Michelle Cunningham, M.D. finished her medical residency in 2001, took time off to have two children, and began her clinical practice in 2007. The 41-year-old Cunningham is board-certified in both internal medicine and geriatrics, and in January, will be taking the hospice and palliative care board examinations. She has five main aspects to her practice, which keeps her almost continuously on the move: she has an office-based solo practice and also sees patients in their homes as part of that solo practice; works in a wound care center; does some hospice practice and is also medical director of a branch of a home healthcare agency. Cunningham reports that her private practice, wound care center, and hospice work each take up about one-third of her time each week, while she spends perhaps 5 percent of her time working for the home healthcare agency.

Cunningham’s saga, which encompasses, inevitably, not just her professional life, but her personal life as well, includes a husband (who is an interventional cardiologist), three children, three dogs, and ther husband’s 91-year-old grandfather, who lives with the family. Ultimately, Cunningham turned to the medical billing solution from the Irvine, Calif.-based Kareo, Inc., which has allowed her to automate processes that, prior to going live with Kareo, consumed precious time and effort. Cunningham recently shared her story with HCI Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

Tell me about your journey with regard to medical billing and practice management.

When I started my practice, I started asking everybody I knew about geriatrics. Most geriatricians work within a group. And I talked to some office managers, and I was referred to this lady who did billing out of her house. It turns out that I ended up doing my own credentialing, and there were further problems; and I ended up working with this billing office in downtown Houston, and I thought, this is perfect, this is a real company. But at some point after that, they called and said, we’re not going to do physician billing anymore. But this lady who did the wound care portion of my billing said she could do it on the side. And all of a sudden, I’m totally falling behind, doing all this work and getting no money.

So I found Kareo together with an office staff person I had hired. And when I decided she wasn’t working out, I called Kareo and asked them to help me, and they took me under their wing, and I did all the video tutorials they had, and as part of the contract, I was able to work with them on my computer directly. And in 30-40 days, I was starting to get paid. But the other thing that was interesting about this is that the big company that had been doing my billing had closed its doors and hadn’t kept records; and the girl I had hired and fired was angry and wouldn’t give me the records she had. So I started billing, and some charges were rejected as redundant. But about 10 percent of the bills had never been submitted. And Kareo helped me with those.The bottom line was, I could not afford any upfront software costs. And this is sold as a subscription.

Michelle Cunningham, M.D.

And you got the handholding, too?

You’ll have to ask them how they do the handholding with average customers, because what they did for me was amazing. With my hospice patients, I’m paid a part-time salary for; the wound care, I do my own billing for, and it’s an outpatient facility, and I simply enter demographics and do the billing in their system for the patients.

But you’re doing your own private practice billing, then?

Yes. And I go to an aging community complex, and I work out of that facility. And I also see patients in their homes, and Medicare allows you to bill for home visits, if they’re homebound—if it’s taxing for them to get out of their home. And so I bill Medicare directly through Kareo.

So it must obviously be an intuitive and user-friendly system?

Very! And sometimes there will be an update or something’s not working the way it should, and I’ll send them an e-mail, and they’ll update me or explain things for me. The thing is that I knew nothing about billing. And whenever someone would try to teach us in medical school just a little bit about billing, we students would say, oh gosh, you’re so concerned about money, and all we want to do is care for patients! But you have to know how to do this kind of thing, even if you’re in a salaried system.

And it’s almost impossible for a physician to learn billing until you’re forced to learn it through suffering. The thing is, as a medical student, you’re overwhelmed by the medical knowledge you’re learning. So you just push that off. But you need to learn this.

How long have you been live?

For two years now. And I had to be able to be very flexible. And I can’t stand to be in one setting; I like multiple settings. In residency, you rotated around. And I needed that kind of different intellectual stimulation. I knew that if I started a practice in just one setting, I’d have to switch jobs soon afterwards.

What would your advice be for other physicians in very small practices?

Almost no physicians are natural businesspeople. And if you’re in a practice and don’t understand how your business works, you’ll lose money. So sit down and listen to the CPA when he visits you, and listen to the office manager when she talks to you. Otherwise, you’ll lose money and time and enjoy your practice less. And physicians who don’t do this right, the amount of money they take home is so much less than what they’d expected, and so they lose satisfaction, and don’t enjoy their interactions with their patients as much. And when I went into solo practice, I wasn’t focused on how much money I wanted to make; I figured out how much money I needed in order to support my basic lifestyle, and then plugged in my opportunities. And there’s a cycle of building volume but then building overhead, and when overhead becomes 70 percent, you’re not going to enjoy your practice. So how do you get to that happy medium? If I add more patients, I’d need to add staff, and I don’t want to do that. This situation works perfectly for me right now.