It's Your Call

Is your call coverage a harmonious arrangement or an issue that leads to verbal sparring between you and your partners? Although the variation in call arrangements is broad, two things are clear: call coverage is less onerous in practices that take the time to delineate and negotiate an arrangement that is considered fair by everyone, and managed-care contract language plays a role in how you structure the arrangement.

"The first order of business is to address call coverage in employment contracts and partnership agreements," says attorney James G. Stuart, of Karen Zupko & Associates Inc. "If the agreement isn't spelled out in writing, the issue can become a divisive one."

According to Stuart, most contracts are silent on the issue of call. He advises groups to at least include general language that states the coverage will be equitable. "That way, no one physician gets dumped on, especially the young guy."

Stuart and others agree that there is no single "right" way to structure call. Some practices divide call equally among all physicians. Others require the newest physician to take more than the others so he can begin to build a practice. Still others have mid-level practitioners take call and triage it, contacting a physician only when necessary.

"How you structure your deal depends on what will mutually satisfy everyone, and that is often a reflection of practice culture," says Stuart. "But regardless of what your arrangement is, provide a general description of it in employment agreements," and keep a written record of any changes.

"You don't just set up a good call arrangement, it evolves," says Richard W. Honsinger, MD, managing partner of Los Alamos-based Allergy and Asthma Associates of Northern New Mexico. "What has worked well in our community is that each practice takes care of covering its own patients during the day but shares call with a larger call group on nights and weekends." Each physician involved takes call an average of twice a month.

Handling sticky issues

The issue of senior partners who want to ease out of call can take some finesse. Says Stuart, "It's common for the senior partner to work less, and often a junior partner doesn't mind working more because it means additional services can be billed, and his practice gets built faster." Stuart is careful to advise that practices should put these details in writing. "Make it clear how taking less call affects the schedule and the income distribution plan, and how long the physician not taking call will continue to practice. Without this clarity, the situation can eventually become dicey."

The physicians at Allergy and Asthma Associates extended a courtesy to senior physicians last year. "After a physician in the call group has taken call for 25 years," says Honsinger, "they can opt out and the group will cover his or her patients."

Another sticky issue: what of physicians who leave town more often than others, or for other good reasons cannot take an equal share of call? Says Honsinger, "We ask these physicians to pay into a common pool if they want the call group to cover their patients. The amount is similar to what locum tenens are paid in the area, about $500 to $700 per month. At the end of each quarter, any money in the common pool is distributed evenly to those physicians who covered call during the quarter."

Honsinger reminds physicians to honor a respectable code of ethics. "Physicians within one practice or a large call group must agree that they will not inherit each other's patients. If you are on call and treat a patient in the hospital over the weekend, stay firm when that patient asks you to become her doctor. Support your partners and colleagues by telling the patient she should return to her doctor for follow up."

Some groups just can't be satisfied, even when their call coverage is distributed equally. Stuart points to one newly merged cardiology group of 14 that decided each physician would take call every 14th day. Most thought this was an improvement over taking call every seventh day, which was the case before the merger -- but several dissented.

Stuart explains, "This group covered three hospitals, so being on call was extremely intense. Those that wanted to exchange intensity for less call overruled those who didn't, but the group is still arguing about it."

Know your contracts

If you are not familiar with the contract language about call coverage, pull out your managed-care contracts and take a look. "In many cases, it's helpful to have a call clause that is broad so you have flexibility," says Marla Durben Hirsch, an attorney and editor of the industry newsletter, "Managed Care Contracting and Reimbursement Advisor." For instance, most contracts stipulate that plan members be covered by credentialed providers on a 24/7 basis. But consider a solo physician in a call group with others in the community. What happens if some of those in the call group are not credentialed with the plans of patients they care for when they take call?

"Look at your contract and understand what you have agreed to," says Hirsch. "If a contract clearly states that providers must be credentialed by the plan, asking noncredentialed providers to cover you is a violation of that contract."

Since violation of the contract is grounds for termination, Hirsch suggests renegotiating the contract language if your practice or call group includes noncredentialed or decredentialed physicians, "as long as these providers agree to accept the plan's allowable as payment for services." This type of arrangement provides greater flexibility with call partners, and also makes it easier for new physicians to see patients while they await credentialed status.

"One local practice sold to an HMO a few years back," recalls Honsinger, "and we were unable to keep them in our call group because the other HMOs would not credential them to see our patients." The sale of the practice meant that call group members had to take more call, but there was no negotiating with the area HMOs. Yet another change in ownership meant the practice later rejoined the call group, "but for several years we could not ask them to see our patients," says Honsinger.

If you plan to add a new physician to the group, get organized with respect to call. "When we added doctor number four, I initiated the credentialing process about four months prior to his arrival," says Diane Arechiga, practice manager of Bakersfield Orthopaedic Medical Group in Bakersfield, Calif. "We could bill for his office and call services the day he started seeing patients."

Other options

For many practices, using mid-level providers is an efficient way to manage call. Many practices use PAs or NPs to triage calls, make rounds, and contact physicians only when treatment or a procedure is warranted. Again, read each contract carefully. Be sure each managed-care contract includes PAs and NPs in the definition of provider; if physicians are the only covered providers, your options are limited. Also, make sure the contract language is clear about how mid-level providers will be paid. Medicare's "incident-to" rules typically won't apply, since a physician will not be present when the mid-level provider takes the call.

In the case of emergency room (ER) call, ask for reimbursement from the hospital. Because so often the patients seen through the ER are uninsured, hospitals will often negotiate reimbursement for covering call; it may come in the form of a specific dollar amount or a percentage of total charges for patients treated.

Tulsa Orthopaedic Surgeons in Oklahoma began receiving ER call pay last year. According to administrator Nancy Nykyforchyn, "The hospital has a fixed budget for paying ER call each month, and it's distributed based on the number of days a physician actually takes call." She admits this amount is not substantial, but it helps offset the uncollectible accounts of uninsured patients.

Arechiga says one of the surgeons in her physicians' call group is trying to arrange a $1,000 payment per weekend to cover the ER. "The hospital is in a tough spot because it can't arrange consistent coverage, and the state medical society is demanding proof that physicians are available to treat patients," she explains. Though this surgeon has not yet been successful, the hospital may have to fork over the payment in the future to secure ample coverage.

Regardless of your practice setting, if you and your partners aren't singing from the same call sheet, open up discussion and address the issue. As you create an equitable arrangement that makes everyone happy, review managed-care contracts to be sure the language supports your policies.

Cheryl Toth can be reached via editor@physicianspractice.com.

This article originally appeared in the January/February 2002 issue of Physicians Practice.