1. I am a physician who would like to start a house call practice. What's the first step should I take and what things should I consider when getting started?Know what you hope to get out of your practice. The easiest means of starting a home care practice is to add home visits to your practice for those patients who are not able to get to your office without difficulty. Many physicians incorporate a half-day session or see the patient at lunch or before/after clinic. Very quickly, you will discover if you wish to do home visits full-time or extend the number of hours that you spend doing home visits. If you are ready to pursue your own full-time home care business, you will need to decide what type of practice you want (primary care, urgent care, etc.) You may choose to supplement your home visit revenue (start-up or long term) by pursuing directorships of hospices, nursing homes or home health agencies, by developing a relationship with a hospital practice, or by working part-time in an ER or urgent care center. In addition to our popular booklets, the Academy now offers a Practice Management Tool Kit containing many helpful articles, Q&A, and standards of conduct. We also hold an annual Practice Management seminar, for both beginning and advanced providers, in conjunction with our Annual Meeting. 2. How do I justify taking time away from the office to make house calls?
Medicare now pays significantly more for house calls than ever before. New technology allow for complete testing and treatment in the home, and the liability risk from house calls is actually less than that of office-based care. Instead of "losing track" of your frail patients as they migrate through the health care system during a medical crisis, you can encourage them to call your office for management decisions. Complex, immobile patients will no longer slow down your office turnover or compromise staff time. Physicians who make house calls are often perceived as "better" and "more caring" by patients, who often refer relatives for care. Making house calls may actually help grow your office practice!
3. How do I finance the start-up? Financing can be from personal resources, banks, investor capital, hospitals, insurers or grants. You can also work as a contractor or employee of a company that provides house calls. Remember, it may be months before you see significant money from insurance payments. Medicare pays in a timely manner, so it is wise to have your Medicare numbers in place prior to starting your practice. 4. How do I market my practice/recruit patients?Word of mouth is always the best source of referrals. Other sources include (but are not limited to) discharge planners at hospitals, sub-acute units, and hospices; home care agencies, Area Agency on Aging, various church or religious groups, senior centers, high-rises and apartments, adult day care centers, and your local Alzheimer's Association office. Giving presentations, participating in health fairs, and/or making media appearances are often effective methods of spreading the word. 5. Do I need to enroll with Medicare? Medicaid?Unless you are in a wealthy area where your patients can all pay privately, you will need to enroll with Medicare. The decision to enroll with Medicaid generally depends upon your state, the level of reimbursement, and level of bureaucracy that working with the program entails. 6. Where is the actual Medicare text that defines homebound status?The Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, defines homebound status and skilled services. Excerpts from this chapter are also included in our booklet, "Making Home Care Work in a Medical Practice." The homebound definition applies to home health agency patients; however, medical necessity must be demonstrated for patients receiving house calls. A CMS intermediary directive outlined the "medical necessity" qualification. Your local Medicare intermediary may issue LCDs (Local Carrier Determinations) further defining the qualifying conditions for "medical necessity." 7. Where can I find samples of a contract between a physician and nurse practitioner?The AAHCP has several sample contracts. Please contact our office for specific information. 8. What type of equipment should I carry with me?Your equipment will vary according to the type of practice you have chosen to pursue. For a chronic care model, the house call bag may include blood pressure cuffs with interchangeable bulb and gauge (regular, obese, pediatric), gloves with lubricant and hemocult slides, otoscope/ophthalmoscope, glucometer (calibrated daily), peak flow meter, digital thermometer, tape measure, hammer and tuning fork, bandage scissors, toenail clippers (industrial strength), portable scale, sterile scissors, forceps, disposable scalpel, and sterile gauze and tape. A durable soft attach? or overnight bag with multiple pockets works well. Purchase compact equipment to avoid removing instruments from the office. Be sure to include a stationery folder with necessary forms, prescription blanks, appointment cards, progress note paper, and referral phone numbers. Many providers are now experimenting with Electronic Medical Records (EMRs), as the technology has become affordable and easy to acquire and use to become paperless. 9. Are the costs of driving to the patient's home billable?No, unfortunately. As the Academy continues its efforts to educate CMS officials about the need to comply with OBRA 89 legislation and pay physicians for the work they do providing beneficiaries with medical care, payment for "travel expenses," remains uncovered by either the "work" or "practice" expense methodologies. Whether it is paid for or not, it is a critical aspect of the unique practice of home visits. 10. Should I buy or lease an automobile for making house calls?A reliable and safe automobile is an absolute necessity. Your mileage and other auto expenses will be deductible. Consider leasing an intermediate or larger car, as the greatest risk in performing house calls is the hazard of vehicular accidents. Many providers drive inexpensive, used cars. If the automobile is listed under your business, be careful to prohibit anyone but employees from driving the car, unless you purchase a special additional insurance policy. 11. Do most physicians work alone or with a team?Home care/assisted living visits may be delivered by an informal or formal home care team. You will need to decide which professionals will be part of your team and which will provide services on referral. In some systems, this includes a physician, nurse practitioner, social worker, PharmD, nutritionist, visiting nurse, and home health aide. In a more informal system, the provider interfaces with community-based agencies for skilled nursing, rehabilitation, and social services as needed. The local practice environment will determine the model best suited to your practice. 12. Do most practices have an office staff and office space? Do I need to hire a receptionist, or is voice mail sufficient?Unless you have large amounts of capital, you will likely start (and may stay) working out of a home office unless you already have a practice. Until you need it, do NOT rent office space. Do what it takes to get the practice off the ground, but hire basic office staff as soon as you can. The key to any efficient mobile practice is in the administrative office (dispatcher/triage person). 13. How many patients does the "typical" house call provider see in a week?Five patients can be seen in their homes in a half-day session; more, if visits can be scheduled in close proximity. On average, patients are seen 10-12 times per year; more often when less stable, and less often if very stable. An experienced NP or PA can handle a caseload of 60-70 stable homebound patients on a half-time basis. 14. I'm the only physician in my practice. How do I handle vacation/holiday coverage?Consider whether your system will allow NPs/PAs to take calls and whether there is a physician back-up for medical issues outside the scope of the NP. Nurse practitioners can often identify a collaborative physician who can serve as a back-up for medical issues. Determine the NPs scope of practice, such as whether the hospital allows NPs to admit and/or interact with hospital staff when managing inpatients. 15. How do I recruit providers?Often, the best recruitment is done locally by word of mouth. If you are unable to find the right person(s) locally, you can advertise or contact residency program directors from primary care programs and geriatric fellowships. List-servs can be very useful. 16. My patient needs a service Medicare won't pay for. What do I do?Try to arrange for someone else who will be paid for the service to perform the service. For example, for labs that require an iSTAT, you can use home health or draw the blood and give it to the caregiver with a prescription and directions to the nearest lab drop-off point. 17. Should I hire billing staff or use an outside company?This can be a complicated decision. If you have experience with billing and coding and have billing software that you or your staff are comfortable using (or can acquire such software at reasonable cost), then you may wish to bill yourself for the greater accountability this will provide. If you decide to use a billing service, talk to colleagues whom you trust, be sure to get references and make sure you have an escape clause. If you are unhappy with your billing company, find someone else to work with! 18. How do I make house calls economically feasible?The Academy has been victorious in getting CMS to raise Medicare payment levels, thereby making house calls a financially viable option for the primary care physician. The 2006 rate change made by CMS makes reimbursement for visits to assisted living facilities comparable to that of house calls. It is crucial to stay productive while you are out "on the road," and vital that you become well acquainted with Medicare rules for coding and billing. If you are able to overcome the overhead problems inherent in the practice of home care medicine, you can expect to be reimbursed at a rate competitive with income from a clinic-based outpatient practice. The best way to ensure adequate income is to join a house call group medical practice or utilize the expertise of a house call management services organization specializing in provider services. 19. What are the rules and regulations associated with involving PA's in long-term care?For nursing home related questions, see the American Medical Directors Association website, www.amda.com. For home care related questions, please refer to the AAHCP booklets "Making House Calls a Part of Your Practice" and "Making Home Care Work in a Medical Practice." 20. I am thinking of hiring a PA. How do I determine appropriate compensation?The American Academy of Physician Assistants website, www.aapa.org, has a salary service which will show you the salary for new graduates and experienced PAs in each specialty and geographic area. The site also has sample contracts and information on hiring, training and supervising PAs. 21. Can an NP do the initial house call, or does it need to be done by a physician?The NP can do the initial house call. The only code NPs and PAs cannot use is initial comprehensive visit for subacute Part A nursing home patients. |
