Small mixed specialty practice in an IRF setting.

[DannMann99]

I was hoping for some help from SDN as this group has been helpful in the past.

I currently run a small independent practice as a Physiatrist at an IRF. I am looking to hire on a IM physician to assist with some of the medically complex patient's that we've been getting. I am afraid of crossing into Stark territory. There are no hospitalists that currently service the IRF, and it is a needed resource.

I spoke with my attorney who had similar reservations but had told me as long as there are legitimate reasons documented for their consultation that it should be okay and my group could bill for the PM&R visit for the day and the hospitalist visit on that same day. They did not sound overly confident when I spoke with them and I figured I'd reach out to this message board to see if anyone has been in similar setups or has any experience.

Always appreciate the help!

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[DMBandFan86]

Most groups are set up like this. Are you providing 24 hour care/call currently?

The hospital should be setting up the consultants with direction from the medical director. IM and PMR are different specialties so there shouldn’t be any issue.

Are you saying that you own the IRF?

If you want IM on only specific cases then you can consult as needed. You can also have them see everyone on admission so they know who they are and have them follow up as appropriate or call for acute issues. You may also consider an IM NP who is overseen by another IM doc.

 

[Iamnew2]

Most groups are set up like this. Are you providing 24 hour care/call currently?

The hospital should be setting up the consultants with direction from the medical director. IM and PMR are different specialties so there shouldn’t be any issue.

Are you saying that you own the IRF?

If you want IM on only specific cases then you can consult as needed. You can also have them see everyone on admission so they know who they are and have them follow up as appropriate or call for acute issues. You may also consider an IM NP who is overseen by another IM doc.

Good question. For those of you who do IRF and have hospitalists, do you guys have them see everyone and are consulted on everyone or just specific patients? I feel that not all of my patients need IM coverage, and at times I end up managing the IM stuff when the hospitalists oversee things which is not that infrequent sadly.

Is it appropriate to have hospitalists cover everyone or do you guys consult on an individual basis for patients that are more complex?

For the more simple patients, I feel that IM coverage is not needed. At times I get the hospitalist NP just writing "no nausea, vomiting, chest pain, VS stable, etc" for days because the patients are stable. Thoughts?

 

[DannMann99]

I do not own the IRF. Just formed a practice out of it. The other PM&R physicians haven't been an issue but brining in the IM is what brought the concern.

In terms of consultations, I am leaving it up to the discretion of the attendings. As I own the practice I am much more discerning in whom will be consulted, with rationale clearly identified in my note.

 

[DMBandFan86]

So your concern is that you will be profiting on the consultant you hire? I would think your lawyer should know that answer easily and help you set up appropriate agreements.


I don’t own my own company, but I consult IM on everyone at the beginning. The patients are supposed to be medically complex to be in an IRF. I don’t believe PM&R board certification would cover you to practice IM on complex patients. I think I’m pretty good at IM, but too much liability and complexity to cover on my own. Easily justifies the consult for me.

I also use other consultants as well, but again am hospital-based.

 

[RangerBob]

We have IM here. They're their own separate practice. They're automatically consulted on every patient from admission--we have a co-management model. They determine how often they need to see patients, so some are seen daily, others every few days. Really healthy patients perhaps they see for the initial visit and then check in once a week or so--it's really up to them.

I think it's appropriate for all patients to have a hospitalist. They're complex enough to be on rehab. The few that are really healthy usually are still at risk of things going south, and the internist can just see them every 4-7 days or whatever they feel appropriate, as they're fielding any medicine-related calls about that patient from nursing.

 

[Slowpoke]

We have IM here. They're their own separate practice. They're automatically consulted on every patient from admission--we have a co-management model. They determine how often they need to see patients, so some are seen daily, others every few days. Really healthy patients perhaps they see for the initial visit and then check in once a week or so--it's really up to them.

I think it's appropriate for all patients to have a hospitalist. They're complex enough to be on rehab. The few that are really healthy usually are still at risk of things going south, and the internist can just see them every 4-7 days or whatever they feel appropriate, as they're fielding any medicine-related calls about that patient from nursing.

Out of curiosity, if IM is following as well. What are you doing as the PM&R doc specifically? Is it primarily running the interdisciplinary meetings and observing the course of rehabilitation/whether the progress is slower than expected and thereby answering why etc.

 

[RangerBob]

Out of curiosity, if IM is following as well. What are you doing as the PM&R doc specifically? Is it primarily running the interdisciplinary meetings and observing the course of rehabilitation/whether the progress is slower than expected and thereby answering why etc.

That, plus pain/MSK, bladder, bowel, psych, neuro (unless acute change—then IM works up), all dispo issues/planning, most consultations with other docs, etc.

 

[Iamnew2]

We have IM here. They're their own separate practice. They're automatically consulted on every patient from admission--we have a co-management model. They determine how often they need to see patients, so some are seen daily, others every few days. Really healthy patients perhaps they see for the initial visit and then check in once a week or so--it's really up to them.

I think it's appropriate for all patients to have a hospitalist. They're complex enough to be on rehab. The few that are really healthy usually are still at risk of things going south, and the internist can just see them every 4-7 days or whatever they feel appropriate, as they're fielding any medicine-related calls about that patient from nursing.

My concern at times is that where I’m at they seem they daily - so 7 days a week - even when stable. Because they didn’t have a PM&R doctor for a while prior to me starting they also made them “rehab “doctors even though they are just hospitalists - I don’t feel comfortable about this “double credentialing” that they have done and at times I wonder how legit it is

 

[RangerBob]

My concern at times is that where I’m at they seem they daily - so 7 days a week - even when stable. Because they didn’t have a PM&R doctor for a while prior to me starting they also made them “rehab “doctors even though they are just hospitalists - I don’t feel comfortable about this “double credentialing” that they have done and at times I wonder how legit it is

If they're billing as rehab doctors then you're in trouble, because only one specialty can bill the patient each day (unless a subspecialist is consulted of course--IM and rheum, for example, can both see and bill a patient, but not two IM or two PM&R doctors).

If they're billing as IM physicians then it's fine. It may not be indicated, but it's the skin off their back if they're billing inappropriately. Hopefully their notes justify why they're seeing the patient. As an attending it's easier to defend seeing a patient daily even when you're not making changes, but as a consultant you have to have a reason to see them. Our IM docs will see those "nothing to change" patients every 4-7 days or so--enough checking in is valid, but not so often that it could constitute fraud (not to mention just over-billing the patient).

 

[Iamnew2]

If they're billing as rehab doctors then you're in trouble, because only one specialty can bill the patient each day (unless a subspecialist is consulted of course--IM and rheum, for example, can both see and bill a patient, but not two IM or two PM&R doctors).

If they're billing as IM physicians then it's fine. It may not be indicated, but it's the skin off their back if they're billing inappropriately. Hopefully their notes justify why they're seeing the patient. As an attending it's easier to defend seeing a patient daily even when you're not making changes, but as a consultant you have to have a reason to see them. Our IM docs will see those "nothing to change" patients every 4-7 days or so--enough checking in is valid, but not so often that it could constitute fraud (not to mention just over-billing the patient).

Yes my concern is that they are billing too much and seeing the patients too much- there is no need to see the patients 7 days a week except for a handful of them. Obviously they are their own group so I don't have anything to do with that but I don't think it's right.

I also think it's ridiculous that they double credentialed them. They don't know the first thing about rehab.

 

[sloh]

If they're billing as rehab doctors then you're in trouble, because only one specialty can bill the patient each day (unless a subspecialist is consulted of course--IM and rheum, for example, can both see and bill a patient, but not two IM or two PM&R doctors).

If they're billing as IM physicians then it's fine. It may not be indicated, but it's the skin off their back if they're billing inappropriately. Hopefully their notes justify why they're seeing the patient. As an attending it's easier to defend seeing a patient daily even when you're not making changes, but as a consultant you have to have a reason to see them. Our IM docs will see those "nothing to change" patients every 4-7 days or so--enough checking in is valid, but not so often that it could constitute fraud (not to mention just over-billing the patient).

Such a good answer. Should be stickied.

 

[Iamnew2]

Such a good answer. Should be stickied.

No when I’m on they bill through their medicine specialty, although we have had an issue where they were billing for dc care 99239 when they weren’t doing it and I was doing all of that - med rec, dme, dc summary etc. they have discontinued thay nonsense but yeah the whole thing about the double credentialing as rehab doctors when they are not makes me very uncomfortable.

 

[sloh]

No when I’m on they bill through their medicine specialty, although we have had an issue where they were billing for dc care 99239 when they weren’t doing it and I was doing all of that - med rec, dme, dc summary etc. they have discontinued thay nonsense but yeah the whole thing about the double credentialing as rehab doctors when they are not makes me very uncomfortable.

I think you quoted the wrong post!

 

[Iamnew2]

I think you quoted the wrong post!

Sigh yes you are right, that's what happens when you are doing 10 things at once *hangs head in shame*