LLOYD & ASSOCIATES was a successful private practice in North Dakota employing four optometrists and 20 staff. Earlier in the year, Dr. Lloyd had purchased a small two-lane practice in a rural town 45 minutes from his office; the previous owner was retiring but agreed to remain as an employee for six months. That deadline was quickly approaching, so Dr. Lloyd moved quickly to catch the wave of new optometry school grads.
ABOUT REAL DEAL
Real Deal scenarios are inspired by true stories but are changed to sharpen the dilemmas involved and should not be confused with real people or places. Responses are peer-sourced opinions and are not a substitute for professional legal advice. Please contact your attorney if you have any questions about an employee or customer situation in your own business.
ABOUT THE AUTHOR
NATALIE TAYLOR is owner of Artisan Eyewear in Meredith, NH. She offers regional private practice consulting and ABO/COPE approved presentations. Email her at info@meredithoptical.com
Three applicants visited for interviews, but student-doctor Dunne was the clear choice. After aggressively negotiating against competing offers, she signed a lucrative contract with Dr. Lloyd. Her final month of school was followed by a month backpacking in Europe; during this time the practice processed her state license and began booking her patients.
Dr. Dunne spent her first few days of work completing a mountain of paperwork, watching EHR webinars and observing the techs. That Thursday afternoon she sat down with Dr. Lloyd to discuss tomorrow’s protocol.
“Your first day seeing patients is going to be pretty busy!” said Dr. Lloyd enthusiastically, handing her a printout of the schedule. “This column over here indicates the insurance they have.”
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Dr. Dunne scanned the page. “Okay, three Medicare, two cash-pay, a UnitedHealth, three VSP and one EyeMed,” she recited.
“Don’t click ‘sign-off’ on the chart in EHR,” instructed Dr. Lloyd. “The insurance team will do the rest of the work for you since we’re billing your charts under my name.”
“That’s legal?” asked Dr. Dunne.
“It’s what we’ve done for all the other associates,” he said. “Until you get credentialed, we’re forced to bill under my ID. I’ll try to look over some of your charts in the beginning, when I have time.”
“How long does credentialing take?” she asked.
“It can take several months, depending on the panel,” he replied.
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Dr. Dunne rubbed her chin worriedly. “This doesn’t feel right. I mean… I could get in trouble!”
“What arrangement were you expecting?”
“Most of my friends are starting off as super-techs: the practice owner comes in at the end to confirm findings. Between patients, they learn about billing or work on projects,” she explained.
“I’d have to pay you a fraction of your base,” said Dr. Lloyd. “And I really don’t need a super-tech. I need a doctor who can work independently, as I said in your interview. I have too many patients of my own to check your work.”
“Can I see cash-pay patients for now, until I start getting approved?” suggested Dr. Dunne.
Dr. Lloyd shook his head. “Your schedule is built for the next three weeks, and I’d say only 5-10 percent are cash-pay. We need you to generate a certain amount each week to justify your pay.”
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He started to clear the table, visibly frustrated. “I suggest you speak to the other associates for reassurance. I have a satellite location that will be without a doctor very soon.”
Instead of speaking to the other doctors, Dr. Dunne went home to call her best friend.
“He said the other docs did it, so that sounds reassuring,” her friend offered.
“If they want me to bend the rules on my first day, who’s to say there won’t be more sketchy compromises?” she replied.
The Big Questions
- Obviously this discussion should have happened earlier; now both parties feel duped. Can you identify a compromise?
- Is it fair for a practice owner to expect a new doctor to agree with pre-credentialing protocol without discussion/collaboration?
- How should a new doctor identify and enforce her own ethical boundaries? Should it be a component of an employment contract?
Jonah H.
Sacramento, CA
Compromise is a state of life when dealing with third party payers. They should have told them that in optometry school.
Of course, this should have been part of the initial discussion so that the new associate could consider/investigate their comfort level with the arrangement. It also should have been written into the agreement that a “billing bridge” must be constructed towards full credentialing.
Here’s the compromise:
The new associate should get to work and kill it.
The owner should agree to block off one or two hours at the end of each week to sit with the new associate and review any cases he/she is uncertain about, and sign off on all charts—taking full responsibility for any errors.
Richard S.
Richmond, KY
In the case of a new graduate, the optometry school has missed something that they should counsel and help new graduates with. Since this is part of private practice, they should teach and help understand insurance companies and help them get credentialed.
Secondly, this is an insurance company issue. With so much technology available, why does it take so long to get credentialed? It is absurd!
Since no one seemed to care enough to deal with these issues, if I were the new doctor, I would not even consider balking at whatever was necessary to begin seeing patients immediately.
Although it should have been discussed earlier, because it is common practice at that particular office, I understand why the owner might have not thought about it.
John B.
Copperas Cove, TX
The super tech idea is the best until she is credentialed. Dr. Lloyd should find the time to look over each and every file and, better yet, he should participate in some concrete, hands-on way to justify the use of his ID for the insurance claims.
David E.
Little Rock, AR
I don’t know what is acceptable here, but am very interested in what other docs have to say. How likely is it that this arrangement would cause problems for either or both doctors? Is this a commonplace arrangement?
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