Endocrinology Fellows Starting a Practice 2012

Getting Started as a Specialist: a Practical Guide: 

Getting Started as a Specialist: a Practical Guide Marshall Dahl MD PhD FRCPC Endocrinology, Vancouver Hospital University of British Columbia

Background: 

Background

Overview: 

Overview Making plans near the end of your fellowship Initial steps needed to establish practice Practical points in managing your business Achieving a sustainable balance Useful resources

The End of the Fellowship: 

The End of the Fellowship Academic distractions Need to organize next stage of career Transition between regulation and autonomy

Moving on….: 

Moving on…. In context: 3-4 years of medical school 4-5 years of postgraduate training 7-9 years Clinical practice: 25-35 years changes in setting and style of practice are common during this time Fellowship

Choosing a Practice Setting: 

Choosing a Practice Setting Locum tenens Low initial costs Uncomplicated Chance to survey different settings Can accumulate some start-up funds Still require initial outlay A chance to “audition” a practice

Locums...: 

Locums ... Office locums: don’t be shy in discussing financial arrangements: split 60:40, 70:30 or pay the overhead use pre-existing infrastructure for booking, billing etc. Hospital locums: may need to have your own billing arrangements different financial arrangements: keep 100% if no overhead

Setting up in Practice: Joining a Group: 

Setting up in Practice: Joining a Group Advantages: Fewer start-up concerns Staff hired, office rented, equipment purchased Lower shared overhead costs Experienced colleagues at hand

Setting up in Practice: Joining a Group: 

Setting up in Practice: Joining a Group Disadvantages: Less autonomy Need to establish and maintain your own style of professional practice You may still feel like the resident….

More about group practice...: 

More about group practice... Varying types: Fee-for-service income, shared costs Currently the only BC model... “Practice-plan”: mixture of fee-for service and other income with percentage passed to academic department or group staff and facility costs may be charged to group or absorbed by an academic centre

Salary, Sessional, Service Contracts: 

Salary, Sessional, Service Contracts Alternate payment mechanisms Many doctors have a blend of these with fee-for-service Template contracts exist at provincial levels: talk to your colleagues and medical association On-call payments frequently based on contracts as well

Getting Started: Permission to Practice: 

Getting Started: Permission to Practice Required: College of Physician and Surgeons: Registration fee, Licensing Fee $1400 annually, corp fee $100 CMPA $1152.00 Billing Number: Provincial Medical Plan (no cost) Royal College Essentially required for MOCOMP c. $800

Getting Started: Professional Associations: 

Getting Started: Professional Associations Provincial Medical Association BCMA 1467.00 and CMA 430.00 conjoint dues Money comes back: Negotiated benefits CPRSP c. $5000 CME fund c.$1500 CMPA rebate. C. $ 1100 PITO c$3000 Endocrinology and Metabolism Society of BC 300.00 SSPS $600.00 optional Hospital Staff Dues c. $100 Insurance: Office, Overhead, Disability. Through BCMA NB: most groups have reduced rate for dues in first year of practice

Getting Started: Hospital Privileges: 

Getting Started: Hospital Privileges These are not guaranteed Locum privileges: take time. Forms to fill out. References to obtain. They may check your references. Copies of certifications. Start the process as soon as you know where you want to go

Getting Started: Interviews: 

Getting Started: Interviews Most institutions must advertise for a position There will be a search committee that interviews and checks references Do your homework about the position in advance Use the interview process to obtain information as well

Organizing the Financial Side: 

Organizing the Financial Side You are about to launch a small business Hire staff Pay taxes Keep books Buy supplies Find customers

Relax: 

Relax None of this is as difficult as managing pituitary insufficiency

The Good News: 

The Good News Income stream is reliable Medical and surgical specialists have highest earnings in Canada Single payer medical insurance system is uncomplicated compared to U.S Billings: current BC range 2009-2010: $ 200-730K Median distribution around 250-350 Overhead: varies with setting. Maximum ~$90K

Getting Started: Financial Arrangements: 

Getting Started: Financial Arrangements Accountant Talk to one before you start Find one that knows physicians There are many tax savings to which you are entitled: Moving expenses, automobile costs, portion of rent for home office, computer, business lunches, promotional costs Advice re: incorporation, year-end, etc...

Financial Issues: Tax Planning: 

Financial Issues: Tax Planning Fellowship: Taxes deducted at source Established in practice: Personal taxes paid by quarterly installment Corporation taxes paid monthly Employees taxes (Current Source Deductions) paid monthly Transition year: You have new income No installment taxes A big tax bill the following year. Save ~30% of billings.

Tax Planning: Incorporation: 

Tax Planning: Incorporation Discuss with Accountant A “corporation” is a separate entity for tax purposes. It receives income, pays employees, pays taxes and distributes the profit to owners as “dividends” Tax rates are lower for corporations and dividend tax rates are lower for individuals

Financial Advice: 

Financial Advice Financial Advisor need the right attitude need to know your goals MD Management is excellent source Debt Management Work out a sustainable re-payment plan Consider living like a resident for a while

Financial Advisor-Should tell you:: 

Financial Advisor-Should tell you: Will Insurance: Life (if you have dependents) Disability Overhead Accident? Debt management Asset Allocation model Retirement planning starts now!

Billing: 

Billing Every jurisdiction has its own billing rules Sit down with the fee guide and read it Discuss with colleagues: but don’t assume that they have it right! Provincial Medical Plan can provide guidance Submit billings through your office or through an agency

Billing: 

Billing Pay particular attention to rules for: consultations after-hours surcharges procedures New endocrinology-specific fees Specialist telephone fees hospital visit fees

Hospital Billing: 

Hospital Billing Be organized: losing a piece of paper is be like losing a $200 bill you can be audited on the basis of your documentation: day-sheets, existence of consult notes don’t let claims accumulate: submit as they occur keep on top of rejections

Office Start-up Costs: 

Office Start-up Costs Minimum: Exam table, Equipment, Chairs, Reception, Waiting Area, Desks, Filing Cabinets, Telephone, Dictation set-up. How much? It depends… Cheap and short-term vs. High-Quality and long-term Second-hand vs Medical Supply Firm Your interior decorating tastes…

You Need Staff…: 

You Need Staff…

Hiring Staff : 

Hiring Staff Decide on job description: Medical Office Assistant, Typist, Nurse Research payment environment: wages, benefits, holidays, sick time Employment standards act Advertising: agencies can help You get what you pay for…. Interview: look for the right “chemistry”

Banking: 

Banking Separate accounts for business and personal use Separate credit card accounts Many banks have special professional plans Your bank manager should become very friendly...

Scheduling: The Key to Happiness: 

Scheduling: The Key to Happiness Time pressures are a major source of professional stress Most of this is avoidable Give yourself enough time to do your job well Periodic re-analysis and re-adjustment Book personal time into your schedule: daily, weekly, CME, vacation

Philosophy: 

Philosophy The Big Picture: You have an entire career ahead of you. The practice of Medicine is stimulating and meaningful. You have a high degree of autonomy. Don’t become fixated on financial, medico-legal, or political issues. Find a balanced, sustainable pace.

More about billing….: 

More about billing….

MSP Fee-For-Service: 

MSP Fee-For-Service Billings must be submitted electronically, either through your office or a service bureau Information required: Patient: Name, birthdate, PHN Service: What was done (billing code), date of service, location Additional services if after hours Location (ie hospital , office) Diagnosis: ICD code Referring Doctor: (MSP #)

Billing: 

Billing In your office: staff take care of the demographic information. You supply diagnosis. In hospital: take demographic information with you (print from computer) Need a clear day sheet for hospital patients for staff and for future audits!

Example: 

Example Joe Sandhu 29 August, 1957, diabetes consultation requested by Dr Bond. Seen in your office. Joseph R Sandhu, 29 August 1957, 9075 123 456. 33210 (Consult). Location code: Office. 250 (Diabetes). 00700 (Referring Doctor)

Billing Rules: 

Billing Rules Some rules are frequently ignored: but subject to audit Others rules are automatically enforced by MSP computer Patient must be present Adequate records must be kept

Endocrinology Fees 2012: 

Endocrinology Fees 2012

Billing Rules: Hospital: 

Billing Rules: Hospital Daily Care (33208) $30.43= $ 213.01/wk Starts day after consult can normally be billed by only one doctor daily if GP and specialist bill: they pay the GP Exception: ICU/CCU. Multiple doctors may bill if this information included with submission Works for you if you are the most responsible physician

Billing Rules: Hospital: 

Billing Rules: Hospital Directive Care (33206) $49.39 x2= $98.78 /wk Billable twice per week Use when someone else doing daily care MSP pays these right away MSP delays paying daily care ( 33208) for a month while it waits to see if someone else will submit for the same patient

Out of Office Surcharges: Continuing Care: 

Out of Office Surcharges: Continuing Care Another fee is for your time with the patient after the first half-hour: 1205 (1800-2300 weekdays) 1206 (2300-0800 nights) 1207 (0800-1800 weekends or stats) If you were called-in for the patient you bill the call-in code and the corresponding continuing care code On average, a consult takes an hour for this purpose but you could bill more continuing care if it went past an hour

Out of Office Surcharges: Continuing Care: 

Out of Office Surcharges: Continuing Care If you have more than one patient to see, then for the next patient you bill the continuing care codes You need to provide time of service for these codes

Example: 

Example You are CTU attending helping the team: Called at 1900 hrs to see Mrs Smith for diabetes. Arrive at 1915. See her until 2015. Assume daily care in hospital. Then go directly to see Mr Jones the 105 year old man with angina and pass him over to hospitalist who will provide daily care. You promise to look in on him for “directive care”.

Specialist Telephone Codes: 

Specialist Telephone Codes Need usual information to bill: referring Dr, Pt demographics etc. Must keep record of the call

Endocrinology Special Codes: 

Endocrinology Special Codes We are a test group...

Endocrinology Special Codes: 

Endocrinology Special Codes

On-Call (MOCAP): 

On-Call (MOCAP) A contractual arrangement with a health authority. Separate from responsibility to out-patients. A group of specialists agrees to provide coverage for new patients seen in hospital (who are not already the responsibility of the group) Currently the Endocrinology group has a contract. Respond 30 minutes. On-site within 17 hrs. $190.96 per day

Sessional/Service Contract/Salary Funding: 

Sessional/Service Contract/Salary Funding Alternate payment mechanisms Template contracts and pay scales exist University Geographic Funding is a separate entity

Other issues: 

Other issues BC College has a number of other practice requirements In the “Red Book” and listed on the College web-site once you have logged-in eg: keep charts for 7 years after last contact for adults or 7 years after child turns 18 On-Call requirements for your outpatients patients are vague. MSP says continuing care rests with referring doctor. College appears to agree.

MSP Audit Types: 

MSP Audit Types Statistical: Pattern of Practice variation from the norm Complaint-driven Random Service Verification Know the rules Complete consult notes Don’t abuse repeat consults Documentation of referral requests from Drs Document all encounters associated with fees: full notes on in and out patients. Daily notes on in-patient charts

Summary: 

Summary Read the fee schedule Preamble for rules Fees section for actual codes consult 33210 office visits 33207 hospital visits 33206 33208 procedures thyroid biopsy out-of-office surcharges Need documentation for everything you do

Summary Points: 

Summary Points Start thinking about post-fellowship practice setting now Be prepared for start-up costs of ~$3000 Talk to an accountant before you start Financial planning should begin shortly Remember the big picture: 30 year career in a stimulating profession