Physicians today are inundated with proposals (and articles) on how to make money to boost the bottom line. In today's climate of declining revenues, it is easy to be tempted by new revenue opportunities. Before signing on, it is wise to note that if it sounds too good to be true, it often is. Even if the arrangement is a financial success, it may lead to damaging consequences including alienation of patients or colleagues, bad publicity, or even lawsuits, loss of medical licensure, and imprisonment.
One manner in which neurologists seek supplemental income is through legal consultations. These activities range from review of cases involving personal injury, worker's compensation, medical malpractice, and peer review of neurological services. Problems arise when minority opinions are rendered and other guidelines for expert opinion are ignored. Some medical societies scrutinize expert witness testimony and sanction or expel members who deviate from expert witness guidelines.
CODE OF PROFESSIONAL CONDUCT
The AAN has developed a Code of Professional Conduct for its members. One purpose of its provisions is to inform Academy members about what constitutes ethical expert testimony. A neurologist who violates these provisions as a member of the AAN is subject to disciplinary action under the By-Laws and Disciplinary Action Policy of the Academy.
Mark Hallett, MD, Chief of the NINDS Human Motor Control Section, has headed the AAN Fair Hearing process for the past four years. “Neurologists who call themselves experts need to be knowledgeable and up-to-date about the standard of practice relevant to the time and place of the case since each case is adjudicated to those aspect,” he said. “Just because someone testifies a lot about a subject does not qualify that person as expert,” Dr. Hallett said. “AAN members may be expelled or reprimanded by the Board of Directors for providing inaccurate testimony, and certain disciplinary actions by the Board must be reported to the National Practioner Data Bank.”
Steven M. Lomazow, MD, President of the New Jersey Neurological Association and a member of the New Jersey State Board of Examiners, cautions: “Physicians who provide false testimony are also at risk of losing their medical licenses.” Dr. Lomazow participated in one case this year when a radiologist's license was revoked due to fraudulent off-site reading of MRI scans.
In particular, activities that require neurologists to participate in off-site interpretations of activity can be risky proposals. Neil A. Busis, MD, former President of the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) and member of the AAN Medical Economics and Management (MEM) Subcommittee, has been asked to review the practices of such businesses on several occasions.
“Physicians are frequently lured into such arrangements by the promise of high volume pay-outs,” Dr. Busis said. “The people who run these operations require a physician's signature to bill for the professional components of tests such as electroencephalograms, nerve conduction studies, or evoked potentials. They will often frame the opportunity as the ultimate win-win proposition.”
“The problem is that if you have not seen the patient, data that may look internally consistent may actually have been gathered the wrong way. Furthermore, your ability to judge the medical necessity of the test is restricted. It may be that the test performed was not the right modality for the question that needed to be answered… for instance, nerve conduction velocities or evoked potentials that are used to evaluate for radiculopathy.”
He advises: “Beware of requests in which you are offered big bucks in exchange for your review and signature. You should stop and ask: What are the conditions of the testing? Are these reports that I want to put my name on? Am I placing my professional reputation at risk, or worse?”
One of the consequences for this burgeoning trade and the rise in unnecessary tests is an increase in Independent Medical Examination (IME) and peer review activities. Such activities, in which neurologists assess whether services performed by other neurologists were medically necessary, are being examined for violations as well.
Michael I. Weintraub, MD, a neurologist in Briarcliff, New York, who has written extensively on the subject of expert witness testimony, has been a longtime proponent of self-regulation among physicians.
“While it is a constructive practice for neurologists to get involved in the claims review process and to help expose parties who abuse the system such as those who participate in accident mills, reviewers should make sure that they follow the guidelines,” he advised.
EXAMINE ALL RECORDS
“Be sure to examine all records in the case,” Dr. Weintraub said. “If a test report is presented without a consultation, it is the responsibility of the reviewing neurologist, before rendering an opinion, to request that the insurer forward the relevant documentation. Physicians should also be sure that their opinion follows current practice guidelines and medical standards and that they practice in the same specialty that they review.”
“Furthermore, if they deny the service as medically unnecessary, they should give adequate reason for the rejection…If they espouse a ‘minority’ opinion, they should divulge that fact. They must be aware of the boundaries of fairness, maloccurrence, and malpractice. They must divulge information about their financial incentives.”
“Unfortunately, since some insurers are looking for sympathetic reviewers to shun their financial obligations, a cottage industry has arisen for neurologists who are semi- or fully-retired and for those who are looking for easy income,” he explained “Sadly, there are wolves in sheep clothing who are trying to make money off of the hard labor of honest neurologists; they recommend denial of all services and use the same language in all their letters. However, they are becoming increasingly exposed by peers and some are under review by state insurance commissioners, professional societies, and medical associations.” Dr. Weintraub believes it is ultimately up to neurologists to report such activities.
EVERYDAY BUSINESS OPERATIONS
And what about simply getting the right advice for everyday business operations? It is often more difficult than it seems. When Bruce Sisgsbee, MD, was first in practice, he retained the services of a CPA who worked for the health care division of one of the major accounting firms. He depended on the CPA to help run his medical practice. But knowing the nuts and bolts of tax accounting is not necessarily the same as understanding the business operations of a medical practice.
“I soon discovered that his advice did not translate into effective practice management advice,” Dr. Sigsbee said.
Dr. Sigsbee, who later earned his own accounting degree, now teaches AAN courses, advising neurologists on how to make informed practice management decisions and how to avoid similar pitfalls. In fact, experts agree that physicians, unlike most business people, seem to move ahead with attempts to extend their services without engaging in a due diligence process. And neurologists, like other doctors, have been known to make hasty decisions to add new tests or treatments and later discover that they have been money-losing propositions.
Rosemarie Nelson, a consultant for the Medical Group Management Association and an expert on medical practice systems and operational analysis, observed: “Physicians tend to engage in revenue diversification plans without undertaking a business plan.” They often forget to address fundamental questions in advance such as ‘If we incorporate an ancillary service or office, how do we maintain our current obligations? What are the costs of doing business? What will be the overall effect on operations?’
DEVELOP A BUSINESS PLAN
“A business plan helps to flush out the elements needed to make the necessary analysis. It forces the practice to define clear objectives and be very specific. It answers the basic question, for example, ‘How many patients will it take to break even?’ It also sets up a formula to re-evaluate the operation at regular intervals, measuring progress, and re-refining goals.”
Physicians also seem to be easy prey to investment scams. And because as physicians, we are not formally trained in business, we are easily lured by the slick marketing language of sophisticated swindlers touting the financial rewards of “a sure thing.” “In one unfortunate incident, a local developer rehabilitated a downtown building using primarily physician investors,” Dr. Sigsbee said.
“On retrospective analysis, even if fully rented, the cash flow would not have covered the debt service or other expenses. The developer got his substantial development fee, but the physicians lost all their investment, which for some meant all their retirement funds.”
‘GET RICH’ SCHEMES
Terry Curran, MD, a neurologist practicing in Vernon, Canada – and author of Prescription For Wealth (Financial Planning For the Health Care Professional) (Crowne Rock Publishing, 1996) and Second Opinion (Hire the Best Financial Advisor or Do It Yourself) (Crowne Rock Publishing, 2000) – said: “Most get-rich-quick schemes – tech mania, tax shelters, and insurance oversells – have major conflicts of interest to which physicians are oblivious; they would be well-served to examine the situation more closely.”
He advises doctors to ask themselves what the potential conflicts of interest may be and then to ask the brokers what they get paid on the deal and then watch their body language. “Most of the time doctors are taken advantage of, the tip-off is the large commission fees.”
As neurologists struggle with declining income from traditional revenue sources, it is easy to succumb to temptations that fall outside our core competencies. But it is prudent to consider that those who purport to give us advice or provide income opportunities may not fully understand the economics of medicine. Furthermore, they may not always share our best interests, and at worst could be working at cross-purposes with us. Finally, when considering outside investments, bear in mind that reward is usually commensurate with risk, and that the “free lunch” remains exceedingly rare.