Organizations are often not aware of pitfalls in both the creation and the execution of physician agreements. By knowing the risks, you can avoid or correct issues before they become potential violations with serious consequences.
2. Agenda
§ Complimentary organizations
§ Introductions
§ Physician contract process
§ Contract compliance risks
§ Best practices for ensuring integrity of physician arrangements
February23,2016
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3. Introducing MD Ranger
§ Access 250+ benchmarks
§ Call coverage
§ Medical Direction
§ Hospital-based services
§ Diagnostics
§ Clinical professional services
§ Standardize FMV documentation across the organization
§ Audit service line spending
§ Monitor contracts with risky rates
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February23,2016
4. Introducing Ludi
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§ Active financial management of physician agreements
§ DocTime Log® suite: a mobile application for physician time logging
and web-based SaaS that automates physician approval and
payment workflows
§ Documentation for compliance audits and reporting to CMS
§ Consulting services for assessing structures and processes for
administering complex physician agreements and ensuring compliant
physician payments
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6. Process for creating arrangements
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Determine
Commercial
Reasonableness
Both parties sign
the agreement
Determine FMV
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7. Results of manual processes:
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Expensive errors
Wasted time and
resources
Compliance risks
Spending too much money
Many organizations apply different processes to different contracts, making more
room for error and risk
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9. 1. Paying when it’s commercially
unreasonable
§ When payment is requested, never grant without thorough analysis
§ If it is commercially unreasonable to pay a physician for a service in
the first place, you have bigger problems than a payment that is too
high
§ Benchmarks can help you establish commercial reasonableness
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February23,2016
10. 2. Using the wrong information
Market data can be a powerful way to determine physician payment
rates, but there are pitfalls you must avoid.
Questions to ask before using market data:
§ Consider sample size and participant characteristics of the survey
§ Who reports the data?
§ Where are the providers?
§ How are Antitrust Safety Zone Guidelines interpreted?
§ Is the data collected consistently and comprehensively, and is it
routinely audited by experts?
§ Are the most helpful, relevant statistics reported?
§ What is the distribution of rates within the data?
§ Am I comparing ”apples to apples”?
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February23,2016
11. 3. Cherry-picking rates
§ Physician: I’ve called my peers around town and I have data from five
local hospitals:
§ Dr. Apple gets $1,000 per diem
§ Dr. Pear gets $1,200 per diem
§ Dr. Grape gets $1,500 per diem
§ Dr. Apricot gets $950 per diem
§ Dr. Berry gets $1,000 per diem
§ Physician: Considering this, I should be paid at least $1,000 per diem
for this service.
Problems:
§ Incomplete picture
§ Can “confirm” the position of party arguing for a particular rate while
ignoring data to the contrary
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February23,2016
12. 4. Paying above FMV
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• 75th percentile and under generally considered within “fair market
value range”
• It’s normal for an organization to have a small handful of
agreements that exceed the 75th percentile, or even a few above
the 90th percentiles
• These contracts must be carefully vetted and reasons for higher
payments should be justified
• Paying above fair market value thresholds should be a rare
occurrence, not standard!
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14. Standardize FMV process with market
data
1. Test for commercial
reasonableness
2. Find benchmarks with
appropriate sample sizes
3. Determine if scope of
services is a good match
4. Find best payments within
the market ranges (your
organization should have a
policy about this; if not,
create one)
5. Negotiate payment with the
physician or group
6. Document FMV!
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February23,2016
16. 16
Paper-based documentation is often lacking necessary details to be
compliant
LEGAL
CONTRACT
MGMT
DUTIES
FAIR
MARKET
VALUE
TERMS
Physician turns in a time log the first
month that puts the organization at risk
February23,2016
17. Manual errors are more likely
Physicians are dissatisfied
Compliance risks are
heightened
Staff time spent on rework is time
consuming and costly
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The costs to your organization aren’t just in dollars
Your organization is at risk with
outdated manual processes
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19. Pitfalls of current processes
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Process Related Agreement Parameters Fair Market Value (FMV)
§ Contract ends § Duties unclear § Operationally not
maintained
§ Late logs submitted
§ Multiple submitted
logs
§ Duties not checked
§ Illegible time logs
§ No routine time logs
submitted
§ Paper is lost
§ Time to submit isn’t
outlined
§ Format leads to
incorrect information
submitted
§ Duplication of duties
across agreements
§ Joinders missing
§ Contract not
adjudicated
§ Layer of agreements
§ Calculations incorrect
§ Math incorrect due to
complex structure
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23. 3. Standardize and Streamline Duties
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§ Ensure that the service line adheres to each hospital’s policies and procedures, applicable
laws and regulations, accrediting body requirement and other regulatory compliance, and
make recommendations to hospital personnel.
§ The Director shall ensure compliance with regulatory agencies governing the medical staff,
including the Joint Commission and state and federal agencies with the assistance of
hospital personnel in the service.
§ The Medical Director, in collaboration with the unit leadership, nursing director and hospital
leadership, facilitates compliance with: department policies; TJC standards; federal rules
and regulations; corporate integrity agreements
10 Unique Duties Per
Facility
(10 x 60 = 600)
§ Time consuming to check time log against
specific duties each month – operational
challenge
Reduce Variation
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24. 4. Approver Training and Accountability
Access to physician’s historical and current logs
Access to actual contract
25. 5. Mind the Math with Automation
Current time log details Year-to-date view
26. Infrastructure Needs to Support
Compliant Tracking and Analysis
Physicians are
accountable
Clear expectations
Manage what you
measure
Dashboards and data
Payments are within
scope
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February23,2016