Fam Pract Manag. 2004 Oct;11(9):58.

Visitors in the office


I’m in a multispecialty clinic of 60 doctors, and we often have our spouses, children or even our parents visiting us in our offices. Sometimes the nurses come in on their days off to catch up on paperwork and have to bring their small children with them. Do these family visits violate the Health Insurance Portability and Accountability Act (HIPAA)?


If you are taking appropriate, reasonable precautions to control access to protected health information (PHI), the incidental overhearing of such information is not a violation of HIPAA. The presence of children in the waiting room ought not be a problem.

Getting paid for depression care


When we diagnose patients with depression, our practice submits psychiatric diagnosis codes with appropriate evaluation and management (E/M) codes, but they are always denied. The patient’s insurance company sends the bill to its mental health services provider, but because we’re not a participating psychiatric provider with that company, our claim is denied and the patient gets billed for the service. Additionally, many patients don’t like this diagnosis and direct their anger at us. How should we handle these situations?


Payers’ refusal to reimburse mental health services provided by family physicians or to recognize family physicians as part of the mental health care delivery system requires a change in mind-set among payers and also employers, who pay the bulk of insurance premiums. Thus, one way to handle these situations is to share with the patient’s insurance company and employer the AAFP position paper titled “Mental Health Care Services by Family Physicians” (available online at

Another way to handle these situations involves overcoming patient anger. This can be done in a couple of ways. First, the physician can avoid the issue by coding signs and symptoms rather than actual diagnoses. This may placate the patient, but I would not recommend it (see “Coding for Depression Without Getting Depressed,” FPM, March 2004, page 23). Another way is to apply some basic patient relations skills (see “Remember Even Angry Customers Are Always Right,” FPM, September 1997, page 87). Finally, the physician may also try to use the patient’s anger to effect a constructive change in the system. For example, the physician could encourage the patient to redirect his or her anger at the insurer that refuses to recognize family physicians as mental health providers or at the human resources department of the patient’s employer for the way his or her benefits are structured.

Lastly, you can handle these situations as you do any others that involve denial by a third-party payer and patient responsibility for the charges. That is, you can appeal, as appropriate, and collect from the patient what is owed to you.

Signing a contract addendum


I am an employed physician and have worked for the same company for almost two years. Recently, four of our physicians quit to join our competitor, and our company responded by increasing our salaries and adding stock options and a signing bonus. These are part of an addendum to the original contract, which also includes a restrictive covenant, a nonsolicitation clause and an agreement that our salary increase must be returned if we decide to leave the company before a year’s time or without a 30-day notice. I feel as though I am being forced to sign this new contract. Is this legal?


It is perfectly legal for the employer to offer more money and other benefits in exchange for your agreeing to a restrictive covenant and nonsolicitation clause. However, the employer cannot force you to sign the addendum. You may decline to sign, and your employer would likely keep you at the same salary and benefits as under your existing agreement. You should seek advice from an attorney before you decide how to proceed.

Employment for residents


What employment opportunities are available for financially struggling residents who would like to gain medical experience and make extra money? Are there alternatives to medical moonlighting?


Since residency programs require the full-time efforts of first-year staff, little if any time is left for other activities, much less outside employment. That said, there are medical moonlighting jobs available for interested residents. The most lucrative of these are urgent-care facilities. Hospital administrators, such as the physician/staff liaison and the chief of family medicine, are an excellent resource for finding these and other available jobs in the medical community.

If medical moonlighting is not permitted, there is nothing stopping residents from working outside the medical field. However, most employers prefer to hire employees who can work a regular schedule, and the rigors of residency make this unlikely.

* Denotes member of FP Assist, the AAFP’s online clearinghouse for consultants and attorneys


Copyright © 2004 by the American Academy of Family Physicians.
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