Managing Your Practice

After numerous assurances that there would be absolutely no extensions, the Centers for Medicare and Medicaid Services has extended the May 23 deadline and is now giving physicians and other entities an extra year to obtain a National Provider Identifier number. My advice, however, is that you get yours as soon as possible to avoid any last-minute disruptions to your practice.

Medicare has been accepting the National Provider Identifier (NPI) since October, but as of next year, that is all they will accept; your so-called Medicare legacy identifier will be history.

The NPI came into being as part of the 1996 Health Insurance Portability and Accountability Act (HIPAA).

The idea was to provide a single, unique health identifier for each physician, health plan, and employer, eliminating all the various PINs, UPINs, and other unique and incompatible identifier numbers used by various plans (SKIN & ALLERGY NEWS, March 2007, p. 10). The ultimate goal is to more efficiently coordinate claims filing and payment, a welcome improvement for us all, should it work.

A popular rumor—that only physicians who participate in Medicare would need an NPI—is not true. All physicians will have to have the number, because the NPI will replace all other identification numbers issued by all third-party payers that fall under HIPAA's jurisdiction.

Some plans, classified as “small” (under 1 million subscribers) by HIPAA, already had an extra year to become NPI compliant, and that is sure to create some confusion. I suggest you communicate individually with each of your payers, regardless of size, to ensure you will have no problems.

One poorly understood aspect of the NPI transition is the “taxonomies,” or “specialty types,” which are associated with the NPI application process. (Most of the questions I'm receiving concern these.) Taxonomies are supplemental codes that categorize the scope of your office's clinical services.

Most dermatology offices will select the taxonomy code for general dermatology—207N00000X—but if your office provides specialized services, there are additional codes that may be required. These include:

▸ Dermatologic Surgery (207NS0135X)

▸ Dermatopathology (207ND0900X)

▸ Mohs Surgery (207ND0101X)

▸ Pediatric Dermatology (207NP0225X)

▸ Dermatologic Immunology (207NI0002X)

Select all of the additional codes that apply to your particular practice situation. Be aware that others may apply as well. There is a Web site devoted to outlining and explaining the taxonomy codes: http://codelists.wpc-edi.com/mambo_taxonomy_2.asp

When applying, be sure to include in your application as many of the numbers to be replaced as possible, such as your Medicare and Medicaid numbers and all identifiers used by various plans to which you belong.

Until the deadline, you are supposed to use both numbers—your NPI and the identifier you are using now—on all claims, so that there will be as little confusion as possible when the deadline passes.

Even if you already have your NPI, you must make sure you have made all the necessary changes to your practice to ensure a smooth transition. CMS lists seven steps:

1. Apply for an NPI at https://nppes.cms.hhs.gov/

2. Update your practice software, including billing applications, to incorporate your NPI.

3. Share your NPI with other providers, health plans, clearinghouses, and any other entity that may need it for billing purposes.

4. Communicate with all of your health plans and clearinghouses; make sure they are all as prepared for the NPI transition as you are.

5. Test your systems to make sure they can process claims and any other HIPAA-related transactions with the NPI.

6. Educate your staff thoroughly on the NPI transition.

7. Implement use of your NPI in all your business practices.

Most importantly, if you have electronic medical records and/or billing software, contact your software vendors as soon as possible to ensure that upgrades incorporating your NPI into all electronic transactions are available and will be installed prior to next year's deadline.

Alert vendors will have already provided these updates automatically, but don't count on that: Some vendors, especially those with relatively few medical clients, may be unprepared for, or even unaware of, the necessary changes. Or if your guarantee or software support contract has expired, you may have to remind the vendor to install the upgrades—and pay for them.

If your vendor is no longer in business, you will have to find an independent consultant to make the changes.

After numerous assurances that there would be absolutely no extensions, the Centers for Medicare and Medicaid Services has extended the May 23 deadline and is now giving physicians and other entities an extra year to obtain a National Provider Identifier number. My advice, however, is that you get yours as soon as possible to avoid any last-minute disruptions to your practice.

Medicare has been accepting the National Provider Identifier (NPI) since October, but as of next year, that is all they will accept; your so-called Medicare legacy identifier will be history.

The NPI came into being as part of the 1996 Health Insurance Portability and Accountability Act (HIPAA).

The idea was to provide a single, unique health identifier for each physician, health plan, and employer, eliminating all the various PINs, UPINs, and other unique and incompatible identifier numbers used by various plans (SKIN & ALLERGY NEWS, March 2007, p. 10). The ultimate goal is to more efficiently coordinate claims filing and payment, a welcome improvement for us all, should it work.

A popular rumor—that only physicians who participate in Medicare would need an NPI—is not true. All physicians will have to have the number, because the NPI will replace all other identification numbers issued by all third-party payers that fall under HIPAA's jurisdiction.

Some plans, classified as “small” (under 1 million subscribers) by HIPAA, already had an extra year to become NPI compliant, and that is sure to create some confusion. I suggest you communicate individually with each of your payers, regardless of size, to ensure you will have no problems.

One poorly understood aspect of the NPI transition is the “taxonomies,” or “specialty types,” which are associated with the NPI application process. (Most of the questions I'm receiving concern these.) Taxonomies are supplemental codes that categorize the scope of your office's clinical services.

Most dermatology offices will select the taxonomy code for general dermatology—207N00000X—but if your office provides specialized services, there are additional codes that may be required. These include:

▸ Dermatologic Surgery (207NS0135X)

▸ Dermatopathology (207ND0900X)

▸ Mohs Surgery (207ND0101X)

▸ Pediatric Dermatology (207NP0225X)

▸ Dermatologic Immunology (207NI0002X)

Select all of the additional codes that apply to your particular practice situation. Be aware that others may apply as well. There is a Web site devoted to outlining and explaining the taxonomy codes: http://codelists.wpc-edi.com/mambo_taxonomy_2.asp

When applying, be sure to include in your application as many of the numbers to be replaced as possible, such as your Medicare and Medicaid numbers and all identifiers used by various plans to which you belong.

Until the deadline, you are supposed to use both numbers—your NPI and the identifier you are using now—on all claims, so that there will be as little confusion as possible when the deadline passes.

Even if you already have your NPI, you must make sure you have made all the necessary changes to your practice to ensure a smooth transition. CMS lists seven steps:

1. Apply for an NPI at https://nppes.cms.hhs.gov/

2. Update your practice software, including billing applications, to incorporate your NPI.

3. Share your NPI with other providers, health plans, clearinghouses, and any other entity that may need it for billing purposes.

4. Communicate with all of your health plans and clearinghouses; make sure they are all as prepared for the NPI transition as you are.

5. Test your systems to make sure they can process claims and any other HIPAA-related transactions with the NPI.

6. Educate your staff thoroughly on the NPI transition.

7. Implement use of your NPI in all your business practices.

Most importantly, if you have electronic medical records and/or billing software, contact your software vendors as soon as possible to ensure that upgrades incorporating your NPI into all electronic transactions are available and will be installed prior to next year's deadline.

Alert vendors will have already provided these updates automatically, but don't count on that: Some vendors, especially those with relatively few medical clients, may be unprepared for, or even unaware of, the necessary changes. Or if your guarantee or software support contract has expired, you may have to remind the vendor to install the upgrades—and pay for them.

If your vendor is no longer in business, you will have to find an independent consultant to make the changes.

After numerous assurances that there would be absolutely no extensions, the Centers for Medicare and Medicaid Services has extended the May 23 deadline and is now giving physicians and other entities an extra year to obtain a National Provider Identifier number. My advice, however, is that you get yours as soon as possible to avoid any last-minute disruptions to your practice.

Medicare has been accepting the National Provider Identifier (NPI) since October, but as of next year, that is all they will accept; your so-called Medicare legacy identifier will be history.

The NPI came into being as part of the 1996 Health Insurance Portability and Accountability Act (HIPAA).

The idea was to provide a single, unique health identifier for each physician, health plan, and employer, eliminating all the various PINs, UPINs, and other unique and incompatible identifier numbers used by various plans (SKIN & ALLERGY NEWS, March 2007, p. 10). The ultimate goal is to more efficiently coordinate claims filing and payment, a welcome improvement for us all, should it work.

A popular rumor—that only physicians who participate in Medicare would need an NPI—is not true. All physicians will have to have the number, because the NPI will replace all other identification numbers issued by all third-party payers that fall under HIPAA's jurisdiction.

Some plans, classified as “small” (under 1 million subscribers) by HIPAA, already had an extra year to become NPI compliant, and that is sure to create some confusion. I suggest you communicate individually with each of your payers, regardless of size, to ensure you will have no problems.

One poorly understood aspect of the NPI transition is the “taxonomies,” or “specialty types,” which are associated with the NPI application process. (Most of the questions I'm receiving concern these.) Taxonomies are supplemental codes that categorize the scope of your office's clinical services.

Most dermatology offices will select the taxonomy code for general dermatology—207N00000X—but if your office provides specialized services, there are additional codes that may be required. These include:

▸ Dermatologic Surgery (207NS0135X)

▸ Dermatopathology (207ND0900X)

▸ Mohs Surgery (207ND0101X)

▸ Pediatric Dermatology (207NP0225X)

▸ Dermatologic Immunology (207NI0002X)

Select all of the additional codes that apply to your particular practice situation. Be aware that others may apply as well. There is a Web site devoted to outlining and explaining the taxonomy codes: http://codelists.wpc-edi.com/mambo_taxonomy_2.asp

When applying, be sure to include in your application as many of the numbers to be replaced as possible, such as your Medicare and Medicaid numbers and all identifiers used by various plans to which you belong.

Until the deadline, you are supposed to use both numbers—your NPI and the identifier you are using now—on all claims, so that there will be as little confusion as possible when the deadline passes.

Even if you already have your NPI, you must make sure you have made all the necessary changes to your practice to ensure a smooth transition. CMS lists seven steps:

1. Apply for an NPI at https://nppes.cms.hhs.gov/

2. Update your practice software, including billing applications, to incorporate your NPI.

3. Share your NPI with other providers, health plans, clearinghouses, and any other entity that may need it for billing purposes.

4. Communicate with all of your health plans and clearinghouses; make sure they are all as prepared for the NPI transition as you are.

5. Test your systems to make sure they can process claims and any other HIPAA-related transactions with the NPI.

6. Educate your staff thoroughly on the NPI transition.

7. Implement use of your NPI in all your business practices.

Most importantly, if you have electronic medical records and/or billing software, contact your software vendors as soon as possible to ensure that upgrades incorporating your NPI into all electronic transactions are available and will be installed prior to next year's deadline.

Alert vendors will have already provided these updates automatically, but don't count on that: Some vendors, especially those with relatively few medical clients, may be unprepared for, or even unaware of, the necessary changes. Or if your guarantee or software support contract has expired, you may have to remind the vendor to install the upgrades—and pay for them.

If your vendor is no longer in business, you will have to find an independent consultant to make the changes.

When Dr. Maggie Blackburn decided to move in 2000 from a hospital clinic to a new solo practice in Stanford, a rural upstate New York town, she had a strong adversity to lining the walls of her already cramped office with paper charts. After test-driving several systems, she spent an estimated $23,000 on software and hardware, and her practice was up and running with a staff of two (a nurse and a front desk assistant). Although the options in electronic medical record systems are a lot different today than they were 7 years ago, Dr. Blackburn's advice still is sage straight talk from a family physician who didn't know what a network server was when she started. In this month's column, she shares her insights about the choices and compromises she made in making an EHR system work for her.

If you're in a small or solo practice and you're looking for an electronic health record system, congratulations. Although you may not have much capital, there are fewer people to please, which makes defining your priorities a lot easier. That said, anyone looking to invest in an EHR system should know two things: First, don't expect the system to run smoothly all the time—it will break down and there will be glitches. And second, it won't pay for itself.

Like buying a house, the financial outlay is ongoing (service contracts for tech support cost me $4,000-$5,000 annually and then there are hardware upgrades). But the investment will pay for itself in terms of enhancing your quality of life. The time you save by not having to do repetitive tasks and the workflow enhancements are priceless, especially to someone who would rather head home at the end of the day than be chained to an office desk finishing chart notes.

There are conveniences that feel like windfalls: When Vioxx was taken off the market in 2004, we had a letter written and addressed to all of our patients who were taking the cyclooxygenase-2 within 15 minutes to advise them about the matter.

And then there is the undeniable ease with which one can participate in clinical trials. Identifying all diabetes patients and tracking HbA_1c levels, or any other quality measure, is almost effortless.

However, selecting the most appropriate system for your practice takes thoughtful research. Prioritize your wish list and then realize that it's likely to change. When I set out to purchase a system, options such as messaging and customizable fields didn't seem very important, but in retrospect, they have made a huge difference. The messaging component has enhanced interoffice communication in unanticipated ways, and having customizable fields has helped make the system interface feel comfortable.

Most physicians want their system to work smoothly right out of the box. But that's not realistic. A common complaint among physicians with new systems is that entering patient information takes more time with EHR than it does with a paper chart. Being able to customize templates myself—and change data entry options as I used the system—has made it much easier to iron out kinks.

The system I ended up with allowed me to finish my chart notes by the time the patient left the exam room and to have a script on the front desk awaiting my signature. My goal was to not have patient charts to catch up on at the end of the day, and having a system I could easily customize myself made that goal attainable.

Another component, having lab interface, has been a tremendous bonus. It eliminates the errors that occur when lab results need to be transcribed by hand. All lab results are downloaded from the lab directly into patient charts, and abnormal values are flagged for my review. A lab requisition component, which I added later, makes it infinitely easier to track what has been ordered and whether results are back.

When I started, I wanted the princess tech support plan, the one that allows the person who knows virtually nothing about computers to call and whine. It costs significantly more, but it's been well worth it. Tech support is an area you definitely do not want to skimp on, and good plans will require a hefty annual fee. Just make sure you check out the company claims regarding tech support by speaking with current users of the system.

Before you buy anything, shop around. Test products yourself. Sales representatives will be able to move around the system a lot faster than you can. Be explicit about needing to be able to use the system yourself. Review the templates; ask yourself if you can live with them as they are and whether the interface meets your needs. How easily can you add components later? Consider visiting a comparable medical office site that uses the software you are planning to buy.

And know the vendors. What is their track record? Many physicians have been burned selecting an EHR because they invested in systems that were sold to them by vendors who are no longer in business, and they end up with no tech support.

The system I bought cost more than I initially wanted to spend. I wanted to do it for pennies, but I finally realized that if was going to do this, it was worth it to spend more money and get more of the things that I wanted. Dollars can be shaved off software licencing and tech support fees by being realistic about the number of workstations you need at any one time for scheduling access vs patient chart access.

After you have a system in place, have a backup plan for when the system breaks down. My system never went down for more than a few hours. I never lost data, but I have heard horror stories from colleagues that did. So good luck. This leap of faith will pay off in unexpected ways. Just be sure to back up your data religiously.

When Dr. Maggie Blackburn decided to move in 2000 from a hospital clinic to a new solo practice in Stanford, a rural upstate New York town, she had a strong adversity to lining the walls of her already cramped office with paper charts. After test-driving several systems, she spent an estimated $23,000 on software and hardware, and her practice was up and running with a staff of two (a nurse and a front desk assistant). Although the options in electronic medical record systems are a lot different today than they were 7 years ago, Dr. Blackburn's advice still is sage straight talk from a family physician who didn't know what a network server was when she started. In this month's column, she shares her insights about the choices and compromises she made in making an EHR system work for her.

If you're in a small or solo practice and you're looking for an electronic health record system, congratulations. Although you may not have much capital, there are fewer people to please, which makes defining your priorities a lot easier. That said, anyone looking to invest in an EHR system should know two things: First, don't expect the system to run smoothly all the time—it will break down and there will be glitches. And second, it won't pay for itself.

Like buying a house, the financial outlay is ongoing (service contracts for tech support cost me $4,000-$5,000 annually and then there are hardware upgrades). But the investment will pay for itself in terms of enhancing your quality of life. The time you save by not having to do repetitive tasks and the workflow enhancements are priceless, especially to someone who would rather head home at the end of the day than be chained to an office desk finishing chart notes.

There are conveniences that feel like windfalls: When Vioxx was taken off the market in 2004, we had a letter written and addressed to all of our patients who were taking the cyclooxygenase-2 within 15 minutes to advise them about the matter.

And then there is the undeniable ease with which one can participate in clinical trials. Identifying all diabetes patients and tracking HbA_1c levels, or any other quality measure, is almost effortless.

However, selecting the most appropriate system for your practice takes thoughtful research. Prioritize your wish list and then realize that it's likely to change. When I set out to purchase a system, options such as messaging and customizable fields didn't seem very important, but in retrospect, they have made a huge difference. The messaging component has enhanced interoffice communication in unanticipated ways, and having customizable fields has helped make the system interface feel comfortable.

Most physicians want their system to work smoothly right out of the box. But that's not realistic. A common complaint among physicians with new systems is that entering patient information takes more time with EHR than it does with a paper chart. Being able to customize templates myself—and change data entry options as I used the system—has made it much easier to iron out kinks.

The system I ended up with allowed me to finish my chart notes by the time the patient left the exam room and to have a script on the front desk awaiting my signature. My goal was to not have patient charts to catch up on at the end of the day, and having a system I could easily customize myself made that goal attainable.

Another component, having lab interface, has been a tremendous bonus. It eliminates the errors that occur when lab results need to be transcribed by hand. All lab results are downloaded from the lab directly into patient charts, and abnormal values are flagged for my review. A lab requisition component, which I added later, makes it infinitely easier to track what has been ordered and whether results are back.

When I started, I wanted the princess tech support plan, the one that allows the person who knows virtually nothing about computers to call and whine. It costs significantly more, but it's been well worth it. Tech support is an area you definitely do not want to skimp on, and good plans will require a hefty annual fee. Just make sure you check out the company claims regarding tech support by speaking with current users of the system.

Before you buy anything, shop around. Test products yourself. Sales representatives will be able to move around the system a lot faster than you can. Be explicit about needing to be able to use the system yourself. Review the templates; ask yourself if you can live with them as they are and whether the interface meets your needs. How easily can you add components later? Consider visiting a comparable medical office site that uses the software you are planning to buy.

And know the vendors. What is their track record? Many physicians have been burned selecting an EHR because they invested in systems that were sold to them by vendors who are no longer in business, and they end up with no tech support.

The system I bought cost more than I initially wanted to spend. I wanted to do it for pennies, but I finally realized that if was going to do this, it was worth it to spend more money and get more of the things that I wanted. Dollars can be shaved off software licencing and tech support fees by being realistic about the number of workstations you need at any one time for scheduling access vs patient chart access.

After you have a system in place, have a backup plan for when the system breaks down. My system never went down for more than a few hours. I never lost data, but I have heard horror stories from colleagues that did. So good luck. This leap of faith will pay off in unexpected ways. Just be sure to back up your data religiously.

When Dr. Maggie Blackburn decided to move in 2000 from a hospital clinic to a new solo practice in Stanford, a rural upstate New York town, she had a strong adversity to lining the walls of her already cramped office with paper charts. After test-driving several systems, she spent an estimated $23,000 on software and hardware, and her practice was up and running with a staff of two (a nurse and a front desk assistant). Although the options in electronic medical record systems are a lot different today than they were 7 years ago, Dr. Blackburn's advice still is sage straight talk from a family physician who didn't know what a network server was when she started. In this month's column, she shares her insights about the choices and compromises she made in making an EHR system work for her.

If you're in a small or solo practice and you're looking for an electronic health record system, congratulations. Although you may not have much capital, there are fewer people to please, which makes defining your priorities a lot easier. That said, anyone looking to invest in an EHR system should know two things: First, don't expect the system to run smoothly all the time—it will break down and there will be glitches. And second, it won't pay for itself.

Like buying a house, the financial outlay is ongoing (service contracts for tech support cost me $4,000-$5,000 annually and then there are hardware upgrades). But the investment will pay for itself in terms of enhancing your quality of life. The time you save by not having to do repetitive tasks and the workflow enhancements are priceless, especially to someone who would rather head home at the end of the day than be chained to an office desk finishing chart notes.

There are conveniences that feel like windfalls: When Vioxx was taken off the market in 2004, we had a letter written and addressed to all of our patients who were taking the cyclooxygenase-2 within 15 minutes to advise them about the matter.

And then there is the undeniable ease with which one can participate in clinical trials. Identifying all diabetes patients and tracking HbA_1c levels, or any other quality measure, is almost effortless.

However, selecting the most appropriate system for your practice takes thoughtful research. Prioritize your wish list and then realize that it's likely to change. When I set out to purchase a system, options such as messaging and customizable fields didn't seem very important, but in retrospect, they have made a huge difference. The messaging component has enhanced interoffice communication in unanticipated ways, and having customizable fields has helped make the system interface feel comfortable.

Most physicians want their system to work smoothly right out of the box. But that's not realistic. A common complaint among physicians with new systems is that entering patient information takes more time with EHR than it does with a paper chart. Being able to customize templates myself—and change data entry options as I used the system—has made it much easier to iron out kinks.

The system I ended up with allowed me to finish my chart notes by the time the patient left the exam room and to have a script on the front desk awaiting my signature. My goal was to not have patient charts to catch up on at the end of the day, and having a system I could easily customize myself made that goal attainable.

Another component, having lab interface, has been a tremendous bonus. It eliminates the errors that occur when lab results need to be transcribed by hand. All lab results are downloaded from the lab directly into patient charts, and abnormal values are flagged for my review. A lab requisition component, which I added later, makes it infinitely easier to track what has been ordered and whether results are back.

When I started, I wanted the princess tech support plan, the one that allows the person who knows virtually nothing about computers to call and whine. It costs significantly more, but it's been well worth it. Tech support is an area you definitely do not want to skimp on, and good plans will require a hefty annual fee. Just make sure you check out the company claims regarding tech support by speaking with current users of the system.

Before you buy anything, shop around. Test products yourself. Sales representatives will be able to move around the system a lot faster than you can. Be explicit about needing to be able to use the system yourself. Review the templates; ask yourself if you can live with them as they are and whether the interface meets your needs. How easily can you add components later? Consider visiting a comparable medical office site that uses the software you are planning to buy.

And know the vendors. What is their track record? Many physicians have been burned selecting an EHR because they invested in systems that were sold to them by vendors who are no longer in business, and they end up with no tech support.

The system I bought cost more than I initially wanted to spend. I wanted to do it for pennies, but I finally realized that if was going to do this, it was worth it to spend more money and get more of the things that I wanted. Dollars can be shaved off software licencing and tech support fees by being realistic about the number of workstations you need at any one time for scheduling access vs patient chart access.

After you have a system in place, have a backup plan for when the system breaks down. My system never went down for more than a few hours. I never lost data, but I have heard horror stories from colleagues that did. So good luck. This leap of faith will pay off in unexpected ways. Just be sure to back up your data religiously.

Pain, oophorectomy, then bowel perforation

Following an abdominal hysterectomy and bladder suspension, a 42-year-old woman began to have pain in the right suprapubic area. During laparoscopy to determine the cause of the pain, an ObGyn removed the patient’s ovaries. The patient began to experience severe abdominal pain and was found to have a perforated bowel. A colostomy was performed—and then reversed 2 months later.

Patient’s claim The laparoscopy, during which the bowel perforation occurred, should have been converted to an open laparotomy because of adhesions and the ovaries adhering with scar tissue to the bowel.

Doctor’s defense Bowel perforations are a known risk of laparoscopy, and the bowel perforation occurred after the surgery.

Verdict Defense verdict.

8 repair surgeries harm career

A 35-year-old country music entertainer who had complained of persistent abdominal pain underwent a hysterectomy and oophorectomy. During the procedure, the ureter and colon were transected, although this was not diagnosed until 5 days later. Nearly 4 L of urine was found when repair surgery was begun, and the patient’s chance of survival was uncertain. She had a total of 8 repair surgeries, which left residual scarring.

Patient’s claim As a result of the injuries, she could no longer perform on tours.

Doctor’s defense The problems were a known complication of the surgery.

Verdict A $500,000 verdict was returned. A post-trial motion by the defendant was pending.

Pain, oophorectomy, then bowel perforation

Following an abdominal hysterectomy and bladder suspension, a 42-year-old woman began to have pain in the right suprapubic area. During laparoscopy to determine the cause of the pain, an ObGyn removed the patient’s ovaries. The patient began to experience severe abdominal pain and was found to have a perforated bowel. A colostomy was performed—and then reversed 2 months later.

Patient’s claim The laparoscopy, during which the bowel perforation occurred, should have been converted to an open laparotomy because of adhesions and the ovaries adhering with scar tissue to the bowel.

Doctor’s defense Bowel perforations are a known risk of laparoscopy, and the bowel perforation occurred after the surgery.

Verdict Defense verdict.

8 repair surgeries harm career

A 35-year-old country music entertainer who had complained of persistent abdominal pain underwent a hysterectomy and oophorectomy. During the procedure, the ureter and colon were transected, although this was not diagnosed until 5 days later. Nearly 4 L of urine was found when repair surgery was begun, and the patient’s chance of survival was uncertain. She had a total of 8 repair surgeries, which left residual scarring.

Patient’s claim As a result of the injuries, she could no longer perform on tours.

Doctor’s defense The problems were a known complication of the surgery.

Verdict A $500,000 verdict was returned. A post-trial motion by the defendant was pending.

Pain, oophorectomy, then bowel perforation

Following an abdominal hysterectomy and bladder suspension, a 42-year-old woman began to have pain in the right suprapubic area. During laparoscopy to determine the cause of the pain, an ObGyn removed the patient’s ovaries. The patient began to experience severe abdominal pain and was found to have a perforated bowel. A colostomy was performed—and then reversed 2 months later.

Patient’s claim The laparoscopy, during which the bowel perforation occurred, should have been converted to an open laparotomy because of adhesions and the ovaries adhering with scar tissue to the bowel.

Doctor’s defense Bowel perforations are a known risk of laparoscopy, and the bowel perforation occurred after the surgery.

Verdict Defense verdict.

8 repair surgeries harm career

A 35-year-old country music entertainer who had complained of persistent abdominal pain underwent a hysterectomy and oophorectomy. During the procedure, the ureter and colon were transected, although this was not diagnosed until 5 days later. Nearly 4 L of urine was found when repair surgery was begun, and the patient’s chance of survival was uncertain. She had a total of 8 repair surgeries, which left residual scarring.

Patient’s claim As a result of the injuries, she could no longer perform on tours.

Doctor’s defense The problems were a known complication of the surgery.

Verdict A $500,000 verdict was returned. A post-trial motion by the defendant was pending.

Too-early birth of twins follows mother’s UTI

A woman in the 26th week of pregnancy with twins (the plaintiffs in the case) called her OB, Dr. A, to report she had a 102° fever. He advised her to take Tylenol, drink fluids, and call back in 2 hours. In the early morning of the next day, the woman presented at the hospital with a temperature of 101°, where Dr. B, another OB, saw her. She underwent testing, and the following day amniocentesis was performed. That afternoon the twins were delivered by emergency cesarean section. Each weighed less than 2 lb. The boy, born with multiple defects, has undergone numerous surgeries on his eyes and legs, but will always be wheelchair-bound. The girl can see after 2 surgeries, but suffers from physical and mental delays.

Patient’s claim The mother had a urinary tract infection, which was not properly diagnosed when she called Dr. A. Also, the amniocentesis should have been performed earlier.

Doctor’s defense They denied receiving further calls from the mother. Also, there was no indication of significant problems.

Verdict A $13.2 million verdict was returned against Dr. B only. Post-trial motions were pending.

MD removes ovaries, cyst—and part of ureter

A physician-employee of the defendant group performed surgery on a 44-year-old woman to remove her ovaries, fallopian tubes, and a cyst the size of an orange on the left ovary. The pathology report confirmed that the physician had removed part of the patient’s left ureter during the surgery. She required emergency reconstructive surgery and remained in the hospital for 2 weeks. A stent was put in place for 4 to 6 weeks. The repair surgery required an iliopsoas hitch. The patient continues to have left flank pain.

Patient’s claim Injury to the ureter was negligent. As the same physician had delivered her third child as well as performed her hysterectomy, he should have been aware of her condition.

Doctor’s defense The patient had complicated anatomy and adhesions because of the hysterectomy done the previous year.

Verdict A $400,000 verdict was returned.

Audible pop at delivery signals diastasis

A 36-year-old woman pregnant with her first child was admitted to the hospital in labor. The next morning she was completely dilated and effaced. She started pushing and, after 2 hours, forceps were used. An audible popping sound occurred at delivery and was noted in the records as a possible fracture of the coccyx. The patient, in great pain after the delivery, had suffered a 3-cm pubic symphysis diastasis (PSD) as shown on a pelvic CT scan. She was discharged after 6 days, and home treatment was arranged. The PSD healed before the trial.

Patient’s claim Inadequate fetal descent during the second stage of labor should have prompted a cesarean section. Cephalopelvic disproportion was present, and excessive force was used during the forceps delivery.

Doctor’s defense There was no cephalopelvic disproportion, and excessive force was not used. Also, PSD is a known risk factor of pregnancy.

Verdict Defense verdict.

Hysterectomy for postpartum hemorrhage

Following a cesarean section, a 39-year-old woman suffered postpartum internal bleeding and then developed disseminated intravascular coagulopathy. To stop the bleeding, a hysterectomy was performed.

Patient’s claim If the medical staff had reacted properly to her drop in blood pressure, which occurred shortly after she arrived in the recovery room following the cesarean section, the bleeding problem could have been prevented.

Doctor’s defense The bleeding problem was not a result of negligence. Also, a doctor was not required to go to the patient when her blood pressure dropped.

Verdict Defense verdict.

Misplaced sutures, then multiple surgeries

A 45-year-old woman underwent a hysterectomy, during which the ObGyn placed several sutures in her bladder. During a subsequent cystoscopy, a urologist identified and removed 2 of the sutures. A third procedure was performed when the woman developed symptoms of a fistula, and a third suture that had not fully penetrated the bladder was discovered. She required multiple surgeries to repair the vesicovaginal fistula.

Patient’s claim The ObGyn was negligent for placing the sutures in the bladder, and the urologist was negligent for not finding all 3 sutures during the initial cystoscopy.

Doctor’s defense Placing sutures in the bladder is a known risk of hysterectomy. The urologist also argued that the third suture could not be seen during the first cystoscopy.

Verdict Defense verdict.

Baby with entrapped head, occluded cord dies at 21 months

A 23-year-old woman in the 35th week of her second pregnancy, believing she was in labor, presented at the hospital, but monitoring equipment detected no sign of contractions. She claimed that the OB examined her, but no one checked her cervix to see if she was dilated. Although she demonstrated no organized contraction pattern, she was fully dilated 18 hours later. The OB attempted a vaginal delivery. The fetus presented in a breech position, and during delivery the head and umbilical cord became stuck in the birth canal. Physically and neurologically impaired at birth, the baby died at 21 months of age.

Patient’s claim The failure to diagnose labor led to the baby’s injuries. As the woman’s first pregnancy had resulted in labor at 36 weeks, there was a very good chance that she’d have a second preterm delivery. Also, the baby was deprived of oxygen for 6 minutes because of the head entrapment and umbilical cord occlusion, which caused hemorrhaging in the brain.

Doctor’s defense There was no negligence. The baby’s problems developed before birth.

Verdict A $2,890,000 verdict.

Too-early birth of twins follows mother’s UTI

A woman in the 26th week of pregnancy with twins (the plaintiffs in the case) called her OB, Dr. A, to report she had a 102° fever. He advised her to take Tylenol, drink fluids, and call back in 2 hours. In the early morning of the next day, the woman presented at the hospital with a temperature of 101°, where Dr. B, another OB, saw her. She underwent testing, and the following day amniocentesis was performed. That afternoon the twins were delivered by emergency cesarean section. Each weighed less than 2 lb. The boy, born with multiple defects, has undergone numerous surgeries on his eyes and legs, but will always be wheelchair-bound. The girl can see after 2 surgeries, but suffers from physical and mental delays.

Patient’s claim The mother had a urinary tract infection, which was not properly diagnosed when she called Dr. A. Also, the amniocentesis should have been performed earlier.

Doctor’s defense They denied receiving further calls from the mother. Also, there was no indication of significant problems.

Verdict A $13.2 million verdict was returned against Dr. B only. Post-trial motions were pending.

MD removes ovaries, cyst—and part of ureter

A physician-employee of the defendant group performed surgery on a 44-year-old woman to remove her ovaries, fallopian tubes, and a cyst the size of an orange on the left ovary. The pathology report confirmed that the physician had removed part of the patient’s left ureter during the surgery. She required emergency reconstructive surgery and remained in the hospital for 2 weeks. A stent was put in place for 4 to 6 weeks. The repair surgery required an iliopsoas hitch. The patient continues to have left flank pain.

Patient’s claim Injury to the ureter was negligent. As the same physician had delivered her third child as well as performed her hysterectomy, he should have been aware of her condition.

Doctor’s defense The patient had complicated anatomy and adhesions because of the hysterectomy done the previous year.

Verdict A $400,000 verdict was returned.

Audible pop at delivery signals diastasis

A 36-year-old woman pregnant with her first child was admitted to the hospital in labor. The next morning she was completely dilated and effaced. She started pushing and, after 2 hours, forceps were used. An audible popping sound occurred at delivery and was noted in the records as a possible fracture of the coccyx. The patient, in great pain after the delivery, had suffered a 3-cm pubic symphysis diastasis (PSD) as shown on a pelvic CT scan. She was discharged after 6 days, and home treatment was arranged. The PSD healed before the trial.

Patient’s claim Inadequate fetal descent during the second stage of labor should have prompted a cesarean section. Cephalopelvic disproportion was present, and excessive force was used during the forceps delivery.

Doctor’s defense There was no cephalopelvic disproportion, and excessive force was not used. Also, PSD is a known risk factor of pregnancy.

Verdict Defense verdict.

Hysterectomy for postpartum hemorrhage

Following a cesarean section, a 39-year-old woman suffered postpartum internal bleeding and then developed disseminated intravascular coagulopathy. To stop the bleeding, a hysterectomy was performed.

Patient’s claim If the medical staff had reacted properly to her drop in blood pressure, which occurred shortly after she arrived in the recovery room following the cesarean section, the bleeding problem could have been prevented.

Doctor’s defense The bleeding problem was not a result of negligence. Also, a doctor was not required to go to the patient when her blood pressure dropped.

Verdict Defense verdict.

Misplaced sutures, then multiple surgeries

A 45-year-old woman underwent a hysterectomy, during which the ObGyn placed several sutures in her bladder. During a subsequent cystoscopy, a urologist identified and removed 2 of the sutures. A third procedure was performed when the woman developed symptoms of a fistula, and a third suture that had not fully penetrated the bladder was discovered. She required multiple surgeries to repair the vesicovaginal fistula.

Patient’s claim The ObGyn was negligent for placing the sutures in the bladder, and the urologist was negligent for not finding all 3 sutures during the initial cystoscopy.

Doctor’s defense Placing sutures in the bladder is a known risk of hysterectomy. The urologist also argued that the third suture could not be seen during the first cystoscopy.

Verdict Defense verdict.

Baby with entrapped head, occluded cord dies at 21 months

A 23-year-old woman in the 35th week of her second pregnancy, believing she was in labor, presented at the hospital, but monitoring equipment detected no sign of contractions. She claimed that the OB examined her, but no one checked her cervix to see if she was dilated. Although she demonstrated no organized contraction pattern, she was fully dilated 18 hours later. The OB attempted a vaginal delivery. The fetus presented in a breech position, and during delivery the head and umbilical cord became stuck in the birth canal. Physically and neurologically impaired at birth, the baby died at 21 months of age.

Patient’s claim The failure to diagnose labor led to the baby’s injuries. As the woman’s first pregnancy had resulted in labor at 36 weeks, there was a very good chance that she’d have a second preterm delivery. Also, the baby was deprived of oxygen for 6 minutes because of the head entrapment and umbilical cord occlusion, which caused hemorrhaging in the brain.

Doctor’s defense There was no negligence. The baby’s problems developed before birth.

Verdict A $2,890,000 verdict.

Too-early birth of twins follows mother’s UTI

A woman in the 26th week of pregnancy with twins (the plaintiffs in the case) called her OB, Dr. A, to report she had a 102° fever. He advised her to take Tylenol, drink fluids, and call back in 2 hours. In the early morning of the next day, the woman presented at the hospital with a temperature of 101°, where Dr. B, another OB, saw her. She underwent testing, and the following day amniocentesis was performed. That afternoon the twins were delivered by emergency cesarean section. Each weighed less than 2 lb. The boy, born with multiple defects, has undergone numerous surgeries on his eyes and legs, but will always be wheelchair-bound. The girl can see after 2 surgeries, but suffers from physical and mental delays.

Patient’s claim The mother had a urinary tract infection, which was not properly diagnosed when she called Dr. A. Also, the amniocentesis should have been performed earlier.

Doctor’s defense They denied receiving further calls from the mother. Also, there was no indication of significant problems.

Verdict A $13.2 million verdict was returned against Dr. B only. Post-trial motions were pending.

MD removes ovaries, cyst—and part of ureter

A physician-employee of the defendant group performed surgery on a 44-year-old woman to remove her ovaries, fallopian tubes, and a cyst the size of an orange on the left ovary. The pathology report confirmed that the physician had removed part of the patient’s left ureter during the surgery. She required emergency reconstructive surgery and remained in the hospital for 2 weeks. A stent was put in place for 4 to 6 weeks. The repair surgery required an iliopsoas hitch. The patient continues to have left flank pain.

Patient’s claim Injury to the ureter was negligent. As the same physician had delivered her third child as well as performed her hysterectomy, he should have been aware of her condition.

Doctor’s defense The patient had complicated anatomy and adhesions because of the hysterectomy done the previous year.

Verdict A $400,000 verdict was returned.

Audible pop at delivery signals diastasis

A 36-year-old woman pregnant with her first child was admitted to the hospital in labor. The next morning she was completely dilated and effaced. She started pushing and, after 2 hours, forceps were used. An audible popping sound occurred at delivery and was noted in the records as a possible fracture of the coccyx. The patient, in great pain after the delivery, had suffered a 3-cm pubic symphysis diastasis (PSD) as shown on a pelvic CT scan. She was discharged after 6 days, and home treatment was arranged. The PSD healed before the trial.

Patient’s claim Inadequate fetal descent during the second stage of labor should have prompted a cesarean section. Cephalopelvic disproportion was present, and excessive force was used during the forceps delivery.

Doctor’s defense There was no cephalopelvic disproportion, and excessive force was not used. Also, PSD is a known risk factor of pregnancy.

Verdict Defense verdict.

Hysterectomy for postpartum hemorrhage

Following a cesarean section, a 39-year-old woman suffered postpartum internal bleeding and then developed disseminated intravascular coagulopathy. To stop the bleeding, a hysterectomy was performed.

Patient’s claim If the medical staff had reacted properly to her drop in blood pressure, which occurred shortly after she arrived in the recovery room following the cesarean section, the bleeding problem could have been prevented.

Doctor’s defense The bleeding problem was not a result of negligence. Also, a doctor was not required to go to the patient when her blood pressure dropped.

Verdict Defense verdict.

Misplaced sutures, then multiple surgeries

A 45-year-old woman underwent a hysterectomy, during which the ObGyn placed several sutures in her bladder. During a subsequent cystoscopy, a urologist identified and removed 2 of the sutures. A third procedure was performed when the woman developed symptoms of a fistula, and a third suture that had not fully penetrated the bladder was discovered. She required multiple surgeries to repair the vesicovaginal fistula.

Patient’s claim The ObGyn was negligent for placing the sutures in the bladder, and the urologist was negligent for not finding all 3 sutures during the initial cystoscopy.

Doctor’s defense Placing sutures in the bladder is a known risk of hysterectomy. The urologist also argued that the third suture could not be seen during the first cystoscopy.

Verdict Defense verdict.

Baby with entrapped head, occluded cord dies at 21 months

A 23-year-old woman in the 35th week of her second pregnancy, believing she was in labor, presented at the hospital, but monitoring equipment detected no sign of contractions. She claimed that the OB examined her, but no one checked her cervix to see if she was dilated. Although she demonstrated no organized contraction pattern, she was fully dilated 18 hours later. The OB attempted a vaginal delivery. The fetus presented in a breech position, and during delivery the head and umbilical cord became stuck in the birth canal. Physically and neurologically impaired at birth, the baby died at 21 months of age.

Patient’s claim The failure to diagnose labor led to the baby’s injuries. As the woman’s first pregnancy had resulted in labor at 36 weeks, there was a very good chance that she’d have a second preterm delivery. Also, the baby was deprived of oxygen for 6 minutes because of the head entrapment and umbilical cord occlusion, which caused hemorrhaging in the brain.

Doctor’s defense There was no negligence. The baby’s problems developed before birth.

Verdict A $2,890,000 verdict.

Before I begin this month, let me take a paragraph to say how nice it is to receive so many excellent questions from readers. Please keep' em coming.

Several recent questions have concerned billing services: Are they a good idea, and are they worth the cost?

As with most things, it depends. To answer the question for your particular situation, you and your office manager should do a detailed analysis of how your billing is being handled now.

In reviews of this type that I've observed or participated in, it is common to find examples of missed charges, as well as failures to add modifiers and unbundle services (where that is legal and proper).

The most common errors made by in-house billing employees include the following: missing filing deadlines, writing off services that should be appealed, appealing issues that are not winnable, not responding to carrier requests for information, not working accounts receivable, and not sending out timely statements.

Engaging a good billing service will correct these problems.

Embezzlement is another serious concern, as I've discussed in the past. (If you missed that column, go to www.skinandallergynews.com

In addition, there are changes coming to the billing process that your staff needs to be aware of. Since the beginning of the year, there has been a new CMS-1500 form to fill out. Beginning in May, you'll need to have your National Practitioner Identification (NPI) number in use. Carriers are mandating in ever-increasing numbers that claims be filed electronically. The same goes for electronic fund transfer and automatic remittance—meaning no more checks or paper explanation of benefit forms. And, of course, electronic health records are adding their own wrinkles. If your office equipment is inadequate to meet these new demands, a billing service could be your best option.

So, should you outsource your billing or not? Inga Ellzey, the noted practice management consultant (and owner of several billing services), suggests you ask the following questions:

▸ How much are in-house billing and collections costing you?

▸ Is your staff writing off services unnecessarily?

▸ Are they following up on unpaid claims?

▸ Do you honestly know what percentage of your gross charges you are collecting?

▸ What is your accounts receivable after 90 days?

▸ Are you losing key employees and having problems finding good replacements?

▸ Are you adding associates, nurse practitioners, or physician assistants, and do you need the space now being occupied by your billing department?

▸ Are you facing expensive computer upgrades?

These are excellent questions, in particular the first. When calculating what billing is costing you now, be sure to factor in postage (the biggest expense); printing of statements; envelopes and return envelopes; computer time; ink and paper; and, of course, staff time (printing, stuffing, stamping, etc.).

The greatest cost to a practice from in-house billing, however, is revenue lost by underqualified employees performing this vital function in a suboptimal manner. So it is worth remembering that even if, on paper, in-house costs are the same as those of a billing service (or even a bit lower), outsourcing may still be preferable due to decreased staffing headaches and increased quality of billing.

If you are considering a billing service, Ms. Ellzey suggests looking for a company with organizational stability, sufficient staffing, knowledge and experience within your specialty, reasonable fees, acceptable contract length and penalties, efficient methods of communication with your office, and state-of-the-art technologic capabilities.

She also suggests you consider the following questions before making a final decision:

▸ Are you willing and ready to give up control of the day-to-day billing process?

▸ Can you accept that a billing service has its own ways of doing things, which may be different from yours?

▸ Is your entire staff willing to change the way billing is handled? (A stubborn holdout could be an embezzler.)

▸ Does outsourcing of billing make economic sense for your practice?

If the answer to all of these questions is an emphatic yes, outsourcing may be the way to go.

Then again, now that I have perhaps convinced you of the merits of billing services, there is another alternative you might consider—one that I've mentioned before.

Consider doing what a growing number of businesses—including every hotel, motel, and country inn on the planet (and my office)—already do: Ask each patient for a credit card, take an imprint, and bill balances to it as they accrue.

It takes time to implement such a system, but once in full swing, your billing needs could decrease by as much as 80%, as they have in my office.

The details of this system were spelled out in my columns of December 2005 and March 2006.

Before I begin this month, let me take a paragraph to say how nice it is to receive so many excellent questions from readers. Please keep' em coming.

Several recent questions have concerned billing services: Are they a good idea, and are they worth the cost?

As with most things, it depends. To answer the question for your particular situation, you and your office manager should do a detailed analysis of how your billing is being handled now.

In reviews of this type that I've observed or participated in, it is common to find examples of missed charges, as well as failures to add modifiers and unbundle services (where that is legal and proper).

The most common errors made by in-house billing employees include the following: missing filing deadlines, writing off services that should be appealed, appealing issues that are not winnable, not responding to carrier requests for information, not working accounts receivable, and not sending out timely statements.

Engaging a good billing service will correct these problems.

Embezzlement is another serious concern, as I've discussed in the past. (If you missed that column, go to www.skinandallergynews.com

In addition, there are changes coming to the billing process that your staff needs to be aware of. Since the beginning of the year, there has been a new CMS-1500 form to fill out. Beginning in May, you'll need to have your National Practitioner Identification (NPI) number in use. Carriers are mandating in ever-increasing numbers that claims be filed electronically. The same goes for electronic fund transfer and automatic remittance—meaning no more checks or paper explanation of benefit forms. And, of course, electronic health records are adding their own wrinkles. If your office equipment is inadequate to meet these new demands, a billing service could be your best option.

So, should you outsource your billing or not? Inga Ellzey, the noted practice management consultant (and owner of several billing services), suggests you ask the following questions:

▸ How much are in-house billing and collections costing you?

▸ Is your staff writing off services unnecessarily?

▸ Are they following up on unpaid claims?

▸ Do you honestly know what percentage of your gross charges you are collecting?

▸ What is your accounts receivable after 90 days?

▸ Are you losing key employees and having problems finding good replacements?

▸ Are you adding associates, nurse practitioners, or physician assistants, and do you need the space now being occupied by your billing department?

▸ Are you facing expensive computer upgrades?

These are excellent questions, in particular the first. When calculating what billing is costing you now, be sure to factor in postage (the biggest expense); printing of statements; envelopes and return envelopes; computer time; ink and paper; and, of course, staff time (printing, stuffing, stamping, etc.).

The greatest cost to a practice from in-house billing, however, is revenue lost by underqualified employees performing this vital function in a suboptimal manner. So it is worth remembering that even if, on paper, in-house costs are the same as those of a billing service (or even a bit lower), outsourcing may still be preferable due to decreased staffing headaches and increased quality of billing.

If you are considering a billing service, Ms. Ellzey suggests looking for a company with organizational stability, sufficient staffing, knowledge and experience within your specialty, reasonable fees, acceptable contract length and penalties, efficient methods of communication with your office, and state-of-the-art technologic capabilities.

She also suggests you consider the following questions before making a final decision:

▸ Are you willing and ready to give up control of the day-to-day billing process?

▸ Can you accept that a billing service has its own ways of doing things, which may be different from yours?

▸ Is your entire staff willing to change the way billing is handled? (A stubborn holdout could be an embezzler.)

▸ Does outsourcing of billing make economic sense for your practice?

If the answer to all of these questions is an emphatic yes, outsourcing may be the way to go.

Then again, now that I have perhaps convinced you of the merits of billing services, there is another alternative you might consider—one that I've mentioned before.

Consider doing what a growing number of businesses—including every hotel, motel, and country inn on the planet (and my office)—already do: Ask each patient for a credit card, take an imprint, and bill balances to it as they accrue.

It takes time to implement such a system, but once in full swing, your billing needs could decrease by as much as 80%, as they have in my office.

The details of this system were spelled out in my columns of December 2005 and March 2006.

Before I begin this month, let me take a paragraph to say how nice it is to receive so many excellent questions from readers. Please keep' em coming.

Several recent questions have concerned billing services: Are they a good idea, and are they worth the cost?

As with most things, it depends. To answer the question for your particular situation, you and your office manager should do a detailed analysis of how your billing is being handled now.

In reviews of this type that I've observed or participated in, it is common to find examples of missed charges, as well as failures to add modifiers and unbundle services (where that is legal and proper).

The most common errors made by in-house billing employees include the following: missing filing deadlines, writing off services that should be appealed, appealing issues that are not winnable, not responding to carrier requests for information, not working accounts receivable, and not sending out timely statements.

Engaging a good billing service will correct these problems.

Embezzlement is another serious concern, as I've discussed in the past. (If you missed that column, go to www.skinandallergynews.com

In addition, there are changes coming to the billing process that your staff needs to be aware of. Since the beginning of the year, there has been a new CMS-1500 form to fill out. Beginning in May, you'll need to have your National Practitioner Identification (NPI) number in use. Carriers are mandating in ever-increasing numbers that claims be filed electronically. The same goes for electronic fund transfer and automatic remittance—meaning no more checks or paper explanation of benefit forms. And, of course, electronic health records are adding their own wrinkles. If your office equipment is inadequate to meet these new demands, a billing service could be your best option.

So, should you outsource your billing or not? Inga Ellzey, the noted practice management consultant (and owner of several billing services), suggests you ask the following questions:

▸ How much are in-house billing and collections costing you?

▸ Is your staff writing off services unnecessarily?

▸ Are they following up on unpaid claims?

▸ Do you honestly know what percentage of your gross charges you are collecting?

▸ What is your accounts receivable after 90 days?

▸ Are you losing key employees and having problems finding good replacements?

▸ Are you adding associates, nurse practitioners, or physician assistants, and do you need the space now being occupied by your billing department?

▸ Are you facing expensive computer upgrades?

These are excellent questions, in particular the first. When calculating what billing is costing you now, be sure to factor in postage (the biggest expense); printing of statements; envelopes and return envelopes; computer time; ink and paper; and, of course, staff time (printing, stuffing, stamping, etc.).

The greatest cost to a practice from in-house billing, however, is revenue lost by underqualified employees performing this vital function in a suboptimal manner. So it is worth remembering that even if, on paper, in-house costs are the same as those of a billing service (or even a bit lower), outsourcing may still be preferable due to decreased staffing headaches and increased quality of billing.

If you are considering a billing service, Ms. Ellzey suggests looking for a company with organizational stability, sufficient staffing, knowledge and experience within your specialty, reasonable fees, acceptable contract length and penalties, efficient methods of communication with your office, and state-of-the-art technologic capabilities.

She also suggests you consider the following questions before making a final decision:

▸ Are you willing and ready to give up control of the day-to-day billing process?

▸ Can you accept that a billing service has its own ways of doing things, which may be different from yours?

▸ Is your entire staff willing to change the way billing is handled? (A stubborn holdout could be an embezzler.)

▸ Does outsourcing of billing make economic sense for your practice?

If the answer to all of these questions is an emphatic yes, outsourcing may be the way to go.

Then again, now that I have perhaps convinced you of the merits of billing services, there is another alternative you might consider—one that I've mentioned before.

Consider doing what a growing number of businesses—including every hotel, motel, and country inn on the planet (and my office)—already do: Ask each patient for a credit card, take an imprint, and bill balances to it as they accrue.

It takes time to implement such a system, but once in full swing, your billing needs could decrease by as much as 80%, as they have in my office.

The details of this system were spelled out in my columns of December 2005 and March 2006.

Patient not told of STD infects (then loses) beau

A Pap smear taken by an ObGyn was reported to the patient as normal. Four months later, the woman’s boyfriend ended their relationship because, he said, she had infected him with a sexually transmitted disease. When she called the ObGyn’s office, she was informed that, in fact, the Pap smear did show a Trichomonas vaginalis infection, but that she was not told so as not to worry her prior to unspecified surgery. The patient was treated successfully by another physician.

Patient’s claim By not telling her about the infection in a timely manner, the defendant caused her to transmit the infection unknowingly. Had she been told, she would have undergone immediate treatment.

Doctor’s defense He planned to treat the patient for the infection on a follow-up visit after surgery, but she did not keep the appointment. Also, the delay in treatment did not cause her any harm.

Verdict A jury found that there was negligence, but awarded no damages.

Who’s at fault in late delivery?

A morbidly obese woman who had diabetes was scheduled for a cesarean delivery several days after ultrasonography showed her full-term fetus to weigh 11 pounds. When she arrived for the delivery, fetal monitoring showed no fetal movement or heart tones. A stillborn baby was delivered.

Patient’s claim The delivery should have been done at the time of the sonogram.

Doctor’s defense The mother failed to report that she noticed decreased fetal movement days before scheduled delivery. She also failed to keep doctors’ appointments and follow prenatal advice.

Verdict Defense verdict.

Retained IUD blamed for infection, prematurity, and child’s problems

A woman received an IUD from her ObGyn. Later, when she thought she was pregnant, and a home pregnancy test confirmed it, she reported to her ObGyn that she was pregnant with an IUD in place. She underwent a sonogram that same day, but the sonographer reportedly saw no IUD in the uterus. Although no physician examined her to look for the IUD’s string, she was assured that the IUD had probably fallen out. Again no vaginal examination was done at her first prenatal visit.

At 30 weeks, her water broke. She was hospitalized in labor, but attempts to stop the labor failed. A significant uterine infection was discovered, and vaginal examination showed the IUD covered in purulent material inside the cervix. Cultures indicated methicillin-resistant Staphylococcus aureus.

Following emergency cesarean section, the baby was hospitalized for 6 weeks. Because of the infection, the mother suffered prolonged wound healing and was unable to work for 6 months. The child was hospitalized 9 times before the age of 4 years because of lung problems due to bronchopulmonary dysplasia. In the 12 months preceding settlement of the case, however, the child required no hospitalization.

Patient’s claim The defendants should have done more to find and remove the IUD during early pregnancy, so it could have progressed to term. The IUD caused the infection, which resulted in premature delivery and damaged the child’s lungs.

Doctor’s defense Not reported.

Verdict A $750,000 settlement was reached.

Tears to the perineum require 2 repairs

When a 35-year-old woman gave birth, she suffered tears to the perineum. The doctor who performed the delivery also repaired the tears after birth. A skin bridge formed and was repaired by another doctor.

Patient’s claim The tears were not repaired properly, causing the skin bridge.

Doctor’s defense The tears were repaired properly. Also scar tissue is a known risk of such a repair.

Verdict Defense verdict.

Foreshortened vagina hinders sex

Following recovery from a vaginal hysterectomy, a woman in her mid-30s suffered unbearable physical pain and discomfort in her vagina during sexual intercourse. Repair surgery, followed by full recovery, allowed her to have sexual activity without pain or discomfort.

Patient’s claim The physician was negligent in foreshortening her vaginal canal, necessitating further surgery.

Doctor’s defense The problems were caused by unusual postoperative scarring in the vaginal canal.

Verdict Defense verdict.

Patient not told of STD infects (then loses) beau

A Pap smear taken by an ObGyn was reported to the patient as normal. Four months later, the woman’s boyfriend ended their relationship because, he said, she had infected him with a sexually transmitted disease. When she called the ObGyn’s office, she was informed that, in fact, the Pap smear did show a Trichomonas vaginalis infection, but that she was not told so as not to worry her prior to unspecified surgery. The patient was treated successfully by another physician.

Patient’s claim By not telling her about the infection in a timely manner, the defendant caused her to transmit the infection unknowingly. Had she been told, she would have undergone immediate treatment.

Doctor’s defense He planned to treat the patient for the infection on a follow-up visit after surgery, but she did not keep the appointment. Also, the delay in treatment did not cause her any harm.

Verdict A jury found that there was negligence, but awarded no damages.

Who’s at fault in late delivery?

A morbidly obese woman who had diabetes was scheduled for a cesarean delivery several days after ultrasonography showed her full-term fetus to weigh 11 pounds. When she arrived for the delivery, fetal monitoring showed no fetal movement or heart tones. A stillborn baby was delivered.

Patient’s claim The delivery should have been done at the time of the sonogram.

Doctor’s defense The mother failed to report that she noticed decreased fetal movement days before scheduled delivery. She also failed to keep doctors’ appointments and follow prenatal advice.

Verdict Defense verdict.

Retained IUD blamed for infection, prematurity, and child’s problems

A woman received an IUD from her ObGyn. Later, when she thought she was pregnant, and a home pregnancy test confirmed it, she reported to her ObGyn that she was pregnant with an IUD in place. She underwent a sonogram that same day, but the sonographer reportedly saw no IUD in the uterus. Although no physician examined her to look for the IUD’s string, she was assured that the IUD had probably fallen out. Again no vaginal examination was done at her first prenatal visit.

At 30 weeks, her water broke. She was hospitalized in labor, but attempts to stop the labor failed. A significant uterine infection was discovered, and vaginal examination showed the IUD covered in purulent material inside the cervix. Cultures indicated methicillin-resistant Staphylococcus aureus.

Following emergency cesarean section, the baby was hospitalized for 6 weeks. Because of the infection, the mother suffered prolonged wound healing and was unable to work for 6 months. The child was hospitalized 9 times before the age of 4 years because of lung problems due to bronchopulmonary dysplasia. In the 12 months preceding settlement of the case, however, the child required no hospitalization.

Patient’s claim The defendants should have done more to find and remove the IUD during early pregnancy, so it could have progressed to term. The IUD caused the infection, which resulted in premature delivery and damaged the child’s lungs.

Doctor’s defense Not reported.

Verdict A $750,000 settlement was reached.

Tears to the perineum require 2 repairs

When a 35-year-old woman gave birth, she suffered tears to the perineum. The doctor who performed the delivery also repaired the tears after birth. A skin bridge formed and was repaired by another doctor.

Patient’s claim The tears were not repaired properly, causing the skin bridge.

Doctor’s defense The tears were repaired properly. Also scar tissue is a known risk of such a repair.

Verdict Defense verdict.

Foreshortened vagina hinders sex

Following recovery from a vaginal hysterectomy, a woman in her mid-30s suffered unbearable physical pain and discomfort in her vagina during sexual intercourse. Repair surgery, followed by full recovery, allowed her to have sexual activity without pain or discomfort.

Patient’s claim The physician was negligent in foreshortening her vaginal canal, necessitating further surgery.

Doctor’s defense The problems were caused by unusual postoperative scarring in the vaginal canal.

Verdict Defense verdict.

Patient not told of STD infects (then loses) beau

A Pap smear taken by an ObGyn was reported to the patient as normal. Four months later, the woman’s boyfriend ended their relationship because, he said, she had infected him with a sexually transmitted disease. When she called the ObGyn’s office, she was informed that, in fact, the Pap smear did show a Trichomonas vaginalis infection, but that she was not told so as not to worry her prior to unspecified surgery. The patient was treated successfully by another physician.

Patient’s claim By not telling her about the infection in a timely manner, the defendant caused her to transmit the infection unknowingly. Had she been told, she would have undergone immediate treatment.

Doctor’s defense He planned to treat the patient for the infection on a follow-up visit after surgery, but she did not keep the appointment. Also, the delay in treatment did not cause her any harm.

Verdict A jury found that there was negligence, but awarded no damages.

Who’s at fault in late delivery?

A morbidly obese woman who had diabetes was scheduled for a cesarean delivery several days after ultrasonography showed her full-term fetus to weigh 11 pounds. When she arrived for the delivery, fetal monitoring showed no fetal movement or heart tones. A stillborn baby was delivered.

Patient’s claim The delivery should have been done at the time of the sonogram.

Doctor’s defense The mother failed to report that she noticed decreased fetal movement days before scheduled delivery. She also failed to keep doctors’ appointments and follow prenatal advice.

Verdict Defense verdict.

Retained IUD blamed for infection, prematurity, and child’s problems

A woman received an IUD from her ObGyn. Later, when she thought she was pregnant, and a home pregnancy test confirmed it, she reported to her ObGyn that she was pregnant with an IUD in place. She underwent a sonogram that same day, but the sonographer reportedly saw no IUD in the uterus. Although no physician examined her to look for the IUD’s string, she was assured that the IUD had probably fallen out. Again no vaginal examination was done at her first prenatal visit.

At 30 weeks, her water broke. She was hospitalized in labor, but attempts to stop the labor failed. A significant uterine infection was discovered, and vaginal examination showed the IUD covered in purulent material inside the cervix. Cultures indicated methicillin-resistant Staphylococcus aureus.

Following emergency cesarean section, the baby was hospitalized for 6 weeks. Because of the infection, the mother suffered prolonged wound healing and was unable to work for 6 months. The child was hospitalized 9 times before the age of 4 years because of lung problems due to bronchopulmonary dysplasia. In the 12 months preceding settlement of the case, however, the child required no hospitalization.

Patient’s claim The defendants should have done more to find and remove the IUD during early pregnancy, so it could have progressed to term. The IUD caused the infection, which resulted in premature delivery and damaged the child’s lungs.

Doctor’s defense Not reported.

Verdict A $750,000 settlement was reached.

Tears to the perineum require 2 repairs

When a 35-year-old woman gave birth, she suffered tears to the perineum. The doctor who performed the delivery also repaired the tears after birth. A skin bridge formed and was repaired by another doctor.

Patient’s claim The tears were not repaired properly, causing the skin bridge.

Doctor’s defense The tears were repaired properly. Also scar tissue is a known risk of such a repair.

Verdict Defense verdict.

Foreshortened vagina hinders sex

Following recovery from a vaginal hysterectomy, a woman in her mid-30s suffered unbearable physical pain and discomfort in her vagina during sexual intercourse. Repair surgery, followed by full recovery, allowed her to have sexual activity without pain or discomfort.

Patient’s claim The physician was negligent in foreshortening her vaginal canal, necessitating further surgery.

Doctor’s defense The problems were caused by unusual postoperative scarring in the vaginal canal.

Verdict Defense verdict.