Economics of Clinical Nephrology Practice
CORE CURRICULUM IN NEPHROLOGY                                                                         169

        Office ...
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      board meeting...
CORE CURRICULUM IN NEPHROLOGY                                                                       171

  ● Who pays the...
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  ● Special guidelin...
CORE CURRICULUM IN NEPHROLOGY                                                                      173

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Nonphysician Practitio...
CORE CURRICULUM IN NEPHROLOGY                                                                    175

      Guaranteed ca...
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  ● Pay smaller claims ...
CORE CURRICULUM IN NEPHROLOGY                                                                         177

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final year...
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Economics of Clinical Nephrology Practice


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Economics of Clinical Nephrology Practice

  1. 1. CORE CURRICULUM IN NEPHROLOGY Economics of Clinical Nephrology Practice Robert Provenzano, MD, and Allen R. Nissenson, MD same geographical area and/or specialty is an INTRODUCTION effective strategy in this regard. During the estab- lishment phase of nephrology practice, any or all “Economics of Clinical Nephrology Practice” the following advisors may be of value: emphasizes learning the information needed to ● Accountant make the best choices for clinical practice, and as ● Attorney a result having a productive and rewarding ca- ● Banker reer as a clinical nephrologist. Decisions about ● Financial/investment counselor where to practice; what corporate structure is ● Management consultant best; who should be providing advice; licensing ● Insurance broker requirements; working with Medicare, Medic- ● Real estate broker aid, and managed care; fraud and abuse issues; ● Nephrology coding and billing professional budgeting and forecasting; financial planning; ● Billing and reimbursement professional understanding basic concepts of marketing; and developing practice-building strategies are all critical when entering or establishing a clinical EMPLOYMENT OPTIONS nephrology practice. As will be apparent, the economics of practice has less to do with medi- Selecting a Practice Location cine and more to do with basic business prin- ciples. This curriculum will serve as a starting Considerations: point for understanding many of these basic ● Professional relationships and opportuni- principles. ties: Relationships you have formed in resi- CHOOSING ADVISORS dency training/medical school Relationships with practicing physicians When entering clinical practice, obtaining Areas that offer continued educational sound advice from local professionals who can opportunities, professional stimulation, assist with various legal and accounting practices and the opportunity to practice at a hospi- is essential. Rather than solicit advice from tal that has technologically advanced fa- friends, family, or outsiders, one is better served cilities if an attorney and accountant are selected in the ● Prior exposure: very beginning, to help anticipate and resolve Where your training occurred (under- key issues, rather than reacting to crises that may graduate, medical school, internship/ arise. Seeking recommendations for attorneys residency/fellowship) and accountants from other physicians in the ● Economic factors Salary or income potential Cost of living ● Environmental factors From the Department of Nephrology, St. John Hospital and Medical Center, Detroit, MI; and the Dialysis Center, Lifestyle choices (eg, hobbies) UCLA School of Medicine, Los Angeles, CA. Geography, climate Address reprint requests to Robert Provenzano, MD, Family, children Department of Nephrology, St. John Hospital and Medical Educational opportunities, housing Center, 22201 Moross Road, Suite 150, Detroit, MI 48230. Cultural opportunities E-mail: © 2004 by the National Kidney Foundation, Inc. ● Other determinants 0272-6386/04/4401-0023$30.00/0 Hospital proximity doi:10.1053/j.ajkd.2004.04.022 Religious affiliations 168 American Journal of Kidney Diseases, Vol 44, No 1 (July), 2004: pp 168-178
  2. 2. CORE CURRICULUM IN NEPHROLOGY 169 Office space availability and cost (both the physicians’ salaries and the Availability of others physicians who may profits of the corporation are taxed) “cover” you Corporations have greater infrastructure costs including attorney fees and must Practice Structures make higher social security payments for the physician Solo proprietorship Management of a corporation requires a ● Advantage: formal organizational structure and a va- Physician autonomy riety of activities including board meet- ● Disadvantages: ings with minutes recorded, issuance of Physician solely responsible for medical formal notices of annual quarterly meet- care and running office ings, election of corporate officers Difficulty negotiating advantageous man- aged care contracts Limited liability company The limited liability company (LLC) has re- Partnership cently been recognized by the Internal Revenue ● Advantages: Service (IRS) as an approved corporate struc- Shared administrative burdens ture. It provides the owners the best advantages Equal rights in management and conduct of both a corporation and a partnership. This of partnership recognition varies from state to state. Equal responsibilities for accounting and Under the provisions of this form of business fiduciary relationships arrangement, members of the LLC are not liable ● Disadvantages: for the overall obligations of the LLC. Yet, each Each partner is responsible for decisions member is liable for any negligence, wrongful the group makes act, or misconduct committed by him or her or Can be cumbersome by any person under his or her direct supervision All partners are liable for “wrong acts” while rendering services on behalf of the LLC. under the partnership Membership in the LLC may only be transferred Partnership losses must be divided equally to other professionals who are eligible. At least one of the professionals forming the Corporate practice LLC must be authorized (licensed) to render All physicians are employed by the corpora- professional services in the state where the LLC tion. Owners of the corporate practice reduce the is formed. personal and financial risks to individual physi- ● Advantages: cians, while at the same time providing opportu- Personal liability of each member of the nities to shelter income through a qualified retire- LLC is limited to his/her personal invest- ment program. ment in the LLC, ie, no member of the ● Advantages: LLC is personally liable for the debts of Individual physician has limited liability the entire organization Centralized management in which au- LLC offers pass-through tax benefits, ie, tonomy and responsibility are fixed to no entity-level tax on the entity’s in- appropriate parties come, but only a tax on their share of the Ownership interests can be transferred entity’s income easily through the sale of stock represent- ● Disadvantages: ing the value of corporate assets Much like corporations, LLCs have Pension and profit-sharing plans are supe- greater infrastructure costs including at- rior to those available in partnerships torney and accounting fees in addition to Arrangement can provide tax savings often requiring higher level business ex- ● Disadvantages: pertise (MBA) Only physicians can be shareholders; in Requires a formal organizational struc- most instances there is double taxation ture and a variety of activities including
  3. 3. 170 PROVENZANO AND NISSENSON board meetings with minutes recorded, ● What is the average length of time accounts issuance of formal notices of annual quar- are in accounts receivable? terly meetings, election of corporate of- ficers SIGNING AN EMPLOYMENT CONTRACT ● Other features: Ownership of an LLC is by its members The LLC may be managed by its mem- Terms of Contract bers or by 1 or more managers appointed ● What is the length of the contract? by the members ● Does it have an automatic renewal? LLC members generally vote in propor- ● Is the contract subject to renegotiation at tion to their ownership interests. the time of renewal? ● What hours are the physicians expected to Employee status work and what specific duties is the physi- An increasing number of physicians have cho- cian expected to handle? sen to become employees of health maintenance ● Is the physician restricted in any way from organizations (HMOs), and many multispecialty seeking additional employment outside the groups have become employees of larger health practice? systems. Additionally, physicians are becoming ● What kind of patients will be assigned to employees of other physicians who have estab- the physician? lished practices. ● What kind of restriction does the physician ● Advantages: have with regard to acceptance of patients Guaranteed income and modes of treatment? No administrative responsibilities ● What locations will the physician cover? ● Disadvantage: ● What call responsibilities are there? Limited potential for growth and little ● What are marketing and promotional re- control sponsibilities? ● What kind of staff support will be pro- vided? CONSIDERING EMPLOYMENT OPTIONS Compensation Assessing Group Practice Opportunities ● What salary will be paid? ● How will the salary be computed? Before interviewing with groups and discuss- ● At what intervals and increments will the ing salaries, bonus, and benefits, a physician salary increase? must have a basic understanding of medical ● What incentive bonus applies and how is it office accounting. If the position accepted is calculated? straight salary plus benefits, the overall financial performance of the practice may not directly Benefits affect the physician—at least for a while. How- ● Is a pension and/or profit-sharing plan avail- ever, if part of the compensation package is a able? bonus based on productivity or profits, then an ● What is the vesting schedule? understanding of medical office accounting is ● Will the employer pay malpractice premi- essential. ums? ● Who pays for the “tail” insurance*? Important Questions to Ask ● Will the physician participate in a group life ● What is the gross collection ratio (total insurance plan? collection total billings)? ● What is the net collection ratio (total collec- tion total billings adjustments)? *Insurance that covers malpractice that occurred during ● Is there a separate fee schedule for Medi- previous employment. This coverage can be expensive and care and managed care contracts? is therefore often negotiated when joining a practice.
  4. 4. CORE CURRICULUM IN NEPHROLOGY 171 ● Who pays the premiums? Loss of hospital privileges ● What additional fringe benefits will the Suspension, revocation, or cancellation physician receive? of employee’s right to practice medicine Life and disability insurance Employee commits act of gross negli- Group health plan gence Vacation Employee is convicted of a crime Sick leave Employee becomes impaired due to alco- Personal leave hol or drug use Continuing medical education (CME)/ Breach of contract terms convention/postgraduate work Employee becomes disabled Professional books and periodicals Professional dues BILLING AND REIMBURSEMENT Medical equipment Office space Clerical help The financial viability of a clinical practice is Automobile allowance predicated upon understanding the details about Moving allowance coding and billing, an area that is seldom taught Cell phone or pager in medical school or residency/fellowship pro- grams. The following is a list of fundamental Buy-In Agreement information that a physician must master before ● On what date will the physician be allowed seeing the first patient in the practice setting. If to acquire part ownership of the practice? one joins an established medical practice, the ● What will part ownership in the practice burden of setting fees will have already been entail? taken care of, as will the need to design an Accounts receivables encounter form or set up current procedural Equipment terminology (CPT) and International Classifica- Goodwill tion of Diseases, 9th revision (ICD-9), codes. It is Supply inventory and prepaid items still the practicing physician’s responsibility, how- Office buildings and real estate ever, to be knowledgeable about billing, coding, Dialysis units and reimbursement. Liabilities Current Procedural Terminology (CPT) ● What will be the cost to the physician to buy into the practice? ● A coding system designed by the American ● How will the value of the practice be deter- Medical Association in conjunction with mined? the Centers for Medicare and Medicaid ● What are the exact terms and payments of Services (CMS) to describe services that buy-in? physicians provide ● CPT manual is publicly available and up- Covenant Not to Compete (Restrictive dated annually Covenant) ● Will the physician be asked to sign a cov- International Classification of Diseases, 9th enant not to compete? Revision; Clinical Modifications (ICD-9-CM) ● Is there a time limit beyond which a ● A list of medical diagnoses used to indicate signed covenant not to compete no longer the spectrum of illnesses being evaluated applies? and/or treated by the clinician ● Divided into 3 volumes: volumes 1 and 2, Termination used by physicians; volume 3, used exclu- ● Can the physician or the employer termi- sively by hospitals nate the contract with 30 days notice? ● “Renal” is a list of different types of renal ● Will the contract automatically terminate disease (majority of the billing codes used under the following conditions? by nephrologists located in this category)
  5. 5. 172 PROVENZANO AND NISSENSON ● Special guidelines regarding physician bill- Consultations and Visits ing ICD-9-CM codes are as follows: As a specialist, a nephrologist has to deter- Code only the known disease (not a mine whether to bill a patient for a visit or suspected disease) consultation. CMS requires adherence to strict Identify each service procedure or sup- guidelines for when a consultation may be billed. ply with an ICD-9 code Code the primary reason for the visit first Consultations followed by the secondary and so forth Then code any coexisting conditions that ● A consultation is billed when 3 criteria are affect treatment of the patient met: Code ICD-9-CM codes with the highest Another physician is seeking profes- level of specificity sional advice Renal Physicians Association (RPA) has The request for the consultation is docu- a nephrology ICD-9 quick-reference mented pocket guide available to assist you in The patient is examined and the nephrolo- finding the correct diagnosis codes gist provides recommendations to the Prioritizing diagnoses is extremely impor- originating physician tant, as this justifies a level of service as well as tests or studies ordered or per- Visits formed ● If the 3 criteria for the consultation are not met, then a regular office or hospital visit CMS Common Procedural Coding System code must be used instead of a consultation (HCPCS) code ● In addition to ICD-9 and CPT codes, the HCPCS is used to describe supplies and Special Coding Issues for Renal Physicians injectable medications used in the medical ● Providers should be aware of and follow practice guidelines provided by their local Medicare ● As nephrology practices continue to ex- carriers plore nontraditional income streams, a good ● In addition to E&M codes, CPT codes will working knowledge of this coding system be used in your treatment of patients takes on increasing importance ● Among the most relevant codes are those for: Evaluation and Management (E&M) Codes Out-patient end-stage renal disease ● As internal medicine physicians, practicing (ESRD)–related services in the subspecialty of nephrology, most Dialysis management services provided will be found in the Evalu- Home training ation and Management section of the CPT ● Codes for out-patient ESRD services are manual “special” in that they cover services based ● E&M codes are divided into broad catego- on the number of visits a month rather than ries and subcategories: the number of services per month super- Office and other outpatient visits: vised by the renal physician. These codes E New patient are currently in a flux and are therefore E Established patient designated as “temporary” (G codes). Hospital observation services ● The following codes apply to adult ESRD Hospital in-patient services: patient visits: E Initial visit 4 or more visits in a month (G0317) E Subsequent visit 2 or 3 visits in a month (G0318) Consultation 1 visit monthly (G0319) Emergency department services ● Similar codes exist for pediatric patients Critical care services based on frequency of visits
  6. 6. CORE CURRICULUM IN NEPHROLOGY 173 ● Medicare will reimburse the patient di- MEDICARE rectly, and the physician in turn will bill the patient and collect from him/her All physicians who wish to participate with ● Advantages: Medicare must contact the CMS to obtain an Allowed to charge more than participat- enrollment form. Because most patients with ing physicians ESRD are reimbursed through Medicare, partici- Permitted to collect from the patient at pation in Medicare becomes essential in nephrol- the time of services, thus decreasing your ogy practice. outstanding accounts receivable Some Decisions When Completing Enrollment ● Disadvantages: Form Responsible for collecting money from patient ● Whether to be a participating or nonpartici- Must monitor the fees if using separate pating physician fee schedules ● How to be listed (specialist versus subspe- Must still take assignment on any labora- cialist) tory tests you perform ● Whether claims are filed manually (paper) or electronically Listing by Specialty Participating Physicians The decision to enroll as an internal medicine ● Paid directly by Medicare for services pro- physician or a subspecialist (nephrologist) has no vided to enrollees impact on the reimbursement for services per- ● Payment equals the Medicare allowed less formed. Rather, Medicare looks at billing pat- the patient’s portion terns of physicians and compares those to other ● Patient portion includes 20% of the allow- physicians in that specialty. If one is listed as an able and any deductibles internal medicine physician who bills for many ● Participating physician must always accept consults, this may trigger an audit. Medicare assignment and wait for Medi- care to pay Medicare and ESRD ● Physician is expected to collect a 20% In 1972, ESRD patients became the only group patient-responsible portion at time of ser- entitled to Medicare coverage whether or not vice they were older than 65 years or disabled. For the ● Advantages: past 20 years, nephrologists’ care for out-patient Listed in Medicare provider directory dialysis has been reimbursed by monthly capi- Receive payments directly from Medi- tated payments (MCP codes). Effective January care, thus eliminating collection efforts 1, 2004, this methodology is no longer used and Benefits from receiving a greater “allow- a new set of codes, designated G codes, has been able” implemented for reimbursement. These codes ● Disadvantages: represent the number of visits to the patient by Receive a lower reimbursement rate than the nephrologist and/or his designees (physician nonparticipating physicians Participating physicians cannot bill the assistant, advanced practice nurse). It is felt that patient more than the allowable increased frequency of visits may act as a surro- gate of quality, although this as yet is unproven. Nonparticipating Physicians Sites of Service for an ESRD Patient ● Patient may be billed directly for the ser- vices rendered ● Physician’s office ● Amount billed to a Medicare patient is ● Out-patient hospital limited by the “limiting charge for non- ● Out-patient setting such as emergency room, participating physicians” which is 115% of transitional care unit, patient home, as well Medicare allowable as the dialysis facility
  7. 7. 174 PROVENZANO AND NISSENSON Nonphysician Practitioners Who Can Provide ● Reimbursement methodology varies from All But 1 of the Monthly Visits state to state and plan to plan ● Nurse practitioners ● One should refer to coverage in the geo- ● Physician assistants graphic area of practice for details ● Clinical nurse specialists ● Other physicians employed or contracted MANAGED CARE by the billing MCP physician or his/her corporate entity Managed care is constantly evolving but in general terms focuses on the “process of manag- Physician Visit ing costs” through efficiency and effectiveness in The billing nephrologist must visit the patient delivering care. While managed care plans vary at least once per month and document that he/she considerably, they all include certain characteris- is providing the “direction of care” in a substan- tics: tial visit reviewing algorithm management (cal- ● A network of contracted providers cium phosphorus metabolism, anemia, adequacy ● Channeling of patients to contracted pro- of dialysis, etc). The remaining visits may be viders performed by a physician designee. ● Some type of utilization management and quality assurance systems Home Dialysis ● A shift of financial risk to providers of ● Includes home hemodialysis and continu- health care ous ambulatory peritoneal dialysis ● The stratified payment system does not Description of Managed Care Organizations apply Health maintenance organizations (HMOs) ● Contract with a network of providers (phy- MEDICAID sicians, hospitals, and others) to deliver care to a defined population of enrollees Medicaid and ESRD Preferred provider organizations (PPOs) ● Medicaid generally follows the same guide- ● Networks comprised of a panel of indepen- lines as Medicare for ESRD services al- dent physicians that health insurance com- though fee schedule is usually lower panies and health benefit plans contract ● “Effective date of coverage” becomes very with for health care services at a discounted important: fee Medicaid can be billed for all services incurred on or after the effective date and Point-of-service plan (POS) the patient will remain responsible for ● System is based on an HMO format and any services incurred prior to the effec- demands the selection of a primary care tive date physician but allows for opting out of the In some cases retroactive eligibility may network at a substantially reduced benefit be granted for up to 6 months prior to the application Independent practice association (IPA) ● A provider must accept Medicaid payment ● Business entity formed by physicians who as payment in full maintain their independent practices but ● Some states have implemented a patient- participate in the IPA to secure managed responsibility copayment care business Advantages and Disadvantages (of all 4 Medicaid and Managed Care plans): ● Approximately one quarter of all Medicaid Increase in patient base recipients are enrolled in managed care Prevention of migration of patients to plans other physicians
  8. 8. CORE CURRICULUM IN NEPHROLOGY 175 Guaranteed capitated income based on Indirect cost the number of patients regardless of the ● Costs such as rent, utilities, and main- number of visits tenance are charged to each physician, Disadvantages (of all 4 plans): usually as a per-square-foot charge; thus, Increase in practice expense each physician pays for only what he/she Decrease in revenue per potential patient uses Accounts receivable delays Liability and malpractice exposure Expenses as the percent of productivity Potential loss of a large group of patients when plan changes ● Each physician is charged for expenses at the same rate he/she generates income for Date requirements the group (eg, if a physician generates 40% Formulary restrictions of income, he/she assumes 40% of ex- penses) INCOME DISTRIBUTION AND EXPENSE ALLOCATION INSURANCE REQUIREMENTS Methods of Income Distribution The purchase of insurance coverage may be Equal distribution one of the most crucial decisions to be made ● Each member receives an equal share of the when entering clinical practice. Beyond the need practice revenue for basic financial protection, some insurance coverage is required by state law, others by Productivity hospitals or managed care plans, and still others by office or equipment leases. The following ● Members are compensated based on the insurance types will/may be required: amount they generate in individual patient ● Professional liability insurance charges ● Group professional liability coverage Formulas ● Tail insurance coverage ● Office insurance protection ● Several factors, weighted by importance, ● Commercial general liability coverage are used to determine remuneration, includ- (CGL) ing the following: ● Property insurance Goodwill/longevity ● Computer coverage Stock ownership ● Business interruption insurance Productivity ● Employee dishonesty Board certification ● Equipment breakdown coverage Administrative roles ● Workers’ compensation insurance New patients Referral sources Tips on Purchasing Insurance Policies Teaching faculty positions ● Choose a company with a strong financial Methods of Expense Allocation condition ● Choose a company with risk management/ Equal assessments loss prevention expertise ● The expenses are subtracted from the gross ● Choose a comprehensive policy revenue and the net income is available for ● Choose a company with experienced claim physician distribution professionals and a strong defense net- work Direct cost ● Higher deductibles mean lower premiums ● Any cost incurred for the benefit of a physi- ● Avoid overbuying and expensive add-ons cian is charged directly to that physician ● Select appropriate policy limits
  9. 9. 176 PROVENZANO AND NISSENSON ● Pay smaller claims directly according to the loans. Lenders will look more favorably on a appropriate legal guidelines physician who displays a clear understanding of ● Give prompt attention to any claim by a business aspects of operating a medical practice. third party The following are strongly recommended prior ● Pay premiums on an annual basis whenever to attempting to secure financing: possible Development of a Business Plan Leasing Space and Purchasing Equipment ● Executive summary Selecting an office location ● Description of business ● Select a geographic area that is convenient ● Description of marketing competition for your patients ● Equipment and furniture needs ● Location should have convenient access to ● Practice pro forma/cash flow projection a large patient base ● Copy of office lease ● Location, not price, should be the pri- ● Advertisement and marketing strategies mary factor in determining an office loca- ● Personal background and curriculum vitae tion ● A lease is a binding agreement that may be Other Finance Methodologies locked in for many years; find a location for long-term suitability ● Securing a bank loan ● Securing a small business administration Factors to be considered in procuring a loan favorable lease: ● Location and description of space ● Parking OFFICE ACCOUNTING PROCEDURES ● Lease term ● Operating expense Establishing Financial Systems ● Option to renew ● Rental ● Accounts payable management ● Escalation clause ● Paying bills ● Damage deposit ● Pay accounts by invoice, not statements ● Escape clause ● Avoid duplicate payment or payment for ● Items and services furnished goods not received ● Insurance ● Pay bills once a month unless a discount is ● Remodeling and redecoration given for payment in less than 30 days ● Subleasing ● Right of first refusal PURCHASING FINANCING THE MEDICAL PRACTICE ● Develop bulk-ordering systems controlled Considering that the average medical student by a 30-day or quarterly timetable graduates with substantial debt and no assets, it ● Take advantage of discounts for volume is generally accepted that every new physician purchasing starting a medical practice will require outside ● Create an inventory listing of all supplies financing. Banks and institutions are more cau- and equipment found on the premises tious than ever in making new physician loans as ● Create vendor files by company name and health care reform has resulted in lower reim- file invoices and statements in chronologic bursement rates than in past years. The cost of order starting a new practice is estimated to range ● Every 6 months check the price paid for between $150,000 and $300,000, resulting in common items and compare vendor pricing new physicians looking for sizable unsecured ● Control rush orders
  10. 10. CORE CURRICULUM IN NEPHROLOGY 177 ● Conciseness PAYROLL ADMINISTRATION ● Easily understood ● Professional appearance ● Have employees create a new IRS form ● Accurate reflection of all charges and pay- W-2 at the beginning of each calendar year ments ● Obtain the most current IRS information ● Mailed at the same time each month and guidelines for preparing deductions ● Obtain the most current information from Written Collection Policy the state government for withholding re- The day-to-day collection process is often quirements neglected in medical practice. This accounts for ● Become familiar with IRS and state revenue a large portion of your income and should not be service forms for reporting staff salaries ignored! Provision of a written collection policy ● Treat all payroll information with confiden- and procedure enables the practice personnel to tiality; keep records in a secure place successfully handle collection issues: ● Seek advice from an accountant on proper ● Educate staff members about protocol reporting guidelines of employee earning ● Educate patients to comply with estab- information lished collection policies ● Maintain revenue/income balance ACCOUNTS RECEIVABLE MANAGEMENT ● Control the accounts receivable balance ● Augment a collection ratio† “Accounts receivable” can be defined as claims ● Manage cycle billing systems against a debtor usually arising from sales or ● Track and define revenue from third-party payer sources services rendered, not necessarily due or past due. In lay terms, it is a measure of business done Keys to Successful Collecting and a measure of your value to a practice. There- fore, it becomes important that your patients ● Patient telephone contacts are more effec- tive than letter writing (customers) have a clear understanding of you and your practice’s expectation of payment. ● Delinquent accounts ( 120 days) should be referred to a collection agency Financial Payment Policy ● Strict adherence to collection policies en- sures the practice will maintain a healthy ● Patient should always be informed of the cash flow practice’s financial payment policy when they call for their initial appointment CONCLUSION ● Have a written financial policy included in the practice brochure ● Post an office fine alert and alert patients that The decision to enter the clinical practice of payment for services is expected before they nephrology is a critical one. If approached with leave the office (current industry standard) attention to the issues outlined in this curriculum, future nephrologists will be set on the path to an Written Financial Payment Policy economically meaningful and rewarding prac- ● Use a simple 1-page form. tice. Many options and opportunities must be ● Avoid any legal terminology considered, and decisions must be made that will ● Define parameters suit the immediate and long-term needs of the ● Be flexible physician and his/her family. These decisions should not be left to the last minute, rather the Patient Billing process of learning about and exploring the com- ponents outlined above should begin early in the The patient’s statement should have the follow- ing characteristics: ● Consistency ● Clarity †The ratio of collections to receivables.
  11. 11. 178 PROVENZANO AND NISSENSON final year of training. Many resources exist to REFERENCES assist in this critical learning process, and should 1. Singer D (ed): The Renal Physicians Guide to Nephrol- be fully utilized. ogy Practice (ed 3). Rockville, MD, Renal Physicians Asso- ciation, 2003 ACKNOWLEDGMENT 2. RPA/ASN White Paper on the ESRD Payment System. Dr. Allen Nissenson is Past-President and current coun- Rockville, MD, Renal Physicians Association, July 20, 2002 cilor of the Renal Physicians Association and Dr. Robert 3. RPA/ASN White Paper on Commercial Payers. Rock- Provenzano is President-Elect. This outline is produced with ville, MD, Renal Physicians Association, July 14, 2001 permission from “The Renal Physicians Guide to Nephrol- 4. RPA Description of Services on Monthly Capitated ogy Practice, Third Edition,” published by the Renal Physi- Payment (MCP). Rockville, MD, Renal Physicians Associa- cians Association for practicing nephrologists. tion, December 1992