Thursday, September 29, 2011

Medicine in the Age of Carelessness

Talk to anyone who has worked in the medical arena for a significant period of time and inevitably you will hear the same complaint: "Nobody Cares Anymore!"   This is not endemic to only medicine, but in our dealings with each other as well as with patients, there is a new attitude that is best described as self-serving and unfeeling.  This applies to the largest hospital systems and the smallest medical office, where physicians are trying to eek out their existence on a day to day basis.

We have become a rude society indulged in a say anything and feel justified attitude that leaves most patients feeling as if they have entered a twilight zone, far removed from the past, where they are no more than a name and number.  I have been serving the needs of medicine for the past twenty years, and I am shocked at the lack of professionalism I find both as an administrator, and as a patient in the offices I work for and make use of as a patient.

Front office staffs are short and unmannerly and the patient is no longer the number one priority.  Physicians and other health care practitioners who are now forced to see larger volumes of patients are prone to more mistakes than they were in the past and I fear that those patients unfortunate enough that they cannot act as they own advocate will fall victim to an increase in sub-standard care.

Nurses are overwhelmed with the number of patients they are expected to care for on their particular units and the paperwork has become an overwhelming catastrophe that does not insure the patient's well being but rather puts it into greater jeopardy.  Nurse no longer appear at the bedside at the first bell ring and patient's without a family member to assist them during their stay often express serious complaints regarding their hospital stays.   The days where nursing is a profession for the most caring and dedicated of individuals has gone the same direction as flight attendants and indeed we are forced to feel as if we are traveling in steerage when we are forced to seek hospital care.

What are we doing as a nation and as a society to deal with these issues?  Perhaps payment for patient satisfaction scores is one answer, but right now all we are doing is giving our physicians and staffs greater obstacles to billing and coding.  So we become more overwhelmed that we were in the past, and the likelihood that this is going to positively affect our patient care is quite slim.

Carelessness in dealing with our patients is now standard fare even as we listen to physicians and staff complain about cuts in reimbursements.   Perhaps we are getting exactly the payments we deserve for the standards of courtesy and professional care that we are rendering today.  Perhaps, we will go the way of the airlines - no meals, no pillows and blankets - smaller seats - and zero advocates.  What can we expect when we have allowed ourselves to practice as a level that is strictly coach rather than first class!

It's time for us to wake up and promote the complete package of professionalism that existed in days gone by.  We need to take the time and promote an arena of excellence before we price ourselves right out of the market and health care becomes little more than a series of walk in clinics that provide only the most basic of care.  It's time to change our attitudes and realize that we are only as good as the patients think we are..... Nothing more !

Monday, September 26, 2011

An Alternative to Hospital Takeover

Many smaller practices have a good patient base, often by serving their immediate communities.  Despite committed patients and active days, some physicians still find that the overhead costs of running their own shop overwhelming.  Often, these physicians turn to hospital employ to solve their cash flow problems, but this situation often has problems of its own.

Hospital employ always means a loss of control.   Staff may be supplied by the hospital and it is often difficult to obtain the goods and services that are a part of your normal routine.  Large hospital corporations are not especially suited to a personal relationship with each physician and you may find yourself somewhat invisible in a large crowd.

One alternative is to seek a partnership with a large established private practice in your area, even if this practice is not aligned with your particular specialty.  These partnerships have proved very successful for a large number of physicians and can be tailored so that you keep more of your independence, while profiting from the protection of a larger revenue source.

The physician may find that in most cases, he or she will be able to maintain their practice address and even the majority of their employees.  Instead of outsourcing for billing, many of the larger private practices have enjoyed great success in revenue collection and this will ultimately save the physician from the monthly costs associated with a billing company.

Parent corporations will often also make an investment in the look of your practice, completing necessary  updates to hardware and software as well as office decor and furniture.  Bills from the physicians practice will be paid by the parent corporation as well and deducted from a bonus structure as overhead.
Suddenly, the physician who joins a large group will find themselves able to dedicated more of their time to patient care and less to the stresses of running and paying for their practice costs.

Prior to any commitment, the physician must take a realistic look at their annual salary expectations.  Contracts for these types of arrangements usually mean that you will be paid a salary for your services and a quarterly or annual bonus minus overhead for your contributions to the parent company.  You can expect both your salary and bonus structure to grow since you will now enjoy the benefits of a new referral source and any marketing efforts the parent company makes on your behalf.

You will be dedicated not only to your own practice but to the success of the parent company as well and will enjoy an easier one on one for meetings and negotiations than you would find in a hospital setting.  Private practice management is at your disposal and less distracted by hospital expectations.   In addition, you will have staff coverage for vacations and personal time.

Make sure that your agreement allows you access to statistics regarding your billing reimbursements.  You may need to reassign your Medicare and private insurance benefits, so you will need to prepare for the changes well in advance to any agreed upon start date in order to assure that your personal revenue remains on track.

Joining a private practice can afford you a new support group for your goals and future ambitions.  Growing your practice is beneficial to the parent corporation so you should gain a new sense of encouragement and a team behind you to assist you in moving ever forward.


Tuesday, September 20, 2011

Simple Prep Work Can Save You Hours For Credentialing

In an earlier blog, I posted some good tips for credentialing your doctors.  From what I have seen lately on discussions on Linkedin, folks are really having a hard time using CAQH, so I thought it was worth taking the time to outline some of the simple prep work that can save you hours of time during the credentialing process.

Indeed, no physician hired into our group was allowed to start unless I had a copy of each of the documents needed for credentialing.   You would be amazed at how quickly the papers reached my desk!

Although we live in the new "paperless" age, you would be wise to organize a folder for each physician in your practice that contains all the paperwork necessary to make the constant credentialing processes a breeze.  On the outside of each folder, I note the following:
Physician's Name, Address, Home Phone, Cell Phone, Pager #,  Date of Birth, Social Security Number, Spouse's Name.
Name and Address of Undergraduate School and Date of graduation.  I also then list : Medical School Name and Address, Date of graduation, Internship location and name of program supervisor and dates, residency- the same and fellowship- the same
State Licensee Number and Expiration Date / UPIN
DEA Number and Expiration Date
NPI number
CAQH number / User ID and password
Medicare / Medicaid ID numbers.
Hospital Affiliations
Malpractice Insurance

A copy of these documents are stored inside the folder, so that easy access allows you to fly through the application process. As I update Registrations and DEA, I merely change the expiration dates on the outside of the folder.   Contained in the folder can also be:
Name/ Address and Phone of 3 physicians for recommendations.
CME credits
ACLS  Certifications
Infection Control Certificate and on and on.

Pulling and making a copy is the hardest work you will have to do after your individual folders are created.  You may also want to consider scanning these into a word document under each doctors name. I have used both methods and still kept the folders up to date because in the long run, I found them easier to use and peruse!

CAQH ID numbers can easily be obtained from a variety of insurance plans.  If you go to the CAQH web-site, they will advise you how to get your personal CAQH number.  The initial application can be lengthy process, but after you input the physicians data once, keeping the file up to date is simple and fast.   Those insurers that demand their own application will almost invariably accept CAQH downloads as long as they have an original signature.

Prepare in advance and you will find that credentialing is an easy and sometimes enjoyable process.


Friday, September 16, 2011

What Makes a Great Consultant ?

Consulting is much more than merely bringing your expertise to a practice and expecting it to fly.  Despite their best efforts, many consultants hired to turn around a failing practice find that they have not or cannot make a significant difference and their entry and exit is often a short and painful process.  In my years in the medical arena, I have seen a number of consultants who barely had time to sign their contracts before they were hastily dismissed.  Physicians who seem thrilled at the idea of having an individual or firm come in to analyze and make changes to their practice can easily become overwhelmed long before change implementation becomes a reality.  Needless to say, this is a huge disappointment to the consultants who have probably spent countless hours preparing for a new challenge only to see themselves curbside without really knowing why.

Several key factors can alleviate this situation. They are simple and logical and will help assure that your consulting experience is satisfying and financially rewarding.

1.  It is an absolute necessity for the physician who heads your consulting practice to inform their staff of your arrival well in advance.  The physician may hold an office meeting where you are introduced or you may prepare a memo to the staff advising them of your arrival and intended goals.   Your goals should always address the initiative to create a team environment of success and to assure the staff that you are looking for ways to enhance their job descriptions, not to eliminate jobs.  If you are speaking to the staff in a meeting, you may want to address how you have made a difference in other practices and that your recommendations are open to suggestion and feedback.

2.   Read and understand the temperature of the room-  A uniform standard of excellence does not mean that every practice functions the same.  Throughout their tenure, a physician and his staff have developed a comfort level with their style of medicine and their team approach.   Unfortunately, too often consultants arm themselves with what they consider the keys to success, but never unlock the personalities or goals and desires of the staff.  Don't be too quick to judge the day to day operations of the individuals in the practice until you have a complete understanding of their routines.  Often, what you may consider the failure to accomplish set goals is due to a needy and demanding physician who sidetracks his or her staff, rather than an employee who is lacking in necessary success skills.

3.   Avoid the gangbuster mentality -  DO NOT under any circumstances alienate the staff.  Suggested changes to protocol or policy should not merely be promoted, but rather the reasons that these changes will positively affect the practice must be carefully explained, over and over again, if necessary until the staff realizes that you are acting in their best interest.  I try to explain to staff that changes that will increase or insure a steady practice revenue is the key to their moving forward as well.  You must work to instill the idea that the personal goals of the staff will only be realized if the practice enjoys success.

4.  Roll up your sleeves and dig in -  Talking about doing- and actually doing are two very different things.  You should be willing and able to perform any task changes that you propose.  You will be viewed in an entirely different light when you actually answer a phone or make an appointment.  Becoming part of the team, rather than merely running the team is a sure way to enhance your image and to reinforce the positive changes you are brining to the workplace.

5.  Rigidity is never an asset -  Be willing to compromise your goals and proposals so that they adapt to the work flow of each individual practice.  You may want to see confirmation calls made at a certain time of day and may have excellent reasons for your proposals.  However, if this cannot work in a certain setting, you must acknowledge other ways to accomplish the same result.

6.  Never alienate a Patient -  I have seen consultants meet with patients that have an outstanding balance and all but demand ransom of their firstborn.  Needless to say, these consultants were shown the door almost immediately after this little show.  Do not assume that insuring collection from every patient is the goal of the practice and by all means always treat each patient with courtesy and respect.  Check with the physician or office manager before attempting to meet with any patient.

7.   First organize -  An office that looks and feels messy will never be organized.  Your first priority is to create a workplace that is neat and clean.  I always recommend ways to remove clutter and help make individual work space an easier and more enjoyable place to accomplish daily routines.  Simple measures such as bins and trays are inexpensive and the staff truly appreciates any small tokens that help them feel that their workplace is one where important things happen.

8.  Analyze the daily routine of the physician - Sometimes you come to realize that the physician is the main reason that the practice is failing to thrive.  This is a difficult situation to address, but it still remains your responsibility if your are going to succeed in your consulting goals.  You would be wise to create a written outline addressing how the physician might make improvements - I mean suggesting - delicately. In many cases, your feedback will be greatly appreciated.  In others, not so much a lot!  Either way, you will be able to rest assured that you have accomplished your goals, even if change is not possible.






Tuesday, September 13, 2011

Developing Your Practice EHR

As you set up the parameters and templates for your Electronic Health Records, it is wise to keep in mind that the initial work will be labor intensive.  You will want to take the time and approach this work with a thoughtful attitude and realize that the work you do at this time should mean smooth sailing in the future.

Prior to creating your practice templates or pull down menus, you would be wise to carefully examine at least ten to fifteen initial examination reports and the same number of follow up reports, so that you have can be assured that you follow the same pattern that your physician does when he verbally dictates his reports.  

Some EHR systems, especially those that are free or offered at bargain rates will not have the ability to build in a letterhead feature, so you if you have the option to create new templates, this should be your first order of business.   You can do each line of your address, phone and fax as a separate listing, so that you can select ALL for an initial evaluation and select only the physician name and title for follow up exams that may not be mailed to other physicians.

Most dictated letters follow a pattern of : History or Chief Complaint /  Review of Systems/ Physical Exam / Impression/ Treatment and finally Plan.   If you would like to follow this procedure in a point and click system, you will need to create a template that shows these highlighted areas and then fill in the appropriate text as follows.   An easy way to customize your templates is to initially choose five to ten of your most common phrases under each one of these headings.  You can then click the heading and find exactly what you are looking for under each topic of your exam.

Many EHR systems come pre-loaded with the specialty procedure codes that your office most frequently uses.  If this works for you, it may be less work-intensive than building your templates on your own.  However, there are benefits to starting at square one, since most practices usually have a uniformity to their physician consults and follow ups and you may find that you are somewhat confused if there are overloads of information that you do not generally use on a day to day basis.  

Systems will also offer you the opportunity to transfer your entire patient base into the new EHR system.  In many cases, this may not be the best choice.  When you do automatic transfer, your data may end up skewed, or some patients may appear more than once.  Insurance information may not transfer seamlessly and you will end up doing more work than it takes to manually enter your patients one by one.   Pick a start date for the use of your EHR that will give you time to input patients with appointments 30-60 days in the future.   You can scan in the insurance cards that should be on file in your charts or add the insurance manually for each patient.   This not only assures that data is transferred correctly, but it also gives you the opportunity to cull old charts that are sitting in your file room, and to re-verify the insurance of any patient that has not been seen in your office for 90 days or longer.

As you are culling your charts, you may also want to send reminders to patients that are past due for a visit or procedure and new patients scheduled for 30-60 days in the future can receive their registration forms in the mail, which always makes check in an easier process.

The process of entering your patients into your EHR system will also help you organize old charts for storage or to arrange shredding of PHI for patients not seen for seven years or longer.   You may want to consider this process as part of an overall practice audit and the chance to determine how organized your front office staff has been in obtaining and filing needed PHI information.

Make sure that you seek hardware recommendations from the company supplying your EHR software.  Some tablets are not compatible with every EHR system, so choose wisely.   Make sure that the software vendor is prepared to assist you in synching your tablets or PC's to the printers and faxes in your office.


Monday, September 12, 2011

Managing Your Patient Follow-Up

It would be wonderful if every physician could monitor the patient relationships of their front office and assure themselves that patients are always treated with respect and a helpful attitude.  Unfortunately, this is more dream than reality and even the strongest administrator cannot always be at the front desk to hear every phone conversation or to make sure that follow-up appointments and confirmation calls are made in a timely manner.

Physicians know it is never easy to entrust your patients to anyone outside of the exam room, and the effect that your front office staff can have on your patient's perception of your practice can be the stuff of sleepless nights!   While the investment you have made in your practice represents a large portion of your life and career, for many of your ancillary staff, your day to day operations are merely a job.  It is difficult to motivate any staff day after day and despite your best efforts your staff may not always embrace a team work state of mind.

In the best case scenario, where your employees are dedicated to the daily grind of eight to ten hours of ringing phones, appointments, authorizations and referrals, practice burn out is a common thread that runs through many of even the best practices.

Fortunately, there are several options that can diminish the overwhelming tasks that are part and parcel of any front office staff.  Several excellent companies are available in today's health care market that can make a large difference in your practice and help alleviate some of the front office tasks so that a greater concentration can be made to the revenue stream.  

Options such as auto-confirmation calls have been adopted by many of the more successful practices. Choosing this option will mean that an independent firm will call your patients, usually via an electronic voice message, informing them of their appointment date and time and requesting that the patient press 1 to confirm their visit.  Additional features, such as directions to the office, phone and fax number, and parking information can be added to these calls.  Reminders to patients to have their insurance cards, co-payments and any referrals are also options you may consider.   Your office will usually receive an
 e-mail message confirming your appointments and cancellations, so that you can reschedule any missed or cancelled visits as soon as possible.

Features such as patient reminder cards and/or reminder calls can also be assigned to an outside agency and serve an important function in keeping your patient base current with their care.  Some of these businesses may be able to access your actual scheduling software and confirm directly into your system.  Just make sure that all PHI is protected by a contractual agreement that patient information cannot be shared or sold to any outside company.  You may also want to add a feature to your HIPAA paperwork to make sure that it is acceptable to leave an appointment reminder on the patient's phone message.

You may also want to invest in a feature that will survey your patients on their office experience.  Despite what you consider to be your best efforts in practice analysis, you may be surprised at the smallest of details that patients are noticing during their visit.  Surveys can assess both the professional and ancillary staff and assist in employee and professional staff evaluation.  A detailed spread sheet is often available as part of your contract that will highlight the positives and negatives of your patient experience.

The better companies that offer these features may also provide you with a monthly or quarterly report that will detail the number of cancellations and visits to your practice.  These will prove to be an important part of your practice analysis and can help you identify and alleviate problems before they pose a significant threat to your practice revenue.

While you will want to assure that your front office staff has job descriptions that keep them busy and active each day, you want to guard against overwhelming them with tasks that may fall by the wayside.  Keep in mind that maintaining those aspects of your practice that will guarantee optimum reimbursement are those that should always be in the forefront of your operation.  Utilizing services that can free your ancillary staff to this goal can be the key to your future success.

Wednesday, September 7, 2011

Must Have Publications

A few years ago, it was easy to develop a relationship with a Provider Representative working for Medicare.  These dedicated individuals were happy to answer all your billing and provider enrollment questions and would help guide you through any changes and implementations that your practice decided to put into play.  I cannot tell you how many times I spoke to these great folks and how invaluable their information was.  Sadly, my personal contacts at Medicare have all moved forward or retired and it is now much more difficult to make a personal connection with any insurance plan representative.  Indeed, many of the larger insurers have networked their Provider Representative units oversees and it sometimes becomes impossible for you to even understand what they are saying, let alone develop any form of professional one on one relationships.

While we are busy running the day to day operations of our practice, changes to procedure coding and reimbursements can slip through the cracks and have a financial impact on our practice that may take some time to correct.  I always advise larger practices to assign a staff member to act as a Medicare and insurance liaison in addition to their regular practice responsibilities.  This individual would be responsible with keeping up to date on Medicare and commercial insurance changes that can impact your practice.  Usually this means downloading and examining the commercial network bulletins along with the Medicare Part B newsletter, which should be a part of each practice routine.

The Medicare Part B newsletter is available online to all providers who electronically bill Medicare for their services.  The newsletter lists changes in coding and reimbursement rates, along with physician incentives.  The publication will also allow you the opportunity to enroll in Medicare seminars that will cover a broad range of topics to assist the beginner to the expert in optimizing their reimbursements.
Downloading the Part B newsletter will allow the practice to quickly implement changes and to avoid costly billing errors.  Those areas that are specific to your practice should be downloaded and reviewed by your billing staff and understood by your professional and clinical teams.  While it can be burdensome at times to wade through all the information that is not relevant to your concentration, the Part B newsletter should be reviewed carefully and its examination should be an important part of your practice routine.

The commercial insurance plans also publish newsletters that will provide you with changes to your billing formats as well as updates and important phone numbers and web-sites that will make your claims  follow up an easier task.  These are also available on line and will help you to understand specific modifiers and any differences in billing that exist between your Medicare and commercial claims.   Discussions relating to information in these commercial newsletters should be a part of your monthly billing meeting.  Changes should be quickly implemented and deadlines for changes should be noted in cases where appeals may be needed.

Another must have relationship should exist between your practice and The Coding Institute.  Since 1947, The Coding Institute has been assisting doctors in developing strategies for a more profitable practice.  They offer a variety of products including Specialty Coding Alerts, SuperCoder.com and Audio Education to their enrollees.  Their quarterly publications can be specifically tailored to meet the needs of your particular specialty and they will quickly become invaluable additions to maintaining the financial health of your practice.  The Coding Institute is currently offering a boot-camp that will assist your practice with solutions to the changes involved in adopting the ICD-10.   This one and a half day training course will allow you to master the skills needed to correctly code using ICD-10 CM.  You can contact the Coding Institute directly @ 1-800 508-2582 for more information.


Monday, September 5, 2011

Hospital Based Practices - Do They Serve Anyone's Need ?

In order for private practices to thrive in the current health care climate, they must maintain a standard of excellence in both patient care and financial matters.   Those who fall short of either mark often bail out of having control over their own business and shelter themselves under the umbrella of a hospital based practice.

Basically there are two types of physicians who opt to align themselves with a hospital model.  The first brand of physicians who choose to abandon the idea of private practice are those who have not and can not understand or involve themselves in the business of medicine.  Since physicians never receive training in running a successful practice, there is a trial and error period involved in creating a structure that succeeds.  Some doctors will try their best and still fail, while others refuse to believe that they have any other responsibility than to practice medicine.  Either way, you will usually find these doctors functioning in a disorganized office that is always on the brink of one catastrophe or another and bail out is sometimes their only means of survival.

The other physicians who need the hospital model are those egomaniacs that have expanded their original model to include either offices or equipment that they can not afford or maintain.  They find themselves in a situation where overhead continues to accumulate, without the patient volume to offset these expenses.

Initially, the idea of a hospital based practice may seem like the greatest invention since sliced bread and indeed physicians who refuse or cannot grasp what it takes to make a successful private practice may find their salvation here.   What could be better, they wonder, than to lose all financial responsibilities, bill and salary paying, and maintenance for the office and equipment?   Ahh!, to just come in each day, collect a salary and go home with a clear head.  Wonderful, right?   Well, before we pay homage to the gods of hospital employ, we should be aware of the many pitfalls that can plague this arrangement and make us realize that it may not be the nirvana that we hoped for.

First and foremost are the staff problems.  While some hospitals will negotiate with physicians and allow them to bring their former staff members with them as part of their deal, many hospitals will require that the new take-over practice use their employees.   Many hospitals are now using their R.N. staff  as part of their practice management team.  This is a great idea if you need blood draws or IV placement, not so much a lot if you need staff that is familiar with verification and authorizations, front desk staffing, and billing protocols.  Many R.N. have never run a private practice before and have no prior understanding of the nuts and bolts of everyday practice life and all that it entails.   Without a team mentality for success, you may find yourself short of your financial goals at the end of each quarter and eventually find that you cannot meet the expectations of your contract.

As hospital employees, your staff is paid by the managing organization and they may have little to zero interest in making the success of your practice their number one goal.   You may have some input into employee evaluations and raises, but in most cases the employee is protected by the hospital job description that was agreed upon at their time of hire and asking them to perform additional tasks or even to change protocols or procedures is akin to expecting them to perform open heart surgery during their lunch hour.   You are just another nameless, faceless physician to these workers and if you could not motivate staff in your own practice, then you can forget about motivating employees who have no direct connection to you at all.  In most hospitals, employees have constant access to human resources and administration if their little world is interrupted in any way, and you may come to find out that unless an employee is in violation of the most serious of crimes, you will be gone before they are!

You will now find yourself in a situation where you have to submit written requests for any and all equipment that is needed to run your daily operations successfully.  Should these requests be granted, you will be placed on the list of all other requests and can expect to wait, sometimes for weeks for a new printer, fax, or telephone.  When these finally do arrive, you can hope and pray that they first work and that they are compatible with your other equipment.  Wait times can be endless.....

Your billing may now be outsourced and reports may go directly and exclusively to the hospital controllers office.  If the billing department is located somewhere off campus, you will never be able to see EOB's and other insurance correspondence and will rely on nameless and faceless personnel to make your financial decisions.  You may never find out if there are a particular set of problems that are preventing the optimization of your financial goals and again you may never meet or exceed your contracted goals.  You could find yourself making the same amount of money year after year, without knowing why your goals are not being met.  And if you did not understand the business of medicine before, you will now find yourself in the deepest and darkest of corners.

Patients may be billed and even harassed for charges that you may have waived or made some time concessions for without your knowledge or input.  What you will get are the patient complaints and exits that can result from a billing staff that does not act in your best interest.  The hospital may not accept all plans that you were formally par with and more patients will exit because of this problem as well.  You may be expected to perform a number of charity procedures and see these patients for private visits as well and this can have an important impact on the number of profitable visits during a financial quarter.
You can also forget about referring to physicians that are not part of the hospital staff.  You will be judged and evaluated upon your constant referral to hospital staff and they can be a tough task master.  Some hospitals may even expect that you obtain their approval prior to vacation and sick time and you may be expected on call whenever other members of the staff are away.  Your life is no longer your own and unfortunately this is exactly what you bargained for.

Finally, there may come a day when someone realizes that the hospital based practice is just another referrals for money scheme.  Eventually, these practices will only be allowed in areas where the affiliated hospital is the only game in town, so if won't matter where the patient is admitted, since no other options exist.  In most urban areas, this is far from the case and your patients, surprisingly enough, may not always want to be admitted to your employer hospital.  Then - What ?