Archive for Members

President’s Statement on Coronavirus COVID-19

President’s Statement on Coronavirus COVID-19

We now have thirty-two confirmed cases of the new coronavirus infection in Alabama.  We have all seen how this new virus has spread around the world from its beginning in China just a few months ago.  The World Health Organization has now classified this as a pandemic.  However, please remember that compared to the flu, the number of cases in Alabama, in this country and worldwide are still quite small.  I am hopeful that folks will not panic and let common sense dictate their response to this situation.  Our state and federal governments, the Alabama Department of Public Health, the Medical Association and others are all working to implement reasonable responses to this evolving situation.  Everyone’s health and safety is our primary concern.

Some important things to remember:

  1.  Over 90% of the cases of COVID-19 have been mild and resemble the common cold.
  2. Half of the people worldwide that have contracted this disease have now completely recovered.
  3. Folks most at risk for this disease include the elderly and especially those with underlying medical conditions such as COPD, diabetes, heart disease or cancer.
  4. Not everyone needs to be tested for the coronavirus, those needing to be tested need to meet certain criteria that suggest they may be at risk for this disease.

How can you best protect yourself and avoid becoming ill from the coronavirus:

  1. If you are sick, stay home.  If you have a cough and fever, stay home.
  2. If you are sick, call your family physician or primary care provider and let them help you determine if you need to be tested or seen. 
  3. During any kind of pandemic, you should avoid going to the Emergency Room or the Doctors’ Office for routine things that could be handled after the pandemic passes.  Remember: that is where the sick folks are and that is who you need to avoid.
  4. Wash your hands frequently with soap and water.  Hand sanitizers should only be used when soap and water are not available.
  5. Cover your cough, cough into your elbow.
  6. Keep your hands away from your face.
  7. Avoid large crowds and crowded spaces.  Social distancing, which means staying at least 6 feet from the nearest person, is the best way to avoid coming in contact with this and other infectious diseases.

We need to all work together to meet the challenge of this new coronavirus disease.  Avoiding panic and using good common sense measures can help us all stay safe and healthy.

John S. Meigs, MD, FAAFP

President, Medical Association of the State of Alabama

Posted in: Leadership, Members, Official Statement

Leave a Comment (0) →

Shift in Patient’s Right to Access Medical Records

Shift in Patient’s Right to Access Medical Records

By: Kelli C. Fleming, Burr & Forman

The Office of Civil Rights (“OCR”), the government agency tasked with HIPAA compliance and enforcement, recently announced a change impacting a patient’s right to access his/her medical records—a change which is, given OCR’s history, surprisingly favorable to providers. 

One of the long-standing premises of HIPAA has been a patient’s right to access his/her medical records. For years, the HIPAA regulations have limited the fees that providers can charge patients when they request a copy of their medical records to a reasonable, cost-based fee (regardless of the permitted state law fees). HITECH expanded this right a few years ago by allowing patients to exercise their right to access medical records, but designate a third-party to whom the records should be sent (e.g., the patient’s attorney). These requests from patients to send their records to a designated third-party are oftentimes referred to in the industry as “HITECH” requests. 

Subsequent OCR guidance stated that the historical limitation on fees that applied when a patient exercised his/her right to access medical records would also apply to the situation where a patient requested that his/her records be sent to a designated third-party pursuant to a “HITECH” request. As a result, providers were limited in what they could charge third-parties, such as attorneys, seeking access to medical records by way of a “HITECH” request from a patient, as opposed to by way of a HIPAA authorization. 

However, based on a recent court order, such limitation on fees no longer applies to “HITECH” requests. As a result of the recent court decision, OCR has clarified that “the fee limitation set forth at 45 C.F.R. § 164.524(c)(4) will apply only to an individual’s request for access to their own records, and does not apply to an individual’s request to transmit records to a third party.” Thus, as a result of this recent court decision, providers, and their business associates, are no longer bound by the HIPAA-imposed limitation on fees when a patient requests that a copy of his/her medical records be sent to a designated third party (e.g., attorney). For these “HITECH” requests, providers can now charge fees acceptable under state law, without applying the HIPAA fee limitations. These state law fees are oftentimes higher than the HIPAA fees. Further, the court decision clarified that such “HITECH” requests are limited to requests for an electronic health record with respect to PHI maintained in an electronic format.

OCR has been clear that the  HIPAA limitation on fees, however, will continue to apply to patient requests to access their own medical records when the records are delivered directly to the patient. Nonetheless, this shift in guidance is favorable to providers and much welcomed by the healthcare industry.

Kelli Fleming is a Partner at Burr & Forman LLP practicing exclusively in the firm’s healthcare industry group.

Posted in: Legal Watch, Members

Leave a Comment (0) →

Appropriate Use Criteria for Advanced Diagnostic Imaging

Appropriate Use Criteria for Advanced Diagnostic Imaging

Contributed by: Gregg Everett, Gilpin Givhan

The Protecting Access to Medicare Act (PAMA) was passed in 2014.  PAMA required the Centers for Medicare and Medicaid Services (CMS) to establish a program that promotes “Appropriate Use Criteria” (AUC) for advanced diagnostic imaging. AUC’s are evidence-based criteria that assist professionals who order and furnish certain imaging services to make the most appropriate treatment decisions for specific clinical conditions. Once the AUC program is fully implemented (2021), payment will only be made for an advanced diagnostic imaging service if the Medicare claim indicates that the ordering professional consulted with a qualified Clinical Decision Support Mechanism (CDSM) about whether the ordered service meets an applicable AUC.  A CDSM is an interactive electronic tool for use by clinicians that communicates AUC information and assists in making appropriate treatment decisions during a patient’s workup.  An ordering professional is a physician or other licensed professional who orders an imaging service.  The settings covered include hospital outpatient departments (which includes the hospital’s ER), ambulatory surgery centers, physicians’ offices and IDTF’s.  

Advanced diagnostic imaging services include MRI’s, CT scans, PET scans and nuclear medicine. The CDSM must be reported on claims for payment using G-codes, modifiers and, eventually, the ordering physician’s NPI. For the period July 1, 2019, through December 31, 2019, only voluntary reporting was required.  Beginning January 1, 2020, an educational and operations testing period will be implemented, which is expected to run through December 31, 2020. For now, CMS will still pay a claim, whether or not the claim correctly includes AUC information. Eventually, CMS must develop outlier criteria (which will require some ordering professionals to obtain prior authorizations) and will not pay those claims that do not have AUC information, unless a specific exception is met. The exceptions include emergency services provided to individuals with emergency medical conditions (EMTALA definition), inpatient care where payment is made under Part A Medicare, or significant hardships, which includes insufficient internet access and EHR or CDSM vendor issues.  

Qualified CDSM’s (only national professional medical specialty societies or other organizations of providers who predominantly provide direct patient care may develop CDSM’s) must be approved by CMS and must meet other criteria, such as providing a certification or other documentation at the time of the order that a qualified CDSM was consulted, and whether or not the service ordered met the requirements of the specific referenced AUC. The regulations also list certain “priority clinical areas” that will be monitored to identify outlier ordering professionals as follows:  coronary artery disease (suspected or diagnosed), suspected pulmonary embolisms, headache (traumatic and non-traumatic), hip pain, low back pain, shoulder pain (including suspected rotator cuff injury), cancer of the lung (primary or metastasis, and suspected or diagnosed), and cervical and back pain. Ordering physicians and settings for these imaging services should begin the process of including AUC’s on Medicare claims in January 2020.

For more information see:

  1. “Protecting Access to Medicare Act of 2014,” Section 216, (Public Law 113-93), 42 U.S.C. Section 1395m(p) and (q).
  2. 42 CFR Section 414.94 – “Appropriate Use Criteria for Advanced Imaging Services.
  3. “Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging – Educational and Operations Testing Period—Claims Processing Requirements”; MLN Matters Number MM11268 Revised December 6, 2019.

Posted in: CMS, Legal Watch, Medicare, Members

Leave a Comment (0) →

Striking Your Best Deal: Things to Look at on the Front End of Negotiating an EHR Vendor Contract

Striking Your Best Deal: Things to Look at on the Front End of Negotiating an EHR Vendor Contract

Article Contributed by Christopher L. Richard, Gilpin Givhan, PC


Imagine you’re selling your practice . . . or leaving your practice . . . or retiring. You want to continue to have access to the patient records you’ve maintained through the practice over the years, and in fact, you have an obligation to do so. Under Rule 540-X-9-.10(1) of the joint guidelines of the Alabama State Board of Medical Examiners and Medical Licensure Commission, physicians are required to retain medical records “for such period as may be necessary to treat the patient and for additional time as may be required for medical-legal purposes.”[1]In addition, you must provide patients notice and a reasonable opportunity to request their records or request that they be transferred to another practice. It used to be you would maintain physical copies of these records in your practice office, a secure storage area, or by some other means. However, your patient records are now stored in an electronic health record (“EHR”) system maintained by a third-party vendor. Your third party vendor is planning to charge you a regular monthly service fee for the entire duration of time you have to keep the records. The alternative is an exorbitant one-time fee for you to obtain a copy of the digital patient records maintained in the EHR system. Neither option is particularly good, but the scenario provides an important opportunity to examine key contractual provisions you and/or your counsel should pay attention to when negotiating EHR and other vendor contracts.

I Have the Need . . . for Legalese

Contracts, especially vendor contracts, can be filled with overly-complicated, legalese-ridden language that tends to earn attorneys their fair share of grief. However, a good portion of this language is born out of experience and necessity. For one, attorneys tend to loathe repeating (or allowing) the same mistakes more than once (“Fool me once, shame on you; fool me twice, shame on me,” as the saying goes). Unfortunately, attorneys cannot anticipate every possible scenario that might unfold, but we often attempt to ensure that contractual provisions at least provide clarity in situations where past ambiguities have turned into disputes.

Secondly, attorneys do their best to memorialize what are often extremely complicated arrangements between their clients. Complicated structures frequently require complicated descriptions. Otherwise, a contract may be lacking in meaningful standards and may be no more useful that the “handshake” agreement that started the contract negotiation process.

With the (perhaps) optimistic notion that attorneys craft documents out of necessity according to the principles above, consider the following contractual provisions that are worth the extra attention in the contract negotiation process.

Important Contract Provisions

Ownership of Records; Rights to Use.  It should go without saying that you and your patients are the owners of your patient records, regardless of whether they are stored in, or on, your vendor’s software and/or hardware. Be wary of any contractual language that seems to give ownership rights in your patient records to the EHR vendor. By that same token, consider what rights your EHR vendor reserves to use and/or disclose information stored on their system. When intense scrutiny of tech company privacy practices is layered on top of HIPAA and increasingly restrictive state, federal, and international privacy laws, it’s worth an extra look to ensure you’re not allowing your EHR vendor to take any actions that would impact your obligations under applicable privacy laws.

Indemnification/Hold Harmless/Limitation of Liability.  Experience tends to show that contracting parties will listen and respond to reasonable concerns, especially when they are trying to earn your business. The same principles apply to the remedies provisions of vendor contracts. For instance, the initial contract presented may require you to “indemnify, defend, and hold harmless” the vendor against a host of liabilities that may be incurred by you or the vendor. It is almost always a reasonable request to have the indemnification language be mirrored between the parties. In other words, if you are required to indemnify the vendor for your negligence, gross negligence, or willful misconduct, they should be willing to indemnify you for their similar conduct.

In addition, the contract may limit the amount of damages recoverable to the total amount of payments you make for the vendor’s services under the contract, or the number of payments in a given time period (e.g., one year or the term of the contract). These limitations are not uncommon, and they are not necessarily unreasonable. However, it’s not the kind of limitation you want to discover after you’ve encountered some significant financial harm and are expecting the other party to cover all the costs.  Similarly, it would be untenable to accept unlimited potential liability to your EHR vendor when they are putting fairly extensive limits on their liability to you.

Termination Provisions.   Now, back to where we started: what happens when you are attempting to terminate your practice or a relationship with an EHR vendor? As an initial matter, it’s worthwhile to consider your options to terminate the contract before the term is over. All too often, I’ve seen clients stuck in long-term contracts with little or no option to terminate. Obviously this is a matter of economics for the vendor. They have up-front investment costs that have to be recouped over the life of the contract, which hopefully (for them) is a long term. However, consider options to terminate the contract for “good cause.” It’s also worthwhile to consider including an illustrative list of items that constitute “good cause,” in an effort to avoid arguing about what “good cause” means when you elect to terminate the contract. In addition, consider a no-fault termination provision, which may be acceptable to both parties if there is a reasonable notice period before the contract can be terminated.

Lastly, consider what your options are to preserve the records or get them out of the EHR system upon termination of the contract. In the example above, you may be caught between a rock (continued EHR service fees for the required record retention period) and a hard place (a costly one-time fee to obtain a copy of the records). Again, these deal points can (and should) be negotiated on the front end of the arrangement with the EHR vendor, especially if you foresee a change in your practice (e.g., retirement) in the near future. An acceptable solution likely looks different for each individual physician or practice, and their respective vendors, and could vary based on the timing (early vs. end of contract term) and reasons (retiring vs. transferring to new vendor) for terminating services. Concepts like these should be considered to address this issue and other contractual issues on the front end of the agreement, rather than when the relationship has soured or ended.


The contracting process can be tedious, frustrating, and at times can seem unnecessary, especially if both parties “seem to be on the same page.” However, there are great benefits to a well-conceived contractual relationship. These may include robust and meaningful standards of performance. They may also include reasonable provisions and limitations on indemnification, liability, and damages, or even a plan for what happens when the relationship is terminated. At any rate, they should be tailored to meet the parties’ needs and should be a help, rather than a hindrance. They simply require some attention from the parties on the front end of the contract.Please note that the information provided in this article does not, and is not intended to, constitute legal advice; instead, all information, content, and materials contained herein are for general informational purposes only.  Readers are encouraged to contact their attorney to obtain advice with respect to contract negotiations or any other particular legal matter.

[1] Although there is no specific retention period, the Board of Medical Examiners suggests keeping patient records for at least 10 years or otherwise consulting with the malpractice liability carrier to determine an appropriate record retention period.

Posted in: Legal Watch, Management, Members

Leave a Comment (0) →

Top 4 Dos and Don’ts For Audits and Investigations

Top 4 Dos and Don’ts For Audits and Investigations

In the spirit of college football season and the inevitable argument about which four college football teams are in the college football playoffs, this article addresses the undisputed top 4 dos and don’ts that physicians should follow during an audit or investigation.  I have represented countless medical practices and individual physicians with a variety of federal payor audits, false claims investigations and DEA investigations.  The following top 4 dos and don’ts are the top issues I see frequently repeated, oftentimes to the detriment of the provider under investigation.

# 4 – Keep an Exact Copy of Everything Produced or Viewed Most of the time I am not retained until after the practice has turned over the requested documents and, in some cases, has also turned over non-requested documents. The usual response by the practice, when asked why it did not keep a copy of what was released, is something along the lines of “we did nothing wrong” or “we know what we turned over and can make a copy if needed.”  However, when I ask for the documents produced, the practice oftentimes cannot replicate what was produced. This puts the practice at a competitive disadvantage from the start. It also makes citing to a particular document extremely difficult when legal counsel does not know (1) if a particular document was actually produced, or (2) if it was produced, where in the mountain of records the document is located. Defending the practice’s conduct or fighting a recoupment becomes challenging without a copy of the documents. Thus, the practice should go ahead and make an exact copy of what is produced and maintain the copy until the practice is reasonably sure nothing will come from the audit or investigation. It is also recommended that the practice hire legal counsel before producing records, so as to ensure that only responsive documents are produced.

# 3 – Review All of the Medical Records Before Producing.  While this seems like a no brainer, I cannot state the number of times a medical practice has printed what it believes to be the entire medical record only to learn when receiving a recoupment demand or allegation of false claims that the entire medical record was not produced.  Another common issue in this age of electronic medical records (“EMR”) is that the printed record looks substantially different than the electronic record.  Some EMR systems will print a paper copy differently if the “print” function is used versus the “print screen” function.  I have experienced numerous occasions when the paper copy looks suspicious or incomplete, particularly the patient’s history or prescription records, because of the way the EMR prints the record.  On a related note, if the practice wishes to use a consultant to conduct a simulated audit, it is important to make sure that the consultant either has access to the EMR or that the printed paper records are complete and identical to the electronic records.

# 2 – Maintain Signature Logs of Alabama Medicaid Patients.  The Alabama Medicaid Agency requires that providers maintain evidence that the patient actually attended the appointment.  It does this by requiring providers to keep a signature on file to prove the patient’s attendance at each appointment. I have represented quite a few physicians and practices in Medicaid audits, and I do not recall an audit that did not request copies of the patients’ signatures.  However, the signature requirement is not well known by Alabama providers, as many of my clients are unaware of the requirement and fail to keep a copy of the signatures. While there are other ways to prove that a patient attended the visit, it is very simple to satisfy the signature requirement and avoid having to gather other forms of proof–simply use the removable signature logs and paste the patient’s signature into the record for that particular visit.

#1 Never, Ever, Ever Voluntarily Surrender A License/Permit/Participation Without First Obtaining Advice of Counsel.  Without question, the undisputed defending champion and current #1 is never ever voluntarily surrender a license, permit or participation in a payor’s program without first obtaining advice of counsel. I have heard on multiple occasions that a particular investigator says something along the lines of the following to a licensee “Things will go much easier if you voluntarily surrender your license.”  I have never in my experience seen where things have gone easier for the physician when he/she has voluntarily surrendered his/her license. However, it does is make things easier for the licensing body, so the statement above is true as phrased. The voluntary surrender substantially compromises the physician’s ability to defend his/her case, as the physician has lost any leverage he/she may have had – the agency already has what it wants – the physician’s license.  Most licensing agencies have due process requirements that must be followed before it can revoke, suspend, or take any adverse action on a license.  One of the most important due process requirements is giving the physician the right to a hearing where the physician can be represented by counsel and present evidence. The hearing process affords the physician the ability to test the agency’s evidence and interpretation of its regulations, which are oftentimes flawed.  The hearing process also gives the physician the ability to reach a compromised resolution of the matter, oftentimes allowing the physician to keep his/her license.  By voluntarily surrendering a license, the physician loses such rights and ability.

Jim Hoover practices with Burr & Forman LLP and works exclusively within the firm’s Health Care Industry Group. Jim primarily handles healthcare litigation and compliance matters.

Posted in: Legal Watch, Members

Leave a Comment (0) →

Staff Retention Leads to a Successful Practice

Staff Retention Leads to a Successful Practice

I visit many practices throughout the year performing medical practice assessments.  One of the first items to review is staffing levels, length of service and each staff member’s role.  The administrator is a key component to engaging the staff.  Increasing the level of staff engagement can raise productivity 20% and reduce the probability of a staff member leaving by 87%.

Administrators who hire an employee for a specific position which is detailed in a job description makes the first step to communicating effectively.  Proper preparation for onboarding is essential to adding value to the employee/employer relationship.  The first day should begin with orientation, discussion of the handbook, employment paperwork and the introduction of the training plan.  More than 5% of employees leave a new job due to a disastrous first day.  It is important to equip a new employee with the tools to learn the job, such as a mentor and a checklist of key tasks they should be able to perform within a 90-day probationary period.

Once an employee is past the probationary period, goals should be set for development.  Ongoing communication and training are essential to engaging the employee and creating buy-in within the organization.

Annual evaluations are useful in rewarding good performance, and also setting goals for development.  An evaluation should not be the first time an employee learns of a performance problem.  Problems should be addressed at regular intervals with specific directions for improvement.  The evaluation should only report the need for continued improvement or acknowledgment of success.

During an office review, I sometimes find the administrator has simply turned new staff members over to the most knowledgeable employee. If the seasoned employee was not trained effectively, how successful could he or she be at preparing the new employee? The better performing practices have an effective training program, regular staff meetings and incentive programs to engage the staff.  I recently assisted a practice that had lost several key employees; they were paralyzed.  They could not even generate financial reports to realize the extent of their problems.  Your staff is your most valuable asset and losing them can be costly. It can cost 150% to replace a valuable employee considering loss of production and training time.

Cross-training staff to perform multiple task is a good way to assure you can get through a short-term absence or the timeline to replace an employee. Documented best practice workflows should be obtained from your practice management vendor and EHR vendor to ensure you can train appropriately. We are assisting practices in changing their employee bonus structure to reward performance and buy-in. Take care of your best asset, the staff you have trained and who know your practice. Warren Averett can assist you with all your recruiting and staff management projects.

MBI Transition Ends This Month: WILL YOU BE PAID ON JANUARY 1?

The 21 month transition period will end on December 31; use Medicare Beneficiary identifiers (MBIs) now.

  • You are currently submitting 86% of claims with MBIs.
  • Get MBIs from your patients and through the MAC portals (sign up) now and after the transition period. You can also find the MBI on the remittance advice.
  • Protect your patients from identity theft – use MBIs.

Starting January 1, if you do not use the MBI (regardless of the date of service) for Medicare transactions:

  • We will reject your claims with a few exceptions
  • We will reject all eligibility transactions

See the MLN Matters Article for more information on getting and using MBIs.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

Posted in: Management, Members

Leave a Comment (0) →

Better Together: Physician-Lead, Team-Based Care

Better Together: Physician-Lead, Team-Based Care

Working as a team is unquestionably the best and most efficient way to maximize the skill sets of a specific group of people. In medicine and depending on the particular needs of the practice, a team-based approach can include various combinations of physicians, nurses, physician assistants, pharmacists, social workers, case managers and other health care professionals. The unique strengths and perspectives of each team member are an asset when providing the safest, best possible care to patients. The best place for physicians to learn how to work as a team is while they are still in training.

“So in a residency world, the team in a hospital setting is going to be the attending physician, usually one or two upper-level residents, and then usually two first-year residents. And in this setting, we have a couple of medical students. That’s our team,” explained Tom Kincer, M.D., Director for the Montgomery Family Medicine Residency Program. “The way that team works in the hospital setting is built on varying levels of responsibility so that as students and residents gain more knowledge and more skills, they’re given more independence yet have oversight of upper levels. So the first-year residents have oversight by the upper-level residents, and the upper-level residents have oversight by the faculty physicians.”

According to Dr. Kincer, the Montgomery Family Medicine Residency Program’s success has been built on this hierarchy of educational independence that has worked for many years and allows for a “symbiotic relationship” between a  mix of disciplines in health care that is patient-centric but always led by a physician. For Dr. Kincer, the ultimate goal of a physician-led team-based model of care will always be to affect change in the health of the population. To do this, there are numerous hurdles to overcome.

“So the team-based model for population health is the best model for patient care,” Dr. Kincer said. “When it comes to providing that one individual patient the best care possible because they can have a physician, right? They could have the physician, lead nurse practitioner, or the pharmacist, or the social worker, or the occupational therapist. All of that is part of the bigger team, but the problem comes in a fee-for-service model with MACRA. How do we pay for all that? Physicians can’t afford to pay for everything out of their pockets, because there’s no direct reimbursement. Once we tackle that, I don’t think we can move forward with a true team-lead model. But it doesn’t exist unless you’re in a health care facility that’s willing to sponsor this team-based model. There are too many competing forces against it.”

While it may appear that the deck is stacked against the physician-led team-based model, as Dr. Kincer noted, if there is a health care facility willing to sponsor it, the advantages to the community are overwhelming.

Perhaps the most frustrating stumbling block in modern medicine today is access to care. For patients who do not have a physician of their own, these patients will use a hospital’s emergency department for all the wrong reasons. Not only does this cause lengthy wait time for patients who need emergency services, but it creates billions in health care treatment costs over time for the hospital. Dr. Kincer’s solution? Spend some money to save not only money but also lives in the long run.

“It’s very difficult for a private practice, primary care physician to have a team-based approach in their office. Other than maybe the physician, a nurse practitioner and their staff. In that model, people need to work to their highest level. So the physician needs to be taking care of patients that require that expert level from the physician, and the nurse practitioner needs to be working at their level and so on to allow the physician to work at their highest level. All this allows the staff to do some of the things the staff needs to do, whether that’s teaching the staff how to apply for drug assistance programs, or to have patients come in and monitor without them actually having to see the nurse practitioner or their physician. If the physician or the nurse practitioner is not seeing the patient, they’re not generating income. There’s got to be enough volume going through the physician and the nurse practitioner over the PA to be able to generate an income to run the office,” Dr. Kincer said.

In an employed physician model, it begins by playing to the institution’s strengths and weaknesses. If the revenue in one department is higher than another, there needs to be a fundamental understanding that the institution can’t work without all departments at the top of their game, so it comes down to budgeting.

“After you find out what the goal of the organization is, you can utilize your resources better for a stronger team-based care model. Certain parts of that model are profit-creating and other parts are patient-oriented that don’t really make the profit, but you can still support the whole team. That’s how most residency programs function as part of the bigger system,” Dr. Kincer said.

The model he created for Baptist Health to use for the Family Medicine Residency Program in Montgomery is called the Care Advisor Program. By identifying a specific group of 250 patients from the tri-county area with chronic illnesses and no insurance who tend to use the emergency department instead of a regular physician to monitor their health issues, the program instituted a team-based model and brought them into their office. Here, patients have access to physicians, nurses, social workers, pharmacy, labs, x-rays, etc., at no cost.

“What we’ve been able to do in our Care Advisor Program in the past 10 years is to save our hospital system about $6 million a year by providing these patients with free medical care. However, it cost us about $4 million a year to take care of this population, but in return, it saves us $6 million a year because prior to the program, it cost the hospital $10 in ER visits to take care of this population that was uninsured. Now with our team-based approach out of the residency program, which is run very efficiently, we’ve taken the average number of ER visits and hospitalizations combined for each patient from 10 to 12 visits a year to less than one per year. The patients get their care in the office, their medications, and follow-up care. We’ve cut expenditures and improved the health of all these patients. The average patients stay in the program for about two years, and their health is improved. Now THAT is population health,” Dr. Kincer said.

Posted in: Management, Members

Leave a Comment (0) →

Physician Burnout

Physician Burnout


While employees in many professions report burnout, physicians appear uniquely susceptible and the consequences can be detrimental. Physicians are fifteen times more likely to suffer burnout than other professions and statistics indicate that at a given time nearly a third of physicians are experiencing symptoms of burnout.[1] Throughout the course of a career nearly one in two physicians are likely to suffer from burnout, and depending on specialty, it can range from 30 to 65% of physicians. Physicians in the mid-point of their career are the most likely sufferers, but the rates and trends across age groups continue to worsen.[2]  Indicated in a Mayo Clinic study, about 50% of physicians will experience symptoms of burnout at some point in his or her career.[3]


Various theories are offered as to why the problem is reaching epidemic proportions for physicians. One commonly identified contributing factor is that physicians feel increasingly overworked. One study identified the lack of control over a physician’s daily schedule as a primary driver for experiencing burnout.[4] Technology is also recognized as a culprit and studies show doctors are increasingly spending time on the computer instead of interacting with patients.[5] Yet another modern contributor to physician stress can be negative online reviews.[6] Physicians may be feeling increasingly judged and scrutinized by the patients they are dedicated to helping. Outside technology, a decrease in healthy eating habits or exercise is also shown to lead to or exacerbate the problem.[7] This decrease in quality of life is likely driving physicians from the practice of medicine, which further increases stress on the health care system already facing a looming physician shortage as baby boomers retire.[8]

The impact of physician burnout can be enormous. On an individual level, it is destroying quality of life for physicians to the point that many leave the practice of medicine or even turn to suicide. Rates for physician suicide are double that of other professions, with female physicians three times as likely.[9] Increased suicide rates are not only high throughout a physician’s career, but are also evident in medical students with 9.4% of students reporting suicidal thoughts.[10] Physician burnout has also been associated with significant decreases in patient care and safety.[11]


While there are no simple or obvious solutions to physician burnout, there are multiple approaches to consider. For starters, physicians and the greater medical community cannot afford to ignore the impact burnout is having on both individual physicians and the practice of medicine.  The impact of burnout continues to worsen and may be approaching epidemic proportions. One component physicians should recognize is that shouldering the burden themselves is not enough; to paraphrase a classic literary character, you can’t just work harder.[12]  Physicians may need to change the way they practice medicine; by recognizing limitations and learning to say “no.”

Other studies point to promoting lifestyle decisions as a way to combat burnout. Specifically, physicians should find ways to maintain a healthy lifestyle. This can involve eating a healthy diet, sleeping 7-9 hours regularly, and exercising appropriate amounts.[13] Besides physical health, physicians should be encouraged to have creative outlets such as hobbies, sports, leisure activities, and vacations.


ProAssurance is also seeking ways to support physicians and the medical community regarding burnout and the implications it may have on patient care.  In September 2017, ProAssurance established a $1.5 million gift to the University of Alabama at Birmingham (UAB) School of Medicine to endow a chair to support physician wellness.  This endowment was to support research and efforts addressing the issues and challenges related to physician burnout. UAB combined the endowed chair with the existing Chief Wellness Officer position, which was filled by David Rogers, MD, MHPE in January 2018.

In a recent interview with Dr. Rogers, he stated, “Many people talk about burnout as though you’re burned out or you’re not.  But it isn’t that simple. There are degrees of burnout or being engaged. Month by month tracking lets you see a pattern and reevaluate before things spiral in a negative way.”

The use of month to month well-being assessments such as the Mayo Clinic Well-Being Index[14] may help identify and track individual physicians’ well-being.   Hospitals may utilize this assessment to identify certain departments where stress and/or engagement are particularly high. These results could customize resilience training for these groups.

Accomplishing goals to reduce burnout in the medical community means that there must be a systemic and cultural shift. Physicians need to be free from judgment in seeking solutions to this crisis. From his experience, Dr. Rogers would also like to focus on training for frontline leaders in the medical industry. Leaders often set the tone for their employees, so teaching them to identify and mitigate stress is essential. Dr. Rogers believes the medical community is at a crucial point and must start having conversations about physician burnout. “There has to be a change in culture,” he concludes. “It’s hard, but critical to think about what happened to the industry, what we can do to correct it, and what lessons we can learn for the future.”

As professional liability insurers, ProAssurance recognizes the increasing danger of physician burnout and the potential harm to our insured physicians and organizations. Although we have identified the increasing seriousness of this problem, but still struggle with how to identify or prevent it.  We are committed to finding ways to discover the problem before it manifests in professional liability claims, and we encourage our physicians to reach out for solutions if they are feeling overwhelmed or at risk for burnout.

Physicians insured by ProAssurance may contact our Risk Resource department for prompt answers to liability questions by calling 844.223.9648 or via e-mail at

[1] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, accessed September 29, 2017.

[2] Staff, “Medical specialties with the highest burnout rates,” AMA Wire, Jan 15, 2016. accessed September 29, 2017.

[3] Tait D. Shanafelt, M.D. et al,  “Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014,” Mayo Clinic Proceedings , Volume 90 , Issue 12 , 1600 – 1613  accessed September 29, 2017.

[4] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, accessed September 29, 2017.

[5] Paige Minemyer, “Study: Docs spend more time with computers than patients,” Jan 31, 2017, accessed September 29, 2017.


[7] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, accessed September 29, 2017.

[8] “Physician Supply and Demand Through 2025: Key Findings,” AAMC

Accessed September 29, 2017.

[9] Pranay Sinha, “Why Do Doctors Commit Suicide?,” New York Times, Sept 4, 2014,  Accessed September 29, 2017.

[10] Louise B Andrew, MD, JD, “Physician Suicide,” Medscape, June 12, 2017. accessed September 29, 2017.

[11] Megan Brooks, “Provider Burnout Tied to Lower Levels of Patient Safety, Care,” MedScape, accessed September 29, 2017.


[13] Dr. Elaine Cox, M.D., “Doctor Burnout, Stress and Depression: Not an Easy Fix,” April 12, 2016, accessed September 29, 2017.

[14]  Accessed December 20, 2018.

Posted in: Members, MVP

Leave a Comment (0) →

Outpatient Visit Evaluation & Management Changes for 2021

Outpatient Visit Evaluation & Management Changes for 2021

For more than 25 years, the American Medical Association has utilized the 1995 or 1997 guidelines for Evaluation and Management (E/M) services in the Current Procedural Terminology (CPT).  The E/M codes have expanded over the years but until now, there has been no update to the elements, in which, we choose a level of service. The Centers for Medicare and Medicaid Services in partnership with the American Medical Association (AMA) collaborated on changes to reduce the administrative burden in documenting outpatient visits for new and established patients.  

The revised guidelines pertain to the new patient codes 99201-99205 and established patient codes 99211-99215.  The revision was announced as part of the 2020 Physician Fee Schedule but does not occur until 2021 due to the many preparations to support this endeavor. The AMA is actually updating the code description for the specified codes, which affects all carriers, not just CMS.  The 99201 code is eliminated for 2021; the remaining codes will retain reimbursement for each code, which is a change from the proposal to condense some codes to a combined rate.  

The inclusion of time has been an explicit factor in the definitions of E/M services in the CPT codebook since 1992.  Beginning in 2021, with the exception of 99211, time alone may be used to select the appropriate level of service. For coding purposes, total time includes both face-to-face and non-face-to-face time spent by the physician or other billable healthcare professional the day of the encounter.  Total time does not include staff preparation time.  

Physician or other provider professional time includes the following:

  • Preparing to see the patient (review test, past visits)
  • Obtaining or reviewing separately obtained history
  • Performing a medically appropriate exam
  • Counseling and education for the patient/family
  • Ordering medication, tests or procedures
  • Referring and communicating with other providers
  • Documenting clinical information 
  • Independently interpreting results (not separately reported) and communicating results
  • Care coordination

Another option for choosing the level of the new or established E/M in 2021 is medical decision-making.  Medical decision-making has always been an element in the level of each new and established visit but never as a standalone element.  The concept of MDM does not apply to CPT 99211. When using MDM in selecting the level of the visit, the documentation should reflect the number and complexity of diagnosis addressed in the encounter.  The amount and complexity of data reviewed or analyzed is also required. The risk of morbidity should be documented to support the level of medical decision-making.  

These changes will most likely reduce the administrative burden for all specialties, but it is also disruptive.  The implementation of electronic medical records has had a huge impact on workflow at the physician/provider level as well as the staff.  Large and small practices have spent time developing comprehensive templates, triage teams, scribe teams, etc. to reduce the physician burden and feed quality data to the EMR.  Each practice will need to analyze the process in which they prepare a patient and how they decide medical necessity of history obtained. Each provider has a different patient schedule; in the past time spent with the patient was explicit.  In 2021, billing on total time spent could send a message of compliance. If a provider sees 25 patients a day coding a level 4 visit, they would be stating they spent 49-60 minutes per patient or 20 hours on that date of service inpatient care.  I do not anticipate providers seeing a higher volume of patients will bill on total time, it is not a common practice for providers to assess time spent with each patient.  

Most providers will probably code using the medical decision-making component. In the past, providers could reach a level 4 established visit based solely on the history and exam, which is not so in 2021! There will be prolonged service codes available to bill in addition to a new or established visit in cases when extended direct patient time is spent with clinical staff and supervised by the physician. 

Managers will spend 2020 assessing the many facets to consider the 2021 changes.  How will they maintain quality data entry in the EMR without the many clicks feeding the data?  Providers may use voice recognition to transcribe the medical decision-making as they did before the EMR.  In a potentially massive cost rebalance, CMS also finalized the relative value units (RVU) for the group of oft-used E/M services, which will determine 2021 pay rates. The RVU changes, for example, would boost payments for code 99214 – the most-reported E/M code – from $109 to $136 per claim, a 25 percent increase. Rates for 99213 would jump nearly 30 percent.  

Changes could occur before 2021, but it’s not likely we will move totally away from the decisions already made by CMS and the AMA.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

Posted in: Management, Members

Leave a Comment (0) →

Call for Elective Offices

Call for Elective Offices

The following are positions for offices in the Medical Association which will be elected at the 2020 Business Session. Nominations for statewide offices are presented through a Nominating Committee process. District offices (*) are nominated from district caucuses.  Qualified candidates shall have been regular, government or academic employee members of the association for at least three years after completion of their residency or fellowship.




Vice President

Board of Censors (3-year term)

District 1          Charles Max Rogers, MD*                    Eligible for re-election

District 2          Michael T. Flanagan, MD*                   Eligible for re-election

At-Large 1        Mark H. LeQuire, MD                          Eligible for re-election

At-Large 2        Beverly Jordan, MD                             Eligible for re-election

AMA Delegation (2-year term)

Delegate 2        Boyde J. “Jerry” Harrison, MD              Eligible for re-election

Delegate 4        George “Buddy” Smith, Jr., MD            Eligible for re-election

Alt. Delegate 1 John S. Meigs, M.D.                             Eligible for re-election

Alt. Delegate 2 William Schneider, M.D.                      Eligible for re-election

Alt. Delegate 3 Harry Kuberg, M.D.                             Eligible for re-election

Alt. Delegate 4 Raymond Broughton, M.D.                   Eligible for re-election

Council on Medical Education (3-year term)

District 1          Holly G. Pursley, MD*                         Not eligible for re-election

District 6          Tracy Jacobs, MD*                               Eligible for re-election

District 7          Catherine Skinner, MD*                       Eligible for re-election

At-Large 1        Russell Barr, MD                                  Not eligible for re-election

Council on Medical Service (3-year term)

District 3          Arden Aylor, MD*                               Eligible for re-election

District 7          Matthew R. Thom, MD*                       Not eligible for re-election

At-Large 3        Deborah Kolb, MD                               Eligible for re-election


The deadline for submitting nominations to the nominating committee is Thursday, January 9, 2020. Please submit nominations to

Posted in: Leadership, Members

Leave a Comment (0) →
Page 3 of 9 12345...»