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Taking Care of Rehab Business

Help Fund the Jane Case Smith Memorial Bunch
October 16, 2014 3:19 PM by Iris Kimberg
As many of you may remember, Jane Case Smith, EdD, OTR/L, FAOTA, BCP passed away over the summer. Every therapist makes contributions to the patients and families they serve, and the colleagues they work alongside.  There are not many clinicians in our field whose extensive reach simultaneously touches the lives of patients, families, students and colleagues. She touched so many of us, some literally, others figuratively .  A few therapists truly shape and influence the way we practice, and Jane Case Smith was one of those therapists. She was a professor, a chairperson, a researcher, a lecturer, and an author. Her expertise and knowledge base extended from assessments, hand skill intervention, evidence based practice, autism, and fine motor outcomes in pre-school children.

There is now a campaign to raise money so that a memorial wooden bench and plaque can be erected at the Columbus Zoo.  Jane loved nature and animals and the bench will create a public place in the zoo where students, alumni, friends and family in the Columbus area can visit, remember, and think about Jane's influence on their lives.  In less than 2 weeks, the campaign raised over $1800 and is now less than $700 from its goal.

For information and to contribute:

http://www.gofundme.com/janecasesmithbench



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Occupational Therapy versus Bureaucracy
October 7, 2014 4:27 PM by Iris Kimberg
We all know that the hallmark of a great OT is one who is creative, a problem solver and someone who can think outside of the box.  It comes as no surprise that it a great OT might butt heads with a giant bureaucracy, in this case the NYC Department of Education. As told by Jim Dwyer in an Oct 3rd New York Times article: "This is a story of an almost unfathomably mindless school bureaucracy at work: the crushing of an occupational therapist who had helped a young boy build a record of blazing success."

"The therapist, Debbie Fisher, raised money on Kickstarter for a program that she and her student, Aaron Philip, 13, created called This Ability Not Disablity. An investigator with the Education Department's Office of Special Investigations, Wei Liu, found that Fisher sent emails about the project during her workday at Public School 333, the Manhattan School for Children, and was thus guilty of "theft of services."

Fisher, is now serving a suspension of 30 days without pay for official misconduct.  This despite the fact that the entire school and the principal supported and participated in the project.

In the Times, Dwyer wrote: " ‘We are all very excited to share our partnership with ThisAbilityNotDisability.org,' P.S. 333's principal, Claire Lowenstein, wrote in an email on Jan. 11.The goal was to raise $15,000. The school's office regularly sent out updates like these: ‘7th Grader Aaron Philip is Almost 2/3 of the Way to His Goal'; ‘Aaron Philip is $1,621 Away From His Goal.' In the end, he raised $16,231. The school celebrated at a town hall session."

Dwyer laments that a person working to excel is being hammered by an investigative agency that began its hunt in search of cheating on tests and record-keeping irregularities. It found nothing of the sort. Instead, the investigation produced a misleading report, filled with holes, on the fund-raising effort. By omitting essential context, the report wrongly suggested that Ms. Fisher was a rogue employee, acting alone and in her own self-interest.  In fact, the entire school, including the principal, was involved in the Kickstarter project, with regular email blasts counting down the fund-raising push.

The Times' story explained: "And the money was to be used not by Ms. Fisher, but by Aaron, who is writing a graphic book and making a short film about Tanda, a regular kid who is born with a pair of legs in a world where everybody else has a pair of wheels. Aaron has cerebral palsy and uses a wheelchair to navigate the world. Ms. Fisher has worked with him since kindergarten.  "It's beyond measure, the greatness, of how she has exposed Aaron to so many things," Aaron's father, Petrone Philip, said. "She goes above and beyond the call of duty."

"Last year, when Aaron wanted to create the book and the film, he and Ms. Fisher realized he was too young to run his own Kickstarter drive. Instead, Aaron told the investigators, they created an organization to help children like himself."

"The report made no mention that the entire building had been involved with the effort, nor did it try to determine whether Ms. Fisher would profit from it in any way. She was suspended on Sept. 15 until the end of October."

"The school disciplinary system is often said to be broken. The case of Ms. Fisher would seem to prove the point. The Education Department did not comment on the case."

 It is hard for every other OT NOT to comment and support Debbie in her efforts.


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Will the FTC Slow Down the Current Medical Merger Mania?
October 1, 2014 11:25 AM by Iris Kimberg

Many of us remember the merger mania in healthcare that occurred in the 1990's, and how the push toward consolidation that started with hospitals trickled down to the private practice  therapy sector. If we fast forward to 2014, it is readily apparent that the "urge to merge" is back.  We see local hospitals in a merger frenzy, and local MDs leaving private practice to become hospital employees. I have more and more therapists contacting me about practice sales. Yet, a strong but dominant voice, namely the Federal Trade Commission, is beginning to weigh in on the topic. Citing antitrust laws, particularly the Clayton Antitrust Act of 2014, they have successfully blocked some deals using antitrust enforcement as a powerful tool to dampen  conglomeration fever. 

Hospitals say they are acquiring other hospitals and physician groups to comply with provisions
of the Affordable Care Act and take advantage of incentives that encourage hospitals and doctors to integrate their operations and collaborate to control costs and improve care.  The concern is that hospitals that face less competition can charge substantially higher prices, which according to Martin Gaynor, Director of the FTC's Bureau of Economics could be as high as 40-50%.  In the last two years the FTC intervened and blocked hospital mergers in Albany Georgia, Toledo Ohio and Rockford Illinois. Although the decisions are currently being appealed, the message is strong. "Vague promises and aspirations that an acquisition will reduce costs and improve care are not sufficient" said Julie Brill, a member of the FTC.  

When hospitals and doctors join forces, their goal is not just to control costs or improve care, but to "get increased leverage" in negotiations with health insurance companies and employers, according to  Ms. Feinstein, Director of the Bureau of Competition at the FTC. "They say they need better rates so they will have more money to invest in their facilities.When you strip that down, it's basically just saying, ‘We want a price increase.' Even if the price increase is motivated by a desire to invest more in the business, that's problematic. That incentive to invest may not be there if you don't have competition as a spur to innovation - if you're not worried about losing business to the hospital down the street."

Look back to the first merger mania in the 1990's particularly the state of Massachusetts, which let its two most prominent hospitals - Massachusetts General Hospital and Brigham and Women's Hospital, merge into   as Partners HealthCare. Investigations by the state attorney general's office of that state have documented that the merger gave the hospitals enormous market leverage to drive up health care costs in the Boston area by demanding high reimbursements from insurers that were unrelated to the quality or complexity of care delivered. Twenty years later, the current Massachusetts Attorney General,  Martha Coakley is trying to rein in the hospitals with a negotiated agreement that would at least slow the increases in Partners' prices and limit the number of physician practices it can acquire.

What's the take away for therapy practices?? Carefully examine your "urge to merge" or be acquired, probably the second most important decision of your professional career. Make sure your motivation is not based on panic, and that you are not being re-active rather than pro-active. As hard as it is to bring a merger to fruition, it is harder still to undo!


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Navigating the Course – Mergers, Acquisitions and Exit Strategies
September 17, 2014 8:35 AM by Iris Kimberg
 Orchestrating the sale of your practice is not unlike the process of starting or growing your practice. It requires intense focus on your end goal, coordination among many professionals working on your behalf, and a firm belief in your ability to navigate the course as it unfolds. Since the sale will impact your professional and private life after the sale, you must structure it to meet your end goal.

Fifteen years after I sold my own therapy practice and 15 days after I helped a physical therapist sell his practice to an employee so he could move back to Australia, I am still in awe of how a therapy entity can be sold. After all, we cannot guarantee that a patient will walk through our doors, we cannot guarantee that a physician will make another referral, or that a therapist will stay at work. Yet, if a practice is built to last and if value is integrated into every aspect of a practice, it is an asset that commands whatever price the marketplace will bear. Anything that increases the volume or the security of future revenue will increase the value of your practice. What makes your practice valuable to you should also make it valuable to a buyer.

In the past, practice owners approaching the age of 60-plus and thinking of retiring were the most likely private practice sellers. Today there is a new face for practice sellers. These include therapists of any age who have grown their practices as far as they can and want "out;" therapists who are selling from a position of strength (for example, their practice is booming, and they want to capitalize on that); therapists who are selling from a position of weakness or desperation; and therapists who need to sell for myriad reasons, death in family, breakup, or dissolution of partnership.

Make sure you understand why you are selling so that you are clear to potential buyers. Be sure about your goal in selling and be flexible about how you might reach that goal. If the goal in selling is to secure enough money to retire: Don't count on it, although many therapists look to recoup their initial investment and be compensated for many years of hard work and endured risk. Others want to end the burden of ownership, but continue working as a highly compensated employee. Typically, the ways to reach your overall goal of selling include an outright sale (stock or asset purchase), a structured buy in/buyout plan, or a merger with a local competitor.

To achieve your goal, you will need to assemble a team to navigate the course, yet I cannot emphasize enough how vital a role and voice you should have in the process. While everyone's focus tends to be on the asking price, and, later on, the gap that is often between the asking price and the offered price, many other facets to any practice deal exist. Life after your practice sale needs to begin well before the ink is dry and the deal is done. How you structure the deal will impact how your life will be after the deal.

Your accountant will play a vital role in your practice sale. The strength and quality of your financial statements is a direct reflection of your practice and should include profit/loss statements/balance sheets from the past three to five years with information backed by filed tax returns. Your accountant should help you break down your clinical costs so that gross profit percentages can be determined. Prospective buyers will want an accurate aging report (AR), and projections for the current year.

Your accountant may or may not be equipped to help you with your practice valuation; if he is not, seek out a professional who is. Your accountant should discuss with you and your attorney the consequences from a tax perspective on structuring your deal as an asset or a stock sale. This is crucial and will directly impact your tax liability. Unfortunately, what is advantageous for a seller from a tax perspective may not be advantageous from the buyer's perspective; fair negotiations are important.

There must be an open and ongoing dialogue between your attorney and accountant for structuring the purchase agreement. Your attorney should make sure you have a good nondisclosure agreement in place before you release any details to potential buyers. Your attorney should help you evaluate any letter of intent from a potential buyer, and review, revise, and sometimes create the purchase agreement. Your attorney should help craft an employment agreement (if that is part of your deal) and evaluate any non-compete clause you will undoubtedly have to sign. Sometimes lucrative employment contracts offset a less than optimal purchase price. Other times a poorly negotiated employment agreement may not compensate you adequately, especially when you may be working less or differently during the non-compete transition period.

Be realistic, be flexible, be clear about what you want for yourself, and what you want your role to be post sale. Most therapists think their practice is worth more than it actually is, so be prepared for some initial disappointment. If you plan on staying on only for a "reasonable transition period," then who you sell to is less important. If you want to stay on post-sale as an employee, then you need a high degree of compatibility between you and the new owners. The negotiation of your employment agreement (terms, salary, etc.) becomes almost as important as the negotiation of the purchase agreement. Your non-compete clause must be reasonable in order for it to be enforceable. Carve out any nuances that you believe are important. You must always be allowed to earn a living, but there are a finite number of nonclinical, academic, or management positions in our field. Do not wait to begin exploring what is next until the day you walk out the door.

The emotional component to a practice sale is rarely addressed or discussed. Regardless of the purchase price and the joy you may envision after a sale, most owners post-sale have some degree of identity crisis. You are probably more attached to your work identity than you realize. Answering "yes" to the question: "Can this practice exist without you?" is easy. Answering "How will you exist without your practice?" may be harder. Even though you may be selling of your own accord and on your own terms, you are likely to feel a sense of loss. Who we were versus who we are today comes into play. One therapist described it best: "It is like I lost my wallet. Suddenly, I don't have a job title, a desk, or a name plate!" Re-inventing yourself post-sale, much like growing and selling your practice, is a process. Capitalizing and leveraging the skills you have amassed over the years will assist your successful transition.

 


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The Value of Our Time
September 10, 2014 11:25 AM by Iris Kimberg
It is not a new concept to any health professional that we all spend some time coordinating the care of our patients, whether it is directly or indirectly related to the service we are providing. It is part of our job, part of treating and caring for the whole patient. What is a "new" concept is that we may start getting paid for our efforts!

The Obama administration announced recently that beginning in January 2015 they will pay monthly fees to MDs who manage care for patients with two or more chronic diseases like heart disease, diabetes and depression. "Paying separately for chronic care management services is a significant policy change" said  Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services. Officials said such care coordination could pay for itself by keeping patients healthier and out of hospitals. With the new initiative, Medicare will adopt some of the techniques devised by health maintenance organizations and early intervention programs which already have service coordination as a paid service.

According to an August 16th New York Times article, doctors will draft and help carry out a comprehensive plan of care for each patient who signs up for one. Under federal rules, these patients will have access to doctors or other health care providers on a doctor's staff 24 hours a day and seven days a week to deal with "urgent chronic care needs." The Obama administration rejected pleas from doctors to relax or delay "the 24/7 requirement," saying it was essential.

 As part of the new service, doctors will assess patients' medical, psychological and social needs; check whether they are taking medications as prescribed; monitor the care provided by other doctors; and make arrangements to ensure a smooth transition when patients move from a hospital to their home or to a nursing home. Doctors can expect to receive about $42 a month for managing the care of a Medicare patient. Care management services can be provided only if patients agree in writing. Patients will pay about 20 percent of the $42 fee, the same proportion as for many other doctor services.

Despite the fact that the fee is ridiculously low (monthly subscriptions to magazines often cost more), it is a symbolic win and acknowledgment.  Hopefully it will lead the way for all health professions to start to bill and be paid for the many hours they put in coordinating the care of their patients.  Ironically, there have been little known and little used case management  service   CPT codes for qualified non physician healthcare professionals available for years. The codes listed below are not recognized by Medicare. However, other health plans may elect to cover them and now hopefully more and more will.  Here are a few:

Medical Team Conferences - If you participate in medical team conferences for a patient's care, you may use medical team conference CPT codes to report 30 minute or longer meetings that meet certain criteria

99366 Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more; participation by non- physician qualified health care professional

99368 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by non-physician qualified health care professional

Criteria  -The following criteria must be met to report the team conference codes:

  • A minimum of three qualified health care professionals from different specialties or disciplines who provide direct care to the patient must participate in the reported team conference.
  • No more than one individual from the same specialty may report 99366-99368 at the same encounter.
  • Reporting participants must be present for the entire team conference.
  • Reporting participants shall have performed face-to face evaluations or treatments of the patient, independent of any team conference, within the previous 60 days.

Reporting participants should record their role in the conference, contributed information, and subsequent treatment recommendations. The time for the team conference starts at the beginning of the case review and ends at the conclusion of the review. Record keeping or report generation time is not included. However, the time is not limited to the time that the participant is addressing the team or patient/family.

Physicians will be able to report 99367 for a medical team conference with an interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more. Physicians are referred to evaluation and management codes for one comparable to 99366.

Telephone Assessments -There are three codes for reporting services provided over the telephone. The telephone assessment codes are for "non-face-to-face assessment and management services provided by a qualified health care professional to a patient using the telephone. These codes are used to report episodes of care by the qualified health care professional initiated by an established patient or guardian of an established patient."

98966 Telephone assessment and management service provided by a qualified non physician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure with the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

98967 11-20 minutes of medical discussion

98968 21-30 minutes of medical discussion

Certain conditions preclude the use of the codes:

  • They cannot be used if the patient is seen within 24 hours of the phone call or during the next available urgent visit appointment, or if the patient was seen within the previous seven days.

 

 


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The Disconnect Between Reality, Education and Service Delivery Models in our Field
September 3, 2014 11:05 AM by Iris Kimberg

More and more, corporate America is working with the institutions of higher education to make sure school curriculums and courses of study meet the needs of the job/employment markets of 2014 and the future. Less and less, certain sectors of the healthcare industry, the public service models of delivery, and the governing bodies of OT and PT are doing the same. There is almost a total disconnect between what is happening in the real world versus the academic work. The personnel shortages of therapy practitioners is an issue that has been around for the last 15 years, and now is readily apparent in both urban and rural settings , in pediatrics and adults. To address shortages of licensed providers of PT, OT, and SLP, especially within certain special education arenas, certain states now support the creation of a new license pathway for persons who hold a bachelor's degree. Upon receiving specified additional training, a person would receive a"mid-level licensure" enabling the license holder to provide such specialized services under the supervision of a licensee. That translates into replacing our services with others, or what I call "service substitution", which already undermines our profession in many cases.

Yet, the educational requirements of our profession are set to increase based on AOTA's spring 2014 conclusion that the "profession move to the doctoral entry for occupational therapists by 2025 to..." ensure that occupational therapy remains competitive and relevant. The changing health care system is requiring more dependence on research and evidence, and many similar professions are going to an entry-level doctorate." Additionally, the AOTA publically stated their position, and then after the fact stated that they"... want to begin a profession-wide dialogue on how to ensure that the profession remains not just relevant but in demand, despite changes and uncertainty." A dialogue that should have been undertaken before, and not after their announcement.

There is a serious disconnect between the decreasing levels of reimbursement for OT, and the proposed increasing level of OT education. Besides the issue of affordability for students, what about their return on their investment for school??? Will the move to a doctoral level lead to proposing a COTA move to a baccalaureate level?  Finally, what will this proposed change have on the increasing demand for OT services both in pediatrics and adults???

Perhaps the AOTA should look medical schools to see the shifts they are contemplating to remain competitive and relevant. An August 1st New York Times article, The Drawn Out Degree, discusses the shortening of medical education, with more than one dozen American medical schools already revamping curriculums to three year programs. Even the AMA is urging changes in the way MDs are taught and awarded $11M to medical schools to spur innovative approaches that decrease time spent in school without shortchanging education or compromising quality of care.

Perhaps the first step for the AOTA to help our profession remain relevant and competitive is to become relevant themselves.



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Thoughts on the Ice Bucket Challenge
August 20, 2014 11:18 AM by Iris Kimberg
There is no denying that the ice bucket challenge continues to be an unqualified success, despite the naysayers who have negated and criticized it from many angles - waste of water, and more of an exercise in raising awareness of one's own craziness, altruism, "slacktivism" and/or attractiveness in a wet T-shirt.

Here's why I am so happy it has taken off.  Back in the day (30 plus years ago), I was one of the first OTs to consult with  the MDA ( Muscular Dystrophy Association), and provided services to children and adults  with  many neuromuscular diseases. I was always hardest hit by the people with  ALS. The decline in function, and decrease in strength was steady, apparent and ongoing. The impact on families was huge. Living rooms became makeshift bedrooms to accommodate hospital beds, hoyer lifts and the like. Spouses became caretakers, while secretly mourning the loss of their spouse as they knew them. Looking back, the challenges as an OT were paramount. With the  physical and functional decline so swift and non forgiving, I was constantly challenged to think on the spot, make immediate accommodations, re-purposing and intuitive adaptations to the environment.  All in the hope of making the moment, or the day more tolerable for the family and patient.  What worked one day didn't the next as the disease ran its course.  My feelings of inadequacy and frustration matched the family's feelings of desperation and isolation, yet in a way it was OT at its finest.

The Ice Bucket Challenge is raising public awareness of ALS  in addition to raising money for research on the disease. Like most fundraising, the efforts will focus more on the cure while families and therapists focus on making day to day living as tolerable as possible. ALS is classified as an "orphan disease", since fewer than 200,000 people get the diagnosis annually. Generally that means there is less research and clinical trials for treatment.  ALS has never been and never will be  as profitable a target for pharmaceutical companies to invest millions of dollars in as they do with  more prevalent diseases ( ie cancer, arthritis etc.).

The New York Times reports that in the last few weeks, ALSA has received $13.3 million and welcomed 260,000 new donors.  While the President of the Association Barbara Newhouse says she appreciates the monetary aspect of the Ice Bucket Challenge, she says, "the visibility that this disease is getting as a result of the challenge is truly invaluable." Monetary donations coupled with social-media-friendly stunts build awareness and encourage others to give in a way that quietly donating cash does not. That's what that silly tub of cold water does; audiences get a little entertainment, which helps the viralness of the cause and encourages donations. It also strives to make people want to learn more about the disease, and what organizations like the ALS Association are doing to fight it and provide assistance to those living with it."

Practice owners who work with neuromuscular conditions may want to jump on this bandwagon- a twin win situation, and what I call "cause -related" marketing. It can be  great publicity for your practice and a great way to help raise money and awareness.  ALS is not only an incurable disease, it is an underfunded one as well.


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The Use of “Cut and Paste” in Electronic Medical Records
August 13, 2014 10:30 AM by Iris Kimberg
As more and more practitioners embrace electronic medical records, the U.S. Department of Health and Human Services Office of Inspector General has made it known that they will begin to scrutinize how these records are completed. Healthcare fraud can be as easy as hitting Control-C, control-V although your intentions may just be to improve documentation efficiency. Federal officials say the cut-and-paste features common to electronic medical records invite fraudulent use of duplicated clinical notes and that there is a need to clamp down on this emerging threat. High priority in audits is the use of "cloning" (inappropriate use of the copy-paste feature) and over-documentation as therapists seek "short cuts" in using EMR. The OIG has recommended that the Centers for Medicare and Medicaid Services evaluate electronic medical records for fraud vulnerabilities. If fraud is suspected, practices will be subject to fines and penalties. The copy/paste functionality in EMRs can result in redundant, and  erroneous health record documentation.

Here are some tips:

Make sure you avoid repeating past information and review all entries in your note.
CMS guidelines state that  a review of a past medical, family, and social history obtained during an earlier encounter does not need to be re-recorded if there is evidence that the therapist reviewed and updated the previous information. Simply put, in your note, you can refer to a previous note that has a comprehensive history of the patient. You can write, "See note dated 8/1/2014 for a comprehensive history of patient A," and then update the present concerns/reason for the visit.

Confirm that all the diagnoses listed are relevant for that particular visit.
EMR systems  often offer the option of  copying of all diagnoses listed in the problem list. That may include  those diagnosis that have been resolved or  are not relevant to that day's patient visit. List  only the diagnoses that are relevant for the reason the patient is seeing you - do not just cut and paste the whole list.

Your note should be individualized for that patient's encounter.
EMR systems often allow you to cut and paste (clone) an entire previous note. Auditors always  look  for patterns in documentation, so take great care in using this feature.  You will be cited for not providing individualized care if all your notes over time are substantially  the same for an individual patient as well as other patients you treat. Make sure each note is relevant for that day's visit.

Make sure you include  a policy on the use of cloning, the copy-paste feature in your policy and procedure manual. Step one to making sure this is not happening in your practice  is having a  policy  and procedure in place. Auditors will look to see if you do, and many practices have not updated their policies when they shifted to EMR. A policy should detail how your practice will safeguard against the misuse of the copy and paste functionality.

 


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Remembering Jane Case-Smith
July 31, 2014 9:07 AM by Iris Kimberg

Every therapist makes contributions to the patients and families they serve, and the colleagues they work alongside.  Some therapists practice, others preach.  A few therapists truly shape and influence the way we practice, and Jane Case Smith, EdD, OTR/L, FAOTA, BCP was one of those therapists.

She was a professor, a chairperson, a researcher, a lecturer, and an author. Her expertise and knowledge base extended from assessments, hand skill intervention, evidence based practice, autism, and fine motor outcomes in pre-school children.

Dr. Case-Smith was the senior editor for the textbook Occupational Therapy for Children, now in its 6th edition with a 7th edition in progress. She has written over 20 chapters and over 100 papers in peer-review. Her chapter on evidence based practice with children with autism in the 2004 edition of Autism: A Comprehensive Occupational Therapy Approach brought to the forefront the efficacy of sensory-motor interventions for children in the autism spectrum. Dr. Case-Smith has received funding for her work from the National Institute of Child Health and Development and the Institute of Education Sciences.

There are not many clinicians in our field whose extensive reach simultaneously touches the lives of patients, families, students and colleagues. She touched so many of us, some literally, others figuratively.  Her untimely death this week will not leave a void. She left us a volume of work and research to fill it.

Our thoughts go out to her family and friends.



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Understanding and Reviewing Your Insurance Policy
July 23, 2014 1:41 PM by Iris Kimberg

Therapists in private practice need safeguards to prevent or manage avoidable risks, and appropriate insurance policies are a major component of any risk-management plan.  Once a year, typically 30-45 days before renewal, it is a good idea to review your policy and make changes during renewal if necessary. As you evaluate your professional risks, consider the strength or extent of your practice policies and procedures and the composition of your staff. For your personal risks, think about the resources you need to uphold your lifestyle and those of dependents or significant others in your life.

Private practice owners and their employees/contractors have different insurance needs. Practice owners may grapple with business relationships gone sour, poor investment decisions, cash flow crunches, damage to office space or equipment, and negative client interactions. Employees may encounter risks related to reduced income, benefits or job loss. Both employees and practice owners risk losses due to disability or death, and professional liability claims.

Insurance coverage should be broad enough to cover unforeseen losses yet specific enough to compensate for high-risk losses. Insurance is highly specialized to provide the best coverage for specific risks. There are a variety of policy types and structures for how coverage is calculated and benefits are paid.

Policy Type

There are two basic policy types: occurrence and claims-made. An occurrence policy provides coverage for covered claims arising from incidents that take place during the policy period, regardless of when they are reported. It provides long-term protection for any covered claim that may arise at any time in the future, up to the limits of the policy that was in force at the time the incident occurred. If a covered claim is brought against you, as long as your occurrence policy was current during the period in which the incident in question occurred, you will have coverage for that claim, even if your occurrence policy was not in force at the time the claim was reported.

By contrast, a claims-made policy offers claims protection on a year-to-year basis. If a claim is brought against you, you only will have coverage if your claims-made policy is current at the time the claim is made and was current at the time the alleged incident occurred.

Limits of Liability

This is the dollar amount a policy will pay in the event of a claim, and almost always has a cap. For both professional liability insurance (malpractice insurance) and general liability insurance, the limits of liability are expressed with two numbers, e.g., $1,000,000/$3,000,000. The first number represents the maximum that can be paid for any one claim; the second represents the maximum that can be paid for all claims during a particular time frame, usually within the policy year.

Some policies include defense costs within these limits, while others cover defense costs in addition to the stated limits.  Coverage gaps-that is, times when you are between policies and without insurance coverage-should be avoided. Most therapists are not in a position to personally cover costs related to risks that result in losses or allegations of loss during a coverage gap.

Tail coverage is associated with claims-made policies and can be purchased from an insurance company to address exposure for incidents that took place during the policy period but were not reported prior to the policy's expiration. Nose coverage provides protection for professional acts, errors or omissions that may have taken place but were not reported prior to a new policy's effective date. Under certain circumstances, prior-acts coverage may be offered at no additional charge.

Take note of what is excluded from coverage. Reviewing and understanding the list of insurance exclusions is as critical as is analyzing the benefits. Being aware of the limits of liability on all of your policies will help ensure you are not caught by surprise when you have to use a policy to respond to a loss or a claim of loss.  Finally, give yourself enough time to shop around - there are many  more than one carrier for malpractice and general liability so it pays to get several quotes.  In addition, some carriers charge if you ask for an entity to be named as additional insured or certificate holder while others do not.  Please feel free to email me  (infonytherapy@aol.com) if you would like a list of carriers that work with therapists providing both malpractice and workplace/general liability.

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Read. Comment. Share. Please!
July 9, 2014 9:14 AM by Iris Kimberg
I have been writing blogs, columns and commentary for many years now for print and internet media. I would not be truthful if I didn't mention that I do more than glance at the number of views, comments, and shares I get. It is important for me, not because of self -aggrandizing, but to see what matters to other therapists. These statistics serve as a barometer of how relevant, or timely I am on various topics that concern me and I think might or should concern others. My assumption has always been that my content drives interest and that a highly commented or shared post would be one that speaks to, directly affects and is most "real" to therapists.

Last week two interesting articles in the New York Times. "Why Computers Won't Be Replacing You Just Yet" and "Clicking Their Way to Outrage" shed new insight on the topic. They detailed algorithms created by computer scientists that predicts (with 67% accuracy) which tweets will be re -tweeted, and which Facebook posts will generate the most comments. The tweets that get re-tweeted are the ones that have certain words contained in it - like - "please" or "retweet". Longer tweets get retweeted more, which hopefully means they have more meaningful content, making each of the 140 characters count. Which Facebook posts gets the most comments? The algorithm shows that if the first comment arrives quickly, then the post will generate many more in the future. The emotion that spreads the most over social media - anger, with joy a distant second. One psychologist, Ryan Martin suggests that, while we tend to share happiness only with those we are closest to, we are willing to share and join in the rage of strangers.

So what's the take away on this???

Blogging, posting, tweeting is often used as a primary or secondary marketing tool for therapists in private practice. When consulting with practitioners on marketing plans, snail or email campaigns, taglines, blog posts etc., I always discuss the importance of framing the message and moving the consumer to action, in part by using action words. I always ask therapists if they directly ask their patients to refer their friends and families to the practice and am amazed at how often therapists tell me they feel "funny " or awkward doing this. Its looking more and more like the adage Ask and you shall receive is true. Move one reader to action, and others will follow. Move one patient to action and others will follow. And make sure you occasionally write a post about a healthcare issue  that angers you be it  low fees, high deductibles, wait times to see doctors, wait time to get paid etc., down time doing documentation etc. And never forget to ask everyone to  Read. Comment. Share - please!


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The Healthcare Dollar Pie
July 2, 2014 8:44 AM by Iris Kimberg
I teach my students about the healthcare dollar pie and its 3 pieces:
  • Piece 1 for the patient or consumer
  • Piece 2 for the service/medical provider
  • Piece 3 for the insurer/payor

I always tell them how the size of the pieces shift over time reflecting the cycles within healthcare delivery.  Most of my students were not even born when patients got a big piece of the pie - that is, when patients received the services they needed for the amount of time that they needed them, all without pre-authorization! Many students can barely remember when the piece for the medical provider was big- when doctors were "rich" and therapists could become financially successful.

My students do learn about the big piece of the pie that the insurers are eating, how well their stocks are doing, how much their CEOs are making, and how big their pended/denied departments are. And just in time for this fall's lecture, the pie is shifting again, and in the wrong direction.

Yesterday, I received a letter from my insurance company (BCBS), informing me, as is required by law, that they are seeking a 17% increase in the premium for the new policy I got in January 2015. This both shocked and bothered me on many levels. Year one and the insurers are already taking "affordable" out of the Affordable Health Care Act. More disturbing is that  this insurance company has systematically been lowering the fees paid to private practitioners--lowering the fee, eliminating CPT codes and time/modality based payment in favor for flat fee methodology, and bundling. While they systematic deny therapists a rate increase based on cost of living and instead lower fees or cancel contracts, they claim they need a 17% increase in part  because of the rising costs of medical care, a new pool of customers, and new providers.

I am beginning to no longer see the 3 pieces of the healthcare dollar pie. Instead, slowly it is becoming one pie solely for the insurers and payors, with 2 crumbs, one for providers and the other for patients.

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Reaching the 6 out of 10
June 25, 2014 3:43 PM by Iris Kimberg

The Kaiser Family Foundation released the results of their recent survey showing that 6 out of 10 people enrolling in health plans were previously uninsured. Most of the uninsured had been without coverage for 2 or more years, and 45% said they had been without coverage for 5 years.  The survey findings were based on telephone interviews from April 3- May 11, 2014 with a random sample of 742 people ages 18 to 64 who bought their own insurance.  Furthermore, Liz Hamel, Director of survey research at the Kaiser Foundation said that the answers suggested that "people buying coverage under the new plans were sicker than those who were previously getting coverage in the individual market.

 I have yet to hear from many therapists that this increase in sicker people who now have insurance  are translating into many new first time therapy patients. Part of the problem may be that the survey also found that many Americans were unfamiliar with the details of their coverage; details ranging from the amount of their monthly premium to what services were covered.  

Yet it is hard not to consider this a prime marketing opportunity, not so much for old school marketing (pounding the pavement to physician offices)  but for marketing  directly to the consumer. The more occupational therapists  can  start  to connect with the public and see new applications of our skill sets, the more we can  broaden  the scope and capacity of our practice, all within the framework of individual state practice acts. If sicker people are coming into the system, we need to make sure we connect with this first timers. 

Now that habilitative services are considered an essential health benefit, we should be  working more and more with patients whom  may not have ever developed normally as opposed to our typical patients who have had skills and then  lost them  after a stroke, head injury, illness, etc. These new patients, many with chronic long term disabilities, patients previously unable to have therapy because their condition may not "improve", in many instances can experience a significant improvement in their quality of life once they seek out therapy services.  Let's do our part to make sure this happens.   


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Non-Compete Clauses That Work
June 18, 2014 10:41 AM by Iris Kimberg

Last week's New York Times featured an article about non-compete clauses and how they are "popping" up in many fields. This should not be "new" news to us in the healthcare industry, since many therapists either ask others or are asked themselves to sign a non compete clause.  I always discuss this issue with therapists  and know that it is an important part of any IC or employment agreement. Legal protection generally falls into three categories that can be included in one agreement, and should include more than just a non compete clause. Non-compete clauses bar employees from competing directly with their bosses. Non-solicitation clauses prohibit employees from recruiting employees or clients of the business they left. Non-disclosure agreements (also called confidentiality agreements) forbid employees from using confidential or privileged information they gleaned from the job.

One consideration is that such agreements can be a double-edged sword in the sense that some employees still go off on their own and decide to fight you legally over the terms of the agreement. Typically, while the non-solicitation and non-disclosure parts of the agreement are more enforceable, the non-compete clause often does not hold up in court (this varies from state to state) if it is felt that it impedes a person's ability to find work.

For a non-compete clause to be effective and enforceable, it needs to be of specific scope, duration and geographic area. If it is too broad or overly aggressive, it most likely is not enforceable. A general rule of thumb is that the contract should be limited to one year, be confined to no more than a 10-block to a 40-mile radius (depending on whether you are in an urban, rural or suburban area), and be specific about the type of work the former employee is prohibited from doing.

Often, it is the smaller-sized practice or business entity that stands to lose the most if they do not have employment agreements with key personnel. If you are a smaller-sized company, you will feel the impact of the loss of just a few referral sources/employees/clients much more than a larger-sized firm would. These are a large part of your assets, and you do want to protect them. It is highly advisable to use an attorney to establish or review this type of agreement. There is nothing worse than relying on an agreement that turns out to be either non-enforceable or invalid.

It is easier to have such agreements in place prior to the start of employment, rather than "back peddling" to get employees to sign them after the fact. (During the sale of a company, any serious buyer would like to see that these are already in place.)

If a potential employee is not willing to sign a contract, then maybe he or she is not the right employee for you. While employees can and do leave for other opportunities all the time, having an enforceable agreement can help to minimize the damage they do on the way out.

When you do find out an employee has left to go work for a competitor, it is absolutely okay for you to send that new employer a copy of the departing staff member's non-solicitation and confidentiality agreement as a not-so-subtle reminder to all parties.


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A Tribute to My Dad for Father’s Day
June 11, 2014 9:14 AM by Iris Kimberg

My beloved 90 year old dad died four years ago after a short battle with an aggressive cancer. Like many therapists, I am the "go-to" person in my family for healthcare; without a physician in our ranks, I am often called into action to find the right doctor, hospital, medical care, etc. My dad became a patient of the "grand poobah" of lymphoma. He was admitted to a prestigious NYC hospital, one dear to my heart - I was born there, my daughter was born there, and sadly enough, my dad died there twelve days after his admission.

I spent 12 days in the hospital with my dad - the longest time I have been hospital based since my days as a staff OT back in the 80's. Twelve days in the hospital taught me a myriad of things; among them, that morphine drips are over rated, it is difficult to turn an ICU into a hospice unit, hospital food is still horrible, and face to face contact with the primary physician by law can be as little as 3 minutes per 24 hours. Above all else, I learned the lack of hospitality in the hospital setting still existed. When I realized I could not alter the outcome of my dad's hospital admission, my thought turned to how I could improve the experience, not only for him, but for my family as well. I knew he could not get better, but that did not mean I did not want him to feel better. This meant hanging up family photos, bringing in comfortable down pillows, having colleagues come in to provide massage and Jin Shin Jyutsu, getting a barber to give him a bedside shave and a haircut, and making sure chocolate milkshakes were delivered twice daily.

The book If Disney Ran Your Hospital, 9 ½ Things You Would Do Differently, by Fred Lee is a must read for all health care administrators and providers. A main premise of the book is that we have to acknowledge that hospitals not only provide a service or product, but also an experience. What kind of an experience? Mr. Lee describes it as an experience that "engages patients on an emotional, physical, intellectual, and yes, spiritual level." Service happens outside of you, while an experience happens within. It is the quality, consistency, and substance of that experience which will likely become the primary differentiator of the hospital. Throughout, Mr. Lee drives home how best to implement this new philosophy, which can be done on a small or large scale, and is adaptable for all healthcare settings. By the end of the book, you will be imagining a patient room as a stage, and health professional as having roles, not jobs. He breaks down major "impact ideas" that hospitals should consider, all based upon the premise that while the services we provide are intangible, the experiences of our patients are memorable, personal and individualized.

The goal is to find those approaches that foster the best behavior in staff while providing the best emotional experience for patients. He breaks down the pillars of the Disney experience, and applies it to a hospital setting - the importance of a patients' perception of the care they are receiving, how courtesy may be more effective than efficiency, why patient loyalty is more important than patient satisfaction, and even how imagination(the hallmark of Disney) has its place in the hospital. Mr. Lee links imagination with compassion: if you can imagine what your patient and their family is going through, what they must be thinking and feeling, through that imagination process, you are growing your capacity for compassion.

When healthcare professionals find themselves on the other side of the equation, getting care instead of giving it, it is usually an enlightening experience. Going forward in my consulting work, I know I now need to give guidance to therapists and their staff on ensuring that the experience we create for our patients is the cornerstone of the quality service we provide. The experience we may have does not guarantee the experience we may give. There are many great articles, and evidence-based research to support the importance of the experience and the need for hospitality in hospitals.  Among them are:

http://www.bizjournals.com/milwaukee/stories/2003/05/05/focus2.html


http://www.scribd.com/doc/21445435/Hospitality-in-Hospitals


http://www.expresshospitality.com/20060215/market01.shtml

 

If Disney Ran Your Hospital... is available at www.amazon.com


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