Mitigating Stacking Risks

Editor's Notes

• #2: Thanks everyone for joining me today for our on-demand video on mitigating risks associated with stacking physician agreements. I’m Allison Pullins from MD Ranger and I’ll be your host today.
• #3: Here’s how we’re going to spend our time in this video. First I’ll introduce MD Ranger before we get into the bulk of our content. Then we’ll talk about what stacking is exactly, and why it’s so risky for compliance. Then we’ll discuss some best practices for preventing stacking before it occurs And then we’ll wrap up with some case studies, which illustrate some common examples of when and how stacking occurs at hospital organizations.
• #4: MD Ranger is an online platform that integrates over 250 physician compensation benchmarks with a suite of compliance and financial tools. A secure, web-based Contract Data Tool to collect and organize contracts Analytics to benchmark contracts, review expenditures, identify compliance issues, and compare facilities Cost and compliance reports to compare your contracts to MD Ranger benchmarks Resources and research to support compliance efforts And Support from experts in physician compensation, FMV documentation, and compliance
• #5: In fact we aim to the the foundation of the physician contracting process MD Ranger helps subscribers standardize their physician contracting process in the way that is best for their organization. Because our benchmarks and online platforms can be integrated into all types of compliance and legal processes, we can be a resource to all types of organizations. . These types of financial arrangements can be very risky to organizations and to physicians—given federal regulations and hightened scrunity by the government. Our subscribers use the MD Ranger platform to mitigate that risk and monitor risky arrangements.
• #6: Here is a comprehensive list of the types of different physician agreements we benchmark. We drill down all our benchmarks by meaningful hospital demographics, like hospital size, trauma status, and more.
• #7: We began producing benchmarks in 2009 have have grown from a database of 4,000 to 28,000 contracts since. This is a map of our subscribers and where our data comes from. MD Ranger has more than 225 participating healthcare organizations. We work with all types of facilities from large urban trauma centers to small, rural critical access facilities, surgery centers, dialysis centers and everything in between. MD Ranger has strong representation from both rural facilities and small, community hospitals in urban areas, as well as large trauma centers and AMCs. 25% of our facilities are Level 1 or Level 2 trauma MD Ranger benchmarks hospital characteristics, allowing you to match the most appropriate data slice for each valuation
• #8: So let’s talk about what stacking is, and why it should be one of your physician contracting compliance concerns..
• #9: First of all, there are ways to catch many overpayments in physician agreements, particularly if the contracts are straightforward and benchmarking is available. Risks for overpayments are things like paying above FMV, or paying for too many hours per administrative deal. But, there are overpayments that are a lot harder to catch—particularly when reasonable looking payments are spread across multiple agreements and turn out not to be commercially reasonable when considered in aggregate.
• #10: So, what does the OIG tell us about problematic physician compensation structures? This opinion from 2007 talks about three areas to pay particularly close attention to that could result in compliance issues. First is X Etc etc.
• #11: So how does stacking commonly happen? Let’s talk about some scenarios. A physician or physician group has two or more agreements with a hospital for coverage or administrative/medical direction services It’s possible that the physician can coordinate his or her time to fulfill both responsibilities within a time frame generally understood as required to fulfill each agreement separately While agreement may be compliant when considered independently, when taken together, payment may be greater than the 90th percentile or the time commitment, particularly in the context of the physician’s clinical practice, requires more hours per year than full-time
• #12: Another likely scenario is that a call payment rate assumes an opportunity cost that actually doesn’t exist.
• #13: Now let’s discuss some ways to avoid stacking in the first place and some best practices to implement in your physician contracting program.
• #14: Develop a policy and review process regarding physicians who hold more than one position or perform more than one service with the hospital or affiliated organizations. If physicians are holding two call positions at the same time, set guidelines around how much they can be paid. If they are effectively an employed physician, set an aggregate payment cap from all sources.
• #15: Ask physicians for time documentation that delineates activities for each role. Time tracking should be standard for all physician administrative positions. As much you can, automate time tracking and coordinate effectively between all parties: physicians, finance, and administration.
• #16: Don’t pay a physician to take call for two services at the same time. Common service combinations where stacking most frequently occurs: Orthopedic surgery and hand surgery Plastic surgery and hand surgery Non-invasive and invasive cardiology Stroke and non-stroke neurology Trauma and general surgery
• #17: Ask the physician to sign a statement to certify that his or her private practice cannot be rearranged to avoid lost income. Another way is to monitor physicians’ OR utilization to compare elective volume with and without on-call coverage.
• #18: Now let’s review some case studies which illustrate common scenarios and services where stacking can easily occur.
• #19: Dr. Sally Smith is a hospitalist at a 300-bed community hospital, covering shifts and serving as medical director of the hospitalist panel. Additionally, Dr. Smithserves as the Vice Chief of Staff and has a consulting arrangement with the hospital to assist with EHR transition. She is a huge asset to the organization and the rate for each position falls with the fair market value for that position.
• #20: Despite Dr. Smiths talents, these responsibilities could be too much for anyone to handle, no matter how competent. If you take all of Dr. Smiths payments and consider them together, she’s being paid more than the 90th percentile of the annual income for a full-time hospitalist. It also raises the question that if a hospital pays a physician to be a full-time hospitalist, and also pays that individual for three additional jobs, can the physician be effective?
• #21: Furthermore, there is the issue of accurate time- tracking and reporting. There is a possibility that Dr. Wong could—in an admirable effort to be efficient and get the heavy workload done— perform additional administrative duties while she is on-duty and paid as a hospitalist. The takeaway here is that Dr. Smith’s total compensation must fall within FMV for the positions she fulfills, and justification for excess payment must be documented to demonstrate non-duplicative payments and duties.
• #22: Dr. George Perez is one of the few ENT physicians on the medical staff who is trained and willing to handle major facial injuries. He staffs two separate panels at the same Level II trauma center: ENT and facial injuries. Both panels are paid at the 75th percentile of their respective fair market value ranges, and he is allowed to take simultaneous call for both specialties. While this might make sense to Dr. Perez, it contradicts the principals in the OIG advisory opinions and OIG guidelines if he is being paid for taking call twice.
• #23: How might the hospital compensate Dr. Perez fairly without overpaying? Some organizations pay physicians in a similar situation at the high end of the market range for the best paid position. Other organizations will choose to pay at the median for one position and at or under the 25th percentile for the second service. No matter what is chosen, be aware of paying for two jobs at the same time. Carefully justify and document whatever payment is made.
• #24: Neurosurgery is particularly vulnerable to hidden compliance risks, especially in trauma centers Frequently both a requirement for restricted coverage, plus most non- emergency private practice revenue comes from a relatively small number of surgical cases that don’t have inflexible scheduling demands
• #25: The standard for Levels I and II trauma centers is that neurosurgeons must be immediately available and cannot conduct private practice when on-call (“restricted call”). Thus, compensation benchmarks for trauma center neurosurgery assume physicians suffer lost private practice income given the restriction of the physician’s activities while on call. This assumption is based on the understanding that the neurosurgeon’s practice is busy and nearly all the physician’s time could be utilized for the private practice.
• #26: However, if a physician’s practice has slack capacity and the private practice cases can be juggled (or traded with a partner), the physician may not suffer any opportunity cost. Aggregate compensation could be significantly beyond the 90th percentile of benchmark annual neurosurgery compensation.
• #27: Dr. Grace Williams is a cardiologist that works with a medical group that has a professional services agreement with the local hospital. In addition to the PSA, Dr. Williams and her colleagues have negotiated both a co- management agreement and additional medical directorship payments, including ad hoc payments for meeting attendance and peer review participation. Though her per diem call coverage payment is quite small and falls in the 25th percentile range, she and her colleagues are paid call stipends.
• #28: Immediately raises some red flags. Additional payments on top of PSA’s could result in payments to physicians above and beyond FMV
• #29: Thanks for joining us, good luck in the new year.