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.

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 ? 

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.