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HCM 302

Financial Management in the Healthcare Industry. HCM 302. NO MORE THERE. - Syllabus Update - Group Project Week II Updates - C-Corp S Corp LLC - NP and PA - Procedure Codes (CPT-4) - Glasgow Family Practice 2011 - You Tube: Why are the HC costs so high?

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HCM 302

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  1. Financial Managementin the Healthcare Industry HCM 302

  2. NO MORE THERE

  3. - Syllabus Update • - Group Project • Week II Updates • - C-Corp S Corp LLC • - NP and PA • - Procedure Codes (CPT-4) • - Glasgow Family Practice 2011 • - You Tube: • Why are the HC costs so high? • Healthcare Systems America vs. India? Week II Outline HCM 302

  4. 1- Dana • 3- Deja • 2-Theresa 4- Nancy • Medical Practice Name: Women’s Specialty Care • Details : • Specialty: OB-GYN • # Of Employees: 10 • # Of Physicians: 6 • # Of PA's :2 • # Of MW‘s: 2 •   # Of Offices: 3 • # Org Type: C-Corp Group A

  5. 1- Diana • 3- Hana • 2- Devon 4- Cailin • Medical Practice Name: Community Care of New Castle County • Details : • Specialty: Family Medicine • # Of Employees: 14 • # Of Physicians: 9 • # Of PA's :3 • # Of NP‘s: 3 •   # Of Offices: 2 • # Org Type: LLC Group B

  6. 1- Natalia • 3- Irene • 2-Norberto 4- Alyssa • Medical Practice Name: Pediatric Physician Care • Details : • Specialty: Pediatric • # Of Employees: 10 • # Of Physicians: 6 • # Of PA's :2 • # Of MW‘s: 2 •   # Of Offices: 3 • # Org Type: C-Corp Group A

  7. 01/26/2012 Group Project Updates

  8. 1) Name of the practice – reserve the name and document things like how much the fee is • Outline the initial steps • 2) Register with the state • 3) Obtain a business license • 5) Articles of Corporation From week I HCM 302

  9. 1) Start up budget Draft a business model • 2) Corporate agreements (between partners) • 3) Loans (most practices have a credit line) • 4) Payer mix – what % of patients pay out of pocket, insurance, Medicare, Medicaid • 5) Who will do billing? • In-house vs. UM (UM charges 4-8%) • 6) Buy furniture/computers/etc) • 7) How to grow business/what is the breaking point Group Project Week II

  10. 1) Physician recruitment • 2) Hiring of other office staff – LPNs/medical assistant/accountants/receptionist • 3) Sample contracts for physicians • 4) Contracts with hospitals • 5) Hospital privileges • 6) Contract with office space (rent/buy) • 7) Insurance Credentialing • 8) NPI numbers • 9) Fee schedule – about 10 CPT codes • 10) Schedule for physicians • 11) Plan for how to grow patient base/how to receive more patients from local PCPs • Uninsured/unassigned/PCPs • PCPs in Southern Delaware that still do not utilize hospitalists to the extent of Christiana area • 12) Mission statement • 13) Hire a lawyer • 14) Cell phones/pagers for physicians • 15) Retention strategy • 16) Flow charts for structure of organization • 17) Use specific dates for process; especially with hospital privileges and/or credentialing • 18) Immigration/J1 waiver application if applies • 19) Website Week III and IV

  11. BUNDLE PAYMENTS

  12. 01/26/2012 Glasgow Family Practice

  13. 01/26/2012 CPT-4 Guide For the group project

  14. CPT-4 OB-GYN

  15. CPT-4 Pediatric

  16. CPT-4 Family-Internal Medicine

  17. 01/26/2012 CPT-4 Guide For the group project

  18. Sole proprietorships Sole proprietorships. This is the simplest, cheapest way to get started in practice. Setting up a sole proprietorship involves minimal paperwork. When you die, so does the proprietorship. You and your business are treated as a single entity for tax purposes, so you simply report your practice's profits on Schedule C of your Form 1040. You also pay its debts from your own bank account. The downside—and it's a biggie—is that your personal assets can be claimed to settle any lawsuit against the business.

  19. C corporations. This structure has three levels of authority: shareholders (owners), a board of directors, and officers. C corporations can issue stock, which means physicians can buy into the practice or sell their shares without dissolving the corporate structure. There are generally no restrictions on how many shareholders the corporation can have, or on the number of shares it can issue. C corporations can issue two types of shares: preferred, which have priority when the practice is liquidated, and common shares. C corps can also issue voting and nonvoting shares, to allow for differences in seniority C corporations

  20. S corporations. Like a C corporation, an S corporation can issue stock. However, it's limited to 75 shareholders and it can't issue both common and preferred shares of stock. In addition, profits in an S corporation have to be distributed in proportion to each owner's stake in the business. S corporations

  21. The biggest advantage S corps have over C corps is that profits can flow directly to the owners' personal tax returns. Because of this, an S corporation's profits aren't double taxed. In that respect, an S corp is similar to an LLP • The major drawback of an S corporation is that, with the exception of health insurance premiums, you can't write off the entire cost of benefits C corporations vs S corporations

  22. Limited liability companies. Limited liability companies are a sort of hybrid; they offer the liability protection of a corporation, but are taxed like a sole proprietorship, if you practice alone, or a partnership, if you have associates. (Owners can choose to be classified as a corporation for tax purposes if they wish.) LLCs are generally structured like S corporations, but with a couple of twists. For one, an LLC can have an unlimited number of owners, which is great for a growing, multispecialty practice. There are also fewer restrictions on ownership of the practice. For instance, an LLC can be owned by another LLC, corporation, or a trust. Those aren't options for an S corporation Limited liability companies

  23. Business Structure

  24. 01/26/2012 Non physician providersnp-pa

  25. Physician Assistant Nurse Practitioner All NPs are Registered Nurses (RN) Masters degree trained in Nursing Certified by a nursing specialty organization Not possible for a non-RN to be a NP • Undergraduate degree from an approved PA program. • It is possible for an LVN, or RN to be a PA

  26. Both NPs and PAs can perform Physician Services defined by their Scope of Practice as stated in state laws • Limited prescriptive authority • NPs and PAs can perform services in; • In all settings • Inpatient • Outpatient • SNF • Home • Nursing Home Services

  27. Written authorization to provide medical aspects of patient care are; • Agreed upon and signed by the NP and the physician • Reviewed and signed at least annually • Maintained in the practice setting of the NP • Protocols or other written authorization shall be defined to promote the exercise of professional judgment by the NP appropriate with his/her education and experience • Such protocols or other written authorization need not describe the exact steps that the NP must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs which may be prescribed rather than just life specific drugs Protocols: Nurse Practitioners

  28. It is the obligation of each team of physician(s) and PAs to ensure that: • The PA’s scope of practice is identified; • delegation of medical tasks is appropriate to the PA’s level of competence; • the relationship between the members of the team is defined; that the relationship of, and access to, the supervising physician is defined; • a process for evaluation of the PA’s performance is established; and • The PA’s annual registration is current. Protocols: Physicians Assistants

  29. Provider-based facility vs.Office-based facility

  30. Designation is determined by CMS Patient receives two bills: hospital and a professional fee bill Hospitals bill DRGs for inpatient services and APCs for outpatient services. Certain clinics are designated as provider-based Provider-Based Facility

  31. Designation if not provider based then you are office-based. Patient one bill: a professional fee bill Office-based clinic bills the RBRVU associated with the CPT code for a “non-facility”. Global or both TC and CPT code are billed. Office-based Facility

  32. Nurse Practitioner and Physician Assistants • Both receive Medicare Provider numbers • Billed in the PA or NP name and provider number • Reimbursed at 85% of the fee schedule • Supervision requirements are as stated in state law • Documentation requirements are same as a “stand alone” note for an attending Medicare ReimbursementProvider-based facility

  33. “Incident to” billing • “Incident to” billing is expressly prohibited in any provider-based setting. Medicare ReimbursementProvider-based facility

  34. Nurse Practitioner and Physician Assistants: • May bill either in the name of the PA or NP using their provider number or • Bill “incident to” i.e., in the name of the physician. • “incident to” billing is reimbursed at 100% of the fee schedule. Medicare ReimbursementOffice-based facility

  35. Medicaid Reimbursement

  36. Option #1 Direct Billing 85% of fee schedule NPs may apply for individual provider numbers for direct billing purposes. All covered services rendered may be billed using the NP’s direct provider number. • Option #2 As a physician service A NP may provide services as a physician’s services using the physician’s provider number. This is similar to “incident to” billing. Medicaid Reimbursement: Nurse Practitioner

  37. Option #2 As a physician service: • A PA may provide services as a physician’s services using the physician’s provider number. This is similar to “incident to” billing. • This is the only option for a PA under Medicaid Medicaid Reimbursement:Physician Assistant

  38. Supervision Requirements • Medicaid does not require supervision of the NP or PA in the clinic. Settings • No limitations • Can’t double bill or “double dip” Medicaid Reimbursement

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