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Posts posted by NeoTrion

  1. I am looking at changing jobs / specialties and I am currently discussing compensation.  Thus far no night or weekends and no call.  Basic 8-5 ish with a half day off if I want it.  Pitfall is they say "you have to pull back all of your own patients.  Nurses /  MAs arn't allowed for NPs or PAs.  It is an Ardent thing."  Now I will split my time between office and help in endo.  The bar seems pretty low on how many patients to see per day.  I think they are looking at 8 per day, but I will have to see if they are basing that on a 5 day work week or only when I am scheduled in office.  I have been told I will use the endo specialists MA and RN when he is on hospital days.  The thing is that he really wants me working with him at the hospital as much as possible so he can get more procedures done at the hospital.  Compensation is 105,000 without productivity bonuses.   This is just what HR spit out to the administrator and I plan on negotiating more.  PTO was originally quoted by the admin as 8.8 per paycheck.  That would roughly give me 5 weeks of PTO, but I want to make sure that is correct.  I currently receive about 3 weeks.  I have about 10 years experience between international radiology, Rheumatology, Immunology, Internal Medicine, Allergy and Interventional Pain Management.  I am also licensed and certified in Radiology, MRI, and Nuclear Medicine.  They plan on using me in Endo to help with fluoro as well.  I believe insurance is paid by them but will double check.

    My main sticking point is the compensation and not having at least an MA.  I also feel with 8 patients a day I might be bored.  I understand if I do not have a lot of office days not having the staff, but I definitely need to know if that 8 patient day is x 5 or only when scheduled for office.  I wanted to get some opinions from my peers here, and to see if anyone works for Ardent and can give an opinion.  Doc is newer out of specialty and seems to want to teach.  I would appreciate any contributions.

  2. Last year the APP staff became aware of some billing irregularities related to incident to billing and how things were showing up on our fee tickets.  After pulling up Medicare guidelines we found that our SP was not seeing Medicare patients for their initial visit.  This was brought to our office manager in an open meeting to which she stated "there is a loop hole for this."  I should note that our office manager / COO styles herself as a billing expert, and we were told that she has vast experience in billing and was certified as a coder and biller.  After two months it was finally decided that the SP would see these patient's for the first visit.  She was mum on how we were billing for exiting Medicare.  Further research in our state found that with Blue Cross Blue Shield that the do not pay incident to.  She refuted this in an open provider meeting and stated we only needed to use an SA code.  One week later she emailed us correspondence from a BCBS rep that confirmed a modifier code could be used when we saw the patient.  I emailed this rep and found out that the modifier code was to denote if an APP saw the patient and if it was billed under the SP.  In return we would only get 85% and that if we are already credentialed with them that it should not be billed under that modifier code but under our NPI.  The rep stated that if we were billing to the contrary we may be committing fraud.  You can only bill under the SP with that modifier code if you are not credentialed.  Our NP is credentialed with BCBS, but all of our billing slips had our SP as the rendering even if he was not on the grounds.  So naturally we sent multiple emails to our office manager / billing expert.  None were answered.  As a result myself and a nurse practitioner separately had a conversation with our only certified / licensed biller.  Based off of that conversation we had a conversation with our CEO/CMO about the billing.  A month later I find myself getting written up for asking the biller about if we were still billing incident to on Medicare and Private Insurance, and it undermined administration that I talked to her.  I pointed out that I emailed her multiple times for answers and that she never responded, and that we can be held responsible for anything billed that we see.  I made it clear to the biller at the time I did not want numbers or information that was considered privileged.    My question to the group is that is there any statute or law that gives us the right to ask how things are being billed, especially after making a formal request?  It should be noted that the NP did not get disciplined for talking to this biller over the phone as well.  The stories were exactly the same, and the main difference is that I talked to the biller in person in my office and the NP discussed it over the phone.   When I asked to COO/office manager for her billing and/or coding certification in front of the CEO she refused.  When I pressed her further she admitted she had let them "lapse" and could not remember when they had lapsed.

  3. Thank you for the responses and I am currently working on this as I have presented it a number of times.  She has finally admitted that they are going to change and have the SP see all new Medicare patients.  This was after insisting that everything.  By doing research I noted that some BCBS do not even recognize indecent to billing.  She states ours in Texas does allow this, but is mum on the details.  I have reached out to the specific rep to get more details on this since I would think if you are going to pay full price you would want the SP involved and documented.  Should I find an issue again I plan on discussing this with the higher ups.  We also have no way to prove how things are getting billed at this time, and is still a work in progress.

  4. I wanted to ask some of you billing gurus on a subject.  So up until recently we were billing incident to and I did bring up the fact that we should not be doing this.  On a number of occasions, they were billing this even when the physician was not in the building.  Upon further reading it also appears that in order to bill incident to that the MD must see the patient for the initial visit.  Our practice is a single MD and he does not see new patients except for a rare occasion (10 a year).  I brought this up to our practice manager with an article from CMS stating this and she stated that there was a loop hole somewhere.  After about 1.5 months she finally admitted in a meeting that we could definitely not bill incident to when our MD is out of clinic.  She is now telling us that we can use direct billing for the initial visit and then incident to for the billing thereafter.  According to CMS to bill incident to at all the new patient has to have their initial visit completed by the MD.  She states that she talked to a “billing expert” and this is not the case.  She once again stated that we can do direct billing for the initial visit and incident to on the follow up visit.  Can someone direct me to someone in Medicare I can talk with in order to confirm or permanently correct her?  I am also open to education on the forum here if things have changed.  My MD is a good man but has gotten bad advice in the past on billing.  She did admit that she missed some of the incident to rules on her watch, but she also holds herself to be a billing professional as well.  Any information would be greatly appreciated as I do not think we can bill through the MD based on incident to guidelines per Medicare.  I do not mind fighting with her on this but I want some data and opinions on this before I go digging a trench for myself. 

  5. Rev Ronin, that is what I was thinking as well.  The closest I can find to a "no that it can't be done" is a recommendation for a committee.   Thus far I have not been able to get anyone to call me back on this that is on these committees or on the various medical boards.  In fairness COVID may be causing some of this communication difficulty.


  6. Thank you for the comments.  Unfortunately Appriss is the one that keeps track of our inquiries and I have found that they do not always log the inquiry.  We have showed them proof of this and initially they blew me off.  After about two weeks the reopened the ticket I initially opened (that they closed the same day) and stated there was a "known issue."  Naturally if I am in pain management and I relying on them to cover my butt with the state, this does make a me a little nervous when relying on them to log my inquiries.  I also like to have the actual report scanned into the EMR to prove what I put in the dictation.  I have had several patients put in as a nick name or middle name when their name does not match what we wrote on their script or in the EMR.  (Ex. real name is Leslie but they go by Dale on PMP, or names are shortened from Marylin to Mary, etc......). I have also had some pharmacies go in and edit the PMP or put the wrong drug/prescriber on the PMP.  This was brought to the attention of the PMP advisory board to which the pharmacy board and Appriss did not want to take responsibility.  So naturally I would rather make sure there is a copy in the EMR that cannot be changed.  I would appreciate if anyone else knows if their state prohibits them from printing or scanning into the chart.  Like some of you have said it does not make sense if you do not have this supporting documentation for your medical decision making.  I was  hoping some of you could say "yes I know we can't print or scan and this is why....."

  7. I was hoping to get some wisdom from some of you in different states.  In Texas we are required to check the PDMP before prescribing any narcotics.  I currently work in pain management and this is an issue, but has been seen as a necessary step.  We have been trying to work with our EMR on seeing if we can save the PDMP into the EMR.  The reason why we are doing this is that we have caught the database not updating/logging our searches.  As you know if it is not documented it did not happen.  We were advised by our professional society to make sure a copy is in the EMR to prove we did pull the report.  This has cost us labor hours (to scan it back into the system) as well as paper cost to cover our butts.  This is why we want our EMR to allow a save button so we can simply save and sign it to the chart.  During a call with them they stated in some states that it is not legal to print the PDMP or save it to the chart.  One example is Kansas and I cannot find any rule that says it cannot be printed or put in the chart, but that the advisory committee for K-Tracs (Kansas PDMP) recommends it not go in the chart.   I am looking to see if some of us in other states know if this information is correct as it does not appear so in Kansas.  I currently have a call out to K-Tracs but because of COVID they are saying it is taking them longer than usual to respond.  Does everyone else just pull the report and hope it tracks your inquiry like it is suppose to?  I think the information given by our EMR is not the total truth concerning saving and printing the PDMP, but I wanted to ask the brain trust here and see if what they are saying is true.  Their argument is they need a product that can be sold in every state, even if it is at the expense of a needed feature in another state.

    PDMP print and save.xlsx

  8. I did not like my eko.  To much ambient noise.  I still use my Littmann that I got 5+ years ago.  It is showing its age and is missing a few buttons but works great.  Not impressed with eko and only use it as a last resort when my electronic Littmann or cardiology STC can't be found. 

  9. I would just pick up the phone and say "By the way did you see this?"  I have done that in multiple specialties and it usually ends up with a pause on the phone.  It doesn't matter to me if they think I am an arse.  There have been times when I have called them and they put the blame on someone else and it was probable.  I would want to know if I missed something but probably an issue of just trying to move on to the next patient and refer out.  

  10. Arthropathy that is the stance I have taken and have pushed them to the SP.  Neither myself or the other APPs I work with do not mind letting them see these patients as we have a full load of patients without them.  I am just looking for someone that can point me to the law in Texas on this one.  I remember learning about this in school years ago but wanted to ask the brain trust here if they can point me to it in writing.  Personally I do not want to see them if trust cannot be built in the first place.  I can always remember that you rarely get sued by friends and those that trust your judgement.  Thank you for removing the apostrophe Medicine Power.

  11. Sounds like splash damage and you were hit by it.  I would think more could be said, but perhaps they used the old "you can resign or we can fire you" bit.  If you find out more it would be interesting to share.   It would help others in the future that come against the same situation.


  12. We had the same problem at a hospital here in Texas.  We had to get our state chapter involved and claim the restriction of trade.  They were making this decision based on a nursing position statement that the Board of Nursing posted on the website.  The admin, that was made up of all nurses with the exception of the legal counsel and the CMO, stated: "we have to protect our nurses."  Our state chapter reached out to the medical board and basically pointed out that the nurses are deciding who can practice medicine in our state.  That caused a meeting between the medical board and the nursing board, and hence that position statement was heavily edited.  The nursing board now recognizes PAs.  

    We then went back to the hospital admin that then tried to blame it on corporate.  When the state chapter lawyers contacted corporate they had no idea what that hospital was talking about.  Eventually, we were given parity with the NPs at that hospital.  The nursing admin was not happy about that, and neither was the head of the medical privilege office which was run by an RN.  The key was the help we got from our state chapter.  I will say this little hospital in Texas was educated and credentialing from Baylor and MD Anderson considering PAs and NPs was shown to them on paper.  I had the CMO and CNO say "that is them and this is our hospital."  They did make it sound like their hospital was better than either Baylor or MD Anderson.  Basically, they did not want to be educated  The only thing they responded to was a legal counsel to legal counsel discussion.  It is the main reason why I choose to get involved in the state chapter.  The difference was that I was already on medical staff there and not trying to get a job.  This may be worth going to your state chapter or asking why you need a co-signer.  In our state, we have no OTP but NPs are not independent.    Neither requires a co-signature unless admitting or discharging.

    I should add that the NPs in the hospital were not opposed to us and even the RNs were happy to take orders from us.  The RNs in our department also signed a petition.  Our obstacle was the RNs in administration.

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  13. So TAPA has had two bills come out of committee so far.  HB 2250 schedule II and HB4066 are up for consideration on the house calendar committee but has not been scheduled to be heard.   Time is starting to run short.  So Texas PAs help is needed to put pressure on the calendar committee.  Members are posted below.  If you live in their areas it would be good to send a letter and put some pressure on them.  Time is growing short to get these bills on the calendar.  

    Rep. Four Price
    Vice Chair: Rep. Joe Moody
    Members: Rep. Joe Deshotel
      Rep. John Frullo
      Rep. Craig Goldman
      Rep. Oscar Longoria
      Rep. Will Metcalf
      Rep. Tom Oliverson
      Rep. Eddie Rodriguez
      Rep. Toni Rose
      Rep. John Wray
  14. I know this has been a topic with some members here, but I just received an email from TAPA looking for applications for committee members and committee chairs.  I know some people have not made it in before, but you can't win if you don't play.  I am on two committees but will be giving up a place in one, but I am trying to hang on to my place in another.  It may not happen, but I would like someone from this forum to get my seat if it does.  I would like to work with some of my respected peers from this forum as well.  We have a large amount of experience on this forum to draw from, and our efforts with getting different schools of thought were successful with the AAPA.

  15. Asking mainly because I am working on my doctorate, working, and on two different committees in TAPA.  I have been a member of PAFT since I was a student and wanted to see if I could take more of a leadership role.  My employer is not the best with taking time off and is stingy with CME money.  The meetings with TAPA have all been on my dime, so there is the financial aspect as well.  I do that because I can contribute in areas that I do well in, and I was challenged to "put up or shut up" by former mentors.  I am trying to see if I can fit something else in rather than commit and then reconsidering.  I have respected many of the officers in PAFT and really want to work with them in person.  I may need to wait until after I finish my classes.  Not personally looking for a resume punch/notch, but I do want to be more involved.  Thanks for the info SAS.    

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