Re: Time to Jump

[Guest guest]

RE Step back and take a breath.

Woa Nelli!

1) Can you get out of your employment contract? Do you have a restrictive covenant.

2) Is there a need for cash only pts?

3) Do you have money reserves while you set this up? 6 months, 1 year....

4) You did this before, can you do this again? Just keep your overhead low, and as long as you have pts on day 1, you should do fine.

5) It will take you 3-6 months to set up your own numbers, and it may take you alot longer to get the insurance companies to recognize you.

Let us know more?

Matt in Western PA

FP residency completed 1988

Solo since 2004

Time to Jump

I joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like old friends.My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.So...It's time to jump. I cannot do this anymore.I actually just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or outsource? Finding a location. The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was ordered by a local ortho. (Drives me crazy!)Thanks for your help!

[Guest guest]

Greg,

Welcome back. Where are you at in the world now? Was it Colorado?

Starting over is hard work you have done it two to three times in 8 yeaars.

What you are fighting with is workflow and for breathing room?

I have more questions for you, but answers to yours.

and I still sit on hold while doing the billing or other task to get the preauthorization. Often we have the patient in front of us and bill for the total time it take to see the patient and obtain the prior authorization.

We do not see HMO patients.

and Egly

Doctors Egly & Associates PC

Sandwich, Il 6058

Subject: Time to JumpTo: Date: Tuesday, February 7, 2012, 9:13 PM

I joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like old friends.My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.So...It's time to jump. I cannot do this anymore.I actually

just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or outsource? Finding a location. The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my

family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was ordered by a local ortho. (Drives me crazy!)Thanks for your help!

[Guest guest]

Thanks for the replies. More below...

" 1) Can you get out of your employment contract? Do you have a restrictive

covenant. "

No problem.

" 2) Is there a need for cash only pts? "

I don't think there is a need. Massachusetts is now famous for Romneycare, or

whatever they're calling it, so almost everyone has some form of insurance,

though quite a few have some form of Medicaid. We have a lot of managed care,

PCP panels, etc.

In spite of this, there may be some room for cash, as long as it is buying

convenience. We have a definite doctor shortage and if I, as 20% of the primary

care providers in town (yep, small, isolated town, see below...), pull out of

the traditional practice, then access to care is going to be much tougher. As a

hospital/med staff, we have already decided to make up for as much of this as

possible with extenders, but this doesn't always sit well with patients. Plus,

even the patients that have a physician, often end up in the ER, paying ER

copays, because there are no times in the office. Lastly, no local physician has

an after-hours call plan. Once the offices are closed, local patients do not

have anyone to call, and can only go to the ER.

With all of this in mind, and in spite of everyone being required to have

insurance, there still may be a role for a cash practice.

" 3) Do you have money reserves while you set this up? 6 months, 1 year.... "

No. Not at all. Might look for some hospital support. Otherwise, we're talking

bank loan.

" 5) It will take you 3-6 months to set up your own numbers, and it may take you

alot longer to get the insurance companies to recognize you. "

Excellent point. I remember how long it took to get numbers through my current

employer. More argument to forego the insurance industry!

Matt in Western PA

-------------

" Where are you at in the world now? "

Nantucket, MA. Very interesting environment to practice. Isolated by 30 miles of

ocean. 10,000 people year-round. 40-50,000 on any day in the summer. 15-bed

hospital. 1 general surgeon (who does more primary care than surgery), 1

internist, and 3 FP/OBs (including me). Lots of money here in the summer. Lots

of just-getting-by workers/immigrants year-round.

" What you are fighting with is workflow and for breathing room? "

Yes. A broken system. I think the primary problem is too many patients. And

backing down, without coming up with some disincentive, e.g., membership or

cash-based practice, is going to be hard.

" We do not see HMO patients. "

We have too much managed care for this to be possible, if I do take insurance.

And if I do not participate, then an HMO patient will not get reimbursed,

referral or not.

and Egly

-------------

[Guest guest]

Hi,To answer your questions:1.  We do all prior auths, referrals, and pre-approvals electronically, when possible.  That leaves only the stat orders that need quick auth.  We also charge for the PA's for meds when the patient refuses to use whatever is in formulary.  The patient chose that insurance, and they always have the option of paying cash for the rx.  We order very few MRI's.  Our MA does all of these in her down time.  

2.  Can't answer that, since we are on insurance, but if we haven't seen the patient for the problem, we won't order it.  If we referred the patient to a specialist, and the specialist is ordering it and wants us to pick it back up, then we will, but it must have documentation from the specialist.  We follow MDC guidelines, and q30d, the PT patients must come in for review.  For other things, my understanding is that as long as the patient uses a participating provider for lab, x-ray, etc, it will be paid in-network.

In the mean time, the way this broken system is set up, it sounds like you are doing lots of uncompensated work, and you need to fix that. Some patients may get mad and leave, so be it, your time is worth $, regardless of what the insurance companies think!  (Also sounds like you need some breathing room!)

I might suggest that you start blocking more of your schedule each day for urgent care type visits so that you don't send those patients to urgent care.  How many add-ons per day do you average?  And then add a % (about 25% of our schedule each day is for same-day appointments).  Stop taking a wait list.  It takes a lot of time to manage a wait list, and it sounds like you don't have staff time to manage it.  Stop taking new patients (the provider can always OK, " just this once " for family members of existing patients, etc).

Are your RN's practitioners? or MD support?  RN's are expensive for a small office.  If you need a nurse instead of MA's, try LVN's.  That alone can save you quite a bit in overhead.  In a 4 provider office, with 6 support staff (really 7 since you outsource billing), you have lower than average staff (less than 2/provider).  But there may be places where you can tweak workflow.  If everyone is feeling buried, take a " staff appreciation day " where you don't see patients and let the staff come in and get caught up on their work and start fresh the next workday.  Bring in lunch and goodies, have a staff meeting and let the staff give their input on now to improve workflow (we don't see patients  on Wed currently, which allows me time to catch up each week on scanning, billing, collections, etc).

We are 1 provider, 1 location.  Staff is 1MD, 1 MA, a part time receptionist and a part time manager who works as a receptionist/biller/manager/human resources/payroll/accounting department (moi-also the wife of the MD).  12-14 patients/day, with about 35% HMO, 20% Medicare, 40% PPO, 5% other.

Good luck in taking the plunge back to solo practice, or fixing the one you're in.  Even in a multi-provider office, you can use IMP principles.  It may take some staff changes and workflow tweaks and changing patient ( & staff) behavior, but I think it is possible.

Cheers, Pratt

 

I joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like old friends.

My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.

So...

It's time to jump. I cannot do this anymore.

I actually just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or outsource? Finding a location.

The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...

1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?

2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was ordered by a local ortho. (Drives me crazy!)

Thanks for your help!

[Guest guest]

Matt, while I agree with most of what you advise, one comment in there gives me serious pause:"...and it may take you a lot longer to get the insurance companies to recognize you."Insurance? Whoa, Nellie, indeed! What tyranny is it that Greg is really fleeing, if not that brought about by the whims and needs of the third party payors?Despite his growing headaches, it isn't really the size of his group that's causing his pain, at least, not directly. (Although larger sizes do bring on a lot of added complexities and decrease flexibility.) Despite our idealization of the 'micro-' practice, there is nothing inherently wrong with joining forces with medical assistants and providers, at least not so long as everybody is pulling their weight and contributing appropriate value to the care of the patient. The reason why micro-practices are so often to be preferred is simply that adoption of a micro-practice model FORCES elimination of inefficiencies.By contrast, the major thing that makes modren models of medicine soil efficient and appalling is the inherent conflict that arises from constantly needing to justify one's actions in order to extract payment from a third party payor whose incentives are not aligned with ours or those of our patients. Payors not only need to protect themselves from fraud, they also are inherently motivated to be 'competitive' by doing everything they can to avoid paying us--including erecting artificial roadblocks to dissuade us from even trying to get paid sometimes.I think that if Greg is mustering the energy and courage to make a Big Leap, he really should be aiming for a pond with cool, refreshing water instead of just another hot sulfur spring that's also teeming with uncomfortably warm frogs. KenSent from my iPad

RE Step back and take a breath

Woa Nelli

1) Can you get out of your employment contract? Do you have a restrictive covenant.

2) Is there a need for cash only pts?

3) Do you have money reserves while you set this up? 6 months, 1 year....

4) You did this before, can you do this again? Just keep your overhead low, and as long as you have pts on day 1, you should do fine.

5) It will take you 3-6 months to set up your own numbers, and it may take you alot longer to get the insurance companies to recognize you.

Let us know more?

Matt in Western PA

FP residency completed 198

Solo since 2004

Time to Jump

I joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like old friends.My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.So...It's time to jump. I cannot do this anymore.I actually just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or outsource? Finding a location. The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was ordered by a local ortho. (Drives me crazy!)Thanks for your help!

[Guest guest]



RE taking insurance.

1) If high deductible plans, then really can get paid "up front."

2) Most people need catastrophic insurance, and most places docs cannot go "cash only" so still more realistic to be participating with some.

That was my "point."

Regards,

Matt in Western PA

Time to Jump

I joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like old friends.My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.So...It's time to jump. I cannot do this anymore.I actually just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or outsource? Finding a location. The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was ordered by a local ortho. (Drives me crazy!)Thanks for your help!

[Guest guest]

Hi GregLooking at the over the line MA stuff compared to RI for priors for medications, referrals and CTs/MRIs I would say the burden of adminstrative crap is way higher in MA than in RI though we appear to be trying to catch up with you. I have a friend/colleague MD mostly solo mostly geriatric practice, blue collar population, who works in southeastern MA who like you has one person full time doing priors, just for his practice. Sounds awful. In RI, I have definitely taken to requiring the patient come in for a visit to charge their insurance(unless they are over 75, or very ill, or I get tired of laying down the law) to fill out/obtain any prior authorization that requires my time in the no-staff model I am using, if not done during the visit. My friend in MA was also wondering if it was possible to make the IMP model work in MA given the burden of admistrative work-feels his workload is out of control Maybe you guys should get together and figure it out - email me off list if you want his contact information.No reason for us to work making money for the insurance companies. Free Massachusetts!Lynn Ho

[Guest guest]

Greg HInson!!   Hey welcome back!  I had a  friend who  practiced on Nantucket did I ever tell ya that?t lasted a yr. Morelater.I will say do the IMP thing and be happy you can do  this . more later.   Good to see you I was wondering

Jean

 



RE taking insurance.

 

1) If high deductible plans, then really can get paid " up front. "

 

2) Most people need catastrophic insurance, and most places docs cannot go " cash only " so still more realistic to be participating with some.

 

That was my " point. "

 

Regards,

 

Matt in Western PA

Time to Jump

 

I joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like old friends.My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.So...It's time to jump. I cannot do this anymore.I actually just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or outsource? Finding a location. The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was ordered by a local ortho. (Drives me crazy!)Thanks for your help!

--      MD          ph    fax

[Guest guest]

I think panel size is the key to handling the administrative load of

Massachusetts. That's where I screwed up, but that mistake was made 6-7 yrs ago,

and is unfixable now. I cannot fire patients, not when there is no one else here

accepting new patients.

Because of panel size, I don't even have the option of bringing someone in for a

visit so I can charge for a prior authorization. That slot, if given away, will

result in an acute patient being sent to the ER to be seen, and another

over-the-phone z-pack prescription just to keep someone out of the office!

Greg

>

>

> Hi Greg

> Looking at the over the line MA stuff compared to RI for priors for

medications, referrals and CTs/MRIs I would say the burden of adminstrative crap

is way higher in MA than in RI though we appear to be trying to catch up with

you. I have a friend/colleague MD mostly solo mostly geriatric practice, blue

collar population, who works in southeastern MA who like you has one person full

time doing priors, just for his practice. Sounds awful.

> In RI, I have definitely taken to requiring the patient come in for a visit to

charge their insurance(unless they are over 75, or very ill, or I get tired of

laying down the law) to fill out/obtain any prior authorization that requires my

time in the no-staff model I am using, if not done during the visit.

> My friend in MA was also wondering if it was possible to make the IMP model

work in MA given the burden of admistrative work-feels his workload is out of

control Maybe you guys should get together and figure it out - email me off

list if you want his contact information.

> No reason for us to work making money for the insurance companies.

> Free Massachusetts!

> Lynn Ho

>

[Guest guest]

Because of the lack of patient access here, I think a reasonably-priced,

technologically efficient, and easily-accessed practice might fly, even if it

meant my patients would be forced to deal with their own insurance companies for

reimbursement (i.e., NOT reimbursed). BUT, with such a high load of managed

care, what I worry about is if their hospital work would be covered, if I

ordered it. As an island, I am trapped into only using the local hospital for

labs and xrays. And it is EXPENSIVE. If am not participating in insurance plans,

and I order and knee MRI, will it be paid? I think also not being able to use

their employer-supplied (or state-granted) insurance for the more expensive

testing might drive patients away.

I think I am going to call my own insurance plan and, as a patient, ask them

some of these hypotheticals and see how they respond. (Though we all know that

what they tell you on the phone and what they do when it is time to pay are

rarely the same thing!)

With technological efficiency in mind, a bit part of my downfall here has been

being forced to use the homegrown, non-integrated Mass General EMR. Things

worked much better on eClinicalworks. But checking out the market right now, I

am drawn to the HelloHealth product. Searching the group, I see there has been a

lot of conversation about one of its founders (Jay Parkinson), but not a lot of

discussion about how the product might facilitate a micropractice. Certainly

the upfront price is right! Anyone know of a practice using it?

THANKS!

>

>

> Hi Greg

> Looking at the over the line MA stuff compared to RI for priors for

medications, referrals and CTs/MRIs I would say the burden of adminstrative crap

is way higher in MA than in RI though we appear to be trying to catch up with

you. I have a friend/colleague MD mostly solo mostly geriatric practice, blue

collar population, who works in southeastern MA who like you has one person full

time doing priors, just for his practice. Sounds awful.

> In RI, I have definitely taken to requiring the patient come in for a visit to

charge their insurance(unless they are over 75, or very ill, or I get tired of

laying down the law) to fill out/obtain any prior authorization that requires my

time in the no-staff model I am using, if not done during the visit.

> My friend in MA was also wondering if it was possible to make the IMP model

work in MA given the burden of admistrative work-feels his workload is out of

control Maybe you guys should get together and figure it out - email me off

list if you want his contact information.

> No reason for us to work making money for the insurance companies.

> Free Massachusetts!

> Lynn Ho

>

[Guest guest]

In my partner's direct practice, a significant minority are uninsured or have such a high deductible that just pay cash for tests.  For many, prior authorizations and referrals are a minor hassle requiring them to call or visit their network PCP but labs and xray payments have not been a problem.

Many of the patients attracted to a lower cost direct practice are willing to travel a good bit to save on expensive procedures.  While the ferry ride is always time consuming, there seems to be a lot of excess imaging and ASU capacity within minutes of the Hyannis terminal and I bet many of those places would take a big discount for cash at time of service.

Would Quest or some other lab pick up specimens at your office?  That would be the easiest way to give patients an alternative to the local hospital fees.

 

Because of the lack of patient access here, I think a reasonably-priced, technologically efficient, and easily-accessed practice might fly, even if it meant my patients would be forced to deal with their own insurance companies for reimbursement (i.e., NOT reimbursed). BUT, with such a high load of managed care, what I worry about is if their hospital work would be covered, if I ordered it. As an island, I am trapped into only using the local hospital for labs and xrays. And it is EXPENSIVE. If am not participating in insurance plans, and I order and knee MRI, will it be paid? I think also not being able to use their employer-supplied (or state-granted) insurance for the more expensive testing might drive patients away.

I think I am going to call my own insurance plan and, as a patient, ask them some of these hypotheticals and see how they respond. (Though we all know that what they tell you on the phone and what they do when it is time to pay are rarely the same thing!)

With technological efficiency in mind, a bit part of my downfall here has been being forced to use the homegrown, non-integrated Mass General EMR. Things worked much better on eClinicalworks. But checking out the market right now, I am drawn to the HelloHealth product. Searching the group, I see there has been a lot of conversation about one of its founders (Jay Parkinson), but not a lot of discussion about how the product might facilitate a micropractice. Certainly the upfront price is right! Anyone know of a practice using it?

THANKS!

>

>

> Hi Greg

> Looking at the over the line MA stuff compared to RI for priors for medications, referrals and CTs/MRIs I would say the burden of adminstrative crap is way higher in MA than in RI though we appear to be trying to catch up with you. I have a friend/colleague MD mostly solo mostly geriatric practice, blue collar population, who works in southeastern MA who like you has one person full time doing priors, just for his practice. Sounds awful.

> In RI, I have definitely taken to requiring the patient come in for a visit to charge their insurance(unless they are over 75, or very ill, or I get tired of laying down the law) to fill out/obtain any prior authorization that requires my time in the no-staff model I am using, if not done during the visit.

> My friend in MA was also wondering if it was possible to make the IMP model work in MA given the burden of admistrative work-feels his workload is out of control Maybe you guys should get together and figure it out - email me off list if you want his contact information.

> No reason for us to work making money for the insurance companies.

> Free Massachusetts!

> Lynn Ho

>

[Guest guest]

Hi Greg!

I remember your name - welcome

back to posting and glad you are ready to make the leap.

I’ll give my 2 cents on

your questions:

1.

With fewer

pts, you’ll have fewer of these to do. If you don’t charge a

NCBF to include your time for this task, then bring the pt in for an Office Visit

so they can sit there while you do it. I often do it with the pt sitting there

during the OV that we decide to do the study, and it often helps to have the pt

there to help answer questions.

2.

Depends on the

region and the insurance it seems. In those instances where the pts are

penalized for you being their doc, I ‘share’ the pt with a doc that

is on the insurance’s panel. I let the pt know this up front (if I

am aware of it), and encourage them to see a doc I know well who is on the

panel. Then I communicate with that doc and tell them what the pt needs.

Often the other doc is happy that I have done the legwork for them and will do

the referral/auth. Sometimes they want to see the pt as well. But I have

also been able to call in to the PAR line for the insurance co and get it

approved, even though I am not a provider (but used to be). That has

happened with Kaiser twice in the last 4 months.

Eads, MD

Pinnacle Family Medicine

Colorado Springs, CO

www.PinnacleFamilyMedicine.com

From:

[mailto: ] On Behalf Of gregandamyhinson

Sent: Tuesday, February 07, 2012 8:13 PM

To:

Subject: Time to Jump

I joined this group 8 years ago, and this is

probably my first post in 6. Yet, reading through some of the recent messages,

I still recognize a lot of the names. Like old friends.

My story is a familiar one. When I joined, I had a small, solo practice in a

high-need area. I was trying to live by many of the IMP principles, but I lost

control. Ultimately, my practice grew, and grew, took on a partner, that didn't

work out, on the brink of poverty, joined a large multi-specialty group and allowed

my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1

receptionist, and 1 manager (and we still outsource billing). And it's out of

control. We have a several week waiting list and are directing many patients to

the ER during office hours. And I am having trouble finishing my notes in a

timely manner, and my employers are screaming about red ink.

So...

It's time to jump. I cannot do this anymore.

I actually just came to this conclusion on Monday. Lots of decisions yet to be

even thought of! Direct pay or membership or traditional insurance? Keep

billing in-house or outsource? Finding a location.

The big questions are to come. But, for now, a couple of little nagging ones

that have me wondering about the upcoming business plan...

1) We now have a full-time medical assistant who simply handles prior

authorizations and pre-approvals. Maybe this is somehow unique to my location,

but has this hassle effected the IMPs in a bad way? I watch her on hold for 20

minutes to get someone to approve the MRI I want to order. How does this work

in a low-overhead, no-help practice?

2) If I were to go to a cash practice, and I am not listed as the PCP for all

of the local HMO practices, and these patients need services like PT or

radiology, would they be left responsible for these bills because I was the

doctor that ordered them? I know now that my family practice often gets calls

from patients that I have not seen for a particular problem needing our office

to get pre-approval for something like PT that was ordered by a local ortho.

(Drives me crazy!)

Thanks for your help!

[Guest guest]

I am in RI and am only open 2 days. If you or you know anyone wanting

to join for the other days let me know.

Deb

> Hi Greg!

>

>

>

> I remember your name - welcome back to posting and glad you are ready to

> make the leap.

>

>

>

> I'll give my 2 cents on your questions:

>

>

>

> 1. With fewer pts, you'll have fewer of these to do. If you don't

> charge a NCBF to include your time for this task, then bring the pt in for

> an Office Visit so they can sit there while you do it. I often do it with

> the pt sitting there during the OV that we decide to do the study, and it

> often helps to have the pt there to help answer questions.

>

> 2. Depends on the region and the insurance it seems. In those

> instances where the pts are penalized for you being their doc, I 'share' the

> pt with a doc that is on the insurance's panel. I let the pt know this up

> front (if I am aware of it), and encourage them to see a doc I know well who

> is on the panel. Then I communicate with that doc and tell them what the pt

> needs. Often the other doc is happy that I have done the legwork for them

> and will do the referral/auth. Sometimes they want to see the pt as well.

> But I have also been able to call in to the PAR line for the insurance co

> and get it approved, even though I am not a provider (but used to be). That

> has happened with Kaiser twice in the last 4 months.

>

>

>

>

>

> Eads, MD

>

> Pinnacle Family Medicine

>

> Colorado Springs, CO

>

> www.PinnacleFamilyMedicine.com

>

>

>

>

>

>

>

> From:

> [mailto: ] On Behalf Of gregandamyhinson

> Sent: Tuesday, February 07, 2012 8:13 PM

> To:

> Subject: Time to Jump

>

>

>

>

>

> I joined this group 8 years ago, and this is probably my first post in 6.

> Yet, reading through some of the recent messages, I still recognize a lot of

> the names. Like old friends.

>

> My story is a familiar one. When I joined, I had a small, solo practice in a

> high-need area. I was trying to live by many of the IMP principles, but I

> lost control. Ultimately, my practice grew, and grew, took on a partner,

> that didn't work out, on the brink of poverty, joined a large

> multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice

> grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we

> still outsource billing). And it's out of control. We have a several week

> waiting list and are directing many patients to the ER during office hours.

> And I am having trouble finishing my notes in a timely manner, and my

> employers are screaming about red ink.

>

> So...

>

> It's time to jump. I cannot do this anymore.

>

> I actually just came to this conclusion on Monday. Lots of decisions yet to

> be even thought of! Direct pay or membership or traditional insurance? Keep

> billing in-house or outsource? Finding a location.

>

> The big questions are to come. But, for now, a couple of little nagging ones

> that have me wondering about the upcoming business plan...

>

> 1) We now have a full-time medical assistant who simply handles prior

> authorizations and pre-approvals. Maybe this is somehow unique to my

> location, but has this hassle effected the IMPs in a bad way? I watch her on

> hold for 20 minutes to get someone to approve the MRI I want to order. How

> does this work in a low-overhead, no-help practice?

>

> 2) If I were to go to a cash practice, and I am not listed as the PCP for

> all of the local HMO practices, and these patients need services like PT or

> radiology, would they be left responsible for these bills because I was the

> doctor that ordered them? I know now that my family practice often gets

> calls from patients that I have not seen for a particular problem needing

> our office to get pre-approval for something like PT that was ordered by a

> local ortho. (Drives me crazy!)

>

> Thanks for your help!

>

>

>

>

[Guest guest]

Deb,

How is this working for you?  Only being open 2 days?  Do your patients have direct access to you outside of those days?

 

Reason I ask is that we are open 4 days, and another internist is looking to start a new practice, and we were thinking of bringing her in the 1 day we are not there.  But, she only wants to work 2-3 days/week long-term.  We're not sure if that is sustainable/reasonable as a PCP.

 

Thanks,

 

I am in RI and am only open 2 days. If you or you know anyone wantingto join for the other days let me know.Deb

> Hi Greg!>>>> I remember your name - welcome back to posting and glad you are ready to

> make the leap.>>>> I'll give my 2 cents on your questions:>>>> 1. With fewer pts, you'll have fewer of these to do. If you don't> charge a NCBF to include your time for this task, then bring the pt in for

> an Office Visit so they can sit there while you do it. I often do it with> the pt sitting there during the OV that we decide to do the study, and it> often helps to have the pt there to help answer questions.

>> 2. Depends on the region and the insurance it seems. In those> instances where the pts are penalized for you being their doc, I 'share' the> pt with a doc that is on the insurance's panel. I let the pt know this up

> front (if I am aware of it), and encourage them to see a doc I know well who> is on the panel. Then I communicate with that doc and tell them what the pt> needs. Often the other doc is happy that I have done the legwork for them

> and will do the referral/auth. Sometimes they want to see the pt as well.> But I have also been able to call in to the PAR line for the insurance co> and get it approved, even though I am not a provider (but used to be). That

> has happened with Kaiser twice in the last 4 months.>>>>>> Eads, MD>> Pinnacle Family Medicine>> Colorado Springs, CO>> www.PinnacleFamilyMedicine.com

>>>>>>>> From: > [mailto: ] On Behalf Of gregandamyhinson

> Sent: Tuesday, February 07, 2012 8:13 PM> To: > Subject: Time to Jump

>>>>>

> I joined this group 8 years ago, and this is probably my first post in 6.> Yet, reading through some of the recent messages, I still recognize a lot of> the names. Like old friends.

>> My story is a familiar one. When I joined, I had a small, solo practice in a> high-need area. I was trying to live by many of the IMP principles, but I> lost control. Ultimately, my practice grew, and grew, took on a partner,

> that didn't work out, on the brink of poverty, joined a large> multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice> grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we

> still outsource billing). And it's out of control. We have a several week> waiting list and are directing many patients to the ER during office hours.> And I am having trouble finishing my notes in a timely manner, and my

> employers are screaming about red ink.>> So...>> It's time to jump. I cannot do this anymore.>> I actually just came to this conclusion on Monday. Lots of decisions yet to

> be even thought of! Direct pay or membership or traditional insurance? Keep> billing in-house or outsource? Finding a location.>> The big questions are to come. But, for now, a couple of little nagging ones

> that have me wondering about the upcoming business plan...>> 1) We now have a full-time medical assistant who simply handles prior> authorizations and pre-approvals. Maybe this is somehow unique to my

> location, but has this hassle effected the IMPs in a bad way? I watch her on> hold for 20 minutes to get someone to approve the MRI I want to order. How> does this work in a low-overhead, no-help practice?

>> 2) If I were to go to a cash practice, and I am not listed as the PCP for> all of the local HMO practices, and these patients need services like PT or> radiology, would they be left responsible for these bills because I was the

> doctor that ordered them? I know now that my family practice often gets> calls from patients that I have not seen for a particular problem needing> our office to get pre-approval for something like PT that was ordered by a

> local ortho. (Drives me crazy!)>> Thanks for your help!>>>>

-- Pratt

[Guest guest]

Share rent.

Be sure they follow their own pts.

I share space with Gen Surgeon in one location and Podiatry practice in another.

Find it works better if you rent NOT from a primary but from specialist.

Matt in Western PA

Time to Jump>>>>>

> I joined this group 8 years ago, and this is probably my first post in 6.> Yet, reading through some of the recent messages, I still recognize a lot of> the names. Like old friends.>> My story is a familiar one. When I joined, I had a small, solo practice in a> high-need area. I was trying to live by many of the IMP principles, but I> lost control. Ultimately, my practice grew, and grew, took on a partner,> that didn't work out, on the brink of poverty, joined a large> multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice> grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we> still outsource billing). And it's out of control. We have a several week> waiting list and are directing many patients to the ER during office hours.> And I am having trouble finishing my notes in a timely manner, and my> employers are screaming about red ink.>> So...>> It's time to jump. I cannot do this anymore.>> I actually just came to this conclusion on Monday. Lots of decisions yet to> be even thought of! Direct pay or membership or traditional insurance? Keep> billing in-house or outsource? Finding a location.>> The big questions are to come. But, for now, a couple of little nagging ones> that have me wondering about the upcoming business plan...>> 1) We now have a full-time medical assistant who simply handles prior> authorizations and pre-approvals. Maybe this is somehow unique to my> location, but has this hassle effected the IMPs in a bad way? I watch her on> hold for 20 minutes to get someone to approve the MRI I want to order. How> does this work in a low-overhead, no-help practice?>> 2) If I were to go to a cash practice, and I am not listed as the PCP for> all of the local HMO practices, and these patients need services like PT or> radiology, would they be left responsible for these bills because I was the> doctor that ordered them? I know now that my family practice often gets> calls from patients that I have not seen for a particular problem needing> our office to get pre-approval for something like PT that was ordered by a> local ortho. (Drives me crazy!)>> Thanks for your help!>>>>

-- Pratt

[Guest guest]

We have no staff, so we have to watch our time carefully. The folks we use for

MRI's do the preauths. They make the big bucks and it is a competive market. GEt

them to do it and free up your staff. Use same day access and book all visits

for the day they call/

________________________________________

From:

[ ] On Behalf Of gregandamyhinson

[hinsons@...]

Sent: Tuesday, February 07, 2012 8:13 PM

To:

Subject: Time to Jump

I joined this group 8 years ago, and this is probably my first post in 6. Yet,

reading through some of the recent messages, I still recognize a lot of the

names. Like old friends.

My story is a familiar one. When I joined, I had a small, solo practice in a

high-need area. I was trying to live by many of the IMP principles, but I lost

control. Ultimately, my practice grew, and grew, took on a partner, that didn't

work out, on the brink of poverty, joined a large multi-specialty group and

allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2

MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out

of control. We have a several week waiting list and are directing many patients

to the ER during office hours. And I am having trouble finishing my notes in a

timely manner, and my employers are screaming about red ink.

So...

It's time to jump. I cannot do this anymore.

I actually just came to this conclusion on Monday. Lots of decisions yet to be

even thought of! Direct pay or membership or traditional insurance? Keep billing

in-house or outsource? Finding a location.

The big questions are to come. But, for now, a couple of little nagging ones

that have me wondering about the upcoming business plan...

1) We now have a full-time medical assistant who simply handles prior

authorizations and pre-approvals. Maybe this is somehow unique to my location,

but has this hassle effected the IMPs in a bad way? I watch her on hold for 20

minutes to get someone to approve the MRI I want to order. How does this work in

a low-overhead, no-help practice?

2) If I were to go to a cash practice, and I am not listed as the PCP for all of

the local HMO practices, and these patients need services like PT or radiology,

would they be left responsible for these bills because I was the doctor that

ordered them? I know now that my family practice often gets calls from patients

that I have not seen for a particular problem needing our office to get

pre-approval for something like PT that was ordered by a local ortho. (Drives me

crazy!)

Thanks for your help!

[Guest guest]

Greg and colleagues,

While checking out software you might be interested in Avado. They are a start up company that does doctor patient communication securely.

I would think of this as enabling communication similarly to what Hello Heath does without taking a percentage of your revenues.

They have a free version.

Also, lately I've noticed that several companies with a subscription model are trying to go national.

You might check out their subscription models when figuring out your pricing and business plan.

Medlion is one that I've seen most recently.

http://techcrunch.com/2011/06/19/the-most-important-organization-in-silicon-valley-that-no-one-has-heard-about/

I think they may use the Avado software.

Best Regards

Ben Brewer, M.D.

solo, then partnered, then sold out busy practice to the hospital as well.

To: " " < > Sent: Thursday, February 9, 2012 10:16 AMSubject: RE: Time to JumpWe have no staff, so we have to watch our time carefully. The folks we use for MRI's do the preauths. They make the big bucks and it is a competive market. GEt them to do it and free up your staff.

Use same day access and book all visits for the day they call/ ________________________________________From: [ ] On Behalf Of gregandamyhinson [hinsons@...]Sent: Tuesday, February 07, 2012 8:13 PMTo: Subject: Time to JumpI joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like

old friends.My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.So...It's time to jump. I cannot do this anymore.I actually just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or

outsource? Finding a location.The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was

ordered by a local ortho. (Drives me crazy!)Thanks for your help!------------------------------------

[Guest guest]

Are you going to still/go back to using eCW? You were a big champ of that platform then.

Regards and good to have you back!

Matt in Western PA

Time to Jump

I joined this group 8 years ago, and this is probably my first post in 6. Yet, reading through some of the recent messages, I still recognize a lot of the names. Like old friends.My story is a familiar one. When I joined, I had a small, solo practice in a high-need area. I was trying to live by many of the IMP principles, but I lost control. Ultimately, my practice grew, and grew, took on a partner, that didn't work out, on the brink of poverty, joined a large multi-specialty group and allowed my 1 Dr, 1 MA, and 1 receptionist practice grow to a 2 Dr, 2 NP, 2 RN, 2 MA, 1 receptionist, and 1 manager (and we still outsource billing). And it's out of control. We have a several week waiting list and are directing many patients to the ER during office hours. And I am having trouble finishing my notes in a timely manner, and my employers are screaming about red ink.So...It's time to jump. I cannot do this anymore.I actually just came to this conclusion on Monday. Lots of decisions yet to be even thought of! Direct pay or membership or traditional insurance? Keep billing in-house or outsource? Finding a location. The big questions are to come. But, for now, a couple of little nagging ones that have me wondering about the upcoming business plan...1) We now have a full-time medical assistant who simply handles prior authorizations and pre-approvals. Maybe this is somehow unique to my location, but has this hassle effected the IMPs in a bad way? I watch her on hold for 20 minutes to get someone to approve the MRI I want to order. How does this work in a low-overhead, no-help practice?2) If I were to go to a cash practice, and I am not listed as the PCP for all of the local HMO practices, and these patients need services like PT or radiology, would they be left responsible for these bills because I was the doctor that ordered them? I know now that my family practice often gets calls from patients that I have not seen for a particular problem needing our office to get pre-approval for something like PT that was ordered by a local ortho. (Drives me crazy!)Thanks for your help!