Friday, September 25, 2020

Current legal, political issues effect physicians assets

With the election around the corner the country may be in for some significant legal and political changes that can affect physician’s assets.

Estate Planning for Affluent Physicians


We’ve examined various estate planning issues for physicians from many angles including the biggest mistakes physicians make and when you should update your estate plan. If the thought of your own mortality during the COVID19 crisis and the need to protect your heirs with an estate plan hasn’t prompted you to get an up to date estate plan in place already, perhaps this will. There are pending expected changes to the current estate tax exemption limits that will create an estate tax exposure for many physicians, the ‘mass affluent’, and ‘HNW’ categories.

I recently reviewed these issues with estate planner Mike Ferrin, a partner at the law firm of Davis, Miles McGuire Gardner* in Phoenix, AZ, who handles estate planning for HNW doctors and business owners. Mike shared some specific numbers, what the estate planning world thinks is going to happen and his concerns on why this issue should be considered time sensitive.

If your current net worth is at or above $3,500,000, or soon will be, you should seriously explore whether you need to do some additional estate tax planning before the end of the 2020 calendar year. Failure to do so could result in a significant estate tax exposure that would reduce what you leave to your heirs being taxed by as much as .40 cents on every dollar (current rate assumed as carrying forward) over the exemption amount.

The current federal estate tax exemption (a.k.a. “death tax”) for 2020 is $11,580,000 per individual and that doubles to a whopping $23,160,000 that a married couple can pass to anyone they want free of federal estate tax exposure. That’s a big number and frankly, a good problem to have, but that is set to decrease dramatically in 2026, decreasing to $5,000,000. Some current lawmakers and political candidates are calling to lower it even further, to $3,500.000 (estate tax) and $1,000,000 (for gift tax). If there is a new administration in place following the November election, the decrease may be enacted even sooner; legislation passed in 2021 could potentially be made retroactive to January 1st.

In plain English, you currently have a limited opportunity to transfer up to $11,580,000 double for married couple) of assets to one or more trusts that may not be subject to either gift tax while you are alive or estate taxes when you die. If you don’t act, that number could be reduced to as little $1,000,000 (double for married couple). This could result in a savings of over $4,000,000 (double for a married couple) in estate taxes.

Given these numbers, strategic gifting and sales to specialized trusts before the end of 2020 should immediately be considered by higher net worth doctors to take advantage of current high exemption rates, provide asset protection for the assets and to maintain the greatest degree of control and economic benefit possible, potentially including any income those assets currently produce. Planning strategies (fact specific, get expert help) may include the potential sale of gifting of assets to irrevocable trusts established for your spouse or children, including tools like ‘Spousal Lifetime Access Trusts’ (SLATs) or by using ‘Grantor Retained Annuity Trusts’ (GRATs).

These trusts hold assets outside your estate so they are exempt from estate taxes but can still be directed by you and/or your spouse subject to the terms established in the trust. Under current law, you are ‘grandfathered’ in and as long as the funds are formally transferred to a trust of this type before the exclusion amount changes, there should not be estate tax due upon death of the individual.

Those physicians to whom this discussion applies have typically put very significant educational efforts, labor, discipline and risk (and perhaps a little luck) into building their net worth. In many cases physicians say that one significant motivation for doing so is to provide a predictable future for their families, and in some cases that wealth can be multi-generational, invest in your legal planning accordingly. Please strongly consider your current and target financial position and planning needs now, while you can still act. I’m not the only person providing this information and top estate planners I work with across the country are already booked over a month out. Add the election, holidays and COVID related delays…the clock is ticking.

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Thursday, September 24, 2020

Three key considerations for patient-focused telehealth

 Even though virtual healthcare has been possible for over a decade, the technology officially became an integral part of the care process as a direct result of COVID-19. Telemedicine can offer on-demand medical attention to patients anytime and anywhere, but it’s essential for virtual care to be easily accessible to anyone who needs it. True patient-focused telehealth addresses patient learning curves, implementation issues, and insurance limitations, but it also addresses primary care physician burnout and workflow concerns.


In today’s medical climate, telemedicine and Value-Based Care (VBC) go hand-in-hand. VBC models allow primary care providers to decrease hospitalizations and the overall cost of care, but this only works through a high-touch approach. With the logistical issues and physician overscheduling that plagues most primary care practices, patient-first telehealth can offload pressure if approached correctly.


Patient Technological Needs


Virtual technology might come naturally to younger patients, but for seniors or patients with cognitive disabilities, using technology can pose challenges. For these patients, it’s helpful to assign a live assistant who can spend a few minutes addressing the technology component. Assistants can ensure a patient’s video and microphone are working properly, monitor the internet connection, and answer questions related to the appointment. When a member of the medical staff can see the patient’s device beforehand, it leads to a better patient experience.

Another way to address technology challenges is to create a one-pager on the “do’s and don’ts” of telehealth. These sheets detail how to use the technology and help patients understand the purpose of their visit. It’s not uncommon for patients, especially those with multiple doctors, to lose track of which doctor they’re talking to. For this reason, it’s also helpful to have patients draft a list of questions to address with their provider. When patients have questions already mapped out, virtual visits become more seamless.


Implementation and Interoperability


Implementation needs to be as easy as possible for both patients and providers alike, and one of the most efficient ways to achieve this is to eliminate all app downloads. Not all patients have systems that can download apps, so for best results providers should send a web link for a virtual consultation. Patients can simply click the link to access their provider, and clinics can capture the patient data and push it back into their Electronic Medical Record (EMR). This not only solves usability issues, but it also addresses the need for workflow interoperability.

Interoperability has been gaining traction in the medical community over the last several years, but some virtual health solutions have been slow to address it. Several practices that lacked telehealth before COVID-19 enacted regular virtual meeting rooms to quickly address demand, but these tools can’t directly transfer patient data to other clinical systems. When prioritizing a patient-first approach, interoperability becomes paramount. Patients don’t want to repeat the same information to five different staff members just as much as providers don’t want to waste time on data entry.


Accessibility


Accessibility is always a difficult topic when it comes to healthcare, but it’s an essential component of high-quality patient care. Innovation keeps healthcare moving forward, but it’s a futile effort if patients can’t access it—especially during a global pandemic. A Gallup study published in late April showed that nearly 15% of Americans aren’t seeking essential coronavirus care over fear of cost, and healthcare costs have been rising substantially over the last several years.

Fortunately, telemedicine is beginning to offer a low-cost solution for affordable primary care. Workplaces are starting to add virtual care to its benefits package—even for employees who don’t have an insurance plan, and patients can talk to their providers during their off-hours. This prevents patients from neglecting healthcare because they’re unable to take paid time off work.

By providing patients with a user-friendly, efficient, and affordable telehealth experience, physicians can retain their patients, allow them to easy receive care, and reduce costs by limiting unnecessary in-person or emergency room visits. Telemedicine is here to stay, and clinics that perfect the virtual patient experience will experience better patient outcomes.



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Wednesday, September 23, 2020

5 questions to ask about wRVU compensation

Physicians employed by a medical group, hospital or academic institution are commonly compensated using a productivity formula based on work relative value units (wRVUs). Since wRVUs drive your paycheck, it’s to your advantage to ask questions in order to understand how the system works - and specifically how your employer counts wRVUs.



What are wRVUs?


Medicare establishes an RVU for each CPT code to determine reimbursement. The RVU has three components: physician work, practice expense and malpractice. The physician work RVU, or wRVU, is a "neutralized" way to quantify and compare the productivity of physicians because it eliminates variables such as fee schedules or geographical costs.

Most groups multiply the wRVUs for services provided by a conversion factor to determine all or part of a physician’s compensation. For example, a surgeon who is paid at $60.00 per wRVU and produces 6,000 wRVUs would be compensated $360,000.



What’s there to understand?


It seems pretty simple, but as the saying goes, the devil is in the details. Counting wRVUs is not entirely straightforward, and too often a lack of transparency between administrators and physicians, whether intentional or not, sows seeds of doubt that can grow into a tree of distrust and hostility.


5 questions to ask your administrator


To avoid this dismal destiny, ask your administrator these five questions to start the conversation of understanding how the system works. (Administrators, be sure you can answer the questions. Better yet, consider proactively discussing your institution’s wRVU methodology with employed physicians to keep communication lines open and clear.)


1. Are wRVUs credited on codes submitted or codes paid?


In most cases, you will be credited for the CPT codes submitted, regardless of the reimbursement received. But get clarification about that, anyway. Furthermore, understand if reports are generated using date of service or the date the charge was billed out. This will make a difference for those services performed in one month that are billed out the following month. Remember: Delays in billing, whether by you or by the billing team, can delay wRVU credit for your compensation.


2. Do modifiers impact the wRVU credit? If so, how?


Modifier impacts to wRVUs commonly cause physicians to believe they’ve been “cheated” out of compensation earned.

Some groups discount the wRVU for the second side of bilateral procedures, consistent with the reimbursement methodology used by most payers. For example, the CPT code 19318 for a breast reduction surgery has 16.03 wRVUs. When billed as a bilateral procedure (by attaching modifier 50), many payers will reimburse for 150 percent of the fee schedule, not 200 percent. Likewise, the hospital will credit the surgeon with 24.0 wRVUs, not 32.06. Physicians who discover this type of wRVU adjustment months or years into their employment are typically shocked at the perceived deception.

Other modifiers that may decrease wRVUs are:



modifier 51 - multiple procedure


modifier 59 - distinct procedural service


modifier 62 - two surgeons/co-surgeons


modifier 76 - repeat procedure


modifiers 80 - assistant surgeon


modifier 82 - assistant surgeon when a qualified resident surgeon is not available


3. What credit do I receive if I bill a code for an unlisted procedure?


CPT codes for unlisted procedures, such as 64999 (unlisted procedure, nervous system), are not assigned a wRVU by CMS. If you use any of the unlisted codes, have a discussion with your administrator about a suitable value for the service. Suggest a similar procedure to use as reference and discuss an appropriate adjustment to the wRVU to reflect the work required for the unlisted procedure.



4. Who is authorized to change the codes/modifiers I submitted?


Best practice is for physicians to assign the CPT codes for services performed. In most cases, after you submit your codes, a coder or biller reviews the charges and potentially changes the code(s) or modifier(s) based on documentation and payer rules. This directly impacts physician compensation, so you should take interest in who is handling your claims.

Understand the protocol for making changes and insist on a system for being notified. And, ensure that you, as well as the coders and billers, stay current on coding education.


5. Can I see a detailed transaction report each month of the codes submitted and wRVUs credited?


Shrewd physicians insist on reviewing the transaction report each month to ensure all services were billed and to confirm the correct wRVUs were credited for each code. Consider keeping your own log of codes submitted and reconciling it with the monthly report to confirm all services were captured. Doing this monthly is a good habit, allowing you to catch discrepancies early so they can be quickly addressed.

To ensure you are paid for the work you do, it’s essential for physicians to be actively involved with reviewing wRVU calculations. Likewise, it’s important to have open and ongoing communication between physicians and administrators to maintain an accurate compensation plan as well as high physician engagement.

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