Nursing Home - Low Overhead --> RE: Re: To take insurance or not. & other ways to make it work financially

[Guest guest]

I don't recall if it was on this list or another, but I believe that nursing home care was promoted as a low overhead option for docs.The idea was....1. Don't need office space -- can see the patients at the nursing home.2. Don't need nurse -- nursing home as nurses to help3. Blood draws can usually be done at the nursing home -- no need to maintain supplies, etc.4. Don't need blood pressure cuff, etc -- nursing home has it.

Overhead is extremely low. My practice overhead is 24 percent and hasn't been over 25 percent in years. That's unheard of in a typical office-based practice, where the usual cost of overhead is 45-60 percent. All you need is a car, a communication system (phone, cell phone, beeper, and exchange), malpractice insurance, and a billing system. If you're presently in practice, you already have all of these prerequisites, so adding a nursing home or two won't increase your overhead. The facility provides the patients, the rooms for exams, the charts, the nursing personnel, the secretarial staff, etc. How can it get any easier? Just show up, see your patient, write your note, and you're done. If you're just starting out and don't open a traditional office, a nursing home practice will save you about half the cost of customary overhead. That's roughly three months of income you don't have to spend on rent, staff, and the like.

Anyway, interesting idea and alternative to traditional practice - even IMP practice.

Locke, MD

Quick search of MeMag found...

http://www.memag.com/memag/article/articleDetail.jsp?id=428769

[Guest guest]

It is low overhead but high in unpaid work, or it was for me.  I

gave it up and it was the best feeling in the world as it had become the thing

that gave me the most grief.

1)

So many phone calls and faxes daily re the patients, weekends

and weekdays.  That takes up your staff time too.  Answering service charges,

etc.

2)

High hospitalization rate and then readmission with strict time

limits so that you have to get there on unplanned days.

I would think these things are universal.  At the nursing home I

was admitting to, they weren’t giving me new patients as they preferred

their own medical director and the psychiatrists husband’s group.  The

last straw is when they gave my patient from my office to another doctor

when he was admitted there.  And the ambulance always refused to bring the

patient to my hospital saying they were “too critical” and had to

go to the closest hospital.

All I am saying is it’s not all good, you need to look at

it all.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Locke's in

Colorado

Sent: Wednesday, January 09, 2008 12:42 AM

To:

Subject: Nursing Home - Low Overhead --> RE:

Re: To take insurance or not. & other ways to make it work financially

I don't recall if it was on this list or

another, but I believe that nursing home care was promoted as a low overhead

option for docs.

The idea was....

1. Don't need office space -- can see the patients at the nursing home.

2. Don't need nurse -- nursing home as nurses to help

3. Blood draws can usually be done at the nursing home -- no need to maintain

supplies, etc.

4. Don't need blood pressure cuff, etc -- nursing home has it.

Overhead is extremely low. My practice overhead is 24

percent and hasn't been over 25 percent in years. That's unheard of in a

typical office-based practice, where the usual cost of overhead is 45-60

percent. All you need is a car, a communication system (phone, cell phone,

beeper, and exchange), malpractice insurance, and a billing system. If you're

presently in practice, you already have all of these prerequisites, so adding a

nursing home or two won't increase your overhead. The facility provides the

patients, the rooms for exams, the charts, the nursing personnel, the

secretarial staff, etc. How can it get any easier? Just show up, see your

patient, write your note, and you're done. If you're just starting out and

don't open a traditional office, a nursing home practice will save you about

half the cost of customary overhead. That's roughly three months of income you

don't have to spend on rent, staff, and the like.

Anyway, interesting idea and

alternative to traditional practice - even IMP practice.

Locke, MD

Quick search of MeMag

found...

http://www.memag.com/memag/article/articleDetail.jsp?id=428769

Error! Filename not specified.

10 reasons I see only nursing home

patients

It's more lucrative than you probably think, yet the rewards are more than

just monetary.

Honorable Mention 2006 Doctors' Writing Contest

Jun 1, 2007

By:

P. Zydiak, MD

Medical Economics

What, you don't go to nursing homes? Why

not? Takes too long, not reimbursed well enough for your time, not

challenging enough, too many phone calls, too depressing? These are some of

the complaints I've heard over the years about practicing in long-term care

(LTC). They couldn't be further from the truth. I've been in LTC for the last

15 or so years and find it to be an ideal environment to combat many of the

problems facing the typical primary care physician today. I feel so strongly

about it that I'd like to share some of the reasons why I believe all

physicians should be involved in the LTC arena.

1. The population of seniors is growing

rapidly. As our baby boomers enter their golden years, they'll need LTC

services in ever-increasing numbers. According to The New York Times,

the supply of physicians available will not meet the need. ( " Geriatrics

lags in age of high-tech medicine, " The New York Times, Oct. 18,

2006.) This combination of high demand and low supply means lots of

opportunity and steady work for properly positioned physicians. These

proactive providers will be valuable players as nursing homes and hospitals

look to capture this market. This doesn't even count the growing numbers of

independent living units that are being built by most large nursing

home/skilled nursing facilities. Look around your neighborhood: Do you notice

a lot of construction around your older, well-established nursing homes?

That's what they're building.

2. Nursing homes are hungry for good

doctors. Historically, the LTC setting was for aging doctors who were

winding down their practice in anticipation of retirement. Some doctors

didn't even consider nursing home work to be real medicine. (I heard this

comment from an internist who's in a leadership role in my hometown.) Many of

these doctors would just go through the motions, and some gave LTC a bad

reputation. This is no longer the case. The typical nursing home and skilled

nursing facility (SNF) is being filled with complicated patients needing

well-trained physicians to care for them. These patients used to be treated

on the inpatient side, but not anymore. Physicians who complete a geriatric

fellowship or who are board certified (typically in internal medicine, family

practice, or, of course, geriatric medicine) will have a leg up, but there's

room for all those truly interested.

3. LTC is not just long-term patients. The

old-fashioned nursing home with its long-term residents still exists and is

still the backbone of long-term care, but more and more of these people are

cared for in skilled nursing facilities. This treatment is short-term

(several weeks) for things like postoperative care of patients who undergo

orthopedic procedures, or stroke patients needing rehabilitation services.

Those of you old enough to remember used to see these people in the

hospitals' rehab units. Now they go to SNFs. This is just another growing

area that's also in need of good physician care. The volume and constant

turnover of these patients makes it a very dynamic and stimulating

environment.

4. You don't have to participate in

managed care. Yes, it's true. According to CMS and The Competitive

Edge from HealthLeaders-InterStudy, the penetration of managed care in

the long-term care/geriatric population is far below that of traditional

medical care. Even in California, total managed care penetration is only

about 65 percent. I wouldn't expect that percentage to increase much in the

coming years, since this frail and sickly population is difficult for

insurance companies to profit from. Personally, I've never participated in

any managed care plan (meaning any capitated or non-fee-for-service product).

Can you say that?

5. LTC practice is more predictable

than an outpatient practice. In LTC, patients are seen once a month (on

average) and as needed. You must show that the visits are medically

necessary, but in most cases you can bill for at least 12 visits a year per

patient, one of which is an initial, readmit, or annual visit. This visit

frequency is much higher than that of your average office outpatient. On the

SNF side, most patients are generally sicker and rate at least weekly

visits—sometimes more in complicated cases. This provides a steady and

predictable patient visit volume with less month-to-month variation, and

therefore more business with less stress.

6. LTC practice offers a forgiving,

flexible work schedule. LTC visits are not by appointment. Whenever you can

show up you're on time. You can spend as much time as you need because

there's no set schedule. Facilities are open 24 hours a day just like a

hospital. The majority of visits do take place during the day or early

evening, but it's all up to you.

The flexibility of this set-up is

wonderful. It forever eliminates the stress of being late or falling

behind—no more waiting rooms filling up with angry patients! It's

possible for me to knock off a little early, without advanced planning. If I

want to skip nursing home rounds and go fishing for bluegills, I can make

rounds the next day. I don't do that too often, but I can without any fuss.

No phone calls to reschedule appointments, no double or triple booking to

make up for the missed day. Did I mention that I take my kids to school each

morning and have for years? Now that's the life.

7. Overhead is extremely low. My

practice overhead is 24 percent and hasn't been over 25 percent in years.

That's unheard of in a typical office-based practice, where the usual cost of

overhead is 45-60 percent. All you need is a car, a communication system

(phone, cell phone, beeper, and exchange), malpractice insurance, and a

billing system. If you're presently in practice, you already have all of

these prerequisites, so adding a nursing home or two won't increase your

overhead. The facility provides the patients, the rooms for exams, the

charts, the nursing personnel, the secretarial staff, etc. How can it get any

easier? Just show up, see your patient, write your note, and you're done. If

you're just starting out and don't open a traditional office, a nursing home

practice will save you about half the cost of customary overhead. That's

roughly three months of income you don't have to spend on rent, staff, and

the like.

8. LTC offers a conduit to many other

opportunities. LTC is predominantly a multidisciplinary affair. You get

involved with home health, physical therapy, hospice, and other ancillary

services. Many of these entities offer opportunities for administrative

duties and medical directorships for physicians already involved with LTC.

Nursing homes all need a medical director to comply with the regulations of

the federal Nursing Home Reform Act. These offer a welcome diversion into

nonclinical components of medicine as well as provide new streams of income

unaffected by insurance regulation and controls. You can charge and receive

whatever the market will bear. While the majority of nursing home medical

directorships are part-time jobs, there are some full-time positions

available. Office-based practitioners who don't make nursing home rounds

aren't offered these opportunities, ever.

9. The practice model is a natural fit

for the use of NPs and PAs. The shortage of physicians in LTC is expected

to grow as fewer doctors are going into geriatric fellowships. If you have a

PA or NP on staff, this shortage provides an opportunity for your practice to

fill the gap. An office-based physician who already uses these extenders can

expand their use to the LTC setting. (Some Medicare rules apply to who can

visit when, as well as to reimbursement.) If you don't do it, someone else

will.

10. Reimbursement for nursing home work

is more than adequate. Reimbursements for LTC care allow the typical

physician to easily make at least as much, if not more, than the median total

compensation for internists and FPs, which are $157,000 and $150,000,

respectively, according to Medical Economics' latest Continuing Survey. This is not only possible but almost

guaranteed, if you take into account the low overhead, the number of visits,

the increased frequency of patient visits on skilled units, and the

opportunity for other nonclinical income from medical directorships and the

like. There are so many opportunities to generate income it's literally

impossible to fail.

Bonus. LTC patients are among the most

challenging, interesting, colorful, and grateful you'll ever encounter. This

may not be important economically, but emotionally it's priceless. I've

learned more from my " old folks " (they don't know it's politically

incorrect to say the word " old " ) than I ever have from my

middle-aged and younger patients. Most have been through several wars and a

depression, and have a different mindset of self-reliance and resilience

that's lacking in subsequent generations. Their generation helped save the

world and I find great honor and pleasure in serving them now. They're a lot

more fun to deal with and much more appreciative.

I hope this article convinces you to give

nursing home care some serious thought. You don't have to switch to a 100

percent nursing home practice, as I have, but could simply add one or two

nursing homes or skilled nursing facilities to your practice. The personal as

well as the financial rewards are there for the taking. It really is that

simple. Give it a try.

If you'd like to discuss this topic

further with me, you can reach me at gzydiak@...

..

Re: To take insurance or not. & other ways

to make it work financially

I joined recently and have read every post with fascination (well, most).

Thank you all, I'm enjoying it.

The issue is not necessarily about taking insurance or not as an absolute, but

being VERY selective about which to take. You might find this strange in

other areas of the country, but I take traditional Medicare almost exclusively,

refusing everything else.

All others pay less now, here in my patient population. I couldn't have

the high quality time-intensive practice that I have any other way.

I do, however, find other ways to supplement my income, and have done so since

I started in practice 14 years ago. All of those ways are FUN and

low-overhead. They include nursing home and outpatient rehab physician

administration, program development, paid lectures, hospice medical

directorship and medical expert witness. Every one of them takes real

time and effort, not just " kick-backs for patient referrals " kind of

money. But it's a good way to be able to pay the bills if patient visits

aren't enough, or you want to limit your practice volume. Plus, it has

allowed me to enact quality changes at a systemic level, not just at the

individual patient level.

I am a geriatric rehab doc who specializes in the most frail, complex, disabled

elderly. Every person who gave me advice before I started in practice

told me I'd never make it financially. They were all wrong- I made a

profit from day one! I just did things very differently from the norm,

like most of the people in this group of docs. I have no employees and no

office, and I started that way in

1994 (back then it was because I was down to my last $500 & couldn't get a

loan).

I'm curious, though, how many of the docs on this listserv are

specialists? I've only seen a couple of posts from neurologists.

There is great potential for micropractice beyond primary care. Think big,

bigger! The patients who need the most time, the elderly, need all sorts

of quality docs; the only way they'll have them is through the

low-overhead movement.

Think outside the box, you people are great!

Rotenberg, MD

Melbourne, Florida

[Guest guest]

Good points, Kathy.

I have/had the same problems with the few nursing home patients I care for.

I think the angle that the article talks about is doing a LOT of nursing home care.

One would basically be visiting the nursing home several days per week and could sign off orders, see patients, etc on each visit.

The nursing home would fax forms, arrange consults, keep the records, etc.

But I agree that doing a little nursing home care can be difficult because of the frequent faxes, calls, etc.

Also, had the problem with the NH taking the patients to a hospital I didn't cover because it was closer.

Just another angle -- bet there would be lots of Level 4 visits.

:-)

But your caviets are well mentioned -- because there can be a lot of hassles with nursing home care.

Locke, MD

From: [mailto: ] On Behalf Of Kathy SaradarianSent: Wednesday, January 09, 2008 6:32 AMTo: Subject: RE: Nursing Home - Low Overhead --> RE: Re: To take insurance or not. & other ways to make it work financially

It is low overhead but high in unpaid work, or it was for me. I gave it up and it was the best feeling in the world as it had become the thing that gave me the most grief.

1) So many phone calls and faxes daily re the patients, weekends and weekdays. That takes up your staff time too. Answering service charges, etc.

2) High hospitalization rate and then readmission with strict time limits so that you have to get there on unplanned days.

I would think these things are universal. At the nursing home I was admitting to, they weren’t giving me new patients as they preferred their own medical director and the psychiatrists husband’s group. The last straw is when they gave my patient from my office to another doctor when he was admitted there. And the ambulance always refused to bring the patient to my hospital saying they were “too critical” and had to go to the closest hospital.

All I am saying is it’s not all good, you need to look at it all.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From: [mailto: ] On Behalf Of Locke's in ColoradoSent: Wednesday, January 09, 2008 12:42 AMTo: Subject: Nursing Home - Low Overhead --> RE: Re: To take insurance or not. & other ways to make it work financially

I don't recall if it was on this list or another, but I believe that nursing home care was promoted as a low overhead option for docs.The idea was....1. Don't need office space -- can see the patients at the nursing home.2. Don't need nurse -- nursing home as nurses to help3. Blood draws can usually be done at the nursing home -- no need to maintain supplies, etc.4. Don't need blood pressure cuff, etc -- nursing home has it.

Overhead is extremely low. My practice overhead is 24 percent and hasn't been over 25 percent in years. That's unheard of in a typical office-based practice, where the usual cost of overhead is 45-60 percent. All you need is a car, a communication system (phone, cell phone, beeper, and exchange), malpractice insurance, and a billing system. If you're presently in practice, you already have all of these prerequisites, so adding a nursing home or two won't increase your overhead. The facility provides the patients, the rooms for exams, the charts, the nursing personnel, the secretarial staff, etc. How can it get any easier? Just show up, see your patient, write your note, and you're done. If you're just starting out and don't open a traditional office, a nursing home practice will save you about half the cost of customary overhead. That's roughly three months of income you don't have to spend on rent, staff, and the like.

Anyway, interesting idea and alternative to traditional practice - even IMP practice.

Locke, MD

Quick search of MeMag found...

http://www.memag.com/memag/article/articleDetail.jsp?id=428769

Error! Filename not specified.

10 reasons I see only nursing home patients

It's more lucrative than you probably think, yet the rewards are more than just monetary.

Honorable Mention 2006 Doctors' Writing Contest

Jun 1, 2007

By: P. Zydiak, MD

Medical Economics

What, you don't go to nursing homes? Why not? Takes too long, not reimbursed well enough for your time, not challenging enough, too many phone calls, too depressing? These are some of the complaints I've heard over the years about practicing in long-term care (LTC). They couldn't be further from the truth. I've been in LTC for the last 15 or so years and find it to be an ideal environment to combat many of the problems facing the typical primary care physician today. I feel so strongly about it that I'd like to share some of the reasons why I believe all physicians should be involved in the LTC arena.

1. The population of seniors is growing rapidly. As our baby boomers enter their golden years, they'll need LTC services in ever-increasing numbers. According to The New York Times, the supply of physicians available will not meet the need. ("Geriatrics lags in age of high-tech medicine," The New York Times, Oct. 18, 2006.) This combination of high demand and low supply means lots of opportunity and steady work for properly positioned physicians. These proactive providers will be valuable players as nursing homes and hospitals look to capture this market. This doesn't even count the growing numbers of independent living units that are being built by most large nursing home/skilled nursing facilities. Look around your neighborhood: Do you notice a lot of construction around your older, well-established nursing homes? That's what they're building.

2. Nursing homes are hungry for good doctors. Historically, the LTC setting was for aging doctors who were winding down their practice in anticipation of retirement. Some doctors didn't even consider nursing home work to be real medicine. (I heard this comment from an internist who's in a leadership role in my hometown.) Many of these doctors would just go through the motions, and some gave LTC a bad reputation. This is no longer the case. The typical nursing home and skilled nursing facility (SNF) is being filled with complicated patients needing well-trained physicians to care for them. These patients used to be treated on the inpatient side, but not anymore. Physicians who complete a geriatric fellowship or who are board certified (typically in internal medicine, family practice, or, of course, geriatric medicine) will have a leg up, but there's room for all those truly interested.

3. LTC is not just long-term patients. The old-fashioned nursing home with its long-term residents still exists and is still the backbone of long-term care, but more and more of these people are cared for in skilled nursing facilities. This treatment is short-term (several weeks) for things like postoperative care of patients who undergo orthopedic procedures, or stroke patients needing rehabilitation services. Those of you old enough to remember used to see these people in the hospitals' rehab units. Now they go to SNFs. This is just another growing area that's also in need of good physician care. The volume and constant turnover of these patients makes it a very dynamic and stimulating environment.

4. You don't have to participate in managed care. Yes, it's true. According to CMS and The Competitive Edge from HealthLeaders-InterStudy, the penetration of managed care in the long-term care/geriatric population is far below that of traditional medical care. Even in California, total managed care penetration is only about 65 percent. I wouldn't expect that percentage to increase much in the coming years, since this frail and sickly population is difficult for insurance companies to profit from. Personally, I've never participated in any managed care plan (meaning any capitated or non-fee-for-service product). Can you say that?

5. LTC practice is more predictable than an outpatient practice. In LTC, patients are seen once a month (on average) and as needed. You must show that the visits are medically necessary, but in most cases you can bill for at least 12 visits a year per patient, one of which is an initial, readmit, or annual visit. This visit frequency is much higher than that of your average office outpatient. On the SNF side, most patients are generally sicker and rate at least weekly visits—sometimes more in complicated cases. This provides a steady and predictable patient visit volume with less month-to-month variation, and therefore more business with less stress.

6. LTC practice offers a forgiving, flexible work schedule. LTC visits are not by appointment. Whenever you can show up you're on time. You can spend as much time as you need because there's no set schedule. Facilities are open 24 hours a day just like a hospital. The majority of visits do take place during the day or early evening, but it's all up to you.

The flexibility of this set-up is wonderful. It forever eliminates the stress of being late or falling behind—no more waiting rooms filling up with angry patients! It's possible for me to knock off a little early, without advanced planning. If I want to skip nursing home rounds and go fishing for bluegills, I can make rounds the next day. I don't do that too often, but I can without any fuss. No phone calls to reschedule appointments, no double or triple booking to make up for the missed day. Did I mention that I take my kids to school each morning and have for years? Now that's the life.

7. Overhead is extremely low. My practice overhead is 24 percent and hasn't been over 25 percent in years. That's unheard of in a typical office-based practice, where the usual cost of overhead is 45-60 percent. All you need is a car, a communication system (phone, cell phone, beeper, and exchange), malpractice insurance, and a billing system. If you're presently in practice, you already have all of these prerequisites, so adding a nursing home or two won't increase your overhead. The facility provides the patients, the rooms for exams, the charts, the nursing personnel, the secretarial staff, etc. How can it get any easier? Just show up, see your patient, write your note, and you're done. If you're just starting out and don't open a traditional office, a nursing home practice will save you about half the cost of customary overhead. That's roughly three months of income you don't have to spend on rent, staff, and the like.

8. LTC offers a conduit to many other opportunities. LTC is predominantly a multidisciplinary affair. You get involved with home health, physical therapy, hospice, and other ancillary services. Many of these entities offer opportunities for administrative duties and medical directorships for physicians already involved with LTC. Nursing homes all need a medical director to comply with the regulations of the federal Nursing Home Reform Act. These offer a welcome diversion into nonclinical components of medicine as well as provide new streams of income unaffected by insurance regulation and controls. You can charge and receive whatever the market will bear. While the majority of nursing home medical directorships are part-time jobs, there are some full-time positions available. Office-based practitioners who don't make nursing home rounds aren't offered these opportunities, ever.

9. The practice model is a natural fit for the use of NPs and PAs. The shortage of physicians in LTC is expected to grow as fewer doctors are going into geriatric fellowships. If you have a PA or NP on staff, this shortage provides an opportunity for your practice to fill the gap. An office-based physician who already uses these extenders can expand their use to the LTC setting. (Some Medicare rules apply to who can visit when, as well as to reimbursement.) If you don't do it, someone else will.

10. Reimbursement for nursing home work is more than adequate. Reimbursements for LTC care allow the typical physician to easily make at least as much, if not more, than the median total compensation for internists and FPs, which are $157,000 and $150,000, respectively, according to Medical Economics' latest Continuing Survey. This is not only possible but almost guaranteed, if you take into account the low overhead, the number of visits, the increased frequency of patient visits on skilled units, and the opportunity for other nonclinical income from medical directorships and the like. There are so many opportunities to generate income it's literally impossible to fail.

Bonus. LTC patients are among the most challenging, interesting, colorful, and grateful you'll ever encounter. This may not be important economically, but emotionally it's priceless. I've learned more from my "old folks" (they don't know it's politically incorrect to say the word "old") than I ever have from my middle-aged and younger patients. Most have been through several wars and a depression, and have a different mindset of self-reliance and resilience that's lacking in subsequent generations. Their generation helped save the world and I find great honor and pleasure in serving them now. They're a lot more fun to deal with and much more appreciative.

I hope this article convinces you to give nursing home care some serious thought. You don't have to switch to a 100 percent nursing home practice, as I have, but could simply add one or two nursing homes or skilled nursing facilities to your practice. The personal as well as the financial rewards are there for the taking. It really is that simple. Give it a try.

If you'd like to discuss this topic further with me, you can reach me at gzydiak@....

-----Original Message-----From: [mailto: ] On Behalf Of schoolrotenbergSent: Tuesday, January 08, 2008 9:19 PMTo: Subject: Re: To take insurance or not. & other ways to make it work financiallyI joined recently and have read every post with fascination (well, most). Thank you all, I'm enjoying it.The issue is not necessarily about taking insurance or not as an absolute, but being VERY selective about which to take. You might find this strange in other areas of the country, but I take traditional Medicare almost exclusively, refusing everything else. All others pay less now, here in my patient population. I couldn't have the high quality time-intensive practice that I have any other way. I do, however, find other ways to supplement my income, and have done so since I started in practice 14 years ago. All of those ways are FUN and low-overhead. They include nursing home and outpatient rehab physician administration, program development, paid lectures, hospice medical directorship and medical expert witness. Every one of them takes real time and effort, not just "kick-backs for patient referrals" kind of money. But it's a good way to be able to pay the bills if patient visits aren't enough, or you want to limit your practice volume. Plus, it has allowed me to enact quality changes at a systemic level, not just at the individual patient level.I am a geriatric rehab doc who specializes in the most frail, complex, disabled elderly. Every person who gave me advice before I started in practice told me I'd never make it financially. They were all wrong- I made a profit from day one! I just did things very differently from the norm, like most of the people in this group of docs. I have no employees and no office, and I started that way in1994 (back then it was because I was down to my last $500 & couldn't get a loan).I'm curious, though, how many of the docs on this listserv are specialists? I've only seen a couple of posts from neurologists.There is great potential for micropractice beyond primary care. Think big, bigger! The patients who need the most time, the elderly, need all sorts of quality docs; the only way they'll have them is through the low-overhead movement.Think outside the box, you people are great! Rotenberg, MDMelbourne, Florida

[Guest guest]

Thanks for that great info, Padma.Just curious -- when you code a nursing home visit -- are you using the 9921+ office codes or the "nursing home" codes -- which always seemed confusing to me.

Plus there is a different set of codes if they are in assisted living.

The FPM says in 2006, the codes were changed for nursing home visits...

http://www.aafp.org/fpm/20060100/28cpt2.html

Codes for care of patients in nursing facilities have undergone a major revision. Codes 99301-99303 and 99311-99313 have been deleted. New initial nursing facility codes 99304-99306 describe only the required key components and problem severity, which makes them consistent in structure with initial hospital care codes. Subsequent nursing facility care should be reported with new codes 99307-99310. Nursing facility discharge codes were not changed. A new code, 99318, for reporting nursing facility assessments has been added under other nursing facility services.

The CPT panel also made major changes in the domiciliary, rest home (e.g., boarding home) or custodial care services codes. Codes 99321-99323 and 99331-99333 have been deleted. Five new codes have been introduced for reporting new patient services: 99324-99328. These are comparable in structure to the codes for new patient office visits. New codes have also been added for four levels of established patient visits: 99334-99337. Most notable in this section are new codes 99339 and 99340, which are to be used for reporting care plan oversight provided to a patient who is not under the care of a home health agency, enrolled in a hospice or residing in a nursing facility. These two new time-based codes allow a physician to bill for complex and multidisciplinary care-plan development or revision, such as care given to chronically ill children in their home or to Alzheimer's patients in an assisted living facility.

http://www.memag.com/memag/article/articleDetail.jsp?id=359026

Rest home/NF codes

Q. Should I use the same codes when I perform an E & M service on a rest home patient as I would if the patient were in a nursing facility?

A. No. When you treat a rest home patient, use domiciliary, rest home, or custodial care service codes. For a new patient, use 99324-99328 and report established patient visits with 99334-99337.

Claim NF services with 99304-99318. Initial care codes are 99304-99306, and subsequent care codes are 99307-99310. There are also NF codes for discharge (99315-99316) and annual assessment services (99318).

Remember to use different place-of-service codes. CPT classifies rest home, domiciliary, and custodial care facilities as POS 33 (custodial care facility). For claims involving NF care, use POS 32 (nursing facility).

Locke, MD

[Guest guest]

I provide care in 2 small rural nursing homes about 25 miles apart and provide home visits to "homebound" patients in the area exclusively Medicare. The population density of the facility makes up for what I loose in home visits that can be very time consuming, mostly because these people get very little company and I'm often asked to share tea and cookies. The problems with nursing calls and faxes can be overwhelming at times but with persistant education and use of standing orders It has become manageble. I might get a middle of the night call once every 3 or 4 weeks. I do like using the fax machine as for me it is quicker than a phone call. The down side is I havn't quite figured out if I can access it from my cell phone and being on the road I might not get to them till later in the day, but much of it is not acute and they all know to call my voice mail for acute issues. Unlike many docs that do nursing homes I keep much of the pt record electronicaly and

so do not have to ask the nurse what their last creatinine is and can fax back an order that is not lost in transcribing a telephone order. Overall its a good mix of acute and fairly stable long term care pts. I have also built a practice of home visit pts that were admitted to the NH for rehab and went home and kept me for their PCP. This area has a severe primary care shortage and I am at risk of becoming spread too thin. I have had to turn down patients as I am behind on bookeeping/billing and now trying to think about taxes. I have found this list serve very educational and motivational over the last few months and its certainly nice to know there are other like minded souls and I am not totally MAD for leaving a regular paycheck. Like anything else nursing home care is probably not for everyone but I enjoy it and certainly have found my niche. Melody Pratt DO Solo/no staff 7/07 Amazing

Charts Locke's in Colorado wrote: I don't recall if it was on this list or another, but I believe that nursing home care was promoted as a low overhead option for docs.The idea was....1. Don't need office space -- can see the patients at the nursing home.2. Don't need nurse -- nursing home as nurses to help3. Blood draws can usually be done at the nursing home -- no need to maintain supplies, etc.4. Don't need

blood pressure cuff, etc -- nursing home has it. Overhead is extremely low. My practice overhead is 24 percent and hasn't been over 25 percent in years. That's unheard of in a typical office-based practice, where the usual cost of overhead is 45-60 percent. All you need is a car, a communication system (phone, cell phone, beeper, and exchange), malpractice insurance, and a billing system. If you're presently in practice, you already have all of these prerequisites, so adding a nursing home or two won't increase your overhead. The facility provides the patients, the rooms for exams, the charts, the nursing personnel, the secretarial staff, etc. How can it get any easier? Just show up, see your patient, write your note, and you're done. If you're just starting out and don't open a traditional office, a nursing home practice will save you about half the cost of customary overhead. That's roughly three months of income you don't have to

spend on rent, staff, and the like. Anyway, interesting idea and alternative to traditional practice - even IMP practice. Locke, MD Quick search of MeMag found... http://www.memag.com/memag/article/articleDetail.jsp?id=428769