Informal Consultations

An informal consultation at a casual lunch can result in a duty to a patient subjecting the consulting doctor to a malpractice claim.  While collegiality is an important part of the practice of medicine, be aware of the risk.  If you are engaging in an informal consultation, keep it informal and keep it generic.  Consider documenting the informal consultation with a note indicating that only generic discussions were involved.  Consult only in your area of expertise.  If discussions go beyond informal, then make the consultation formal and go through all the appropriate steps for such a consult.

© 2008 Parsonage Vandenack Williams LLC

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How to Fire an Employee

  Firing an employee is not an easy task – preparation is key.  When firing an employee, careful planning can limit misunderstandings, anger and recrimination.  Before you meet with the employee, make sure that there is detailed documentation in regard to the employee justifying your actions.  Pull together performance appraisals, written warnings, salary information, and all correspondence with that employee, especially if it is related to job performance.

             If an employee is entitled to additional consideration, such as severance, medical coverage, or additional vacation days, you should have your attorney draft a waiver for the employee to sign.  It is important to include all termination benefits to which the employee is entitled.  Make the employee’s receipt of the additional consideration dependent on his or her agreement not to sue.

             You will want to collect everything that the company has given to the employee.  Determine which computer passwords, access codes, and permissions need to be changed.

 If possible, have a witness such as your Human Resources manager observe the proceedings.  This witness will then be available to corroborate the events of the meeting should the former employee decide to sue.

 At the beginning of the meeting, explain to the employee why he or she is being terminated. Be firm but courteous while outlining the reasons as succinctly as possible.  Make sure that the employee completely understands why he or she is being fired, rather than just reprimanded.  Still, try to limit explanations and discussion about the termination.  It is important no to apologize for taking this action.  Give the employee time to express his or her feelings and provide honest answers without leaving room for any debate.

 Finally, explain the conditions of the termination, such as the severance package and any benefits or outplacement services offered. Then have the employee sign all related paperwork, including any appropriate waivers or agreements.  Try to conclude the meeting with a handshake and a sincere wish that the employee do well in the future.  It is always best to leave things on a positive note and keep any hard feelings or upset to a minimum.


 © 2008 Parsonage Vandenack Williams LLC


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Retirement Planning Key Numbers 2009

For 2009, the retirement plan limits are as follows:

Annual Additions $49,000

Elective Deferrals  $16,500

Catch up Contributions  $5,500

Maximum Covered Compensation  $245,000

Social Security Wage Base  $106,800.  If you have a profit sharing plan formula integrated with social security, be sure to review whether the formula still makes sense as the social security wage base increases.

 © 2008 Parsonage Vandenack Williams LLC  

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Year End Coding Review

For 2009, there are 291 new codes, 375 revised codes and 95 deleted codes.

Consider a year end  analysis related to coding. Be sure you are ready for the 2009 changes.  Generate lists showing procedures and reimbursement levels.  Use the information in contracting.  Review coding changes.  As a group, review and discuss changes and the impact on your practice. Disactivate discontinued codes.  Be sure new codes are available.  Communicate coding changes to everyone involved in the process.

 © 2008 Parsonage Vandenack Williams LLC  

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Physician Communications Via Email

If a physician (or physician’s office) is going to email patients, due consideration should be given to HIPAA implications as well as medical malpractice issues. Whenever drafting an email, consider what the email could look like posted as evidence in a courtroom. Adopt a policy concerning email communications and stick with the policy.

Consider the following:

Encrypt email for secured communications.

Save emails to your medical record. You do not want to be in a position ever where a patient can produce an email from you but you don’t have a copy of it.

Include a confidentiality notice on all email.

Include the minimum necessary information in an email.

Never write emails when you are tired or angry. Save your email as a draft. Review once more before sending.

Do not copy others on emails to patients unless it is to your office administrator who is responsible for diligently saving the email.

Do not use email as a replacement for office visits.

Require patients to agree to the use of email for communications. Provide the patient a policy specifying what email can be used for.

 © 2008 Parsonage Vandenack Williams LLC  

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Portable Devices Pose Challenges to Protecting Patient Privacy

Covered entities (“CEs”) need to be aware that their wireless networks and portable devices such as iPhones and BlackBerrys are not necessarily secure.

Almost twelve people have been charged with various counts of computer intrusion, fraud and identity theft, among other charges, for participating in a crime ring that allegedly hacked into nine major retailers’ wireless computer networks.  The feds believe that the conspirators stole credit and debit card numbers through “wardriving,” which involves one person who drives a car around while another person in the car attempts to gain access to a wireless network through a laptop computer.

CEs could be targeted in similar schemes and should make sure that their wireless networks are properly encrypted.  CEs should have already converted from using the Wired Equivalent Privacy (“WEP”) system of encryption to the more secure Wi-Fi Protected Access (“WPA”) protocol.  WEP encryption was more common until about a year ago, when researchers discovered weaknesses in it.

Additionally, CEs should remind staff members to use portable devices with care. There are two main risks: (1) if a doctor is in a public place and is using an unsecured network to transmit PHI [i.e., protected health information], then people could intercept that traffic if it is not encrypted or if it is encrypted with a weaker method; and (2) piggybacking on a signal to get into a laptop.  The second risk is much more difficult to accomplish, but it can be done so that perpetrators can look at the traffic coming from the device.

Use of portable devices like laptops and iPhones falls under HIPAA’s workstation use and security policies.  Therefore, CEs should remind staff members about where they can or cannot use these devices.  An airport is a particularly risky place to use such devices because anyone can log in for wireless access with a credit card and can intercept information.  Also, employees should use the locking features of the devices so that no one can open them without a password.  Finally, CEs should go over what kind of information is acceptable to transmit.  This will help to ensure that patient information is protected and HIPAA compliance is maintained at all times.

Health Business Daily, Sept. 17, 2008.


© 2008 Parsonage Vandenack Williams LLC


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Joint Commission Makes Accreditation Manuals Electronically Available

The Joint Commission Resources has announced that it will now provide its accreditation manuals in electronic form.  The electronic manuals are a web-based tool for understanding the Joint Commission’s accreditation requirements.  The tool allows users to retrieve accreditation standards, to search text and to locate specific elements of performance that are needed by the facility.  The Commission’s consulting and education subsidiary, the Joint Commission Resources, released the new electronic manuals as part of the organization’s Standards Improvement Initiative.


            Manuals for the hospital, critical-access hospital, ambulatory, office-based surgery and home care programs offer filtering tools which focus on the standards relevant to those organizations and a history tracking tool to monitor changes to the standards.  There will be filtering and history tools for the behavioral healthcare, laboratory and long-term-care programs available in the 2010 electronic manuals.


            To access the electronic manuals, go to



Jean DerGurhian.  “Join Commission Resources Moves Manuals Online.”, Dec. 3, 2008.



© 2008 Parsonage Vandenack Williams LLC


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Clinical Trial Participants: How to Obtain Informed Consent

              Before enrolling in a clinical trial, human subjects must sign a consent form that details the nature of the study and the types of risks involved.  One survey conducted by CenterWatch determined that 30% of participants did not understand that their study could pose additional risks, and 70% did not know what questions to ask at the beginning of the informed consent process.  Companies can protect themselves in clinical trials through careful preparation of the consent form and extensive investigator training on the consent process.

             The consent document needs to be easy for the participant to read and understand.  The industry standard for consent forms is that they are written at or below an eighth grade reading level.  It is very important that the potential subject is able to understand the information in the form.  It can be challenging to write consent documents, which often need to explain complex medical issues, at such low grade levels.  However, the sponsor and the investigator should treat the task as important.  It should not be left up to the institutional review board to make adjustments.  Rather, sponsors should review any changes that institutional review boards make to ensure that no critical information has been deleted and that the readability and comprehension levels have not been corrupted.

             Researchers should never just hand the consent form to participants to read and sign.  Instead, they need to have face-to-face discussions with them and answer any questions they may have.  After reviewing the consent document with the participant, some investigators test potential subjects to see how much information they actually understood.  If a subject does not appear to grasp the critical points, the researchers need to discuss those issues with them again until they fully understand.  This will help to ensure that true informed consent is obtained from all trial participants.

 Wadlund, Jill.  Heading Off a Clinical Trial Liability Lawsuit.  APPLIED CLINICAL TRIALS. vol. 12, no. 4.

   © 2008 Parsonage Vandenack Williams LLC

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New Email Drug Alerts for Physicians

The new Health Care Notification Network (“HCNN”) has started sending drug alerts to physicians via email, replacing traditional mail delivery of urgent drug warning and recall letters.  The network’s first alert centered on a widely manufactured and commonly used class of antibiotics and was sent immediately via the HCNN to health care providers.  The HCNN is a free service offered to all licensed U.S. physicians and their staff is used solely for FDA-mandated Patient Safety Alerts.  It is not used for advertising or marketing. Physicians and health care providers can register to receive electronic alerts at or through participating medical societies and other HCNN partners.

Health Care Notification Network, October 28, 2008.


© 2008 Parsonage Vandenack Williams LLC



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How to Select a Third-Party Billing Entity

 Selecting a third-party billing entity (“TPBE”) can be a difficult process for medical group administrators and their organizations.  A TPBE usually offers medical billing services, which may include charge-data entry, billing, electronic claims submission, payment posting and collection follow-up.

             Upon beginning a search for a TPBE, a medical group must first set its own priorities and determine the services it needs.  The following are some important things to consider regarding TPBEs:

 1.    Size. 

 Large TPBEs typically have the benefits of in-depth compliance programs, multispecialty expertise, many employees, cross-training, and the ability to offer additional services.  However, large TPBEs may also include higher TPBE overhead costs, inconvenient locations, and the potential for high employee turnover.

 Small TPBEs typically have the benefits of lower prices and less overhead, more personalized service, quicker response time, and potentially more control for the medical group.  On the other hand, they may only have limited compliance plans and limited multispecialty expertise, there may be coverage issues due to fewer employees, and they may offer fewer services.

 2.    Scope of Services.

 The medical group should decide whether it wants to pay extra for services such as record storage, computer equipment, software upgrades, ad-hoc reports, correspondence backlogs, and in-person representation for appeals with payers.

 3.  Billing.

 The group should decide how to be billed: per transaction or per claim? By a flat monthly fee or a percentage of practice revenue collected?  It is important to ask vendors for samples of management reports such as accounts receivable, charges billed, collection/revenue, denied claims, credit balance, and contractual and other write-offs.  Vendors should also be asked for a list of policies and procedures, a sample contract, and a tour of the facility.

             Finally, before entering into a contract, the medical group should refer to the Department of Health and Human Services’ Office of Inspector General’s guidelines for TPBEs ( to ensure vendor compliance. 

It is a good idea for medical groups to include specific terms and agreed-upon standards in the contract for the following: (1) maximum average number of days in accounts receivable; (2) maximum number of charge lag days; (3) other benchmark numbers important to the group; and (4) consequences if the TPBE does not achieve the stipulated benchmarks.  The group will need to provide the TPBE with accurate billing and patient information so that both parties can meet the terms of the contract.  Knowledge on both sided will greatly help to build a successful long-term billing arrangement.[1]

 [1] (Billing) Help Wanted, MGMA Connexion, February 2008, pp. 27-28.


© 2008 Parsonage Vandenack Williams LLC


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