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patients extra fees is not likely to take practices very far if patient care is not the primary motivation. If physicians de- pend upon such income, “but patients do not see the value in the care you provide, and you are just doing it for the money, they will sense that.” Physicians also must recognize that the health care legal and regulatory en- vironment evolves rapidly, and if they do not keep up, they risk running afoul of those rules, he added. Mr. Ball, the South Carolina attorney, also says practices can charge extra fees so long as they are carefully structured. Physicians must specifically describe what they are charging for and make sure they bear relationship to the fair market value for those services. Practices also should prepare for pushback from patients and have a plan to refer those who don’t wish to pay.


Take a step back


If physicians look to fees for extra in- come, they should first take a step back and evaluate their practices to find out why, says TMA Medical Economics Spe- cialist Donna Kinney. That means looking at overall prac-


tice revenues and costs and determining whether the former outweighs the latter. Solutions can come from increasing rev- enues or from decreasing costs, or both. A good place to start: “Physicians per- form lots of services that they don’t get paid for, but some new programs might help,” Ms. Kinney said. For example, Medicare and some


commercial carriers now cover transi- tional care management, even for prac- tices that are not part of a formal medi- cal home or accountable care organiza- tion. That means practices may receive payment for time spent coordinating patient discharges from the hospital to the home, including services that are not part of a face-to-face visit. Taking stock of payer mix and health plan contract rates is another good step. TMA’s 2012 Physician Survey results show that only half of physicians at- tempt to negotiate with insurers, and solo and small group practices are less likely to do so. But even small practices that do try to negotiate with plans report


that they are sometimes successful in se- curing better terms and fees. When evaluating income from a health plan contract, rather than com- paring a single procedure code, Ms. Kinney recommends physicians look at income in the aggregate, because often higher-paying procedures will make up for lower-paying ones. “The plan’s use of coinsurance and deductibles and your practice’s ability to collect these fees can also determine whether a contract is profitable,” Ms. Kinney said.


TMA Practice Consulting has a tool- kit to help physicians conduct an opera- tions assessment and evaluate whether they are properly paid. Log on to www .texmed.org/operations_assessment. When it comes to evaluating prac- tice expenses, Ms. Kinney recommends the Medical Group Management Asso- ciation’s (MGMA) annual cost data as a good benchmark tool to compare costs for things like office space, staffing lev- els, average staff salaries, and medical supplies and equipment. More informa- tion is available through MGMA at www .mgma.com/. Click on Store, then Cost Survey.


out of network for care, so-called bal- ance bills. At the same time, lawmakers authorized health plans to market the narrower EPO networks as a more af- fordable option for patients. TMA decried a move by newly ap-


pointed TDI Commissioner Eleanor Kitzman to suspend, rescind, and redraft regulations adopted by her predecessor, former Commissioner Mike Geeslin. In so doing, TDI removed a number


of provisions TMA had argued were necessary to ensure health plans remain transparent about the status of their net- works and to help patients assess their coverage. The move also left the market without a regulatory framework for the network adequacy requirements. The newly adopted rules restore re-


quirements for health plans to disclose in writing basic network demograph- ics, such as the number of specialists in a given area. Health plans also must notify patients when networks no lon-


RESEARCH PHYSICIAN


Research corporation needs a physician for an ongoing national health/nutrition study. Individual will be part of a large medical team.


TDI adopts network adequacy rules


In a partial victory, new rules adopted by the Texas Department of Insurance (TDI) restored some previously stripped provisions that the Texas Medical Associ- ation advocated were crucial to protect- ing consumers from PPO health plans’ failure to maintain adequate physician networks.


But TMA officials worry the new rules lower the bar for even more restrictive “exclusive” provider organization (EPO) products that insurers can now sell. The legislature mandated the net-


work adequacy rules — four legislative sessions in the making — to help pre- vent patients from receiving unexpect- edly high medical bills for having to go


May 2013 TEXAS MEDICINE 31


Must be licensed in at least one state. FULL-TIME CONTINUOUS TRAVEL REQUIRED. Fluency in reading, writing, and speaking English is required. Competitive salary is augmented by paid malpractice, meal/travel allowance, holidays, and individual housing/car; subsidized health insurance available.


To learn more about this position and apply, go to www.westat.com/ fieldjobs and enter Job ID 5918BR. WESTAT EOE


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