Despite the reasons for pursuing medicine as a career, there will always be speed bumps that can lead to frustration, stress, burnout, or even a career or job change. Michael Morkos, MD, offers some tips on navigating the challenging and often confusing world of medical billing.

By Michael Morkos, MD, MS, MHI, ECNU

Many of us decided to pursue medicine for a humane, noble reason. You may have experienced the healing power of a physician or their impact on others’ lives. It took a considerable investment to reach independent practice, including many years of schooling, training, and, frequently, humongous loans. Banks will not understand the human nature of medicine, and you must pay your loans back on time. Also, you deserve a good living.

Why Medicine?

Some chose medicine from the very beginning as it is one of the highest-earning jobs, which is valid from one point of view. Some also chose their specialties or subspecialties mainly for income potential. As an academic endocrinologist, I get many rotating internal medicine residents in my clinic and during inpatient service as part of their electives. Is endocrinology no longer attractive? I highly doubt it as the science of hormones is very intriguing, but it does not pay well. Therefore, it is rare that I see residents interested in endocrinology, but mostly, they are looking for high-earning specialties. Nephrology was a very competitive medical specialty years ago, and they used to charge for every dialysate adjustment, boosting their revenue. When the Centers for Medicare and Medicaid Services (CMS) took over the payment for dialysis and decided to make it a package payment, their income dropped significantly. Many unfilled nephrology fellowship spots are available yearly, even in the most prestigious programs. Although revenue doesn’t come up in discussions as the primary influencer of specialty or subspecialty decisions, it is frequently a big reason for these choices.

Money Mindsets

Many emotions come up around productivity and money, and I find them fascinating. First is the guilt and shame in talking about money. It is as if physicians should continue to work and do tremendous humane service but dismiss the details of their revenue. Second is fear of insurance audits and the need to pay back money if overbilling was found. Next, on the opposite side of the spectrum is greed, with some physicians working for extended hours and pursuing inflated billing to maximize their revenue. The questions that come up are: what is fair billing? Do you understand the ins and outs of billing based on the complexity you are managing? Can you defend your billing in an audit?

Current Training

The billing and coding education provided to trainees is minimal. Attending physicians shouldn’t be blamed, as no one taught them these basics. The above-mentioned shame, guilt, and fear likely play a role. And like beginners’ training, they learn by trial and error. When simulated or actual audits happen, the feedback provides a learning opportunity that can be frequently painful. It usually results in more conservative billing due to fear of future audits, but this is not how we learned medicine. To build a strong structure, you have to pour a strong foundation, which is the most expensive and hidden part. This foundation takes time, effort, dedication, and investment. The stronger the foundation is, the more stable this building will be. Before we could study the topics of internal medicine and surgery, we needed to digest the basics: physiology, biochemistry, anatomy, and pathology. We didn’t get any lessons in billing and coding.

During my fellowship, I learned about a two-day billing and coding course provided by one of our endocrinology societies. I got excited about it and reserved a spot. I contacted my co-fellows and attendings, hoping they would join me in the learning journey. As you correctly anticipated, no one was interested. It was a hidden area of deficiency that no one realized. This course was a gem in my learning path, and I became the coding expert to my attendings for the remainder of my fellowship.

Additionally, the vast difference in compensation models makes it even more confusing: The wRVU (Work Revenue Value Unit) system, collections, bundled payments, and quality-based models in an insurance-driven system. These are different from the old straightforward fee-for-service model. The billing levels, various procedural Current Procedural Terminology (CPT) codes, and their requirements add to the system’s complexity. Also, the different practice systems, including community-based institutions, academia, county hospitals, Veterans Affairs, and other private practice models, can make choices challenging. The compensation section is frequently not detailed in the contracts, and a lucrative sign-on bonus and initial guaranteed salary may seal the deal. Compensation intricacies may be a reason for dissatisfaction down the road and result in the expensive decision to change jobs, which may affect many other aspects of physicians’ lives. On the other hand, money can be very enticing and push physicians to oversee apparent mismatches. Of course, revenue is not the reason for all the job changes, but it can be a significant factor in many.

As physicians, our jobs are unique and fulfilling. It is gratifying to see healing happen through our hands. Yet, I feel brokenhearted when I see overwhelmed physicians with overflowing work before or after hours and the need to add more hours to achieve their desired income.

The Compound Effect

Based on the concept of compound effect, small changes add up significantly in the long term. If you have mastered the billing guidelines, precisely determining the billing level and documentation phrasing takes a few seconds. It also doesn’t correlate with the time spent in the encounter if you rely on medical decision-making. It is not uncommon to charge a high-complexity established patient (CPT 99215; 2.8 wRVU) for short encounters, like 5-15 minutes, and a high-complexity new patient (CPT 99205; 3.5 wRVU) for 15-25 minutes. There can also be add-on charges like continuous glucose monitoring interpretation (CPT 95251; 0.7 wRVU). 

Two main ways to boost your revenue are more aggressive billing and higher volume, and it would be fantastic if you could do both. If you must choose one over the other, I suggest the volume. But they are not mutually exclusive, and you can work on both. Let us take a more extreme example from an endocrinologist’s standpoint: if you see three established patients in an hour and charge high complexity for two (99215; 2.8 wRVU each) and a moderate complexity for one (99214; 1.92 wRVU), you reap a total of 7.52 wRVU. On the other hand, if you add a moderate complexity patient and charge the four as moderate complexity, this will come up to 7.68 wRVU, which is higher than the previous example and with no high complexity charges. On the other hand, if you see four patients in an hour, with two being moderate and two being high complexity, the total will be 9.44 wRVU. This is why I believe that volume is more important, and if you compound it with higher complexity, it can significantly boost your revenue.

When you build your practice, you will have more time to communicate well and be available to accommodate urgent patients promptly. As time passes and your patient panel is full, it will get more challenging. You need some workflow engineering skills to ensure that you can accommodate urgent patients promptly, whether referrals from colleagues or your patients with urgent issues.

Some obstacles may cross your mind. The higher-complexity charges you place, the more likely you will get flagged and audited. Another fear is that the higher the volume you see, the more you can get overwhelmed, burned out, behind in the clinic, and get a busier in-basket (or inbox) with patient messages, calls, labs, and scripts. An additional risk is that you may have much more work after hours to finish. So, you got more money, but it adversely affected your personal life.

If I were in your shoes, fear shouldn’t be in my dictionary, but rather, how can I do it right? As for the other concerns, I believe in efficacy, the combination of efficiency and effectiveness. You can see more patients, understand the correct complexity of your current patients (not that you have to see many more new complex patients) based on the current CMS guidelines, and finish everything on time. You can’t jump from seeing 14 patients per day to 28 overnight. This won’t happen, and it is not healthy growth. But if you follow correct guidance and work on improving your workflow, it will happen slowly but surely.

Good Communicator

Imagine that you are a primary care physician and see a patient in the clinic with an incidental suspicious large thyroid mass noted incidentally on a CT chest scan. You want to get this patient as soon as possible with endocrinology. You sent an EHR communication message to the endocrinologist, and surprisingly, they responded within an hour and took over the care of that thyroid mass. How will you feel about that endocrinologist? If I were in your shoes, they would be my favorite, right? On the other hand, imagine that they responded two weeks later when the patient already found an outside endocrinologist as they were scared and didn’t want to wait.

Having open communication channels and establishing good relationships with your colleagues and referral base is crucial. If you are consistent, trust builds over time. Specific, good automatic habits are necessary to ensure this happens. I prioritize EHR messages and communications from colleagues and strive to respond to them within minutes to a few hours, at most 24 hours.

I am not asking you to have no boundaries and to call others before, during, and after hours, as this will adversely affect your life and end up causing burnout. I guide them to use the EHR messages rather than pages as they are less disruptive. When I am not in the office, I use the out-of-office option. It gives the expectation that I will respond when I return, and they can use a backup for urgent issues.

Availability

Remember the patient with the suspicious thyroid nodule mentioned above? Imagine that the endocrinologist responded within a minute and told you what to do, but their first availability is in four months, and there is no way around it. How will you feel? Will you refer any patients to them? Their practice is busy, and they won’t help when you need them the most. Availability is crucial.

When you build your practice, you will have more time to communicate well and be available to accommodate urgent patients promptly. As time passes and your patient panel is full, it will get more challenging. You need some workflow engineering skills to ensure that you can accommodate urgent patients promptly, whether referrals from colleagues or your patients with urgent issues.

As physicians, our jobs are unique and fulfilling. It is gratifying to see healing happen through our hands. Yet, I feel brokenhearted when I see overwhelmed physicians with overflowing work before or after hours and the need to add more hours to achieve their desired income.

I freeze 20% of my slots for urgent practice issues, so half will thaw in three weeks and the other a week beforehand. We have a well-run waitlist that will offer these slots to patients on the waitlist. This way, I ensure a well-established system of running an available practice while continuing to be busy.

My practice is heavily focused on thyroid disorders, and like any endocrine practice, I have a big panel of patients with diabetes on insulin therapy. Many of these patients need close follow-ups, frequently in four to six weeks. The frozen slots give me this luxury, and I see them as planned. If you don’t have a good plan and are booked six months in advance, you will do a lot of unpaid work between the visits, take work after hours, and hasten your burnout.

Competent Clinician

Let’s imagine two different scenarios. After the endocrinologist saw that patient, they ordered a thyroid ultrasound and a biopsy that showed papillary thyroid cancer. The patient saw the recommended surgeon and had a total thyroidectomy. Unluckily, while preparing for radioactive iodine, the pre-therapy scan revealed a 4 cm highly suspicious lymph node, and the patient necessitated a second surgery. The patient and her primary care doctor got frustrated as the endocrinologist and surgeon could have easily picked it up if they had ordered a neck ultrasound preoperatively, which is the standard of care. The patient found another competent endocrinologist, and the primary care physician stopped referring patients to them.

Let’s imagine the other scenario: The patient saw a competent endocrinologist who ordered a thyroid ultrasound and neck ultrasound for lymph node mapping at the same time along with baseline labs and got the patient back right after these studies to review the results. They reviewed the images together, and the patient saw the suspicious thyroid nodule and ipsilateral lymph node. The patient understood the high risk of metastatic cancer, and the biopsy of the lymph node and suspicious nodule confirmed it. The surgery and radioactive iodine happened as planned, and the patient and the primary care physician were grateful for the endocrinologist’s high-quality care, excellent communication, and availability.

The first two components are like a salesman who may have great skills. The question is: Will you go back to them again or not? It depends on the product. If you have an excellent product, you will definitely go back and ensure everyone knows about them. On the other hand, if you receive a poor product, you will never go back, despite the convincing pitches.

In Conclusion

As much as I enjoy caring for patients, and it is very fulfilling, I find the billing and coding an exciting game. There is a learning curve, such as playing sports, board games, or video games. And when you finish one level, you move on to the next. The same applies to learning billing, coding, and various practice tweaks to improve your efficiency, effectiveness, and productivity. The good thing is that there is no finish line when you say you did it all 100%; it is a path of continuous improvement and progressive growth. I hope you will enjoy it as well.

Endocrine Society member Michael Morkos, MD, is codirector of the IUH Thyroid and Parathyroid Center, and assistant professor of clinic medicine in the Department of Endocrinology, Diabetes, and Metabolism at the Indiana University School of Medicine, in Indianapolis. An Endocrine Society member since 2015, he is an active member of the Society’s Early-Career Special Interest Group. He has authored two books, No Work After Hours and Physician Revenue Secrets.