Under investigation. The government will continue to focus on fraudulent billing in nursing homes this year, but now individual physicians are coming under suspicion.
HHS' inspector general's office, which investigates Medicare and Medicaid fraud and abuse, late last year issued a 54-page work plan outlining its 1998 initiatives. Included is a proposal to audit physicians with "excessive visits" to Medicare patients in nursing homes. According to the work plan, the investigations will target physicians who bill for excessive visits in a single day or to the same beneficiaries. A spokesman for the inspector general would not define "excessive" and was not sure when the audits would begin.
The inspector general's office also plans to continue its investigation into the Medicare billing practices of physicians at teaching hospitals and will begin a probe into the improper billing for services rendered by physician assistants.
NYLCare doctors image. NYLCare Health Plans of the Mid-Atlantic, a Greenbelt, Md.-based managed-care company, this month will implement a new bonus plan for participating primary-care physicians. Bonuses will now be distributed monthly and will be based on a number of quality measures, not utilization review, says spokeswoman Kathleen Milanich.
NYLCare covers more than 600,000 people between Baltimore and North Carolina and more than 3,500 primary-care physicians contract with NYLCare.
The new compensation program will consist of a monthly capitation payment plus a quality bonus based on these 10 measures: panel size, panel status, extended office hours, administrative compliance, board certification, patient panel turnover, enrollee comments, preventive health measures, chart audits and enrollee satisfaction.
Milanich says the bonuses will improve provider relations and improve the company's public image. NYLCare physicians, however, are more skeptical of the new bonus plan. "It still sounds like micromanagement; they just put a different name on it," says Joseph Zebley, M.D., a Baltimore family practitioner.
Zebley, who refers to the company as "denial care," worries that the new quality criteria will lead some physicians to become "consumerists and market-driven, as opposed to being a physician," he says. "It makes me nervous when these kinds of things are published and they say this is what we will be looking for, because some doctors will lose sight of their mission to take care of patients and start taking care of the chart."
GE deal a boost for Inphact. Inphact's virtual radiology program got a boost from GE Medical Systems, which recently signed a five-year joint marketing agreement with the Nashville-based company.
Inphact, founded in 1996, provides on-line radiology services to rural hospitals and health centers in towns such as Pahrump, Nev., Thomasville, Ga., and Eflin, Ala. Inphact installs digital radiology equipment purchased by its partner practices and provides 24-hour access to its employed radiologists in Nashville.
The company charges about $100,000 to $150,000 per month per hospital or practice, says Jeffrey Landman, its founder and chief executive officer.
The GE deal gives Inphact preferred pricing on teleradiology equipment. In an unrelated move, another GE subsidiary, GE Capital, has set up a $20 million equipment financing loan for Inphact.
Landman says he hopes the GE deal will expand his business beyond its current nine facilities in four states. The facilities are owned by Arcon Healthcare, which is run by former Healthtrust Chief Operating Officer Hudson Connery Jr. Inphact provides the radiology services.
Embrace the inevitable. More than 80% of all physician organizations will be receiving capitated payments by the year 2000, according to a new survey by Evergreen Re, a Coral Gables, Fla.-based managed-care stop-loss and reinsurance consulting and brokerage firm. The study concentrated on physician groups in metropolitan markets with greater than 10% HMO penetration.
Under capitation, physicians agree to provide all the care needed for a group of patients in exchange for a fixed per-enrollee, per-enrollee payment.
According to the survey, 56% of physician organizations accept patients through capitation, and capitated contracts generate 31% of their total revenues. Of the respondents not participating in capitation, 44% saw the acceptance of capitated enrollees as imminent in the next few years. The groups already in capitation said on average they expect to sign four new contracts.
IPAs for dummies. The National Independent Practice Association Coalition is putting out the NIPAC Financial Operations Manual to help guide IPA boards and executives in running their business.
The 200-page book, written with the assistant of St. Louis-based healthcare consultant Beth Freeman, includes chapters on how a physician board should operate, how to use capitation payments to establish future revenue projections, and how to account for IBNR (incurred but not reported) revenues, the bugaboo of many practices, Freeman says.
"This is not for physicians to become MBAs," says NIPAC President Nancy Oswald. "It's there for physicians to have the appropriate information to direct their business."
The book will premiere at NIPAC's physician organization finance conference, scheduled to begin Jan. 23 in San Antonio.