per visit (see Revenue Projection Worksheet).
Don’t forget ongoing costs such as machine calibration and service contracts.
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5. Implementation.
• Identify a champion for the new procedure. This will be the go-to person who will
know everything about this service. Tip: Two champions might be necessary, one
clinical and one billing.
• Identify target date to begin implementation.
6. Create waivers.
Non-covered services may require written acknowledgment of patient responsibility for
payment.
7. Provide incentives.
As revenue begins to increase, don’t forget to reward staff for promoting and
providing a new service. This will further increase revenue. Some examples are gift
cards, certificates for 2-hour lunches, and a prime parking spot for X amount of time.
8. Review and reassess.
Ensure that review of revenue and expense is done on a quarterly basis. Supply costs
can creep up and payments can change when RBRVS changes take place or the
managed care organization to bundle the service. Set up annual or semiannual review
dates.
REVENUE PROJECTION WORKSHEET
Service Name Initial
Cost
Average No. of
(CPT)
Cost
Per
Payment Times
Use
Per
Day
Laboratory
Tests
Lead (83655)
Lipid (80061QW)
Transcutaneous
bilirubin
(88400)
Spirometry
99010
94060
Vision
VEP (95930)
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No. of
Times
Per
Month
No. of
Times
Per
Year
Annual
Revenue
Refraction
(92015)
Hearing
OAE (92587)
Professional
Services
Medications
DME
Spacers
Masks
Nebulizers
Splints
Cosmetic
Ear piercing
Dental
Fluoride
(D1203)
Flu vaccine
CPT, Current Procedural Terminology; VEP, vision evoked potential; OAE, otoacoustic
emissions testing; DME, durable medical equipment.
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