Webinar #1 - Distilled Chat Comments

If you’d like to address any of these comments, reply below!

1 Thank you guys for doing this. questions, shortage of masks, delaying well visits, who to bring to the office, telemedicine and popup tent in the parking lot
2 Insurances do not pay phone calls or portal exchange no matter what we do!
3 Is there a recommendation to cancel non essential HMVs? Such as visits with no immunizations
4 How do we keep staff morale high and reduce panic with reduction in time/ pay right now?
5 is there a CPT code for billing telephone calls from nurses
6 this is a business/ clinical question - I know that clinical questions are out - the issue is - do we continue seeing well patients, only well under age 2 or under age 2 plus 4-5 year old who need immunizations - peds are all doing different things here
7 Is there any way to bill for well child care via telemedicine or only problem focused visits? Also what is the reimbursement for telemedicine vs alternative non face to face/telephone call vs portal message?
8 Regarding Employed physicians, if they want their full pay when the practice is struggling, what is your suggestion on that?
9 How can we justify billing for telephone calls and portal questions when many of our families may also be struggling financially during this time? Do insurance companies or the patients bare the brunt of these costs?
10 For an office that hasn't charged for phone calls, what's a good way of letting parents know?:Just do it and wait for complaints, have the staff tell them when they ask to speak with a doctor, some other method? Website and Facebook announcements likely won't reach enough families to make a huge difference.
11 We totally eliminated the waiting room by doing car check in via phone. parents love it.
12 What about the pregnant provider who refuses to see sick patients at all? Strep and ear infections haven't magically disappeared!
13 SOTC (Section on Telemedicine) has vetted several telemedicine platforms to make it easier for you to decide.
14 as chip said, we now require EVERY sick visit to start as a telehealth. very few need to be seen, and when we do see them the face to face time is limited just to the PE
15 Is it best for Owner of practice to not take salary and just take owner distribution for rest of year, since there is no tax penalty for 2020?
16 Today with a suggestion from another call, we generated a list of higher risk patients (respiratory). MA is calling them to ensure they are following precautions and that we now offer telemedicine
17 yes-can SOAPM work together to connect Pediatricians who want to work locums during this time frame but not want small practices to have to pay the locums surcharge to help connect people together
18 Recall all your behavioral health visits to TM. They need their meds and they need to be seen. This can be many patients depending on the size of your practice.
19 Can you have that discussion asking for lowering of salary for employed providers that are bound by contract?
20 this may sound crazy but as time in office may need to be cut, ED’s are having to quarantine staff. our ED has an emergency credential waiver where pediatricians may want/need to cover for their peds ED or UCC staff
21 those nurses may be putting you at work comp risk if they don’t have PPE
22 salaried staff- can we change to hourly during this time?
23 Any thoughts about not only having hourly staff reduce hours to 25-30 hrs per week but also asking physicians/NP's to amend their contract and reduce salary by 15-20%?
24 Regarding parking lot visits, do we bill for those as a regular office visit if they are non-emergent and done to keep them out of the office?
25 everyone take their week(s) off. rotate. demonstrate the lower numbers coming in and reduce everyone's intake... np pa and ma all included. including oneself
26 When things clear up, it is going to be weeks before sick visits return to normal volume

I’ll start!

#5: is there a CPT code for billing telephone calls from nurses

There sure is! I’ve shared 2 helpful coding documents on my blog HERE and some data about how it’s being used nationally as of 03/27/20 HERE.

#3/#6 The AAP does not have a recommendation what practices should do in terms of delaying visits vs. doing visits. It certainly does not have a recommendation that well visits “should” be done by telehealth.
The following is my personal opinion.

  1. Prioritize checkups for ages <=2 years. Not only are these visits at which vaccines are required, there are also other time-sensitive screenings (development, lead, growth/FTT, autism, hemoglobin) where delay significantly increases the child’s risk of a bad outcome. And since “delay significantly increasing the child’s risk of a bad outcome” sounds a lot like “urgent,” these visits are totally justified even during a lockdown. Checkups age 30 months and under accounts for 43% of your Bright-Futures recommended checkups, assuming a more-or-less equal age distribution amongst your patient panel.
  2. Consider your PPE. If you have hardly-any-to-no PPE, you should probably stop here. We know COVID-19 is community spread, and many people early in the disease are asymptomatic and/or don’t have fever or cough. You will be exposed to patients and parents with COVID, and without PPE, you’re at high risk of having to sit out for 2 weeks - and that’s the best case scenario. If you have enough PPE to wear (at least) surgical masks during all patient visits, then you have reduced the chance of patients infecting you, and you infecting patients.
  3. Consider what your physical plant permits. If you can eliminate your waiting room, check patients in from their car, and clean surfaces well after every visit in an exam room, then you have significantly reduced the chance of patients infecting each other on visits to your office.
  4. Consider how many appointment slots you have. If you want to leave your afternoon open for sick visits, and not have sick patients in the office at the same time as well visits, then you can only see well patients in the morning. This necessarily limits the number of well slots you can have in a day. If you have little demand for sick visits (or at least, in-office sick visits), but you’ve furloughed 1.5 providers of your 5, this will also effectively reduce your potential well visit throughput. You don’t want to book 6 yo and 14 yo well visits so tightly that you’ll won’t have any room to add in 4 mo visits.
  5. Based on factors 2-4, judiciously add checkups from the remaining 57% of age ranges remaining, until your well visits approach saturation. Consider your patient population and consider targeted recall for:
  • Patients with mental & behavioral health challenges (anxiety, SUD)
  • Patients with physical comorbidities putting them at risk for complicated COVID (e.g. asthma, DM)
  • Patients at risk for unintended pregnancy/STDs
  • Patients whom you haven’t seen in a while for anything and can’t assess their risk

Even if you do the interval history, screening, counseling and anticipatory guidance by telemedicine (billing 9940x or 9921x based on time), you’ve touched base with patients who are most at-risk. If you can bring them in for an exam, vision/hearing screening, and labs safely, that’s even better.

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I wish I could give this response >1 heart.

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#8 , #19 , #23b: Of course clinicians want the full pay that’s guaranteed to them by contract (don’t we all!). And yes, you should sit down and have a chat with your clinicians.

First of all, study the contract you have with your providers and be sure it says what you think it says.

It appears that you have multiple choices:

  1. Make no change. You’d have to get a loan to finance the delta between practice revenue and provider salary. Alternatively: the provider sees 1/3 of their usual patients but, by contract, collects their full salary until a) you can let them go for no cause or b) your practice goes bankrupt, at which point the provider can take up their salary with the court. Providers who “just don’t want to change anything” need to look at the mid- and long-term picture.
  2. Cut their salary, with a cut in productivity expectation. The provider who used to work M-F 8-5 now works three days a week at 60% former salary for the next 3 months, at which point you will mutually reassess the picture. If you want to pay a flat salary, put it prospectively in writing as an agreement. If you don’t, and her salary goes up and down, e.g. “pay more if you work more, pay less if you work less” - you’ve just disqualified her from being an exempt employee. This is my preferred option for clinicians who are good at being clinicians but don’t have other flexible or versatile skill sets. If your employee gets cut to part time work but still wants full time employment, they may also qualify for partial unemployment.
  3. Keep their salary the same, but increase or change their productivity expectation. If you have guaranteed a particular salary, but not maximum hours of work, this is fairly straightforward. How do you increase someone’s productivity during a slowdown? Move them to the front lines. (We make it hard for our patients to connect with us, putting phone trees and nurse message-takers between us and them.) For example, the clinician starts answering the phone and triaging calls herself; the clinician takes back night “mommy calls” from the nurse service and turns them into evening telemed visits. This requires a dynamic, can-do sort of clinician who likes a challenge.

Alternatively, you can give them other projects that require a clinician’s knowledgebase to complete.

  • Clean up your EMR; learn those shortcuts and make those templates you’ve been putting off.
  • Clean up your patient records. Update those laggard problem lists and social histories.
  • Learn something new; have them complete online suboxone training.
  • Put them in charge of your patient communications during the crisis. Rewrite all the patient articles on your website.
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#22: Yes. If your salaried staff do not have enough work to keep them busy, the best way is to convert their salary to hourly wages. You’ll need them to keep track of their hours, but if their work is variable, e.g. 35 hours one week and 25 hours the next, you can pay them proportionately for their time. Obviously, if they work more than 40 hours in a week, they are qualified for overtime pay.

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#15. Hard to say without knowing more. I assume this is an S corp physician owner who proposes to pay a very low salary and take out a distribution as profit, to avoid paying self-employment taxes. I have not read anything that suggests that COVID has changed what the IRS considers a reasonable salary for services rendered to the company.

In fact, since a quarter of this year’s self-employment taxes won’t be due until December 2021, and another 25% won’t be due until December 2022, keeping it in salary may not be as bad as it sounds!