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More on high-low agreements

I liked Dr. Peter G. Teichman's article "How High-Low Agreements Work in a Malpractice Case" [May 2007]. However, the article incorrectly states that the "winning" defendant will suffer career-long consequences of disclosure to the National Practitioner Data Bank (NPDB). According to the most recent NPDB Guidebook, reporting a win for a defendant in a liability case, whether by jury verdict or arbitration, is not required.

Frank J. Feci
Princeton, N.J.

Author's response:

Mr. Feci identified an error in my statement regarding reporting to the NPDB payments made to plaintiffs in high-low agreements. I regret the error and am grateful for his insight and for the opportunity to provide clarification.

Per the NPDB Guidebook, payments made by an entity to satisfy a written claim or judgment against a practitioner, in whole or in part, must be reported to the NPDB. Individuals are not required to report payments made for their benefit out of personal funds.1

Payments made because of a high-low agreement should be reported to the NPDB if the defendant practitioner has been found to be liable by a fact-finding authority and payment is made at the high end of a high-low agreement; if the plaintiff and defendant settle the case (with payment) prior to the conclusion of a trial; or if binding arbitration determines a payment amount without a determination of liability.1

Payments made after the execution of a high-low agreement do not need to be reported to the NPDB "… if the fact-finder rules in favor of the defendant and assigns no liability to the defendant practitioner. In this case, the payment is not being made for the benefit of the practitioner in settlement of a medical malpractice claim. Rather, it is being made pursuant to an independent contract between the defendant's insurer and the plaintiff."1

Peter G. Teichman, MD, MPA
Ho Chi Minh City, Vietnam

1. The National Practitioner Data Bank Guidebook, Chapter E Reports. U.S. Department of Health and Human Services: September 2001. Available at: http://www.npdb-hipdb.hrsa.gov/pubs/gb/npdb_guidebook_chapter_e.pdf. Accessed June 4, 2007.

Dr. Teichman's article on high-low agreements is an excellent presentation about the "sausage making" that occurs behind the scenes in our legal system. I have noticed an additional problem when high-low agreements are agreed upon in the pretrial period: Since the potential loss or gain for either side is already set, I have seen malpractice insurance companies apply a cost-saving approach to their trial preparation by using less qualified (and less expensive) litigators and hiring less expensive and fewer expert witnesses. Obviously this can have a negative effect on the trial outcome for the physician defendant.

Arthur M. Altbuch, MD
Janesville, Wis.

TransforMED and rebuilding family medicine

After reading "TransforMED Tries to Rebuild Family Medicine" [May 2007], I am reminded that the bottom line drives our system. We are faced with the difficulty of being physicians, taking care of sick patients and having to accept inadequate reimbursement by payers. A true physician will not abandon a patient regardless of reimbursement or failure of the health care system. The AAFP, American College of Physicians and American Academy of Pediatrics, which are the leaders in primary care in this country, should come together to gain political power and drive health care to a better place. If this is not done, I can see the most powerful country in the world losing primary health care.

Juan R. Perez, MD
El Paso, Texas

With regard to TransforMED, I think the AAFP's efforts would be better directed at changing the U.S. health care system. We are being slowly destroyed by an insurance industry whose sole purpose is to maximize profits for its shareholders and corporate officers at the expense of patients and physicians. Insurance companies have the power or, rather, the money. We have lost control of our future. We have lost control of medicine as a profession of intellectual pursuit, curiosity and independence. We are no more than factory workers on an assembly line. We have been commoditized.

Roger Cyrus, MD
Westbrook, Conn.

Managing your panel size

"Panel Size: How Many Patients Can One Doctor Manage" [April 2007] by Mark Murray, MD, MPA, Mike Davies, MD, and Barbara Boushon, RN, nicely explained what I did intuitively in 1970. As a junior associate in a busy family practice, I was accepting a lot of new patients while my established patients, when unable to see me when needed, were forced to see an even more junior physician at our clinic. My optimal workload was 110 office visits per week. After taking note of these things, I initiated these guidelines: My established patients would generally be seen by me, and new patients would generally be seen by the more junior doctor. At the end of each week I would ask the office staff to total my office visits. I would accept one or two new patients the following week if my total number of office visits was less than 110. This system kept me busy but not overwhelmed, and my patients liked the continuity.

E.H. "Bert" Krikke, MD
Edmonton, Alberta

Editor's note:

Watch for an upcoming article by Dr. Murray in which he answers frequently asked questions about panel size.

How do you define "new patient"?

I respectfully disagree with the coding advice in "New patients for a new physician?" [Coding & Documentation, April 2007]. Current Procedural Terminology (CPT) does not differentiate between locations of service when defining a new patient. It does, however, define a new patient as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."

When the physician sees a patient in his new practice after having left his residency practice, the patient would clearly be defined as new. In fact, the first visit would be billed under a new tax identification number. This fulfills the requirement of belonging to a different group practice.

In this and the second example in the article, the practices have the added burdens associated with new patient visits: medical and insurance information must be collected and verified, a chart or new record must be made, confidentiality paperwork must be given to the patient and filed, and so on. In each case, the patient qualifies as new.

Ralph C. Samlowski, MD
Huntsville, Ala.

Author's response:

Dr. Samlowski is interpreting the CPT definition incorrectly. The determining factor is whether the physician has seen the patient in the past three years or another physician of the same specialty who belongs to the same group practice has seen the patient in the past three years. Dr. Samlowski's interpretation of the definition is that the patient is new if he or she hasn't been seen by "the physician … who belongs to the same group practice" or "another physician of the same specialty who belongs to the same group practice." Therefore, he concludes that because the physician changed practices he can bill a new patient visit code when seeing a patient he saw in his previous setting.

Per CPT, if a physician or any physician of the same specialty in the same group practice or any physician for whom a physician is providing call coverage has provided a face-to-face professional service in the past three years, the patient is established. It is the relationship that is the determining factor.

If you follow the flow chart in the CPT Evaluation and Management Services Guidelines, the first question asks whether the patient has "received any professional service from a particular physician, within the past three years, who is now reporting service?" If the answer to this question is "yes," the patient is established.

Cindy Hughes, CPC
Leawood, Kan.

Correction

The coding advice given in "Hospital admission and discharge" [Coding & Documentation, January 2007] was incorrect. CPT defines hospital admission as the first encounter between the physician and the patient at the site of service, regardless of the calendar date the patient becomes an inpatient. In this case, the patient was assigned to inpatient status at 11 p.m. but was not seen by the physician until the following morning. The physician then discharged the patient later that day, resulting in a same-day admission/discharge service, which should be reported with a code from the series 99234-99236.