Patient Waiting Times - How Long Is Too Long?

Patients need to realize that a physician's office is not a restaurant.  You may not get called to your table immediately and your doctor may have times where the schedule falls behind due to emergencies or especially complicated patients with an extended history of illness and medications.

You should expect that the care you will be rendered when you finally see the doctor will be unhurried and that all of your questions and treatment options will be discussed in detail.  When you leave the office, you should be satisfied that you received the best treatment possible and that you are certain of any post visit instruction.

Unfortunately, many physician practices have no idea what a schedule means and chronically run behind schedule day after day.   The problem here is two fold.  First, if a physician is not meeting his daily schedule obligations and patients and extended waiting times are the norm, his or her schedule is almost certainly overcrowded.   Every office should have a time protocol for both new patients and return visits and gauge the physicians overall practice style and adjust his schedule accordingly.   In the rush to meet volume requirements, you may end up losing valuable patients along with new patients who will leave prior to their visit or never return.   After only a few weeks, the front office should be aware of the practice style of each of their physicians and adjust time schedules to meet his or her method of treatment.

Secondly, the front office should note the ebb and flow of daily visits.  If the physician is running two hours behind, the front office staff should call the next set of patients and ask them to arrive two hours later.  Often the staff is anxious to go home for the day and would rather deal with disgruntled patients who approach the front desk to voice complaints rather than having to put in extra hours or call in alternate staff to cover the late hours.  

In the worst case scenario, patients are put into a treatment room and forgotten for extended periods of time, behind a closed door without reading materials or anything else to do.  Many patients will wait for ridiculous amounts of time without opening the door and checking on the doctors progress, while others will simply get dressed and exit without saying a word to the staff.   They will often, however, be quite vocal to friends and family and can exert a substantial negative impact on your practice.  I have left one of my favorite doctors after time and again his eleven o'clock patients were not seen until one p.m.  I just did not have the time to wait two hours for each visit and although he was attentive and well skilled when he finally did see me, the burden of this wait just became too much.

We patients should expect a reasonable wait of fifteen to twenty minutes, and understand that treating patients can be complicated and difficult, but extended wait times mean that the office is not run properly and this problem is often symptomatic of other problems that may include a discourteous staff, lack of return phone calls or in the worst case problems that can result in medical malpractice.

Physicians often try to schedule an entire patient day without allowing for a break for lunch or to take and return important phone calls.  This is an unreasonable way to practice and one that cannot be sustained for any extended period of time without significant breakdown in patient care and waiting times.  Even if a physician has a fifteen minute lunch and uses the rest of his break time to catch up, each doctor should have at the very least a forty five minute mid-day break built into an eight hour schedule.

Front office staff should also have scheduled breaks and lunch time to avoid burn out.  It is often a good idea to place the phone on service during lunch hour so that the office has a quiet time each day to recharge and enjoy a few minutes of peace.  You may want to schedule your last morning session patient thirty minutes prior to lunch hour and try to save this time for a return patient rather than a new visit that may run overtime.  New patient visits may be best scheduled for the first visit in the morning, right after lunch and an hour prior to the end of office hours.  Back to back new patient scheduled visits will certainly contribute to longer waiting times so schedules should be built with specific new patient slots that work best for each particular office and practice style.   You should, however, try to schedule new patients within twenty four hours of appointment request whenever possible.  Unless your physician is the only game in town, new patients will shop around for an earlier appointment.

Should a patient become sullen and critical with the physician due to a long waiting time, the doctor should apologize for the wait and explain that certain visits may become complicated and the schedule cannot be written in stone.  The staff should always be patient and courteous with those waiting to be seen and if the patient should become overly hostile, management should take charge and try to smooth out the problem rather than leaving the often already overworked front office to deal with it alone.

You are not going to satisfy each patient who visits your office, but you should make every attempt to give your patients the opportunity to be seen in a timely manner and adjust your office schedule to meet these particular needs.  

Hats Off to Our Health Care Workers in New York

To all the health care workers who dedicated their time and efforts during Hurricane Irene, you have our deepest gratitude !
 
Making a smooth evacuation from one hospital location to another is no small effort and our area hospitals handled it with the skill and dedication that we have come to expect in our New York area.  So many nurses and doctors put in tremendous amounts of overtime to assure the health and safety of our patients as they were transferred to facilities throughout our state.   Those healthcare professionals evacuated from their own homes made a new weekend home in their hospitals, with little regard for their own possessions.

We still have the greatest city in the world and these efforts by our NY healthcare professionals is just another indication of how New Yorker's always rise to the the occasion.

Great Job Everyone !

Smart Shopping for Your Medical Practice

All of us in the healthcare industry are well aware that it's all about the overhead!   For many practices, the day to day costs of running the ship can have a serious impact on overall financial health.  With some careful planning and smart shopping, your budget can remain intact.

So many practices in serious financial shape spend money foolishly simply because they are not taking the time to become smart shoppers.   It is relatively simple to make some significant changes in your shopping habits that will quickly add more dollars to the practice coffers.  The following tips can alleviate both the stress of running out of supplies and keep your overhead from running you over!

1.   Do Not purchase toilet paper or hand towels from the same vendor that provides you with your injectables and/or medication.  You will pay dearly for the privilege and way above sale prices for these items.  Shop supermarket sales, especially when Scott tissue 20 roll, for example, is on sale.  Buy 2-3 packages which will give you 40-60 rolls anytime the local grocer advertises this bargain.

2.  Install a simple paper towel holder on the wall above your sinks and purchase bulk supplies of paper towels when they are on sale.  Consider using an electric hand dryer in your patient restrooms instead of hand towels, which are often quite costly and are sometimes used two or three at a time.

3.  Buy liquid soap at your local dollar store or purchase the large drum of refill soap and a funnel to re-fill the bottles when empty.

4.   Consider using a local laundry service instead of disposable paper gowns.  Many practices are now installing their own washers and dryers when they build or update their suites.  If you do not have the room in your office, you can get a great price for your laundry at most laundromats in your area.  Many will pick up and deliver your laundry for you and you will get to use the same gowns over and over, instead of purchasing a new supply of paper gowns each month.

5.   Even if you have a cleaning service, you will need to do some maintenance to keep your office clean and neat.  Again, Do Not order your cleaning supplies from Staples or Office Max.  They will charge you well above the wholesale prices you can get when these items are on sale.  I do feel, however, that every medical office should invest in a good vacuum, broom, and sponge mop for those spills and paper messes that are part of the everyday life of a medical office.  You may want to add a decent rug cleaner to the above mentioned items to avoid permanent stains when spills happen.

6.   If you are still using a chart system, purchase less expensive charts and consider using tabs to separate your dictation, lab results, etc.   The cheaper charts hold up just as well and can help you realize substantial savings.

7.   Now that the age of free pens, post it notes, and other little goodies is almost at an end, you will need to stock up on pens and paperclips whenever they are on sale.  The end of August and beginning of September, when back to schools sales are in full swing, is the perfect time to pick up these items for far less than you will during the year.  Make sure your patients are not walking away from the front desk with the office pens and this is least likely to happen with a plain black Bic pen which you can find on sale @ 10 for 99 cents in places such as Target and Wal-Mart.

8.   Do whatever you have to do, to find room to store and organize your supplies.  Clean out an old closet or put shelves in your file room.  Whatever area you choose to store your supplies, they should be easily visible for inventory.  Don't wait till the last minute to shop for your needed items, rather, take the time to shop sales and then stock up.  You will find that you do not have to shop for the same items month after month if you become a savvy shopper and buy in bulk.

9.   Vendors such as Costco and Price Club can also be another good place to look around for bargains.  Just make sure that what you purchase there is worth the membership cost each year.  Frankly, I would rather look for sales at my local Pathmark than troll the aisles of those immense warehouses, but this is a matter of personal preference.

10.   Try shopping online for lab coats.  The prices are cheaper and as long as you know your measurements, you will get the same quality as you would from a private vendor.  Ask yourself if it is really necessary to have the physicians or staff members name embroidered on the pocket.  You can create your own name tags in house by using your computer generated logo and printing the name.  Name tag kits are available at your local crafts store for far less than personal embroidery, so check it out before you spend.

11.  W.B. Mason is an excellent provider for your paper supplies and their prices are often much cheaper than Staples.  In an emergency, W.B. Mason will hand deliver any supplies you request and their sales staff is always courteous and helpful.

12.  Make sure you test your copier before purchasing paper.  Some copiers are fussy about paper and will repeatedly jam if the paper quality is not recommended for the machine.  In most cases, a standard white, inexpensive paper will work in most machines, but give the paper a try before you buy in bulk.

13.   For office hardware, shop the big names such as Dell and Hewlett Packard.  They usually have a business lease/ buy program with great prices.  You can also shop Best Buy and see if their geek squad will work with you to support your hardware.  Check carefully before purchasing new or replacement phones.  The AT&T products are good hardware but may be costly.  You want to make sure that your phones are meant to last since they will be used and abused on a daily basis.  In this case, you may want to spend a little more for a better product with good support and replacement policies.

14.   Keep your supply area clean and well organized.  One staff member should be in charge of the shopping and inventory.  After you have shopped the bargains for a few months, you will have a good idea of your inventory budget.  Money should be assigned strictly to keep your supplies from running low.  Don't be hesitant to shop around and change brands if you find a better price.  Do a 90 day price check to make sure you are always getting the best bang for your buck.

Medical Malpractice and EHR

Each year approximately 7.5 percent of doctors have a malpractice claim filed against them with the largest concentrations in the fields of neuros and cardiac surgeons.  Only 1 in 5 cases are successful, but the financial and emotional tolls they can take on a practice are substantial.

EHR systems usually contain a practice specific template that is geared to the specialty and makes it easier for physicians to pull down their most commonly used diagnosis and procedure codes.  This allows for the production of a clean encounter or billing sheet and gives the physician the advantage of billing at the highest allowable codes for his services.   Upon completion of the electronic dictation, the note is usually sealed and changes are not permitted after electronic signature.

Systems that include features such as Dragon-Speak will allow you more room to include patients with a more complicated history than those that work exclusively with pull down or click menus.  Voice recognition systems are much improved than in past years, but it still may take some time to recognize new words or phrases when you use them for the first time.

There are just so many diagnosis and procedure codes that you can program into your system before you start making it profitable and usable, but it is necessary to guard against letting the system dictate what codes you use for your patient's visits.  This is especially true to protect yourself in case of a malpractice claim against the practice.

Traditional dictation allows you to pre-program your review of systems while it also give you the opportunity to create a more complete record tailored to your patient's specific symptoms and history.  You have room to break away from the boilerplate notes that are often part and parcel of most EHR systems.  The EHR notes may be fine for insurance reimbursements where notes are requested, but if you rely on a standard note using only your typical pull down options, you may find yourself coming up short should your practice be subject to a malpractice claim.

You will want to assure that your EHR system allows you to easily input those specific symptoms and histories that are not part of your usual patient routine.  A combination of a pull down menu and some dictation program will give your practice the opportunity to create unique notes when they are necessary.

It has recently been decided that EHR records may be used in cases of malpractice defense and these notes will be as carefully scrutinized as those that were handwritten several years ago.  The EHR system also may make your practice prey to unfinished notes that may remain incomplete unless you have a good checks and balance system in place.  You may be able to produce a viable encounter with just the basic input, but your note may not be good enough to provide you with a good defense in a malpractice case.

You should view your EHR system as an ongoing creation and it may be wise to make a careful analysis of your patient notes every ninety days to make sure that you are not carbon copying note after note regardless of patient presentation.  Assure yourself that you are in charge of the finished product and that you are satisfied with the result.  In our old system of dictation, the physician was required to think about his description of each particular patient and to use his thoughts to create an effective record.  Let's not rely on the built in technology of EHR to organize and create our thoughts for us.

We will be dealing with a more savvy patient population in the future and we will want to assure that we do not fall prey to damage that originates from our systems, despite our goal of excellence in medical care.

The Hospital Conundrum

Last week, there was an interesting piece on the evening news.  A child was bitten by the family dog and required the services of a plastic surgeon in the emergency room.  The procedure went fine and the child and his parents returned home, unaware that the plastic surgeon that handled their case was not part of their insurance plan.  The parents received a four thousand dollar bill for the physician's services.

A year ago, my brother drove the three miles to his local hospital after suffering chest pains.  After determining that he did indeed have a serious heart attack, the hospital transported him via ambulance to their sister hospital, thirty minutes away for a cardiac catherization.   Later that same month, he received a two thousand dollar bill for ambulance services!

There is a patient's bill of rights for all hospital treatment.  This bill is usually standard for all patients and covers the rights to privacy as well as the right of the patient to allow or refuse treatment and to make decisions regarding this treatment or have them made by their health care proxy in cases where a conscious decision by the patient is not possible.   The bill of rights also allows the patient to be treated by a physician that participates in their health care plan.

Now, we are all aware that emergency services are aptly named and none of us would want to wait for a participating physician in cases where emergency services are needed in a life or death situation.  Someone who is having a heart attack is certainly not going to phone around town to find an ambulance company who participates in their plan, nor is someone who is bleeding going to call their insurance company to find a par physician to assure that no out of pocket expenses are charged.

Who should be responsible for situations such as those outlined above?  Once again, we see case after case where those individuals who are actively insured and paying their premiums on time are still charged fees that may be a serious hardship for a working family.  The hospitals would argue that the large number of uninsured or underinsured patients that come to the ER for treatment have posed a serious financial threat to their future survival.   The insurance companies realize that past coverage that included a zero payment for ER services meant more and more individuals turned to their hospital emergency rooms to avoid any out of pocket expense.  Now, most insurance plans have a deductible and or co-payment for ER services and expect the physicians who practice there to par with their plan.  Patient bills for non par services often go unpaid, even after the most stringent collection efforts and are eventually written off as bad debt.  This is just another example of why our health care system is overtaxed.

Perhaps hospitals and insurance carriers need to come to a better arrangement when it comes to emergency room coverage.   Should a physician decide not to be a par provider with certain plans, then he or she should agree to provide coverage for 50% of the reasonable and customary fee for services.  This would assure that patient's are not straddled with overwhelming hospital bills and still provide the physician with some form of reimbursement for their services.

It is not always the physician's choice not to participate in a particular plan.  The insurance companies will often gauge the number of specialists in a demographic area and decide to close their panel when the area is adequately covered.   Hospitals may not par or even drop a particular carrier if they feel the reasonable and customary fees are not enough to cover the expense of caring for the covered members.
In any case, the patient is the one who generally loses in the battle for coverage and the health care system in general also pays a steep price.

Will the new Obama plan help alleviate these problems?  Once all citizens are covered, will doctors still receive an adequate fee that motivates them to continue to provide care?  We know that by 2025, we will face a shortfall of physicians in the United States and cuts in reimbursement rates and the need to see more and more patients to make the same or less money than in past days is certainly a factor affecting the predicted shortfall.  We may indeed face a future where students are hesitant to choose medicine as a career.  We are regulating ourselves out of business just at the time where the largest population is going to be taxing the system even further.  Once we de-privatize medicine and move toward a more socialized system, we will definitely see a change in the quality of care that our physicians provide and that we as patients have paid for our entire lives.

Terminating An Employee

It is never an easy task to terminate an employee.  After sifting through resumes, interviewing, and finally choosing a candidate, it is so frustrating to find that your employee choice was not what you expected.
In this economy, you will have been inundated with hundreds of resumes for every posted job.  Although you were certain to ask for specific skills in your posting, you will find that you receive resumes from persons in all walks of life and more times than not, these individuals lack the skills that you are seeking.

When you finally find what you think is the right person to fit your job description, you may discover after a period of time that it wasn't the right person at all.   People can misrepresent their skills and experience levels, which is why it is always necessary to perform a thorough background check.  Often times you will find that your candidate has been employed in an office not far from your own and you may know the office manager or human resources manager, where the candidate was employed.  You should have a specific task list ready prior to your background check and you may feel free to ask if your candidate was proficient at the tasks you require.  You may also ask whether the former employer would consider re-hire of this employee, but you may not delve into the personal details of their lives.

Many on-line companies offer inexpensive background checks that will detail any prior undesirable history and you may feel free to use these tools as long as you have the prospective employees understanding and signature on file allowing you to investigate their past.   Should your office require drug testing, you will want to use an independent laboratory and send only those candidates that you are considering seriously.

As previously discussed, you should have a standard training schedule and your new employee should be able to perform certain tasks independently, within an expected time frame.  In addition to becoming proficient at their new job description, your new hire must show that they are able and willing to work well with their colleagues and show courtesy and respect to both the patients and their fellow workers.

Despite your best efforts to integrate your new hire into your work force, they may fall short of your expectations and you may discover that this individual is not suited to your organization.  In this case, your most important task is to document each instance where the employee has fallen short of expectations.  Your report should be in writing and you should meet with the employee and explain how they have not met your expectations and obtain their signature post meeting.   A careful record of problems will avoid any labor issues in the future should you decide to terminate this employee.  

You may want to consider whether or not an employee who does not show promise for their hired job description may be able to make a good fit elsewhere in your organization.  Perhaps they have show a particular talent in working with patients, or they are not great with patients, but are highly skilled at obtaining referrals or pre-certifications.  Since they have already become familiar with your office and your other employees, it will save you additional training.  Alert the employee to the possibility that you are considering them for an alternative position and should this new position hold a lower salary or benefit level, make sure they have a clear understanding of the ramifications of a lateral move and agree to it in writing.  Assure the employe that this change does not represent a demotion, but an attempt to keep them employed at a job where their particular skills may be better represented.

If all else fails and you must terminate the employee, you would be wise to provide them with copies of your evaluations and discuss their positive skills and suggest that they may be better suited to a different type of employment.  Unless there has been a clear cut violation of the policies and procedures in your employee handbook, or instances of behavior that you have stated hold zero tolerance, it is never necessary to treat a terminated employee with anything less than courtesy and respect.

It is never easy for someone to lose a job and the employee often feels humiliated and deeply hurt that they could not meet the practice expectations.  Your purpose is not to demean any individual but to express appreciation for their efforts and to suggest that their particular skill set is not suited to your office needs.  Make sure that you provide your employee with an exit interview and information necessary to obtain Cobra coverage, if your office has provided health insurance or other benefits that the employee may want to continue to receive.  In cases, where immediate dismissal is not an issue, you will want to give the employee some notice prior to their last day of work.  You may want to restrict their computer access during their last days or even simplify their job description.  Assure them that they will be paid, according to the payroll schedule for any last days of work.  Do not hold paychecks hostage, even if your employee did not respond well to their dismissal or chose not to finish out their last days.

Remember the way you treat your former employees reflects as strongly on the practice as your treatment of your present ones.   You will find that even terminated employees will be gracious when it comes to the practice reputation if you treat them with a sense of genuine loss and disappointment that their skills did not match your needs. 

Prescription Drugs - Panacea or Tragedy

Most patients in this country feel that if they schedule a sick visit with their physician and they don't come home with a prescription, then they really weren't sick.  Those white sheets and the pills that come from the local pharmacy are proof positive that going to the doctor was a wise move.  We are a pill freak culture and the drug companies that supply us with our daily doses are laughing all the way to the bank.

Trillions of dollars are made each year by the pharmaceutical companies and there is little reason to wonder why so many drugs are rushed to market each year to keep the cash flowing.  After drugs such as Avandia prove to be fatal to many patients, we are often left to wonder who is overseeing drug trials and how are such good results published with such horrible consequences?   I attended elementary school with a little girl who was missing an arm as a result of Thalidomide, my daughter-in laws cousin died from a prescription heartburn medication, and I saw the effects of Avandia on my own mother.

One answer lies in the fact that the American public has an insatiable demand for immediate gratification.  We feel pain and expect immediate relief, without giving much consideration to the consequences of the medication that we ingest so mindlessly.  Over the years, I have consulted with two physical medicine and rehabilitation practices and during my years there, the staff came to realize just how many drug seeking patients are floating around in the general population.  These individuals may have started out with a real injury or some form of chronic pain.  Instead of seeking some alternative relief after initial doses of medications did not ease their pain, they move instead to a chronic cycle of pills and more pills, using any and all methods to obtain their meds.  Drug seeking patients may move from doctor to doctor and try to fill scripts at different pharmacies to avoid detection.  Luckily, the larger chain pharmacies are now alerting each other when patients try to fill multiple scripts for narcotics.  They will also act to notify the physicians in question, trying to put a stop to what could be a life threatening situation.

More PM&R practices are now using trigger point injections, physical therapy and even acupuncture rather than medication to treat acute and chronic pain.  They are examining the patient's lifestyle, work and home environment and suggesting exercise and ergonomic strategies that will promote a healthier lifestyle where the patient is less prone to injury or exacerbation of pain.  Patient's are often grateful for a more homeopathic approach to their complaints and find that by making small changes in their daily activities, they can become pain free without medication and its associated risks.

Type II diabetic patient should always be encouraged to change their diet and exercise routines before they become one of the millions of Americans whose blood sugar levels are dependent on medication.   The same holds true for those of us who suffer from high cholesterol.  There are some homeopathic remedies, such are red yeast rice, which can lower cholesterol without the side effects of most statins and I have seen cardiologists recommend these over the counter drugs to patients who could not tolerate or refused statin treatment.

It is important for our doctors to adequately explain to patients that viral syndromes do not respond to antibiotic treatment so it is not always necessary to receive medication for a cold or sore throat.  In cases, where serious illness has been ruled out, patients with such problems as chronic headaches or other chronic pain, should be encouraged to seek help from a homeopathic provider before embarking on a future where medication is the only way to alleviate pain.

We are starting to see some progress towards a blend of allopathic and homeopathic treatments in a number of our medical communities.  Physicians and Chiropractors are often working together to treat some chronic pain patients, and many doctors are now embracing the use of acupuncture and herbal therapies with their patients.

All of us are grateful for the extraordinary drugs and vaccines that have kept us healthy and safe from diseases, but we must admit that some of the drugs that come to market may have tragic consequences, and that no drug is without its effect on the human body.  
 

The Insurance Game

Month after month, we, the faithful, pay our insurance premiums or face the probability that we will be denied health care coverage if we should become ill.  All over our country, those who have lost their jobs, or fell on difficult times found that their children could no longer visit their pediatrician, husbands and wives pray nightly that serious illness will not land on their doorstep.

Even those of us lucky enough to have current coverage have to sweat it out every time we need a test or procedure, the recommendation of our physicians not good enough to guarantee us diagnosis and treatment, unless our carriers feel that we should be privileged enough to get a positive nod.

Our physicians wait patiently for reimbursement for services, in a cat and mouse game of how long can we keep our money in the bank before we need to release a check for payment.  How many notes will we request?  Letters of medical necessity?  People are no sicker now than they were forty years ago, when the physician would send a hand written note to the insurance giants and received a check, most times for close to the full amount billed.  How did our physicians and our patients lose the ability to gain assured treatment ?  Who are these guys and what's their problem?

Certainly there is no greater rip-off in the American way of life than car insurance.  We pay month after month for a service we don't use and then get charged an even higher fee if, heaven forbid, we do make a claim.  Think about it for a minute.  Every month, a charge for nothing....  I could understand if our premiums payed for oil changes, or new tires, or a tune-up every six months, but literally we send a check to a strange location for NO service.  Only in America!!!!!  

I propose that for every year we do not make a claim, our total premium, minus a small administrative fee should be refunded in full.  You say you want to boost the economy?  What would be better than getting a check every year on December 31st for driving safely?  Imagine how much of this money would serve as a stimulus to the economy.   Perhaps, instead of billions of dollars in profits each year, the insurance giants would only make millions.  What a damn shame !!!!

It wouldn't be a bad idea to make the same transition with health insurance.  Instead of forming more ACO groups, whose sole purpose is to save money by denying treatment, let's reward our patients for making an effort towards preventative medicine.   No emergency room visits in a year would guarantee you a refund on your yearly premium.  Compliance with testing and physician recommendations would give you another small bonus.  Enrolling in an exercise program - more cash....  Soon, we would have a society where individuals sought treatment to maintain health and prevent illness, rather than using their local emergency room as a refuge for a sore throat because in many cases, emergency care is covered in full.

We expect the American public to pick up the slack for every shortfall in our country and to pretend that they don't have the foggiest notion of the profits made by the insurance companies, year after year.  We expect physicians to render excellence in health care, when their reimbursements are cut again and again.
Right now, we pay a ridiculous amount for gas and home heating oil, but I can assure you that the big shots at Exxon or Mobil are not going hungry to be able to afford their prescription medicine.

In the years to come, we will lose many good physicians and our future students will avoid the study of medicine like the plague.  It's time we stopped dreaming and expecting the American middle class to keep doling out dollars for zero services. 

Women and Health Care

Over the past ten years, we have seen extensive changes in the healthcare industry and those of us involved in dealing with these changes often channel our energy into making sure that our office is in compliance with everything new that comes our way.   We pride ourselves on implementing the details that will make our office state of the art and dedicate ourselves to the difficult challenges that we need to follow carefully.

So many discussions that I have seen recently come from my colleagues who are interested in assuring that medical practices meet today's tough standards.  The discussions that I have seen my brilliant colleagues promote are no doubt helpful and necessary, but sometimes it seems as if we are talking about the best way to organize and run an empty location.  In keeping with this idea, I would like to discuss the disparity that still exists in the diagnosis and treatment of men and women.

Five years ago, I was diagnosed with Graves disease.  For those who are not aware, Graves is basically auto-immune hyperthyroid disease and can pose serious health risks if not treated, or not treated properly.  I was lucky enough to be diagnosed and treated early in the progression of the disease and finally received treatment with radioactive iodine in the hopes of alleviating my symptoms.  This treatment may eventually lead to hypothyroidism and I will need to be treated with other medications to keep me in a normal range.

Hyperthyroidism, like many thyroid disorders can have a neuro-psychological component, which may include anxiety, depression, rapid heart rate and in some cases can manifest itself as bi-polar disorder.
Some Grave's patients may experience these feelings even if their ranges are just slightly abnormal and others may have blood results that are off the charts and remain unaware of the disease until they suffer some serious health risks.

My experiences with Graves were the first time I noticed how difficult it can be for physicians to recognize and treat the components of disease that are not strictly physical.   Indeed, at times over the past five years I felt like one of Freud's garden variety neurotics anytime I would express a symptom that was outside the physician's realm of expertise.   If I expressed the fact that I felt more anxious than usual, the physician would state: "People get anxious for all kinds of reasons!"  It got so bad, that I found myself searching the internet looking for research that would convince me that I was not neurotic or crazy.   I looked at message boards where Grave's patients discussed their symptoms and noted that these patients were meeting with the same denial from their physicians.  I finally decided to seek help from a female doctor who assured me that the symptoms that I was experiencing were all part of the Grave's syndrome.

As a younger woman, I was treated by the same family physician who treated my parents and grandparents.  He knew our entire family history, including the state of our mental as well as physical health and was able to diagnosis and provide treatment that included both our physical symptoms as well as our genetic pre-disposition to certain diseases.  That time is long past and it is unfortunate that medical care has become so specialized and so limited that patient treatment is no longer a consideration of the individual as a whole, but rather Part A and Part B and all the other parts that make us who we are demand that we see an entire arsenal of doctors to keep ourselves healthy and happy.

I have accompanied my husband on many of his doctor visits and have noted the clear difference in the way physicians treat his complaints.  They seem to listen more carefully and prescribe treatment for the slightest of his complaints.  Since I have worked in this industry for so long, I know many of these physicians and even this fact has not made much of a difference.  I am not alone in this feeling and have found that many of the women I know make it a priority to see a female physician for all their health care needs.

In order for us to provide our patients with excellence in health care as we move forward into the future, we need to see our patients not merely as a symptom, but as an entire individual who may need help with both the physical and psychological implications of disease.  A quick family history will not help us in this goal.  We need to spend more time listening to our patients and to assure that we do not merely discharge them to another provider if we are outside our comfort zone.

Missing Billing Sheets

Despite the push forward to electronic medical records, many physicians in my New York area are still using the old chart system.  Some physicians are not even ready to e-prescribe and have told me that when the penalty matches the cost of the system, they will think about spending the money to update and participate.

I have implemented my "Daily Data Sheet" in the routine of many practices.  It is available in an installment of this blog and has succeeded in increasing the amount of daily co-payments that are collected and has tried to assure that the amount of billing sheets matches the amount of patients that are logged in each day after they sign in for services.  The purpose of the data sheet is two-fold.  One is to prompt the front desk or check-in to collect the correct co-payment amount for each purpose.  The second is to assure that each patient that signs in has an appropriate encounter for his or her visit.  Herein may lie the rub!

Some physicians do not think it is a priority to finish their billing sheets each day and in some respects you can hardly blame them.  With the cuts in reimbursements, more patient visits are required to keep the financial aspect of the practice on track.  These means more patients and less hours in a normal work day.   Secondly, the insurance companies are requesting patients notes for almost everything and this means that a short progress note, made in the chart, is no longer viable, even for the quickest of return visits.  Consequently, for each minute that the doctor is dictating his patient notes, patients wait in the exam room or if the physician jots a quick progress note, with the intention of finishing his dictation after business hours, he may find himself without any other life but the one he pursues in the office.

This can present a serious problem, especially if the practice is farming its billing out to a service.  The daily package often goes out incomplete.  The physician reasons that if the majority of his claims go out complete, than he will catch up in a few days and this won't present a serious problem.  Wrong !!!!
Your daily billing package should always go out complete or you will find yourself mired in paperwork with no end in sight.   Your billing company will be contacting you daily or weekly to find out if the patient listed on the data sheet was seen and if so, where is the encounter ?   If these issues are not immediately addressed, you will receive the same request from the billing company over and over again, and find your office pulling the same charts, copying the same letters, and sending the same notes again and again, wasting valuable time.

Saving five charts today means ten charts tomorrow and so on and so on, until the doctor is literally buried in unfinished work.  An incomplete billing package means that encounters from June will be completed in August and this will have a cumulative effect on your daily revenue.

What's the solution?  Short of taking charts home on the weekends, which many physicians do and which is not a good practice, or in keeping with HIPAA policies, the answer is to make time to finish all of your dictation the same day as you see the patients.   Regardless of how you prepare chart notes, the doctor always knows what services he renders to each patient.  Therefore, a completed billing sheet should accompany each patient exit.  If notes are necessary, you can jot a quick progress note in the chart and mark the outside of the chart with a sticky note that will alert the physician that he has not dictated for this particular patient.  For those truly fanatical physicians, you can make a copy of the encounter and mark it with a D- for dictation and place it on the outside of the chart, removing and disposing of it when the dictation is completed.

I have seen doctors keep a record of patient visits on the outside cover of the chart, noting special procedures performed.  You could initial this medical log sheet every time you dictate on a patient and be assured that all work is completed.  Those charts without an initial complete, can be placed to the side and dictated at a more convenient time in the physicians schedule.  This outer chart logging of procedures also reminds the doctor when a patient needs a follow up test or procedure, without them having to explore all the chart pages individually.  This method also serves to make life easier when calling patients to remind them that they need a return visit.

At the end of each day of patient appointments, the number of patients seen should equal the number of billing sheets that are turned over to be processed.  While this may seem so old fashioned to those who are already entrenched in the spirit of the electronic world, it is essential to those physicians who have not yet made the leap.  While so many doctors get comfortable in their old ways of doing business, the business world of medicine is leaving them behind.  Whatever it takes to get the job accomplished and to prevent the duplication of tasks is mandatory if your practice is going to survive the health care changes that are here now and in the future.

What is the Future of Nursing?

So many nurses are expressing dissatisfaction with their field today that many of them are making the quickest leap possible away from the bedside and into administration.  Consequently, patient satisfaction scores are going down , especially in our city hospitals and many patients are scared to enter today's hospital systems unless they have a patient advocate, a family member or friend, to speak for them and to assure that their care is not sub-par.

Our city hospitals are overburdened by too many patients and too little qualified staff.  There is a large immigrant population in our hospitals today and these patients often bring with them their own set of cultural mores and sense of entitlement.  Indeed, many of today's nurses are foreign graduates as well and we face serious issues when the standards of training from country to country vary to the extreme.  In many cases we are getting nurses who do not possess the standard of care skills that are basic to United States nursing and this can have terrible, and sometimes tragic results for their patients.  Nursing supervisors and directors often feel the burden of these issues.  They expect their RN's to be well trained and educated and are shocked to find that the patients are suffering when the basic standards are not adhered to.

There may also be language barriers that prevent a sense of communication between the nurse and the patient, which also places their care in jeopardy.   Nursing directors are often throwing up their hands in frustration and abandoning their reports and paperwork to make sure that bedside care is administered in a proper fashion.   In a busy environment, where nurses are in short supply, it is not that easy to call upon your department of nursing education and have your nurses re-trained in the skills and procedures that are lacking when you have one nurse for sometimes twenty to thirty patients.   Couple that with our present electronic age and you may now find your nurses spending much of their time on cell phones, and text messages.  

I don't know why, but there seems to be a general lack of apathy that exists in the workforce today.  Years ago, the worst thing that could happen to an employee was to have the feeling that they were not up to the tasks required of them.  People seemed to take more pride in their work and looked for ways to increase their own productivity and skills.  Much of today's work force exists from check to check.  They have child care issues, and family issues, and lack of skills issues, that make them more of a burden on the system than a correction.  Couple that with a population that is more than ever, uninsured or under insured and the city hospital of today, finds itself in serious financial hot water.

Thirty years ago when my children were born, the hospital where I gave birth was immaculate.  The floors were spit polished constantly, the bathroom fixtures gleamed, and the nurses were all is their starched whites, shined white shoes and caps, no less.  The food was glorious, you rang your buzzer and someone was at your bedside in a flash, and they took your vitals in what seemed to be fifteen minute intervals for two full days.   A few years ago, my father-in law had cancer surgery in the same hospital.  The place was filthy, the bathrooms disgusting, and you couldn't tell the nursing staff from the maintenance staff were it not for the name tags.  No one came to take him to the bathroom, physical therapy never showed, he did not get meals for two days, and he died in a literal hell hole of incompetence and apathy.

It's almost impossible to find the cure-all for these problems, but when the time comes, where hospitals are reimbursed for patient satisfaction, you are going to find that many of them will simply have to close their doors.  How ridiculous is it that we are making doctors spend hundreds of thousands of dollars for electronic gadgets to standardize medical care, while we are allowing our sickest patients to wallow in an environment where their lives depend on so many who are unqualified to meet the challenges that medicine demands.   We should insist that the staff of our hospitals are trained with a uniform method of care, that our nurses know the expectations that we place on them and more important that they are qualified to meet these expectations.   We are living in an age where there will be a literal explosion of patients who are entering their twilight years and will become by their sheer numbers, the highest demand on an unprepared health care system.   Isn't it about time we started to get prepared?

Is Your Work Force Still Viable?

Single practice physicians are the most vulnerable to the curse of "The Corrupted Employee."   Often these docs have practiced in a framework that is somewhat disorganized and without set policies and procedures for the performance of daily tasks.  In addition, the physician may be prone to cancel office hours or reschedule his patients based on his or her personal demands.  Vacations and sick days happen and while the staff needs to be paid and to work a sufficient number of hours to assure that their paychecks are viable, the office sometimes becomes a free for all.

When the cat's away, the mice will play is an unfortunate fact of life that you can count on if your staff is left without proper supervision.  Many senior staffers fall into the role of office managers, often without the skill set or authority to enforce the rules of the day when the doctor is not in the office.  The greater freedoms that are allowed, the more the rules will be broken, and many times they are broken to the point that they really cannot be repaired.

I have seen situations where staff clocks in, then goes to the deli for something to eat and drink, then sits for forty minutes, eating and drinking.  These are the first employees who will claim,"I don't have time," when you suddenly expect them to follow any new policy.  You will find paperwork in drawers, files or notes everywhere, and a general lack of accountability in these offices.  What becomes the norm when the physician is away, then becomes more the norm when he or she is in the office.

You can try your best to change these situations, unfortunately, many times to no avail.  There comes a point when even the greatest consultant or practice manager can no longer inspire the corrupted employee.   Doing as little as possible becomes the new job description and employees resent having to change their style and attitude.  

You should of course do your best to rectify this type of situation, but it is not beyond the realm of possibility that cleaning house becomes your only option.  If you have promoted a practice without a daily routine or reasonable expectations, you may not be able to salvage your present staff.  It is essential that employees have a job description that keeps them busy for their entire day.  They must complete a number of tasks and have an hour by hour routine, day after day, that promotes organization.  If you have employees with too much time on their hands, then you have too many employees.

Work is a privilege and in the current economic situation, there are people that would wait outside your office door for the chance to earn a paycheck each week.  If your present employees are not meeting your expectations, then it may be time to train a new set of employees and expect that they will be grateful for the opportunity to work and be productive each day.

Don't fall into a pattern of laziness where all your employees are still on the job when you are away.  Paying people to do nothing is ridiculous as well as a tremendous strain on your payroll revenue.  If you are away on vacation, or need to cancel hours for the day, make sure you only keep a skeleton crew in the office to answer the phone and make future appointments.  You will see how fast your employees want to become essential, whether or not you are there.

You cannot change from an easy breezy individual who lacks the ability to discipline your staff to someone who now wants total compliance to the rules that were never enforced in the past.  Change takes time and effort and change must first begin with the physician.  Put in the effort to speak to your staff and to tell them what you expect and the changes you want to put into play.   Make sure that the principles of change- the desire for organization and assured revenue - start first with you.

If after a time, you find your staff cannot make the proposed changes then you must take steps to replace these individuals with others that are vested in your practice mission statement and goals for the future.

Participate in Apprentice Medical Assisting Programs

In spite of the current economic situation in the United States, health care training programs in coding and medical assisting continue to flourish.
Medical Assistants can be a lifesaver for a busy doctor whose schedule is packed day after day, and many specialty and internal medicine practices have used a medical assistant from the day their practices opened.
They usually assist the physician by showing the patient to the exam rooms, taking the patient's vital signs, performing testing such as EKG, drawing blood, and noting the patient's chief complaint in advance of the physicians exam.

Without an assistant, the front desk is often overwhelmed by their daily tasks and important issues such as referrals and authorizations may fall by the wayside.  Those physicians who do not utilize the skills of the medical assistant often rely on the front desk staff to prepare the patient rooms, show the patients in and out and keep stock of the inventory for exams and procedures.  

Of course payroll considerations are often the issue when physicians decide whether or not to employ an assistant.  However, this may not have to be the deciding factor.  

All students preparing for their certification in medical assisting must undergo some form of apprenticeship program.   Schools that offer training in this field are always looking for practices to participate in their programs, thereby offering their students experience not only in their craft, but also in the ability to better understand the dynamics of working closely with a physician and what medicine will demand from them as they move forward.

A simple phone call to a school in your area that offers this type of training should automatically enable you to participate as a mentor to an apprentice medical assistant.   These students are usually highly motivated to excel in their field.   They understand that the participating physician will be expected to provide their school with an evaluation of their skills and overall knowledge.  Without the completion of a satisfactory apprenticeship, these students will not receive certification, nor will they graduate from their program.  

Best of all the apprenticeship is an unpaid position and your practice will be able to utilize and help further develop a student's skill set without any adverse financial effects.  Often these assistants will become part of your full time staff when they graduate and have a significant impact on the health of your operation.  I encourage every practice to participate in these valuable programs.

Accountable Care Organizations - Will They Cure or Kill Us ?

Our current system of delivering health care has been based on volume of patients seen in the office or volume of admissions for hospital care.  The Medicare legacy system always rewarded this model, with little concern for quality of care and without much accounting for the number of medical errors or lack of patient satisfaction.

Accountable Care Organizations are the newest proposed change to a healthcare system that finds itself on the brink of disaster.   As part of an ACO, you would see your primary care physician and should you need the services of any other physician, your primary would refer you to a doctor in the ACO and work closely with them to coordinate your health care as a total package.   When I first started to investigate ACO's, I have to admit that I thought - "Is this News?"  After spending ten years as an Administrator in Cardiology, I hardly thought that the idea of coordinated care was a novel concept.

Patients receiving care in our office were usually referred to us with a specific set of symptoms or pathologies.  Chest pain, shortness of breath, high blood pressure, diabetes, etc.   If we found our patients on call during hospital rounds, our first order of business was contact with the referring hospital doctor and then with the patients primary physician.   We sent and received detailed consult notes and many hours were spent on the phone discussing and coordinating patient care.

We held symposiums for primary care doctors on the latest trends in cardiac care and knew almost all the primary care doctors that served our demographic area.  If we didn't know them either personally or by reputation, we made sure that at some point, early in our patient's care, that we visited their office or invited them to a meeting, either with other physicians or as a solo dinner companion.

Any decent physician specialist will make sure that their patients receive continuity of care, so that patients are not treated as a jumble of parts.  The idea of a "wholistic" approach to health care is not new, especially in the New York area.  

So, ACO's - what's the big deal?

The aim of Accountable Care Organizations is to provide an overall approach to prevention and treatment of disease, while keeping costs in line and in fact, being accountable and rewarded for keeping costs in line.   Oh Boy !  

Some patients may be totally delighted to have a home base for all their health care needs, but those of us in this business, who are used to anticipating and dissecting the most remote possibilities are not too sure.
Keeping costs low!  What does that mean in the long term?

Can we anticipate a time where doctors are rewarded for not providing services?  What if the services are diagnostic or essential?  Will we determine these factors based on the age and overall health of the patient?   Will we discriminate against the emerging patient base of the baby boomers?  What if a CT scan will save my life by finding a curable tumor, but the ACO has already met their overall criteria for CT referrals and will suffer financially if they prescribe one for me?   I don't know if I am so thrilled with my doctor thinking about the state of my health based on a reward for not treating me!

Let's face it.  We are not living in the age of innocence where doctors will run out in twelve feet of snow, black bag in hand, and sit at our bedside until the fever breaks!   This is a business of dollars and cents and we are hard pressed to count on the altruistic behavior of our physicians to put our needs ahead of their financial gain.  Cynical?  Perhaps.  But, I don't want to be eighty years old and have someone disconnect my telemetry equipment because I am a financial drain on the healthcare system.   Again, the best physicians often discuss treatment options with the elderly, based on their overall satisfaction with their lives and their desire to minimize or maximize treatment.  I have seen the Cardiologists in my group have these types of discussions with patients whose conditions were rapidly deteriorating, day after day, and any physician with empathy for his patients will continue to practice in this matter.

Offering a reward for the denial of services is something entirely different.  Are we finding ourselves in an age where treatment is decided by the patients IQ, or financial success?  Will the financial consideration lead to fewer errors in treatment?  I doubt it.  We have seen that the number of medical errors are the same in both sophisticated urban areas as they are in more rural ones where treatment options are limited.  So, what's the point?

When I am sick or in pain, I know that I want my physician to find out what is wrong with me, by using every tool of the trade.  I don't expect that he or she will be a psychic and decide my treatment options based on a sliding scale of financial gain.

Perhaps we need to take a closer look at the extraordinary profits of the insurance carriers and the pharmaceutical companies and ask them to make a little less profit, instead of denying our patients the care and quality of life they deserve.

I Work For Dr. Needy

After sixteen years in medical practice management, I can sense a medical environment rife with chaos, soon after walking in the door.  Years ago, when reimbursements were high and the rules of medicine less stringent, a freewheeling office was often overlooked.  A claim lost here or there, a missing authorization was almost expected as part of the daily routine.  Papers and charts strew everywhere, the doctors desk a veritable mountain of "to do" lists often defined the face of your physician.  Patients were willing to wait almost forever and money flowed freely.

Today, medicine is a business deal, clawing and scratching for every dime.  HIPAA regulations abound, CMS and the private insurance companies holding on to every last cent of reimbursement and expecting near perfection before they release the thinnest of dimes.  Unfortunately, even with all these new expectations, if you work for Dr. Needy, chances are your office is on a serious downslope.

Despite the most stringent of job descriptions and army style training, there are only so many hours in a day.  Your employees will keep busy until the end of their shift and then they will go home.  They don't have a vested interest in your practice and as long as they perform the hundreds of tasks that Dr. Needy requires, a clear conscience will carry them out the door, while the practice money flies out the window.

Dr. Needy is characterized by an inability to separate the practice of medicine from the business of money.   He is constantly at the front desk, looking for a pen, a prescription pad, a chart, a routing slip, etc, etc, etc.   Sometimes he even leaves his private cell phone for the girls to answer to assure he never misses a call from the wife or kids or buddies.  He can never find anything alone, is incapable of working quietly behind a desk in his own office, and consequently, no matter if he has one employee or ten, all of them will be dancing all day long, while the business suffers a slow agonizing decline.

You often find that Dr. Needy has practiced medicine for some time.  His father may have been a doctor and he is stuck somewhere in the world of the 1950's or 60s, believing that he knows everything there is to know about running an office and practicing his specialty.  He suffers from tunnel vision, doesn't feel he has the time to read a fax, or understand how to move forward, unless his entire small universe is spinning round and round.

What happens in Dr. Needy's office ?   He is either with every patient for one hour, or three minutes.  His charts are everywhere, dictation lags, bills are submitted too late to meet the timely filing requirements.  Not a single drawer is organized, verification is left undone, the front desk scans only the front of the insurance card, no one ever checks the patient's outstanding balance, co-payments remain uncollected while the secretaries find pens, make calls, and run around with no meaningful purpose,  They payroll is escalated since the only time to prepare for the next days patients is after the doctor leaves the office.  It becomes the norm for papers to accumulate on the floor, the bathrooms never get cleaned and in general, it looks as if a small typhoon has blown through leaving disaster in its wake.

There are a number of physicians who rent their space, hang their diplomas and forge ahead, seeing a large volume of patients every day and scratching their heads when everything goes haywire.  In the case of Dr. Needy, it may be wise to hire a consultant to bring some order back to the arena.  Caution is urged in this matter, since you do not want to bring someone into your office who is going to alienate your staff and leave you with an empty office.  As a consultant, I have often heard the staff tell me that they have heard my procedures all before and they never worked.  They were often under the wing of a consulting company that believed that browbeating was the best employee approach, and the staff was often left with a built in hostility for anyone with a good idea or a policy or procedure that was innately successful. So choose wisely - someone who knows how to motivate the staff and explains why the proposed changes will benefit them in the long run and make their jobs easier.

You may want to consider getting Dr. Needy a medical assistant.  This individual can not only take the patient's vitals and chief complaint, but also make sure that Needy has his pens and pads handy, his rooms stocked, and to urge him to move from room to room without interruption.   I found it useful for the snail-like physician to show him his minute by minute reimbursement when he decided to lounge in a particular room for an extended period of time.  

Make sure, once again that your doctor understands the review of systems and how this can guide him through his daily schedule and help decide the correct options for the treatment of the patients and the need for consultation.   Always give Dr. Needy a break in his schedule.  Inevitably, he will need to run to the store or the bank or on a household errand, not connected to medicine.   Urge him gently to finish his chart notes and billing and to move the day forward.

Above all, try to keep Dr. Needy away from the check in and check out areas.  Patients are sure to note if the doctor seems disorganized and will walk out of the waiting room if they get the wrong impression. The office should be as quiet as possible, with the front office team performing their tasks in an organized pattern.  Phones should be answered in as few rings as possible and save the schedule preparation for your least busy appointment hours.

Dr. Needy can be re-trained if he notes an improvement in his reimbursement rate and his staff seems less distracted and more purposeful.  It is imperative that these changes be made.  In the next ten years, it appears as if many medical practices will fall by the wayside, simply because their infrastructure is flawed.  We will inevitably lose good physicians who simply never learned the business of medicine.

The Illusion of Electronic Medical Records

A few years ago I received an Amazon Kindle for Christmas.  I was amazed and delighted that I could get any book I wanted to read, with the click of a button, while sitting on my living room couch.  I found it lightweight and easy to tote around and the writing was clear even in direct sunlight.  I was hooked.

After about six months, however, I found that there were moments when I just had to go to my vast inventory of hardcover and paperbacks and literally hold a book.  I missed the feel and the smell of the paper, and the two-sidedness of something substantial in my hands.  It was wonderful to simply flip a page if I momentarily lost concentration and I found that I was less likely to forget the characters within a real book than I was on books that were in my Kindle.  Somehow, the touch of the book embedded the story in my consciousness, just as writing embeds a thought more firmly in your mind.

I found that I thought about this quite often while investigating different EHR systems.  I would miss the feel of the paper chart, no matter how voluminous.  The book-likeness of it gave you no excuse for a missing an insurance card or signature on file.  I loved the physician notes scrawled on the cover, showing the last test or procedure and looking at the patient's chart somehow created a character that came alive with each turn of a page or flip to a progress note.  

As ridiculously romantic as this is, and the fact that EHR is the wave of the future, the real possibility exists that we are reducing our patient's history to bits and bytes and opening the door to a carelessness that no one will notice.   I completely understand its relevance to a history of treatment that is universal and can be transferred anywhere, and I do admit that clarity and organization is streamlined.  However, I do know that the same process used prior to a scheduled day of patient care must also be utilized with any EHR system.  I fear that a new laziness will come from using our computers for everything and that many employees will give themselves the illusion that our systems will now do the work that we painstakingly did by hand.

EHR systems come with enough bells and whistles that sooner or later, someone will come up with a program that allows you to examine the patient at home and send their medications though a slot in their PC's.  For now, however, some basic rules should remain in place to assure that your revenue is steady and growing.

Your front desk staff should still print out a daily schedule and make sure that the following tasks are accomplished.

Check the patient accounts receivable and note any large outstanding balances and missed co-payments. The front office staff should never bully the patient into making a payment but rather suggest that a large balance shows in their records and perhaps they might want to check with their insurance company for clarification.  Many physicians have patient responsibility balances that are mind boggling and find themselves without available cash when money is uncollected.  The collection of co-payments at the time of patient check in is essential to assuring that every patient with a financial responsibility, honors that responsibility before the actual visit.  

While you may have an EHR system that auto counts the number of visits left on a patient's referral, care should be exercised that the referral covers consultations and treatments.  If you can view the actual referral in your system, this should be done prior to office visit for each patient.  Authorizations should also be viewed to assure that procedures and tests are noted as code specific or your payments will be denied or reduced.

You should also verify the insurance for every new patient and re-verify the coverage of any patient who has not been seen in your office in the last 90 days.  Patients change insurance coverage so often that gambling with their previously noted coverage will definitely result in loss of revenue.  Be extra cautious with your Medicare patients.  They often are not aware that they surrender Part B coverage when they enroll with a commercial Medicare plan.  You should verify every Medicare patient prior to visit.

If your office provides such services as Physical Therapy or Acupuncture, you must note whether your patient's coverage provides reimbursement for these services and/or limits the number of visits each year. Restrictions on coverages or testing must be noted and should pop up in your system when you pull up the patient electronic chart or at least appear as a highlight in the patient's note section.

Physicians should take caution against relying on their EHR systems to determine the level of care provided and should guard against allowing the system to assign their diagnosis codes.  Each physician should have a clear understanding of the Review of Systems and not necessarily allow their system to assign the highest coding for a quick follow up visit.

Let's face facts.   The smartest physicians always had a billing sheet with procedures followed by diagnosis codes that would assure reimbursement.   This is not news people.  If you did an echocardiogram for a patient that was asthmatic and coded your claim for asthma, you would never be paid, regardless of whether the patient literally wheezed themselves to the point of death.  Unless you noted a problem related to valve issues, you could argue until you were blue in the face and never get a penny in claim reimbursement.   The EHR systems will do exactly the same thing.  Specialty physicians will still use the same 5 or 6 codes that are acceptable, both to CMS and the commercial insurers or else they may as well hang up the white coat and study plumbing.  

Despite all the new changes coming down the turnpike, and the urging towards uniformity in all things medical, the driving force for private practices will still be getting reimbursement for services rendered.  While all our paper may now be in our computers, we will still need to do the same work to assure that we can afford to show up at the office each day and get paid each week.