Joseph S. Eastern

Electronic prescribing was supposed to be standard practice by now.

With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would quickly adopt the new technology—but the associated costs and hassles dissuaded most. And many didn't see any benefits, either for patients or for themselves.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various “G” codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing.

If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort; plus, a consortium of tech companies has made the technology readily accessible and free.

This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories. And they hope you'll see a decrease in pharmacy phone calls, prior authorization nonsense, and treatment delays because of formulary issues. Further, they hope, your patients will appreciate seeing their prescriptions filled faster, with fewer errors.

To address cost and accessibility problems, a coalition of insurance and technology companies, the National e-Prescribing Patient Safety Initiative (NEPSI), has provided $100 million in funding to offer free e-prescribing technology to all phsyicans nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health.

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system.

In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection (not dial-up), and a database of patients.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians who are considering making the switch to e-prescribing, as well as for those who have already switched. You can find it at www.ehealthinitiative.org/basics-what-electronic-prescribing.html

You can learn more about NEPSI and sign up for their free, online-based prescribing software at their Web site, www.nationalerx.com

A list of other companies that currently offer e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/eprescribe/companylist.aspx

Details of the CMS incentive program are available at www.cms.hhs.gov/ERxIncentive/

With cost, accessibility, and hassle roadblocks removed, bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade due to increased use of generic drugs and decreased prescribing errors.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it's a “no-brainer” to give electronic prescribing a try.

Electronic prescribing was supposed to be standard practice by now.

With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would quickly adopt the new technology—but the associated costs and hassles dissuaded most. And many didn't see any benefits, either for patients or for themselves.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various “G” codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing.

If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort; plus, a consortium of tech companies has made the technology readily accessible and free.

This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories. And they hope you'll see a decrease in pharmacy phone calls, prior authorization nonsense, and treatment delays because of formulary issues. Further, they hope, your patients will appreciate seeing their prescriptions filled faster, with fewer errors.

To address cost and accessibility problems, a coalition of insurance and technology companies, the National e-Prescribing Patient Safety Initiative (NEPSI), has provided $100 million in funding to offer free e-prescribing technology to all phsyicans nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health.

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system.

In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection (not dial-up), and a database of patients.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians who are considering making the switch to e-prescribing, as well as for those who have already switched. You can find it at www.ehealthinitiative.org/basics-what-electronic-prescribing.html

You can learn more about NEPSI and sign up for their free, online-based prescribing software at their Web site, www.nationalerx.com

A list of other companies that currently offer e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/eprescribe/companylist.aspx

Details of the CMS incentive program are available at www.cms.hhs.gov/ERxIncentive/

With cost, accessibility, and hassle roadblocks removed, bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade due to increased use of generic drugs and decreased prescribing errors.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it's a “no-brainer” to give electronic prescribing a try.

Electronic prescribing was supposed to be standard practice by now.

With all the predictions of increased efficiencies and cost savings, policymakers and health plan administrators were sure physicians would quickly adopt the new technology—but the associated costs and hassles dissuaded most. And many didn't see any benefits, either for patients or for themselves.

The Centers for Medicare and Medicaid Services thought it could turn the tide last year by adding a financial incentive: a 2% bonus on Medicare Part B payments. That didn't do the trick either; accessibility and cost issues remained, and the various “G” codes that had to be added to Medicare claims to document e-prescribing were confusing and annoying.

As 2009 ended, only 10%-15% of American physicians were e-prescribing.

If you're in the prehistoric majority, 2010 may be the year to reconsider: CMS has made it much easier to collect the 2% bonus with a minimum of e-prescribing effort; plus, a consortium of tech companies has made the technology readily accessible and free.

This year, if you can show that you are using a qualified e-prescribing program on only 25 Medicare claims over the course of the entire year, you'll get the 2% bonus on every Medicare Part B claim you file in 2010.

In addition, CMS has simplified the reporting process by eliminating all add-on codes except G8553, the one that indicates you have a qualified e-prescribing program and you used it to provide at least one prescription at the visit being billed.

Of course, CMS is hoping you won't quit after only 25 claims; they're betting you'll notice a decrease in paperwork, simplification of record keeping, fewer misspellings and handwriting misreads, and a greater awareness of contraindications and drug interactions, plus simplified access to patients' medication histories. And they hope you'll see a decrease in pharmacy phone calls, prior authorization nonsense, and treatment delays because of formulary issues. Further, they hope, your patients will appreciate seeing their prescriptions filled faster, with fewer errors.

To address cost and accessibility problems, a coalition of insurance and technology companies, the National e-Prescribing Patient Safety Initiative (NEPSI), has provided $100 million in funding to offer free e-prescribing technology to all phsyicans nationwide. NEPSI members include Allscripts, SureScripts, and NaviMedix, as well as Google, Dell, Cisco, Fujitsu, Microsoft, Sprint, Aetna, Horizon Blue Cross/Blue Shield, WellPoint, and Wolters Kluwer Health.

Thanks to the efforts of NEPSI and others, e-prescribing is now quick and easy for most practices to set up and use. Pharmacies have already done most of the work to make themselves compatible; about 70% of U.S. pharmacies can now handle electronic prescriptions. You can incorporate e-prescribing into many electronic health record systems, or set it up as a separate, stand alone system.

In most cases, all you need to get started is an Internet-enabled computer with a high-speed connection (not dial-up), and a database of patients.

A nonprofit foundation called eHealth Initiative has released an excellent guide for physicians who are considering making the switch to e-prescribing, as well as for those who have already switched. You can find it at www.ehealthinitiative.org/basics-what-electronic-prescribing.html

You can learn more about NEPSI and sign up for their free, online-based prescribing software at their Web site, www.nationalerx.com

A list of other companies that currently offer e-prescribing software, along with links to their respective Web sites, can be found at www.eprescribing.info/eprescribe/companylist.aspx

Details of the CMS incentive program are available at www.cms.hhs.gov/ERxIncentive/

With cost, accessibility, and hassle roadblocks removed, bureaucrats hope 75% of us will be prescribing electronically by 2014, 90% by 2018. And that, in turn, they claim, will save the government $22 billion over the next decade due to increased use of generic drugs and decreased prescribing errors.

Maybe, maybe not. But with only 25 e-prescriptions required to collect the 2% bonus this year, it's a “no-brainer” to give electronic prescribing a try.

A brand new year has begun, and that, as usual, means brand new surprises from our friends at the Centers for Medicare and Medicaid Services. This year's big surprise: The CMS has decided it will no longer pay for consultations in either outpatient (99241-99245) or inpatient (99251-99255) settings.

This decree has caused a great deal of protest, particularly from neurologists, rheumatologists, and other specialists who depend on consultations for a majority of their income. After all, specialists should be appropriately compensated for the special expertise they provide.

It is hard to envision how eliminating consultation payments could be anything but detrimental to patient care. At the least, consulting physicians may feel less inclined to provide reports to referring physicians, which will substantially hurt coordination of care at a time when policymakers claim to be looking for ways to improve it.

Further objections abound; nevertheless, the decision has been made, and adjustments must be taken to accommodate it.

For office visits, the CMS expects consultation codes to be replaced with new or established visit codes (99201-99205 or 99212-99215). They have increased relative value units for those visit codes by 6% to soften the blow, but the difference will be substantially noticeable if a lot of consultations were billed last year.

On the inpatient side, admission codes (99221-99223) are to be used in lieu of consultation codes. The “true” admitting physician will use a new modifier (not yet published at press time) along with the admit code, while all consulting physicians will use the admit code unmodified.

Physicians performing a lot of inpatient consultations should anticipate denials, appeals, and confusion as admitting physicians and consultants alike adjust to this change.

As usual, some commercial insurers will follow the CMS lead, while others will continue recognizing the consultation codes (which remain in the 2010 CPT book). This means a decision will need to be made about whether to continue billing consultations for non-Medicare patients whose insurers continue to pay for them. If this route is chosen, Medicare will provide secondary coverage, and will, of course, not pay its portion. So this situation needs to be recognized in advance.

It is probably worth reviewing some past explanation of benefits to determine how often Medicare is a secondary payer, and whether any extra revenue will be worth the extra vigilance and work involved.

Discussions on this issue have been widespread and heated, and opinions vary widely.

Some specialists claim they actually welcome the change because they will no longer need to worry about complying with the CMS's confusing and ever-changing consultation rules.

Others are understandably concerned about a potentially significant loss of income. Do not be tempted, however, to bill for more services, such as biopsies and surgical procedures, as compensation for lost revenue. The CMS is well aware of that tendency (they even have a name for it: “code creep”), and they will be watching.

If billing patterns change significantly, an audit can be expected; increased billings must be proved to be of medical necessity, not compensatory revenue generation. If increased billings cannot be proved to be medically necessary, abuse or fraud charges will come. In an audit, remember, everyone is guilty until proven innocent.

Billing patients directly for consults has been proposed as a way to recover lost revenue. If consults are no longer covered by the CMS, physicians have reasoned that they should be able to use a “noncovered service” code (such as 99199-GA) and have Medicare patients sign an Advance Beneficiary Notice (ABN). This signifies their understanding that Medicare will not pay for the service, the same procedure used for noncovered cosmetic services. It is not clear, however, if this is permissible by the CMS.

Another proposed counter strategy is to bill Medicare for a new patient visit and add a “surcharge” for consultative care, billed directly to the patient (again using a National Supplier Clearinghouse [NSC] code and an ABN). This would be considered a “priority service,” analogous to “concierge services” offered by some internists. No one knows if the CMS (or patients) would go along with this option either.

Even proponents of such strategies admit they are speculative and untested; I would not advise attempting them without a careful legal review with an experienced health care attorney.

No matter how individuals choose to deal with the loss of consultation codes, I believe physicians should continue sending reports to referring physicians even though they will not specifically be paid for them.

Doing what is best for patients should always be the top priority.

To respond to this column, e-mail Dr. Eastern at [email protected]

A brand new year has begun, and that, as usual, means brand new surprises from our friends at the Centers for Medicare and Medicaid Services. This year's big surprise: The CMS has decided it will no longer pay for consultations in either outpatient (99241-99245) or inpatient (99251-99255) settings.

This decree has caused a great deal of protest, particularly from neurologists, rheumatologists, and other specialists who depend on consultations for a majority of their income. After all, specialists should be appropriately compensated for the special expertise they provide.

It is hard to envision how eliminating consultation payments could be anything but detrimental to patient care. At the least, consulting physicians may feel less inclined to provide reports to referring physicians, which will substantially hurt coordination of care at a time when policymakers claim to be looking for ways to improve it.

Further objections abound; nevertheless, the decision has been made, and adjustments must be taken to accommodate it.

For office visits, the CMS expects consultation codes to be replaced with new or established visit codes (99201-99205 or 99212-99215). They have increased relative value units for those visit codes by 6% to soften the blow, but the difference will be substantially noticeable if a lot of consultations were billed last year.

On the inpatient side, admission codes (99221-99223) are to be used in lieu of consultation codes. The “true” admitting physician will use a new modifier (not yet published at press time) along with the admit code, while all consulting physicians will use the admit code unmodified.

Physicians performing a lot of inpatient consultations should anticipate denials, appeals, and confusion as admitting physicians and consultants alike adjust to this change.

As usual, some commercial insurers will follow the CMS lead, while others will continue recognizing the consultation codes (which remain in the 2010 CPT book). This means a decision will need to be made about whether to continue billing consultations for non-Medicare patients whose insurers continue to pay for them. If this route is chosen, Medicare will provide secondary coverage, and will, of course, not pay its portion. So this situation needs to be recognized in advance.

It is probably worth reviewing some past explanation of benefits to determine how often Medicare is a secondary payer, and whether any extra revenue will be worth the extra vigilance and work involved.

Discussions on this issue have been widespread and heated, and opinions vary widely.

Some specialists claim they actually welcome the change because they will no longer need to worry about complying with the CMS's confusing and ever-changing consultation rules.

Others are understandably concerned about a potentially significant loss of income. Do not be tempted, however, to bill for more services, such as biopsies and surgical procedures, as compensation for lost revenue. The CMS is well aware of that tendency (they even have a name for it: “code creep”), and they will be watching.

If billing patterns change significantly, an audit can be expected; increased billings must be proved to be of medical necessity, not compensatory revenue generation. If increased billings cannot be proved to be medically necessary, abuse or fraud charges will come. In an audit, remember, everyone is guilty until proven innocent.

Billing patients directly for consults has been proposed as a way to recover lost revenue. If consults are no longer covered by the CMS, physicians have reasoned that they should be able to use a “noncovered service” code (such as 99199-GA) and have Medicare patients sign an Advance Beneficiary Notice (ABN). This signifies their understanding that Medicare will not pay for the service, the same procedure used for noncovered cosmetic services. It is not clear, however, if this is permissible by the CMS.

Another proposed counter strategy is to bill Medicare for a new patient visit and add a “surcharge” for consultative care, billed directly to the patient (again using a National Supplier Clearinghouse [NSC] code and an ABN). This would be considered a “priority service,” analogous to “concierge services” offered by some internists. No one knows if the CMS (or patients) would go along with this option either.

Even proponents of such strategies admit they are speculative and untested; I would not advise attempting them without a careful legal review with an experienced health care attorney.

No matter how individuals choose to deal with the loss of consultation codes, I believe physicians should continue sending reports to referring physicians even though they will not specifically be paid for them.

Doing what is best for patients should always be the top priority.

To respond to this column, e-mail Dr. Eastern at [email protected]

A brand new year has begun, and that, as usual, means brand new surprises from our friends at the Centers for Medicare and Medicaid Services. This year's big surprise: The CMS has decided it will no longer pay for consultations in either outpatient (99241-99245) or inpatient (99251-99255) settings.

This decree has caused a great deal of protest, particularly from neurologists, rheumatologists, and other specialists who depend on consultations for a majority of their income. After all, specialists should be appropriately compensated for the special expertise they provide.

It is hard to envision how eliminating consultation payments could be anything but detrimental to patient care. At the least, consulting physicians may feel less inclined to provide reports to referring physicians, which will substantially hurt coordination of care at a time when policymakers claim to be looking for ways to improve it.

Further objections abound; nevertheless, the decision has been made, and adjustments must be taken to accommodate it.

For office visits, the CMS expects consultation codes to be replaced with new or established visit codes (99201-99205 or 99212-99215). They have increased relative value units for those visit codes by 6% to soften the blow, but the difference will be substantially noticeable if a lot of consultations were billed last year.

On the inpatient side, admission codes (99221-99223) are to be used in lieu of consultation codes. The “true” admitting physician will use a new modifier (not yet published at press time) along with the admit code, while all consulting physicians will use the admit code unmodified.

Physicians performing a lot of inpatient consultations should anticipate denials, appeals, and confusion as admitting physicians and consultants alike adjust to this change.

As usual, some commercial insurers will follow the CMS lead, while others will continue recognizing the consultation codes (which remain in the 2010 CPT book). This means a decision will need to be made about whether to continue billing consultations for non-Medicare patients whose insurers continue to pay for them. If this route is chosen, Medicare will provide secondary coverage, and will, of course, not pay its portion. So this situation needs to be recognized in advance.

It is probably worth reviewing some past explanation of benefits to determine how often Medicare is a secondary payer, and whether any extra revenue will be worth the extra vigilance and work involved.

Discussions on this issue have been widespread and heated, and opinions vary widely.

Some specialists claim they actually welcome the change because they will no longer need to worry about complying with the CMS's confusing and ever-changing consultation rules.

Others are understandably concerned about a potentially significant loss of income. Do not be tempted, however, to bill for more services, such as biopsies and surgical procedures, as compensation for lost revenue. The CMS is well aware of that tendency (they even have a name for it: “code creep”), and they will be watching.

If billing patterns change significantly, an audit can be expected; increased billings must be proved to be of medical necessity, not compensatory revenue generation. If increased billings cannot be proved to be medically necessary, abuse or fraud charges will come. In an audit, remember, everyone is guilty until proven innocent.

Billing patients directly for consults has been proposed as a way to recover lost revenue. If consults are no longer covered by the CMS, physicians have reasoned that they should be able to use a “noncovered service” code (such as 99199-GA) and have Medicare patients sign an Advance Beneficiary Notice (ABN). This signifies their understanding that Medicare will not pay for the service, the same procedure used for noncovered cosmetic services. It is not clear, however, if this is permissible by the CMS.

Another proposed counter strategy is to bill Medicare for a new patient visit and add a “surcharge” for consultative care, billed directly to the patient (again using a National Supplier Clearinghouse [NSC] code and an ABN). This would be considered a “priority service,” analogous to “concierge services” offered by some internists. No one knows if the CMS (or patients) would go along with this option either.

Even proponents of such strategies admit they are speculative and untested; I would not advise attempting them without a careful legal review with an experienced health care attorney.

No matter how individuals choose to deal with the loss of consultation codes, I believe physicians should continue sending reports to referring physicians even though they will not specifically be paid for them.

Doing what is best for patients should always be the top priority.

To respond to this column, e-mail Dr. Eastern at [email protected]

A dermatologist recently sought my input regarding his two-physician private practice on the West Coast. They were struggling with an increasing problem, he said, of employees sending personal text messages and surfing the Internet during office hours.

“We added a page to our office manual prohibiting these activities, but there has been no improvement. If anything, it's getting worse,” he added.

It always surprises me when physicians think that the solution to any employee issue is an unannounced new page in the office manual. How often do you suppose your employees peruse your manual, looking for new entries?

Ignorance of the rules is seldom a viable excuse, but if an employee charges you with unreasonable termination, arbitrators may be sympathetic to the contention that policies were established essentially in secret, and no effort was made to make the employee aware of the policy he or she was accused of violating.

Anytime a policy change is made in my office, I call a staff meeting to explain it and answer questions about it. If the change is significant, I also have my manager sit down with each staff member individually and review the new policy in detail, (all of this is documented, of course) making certain everyone fully understands the new policy and the consequences of violating it.

We then have each staffer sign a written copy of the new policy and we post a copy on the bulletin board in our lunch room. Call it overkill if you wish, but no one can plausibly claim they weren't told the rules had changed.

As to the specific problem on the West Coast, the issue clearly is neither local nor trivial. Nor is it medicine specific. When I shop with my wife, I'm increasingly amazed at how many salespeople we see texting or chatting on cell phones, often oblivious of waiting customers.

This is especially true of younger workers. Surveys have shown that most Americans in their teens and twenties find nothing inappropriate or rude about using this technology in any conceivable situation, including the workplace. Without firm policies in place, some staffers will inevitably abuse this technology.

And the damage can be significant. A typical text message, according to one study, takes about 1 minute to send or receive, so an employee who sends and receives 30 messages a day squanders an hour of office time. For a full-time employee that's about 20 hours a month.

How many additional patients could you see in that 240 hours? How much less liability risk would there be if that one employee were paying attention instead of texting? Add a second texter, and a couple of Web surfers, and suddenly you have a major problem.

If you have yet to establish a formal policy on this issue, I recommend that you put one in place immediately. When you call a staff meeting to explain it, speak plainly: Using office time for personal texting and Web surfing is theft, pure and simple. They are stealing your time. Make this crystal clear.

As with any policy, the keys are diligence and consistency. Always enforce this and every other rule, and follow through with consequences when necessary—even if it means penalizing a key employee, or even terminating someone. Firings should always be a last resort, but nothing will make it clearer that you are serious, nor send a stronger message that it is never permissible to steal any office property—least of all your most marketable commodity, office time.

To respond to this column, e-mail Dr. Eastern at [email protected]

A dermatologist recently sought my input regarding his two-physician private practice on the West Coast. They were struggling with an increasing problem, he said, of employees sending personal text messages and surfing the Internet during office hours.

“We added a page to our office manual prohibiting these activities, but there has been no improvement. If anything, it's getting worse,” he added.

It always surprises me when physicians think that the solution to any employee issue is an unannounced new page in the office manual. How often do you suppose your employees peruse your manual, looking for new entries?

Ignorance of the rules is seldom a viable excuse, but if an employee charges you with unreasonable termination, arbitrators may be sympathetic to the contention that policies were established essentially in secret, and no effort was made to make the employee aware of the policy he or she was accused of violating.

Anytime a policy change is made in my office, I call a staff meeting to explain it and answer questions about it. If the change is significant, I also have my manager sit down with each staff member individually and review the new policy in detail, (all of this is documented, of course) making certain everyone fully understands the new policy and the consequences of violating it.

We then have each staffer sign a written copy of the new policy and we post a copy on the bulletin board in our lunch room. Call it overkill if you wish, but no one can plausibly claim they weren't told the rules had changed.

As to the specific problem on the West Coast, the issue clearly is neither local nor trivial. Nor is it medicine specific. When I shop with my wife, I'm increasingly amazed at how many salespeople we see texting or chatting on cell phones, often oblivious of waiting customers.

This is especially true of younger workers. Surveys have shown that most Americans in their teens and twenties find nothing inappropriate or rude about using this technology in any conceivable situation, including the workplace. Without firm policies in place, some staffers will inevitably abuse this technology.

And the damage can be significant. A typical text message, according to one study, takes about 1 minute to send or receive, so an employee who sends and receives 30 messages a day squanders an hour of office time. For a full-time employee that's about 20 hours a month.

How many additional patients could you see in that 240 hours? How much less liability risk would there be if that one employee were paying attention instead of texting? Add a second texter, and a couple of Web surfers, and suddenly you have a major problem.

If you have yet to establish a formal policy on this issue, I recommend that you put one in place immediately. When you call a staff meeting to explain it, speak plainly: Using office time for personal texting and Web surfing is theft, pure and simple. They are stealing your time. Make this crystal clear.

As with any policy, the keys are diligence and consistency. Always enforce this and every other rule, and follow through with consequences when necessary—even if it means penalizing a key employee, or even terminating someone. Firings should always be a last resort, but nothing will make it clearer that you are serious, nor send a stronger message that it is never permissible to steal any office property—least of all your most marketable commodity, office time.

To respond to this column, e-mail Dr. Eastern at [email protected]

A dermatologist recently sought my input regarding his two-physician private practice on the West Coast. They were struggling with an increasing problem, he said, of employees sending personal text messages and surfing the Internet during office hours.

“We added a page to our office manual prohibiting these activities, but there has been no improvement. If anything, it's getting worse,” he added.

It always surprises me when physicians think that the solution to any employee issue is an unannounced new page in the office manual. How often do you suppose your employees peruse your manual, looking for new entries?

Ignorance of the rules is seldom a viable excuse, but if an employee charges you with unreasonable termination, arbitrators may be sympathetic to the contention that policies were established essentially in secret, and no effort was made to make the employee aware of the policy he or she was accused of violating.

Anytime a policy change is made in my office, I call a staff meeting to explain it and answer questions about it. If the change is significant, I also have my manager sit down with each staff member individually and review the new policy in detail, (all of this is documented, of course) making certain everyone fully understands the new policy and the consequences of violating it.

We then have each staffer sign a written copy of the new policy and we post a copy on the bulletin board in our lunch room. Call it overkill if you wish, but no one can plausibly claim they weren't told the rules had changed.

As to the specific problem on the West Coast, the issue clearly is neither local nor trivial. Nor is it medicine specific. When I shop with my wife, I'm increasingly amazed at how many salespeople we see texting or chatting on cell phones, often oblivious of waiting customers.

This is especially true of younger workers. Surveys have shown that most Americans in their teens and twenties find nothing inappropriate or rude about using this technology in any conceivable situation, including the workplace. Without firm policies in place, some staffers will inevitably abuse this technology.

And the damage can be significant. A typical text message, according to one study, takes about 1 minute to send or receive, so an employee who sends and receives 30 messages a day squanders an hour of office time. For a full-time employee that's about 20 hours a month.

How many additional patients could you see in that 240 hours? How much less liability risk would there be if that one employee were paying attention instead of texting? Add a second texter, and a couple of Web surfers, and suddenly you have a major problem.

If you have yet to establish a formal policy on this issue, I recommend that you put one in place immediately. When you call a staff meeting to explain it, speak plainly: Using office time for personal texting and Web surfing is theft, pure and simple. They are stealing your time. Make this crystal clear.

As with any policy, the keys are diligence and consistency. Always enforce this and every other rule, and follow through with consequences when necessary—even if it means penalizing a key employee, or even terminating someone. Firings should always be a last resort, but nothing will make it clearer that you are serious, nor send a stronger message that it is never permissible to steal any office property—least of all your most marketable commodity, office time.

To respond to this column, e-mail Dr. Eastern at [email protected]

[email protected]

The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that it has already paid to you.

The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.

Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount recovered so pleased CMS that it has now authorized a nationwide rollout.

Here's how it works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.

Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/

RACs are paid a percentage of any overpayments they can identify and collect from providers. They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.

They will mostly be looking for only four basic transgressions:

▸ Incorrect payment amounts (either too much or too little).

▸ Noncovered services, including those that are not considered “reasonable and necessary.”

▸ Incorrect coding.

▸ Duplicate payments.

The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That's a relatively short period of time requiring your review, and a relatively small number of transgressions to look for.

So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.

So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game.

If an RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.

The law provides you 45 days to respond to an RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss!

If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.

In case you're wondering, RAC audits will not replace regular Medicare audits. However, the RACs will not be permitted to audit claims that have already been audited conventionally.

[email protected]

The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that it has already paid to you.

The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.

Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount recovered so pleased CMS that it has now authorized a nationwide rollout.

Here's how it works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.

Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/

RACs are paid a percentage of any overpayments they can identify and collect from providers. They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.

They will mostly be looking for only four basic transgressions:

▸ Incorrect payment amounts (either too much or too little).

▸ Noncovered services, including those that are not considered “reasonable and necessary.”

▸ Incorrect coding.

▸ Duplicate payments.

The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That's a relatively short period of time requiring your review, and a relatively small number of transgressions to look for.

So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.

So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game.

If an RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.

The law provides you 45 days to respond to an RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss!

If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.

In case you're wondering, RAC audits will not replace regular Medicare audits. However, the RACs will not be permitted to audit claims that have already been audited conventionally.

[email protected]

The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that it has already paid to you.

The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.

Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount recovered so pleased CMS that it has now authorized a nationwide rollout.

Here's how it works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.

Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/

RACs are paid a percentage of any overpayments they can identify and collect from providers. They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.

They will mostly be looking for only four basic transgressions:

▸ Incorrect payment amounts (either too much or too little).

▸ Noncovered services, including those that are not considered “reasonable and necessary.”

▸ Incorrect coding.

▸ Duplicate payments.

The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That's a relatively short period of time requiring your review, and a relatively small number of transgressions to look for.

So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.

So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game.

If an RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.

The law provides you 45 days to respond to an RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss!

If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.

In case you're wondering, RAC audits will not replace regular Medicare audits. However, the RACs will not be permitted to audit claims that have already been audited conventionally.

The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that they have already paid to you.

The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.

Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount that was recovered so pleased CMS that it has now authorized a nationwide rollout.

So RAC audits could be in your future no matter where you practice. And now is the time to examine your Medicare claims to determine where you may be vulnerable in the event of an RAC audit of past claims and to minimize your risk of audit on future claims. Limitations on scope and look-back period should make that process relatively painless.

Here's how the program works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.

Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/

RACs are paid a percentage of any overpayments they can identify and collect from providers.

They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.

Although most audits are automatic, meaning an analysis of computer data only to identify administrative errors, the RACs are also authorized to undertake “complex” audits in which patient records are examined.

They will mostly be looking for only four basic transgressions:

▸ Incorrect payment amounts (either too much or too little).

▸ Noncovered services, including those that are not considered “reasonable and necessary.”

▸ Incorrect coding.

▸ Duplicate payments.

The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That is a relatively short period of time requiring your review, and a relatively small number of transgressions that you need to look for.

So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.

So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game. And it's only a matter of time before state-run Medicaid programs become targets as well.

CMS has hinted that a majority of audits will take place in California, New York, and Florida, because 25% of all Medicare payments are made to those three states alone.

If a RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.

The law provides you 45 days to respond to a RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss! The RAC's medical director is “required to be actively involved in examining all evidence used to make determinations,” and you have a right to speak to him or her if you wish.

If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.

In case you're wondering, RAC audits will not replace regular Medicare audits, which I discussed in my June 2004 column.

To respond to this column, e-mail Dr. Eastern at [email protected]

The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that they have already paid to you.

The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.

Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount that was recovered so pleased CMS that it has now authorized a nationwide rollout.

So RAC audits could be in your future no matter where you practice. And now is the time to examine your Medicare claims to determine where you may be vulnerable in the event of an RAC audit of past claims and to minimize your risk of audit on future claims. Limitations on scope and look-back period should make that process relatively painless.

Here's how the program works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.

Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/

RACs are paid a percentage of any overpayments they can identify and collect from providers.

They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.

Although most audits are automatic, meaning an analysis of computer data only to identify administrative errors, the RACs are also authorized to undertake “complex” audits in which patient records are examined.

They will mostly be looking for only four basic transgressions:

▸ Incorrect payment amounts (either too much or too little).

▸ Noncovered services, including those that are not considered “reasonable and necessary.”

▸ Incorrect coding.

▸ Duplicate payments.

The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That is a relatively short period of time requiring your review, and a relatively small number of transgressions that you need to look for.

So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.

So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game. And it's only a matter of time before state-run Medicaid programs become targets as well.

CMS has hinted that a majority of audits will take place in California, New York, and Florida, because 25% of all Medicare payments are made to those three states alone.

If a RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.

The law provides you 45 days to respond to a RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss! The RAC's medical director is “required to be actively involved in examining all evidence used to make determinations,” and you have a right to speak to him or her if you wish.

If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.

In case you're wondering, RAC audits will not replace regular Medicare audits, which I discussed in my June 2004 column.

To respond to this column, e-mail Dr. Eastern at [email protected]

The Centers for Medicare and Medicaid Services thinks it is overpaying you. That probably comes as no surprise, nor will the news that CMS has devised yet another scheme for taking back money that they have already paid to you.

The new reel-in is called a recovery audit contractor (RAC) audit, and if this is the first you've heard of it, you probably don't practice in California, Florida, New York, Massachusetts, or South Carolina.

Those states were the sites of a pilot program conducted over the last 3 years to test the RAC system. The total amount that was recovered so pleased CMS that it has now authorized a nationwide rollout.

So RAC audits could be in your future no matter where you practice. And now is the time to examine your Medicare claims to determine where you may be vulnerable in the event of an RAC audit of past claims and to minimize your risk of audit on future claims. Limitations on scope and look-back period should make that process relatively painless.

Here's how the program works: CMS has divided the country into four regions and put an RAC in charge of each one. Region A (Northeast states) is covered by Diversified Collection Services; Region B (the Midwest) by CGI Technologies and Solutions; Region C (the South) by Connolly Consulting Associates; and Region D (the West and Southwest plus Alaska and Hawaii) by HealthData Insights.

Each RAC has its own unique procedures and criteria for audits. You can learn more about your RAC's idiosyncrasies, and confirm which region includes your state, at the CMS Web site: www.cms.hhs.gov/RAC/

RACs are paid a percentage of any overpayments they can identify and collect from providers.

They are supposed to identify underpayments too, but in the pilot program that amounted to less than $38 million, compared with over $900 million in overpayments.

Although most audits are automatic, meaning an analysis of computer data only to identify administrative errors, the RACs are also authorized to undertake “complex” audits in which patient records are examined.

They will mostly be looking for only four basic transgressions:

▸ Incorrect payment amounts (either too much or too little).

▸ Noncovered services, including those that are not considered “reasonable and necessary.”

▸ Incorrect coding.

▸ Duplicate payments.

The RACs are required to have good cause to audit your claims. They cannot randomly select claims or focus only on high-paying claims. And they can only look back a maximum of 3 years—and no earlier than Oct. 1, 2007. That is a relatively short period of time requiring your review, and a relatively small number of transgressions that you need to look for.

So now is the time for your staff to start getting out Medicare EOBs (explanation of benefits) and determine where you might be vulnerable on the past 2 years' claims. And once you identify any vulnerabilities, you can take steps to audit-proof future claims.

So far, the RACs have mostly targeted hospitals, nursing homes, home health care organizations, and medical equipment companies, but anyone who bills Medicare is fair game. And it's only a matter of time before state-run Medicaid programs become targets as well.

CMS has hinted that a majority of audits will take place in California, New York, and Florida, because 25% of all Medicare payments are made to those three states alone.

If a RAC wants to look at your records, they must make the request in writing and they must tell you what they are looking for. They are limited by law to auditing no more than 10% of the average number of Medicare claims you file each month. The law states they must pay the costs of copying records, both paper and electronic.

The law provides you 45 days to respond to a RAC's request for patient records. It also specifies a “discussion period,” so if your records are requested, don't rush to send them. Call the RAC and discuss! The RAC's medical director is “required to be actively involved in examining all evidence used to make determinations,” and you have a right to speak to him or her if you wish.

If a repayment is demanded, you have 120 days to appeal that determination, in the same way (and by essentially the same process) that conventional Medicare audit determinations are appealed.

In case you're wondering, RAC audits will not replace regular Medicare audits, which I discussed in my June 2004 column.

To respond to this column, e-mail Dr. Eastern at [email protected]

Staying abreast of new information just might be the greatest challenge in medicine today. All of us suffer from information overload, a phenomenon of relatively recent onset that can only get worse.

Five hundred years ago, Leonardo da Vinci could be an artist, an engineer, a musician, a scientist, and an inventor. One hundred years ago, a physician could actually aspire to know virtually all there was to know about medicine at the time.

Today, with a body of medical knowledge that is estimated to double every 3-5 years, keeping current is an exercise in futility. Furthermore, as our medical knowledge increases in depth, we are forced to surrender its width—with the perennial fear that we eventually will end up, as the old joke goes, knowing everything about nothing.

This is the age of information, but it is also the age of cyberspace, and the Internet was supposed to help us solve our information problem. Computers, we were promised, would give us paperless offices, instant continuing medical education, and a venue for gathering new information as it became available and organizing it efficiently.

Some progress has been made. All of the major dermatology print journals are now available online. But the Internet promised us so much more.

Wouldn't it be great if there were a real-time online forum, devoted exclusively to dermatology, where new therapies, fascinating and rare cases, and controversial ideas could be exchanged with other dermatologists from around the world? One where you could get virtually instantaneous answers to pressing medical questions and share hard-to-find information at the speed of light?

As a matter of fact, there is. RxDerm-L, the brainchild of Dr. Arthur C. Huntley, is a medical forum that does all of that and more. And it's free. I joined several years ago, and I'm not sure how I ever got along without it.

An e-mail list open only to dermatologists, RxDerm-L currently has about 1,500 members from all over the world. We have residents eager to share the latest data, retired practitioners with decades of priceless experience, and everybody in between.

Think of it as the “Schoch Letter” on amphetamines.

Every day, I have the ability to discuss issues of importance to our specialty with excellent clinicians in the United States, Canada, Mexico, South and Central America, Europe, India, Australia, New Zealand, and the Middle East. They look at my interesting cases (via digital photos), and I look at theirs. They suggest treatment options I've never heard of, or have forgotten about. They offer their opinions on every medical subject imaginable and I offer mine, and we rant and debate and, in general, have a great time. Continuing education was never so much fun.

When I have a baffling case, I present it on RxDerm-L. Within hours I've accumulated a world class clinical symposium with plenty of ideas for therapy.

When I need clinical photos for a presentation, at least one list member has them, or knows where I can get them. If I'm writing a new patient information handout or a consent form, list members will share ideas with me and critique the result.

We discuss new ideas, concepts, and treatments long before they become generally known. Biologic therapies, topical calcineurin inhibitors, cyclosporine and related compounds, filler substances and botulinum toxin, the sentinel lymph node controversy, lasers, blue lights—all of these topics (and countless others) were discussed extensively on RxDerm-L long before they became mainstream.

There is no charge to join either forum—all you need is a computer and Internet access. Both RxDerm-L and DermChat are open only to dermatologists and dermatology residents, so if you are not a member of the American Academy of Dermatology, you will have to furnish some other form of proof that you are a dermatologist.

To respond to this column, e-mail Dr. Eastern at [email protected]

Staying abreast of new information just might be the greatest challenge in medicine today. All of us suffer from information overload, a phenomenon of relatively recent onset that can only get worse.

Five hundred years ago, Leonardo da Vinci could be an artist, an engineer, a musician, a scientist, and an inventor. One hundred years ago, a physician could actually aspire to know virtually all there was to know about medicine at the time.

Today, with a body of medical knowledge that is estimated to double every 3-5 years, keeping current is an exercise in futility. Furthermore, as our medical knowledge increases in depth, we are forced to surrender its width—with the perennial fear that we eventually will end up, as the old joke goes, knowing everything about nothing.

This is the age of information, but it is also the age of cyberspace, and the Internet was supposed to help us solve our information problem. Computers, we were promised, would give us paperless offices, instant continuing medical education, and a venue for gathering new information as it became available and organizing it efficiently.

Some progress has been made. All of the major dermatology print journals are now available online. But the Internet promised us so much more.

Wouldn't it be great if there were a real-time online forum, devoted exclusively to dermatology, where new therapies, fascinating and rare cases, and controversial ideas could be exchanged with other dermatologists from around the world? One where you could get virtually instantaneous answers to pressing medical questions and share hard-to-find information at the speed of light?

As a matter of fact, there is. RxDerm-L, the brainchild of Dr. Arthur C. Huntley, is a medical forum that does all of that and more. And it's free. I joined several years ago, and I'm not sure how I ever got along without it.

An e-mail list open only to dermatologists, RxDerm-L currently has about 1,500 members from all over the world. We have residents eager to share the latest data, retired practitioners with decades of priceless experience, and everybody in between.

Think of it as the “Schoch Letter” on amphetamines.

Every day, I have the ability to discuss issues of importance to our specialty with excellent clinicians in the United States, Canada, Mexico, South and Central America, Europe, India, Australia, New Zealand, and the Middle East. They look at my interesting cases (via digital photos), and I look at theirs. They suggest treatment options I've never heard of, or have forgotten about. They offer their opinions on every medical subject imaginable and I offer mine, and we rant and debate and, in general, have a great time. Continuing education was never so much fun.

When I have a baffling case, I present it on RxDerm-L. Within hours I've accumulated a world class clinical symposium with plenty of ideas for therapy.

When I need clinical photos for a presentation, at least one list member has them, or knows where I can get them. If I'm writing a new patient information handout or a consent form, list members will share ideas with me and critique the result.

We discuss new ideas, concepts, and treatments long before they become generally known. Biologic therapies, topical calcineurin inhibitors, cyclosporine and related compounds, filler substances and botulinum toxin, the sentinel lymph node controversy, lasers, blue lights—all of these topics (and countless others) were discussed extensively on RxDerm-L long before they became mainstream.

There is no charge to join either forum—all you need is a computer and Internet access. Both RxDerm-L and DermChat are open only to dermatologists and dermatology residents, so if you are not a member of the American Academy of Dermatology, you will have to furnish some other form of proof that you are a dermatologist.

To respond to this column, e-mail Dr. Eastern at [email protected]

Staying abreast of new information just might be the greatest challenge in medicine today. All of us suffer from information overload, a phenomenon of relatively recent onset that can only get worse.

Five hundred years ago, Leonardo da Vinci could be an artist, an engineer, a musician, a scientist, and an inventor. One hundred years ago, a physician could actually aspire to know virtually all there was to know about medicine at the time.

Today, with a body of medical knowledge that is estimated to double every 3-5 years, keeping current is an exercise in futility. Furthermore, as our medical knowledge increases in depth, we are forced to surrender its width—with the perennial fear that we eventually will end up, as the old joke goes, knowing everything about nothing.

This is the age of information, but it is also the age of cyberspace, and the Internet was supposed to help us solve our information problem. Computers, we were promised, would give us paperless offices, instant continuing medical education, and a venue for gathering new information as it became available and organizing it efficiently.

Some progress has been made. All of the major dermatology print journals are now available online. But the Internet promised us so much more.

Wouldn't it be great if there were a real-time online forum, devoted exclusively to dermatology, where new therapies, fascinating and rare cases, and controversial ideas could be exchanged with other dermatologists from around the world? One where you could get virtually instantaneous answers to pressing medical questions and share hard-to-find information at the speed of light?

As a matter of fact, there is. RxDerm-L, the brainchild of Dr. Arthur C. Huntley, is a medical forum that does all of that and more. And it's free. I joined several years ago, and I'm not sure how I ever got along without it.

An e-mail list open only to dermatologists, RxDerm-L currently has about 1,500 members from all over the world. We have residents eager to share the latest data, retired practitioners with decades of priceless experience, and everybody in between.

Think of it as the “Schoch Letter” on amphetamines.

Every day, I have the ability to discuss issues of importance to our specialty with excellent clinicians in the United States, Canada, Mexico, South and Central America, Europe, India, Australia, New Zealand, and the Middle East. They look at my interesting cases (via digital photos), and I look at theirs. They suggest treatment options I've never heard of, or have forgotten about. They offer their opinions on every medical subject imaginable and I offer mine, and we rant and debate and, in general, have a great time. Continuing education was never so much fun.

When I have a baffling case, I present it on RxDerm-L. Within hours I've accumulated a world class clinical symposium with plenty of ideas for therapy.

When I need clinical photos for a presentation, at least one list member has them, or knows where I can get them. If I'm writing a new patient information handout or a consent form, list members will share ideas with me and critique the result.

We discuss new ideas, concepts, and treatments long before they become generally known. Biologic therapies, topical calcineurin inhibitors, cyclosporine and related compounds, filler substances and botulinum toxin, the sentinel lymph node controversy, lasers, blue lights—all of these topics (and countless others) were discussed extensively on RxDerm-L long before they became mainstream.

There is no charge to join either forum—all you need is a computer and Internet access. Both RxDerm-L and DermChat are open only to dermatologists and dermatology residents, so if you are not a member of the American Academy of Dermatology, you will have to furnish some other form of proof that you are a dermatologist.

To respond to this column, e-mail Dr. Eastern at [email protected]

[email protected]

Fraud and economic crime are on the rise, according to many law enforcement officials around the country. The Denver District Attorney, for example, reported that theft and embezzlement complaints increased by 30% in his jurisdiction in 2008.

A lot of embezzlement goes undetected in medical offices. People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected because no one is looking.

The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.

“It wasn't at all clever,” he said, “and I'm somewhat chagrined to admit that it happened to me.” Is it happening to you, too? You won't know unless you look.

Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:

▸ Hire honest employees. This may seem obvious, but it is amazing how few doctors check applicants' references. Call them and find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites such as www.KnowX.com

▸ Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, other than paying a fair, competitive wage and doing what you can to maximize job satisfaction, but there are lots of things you can do to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that. Be on the lookout for holes in your accounting system that provide opportunity for theft, and if you find one, close it. Your accountant can help with this.

▸ Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the receipts and the cash daily.

▸ Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check, and a third should match invoices to goods and services received.

▸ Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.

▸ Safeguard your computer. You would think that computers would have helped to alleviate embezzlement, but they have made it easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system. Ask about them.

▸ Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility? Is an employee suddenly living beyond his or her means?

▸ Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.

[email protected]

Fraud and economic crime are on the rise, according to many law enforcement officials around the country. The Denver District Attorney, for example, reported that theft and embezzlement complaints increased by 30% in his jurisdiction in 2008.

A lot of embezzlement goes undetected in medical offices. People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected because no one is looking.

The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.

“It wasn't at all clever,” he said, “and I'm somewhat chagrined to admit that it happened to me.” Is it happening to you, too? You won't know unless you look.

Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:

▸ Hire honest employees. This may seem obvious, but it is amazing how few doctors check applicants' references. Call them and find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites such as www.KnowX.com

▸ Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, other than paying a fair, competitive wage and doing what you can to maximize job satisfaction, but there are lots of things you can do to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that. Be on the lookout for holes in your accounting system that provide opportunity for theft, and if you find one, close it. Your accountant can help with this.

▸ Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the receipts and the cash daily.

▸ Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check, and a third should match invoices to goods and services received.

▸ Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.

▸ Safeguard your computer. You would think that computers would have helped to alleviate embezzlement, but they have made it easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system. Ask about them.

▸ Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility? Is an employee suddenly living beyond his or her means?

▸ Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.

[email protected]

Fraud and economic crime are on the rise, according to many law enforcement officials around the country. The Denver District Attorney, for example, reported that theft and embezzlement complaints increased by 30% in his jurisdiction in 2008.

A lot of embezzlement goes undetected in medical offices. People who investigate embezzlement crimes for a living say that most cases are uncovered by accident. Finding it is usually relatively easy, because most embezzlers are not particularly skillful nor very good at covering their tracks, but many cases go undetected because no one is looking.

The experience of a friend of mine was all too typical: His bookkeeper wrote sizable checks to herself, entering them in the ledger as payments to vendors commonly used by his practice. Since she also balanced the checkbook, she got away with it for many months.

“It wasn't at all clever,” he said, “and I'm somewhat chagrined to admit that it happened to me.” Is it happening to you, too? You won't know unless you look.

Detecting fraud is an inexact science. There is no textbook approach that one can follow, but a few simple measures will uncover or prevent a large percentage of dishonest behavior:

▸ Hire honest employees. This may seem obvious, but it is amazing how few doctors check applicants' references. Call them and find out if the applicants are really as good as they look on paper. For a few dollars, you can screen prospective employees on public information Web sites such as www.KnowX.com

▸ Minimize opportunities for dishonesty. Theft and embezzlement are the products of motivation and opportunity. It is hard to control motivation, other than paying a fair, competitive wage and doing what you can to maximize job satisfaction, but there are lots of things you can do to minimize opportunities for dishonesty. No one person should be in charge of the entire bookkeeping process. The person who enters charges should be different from the one who enters payments. The employee who writes the checks should not balance the checkbook, and so on. Internal audits should be done on a regular basis, and all employees should know that. Be on the lookout for holes in your accounting system that provide opportunity for theft, and if you find one, close it. Your accountant can help with this.

▸ Reconcile receipts and cash daily. The most common form of embezzlement is simply taking cash out of the till. In a typical scenario, a patient pays a $15 copay in cash but the receptionist records the payment as $5 and pockets the rest. Make sure a receipt is generated for every cash transaction, and that someone other than the person accepting cash reconciles the receipts and the cash daily.

▸ Insist on separate accounting duties. Another common scam is false invoices: You think you are paying for supplies and services, but the money is going to an employee. Once again, separation of duties is the key to prevention. One employee should enter invoices into the data system, another should issue the check, and a third should match invoices to goods and services received.

▸ Verify expense reports. False expense reports are another common form of fraud. When an employee asks for reimbursement of expenses, make sure they are real.

▸ Safeguard your computer. You would think that computers would have helped to alleviate embezzlement, but they have made it easier and more tempting. Data are usually concentrated in one place, accounts can be accessed from remote workstations or off-premises servers, and a paper trail is often eliminated. Your computer vendor should be aware of this, and should have safeguards built into your system. Ask about them.

▸ Look for red flags. Do you have an employee who refuses to take vacations, because someone else will have to look at the books? Does someone insist on approving or entering expenses that are another employee's responsibility? Is an employee suddenly living beyond his or her means?

▸ Consider bonding your employees. The mere knowledge that your staff is bonded will scare away most applicants with a history of dishonesty, and you will be assured of some measure of recovery should the above safeguards fail.

You have a lot of money invested in your medical equipment, so you are careful to do whatever is necessary to keep it in good working order. Your cauteries, light boxes, and lasers get regular maintenance, and your curettes and scissors get resharpened as soon as they begin to dull. Your computer files get backed up, software gets upgraded, and new applications get installed whenever necessary.

Interesting, isn't it, how we devote so much time and attention to maintaining tools—and so little to maintaining ourselves. I have written about this issue before, and I certainly will again, because it is critical to overall well-being.

Most physicians are compulsive. We feel obligated to work strenuously and unceasingly. We become enmeshed in our daily routine. We are reluctant to take vacations because we fall behind, and patients might go elsewhere while we are gone; every day the office is idle we “lose money.”

Sooner or later, no matter how dedicated we are, the grind gets to us, leading to fatigue, irritability, and a progressive decline in motivation. We are too busy to sit down, look at the big picture, and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.

You need to maintain your intellectual and emotional health as carefully as you maintain your equipment by scheduling “mental rejuvenation days.” Once a month, take a day off to relax, think, and challenge your mind.

Stephen R. Covey, author of “The 7 Habits of Highly Effective People,” calls this “sharpening the saw,” and applying it regularly can be a life-changing experience.

I'm not simply talking about catching up on journals or taking a CME course, although that's how I spend some of my rejuvenation days. Once in awhile, try something new, something you've been thinking about doing “someday, when there is time.”

Take a piano lesson. Learn to sail. Finally read “War and Peace.” Take your spouse someplace for a long weekend. Get out of your comfort zone. Challenge yourself.

I know how some of you feel about “wasting” a day: You consider it lost money. Vacations are even worse, because overhead money continues to go out and no revenue is coming in.

That whole paradigm is wrong. Stop thinking day to day. Think year to year instead. You bring in a given amount of revenue per year—more on some days, less on other days, none on weekends and vacation days. It all averages out in the end. Besides, this is much more important than money. This is breaking the routine, clearing the cobwebs, living your life.

Last month my wife and I drove to New Hampshire, checked into a bed-and-breakfast, and climbed Mount Monadnock, the most-climbed mountain in North America. It was her idea (she is much more fit than I), but as I huffed and puffed up the trail, I didn't have the time—or the slightest inclination—to worry about the office. We were only gone 3 days, but it felt like a week, and I came back ready to take on the world and my practice.

And I came back with some great ideas—practical, medical, and literary. Original thoughts are hard to come by during the daily grind, but they often appear, unannounced, in a new and refreshing environment.

Creative people have long recognized the value of rejuvenation days. A classic example is the oft-told story of Swiss research scientists K. Alex Müller and J. Georg Bednorz. In 1986 they reached a major impasse in their superconductivity research; it appeared 2 decades of work might be for naught. Spending a day in the library to clear his head, Müller decided to put aside his troubles and look up a subject that had always interested him: ceramics.

Nothing could have been further from his research field, of course, since ceramics are among the poorest conductors known. Yet as he relaxed and read, it occurred to Müller that a unique property of ceramics might apply to their project. Back in the lab, the team created a ceramic compound that became the first successful “high-temperature” superconductor.

The rest, as they say, is history; Mr. Müller and Mr. Bednorz won the 1987 Nobel Prize in Physics and triggered an explosion of research leading to breakthroughs in computing, electricity transmission, magnetically elevated trains, and many other applications.

Your rejuvenation days may not change the world, but they will change you. They will give you fresh ideas, and help you look at the same old problems in completely new ways.

And to those who still can't bear the thought of taking time off, remember Eastern's Second Law: Your last words will NOT be, “I wish I had spent more time in the office!”

To respond to this column, e-mail Dr. Eastern at [email protected]

You have a lot of money invested in your medical equipment, so you are careful to do whatever is necessary to keep it in good working order. Your cauteries, light boxes, and lasers get regular maintenance, and your curettes and scissors get resharpened as soon as they begin to dull. Your computer files get backed up, software gets upgraded, and new applications get installed whenever necessary.

Interesting, isn't it, how we devote so much time and attention to maintaining tools—and so little to maintaining ourselves. I have written about this issue before, and I certainly will again, because it is critical to overall well-being.

Most physicians are compulsive. We feel obligated to work strenuously and unceasingly. We become enmeshed in our daily routine. We are reluctant to take vacations because we fall behind, and patients might go elsewhere while we are gone; every day the office is idle we “lose money.”

Sooner or later, no matter how dedicated we are, the grind gets to us, leading to fatigue, irritability, and a progressive decline in motivation. We are too busy to sit down, look at the big picture, and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.

You need to maintain your intellectual and emotional health as carefully as you maintain your equipment by scheduling “mental rejuvenation days.” Once a month, take a day off to relax, think, and challenge your mind.

Stephen R. Covey, author of “The 7 Habits of Highly Effective People,” calls this “sharpening the saw,” and applying it regularly can be a life-changing experience.

I'm not simply talking about catching up on journals or taking a CME course, although that's how I spend some of my rejuvenation days. Once in awhile, try something new, something you've been thinking about doing “someday, when there is time.”

Take a piano lesson. Learn to sail. Finally read “War and Peace.” Take your spouse someplace for a long weekend. Get out of your comfort zone. Challenge yourself.

I know how some of you feel about “wasting” a day: You consider it lost money. Vacations are even worse, because overhead money continues to go out and no revenue is coming in.

That whole paradigm is wrong. Stop thinking day to day. Think year to year instead. You bring in a given amount of revenue per year—more on some days, less on other days, none on weekends and vacation days. It all averages out in the end. Besides, this is much more important than money. This is breaking the routine, clearing the cobwebs, living your life.

Last month my wife and I drove to New Hampshire, checked into a bed-and-breakfast, and climbed Mount Monadnock, the most-climbed mountain in North America. It was her idea (she is much more fit than I), but as I huffed and puffed up the trail, I didn't have the time—or the slightest inclination—to worry about the office. We were only gone 3 days, but it felt like a week, and I came back ready to take on the world and my practice.

And I came back with some great ideas—practical, medical, and literary. Original thoughts are hard to come by during the daily grind, but they often appear, unannounced, in a new and refreshing environment.

Creative people have long recognized the value of rejuvenation days. A classic example is the oft-told story of Swiss research scientists K. Alex Müller and J. Georg Bednorz. In 1986 they reached a major impasse in their superconductivity research; it appeared 2 decades of work might be for naught. Spending a day in the library to clear his head, Müller decided to put aside his troubles and look up a subject that had always interested him: ceramics.

Nothing could have been further from his research field, of course, since ceramics are among the poorest conductors known. Yet as he relaxed and read, it occurred to Müller that a unique property of ceramics might apply to their project. Back in the lab, the team created a ceramic compound that became the first successful “high-temperature” superconductor.

The rest, as they say, is history; Mr. Müller and Mr. Bednorz won the 1987 Nobel Prize in Physics and triggered an explosion of research leading to breakthroughs in computing, electricity transmission, magnetically elevated trains, and many other applications.

Your rejuvenation days may not change the world, but they will change you. They will give you fresh ideas, and help you look at the same old problems in completely new ways.

And to those who still can't bear the thought of taking time off, remember Eastern's Second Law: Your last words will NOT be, “I wish I had spent more time in the office!”

To respond to this column, e-mail Dr. Eastern at [email protected]

You have a lot of money invested in your medical equipment, so you are careful to do whatever is necessary to keep it in good working order. Your cauteries, light boxes, and lasers get regular maintenance, and your curettes and scissors get resharpened as soon as they begin to dull. Your computer files get backed up, software gets upgraded, and new applications get installed whenever necessary.

Interesting, isn't it, how we devote so much time and attention to maintaining tools—and so little to maintaining ourselves. I have written about this issue before, and I certainly will again, because it is critical to overall well-being.

Most physicians are compulsive. We feel obligated to work strenuously and unceasingly. We become enmeshed in our daily routine. We are reluctant to take vacations because we fall behind, and patients might go elsewhere while we are gone; every day the office is idle we “lose money.”

Sooner or later, no matter how dedicated we are, the grind gets to us, leading to fatigue, irritability, and a progressive decline in motivation. We are too busy to sit down, look at the big picture, and think about what we might do to break that vicious cycle. This is detrimental to our own well-being, as well as that of our patients.

You need to maintain your intellectual and emotional health as carefully as you maintain your equipment by scheduling “mental rejuvenation days.” Once a month, take a day off to relax, think, and challenge your mind.

Stephen R. Covey, author of “The 7 Habits of Highly Effective People,” calls this “sharpening the saw,” and applying it regularly can be a life-changing experience.

I'm not simply talking about catching up on journals or taking a CME course, although that's how I spend some of my rejuvenation days. Once in awhile, try something new, something you've been thinking about doing “someday, when there is time.”

Take a piano lesson. Learn to sail. Finally read “War and Peace.” Take your spouse someplace for a long weekend. Get out of your comfort zone. Challenge yourself.

I know how some of you feel about “wasting” a day: You consider it lost money. Vacations are even worse, because overhead money continues to go out and no revenue is coming in.

That whole paradigm is wrong. Stop thinking day to day. Think year to year instead. You bring in a given amount of revenue per year—more on some days, less on other days, none on weekends and vacation days. It all averages out in the end. Besides, this is much more important than money. This is breaking the routine, clearing the cobwebs, living your life.

Last month my wife and I drove to New Hampshire, checked into a bed-and-breakfast, and climbed Mount Monadnock, the most-climbed mountain in North America. It was her idea (she is much more fit than I), but as I huffed and puffed up the trail, I didn't have the time—or the slightest inclination—to worry about the office. We were only gone 3 days, but it felt like a week, and I came back ready to take on the world and my practice.

And I came back with some great ideas—practical, medical, and literary. Original thoughts are hard to come by during the daily grind, but they often appear, unannounced, in a new and refreshing environment.

Creative people have long recognized the value of rejuvenation days. A classic example is the oft-told story of Swiss research scientists K. Alex Müller and J. Georg Bednorz. In 1986 they reached a major impasse in their superconductivity research; it appeared 2 decades of work might be for naught. Spending a day in the library to clear his head, Müller decided to put aside his troubles and look up a subject that had always interested him: ceramics.

Nothing could have been further from his research field, of course, since ceramics are among the poorest conductors known. Yet as he relaxed and read, it occurred to Müller that a unique property of ceramics might apply to their project. Back in the lab, the team created a ceramic compound that became the first successful “high-temperature” superconductor.

The rest, as they say, is history; Mr. Müller and Mr. Bednorz won the 1987 Nobel Prize in Physics and triggered an explosion of research leading to breakthroughs in computing, electricity transmission, magnetically elevated trains, and many other applications.

Your rejuvenation days may not change the world, but they will change you. They will give you fresh ideas, and help you look at the same old problems in completely new ways.

And to those who still can't bear the thought of taking time off, remember Eastern's Second Law: Your last words will NOT be, “I wish I had spent more time in the office!”

To respond to this column, e-mail Dr. Eastern at [email protected]

If you haven't taken a close look at your managed care plans recently, you may be shocked to find that you have been staying with a doddering old plan whose fee schedule is terrible, and whose few patients are generating negligible remuneration for your practice—when long ago you could have replaced it with a young, aggressive, well-paying organization.

This is the sort of disagreeable task most physicians plan to do in their “free time” (which, of course, is never). But the effort can be well worth it.

It is a pretty safe bet that third-party payers aren't going to take it upon themselves to pay you more. You have to ask for a raise.

Here's how to do it: First, ask your employees to assemble data starting with lists of the last 50 patients affiliated with each third-party contract. Your computer should be able to assemble these. For each patient, compile diagnoses, procedure codes billed, amount billed and paid for each code, and any problems encountered (especially payment delays and requests for records). Ask for any correspondence on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to each provider relations department. Indicate that you are updating your managed care data. Include a list of your 25 most commonly used CPT codes, and ask for the plan's maximum allowable reimbursement for each.

Then ask some basic questions. Here are the five we ask:

▸ Does your organization recognize the “-25” modifier?

▸ If a diagnostic or surgical procedure and an evaluation and management encounter are performed during the same patient visit, does your organization reimburse them as separate services?

▸ If multiple diagnostic or surgical procedures are performed on the same day, how does your organization reimburse such procedures?

▸ What are your official criteria for coding consults versus office visits?

▸ What is your average and maximum time for processing a clean claim?

Have a staffer follow each letter with a telephone call in 10 days to make sure the letter was received and will be answered promptly.

Once the data have been assembled, schedule a meeting with your office manager and your insurance specialist. At the meeting, armed with the answers received from each payer and the data collected, analyze each plan in detail.

How many patients enrolled in the plan are currently active in your office? Is that number increasing or decreasing? How well, compared with other plans, Medicare, and your regular fees, does each one compensate you? How promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for noncovered charges?

Now, get more specific. Precisely what is not covered? Which procedures are paid particularly well and which particularly poorly (or not at all), despite being ostensibly “covered”? Are there any weird rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for “further information”? Are you asked for the same information repeatedly? Are there problems with “-25,” “-78,” or other modifiers?

Take a look at the numbers. What fraction of accounts receivable is due to each plan at any particular moment? Is that number increasing? Is that because the number of patients in the plan is increasing, or is the plan losing momentum in bill paying? (The latter is a red flag.)

Also, look at mechanics. How easy is it for patients in each plan to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? (Some plans still give PCPs financial incentives not to refer. Review your contracts.) On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your staff. Their subjective impressions are just as important as any hard data. They'll separate the “good” plans from the “bad” immediately, but ask some specific questions, too. Are staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to reach provider relations—and are they helpful and courteous? Are provider relations representatives constantly calling with inappropriate questions?

Now you have your own up-to-the-minute managed care database. Use it immediately to determine which plans to keep and which to cut loose. Repeat this exercise regularly.

And there's one other important use for the database: Use it to renegotiate fee schedules. Any plan whose fees are below your average remuneration should receive a letter informing them of this. However, tell them that you will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are increased.

They may not give the entire increase you want, but you'll usually get something. If not, reconsider your decision to keep that plan aboard.

If you haven't taken a close look at your managed care plans recently, you may be shocked to find that you have been staying with a doddering old plan whose fee schedule is terrible, and whose few patients are generating negligible remuneration for your practice—when long ago you could have replaced it with a young, aggressive, well-paying organization.

This is the sort of disagreeable task most physicians plan to do in their “free time” (which, of course, is never). But the effort can be well worth it.

It is a pretty safe bet that third-party payers aren't going to take it upon themselves to pay you more. You have to ask for a raise.

Here's how to do it: First, ask your employees to assemble data starting with lists of the last 50 patients affiliated with each third-party contract. Your computer should be able to assemble these. For each patient, compile diagnoses, procedure codes billed, amount billed and paid for each code, and any problems encountered (especially payment delays and requests for records). Ask for any correspondence on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to each provider relations department. Indicate that you are updating your managed care data. Include a list of your 25 most commonly used CPT codes, and ask for the plan's maximum allowable reimbursement for each.

Then ask some basic questions. Here are the five we ask:

▸ Does your organization recognize the “-25” modifier?

▸ If a diagnostic or surgical procedure and an evaluation and management encounter are performed during the same patient visit, does your organization reimburse them as separate services?

▸ If multiple diagnostic or surgical procedures are performed on the same day, how does your organization reimburse such procedures?

▸ What are your official criteria for coding consults versus office visits?

▸ What is your average and maximum time for processing a clean claim?

Have a staffer follow each letter with a telephone call in 10 days to make sure the letter was received and will be answered promptly.

Once the data have been assembled, schedule a meeting with your office manager and your insurance specialist. At the meeting, armed with the answers received from each payer and the data collected, analyze each plan in detail.

How many patients enrolled in the plan are currently active in your office? Is that number increasing or decreasing? How well, compared with other plans, Medicare, and your regular fees, does each one compensate you? How promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for noncovered charges?

Now, get more specific. Precisely what is not covered? Which procedures are paid particularly well and which particularly poorly (or not at all), despite being ostensibly “covered”? Are there any weird rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for “further information”? Are you asked for the same information repeatedly? Are there problems with “-25,” “-78,” or other modifiers?

Take a look at the numbers. What fraction of accounts receivable is due to each plan at any particular moment? Is that number increasing? Is that because the number of patients in the plan is increasing, or is the plan losing momentum in bill paying? (The latter is a red flag.)

Also, look at mechanics. How easy is it for patients in each plan to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? (Some plans still give PCPs financial incentives not to refer. Review your contracts.) On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your staff. Their subjective impressions are just as important as any hard data. They'll separate the “good” plans from the “bad” immediately, but ask some specific questions, too. Are staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to reach provider relations—and are they helpful and courteous? Are provider relations representatives constantly calling with inappropriate questions?

Now you have your own up-to-the-minute managed care database. Use it immediately to determine which plans to keep and which to cut loose. Repeat this exercise regularly.

And there's one other important use for the database: Use it to renegotiate fee schedules. Any plan whose fees are below your average remuneration should receive a letter informing them of this. However, tell them that you will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are increased.

They may not give the entire increase you want, but you'll usually get something. If not, reconsider your decision to keep that plan aboard.

If you haven't taken a close look at your managed care plans recently, you may be shocked to find that you have been staying with a doddering old plan whose fee schedule is terrible, and whose few patients are generating negligible remuneration for your practice—when long ago you could have replaced it with a young, aggressive, well-paying organization.

This is the sort of disagreeable task most physicians plan to do in their “free time” (which, of course, is never). But the effort can be well worth it.

It is a pretty safe bet that third-party payers aren't going to take it upon themselves to pay you more. You have to ask for a raise.

Here's how to do it: First, ask your employees to assemble data starting with lists of the last 50 patients affiliated with each third-party contract. Your computer should be able to assemble these. For each patient, compile diagnoses, procedure codes billed, amount billed and paid for each code, and any problems encountered (especially payment delays and requests for records). Ask for any correspondence on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to each provider relations department. Indicate that you are updating your managed care data. Include a list of your 25 most commonly used CPT codes, and ask for the plan's maximum allowable reimbursement for each.

Then ask some basic questions. Here are the five we ask:

▸ Does your organization recognize the “-25” modifier?

▸ If a diagnostic or surgical procedure and an evaluation and management encounter are performed during the same patient visit, does your organization reimburse them as separate services?

▸ If multiple diagnostic or surgical procedures are performed on the same day, how does your organization reimburse such procedures?

▸ What are your official criteria for coding consults versus office visits?

▸ What is your average and maximum time for processing a clean claim?

Have a staffer follow each letter with a telephone call in 10 days to make sure the letter was received and will be answered promptly.

Once the data have been assembled, schedule a meeting with your office manager and your insurance specialist. At the meeting, armed with the answers received from each payer and the data collected, analyze each plan in detail.

How many patients enrolled in the plan are currently active in your office? Is that number increasing or decreasing? How well, compared with other plans, Medicare, and your regular fees, does each one compensate you? How promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for noncovered charges?

Now, get more specific. Precisely what is not covered? Which procedures are paid particularly well and which particularly poorly (or not at all), despite being ostensibly “covered”? Are there any weird rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for “further information”? Are you asked for the same information repeatedly? Are there problems with “-25,” “-78,” or other modifiers?

Take a look at the numbers. What fraction of accounts receivable is due to each plan at any particular moment? Is that number increasing? Is that because the number of patients in the plan is increasing, or is the plan losing momentum in bill paying? (The latter is a red flag.)

Also, look at mechanics. How easy is it for patients in each plan to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? (Some plans still give PCPs financial incentives not to refer. Review your contracts.) On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your staff. Their subjective impressions are just as important as any hard data. They'll separate the “good” plans from the “bad” immediately, but ask some specific questions, too. Are staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to reach provider relations—and are they helpful and courteous? Are provider relations representatives constantly calling with inappropriate questions?

Now you have your own up-to-the-minute managed care database. Use it immediately to determine which plans to keep and which to cut loose. Repeat this exercise regularly.

And there's one other important use for the database: Use it to renegotiate fee schedules. Any plan whose fees are below your average remuneration should receive a letter informing them of this. However, tell them that you will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are increased.

They may not give the entire increase you want, but you'll usually get something. If not, reconsider your decision to keep that plan aboard.

For most physicians, the resolution of patient complaints ranks second only to firing an employee on the least favorite tasks list. With so many potential problems and the many ways patients can react to them, it seems impossible to construct a template for consistent, mutually satisfactory resolutions.

But it can be done, and it is not as complex as it appears once you realize that the vast majority of complaints have the same basic roots: The patient's expectations have not been met. Sometimes it is your fault, sometimes it is the patient's fault, and often a bit of both, but either way, the result is the same. You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple three-part strategy:

▸ Discover which expectations went unmet and why.

▸ Agree on a solution.

▸ Learn from the experience to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It is what you would want if you were the complainant, and it is often too important to trust to a subordinate.

At this point, you may be asking, “Why should I care?” Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, while a patient who is dissatisfied will frighten away 20 or more potential patients.

Besides, if the complaint is significant and you do not resolve it, the patient is likely to find someone who will; and chances are you will not like their choice or the eventual resolution.

The easiest way to deal with complaints is to prevent as many as possible. Try to nip unrealistic expectations in the bud. Take the time beforehand to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And, since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation (I say, yet again) is like garlic: There is no such thing as too much.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill is the one most people—especially physicians—do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

Listen to the patient's entire complaint without interrupting, defending, or justifying. Angry patients do not care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand correctly, you expected “X” to happen, but “Y” happened instead.” If I'm wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind—additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. By all means, let the patient propose a solution.

If the solution is reasonable, I will agree to it; if it's unreasonable, I will try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Do not be defensive; remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) interpret a refund as a tacit admission of guilt, so I try to avoid this approach. However, canceling a small fee for an angry patient can be prudent, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But usually, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, document everything. However, consider reserving a “private” chart area for such documentation so that it will not go out to referrers and other third parties with copies of your clinical notes. Consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in the future.

Above all, do not take complaints personally—even when they are personal. No matter how hard you try, you can never please everyone.

To respond to this column, e-mail Dr. Eastern at [email protected]

For most physicians, the resolution of patient complaints ranks second only to firing an employee on the least favorite tasks list. With so many potential problems and the many ways patients can react to them, it seems impossible to construct a template for consistent, mutually satisfactory resolutions.

But it can be done, and it is not as complex as it appears once you realize that the vast majority of complaints have the same basic roots: The patient's expectations have not been met. Sometimes it is your fault, sometimes it is the patient's fault, and often a bit of both, but either way, the result is the same. You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple three-part strategy:

▸ Discover which expectations went unmet and why.

▸ Agree on a solution.

▸ Learn from the experience to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It is what you would want if you were the complainant, and it is often too important to trust to a subordinate.

At this point, you may be asking, “Why should I care?” Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, while a patient who is dissatisfied will frighten away 20 or more potential patients.

Besides, if the complaint is significant and you do not resolve it, the patient is likely to find someone who will; and chances are you will not like their choice or the eventual resolution.

The easiest way to deal with complaints is to prevent as many as possible. Try to nip unrealistic expectations in the bud. Take the time beforehand to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And, since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation (I say, yet again) is like garlic: There is no such thing as too much.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill is the one most people—especially physicians—do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

Listen to the patient's entire complaint without interrupting, defending, or justifying. Angry patients do not care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand correctly, you expected “X” to happen, but “Y” happened instead.” If I'm wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind—additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. By all means, let the patient propose a solution.

If the solution is reasonable, I will agree to it; if it's unreasonable, I will try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Do not be defensive; remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) interpret a refund as a tacit admission of guilt, so I try to avoid this approach. However, canceling a small fee for an angry patient can be prudent, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But usually, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, document everything. However, consider reserving a “private” chart area for such documentation so that it will not go out to referrers and other third parties with copies of your clinical notes. Consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in the future.

Above all, do not take complaints personally—even when they are personal. No matter how hard you try, you can never please everyone.

To respond to this column, e-mail Dr. Eastern at [email protected]

For most physicians, the resolution of patient complaints ranks second only to firing an employee on the least favorite tasks list. With so many potential problems and the many ways patients can react to them, it seems impossible to construct a template for consistent, mutually satisfactory resolutions.

But it can be done, and it is not as complex as it appears once you realize that the vast majority of complaints have the same basic roots: The patient's expectations have not been met. Sometimes it is your fault, sometimes it is the patient's fault, and often a bit of both, but either way, the result is the same. You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple three-part strategy:

▸ Discover which expectations went unmet and why.

▸ Agree on a solution.

▸ Learn from the experience to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It is what you would want if you were the complainant, and it is often too important to trust to a subordinate.

At this point, you may be asking, “Why should I care?” Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, while a patient who is dissatisfied will frighten away 20 or more potential patients.

Besides, if the complaint is significant and you do not resolve it, the patient is likely to find someone who will; and chances are you will not like their choice or the eventual resolution.

The easiest way to deal with complaints is to prevent as many as possible. Try to nip unrealistic expectations in the bud. Take the time beforehand to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And, since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation (I say, yet again) is like garlic: There is no such thing as too much.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill is the one most people—especially physicians—do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

Listen to the patient's entire complaint without interrupting, defending, or justifying. Angry patients do not care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand correctly, you expected “X” to happen, but “Y” happened instead.” If I'm wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind—additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. By all means, let the patient propose a solution.

If the solution is reasonable, I will agree to it; if it's unreasonable, I will try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Do not be defensive; remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) interpret a refund as a tacit admission of guilt, so I try to avoid this approach. However, canceling a small fee for an angry patient can be prudent, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But usually, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, document everything. However, consider reserving a “private” chart area for such documentation so that it will not go out to referrers and other third parties with copies of your clinical notes. Consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in the future.

Above all, do not take complaints personally—even when they are personal. No matter how hard you try, you can never please everyone.

To respond to this column, e-mail Dr. Eastern at [email protected]