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.

Playing With the Big Boys

Once your current marketing strategies translate into new patients and referrals, you may want to think abut expanding your efforts into more commercial advertising such as newspapers, radio, or even television.

Again, there are several commercial agencies that will provide you with these services.  The price tag is often hefty, however, and you may find that the message you wish to convey is not adequately understood.
There are a few simple tips that can help you produce your advertisements in house, saving you additional costs and assuring that your practice message reaches your target audience.

Begin with a small quarter page newspaper ad.  What message do you want to convey?  What types of patients do you want to attract?   Don't waste your time and money paying for a newspaper ad that simply shows your name, address, phone number and specialty.  Save that information for your practice brochure and marketing handouts.  Your ads should be designed to grab the patient's attention, have relevance to their symptoms and convey the message that your are present to deal effectively with the particular complaint.

Building a practice web-site also gives you the opportunity to display your beautiful office and highlight the most recent medical trends that your office is following and offering to your community.  You may want to include sections specifically devoted to patient information along with an FAQ page to answer what your office finds to be the most commonly asked questions.  Some web-sites provide on-line appointments or live chats at specific periods of time.  Today's patients are more informed than those of years ago, and appreciate an office where their specific concerns are immediately addressed.  Your web-site can allow your front office more time to concentrate on the money aspect of the practice and less time answering the same patient questions over and over again.

Use creativity when planning your site and target your advertising to a savvy patient base that is computer literate and represent the consumer population at large.  Produce attention grabbing advertisements, especially if you are going to present radio commercials or television spots.  

Take What You Have and Run With It !

Imagine that you are an ophthalmology practice that shares space with an optometrist. The possibilities are endless for collaborative enterprises.  You might want to offer a plan where patients can receive a free eye exam and eyeglasses for a price just above wholesale.  Purchase a selection of wholesale frames for the patients to choose from and then offer the plan free to the human resources department of every small business or organization in your area. Print membership cards that offer this benefit to employees and to their families.  In our case, in 1994, we charged $ 29.00 for an eye exam and glasses.

Think about the number of new cataract and glaucoma patients you could discover from offering an exam and glasses well below market price.  Discover how many patients will upgrade to more expensive frames.  Then think about expanding your efforts into producing safety eyewear and contracting with labor groups who require this service and who will also need annual eye exams.  In the early 1990's, I was shocked to find that the eyeglass frames that I spent $200.00 buying cost the optician $5.00.  I am sure that the same level of mark-up exists today so believe me when we charged the patient $29.00 for the exam and glasses, we still made a profit.

This is an actual success story that I brought to my first job in medicine as the director of marketing.  The idea was the brainchild of an extremely well know ophthalmologist who was as devoted to marketing as he was to his specialty.  He had a talent for looking at his practice and envisioning how it would move forward each year.  The "Eyes Plus" program was a huge marketing bonanza for the practice; a simple idea that translated into a new source of revenue.

Any practice looking to grow and change has the ability to tap into the current trends in medicine and the resources already exist if you use a little imagination and are dedicated to your specialty.  For example:  It is widely known that women face an additional risk of fatal heart attack simply because they may present with symptoms so different from their male counterparts.  A Cardiology practice with concerns for these differences may be wise to promote a women's heart program with marketing materials that outline the risk markers designed especially for this demographic group.  This type of program will go over well with women's groups, OB-GYN practices, infertility practices, cosmetic surgeons, endocrinologists and on and on...

Growing your practice by expanding on your established skills not only has the potential for increasing practice revenue but it can also provide your physicians with a chance to diversify their current patient base and add new challenges to the daily routine.

Tomorrow :  Playing With the Big Boys

Community Services

Years ago, when drastic cuts in reimbursements were not an issue, certain medical practices offered everything from pick up and drop off services to fully equipped medical offices on wheels that would travel the community and provide free medical evaluations.

Today, when it seems as if money is dwindling more and more each year, and cuts in reimbursement have reached an all time high, physicians spend most of their time trying to make up for lost revenue by increasing the number of patients they see each day.  In this vein, many doctors now feel that community services are no longer a viable option.

Providing a link between your office and your community doesn't have to be cost prohibitive and is still a good way to attract new patients to your practice.

For very little money, you can become familiar with the labor organizations, women's groups, PTA, fire and police departments in your area.  Most of these groups have monthly meetings and welcome speakers from the medical community.  Labor organizations with their own health coverage often have the opportunity to contract exclusively with specialty physicians for office and testing services.   Police and the volunteer fire departments in your area require annual fitness testing for their employees and special needs groups are often looking for practices to accommodate their members.  Small businesses in your community may need a physician for their sick employees or to provide treatment for minor on the job injuries.

Your office can also become a community service center at little to no cost to the practice.  Patients love free testing.  Blood pressure or cholesterol screenings, cataract and glaucoma testing, or testing for diabetes can be offered in your office using a separate appointment scheduler.  These free screenings often translate into the discovery of untreated problems that will provide new patients for your practice. You might want to consider dedicating four hours on a Saturday morning to these services which can familiarize the community with your practice as well as providing a valuable service.    

You can also consider advertising a series of in office lectures for your established patients and the community at large.  These programs can work well for a large number of specialties.  For example, you may want to promote a lecture series for diabetic patients that would include something like:  "Diabetes - An Introduction to Nutritional Choices."   Inviting physicians in your area to speak or attend these lectures is a good way to develop long lasting relationships with other medical professionals.

Your billing staff may want to chair an informational meeting on Medicare changes or the benefits and drawbacks to various HMO and PPO plans that serve your specialty.  

Local community papers are the most cost effective way to advertise these meetings.  A quarter page advertisement in the weekly community mailer usually fits into the most stringent practice budget.  Flyers can be produced in house and distributed to local businesses.  Don't forget that you can also use your local supermarkets.  Often they have a bulletin board dedicated to community affairs.  It is a good idea to have an R.S.V.P. in place for any in house lectures.  This will guarantee that you have enough available seating or help you plan ahead if you want to serve refreshments.

Put on your thinking cap and you and you and your staff will come up with a number of brilliant ideas.

Tomorrow :  Expanding Services :  Take what you have and run with it !!!!