I Introduction 1 1 2 3 - The Physicians Foundation · 2018-02-14 · Chapter V returns to the topic...

Introduction ................................................................................................................................................................ 1

The Art of Finding, Training, and Evaluating Qualified Personnel for Today’s Medical Practice ....................................... 6 •CreatinganEffectiveJobDescription •Recruitment,ApplicantScreening,Interview,andSelection •TrainingandStaffMotivation •EmployeePerformanceEvaluations

Tools and Resources for Practice Success ......................................................................................................................24 •CriticalCodingandBillingResources •Consultants:ACureforPracticeIlls?

Time Management and Administrative Simplification: Running Your Practice Efficiently and Effectively! .......................32 •LookingatYourPractice •TheAssessment •IdentifyingandEliminatingVariances •OfficeCommunications •MaketheMostoftheVisit •UseYourOnlineResources •StrategiesforEfficiencyandEffectivenessinYourPractice

Assessing Customer Expectations and Improving the Patient Experience ......................................................................46 •SolicitingFeedback •UnderestimatingtheValueofPatientSatisfaction •PhysicianReferralSatisfactionSurveys

Understanding Your Revenue Stream ...........................................................................................................................50 •MeasuringDAR •RevenuebyPayor •ManagingSelf-PayRevenue •RegularlyMonitorFinancialBenchmarks •HowCanaPracticeImproveitsDAR? •BeyondARBenchmarking

Practical Steps Practices Can Take to Ensure HIPAA Compliance ...................................................................................60 •HIPAAEnforcement •HowCanYouLowerYourRisk? •MedicalIdentityTheft •ComplianceReviewsandInvestigations •NoticeofPrivacyPractices •ProtectingIndividualsWhoComplain

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Contents

Successful Preparation and Implementation of an Electronic Health Records System ................................................... 64 •EMRvs.EHR •WhatIsaBusinessCase •TheEHRImplementationProcess •TheBestWaytoDoaNeedsAssessment •CompletingaReadinessAssessment •PerformingaWorkflowAnalysis •WhyDoaWorkflowAnalysis? •HIPAAConsiderationswhenSelectinganEHR •WhatIsitYouNeed? •WhatAboutDiseaseRegistries? •ReadyforanEHR?TheNextSteps •CreatinganEHRRoadMap

Building a Defensible Fee Schedule: An Analytical Approach to Establishing and Maintaining Charges ........................ 74 •WhatIsaFeeSchedule? •MethodologicalConsiderations •WhatIsaConversionFactor? •WhatIstheCFUsedfor? •CalculatingConversionFactors •CalculatingMeasurementsofCentralTendency •BenchmarkingFees •CompetitiveFactor •Cost-BasedMethods •BenchmarkingUsingRBRVS •Time-BasedCalculations •GlobalConversionFactors •ChargeDataComparisons •TheCohenAcuityFactor(CAF)

Surviving Out-of-Network: One Physician’s Experience .............................................................................................. 92 •CreatinganOpportunity •PlanYourStrategyforsuccess •ApproachingtheDecision •IdentifyaStrategy •DevelopanOut-of-NetworkStrategicPlan •BeOptimistic

Appendix ................................................................................................................................................................ 102

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IIntroduction

Soloandsmall-grouppracticesarethemainstayoftheAmericanhealthcaresystem.EveninCalifornia,thebirthplaceofhealthmaintenanceorganizationsandhometosomeofthelargestmedicalgroupsinthecountry,mostofthestate’sresidentsreceivetheirmedicalcarefromphysicianofficeswithonlyoneortwopracticingdoctors.Soloandsmall-grouppracticesalsoplayacrucialroleinAmerica’shealthcaresafetynet.AndinCalifornia,soloandsmall-grouppractitionersmakeupthelion’sshareofthesafetynet—withoutthem,entireCaliforniacountieswouldnothaveaccesstoaphysicianandmanyofthestate’salreadyoverwhelmedemergencyroomsandtraumacenterswouldbeforcedtoclose.Fortheseandmyriadotherreasons,itisworthpayingcloseattentiontotheplightofsoloandsmall-grouppractitioners.ThehealthoftheirpracticesisessentialtothegoodhealthofCalifornians.

Thistoolkitoffersaseriesofprovenstepsthatsoloandsmall-grouppracticescantaketoimprovemanyfacetsoftheirpractice,includingthedeliveryofbetter-qualitymedicalcare.Itisbasedonanimportantpremise:thatinordertoprovidequalitymedicalcare,aphysicianpracticemustbeefficientandwellrun.Thereareanumberofreasonswe’vetakenthisview.Thefirstandmostobviousisthatapracticecannotprovidequalitymedicalcareunlessitcankeepitsdoorsopen,andeventhemostmagnanimousphysiciancan’tsupportanunprofitablepracticeforever.Moretothepoint,though,isthatphysicianswhoworkinwell-runpracticescanspendlesstimeworryingaboutmakingendsmeet,which,inturn,affordsthemmoretimeforpatientcare.Efficient,well-runpracticesarealsosaferpractices;anofficewithmodernandefficientrecord-keepinghabits,forexample,islesslikelytocommitmedicalerrors.

Manyoftherecentinnovationsthatmakepracticesmoreefficientalsomakeforbettermedicine.Bywayofillustration,considertheimpactthatelectronichealthrecordshavehadonboththephysician’sbottomlineandpatienthealth.Severalstudieshaveshownthatusingelectronichealthrecordsbringssizablefinancialbenefitsforphysicians—onerecentstudyreportedthatphysicianswhomaketheswitchincreasetheirincomebyanaverageof$33,000peryear.Thestudiesreportthatthesavingscomefromseveralsources,chiefamongthemadecreaseinpersonnelcosts1.Suchstudiesarenotwithouttheirdetractors;anecdotalreportsfromthesoloandsmall-grouppracticesweworkwithinCaliforniasuggestthatelectronichealthrecordsystemssometimestakeyearstopayforthemselvesandcanactuallycostsomepracticesmoneyintheshortandlongterm.Butweknowthatgoingforward,pickingtherightelectronichealthrecordsystemisgoingtobeessentialtothesuccessofapractice,especiallyasprivatepayorsandprogramssuchasMedicarewillbasepaymentsonwhetherornotapracticehassuchcapabilities.

Someofthequalitiesofelectronichealthrecordsthatsavemoneyarealsothesameonesthatmakethemgoodforpatientcare.Thepaperhealthrecordstheyrenderobsoletenotonlyareinefficient,buttheyalsocontainlessinformationaboutapatientandthustellaphysicianlessaboutwhomheorsheistreating.Similarly,someofthelabor-intensivetasksmademuchsimplerbysuchasremindingpatientstostayontopofchronicconditions—arebothlessexpensiveandmoreeffectivewhentheyaredonewiththehelpofanelectronichealthrecordssystem.

Practicemanagementsystemslikewisecanimprovebothapractice’sbottomlineandqualityofcare.Forexample,sincetheyallowaphysician’sofficetorunreportsbydiagnosis,theyallowthemtoidentifypatientswithchronicdiseasesandthedate

1 RobertMiller,ChristopherWest,TiffanyMartinBrown,etal.,TheValueofElectronicHealthRecordsinSoloorSmallGroupPractices,HealthAffairs,September/October2005,24(5):1127-1137. Introduction- 1

thosepatientswerelastseen.Practicemanagementsystemscanthengenerateappointmentrecallandreminderlettersandtrackmissedappointments—stepsthatarecentraltogooddiseasemanagement.

USING THIS TOOLKITTheadviceinthistoolkitiswrittenforphysiciansandofficemanagers,butitcanreallybenefitanyonelookingforhelpwiththeactivitiesitdiscusses.AndwhileitisaimedprimarilyatpracticesinsideCalifornia,muchofthecontentisapplicabletopracticesinotherstates.We’venotedfactualcontentthatisCalifornia-specific.We’vealsotriedtoidentifyareaswhereCaliforniadiffersfromotherstates—withregardtolaborlaw,forexample—sothatphysiciansfromotherstateswhoareusingthetoolkitwillknowtochecktheirownstatestatutes.

Thetoolkitisorganizedintoninechaptersthatcanbereadsequentiallyoronanas-neededbasis.We’veoutlinedthecontentsofeachchapterheresouserscangostraighttotheinformationtheyneed.

THE CHAPTERSChapter Iofthistoolkitlooksattheveryfirststepaphysicianmusttakewhenstartingapractice.Eventhemosttalentedphysiciancannotdeliverhigh-qualitymedicalcarewithouthiringagoodstaff.Therefore,weofferadviceontheartoffinding,interviewing,hiring,training,andevaluatingemployees.Amongotherhelpfulpiecesofinformation,we’veincludedquestionsforbothtelephoneandin-personstaffinterviews,asectiononhiringandthelaw,hintsformarryingworkassignmentswithperformancestandardsandpracticegoals,andadiscussionofhowwell-trainedreceptionistscanbeinstrumentalinimprovingpatientcare.

Chapter IIlooksattheelementsofasuccessfulpractice.Everypracticeisdifferent,buteachrequiresthesamebasicresourcestobefinanciallysuccessfulandtodeliverhigh-qualitymedicalcare.Identifyingtherighttoolshelpsmedicalpracticesimprovetheaccuracyoftheirrecord-keeping,coding,andbilling.ItalsohelpspracticesbecomemoreefficientbusinessesandmaintaincompliancewithprotocolsthatareestablishedbyprivateinsurersandgovernmentprogramssuchasMedicareandMedicaid.Anothertooldiscussedistheconsultant.Outsideconsultantsofferavarietyofservicesandcanbehelpfulwitheverythingfromregulatorycompliancetochoosingandimplementingpracticemanagementandelectronichealthrecordsystems.Welookatwhenandhowaconsultantcanbehelpfulandoffersuggestionsforfindingtherightone.

WithMedicarereimbursementsprojectedtodecreasebyasmuchas30percentoverthenextseveralyears,andwithmajorhealthplansunwillingtonegotiatecontractratesthatcoverthecostofcare,theviabilityoftoday’smedicalpracticedependsincreasinglyonimprovedefficiency.

Chapter IIIlooksatareassuchastimemanagementandadministrativestreamlining,withpracticaladviceonhowtoconductaneedsassessmentforyourpracticeandhowtoidentifyvariancesinthewayscommontasksareexecuted.Leftunaddressed,variancescancauseinefficienciesandcompromisethequalityofmedicalcare.Wealsodiscusstechniquesforreducingpatientwaitingtimesandformaximizingthevalueofthetimepatientsspendinaphysician’soffice.Managingcallvolume,reducinglatearrivalsandno-shows,usingefficiency-relatedtechnology,andmakingmaximumuseofphysiciantimearealsocovered.Allthesechangesdirectlyimpactthebottomline,improvepatientexperience,andcanresultinbettercare.

Chapter IVlooksatimprovingpracticesfromtheperspectiveofthepatient.Becausebothphysiciansandpatientsaresuchanimportantreferralsourcefornewpatients,goodcustomerserviceisavitalcomponentofasuccessfulpractice.Improvingthepatient’sexperiencestartswithsolicitingfeedback.Herewediscusshowtosurveyyourpatientsandwhatyoucandowithvariousresults.Patientsurveyscanbestprovideinformationaboutthreeareas:qualityissues—whetherthepatientissatisfiedwithhisorhermedicalcare;accessissues—whetherheorsheishavingahardtimebeingseen;andinterpersonalissues—whetherpracticestaffareprovidinggoodcustomerservice.ChapterIValsolooksattheprocessofsurveyingreferringphysicians,astepthatcanrevealwaystoshortenreferraltimesandimprovethepatient’soverallcare.Thesetypesofsurveysalsogiveyouabetterpictureofhowwellyouaremeetingtheneedsofreferringphysiciansand,moreimportant,howyoucandoitbetter.

Chapter Vreturnstothetopicofstayingfinanciallyhealthy,scrutinizinghowpracticescanbetterunderstandandimprovetheirrevenuestream.Financialcrises,evenshort-termones,jeopardizeboththeviabilityofapracticeandqualityofcare.Thekeytopreventingrevenueshortfallsisactivelymonitoringwhatiscominginthedoor.Weofferguidanceonhowtomanageaccountsreceivablethroughprovenbestpracticesinanumberofareas:measuringdaysinaccountsreceivable,orDAR,bypayor,service,andprovider;managingself-payrevenuestemmingfromco-pays,co-insurance,deductibles,andothernon-coveredservices;benchmarkingkeyfinancialindicators;andminimizingDAR.

-Best Practices2

Chapters VI and VIIlookattwoareasthatpresentchallengestoallphysicians,butparticularlythoseinsoloorsmall-grouppractices.ThefirstiscompliancewiththefederalHealthInsurancePortabilityandAccountabilityAct,orHIPAA,forshort.Thesecondisselecting,implementing,andusingelectronichealth-recordssystems.Ironically,partoftheimpetusbehindHIPAAwasthethoughtthatitwouldfacilitateconversionfrompaper-basedmedicalrecordstomoreeasilysharedelectronicones.Asapracticalmatter,HIPAAcompliancehasbeenoneofthemainobstaclestoachievingthatend.

ThediscussioninChapter VIlooksatanumberofgapsthatfrequentlycausemedicalpracticestoviolateHIPAAandwaystosignificantlylowerthatrisk.ThechapteralsolooksatmedicalidentitytheftandstateprivacylawsthatcanbeevenstricterthanHIPAA.Itrecommendsaseriesofpracticalstepsthatphysicianpracticescantaketoensurecomplianceinthoseareasaswell.

ThediscussionofelectronichealthrecordsinChapter VIIaimstodemystifywhatisoftenaveryfrustratingprocess.Thereisnodoubtastothegreatpotentialofelectronichealthrecords.Properlyused,theycanreducemedicalerrorsandimprovepatientcare.Usingelectronichealthrecordscanalsosaveapracticealotofmoneyinthelongterm.ButmakingEHRworkforsoloandsmall-grouppracticescanbetricky.Inthischapterwetellyouexactlyhowtodoit.WestartwithadviceforconductinganEHRneedsassessment,discusstheissuesofreadinessandtiming,andofferadviceforselectingtherightsystemforyourpracticeandmakingsureitwillmeetyourHIPAAcomplianceneeds.

Chapter VIIIlooksatyetanotherkeytopracticeviability—developingadefensiblefeeschedule.Thefeescheduleisthesinglemostimportantfinancialtoolwithinamedicalpractice.Yetmostpracticesdeveloptheirfeescheduleswithverylittle,ifany,understandingofthemethodologyfordoingso.Understandingthismethodologyisnoteasy,butthephysicianwhoputsthetimeintolearningitwillbenefitgreatly.Thechapterlooksatthebasicperspectivesunderlyingsoundfeeschedulingandwalksphysiciansthoughthetaskofcreatingtheirown.

Chapter IXoffersamodelthatonephysicianbelievescanimprovebothqualityofpatientcareandthequalityoflifeforaphysician.Dr.DanLensinkisaboard-certifiedophthalmologistinRedding,California,whosepracticefocusesonplasticsurgeryoftheeyes.Ashewrites,dissatisfactionwithlossofcontroloverhispracticepromptedashifttohiscurrentpracticestatus—providinghisservicesoutsidemosttraditionalcommercialinsurancenetworks.Lensinkcontendsthischangegiveshim,andotherphysiciansmakingsimilarchoices,more

timewithhispatientsandahigherqualityoflife.Makingthecaseforpracticingoutofnetwork,hedeemsitoneofthebestwaystoimprovequalityofcare.Heofferspracticaladviceforsurvivingoutofnetwork,includingtipsondevelopinganout-of-networkstrategicplan.

CMA ON-CALL SYSTEMThisguidereferencesmanydocumentsthatexplaininmoredetailmanyoftheissuesandlawsdiscussedherein.Thesedocumentsareknownas“CMAOn-Call”documents.CMAOn-CallisCMA’sonlineinformation-on-demandserviceforphysicians.

CMAOn-CalldocumentsareavailablefreetomembersonCMA’swebsite,www.cmanet.org.NonmemberscanpurchaseOn-CalldocumentsintheCMABookstore,atwww.cmanet.org/bookstore.Moreinformation,includingstep-by-stepinstructionsonhowtoaccesstheOn-CallsystemcanbefoundintheAppendixofthisdocument.

THE PEOPLE WHO PUT THE TOOLKIT TOGETHERThistoolkitistheworkofseveralindividualsandwasgenerouslysupportedbyagrantfromthePhysicians’Foundation.Itwasresearched,written,andeditedbyJodiBlackandFrankNavarro.BlackandNavarroaredirectorsoftheCaliforniaMedicalAssociation’sCenterforEconomicServices,establishedin1999toprovideeducationalassistancetophysicianmembersandtheirstaffandtodevelopresourcestoimprovepracticeperformance.InadditiontothedirectassistancetheyprovidethroughCMA’sreimbursementhelpline,BlackandNavarroconducteducationalseminarsforphysiciansalloverCaliforniaandadvocateonbehalfofCMA’sphysicianmemberswithpayorsandregulators.Combined,theyhaveover45yearsofpracticemanagementexperience.

Someofthechapterswerewrittencollaboratively,orinsomecasesprimarily,byoutsidecontributorswhograciouslyagreedtovolunteertheirtime.TheseincludeDavidGinsberg,cofounderandpresidentofPrivaPlanAssociates;FrankCohen,senioranalystforMITSolutions,Inc.;MaryJeanSage,foundingprincipalandseniorconsultantoftheSageAssociates;SeanWeissandJayLechtmanfromDecisionHealthProfessionalServices;DavidT.Womack,NancyClements,andKathleenRiexinger,fromthePracticeManagementInstitute;DebraPhairas,presidentofPractice&LiabilityConsultants;LindaCole,AlanMorrison,andMelissaLukowski,fromathenahealth;andDanLensink,M.D.FullbiographiesforeachofthecontributorsareavailableintheAppendix.

Introduction- 3

SpecialthanksgototheAlameda–ContraCostaMedicalAssociationforitsinvaluablesupportandadviceonthistoolkitandforarrangingtheparticipationofanumberofitsphysicianmembersandtheirstaffs.Wewouldalsoliketothankthephysiciansthemselves,inparticularMarieAgleham,M.D.,LisaAsta,M.D.,JulianDavis,M.D.,JudithHartman,M.D.,LeonardKutnik,M.D.,LiliaLizano,M.D.,andAnthonySomkin,M.D.Allcontributedsignificantamountsoftheirowntimetotheearlystagesofthisproject.

Lastly,thetoolkitwasedited,re-edited,andeditedsomemorebyKatherineBoroski,CMA’sdirectorofcommunications.ThedesignandhelpfulgraphicsarethefineworkofDavidFlatter,headgraphicdesignerforCMA.Withouttheirinvaluablehelp,completingthetoolkitwouldhavebeenimpossible.

LEGAL DISCLAIMERThistoolkitprovidesinformationaboutthelawdesignedtohelpusersdealwiththeirownlegalneeds.Theinformationinthetoolkit,however,isnotintendedtoprovideuserswithspecificlegaladvice(theapplicationoflawtoanindividual’sspecificcircumstances).Foralegalopinionconcerningaspecificsituation,consultyourpersonalattorney.

Forinformationonotherlegalissues,refertotheCMA’sCalifornia Physician’s Legal Handbook(CPLH).Thisbookcontainslegalinformationonavarietyofsubjectsofeverydayimportancetopracticingphysicians.WrittenbyCMA’sLegalDepartmentthebookisavailableonafullysearchableCD-ROM,orinaseven-volume,softboundformat.Toorderyourcopy,call(800)882-1262orvisittheCMABookstoreatwww.cmanet.org.CMAmemberscanaccessmostoftheCPLHcontentfreeviaCMAOn-Call,CMA’sonlinelibraryofmedical-legalinformation.(SeeAppendixformoreinformation.)

-Best Practices4

-Best Practices6

The Art of Finding, Training, and Evaluating Qualified Personnel for Today’s Medical Practice

By David T. Womack, Nancy Clements, and Kathleen Riexinger from the Practice Management Institute

Probablythemostimportantdecisionthephysicianorofficemanagerwillmakeishiringtherightindividualstorepresentthepractice.Whetheryou’reseekingareceptionist,biller,orofficemanager,assemblingawell-trained,qualifiedstaffcanbeadauntingtaskandtakescarefulconsideration.Therightindividualsshouldnotonlypossessthenecessaryskills,knowledge,andexperience,butalsohaveapositiveattitudeandworkwellwithotheremployeesandmanagement.Oneencounter,face-to-faceoronthephone,isallittakesforapatientorpatient’sfamilymembertoformanopinion.Agreatteamthatworkswelltogethercandowonderstoimproveyourpracticeanditsviability.

Wheredoyoufindenthusiastic,hardworkingpeoplewholookforwardtomakingthemostofthemselvesandtheirpositions?Whereisthatrarebreedofpersonwhoissmartandmotivated,someonewhoisloyalandviewsemploymentnotasajob,butasacareer?Dosuchpeopleevenexist?Ofcoursetheydo.However,theyarenoteasytofind.

Thischaptertellsyouhowtomastertheartofeffectivelyhiring,training,andevaluatingemployees,aswellasimprovestaffcommunication,motivatestafftomaximizeproductivity,and,ideally,minimizeemployeeturnover.

CREATING AN EFFECTIVE JOB DESCRIPTIONThecornerstoneofeffectivepersonnelmanagementisaclearlydefinedjobdescription.Awell-writtenjobdescriptionprovidescontrolandstructureforeachemployee,definingtheemployee’sresponsibilitiesandestablishingexpectations.∆

Background WorkAwell-writtenjobdescriptionlaysthefoundationforimprovedperformancemanagementofemployees.Writingajobdescriptionisadevelopmentalprocessthatinvolvessharedmanagerial,individual,andteaminput.Thegoalistoprovideatoolthatclearlycommunicatespositionexpectationsandallowsforcontinualemployeegrowthandimprovement.Thisimprovementwillenhancecustomersatisfactionandhelpachievebusinesssuccessforthepractice.

Beforeyoubegindevelopingthisdescription,considertakingafewhelpfulpreliminarysteps:

•Contactotherpractices.Mostofficeswillbewillingtosharecopiesoftheirjobdescriptionsorlistsofemployeedutiesandresponsibilities.

•Modifyanexistingjobdescription.

•Askemployeestowritetheirownjobdescriptionsandthenreviewthemwiththoseemployees.

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Thistoolkitprovidesinformationaboutthelawdesignedtohelpusersdealwiththeirownlegalneeds.Theinformationinthetoolkit,however,isnotintendedtoprovideuserswithspecificlegaladvice(theapplicationoflawtoanindividual’sspecificcircumstances).Foralegalopinionconcerningaspecificsituation,consultyourpersonalattorney.

Ajobdescriptionisnotthesameasarecruitmentad,whichwillbediscussedinthenextsectionofthischapter.

The Employee’s PerspectiveIfyou’rewritingajobdescriptionforanexistingposition,gettheemployee’shelp.Havetheemployeemakealistofallthetasksperformed.Don’tbesurprisedifthesetasksdifferfromtheoriginaljobdescription.Thisisnormal.Instructtheemployeetowritedownallknownresponsibilities/dutiesandthentrackandaddtothelisttasksthatareperformedoveratleastaone-weekperiod.Becausesometasksareonlyperformedonaweekly,biweekly,ormonthlybasis,youmaywanttohavestafftrackdutiesoveraone-monthperiod.

Organizational ChartsAnorganizationalcharthelpsdefineauthorityboundariesandjobrelationships.Anorganizationalchartveryclearlyshows“whoreportstowhom.”Suchchartsdonothavetobefancytobeeffective.Severalveryinexpensivesoftwarepackages(e.g.,MicrosoftWord)canhelpyoucreateorganizationalchartsandalsohaveframeworksforcreatingjobdescriptions.Mostcanbecustomizedforuseindifferentemployeesettings.

Putting Pen to PaperIndevelopingjobdescriptions,itisagoodideatomakeacomprehensivelistofalltaskswithinthepracticethataretobeperformedbyanyoneotherthanthephysician.First,grouptasksbyfunction.Forexample,grouptogetheralltasksinvolvedinregisteringapatientoralltasksinvolvedinhandlingaccountspayable.Then,categorizethetasksbyposition.Keepinmindhoweachtaskmayimpactjobperformance.

Oncealltasksarelistedanddefined,categorizeeachtask.Aftertasksarecategorized,youwillthenwanttoprioritizeeachone.Beyondspellingouttheparticularsofspecifictasks,youshouldalsoincludedescriptorsforhowmucheducation,training,orcredentialingisrequiredorwhetherstatelicensureisessential.

Job Description BasicsEveryjobdescriptionshoulddefinealltasksandresponsibilitiesofthepositionandshouldfollowtheseguidelines: •Avoidgeneralizations.

•Bepreciseindescriptions.

•Includeonlypertinentinformation.

•Describetoolsandequipmentusedinthejob.

•Explainworkrelationshipsandauthorityboundaries.

•Listallrequiredskills(typing,tenkey,MicrosoftWordandExcel,etc.).

•Ifthereisoverlapofresponsibilitiesoremployeesarerequiredtofillinfor thoseinotherpositions,thisinformationshouldbeincludedineachindividualjobdescription.

Thesalaryorhourlyraterangeforthepositionshouldalsobedefined,withsomewiggleroomfortherightcandidate.Whilesalaryisanimportantconsideration,keepinmindthatpeopledonotworkforsalaryaloneandgoodsalariesdonotautomaticallyguaranteegoodemployees.Compensationandbenefitpackagesshouldbecompetitivetopreventfrequentturnover.Ω

AsamplejobdescriptionisavailableintheAppendix.

TheArtofFinding,Training,andEvaluatingQualifiedPersonnelforToday’sMedicalPractice- 7

-Best Practices8

RECRUITMENT, APPLICANT SCREENING, INTERVIEW, AND SELECTION

RecruitmentOnceajobdescriptioniscreatedandemploymentneedsareidentified,thesearchforaqualifiedcandidateisnarroweddownandmadeeasier.Lesstimewillbespentlookingsince“qualified”hasbeendefined.Itisbettertoconsiderthreepeoplewhocouldperformthejobwellthantostrugglethrough30candidateswhocannotperform.

The SearchNowthatallthepreparatoryworkhasbeendone,itistimetobeginthesearchforqualifiedemployees.Herearesomesuggestedresources: •Localnewspaper

•Employmentagencies

•Internetjoblistings(suchasMonster,CareerBuilder,craigslist)

•Technicalschools

•Stateandlocalmedicalsocieties

•Juniorcolleges

•Privatecontacts

•Patients

•Friends

•Hospitals

•Otherproviders

Placing an AdYourobjectiveshouldbetosolicitanadequatenumberofapplicationsandrésumésofpotentialemployees.Ideally,youwillwindupwithatleasttwo,butpreferablythree,qualifiedcandidatestochoosefrom.Whenyouhavemorethanonequalifiedcandidate,itiseasiertocompareandmeasureacandidate’sstrengthsandweaknesses,whichultimatelywillhelpyouselecttherightpersonforthejob.

Oneofthebestwaystoletpeopleknowoftheavailablepositionisthroughnewspaperwantads.Certainpointstocoverinthead:

•Thepositiontobefilled

•Requirementsfortheposition(degree,licenses,certifications)

•Yourrequirementsfortheapplicant(appearance,demeanor)

•Salary

•Skillsrequired

•Aresponsee-mail,phonenumber,orfaxnumber

Otherinformationyoumaywanttoinclude:

•Typeofpractice

•Numberofphysicians

HIRING THE RIGHT RECEPTIONISTThereceptionistwillbethefirstpersonyourpatientsandpotentialpatientsencounter.Asthefaceandvoiceofyourbusiness,thisisoneofthemostimportantmembersofyourstaff.Abadhiringdecisionforthispositioncanhavefar-reachingconsequences.

Tounderstandwhetheryou’rehiringtherightpersonforthejob,youmustfirstexaminethereceptionist’scorecompetencies.Istheapplicantarticulate,accurate,capable,andconfident?Theanswerforeachoftheseshouldbeyes.Ifyouidentifyshortcomingsinanexistingemployee,insomecasesthatpersonmaybenefitfromadditionaltraining.However,youmayfinditnecessarytopartwaysormovetheemployeetoanotherposition.

Next,performanassessmentoftherequiredtasksforthepositionandaskyourselfwhetheryourreceptionistorpotentialhireiscapableofdoingallthesethings.Andlastbutnotleast,determineifacandidate’spersonalityandinterpersonalqualitieswillmeshwithyourstyleofpractice.

Inmostsoloandsmallgrouppracticesthereceptionistisrequiredtowearmanyhats.Failuretofulfillthefollowingkeyresponsibilitiesproperlycanaffectotheraspectsofthepractice.

• Present a professional demeanor. Remember,receptionistsarethefirstpointofcontactforexistingandpotentialpatients,aswellasforreferringphysicians.Theyrepresentyourcompany.Acrankyorunprofessionalreceptionistcanquicklydrivebusinessaway.

• Understand your office and financial policies. Receptionistsmusthavetheabilitytoexplainofficeandfinancialpoliciestopatientsandansweranyquestions.Thiswillpreventmisunderstandingsanddissatisfiedpatientslater.

• Understand the insurance contracts your practice holds with payors.Clearlycommunicatingthepractice’shealthplanparticipationstatusatthetimeofschedulingandagainatthetimeofservicewillhelppreventconfusionandcomplaintsaboutthepatient’sout-of-pocketresponsibility.

• Understand the importance of patient confidentiality. Keepinmindthatpatientsinthewaitingroomcanfrequentlyhearconversationsthattakeplacebehindtheregistrationwindow.Evenifthediscussionsarenotaboutprotectedhealthinformation,ifthepatienthasbeenwaitingforalongtimetheremaybeanimpressionthatthestaffbehindthecounteriscontributingtothedelay.

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•Generallocationofoffice

•Titleofposition

•Full-/part-timerequirements

•Responsibilities

•Experiencenecessary

•Specialrequirements

•Education

•Benefitsofposition

Whenwritingyourad,trytouseheadlinesandlanguagethatattractreadersandexplainwhatthepracticeislookingfor.Theadshouldbewrittensothatitelicitsinterest.

Sample Job Posting

Medical Office Receptionist North Side Pediatric Practice is seeking a full-time receptionist. An exciting and challenging position is available for the right person. Make appointments for the doctor, assist and direct patients. Some typing and filing. High school education required. Prior experience in a medical office a plus. Minimum typing speed 60 wpm. Must be comfortable working with sick children. Competitive salary based on experience. Excellent benefits with opportunity for advancement. Fast-paced environment. We would like you on our team! E-mail resume with salary history and references to [email protected].

Applicant ScreeningChoosingtherightcandidatewilltakeintoaccountexperience,salaryexpectation,skills,andperhapsmostimportant,theproper“chemistry”requiredtoworkwellwiththeteam.Theinitialselectionprocess,however,willbeoneofelimination.Themoreresponses,themoreselectivethedecisioncanbe.

Thefirsteliminationisrejectionofrésumésthataresloppy,areincomplete,havespellingmistakes,orareimproperlywritten.Next,screenforcontent,measuringtheskillsandexperiencesofeachcandidate.Lookforexperiencefactorsthatindicateaproventrackrecordforsimilartasks.Gradeeachrespondent’srésumé,coverletter,workexperience,andeducationandgeneralcharacteristicswithan“A,”“B,”or“C.”Thiswillpreventyourhavingtorereadrésumésunnecessarily.

Jobturnovercanbearedflag.Reviewtherésuméforemploymentlongevityandgapsinemployment.Ideallyyouwantanemployeewhoiscommittedandwantstogrowwithyourpractice,notonewhochangesjobseverysixto12months.Therearevalidreasonsforgapsinemployment,suchasthedecisiontostayhometoraiseafamilyorcareforalovedone.Don’tautomaticallydiscountarésuméthatincludesemploymentgaps,butitisveryimportanttoaskthepotentialemployeeaboutgaps.

Ifyoufeelyou’veonlyattractedonequalifiedcandidate,youmaywanttoconsiderexpandingyouradvertisingtootherpublicationsorreviewingthejobdescriptiontoensureyouradwaswritteninawaythatgeneratedenoughinterestfromqualifiedcandidates.

• Determine why the patient needs to be seen. Receptionistsmusttriagethepatientanddeterminetheappropriateamountoftimetoschedule.Failuretoaccuratelydeterminetheamountoftimerequiredforthephysiciantoaccuratelyassessthepatientcancauseabacklogforthephysicianandforpatients.

• Ensure patient demographics are accurate. Collectionofaccuratedemographicsplaysanimportantroleinpatientcareandappropriatereimbursement.Withoutaccuratecontactinformation,thephysicianmaybeunabletogetintouchwiththepatientwithnewsabouttestresultsandthelike.Additionally,afailuretoobtainaccurateinsuranceinformation(e.g.,acopyofthefrontandbackofthepatient’sinsurancecard)atthetimeofservicecanresultinreimbursementdifficultiesand/ordelays.

• Verify benefits and collect co-pays/deductibles. Itisbestpracticetoverifyeligibility,benefits,andco-pay/deductiblesatthetimeoforimmediatelyafterschedulingofanappointment.Thisenablesthepracticetoidentifycoverageissuesanddiscussthemwiththepatientbeforetheappointment.Itisimportantforthereceptionisttocollectanymoneydueatthetimeofservice.

• Know whether the procedure requires an authorization.Dependingonthenatureofthepatient’scondition,itcantakeuptofivebusinessdaystoobtainanauthorizationfromapayor.Soinschedulingthepatientforaprocedure,itisimportantthatthereceptionistallowsenoughtimetoobtainthatauthorization,toavoidhavingtorescheduleorcancelappointments.Equallyasimportant,failuretoobtainanauthorizationcanresultindelayedornopayment.

• Mesh with your practice personality and philosophy. Ifyouhaveacurmudgeonatthewindow,chancesarebythetimepatientsgettoseeyouthey’llbeequallysour.Toleratingtemperamentalbehaviorisnotworththeriskofchasingpatientsaway.

Thesereal-worldexamplesdemonstratewhycorecompetencies(articulate,accurate,capable,andconfident)aresocriticaltothepractice.Theyalsohighlighttheimportanceofthoroughtrainingandofmaintainingasufficientlyexpandedknowledgebase.Tobetrulyeffective,areceptionistmustreceivetheappropriatetrainingandhaveaccesstonecessaryresources.


-Best Practices10

The Telephone InterviewOnceyouhavesuccessfullypareddowntherésuméstoaworkablenumber,scheduleatelephoneinterviewtofindoutmoreabouteachapplicant.Thisstepisparticularlyhelpfulinhiringareceptionistbecauseit’sanopportunitytoevaluatehowcandidatescomportthemselvesoverthephone.

Sample Interview Script

Whenconductingatelephoneinterview,taketimetodescribethepositionandconsideraskingthefollowingquestions:

Hello! I’m __________ from Dr.__________’s office. We received your résumé in response to our ad. Do you have time now to talk for a few minutes or would it be possible to schedule some time later this week to briefly discuss your qualifications? (A few interchanges to describe the job and the practice, followed by some basic questions:)

What is it about this job that interests you?

What type of work are you doing now?

Why are you considering leaving?

What do you feel you would bring to this job?

Tell me about your training.

Tell me about your previous work experiences.

How do you feel about working with people who are ill?

When could you be available?

Name ____________________________ Rating ___________

Interviewing Possible CandidatesEveryoneyouinviteforaface-tofaceinterviewshouldbeaskedtocompleteajobapplication,regardlessofwhetherthepersonalsobringsinarésumé.Theapplicationletsyouassesspenmanshipandgatherinformationnottypicallyincludedinarésumé.Whileallapplicantswillprobablysendrésumés,thesemaydifferfromeachotherinstructureorformatandhencemakecomparisonsdifficult.

Evaluating the ApplicationInevaluationoftheapplication,certaincriteriashouldbeexamined:

•Istheapplicationcomplete?

•Istheapplicationlegible?

•Weredirectionsfollowedcorrectly?

•Isthespellingcorrect?

•Doesthecandidatehavethebasicqualifications?

•Isthereagoodworkhistory?

•Wereacceptablereferencesprovided?

•Dotheinformationanddatesprovidedmatchtheinformationontherésumé?Ω

Preparing for the InterviewThepurposeoftheface-to-faceinterviewistoevaluatefactorsnotpresentontheapplication;toinformtheapplicantabouttheresponsibilitiesoftheposition;andtoclearupanyquestionsconcerningtheapplicant’squalifications.Anin-personinterviewisanimportantopportunitytoobserveacandidate’scomposure,appearance,andtemperamenttodeterminewhetherthatpersoncanworkwellwiththerestoftheteam.Themethodofinterviewingmustbeappropriateandconsistentinordertopermitfaircomparisonsbetweenapplicants.

Forconductingapersonalinterview,werecommendthefollowingsteps:

•Reviewthecurrentjobdescriptionandprovideacopy tothecandidate.

•Reviewapplication/résumépriortointerview.

•Familiarizeyourselfwiththejobdetails(pay,hours, benefits,etc.).

•Outlinedesirabletraitstoexplore.

•Writeupastandardlistofquestionstoaskallcandidates.

•Askcandidatestoarrive15minutesearlytofillout thejobapplication.

•Conducttheinterviewinprivatewithoutdisruptions.

•Maketheapplicantfeelcomfortable.

•Reserveenoughtimetogettoknowtheapplicant.

•Makesureyouhaveansweredanyquestionsfromthecandidateabouttheorganizationandposition.

•Makenotesduringandimmediatelyaftertheinterview.

•Completeallinterviewsbeforemakingafinaldecision.

Rememberthatanemploymentinterviewshouldbeastructuredconversationwithaspecificgoal.Thegoalistodetermineifthecandidatehastheeducation,experience,interests,andtemperamenttofillthespecificjobavailable.

Testing Candidates Incompetencetakesacostlytollonapractice.Aproblememployeecanincreaseyourstress,yourworkload,yourlegalliability,andyourexpenses.Thebestwaytohavethebeststaffistohirethebestpeopleinthefirstplace.Onewaytoensureyouarehiringtherightpersonfortherightjobistotestapplicants’skills.Objectivetestscanprovidevaluableinformationaboutthedegreeofcompetenceinaparticulararea.

Fine-Tuning the Interview Toefficientlyandwiselyinterview,developastandardizedlistofquestionsinadvanceandfollowaconversationalstructurethatwillprovidetheneededinformation.Onlyaskjob-relatedquestions.

Herearethetwomostcommonerrorsmanagersmakeinthehiringprocess:

1.Nottakingorallowingenoughtimefortheinterview

2.Talkingtoomuchaboutthemselvesinsteadofusingtheinterviewtolearnasmuchaspossibleaboutthecandidate

Trynottouseclosed-endedquestions.Aclosed-endedquestionrequiresonlyayesornoanswer.Anopen-endedquestionrequiresexplanationsandencouragesthecandidatetoexpandontheresponse.Examplesofsomeeffectiveopen-endedquestions:

•Tellmeaboutyourself.

•Whatareyourlong-andshort-termcareergoals?

•Whatdidyoulikebestaboutyourlastpositionandwhy?

•Whatdidyoulikeleastandwhy?

•Ifyoucoulddesigntheperfectjob,whatwoulditlooklike?

•Whatareyourstrengths/weaknesses?

•Whatthreewordswouldyourcurrentsupervisorusetodescribeyou? Yourcoworkers?

•Whatdoyouthinkyoucancontributetothispractice?Tothepatients?

•Whatexactlydidyoudoinyourlastjob?Beforethat?

•Whatisitaboutthisjobthatinterestsyou?

•Howhasyoureducationaltrainingpreparedyou forthisjob?

•Inschool,whatwerethesubjectsyouenjoyedandfoundeasytomaster?

•Whatcircumstanceshavepromptedyoutochangeorconsiderchangingjobs?

•Attimeswehaveallhadtoworkwithdifficultindividuals;tellmeaboutthemostdifficultpersonwithwhomyou’vehadtowork.

•Howdidyoulikeworkingforyourlastemployer?Maywecallhim/her forareference?

•Whatotherexperienceshavepreparedyouforthisjob?

•Areyouwillingtobebonded?

AsampleinterviewreportformisavailableintheAppendix.


-Best Practices12

ontheemploymentapplication,buttheapplicationmustincludeastatementthataconvictionwillnotnecessarilydisqualifyanapplicantforemployment)

•Creditrating

•Homeownership

•Education(basedonresponsesprovidedonanapplication,youcanaskconfirmingquestionsaboutacademicdegreesorschoolsattended,butyoushouldneveraskthedatesomeonereceivedadegreeordiploma,asthatcanleadtochargesofagediscrimination.Suchinformationcanbeconfirmedthroughabackgroundscreening)

•Socialsecuritynumber(thiswillberequiredatthe timeofemployment)

•Receiptofunemploymentbenefits

•Physicalcondition(unlessrelatedtorequirementsforperformingjobduties)

•Anyquestionrelatedtopregnancyorapplicant’smedicalhistoryorcondition

•Questionsregardingworkers’compensationclaims

•Modeoftransportationy Ω

Next StepsIffurtherinterestedinacandidate,followtheseguidelines:

•Setupasecondinterview.Candidatestendtobemorerelaxedthesecondtimeandyoucangetmoreinformationandconfirmyourearlierassessmentsorimpressions.

•Providemoreinformationabouttheposition andthepractice.

•Conductabrieftourofyourfacility.

•Introducetheapplicanttootherstaffmembers.

•Encouragequestionsaboutthejobandpractice.

•Thanktheapplicantforhisorhertime.

•Makefinalnotesontheinitialinterviewform.

•Considerhavingsomeoneelseinterviewthecandidate,foranotheropinion.

•Asktheapplicantwhetheryoucancontactcurrentand/orformeremployersforareference.

•Askthecandidateforalistofotherreferencesyoucancontact.

•Allowenoughtimetoreachyourdecision.

•Whathascontributedtoyoursuccessinpreviousjobs?

•Whatcircumstanceshavecontributedtoproblems inpastjobs?

•Ifyouwereinmypositionandinvolvedinhiring,whatqualitiesaboutyourselfwouldyouconsiderappealing?

•Whatadditionalinformationaboutyourselfdoyouwantmetoknow?

•DoyouhaveanyquestionsaboutthepositionorthecompanythatIcananswer?

Telltheapplicantabouttheorganizationandthepositionforwhichheorsheisbeingconsidered.Makeappropriatecommentsregardingthatperson’sbackgroundandexperience.Explainthatthereareothercandidatesbeinginterviewedandgivesomeideaofwhenyouwillbenotifyingapplicantsofyourdecision.

Keeping the Interview LegalImproperinterviewingtechniquescanexposephysicianpractices,hiringmanagers,andtheiremployeestopotentiallawsuitsfromindividualsorinvestigationbygovernmentagencies.Mostsuchviolationsarecommittedbymistakeandoutofignorance.Unfortunately,ignoranceofthelawisnoexcuse.Avarietyoftopicsandissuesmustbedealtwithdelicatelyandinsomecasesavoidedaltogether.Becauselawschangeandvarybystate,youmustobtaintheappropriateinformationfromyourstate’sdepartmentoflabortomakesurethequestionsyouareaskingandmethodsyouemployarewithintheparametersofthelaw.Anemployershouldneveraskapotentialemployeequestionsrelatedtoanyofthefollowing:

•Race,creed,orcolor

•Nationalorigin

•Gender

•Age

•Sexualorientation

•Maritalstatus

•Children

•Religion

•Residencyorcitizenship(thisinformationwillberequiredatthetimeofemployment)

•Physicalormentalconditionordisabilities

•Foreignlanguagesspokenathome

•Arrestrecord(youcanaskforadditionalinformationrelatingtocriminalconvictionsthattheapplicantlists

Checking ReferencesItisimportanttocheckreferencesoncandidatesbeingconsideredforhire.

Performingareferencecheckallowsyoutoconfirmemploymenthistoryandmayalsoprovideinformationonthestrengthsandweaknessesofacandidate.Additionally,speakingwithadirectsupervisorcanhelpyoudeterminehowthecandidateperformedonaday-to-daybasis.Ingeneral,referencecheckingcanbehelpfulifyouhavedoubtsaboutthecandidateandcanalertyoutodishonestyorotherseriousproblems.

Whiletherearecertainlybenefitstocheckingreferences,besuretoavoid someofthepitfalls:

•Employersmaybesuedfordefamationofcharacteriffoundgivinginaccurateorfalseinformation.Forthisreason,manyemployerswillnowonlyverifybasicinformation,suchastitleheldanddatesofemployment.

•Referencesareoftenopinionsandsometimesnothingmorethangossip.

•Afavorablereplycouldmeantheapplicantisagoodcandidateoritcouldmeanthepreviousemployerisjusthappynottohavetopayforunemploymentbenefits.

•Informationgiveninareferencetendstobegeneralandnotparticularlyhelpful.

•Thereisnoguaranteethepersononthetelephoneistrulythepersonbeingcalled.

•Youcouldendupscreeningoutanexcellentcandidatebecauseofpersonalityconflictsordisagreementswiththepreviousemployer.Ω

Other ConsiderationsAddedfactorstorememberinusingreferencestoevaluatecandidates:

•Nobodyeverprovidesareferencelistofemployerslikelytogiveabadreport.

•Mostlargeorganizationshaveapersonneldepartmentthatprovidesonlyaconfirmationofemploymentbecauseofthepotentialforlawsuits.

•Manycandidatesleaveanorganizationbecausethemanagementhasproblems—whichhavenobearingonanindividual’squalificationsorabilitytodoanexcellentjobforyou.

•Manyapplicantsarehiredbecauseofgoodreferencesbut,intheend,areunabletoperformtostandardorworkwellwiththeteam.Referencesshouldbeusedonlyasanadditionaltoolinthelargercontextofdecidingonaparticularhire.

•Manybusinessesandpracticesarescreeningapplicantsbytestingthecandidate’sskillsinsteadofrelyingonsubjectiveevaluationsandjobhistoryalone.

•Ifpossible,speakonlytothedirectsupervisorwhoobservedthepersoninaction,nottoacoworker.Thesupervisorcantellyouhowapersonperformedonaday-to-daybasis.Getsignedpermissiontocheckreferences.Unfortunately,asstatedabove,manyemployersrequirethatallreferencesbehandledthroughtheirhumanresourcesdepartment.

Foracomprehensivediscussiononpre-employmentinquiries,pleasereferenceCMAONCALLDocument#0233,“Pre-EmploymentInquiries.”

AsampleinterviewreportformisavailableintheAppendix.

“PersonalReferenceCheck”and“PastEmployerReferenceCheck”formsareavailableintheAppendix.


-Best Practices14

hasbeenrecordedinaformalcontextavailabletoallsuchemployeesandpotentialfutureemployers.

The Commitment InterviewOnceamatchisfound,actonitquickly.Ifthereisprocrastination,thebestcandidatewilltakeanotherpositionwithsomeoneelse.Seta“commitmentinterview”withthecandidateyou’veselected,toreviewpersonnelandofficepoliciesandprovideageneralideaoftheworkingenvironment.Thismeetingshouldalsoconfirmsalaryandstartingdate.Straightforwardcommunicationattheoutsetofemploymentwillreducemisunderstandingsandconflictlater.Thecandidateshouldagreetothesalaryprovisionsandreadandunderstandthewrittenofficepoliciesandfringebenefits.Thecandidateshouldbegiventheopportunitytoaskanyquestions.Itisalsoagoodideatoputyourofferinwritingforthepotentialemployeetoread,sign,andreturntoyou.

ContingencyKeepthepaperworkonyoursecond-choicecandidateforaperiodoftime.Ifforsomereasonthefirstapplicantdoesnotworkout,youmayneedtofallbackonyoursecondchoice.

TRAINING AND STAFF MOTIVATIONTrainingnewemployeesisabsolutelyessential,nomatterhowmuchexperiencetheybringwiththemtothepractice.Everypracticedoesthingsdifferently,andifyouwantanewemployeetosucceedinyourpractice,youmustprovidetraining.Partofthattrainingincludesthefollowing:

•Ensurethatthenewemployeeclearlyunderstandstheresponsibilitiesofthejobbasedonthewrittenjobdescription.

•Reviewtheofficepoliciesandproceduresmanualwiththenewhire,andgettheemployee’ssignatureconfirmingheorshehasreceivedandreadthemanual.Placetheoriginalofthissigneddocumentintheemployee’spersonnelfile.

•Ensurethatallnecessarypaperworkiscompletedinatimeframewithinthescopeofthelaw.

•Setapredeterminedintroductorytimeframe,suchas90days,andevaluatetheemployeeattheendofthatperiod.Allowforinterimevaluationsbeforetheendoftheintroductoryperiodtoresolveanyproblemsthatarise.Questionscanbeaddressedandclarificationprovidedalongtheway.

•Ensurethatthenewemployeeisattheminimumperformancestandardlevelattheendofthe introductoryperiod.

•Ensurethateverysteporaspectoftrainingforeachtaskiscovered.Ifataskislongordifficult,breakitintosubunitsfortrainingpurposes.

Providing References for Past EmployeesWrongfuldismissalandlibelsuitsarecostly,bothindollarsandinemotionalpain.Ifnotcareful,yourmedicalofficecouldfinditselfcaughtinawrongfuldismissalsuitorcontendingwithmyriadinvestigativeagenciesbecauseofanunhappyformeremployee.Itisbesttotakecontrolofyourreference-providingprocessnowandavoidfutureproblems.Ofcourse,youshouldconsultwithyourattorneyonthisandallothermattersthatrequirelegaladvice.

Itiscriticalthatyoudesignateoneindividual,whetheritistheofficemanageroraphysicianorsomeotheremployee,tobethepointpersontofieldallreferencerequests.Besureeveryoneinyouroffice,includinganyphysicianwhomightbeapproachedforareference,contactsthedesignatedpointpersonaboutallreferences.Theworst-casescenarioforawrongfuldismissalcaseiswhentheofficemanagerhasmovedanemployeethroughappropriatedisciplinarystagesanddismissesthatemployee,andthensomeoneelsewithintheorganizationprovidesawrittenorverbalreference.

Whatinformationshouldyourpracticediscloseaboutapreviousemployee?Inadditiontoconsultingwithyourpersonalattorneyaboutwhattosay,anotherimportantsafeguardagainstlawsuitsistoavoidissuingwrittenlettersofreference.Oncesuchaletterisinthehandsofadepartingemployee,itcouldbeusedagainstyou.

Yourpracticecanavoidthesetypesofproblemsbyprovidingonlythedateofemploymentandthetitleoftheworker’spositionatthetimeofdeparture.Ifsomeonerequestssalaryinformation,youcandirecttheinquirertoW-2formsandpaystubs,whichshouldbeinthepossessionoftheemployee.Theformeremployeeshouldalsobeabletoprovideaprospectiveemployerwithcopiesofanyperformancereviewsyouprovidedduringthatperson’semployment.Itiswisetorefusetoprovidesuchinformationoverthephonetoapotentialemployer.Instead,demandawritteninformationreleaseformsignedbytheemployee.Somefirmswillaskwhetherornotanemployeeis“eligibleforrehire.”Byaskingthisquestion,they’reessentiallyaskingiftheformeremployeeleftongoodterms.Staffwholeaveingoodstanding(becauseofresignation,layoffor,insomecases,discharge)wouldbeconsidered“eligibleforrehire.”Aformeremployee’s“rehirestatus”issensitiveinformationandyoucouldwinduppayingattorneystodefendyouinalibelsuitifyouanswerthatquestionwitha“no.”Remember,foraformeremployer,thereisnoobligationtoanswerthisquestion.

Itisunfortunatethatyouarerestrictedbypotentialliabilityfrompraisinggoodemployeeswhohavemovedthroughyourorganization.Ifyouhavebeenprovidingallemployeeswithcopiesoftheirperformancereviews,however,youropinion

•Bepatient.Noteveryonelearnsatthesamerate.Someemployeesareslowertolearncertainaspectsofajob,butifproperlytrainedwillbecomestarperformers.

•Encourageemployeestotakenotestheycanrefertolaterwhenquestionsorpointsofconfusionarise.

•Setcompletiondatesforeachportionofthetraining,andmonitorprogress.

•Documentalltrainingandevaluationsandkeepthisinformationintheemployee’spersonnelfile.

Methods of TrainingThereareseveralmethodsoftrainingemployees.Hereisabrieflistoftrainingmethodsusedbymostmedicalpractices:

•On-the-jobtrainingisconductedperiodicallybytheofficemanageror,insomecases,bystaffmembers.Ifstaffmembersareconductingthetraining,itisimperativethattheyarequalifiedandcanbereliedupontoexplainhowthingsaredone.Employeesaresetupforfailureifaninexperienced,poor-performingstaffmemberisputinchargeoftheirtraining.

•Formaltrainingisconductedclassroomstyle,eitherbyqualifiedtrainerswhoarepartoftheorganizationorbyoutsideexperts.

•Groupseminarstocross-trainandenhanceexistingpersonnelareconductedeitherbyformaltrainerswhoarepartoftheorganizationorbyoutsideexperts.

•Employeesenrollintraditionalcollege,university,tradeschool,orcorrespondencecourses.

Cross TrainingCross-training—educatingindividualsinmultiplejobfunctionsorduties—isavaluabletoolforapractice.Frequentturnover,thedemandforqualifiedandcommittedworkers,andtheneedtocoverforsickness,vacations,andleavesofabsencemakeitessentialforawell-runandprofitableoffice.

Staff MotivationFindinggoodemployeesisdifficultenough;onceyoudo,itisimportanttokeepthem.Salariesclearlymatter;still,whilemoneycanbeadis-satisfier,itisrarelythekeymotivatorforagoodemployee.Oneofthetoughestrolesinmanagingemployeesistokeepthemhappyanddedicated.Praise,acknowledgmentofajobwelldone,andpublicappreciationwillgenerallykeepagoodemployeefromlookingforanotherjob.

Somebasicwaystodemonstrateappreciation:

•Recognizeexceptionalperformanceatthetimeitoccursratherthanweeksormonthslater.

•Praiseemployeesperiodicallyandimmediately,notjustattheannualreview.

•Encourageemployeestobecomeconfidentintheiractionsandabilities.

•Sayhelloandgood-byetoemployeeswhenenteringandleavingtheoffice.

•Givecreditwherecreditisdue;recognitioninspiresmoreloyaltyandgoodwork.

•Askhowyouremployee’svacationwentorhowthesickfamilymemberisdoing.Thepersonaltouchisusuallyappreciated.

POLICIES AND PROCEDURES MANUAL

Anypractice,nomatterhowmanyemployees,shouldhaveapoliciesandproceduresmanual.Anumberofcompaniesandattorneysofferguidancetophysiciansandmedicalgroupsputtingtogethersuchmanuals.Thecostofobtainingsuchassistanceshouldbeviewedasmoneywellspentifyourpracticedoesnothaveamanualorthereisanyquestiontheexistingmanualiscompleteandup-to-date.


-Best Practices16

•Showexcitementaboutthework;enthusiasmiscontagious.

•Don’tpunishemployeesforunderstandablybeinglessinvestedinthepractice’ssuccessthananowner/managerwouldbe.

•Keepemployeesinformedaboutwhatishappeningwiththepractice;don’texpectthemtoperforminavacuum.

•Fairnessandconsistencyinstylearefundamentalincultivatingrespect.

•Employeeswillmakemistakes.Usethosemistakesasgrowthandlearningtoolsandindicatorsofareaswherethereisroomforimprovement.

•Treatemployeesthesamewayyouwishtobetreatedandemployeeswilltakeprideinthepractice.

•Supportemployeeswhentheyareenforcingofficepolicy.Otherwisetheymayfeeltheirresponsibilitytodosoisbeingundermined.

•Redesignjobswhennecessarytokeepemployeesfromgettingboredandlosinginterest.Noonelikestoperformtheexactsametasksdailyoverlongperiodsoftime.

•Leadbyexample.

•Showawillingnesstochangewhennecessary.

•Consideranemployeeprofit-sharingplansoworkerswillbeencouragedtobehavelikeowners.Amountsmightbebasedonachievingcertaingoalsduringaquarter,suchasimprovingthebottomlineby$10,000.

•Bonusesarealsovaluableasmotivators.Abonusneednotbebigtocommunicateappreciationofanemployee’scontributionorajobwelldone.Ensurethatgoalsareattainableandclearlycommunicated.

Praise Will Create ChampionsPeopleatworkneedmanythings,butamongthemostcrucialisencouragementandrecognition.Inallcasesseekreasonsandopportunitiestocomplimentyouremployees.Tomotivate,employersmustbuildconfidence.Withconfidence,employeeshavetheprideinthemselvesneededtotakeknowledgetheyobtainandturnitintoperformance.Asanemployeryoucansuccessfullymotivateothersbyadheringtotheseguidelines:

•Communicatestandards,andbeconsistent.

•Beawareofyourownbiasesandprejudices.

•Letpeopleknowwheretheystand.

•Givepraisewhenitisappropriate.

•Keepyourstaffinformedofchangesthatmayaffectthem.

•Careaboutyourstaff.

•Donotbehaveasthoughyouperceivepeopleasa meanstoanend.

•Gooutofyourwaytohelpothers.

•Takeresponsibilityforthelearnersonyourstaff.

•Buildindependence.

•Exhibitpersonaldiligence.

•Betactfulwithlearnersandfellowstaffmembers.

•Bewillingtolearnfromothers.

•Demonstrateconfidence.

•Allowfreedomofexpression.

•Delegate,delegate,delegate.

•Encourageingenuity.

•Praiseandencourageeveryimprovement.

•Lettheotherpersonsaveface.

•Lettheotherpersondomostofthetalking.

•Lettheotherpersonthinkmostoftheideasaretheirs.

•Trytoseetheotherperson’spointofview.

•Provideotherswithachallenge.

EMPLOYEE PERFORMANCE EVALUATIONSPerformancestandardsaretheexpectationsforstaffperformanceofdutiesandconductinthemedicalpractice.Thesestandardsshouldbeoutlinedsoeverystaffmemberknowswhatisexpectedineverydayoperationsandincaseofunexpectedevents.

Developing a Fair and Consistent PerformanceAppraisal SystemManagersshouldbetrainedtousetheappraisalsystem.Subjectivemeasurementsmustbeappliedasuniformlyaspossibletoavoidchargesofdisparatetreatment,especiallyinpromotion.Awell-definedjobdescriptionandclearlycommunicatedjobstandardsandexpectationshelpestablishabaselineoffairnessforeachemployee.Followspecified,writtenproceduresforconductingappraisalsand,tothegreatestextentpossible,useobjectiveratherthansubjectivemeasurements.Italsohelpstobefactualandspecificaboutshortcomingsandtocitespecificinstancesofbehaviorinallcases.Givetheemployeespecifictimeframestocorrectfaultybehaviorandconsiderretrainingtheemployee,ifnecessary.Ω

Establishing Performance StandardsToeffectivelyevaluateanemployee’sperformance,youmustfirstestablishperformancestandards.Jobperformancestandardsshouldoutlinethequalityoftheworktobeperformed;conductstandardsmustestablishrulesofbehaviorandascopeofinfractions.Alsoimportantareappearancestandardstodefinetheofficedresscodeandetiquettestandardsforemployeeinteractionandbehavior.Additionally,itiscriticaltoestablishpatientrelationsstandardsthatspellouttheemployee’sroleinpatientcontactandexplainwhatisexpectedinconductanddemeanor.

Practice GoalsAllperformancestandardsshouldreflectexpectationsthatemployeesupholdandpromotethepracticegoalsoftheofficeasawhole.Thesegoalsshouldbestatedatthebeginningofthepersonnelmanual,possiblyintheformatofamissionstatement.Someexamples:

•Toprovidethebestpossiblemedicalcaretoourpatients

•Totreateverypatientwithdignity,respect,understanding,kindness,andcourtesy

•Toserveourcommunity

•Tomaintainafullyfunctionalpracticewherestaffandphysiciansworktogetherinaspiritofcooperation

•Tocreateanefficientpacewithouthurryorconfusion

•Toemployhighlyqualifiedandmotivatedpersonnel

Evaluation Factors Inanemployeeevaluation,amanagerwillwanttoevaluatebothqualityandquantityofwork.Determinewhichjobfunctionsareessentialforsuccessfulcompletionoftasksandassesswhethertheemployeeperformsthesewell.Itisalsoimportanttoassesswhetheremployeesaredependableandwhethertheytakeinitiativeintheirwork.Abilitytoworkwellwithothersanddecision-makingskillsarealsocriticalfactors.Iftheemployeesbeingevaluatedareinamanagementrole,youwillalsowanttoassesssupervisoryabilities.

Ofcourse,itisalwaysimportanttogaugewhetheranemployeehasachievedthegoalspreviouslyestablished.However,employeesfeelasenseofownershipandaremorelikelytoachievetheirgoalswhentheyhavehadtheopportunitytoprovideinput.So,whenestablishinggoalsforthenextevaluationperiod,it’ssmarttodoitincollaborationwiththeemployee.

Sample Performance Standard

Name: Mary Doe

Position: Accounts Receivable/Insurance Processing

Responsibility: Minimum Standards

Insurance: 80 percent of claims to carrier in 3 days, 80 percent paid in 45 days

Collections: 85 percent of office visits under $100 at time of service. Maintain 80 percent collections in 120 days.

THE POWER OF FEEDBACKFeedbackprovidedaboutaperson’s(orteam’s)performanceorbehaviorisessentialforreinforcingorchangingtheperformanceorbehavior.Byopenlyandconstructivelygivingandreceivingfeedbackwecancreatemotivationandenergyinothers.Employeesreceiveananswertothequestion“HowamIdoing?”whichusuallyremovesstressandincreasesjobsatisfaction.Feedbackprovidesdirectionandhelpsemployeesstayorgetbackoncourse.Itcanalsoconfirmwhetheremployeesareperformingasrequiredandwhentheyareattaininggoals.Byprovidingpositivefeedback,youalsostrengthenrelationshipsandpromotehighself-esteem.

Asample“StaffPerformanceAppraisal”formisincludedintheAppendix.

COMMON EVALUATION MISTAKESToavoidcommonperformanceevaluationmistakes,managersshouldalwaysfollowsetprocedures.Theseincludemakingsurethatthereviewaccuratelymeasurestheskillsrequiredforthejobandcoverstheentiretimeperiod.Thereviewshouldalsoexpresslyaddressconflictsandproblems.


-Best Practices18

•Don’tsuccumbtothe“halo”effect—givingahighoverallratingbecauseofonetaskperformedwell.Eachareaoftheperson’sperformanceshouldbeevaluatedseparately.

•Don’tbesolenientthatyouoverrateperformance.Itismisleadingandunfairtoemployeesandkeepsthemfrombeingabletoviewthemselvesrealistically.

•Don’tgototheother,severeextremeandratetheemployeetoolow.“Powertrips”areinappropriateandneverwellreceived.Don’tassumeanemployeecannotachievea“10”status.

•Don’tratepeoplebasedonwhotheirfriendsare,whatsocialgroupstheycirculatein,theirreligion,oramanager’sownpersonaldislike.Everyonehasprejudiceandbiases,butkeepitoutofthereview.Employeesshouldberatedunemotionallyonobservable,measurablebehavior.

•Donotoveremphasizeisolatedmatters.Peoplehaveatendencytodwellonthenegative,buttheevaluationshouldbebasedonthetotalperson.Maintainrecordsofboththegoodandtheless-than-goodbehaviorovertimetokeepthebigpictureinview.

Employee PerformanceEveryoneneedspraise,includingyourstaff.Expressedappreciationofworkisthenumberonecriteriaforjobsatisfaction,rankingfarabovemoney.Praiseshouldbemorethancasual,althoughfrequentreinforcementisapositiveforce.Withastructureforpositivefeedback,there’sabuilt-inchannelformeaningfultwo-waycommunication.

Ofcourse,thereisalwaysroomforimprovement.Nooneisperfect.Performancereviewscanbeavitaltoolforpositivereinforcement,correctingdeficiencies,examiningproblems,sayingthankyou,andprovidingstimulationandmotivationforbetterperformance.

Follow a ProcessManagerswhofollowastandardprocesswhendiscussingemployeeperformancepresentamoreorganized,structured,andclearreview.Thefollowingstepshelpensureasmoothdiscussion: •Puttheemployeeatease

•Opentwo-waydialogue

•Generaloverview

•Reviewoftasks

•Praiseand/orcounsel

•Theproblems,withspecificexamples

•Thesolutions,withspecificexamples

Attitude: Courteous with patients 100 percentof time. Cordial to coworkers and pleasant attitude.

Appearance: Within standards for administrative staff members

Additional Information:

Preparing for and Conducting the ReviewSeveralstepscanhelpamanagerproperlyprepareforareview.First,itisimportanttoasktheemployeetocompleteaself-evaluation.Theself-assessmentshouldfollowthesameformatthemanagerwilluse.Comparetheself-assessmenttothemanager’sassessmentpriortothereviewmeetingtoidentifysimilaritiesanddifferences.Anysimilaritiesordifferencesshouldbeopenlydiscussedduringthereviewsession.

Agoodmanagerwillalsoexaminethecurrentjobdescriptiontobesurethejobisclearlydefinedbeforesittingdownwiththeemployee.Doestheemployeemeettheminimumstandardsorgowellbeyondtheestablishedstandards?Thisisalsoanexcellentopportunitytoreviewand/orupdatethejobdescription,asthejobmayhaveevolvedsincethedescriptionwaswritten.Itisunfairtoholdanemployeeaccountablefordutiesnotlistedinthedescription.Duringtheevaluation,itisimportanttocommunicateeffectively.Evaluationsshouldallowforatwo-waydialogue.Youshouldbepreparedtogivefeedbackonactualmeasurableperformancethroughoutthedocumentedreview.Aperformancereviewshouldnotgiverisetodebates.Ifaproblemareaisdefined,discusstheproblemwiththeemployee,outlinethesolution,providefortrainingifnecessary,andsetaspecificgoalandtimeframeforimprovement.Althoughtwo-waycommunicationshouldbeencouraged,arguingshouldnot.

Whendiscussingareasforimprovement,trytofirstusepraise,thenoutlinetheproblem,andthenoffersolutions—anapproachknownasthe“sandwich”technique.(Thecriticalfeedbackissandwichedbetweenpositivecomments.)Thatmakestalkofimprovementeasierfortheemployeetoaccept.Alwayskeeppersonalfeelingsoutoftheconversationandspeaksolelyaboutobservablebehavior.Goalsshouldbemeasurableandsetwithspecifictimeperiodsforachievement.

Common Rating Errors

Mistakeshappenduringevaluations.Herearecommonbutavoidableerrors:

•Itishardtorateemployeesifyoudon’tknowthemwell.Makeapointofgettingtoknowyouremployees.

•Retraining

•Cross-training

•Resources

•Employeeinput

•Areashandledwell

•Goals

CounselingMostemployeeswanttodoagoodjob;however,theremaycomeatimeinwhichyouwillneedtodisciplineemployeesfornotdoingtheirjobeffectively.

Counselingand/ordisciplininganemployeeisusuallysomethingamanagerpreferstoavoid,butitisessentialtouseprogressivedisciplinaryprocedurestoresolveproblemsthatarise.Failuretocorrectanemployee’sperformanceorworkhabitproblemscanhavefar-reachingnegativeeffects.Theotheremployeeswillseeinactionasunfair,especiallyiftheyenduppickinguptheslack,ortheymaylapseintosimilarmisbehavior.Ineitherinstance,moraleandperformancesuffers.

Disciplineshouldnotbeapproachedasnegativeoraspunishment.Havingawell-disciplinedteammeansworkingtogetherwithprecisionandskill.Disciplineisameanstoanend—hopefullynottermination,butanendtotheproblem.Duringadisciplinarydiscussion,youshouldemphasizeproblemsolving,notpunishment.

Inpreparingforsuchadiscussion,besuretodoyourhomeworkbyreviewinganypreviousdiscussionsandallavailabledocumentationonthesubject,examiningcompanypolicyguidelines,andgatheringanyotherrelevantinformation.Byobtainingallthenecessaryinformationandbeingprepared,youwillbeabletofocusonthefactsratherthantheemployee,whichiswhatyouwanttocorrect—thebehavior,nottheperson.Anymanager-employeecounselingmustbeconductedinprivatetopreventembarrassmentorviolationofprivacylaws.

Threekeytacticstouseinanydiscussionofaperformanceorworkhabitproblemwithemployees:

•Maintainorenhanceself-esteem.

•Listenandrespondwithempathy.

•Askfortheirhelpinsolvingtheproblem(s).

Ifyouadheretothoseprinciples,theemployeeshouldnotfeelthreatenedorbecomeemotionalduringthediscussionandshouldfeelmotivatedtochangetheunproductivebehavior.

Grievance ProceduresFairemployeetreatmentmustincludeastructuredgrievancesystemforresolvingproblemsanddealingwithemployeecomplaints.Thesystemneednotbeelaborate;insomemedicalpracticesasimplesuggestionboxwillsuffice.Butthemosteffectivesystemhasaformalwrittencomponent.Ω Asamplegrievanceformisavailablein

theAppendix.


-Best Practices20

AsamplecorrectiveactionplanformisavailableintheAppendix.

TIPS ON PROPER DOCUMENTATIONOnly job-related information should be documented.Donotdocumentanyoff-dutyactivityoranypersonalsituationsthatdonotinterferewiththeemployeeeffectivelyfulfillingjobresponsibilities.

Documentation must be consistent and impartial. Besuretobefair.Ifyouaregoingtowriteupsomeoneforbeinglate,thenyouneedtodothatforeveryoneelsewhoshowsuplateaswell.

Be specific.Donotwritegeneralities.Providedocumentationthatgivesspecificdates,times,andincidentsfortheemployee’sinfractionormisconduct.Donotjuststate,forexample,“Youarelateallthetime.”

Documentation must be substantiated.Allinformationwrittendownmustbetrue.Accusations,falsetestimony,orrumorsshouldnotberecordedinwriting.

Documentation should be timely.Makearecordofanincidentofmisconductassoonaspossible.Documentingitlateronorterminatingtheemployeelongaftertheincidentwillbeoflittlevalueindefendingyourmanagementactions.

Whendevelopingagrievancesystemforyourpractice,clearlycommunicatethestepsoftheformalfilingprocessandguidelinesforairinggrievances,aswellasstepsonhowtoappealadecision.

MisconductMisconductisdefinedasaviolationofpolicyorpublishedrules.Commonexamplesincludetheft,insubordination,useofdrugsoralcohol,orexcessiveabsenteeism.

Refertoyourpoliciesandproceduresmanualwhenaddressingamisconductincidentwithanemployee.Disciplinaryactionformisconductcommonlytakestheformoforalwarnings,writtenwarnings,suspensionswithoutpay,andultimately,ifnecessary,discharge.

Ifthewarningisoral,recordthedateofthewarningandabriefdescriptionoftheinfractionintheemployee’spersonnelrecord.Forexample:

June 25, 2006Maryann was warned about her absenteeism today as she was out again yesterday. Maryann has missed a total of x hours in the year. (Signature)

Thedisciplinaryprocessshouldbedescribedintheofficepoliciesandproceduresmanualandtheguidelinesfollowedexactlyforeverycaseofpoorperformanceormisconduct.

Othercorrectiveactiontips:

•Investigatetheincident.

•Verifyfacts,checkrecords,getstatementsfrom“witnesses.”

•Speakwiththeemployeeinprivate.

•Specifythenatureofthemisconductandwhyitisundesirableorinappropriate.

•Specifywhatcorrectiveactionmustbetaken.

•Specifywhathappensifthemisconductcontinues(forinstance,suspensionortermination).

Themostimportantstepindealingwithdisciplinaryproblemsistodocumentincidents,makingsurethedocumentationisfactuallyaccurateandcomplete.Ω

The Importance of Progressive Disciplinary ActionTheCaliforniaSupremeCourthasmadeitclearinrecentyearsthatanemployerhastherighttoterminateanemployeewithoutcauseprovidedtheemployee,atthetimeofhire,isputonsufficientnoticethattheemploymentbeingofferedis“atwill.”However,thereareexceptionstothe“atwill”doctrinethatprohibitterminationforanyreasonsinvolvingretaliationordiscriminationagainstaprotectedgroup.

Contracts,including“atwill”employmentcontracts,arelikelytobeviewedbycourtsasimposingadutyofgoodfaithandfairdealingupontheemployer.Forthatreason,itiscommonlyrecommendedthatofficepoliciesandproceduresmanualsspecifythatemployeejobperformancebeformallyassessedatcertainintervals,possibly

asinfrequentlyasonceayearforestablishedemployeesbuttypicallymorefrequentlyfornewemployees.

Equallyimportantismakingsuretheevaluationsareconducted,documentedinwriting,andkeptintheemployee’spersonnelfile.Thepersonnelfileshouldincludewrittendocumentationofanyinstancesinwhichtheemployeehas1)violatedanyofthepractice’spoliciesandproceduresor2)failedtoadequatelyperformjobduties.Suchdocumentationrepresentswhatiscommonlyreferredtoasprogressivedisciplinaryaction,inwhichemployersletemployeesknowcertainbehaviorwillnotbetolerated,andthatanemployee’sfailuretoremedythesituationmayleadtheemployertotakefurtheraction,“uptoandpossiblyincludingtermination.”

Itisessentialthatemployersmeetwithemployeesanddocumentmisconductorpoorjobperformancethatwarrantsprogressivedisciplinaryaction.Specifically,youmustprovidewrittenevidence(inthepersonnelfile)thatthepoorconductorjobperformancehasbeenbroughttotheemployee’sattentionandtheemployeehasbeenwarnedthatfurtheraction“uptoandincludingtermination”mayresultifthesituationisnotimmediatelyresolved.Withthisdocumentationandanappropriatepoliciesandproceduresmanualasoutlinedabove,anemployerisinamarkedlybetterpositiontosuccessfullydefenditselfagainstawrongfulterminationaction.

Progressive Disciplinary Action Is Not Always AppropriateTheemploymentterminationprotocolssuggestedaboveassumethepresenceofandadherencetoapoliciesandproceduresmanual.Whileitisstronglyrecommendedthatallpracticesimplementandfollowsuchamanual,itshouldalsobenotedthatcircumstancesmayarisethatmakeitappropriateandadvisabletoterminateanemployeeimmediately,withoutany“progressivedisciplinaryaction,”andregardlessofwhetherthepracticehasapoliciesandproceduresmanual.Examplesofthesecircumstancesincludesituationswhereanemployeehasengagedinviolentbehaviororiscaughtstealing.Suchconductrequiresacommonsensejudgmentcallastowhethertheparticularfacts—andtheyshouldbefacts,notspeculation—warrantimmediatetermination.Insuchcircumstancesitisimportanttoconsultyourpersonalattorney.

Is Termination Appropriate?Anumberofissuesshouldbeconsideredbeforeyouterminateanemployee.Apartfromlegalmatters,morepracticalconsiderationsmayincludewhetherthereisanyrealisticprospecttheemployeemightberehabilitatedthroughadditionaltrainingorwhethertheremightbeanotherpositioninthepracticetowhichtheemployeemightbebettersuited.

The Actual Termination ProcessTerminatingemploymentofamemberoftheofficestaffisataskthatcreatesconsiderableuneasinessinmanyphysiciansandpracticeadministrators.Suchuneasinessisnotaltogetherunwarrantedintoday’sclimateofwrongfulterminationlawsuits.

Asemphasizedthroughoutthischapter,oneofthemostimportantkeystoasmoothandlegallydefensibleemploymentterminationisthepresenceof,andadherenceto,anappropriatepoliciesandproceduresmanual.Assumingyouhavesuchamanual,herearesomegeneralsuggestionsonhowtoadviseanemployeethathisorheremploymentisbeingterminated.Thesearemerelyguidelines;consultationwithanexperiencedemploymentlawattorneyisstronglysuggestedifthereisanyquestionastotheemployer’srighttoterminatetheemployeeoriftheemployeemaybeamemberofalegallyprotectedclassbasedonconsiderationssuchasage,disability,gender,orrace.

Preparing for the Termination

PrivacyConductthediscussioninprivate,forexampleinthe manager’soffice.

WitnessesItisoftenadvisabletoconductemploymentterminationmeetingsinthepresenceofmorethanonepersonfromtheemployer’sside.Inamedicalpractice,thatmightmeanthepracticeadministratorandaphysicianmeetingjointlywiththeemployee.Havingawitnesscanhelpprotectthepracticeagainstanysubsequentallegationsbytheemployeeofmisconductoccurringorpromisesmadeduringthemeeting.

TimingPlanthetimingofactualterminationforwhenyouarementallyprepared.Youmaydecidetomeetwiththeemployeeatthebeginningorneartheendofthedayandschedulethesessionforpaydayorthelastdayoftheworkweek.

What to Say to the EmployeeThereisnoeasywaytotellsomeoneheorsheisbeingfired.Mostexpertsagreetheactualterminationmeetingshouldbekeptfairlybriefandthatemployeesshouldbegivenashortoverviewofthereasontheyarebeingletgo.Onceagain,ifthebasisforterminationispoorjobperformanceorviolationsofacompanypolicy,theemployeeshould,inmostcases,havepreviouslybeenapprisedoftheproblem.Donotgetintoanargumentwiththeemployeeoverthemeritsofthedecisiontoterminate,andtrytousewordsthatarecompassionateyetfirm.Onceterminationhasbeendecided,donotallowtheemployeetochangeyourmind.Speakoftheterminationinthepasttense.“Ithasbeendone.Youhave


-Best Practices22

Formoreinformationonspecificemploymentissues,pleasereferenceCMAONCALLDocument#0217,“OverviewofSelectPhysicianPracticeEmploymentIssues.”

alreadybeenterminated.”Ifanemployeereactsinaviolentorthreateningmannerorifthereisanyquestionofpotentialforworkplaceviolence,thepoliceshouldbealertedimmediately.

Items to Be Delivered to the EmployeeUnderCalifornialaw,duringameetingwhenanemployeeisinformedoftermination,theemployeemustbegivenafinalpaycheck,includingpaymentforanyaccruedunusedvacationtime.Ifthebusinessemploys20ormoreemployees(fullorparttime),youmustmakeapointofnotifyingadepartingemployeeofhisorherrightsregardingcontinuationofhealthinsuranceundertheConsolidatedOmnibusBudgetReconciliationAct(COBRA).

Items to Be Retrieved From the EmployeeAttheterminationmeeting,besuretocollectallitemspreviouslyentrustedtotheemployeethatareusedorownedbythepractice,suchasofficekeys,laptopcomputers,files,records,orthelike.Alsomakesureyouhavebarredtheemployee’saccesstothepractice’selectronicsystemsandchangedordeletedanyrelevantbuildingentrycodes.Delayingsuchaccessdenialcanleadtoseriousproblemsthatcouldeasilyhavebeenprevented.y

Employee Termination Checklist

Resignationletter

Copiesofdisciplinaryreports

Officekeys,ifapplicable

Lockschanged,ifapplicable

Securitynotified

Computeraccessdeleted

Pagercollected,ifapplicable

Parkingcardcollected

Otherofficepropertycollected

Long-distancephonecards/access

Forwardingaddressandphonenumber

COBRAinformationprovided

Retirementplanpayoutinformationprovided

Finalpaycheckissued

Personnelfileexaminedforcompleteness

Personalbelongingscollected

Employeeescortedfromproperty

Exitinterviewperformed

-Best Practices24

Tools and Resources for Practice Success

By Sean Weiss and Jay Lechtman, DecisionHealth Professional Services

Everypracticeisdifferent,buteachrequiresthesamebasicresourcesinordertobesuccessful.Accesstotherighttoolshelpsensureyourpracticesubmitscompleteandaccurateclaimstoinsurancecarriersthefirsttime,whichdecreasesdaysinaccountsreceivable(AR)andcanincreasepracticeviability.Inanindustryoverloadedwithcoding,compliance,andpracticemanagementhow-toresources,howdoyouknowwhichresourcesmakesenseforyou?

Practicesshouldtakeadvantageofthewidearrayofcommercialpublicationsandotherpracticemanagementproductsonthemarkettoday.Whilemanyoftheresourceswewilldiscussinthischapterareavailablefreeofcharge,thesecanbecumbersometouse.Purchasingasuperiorproductwillimproveaccuracyandproductivity;becausetheseresourcesareofteneasiertouseandunderstand,theycanbemorevaluabletothepractice.Itisimportanttoconsiderthecostoftheseproductsandincludetheminyourannualbudget.

Considerthreethingsbeforeyoupurchasearesource: 1.Willithelpimproveaccuracy?

2.Willithelpyoubecomemoreefficientasabusiness?

3.Willithelpyouminimizecomplianceriskswhileimprovingyourbottomline?

CRITICAL CODING AND BILLING RESOURCESEverypracticemusthavethemostup-to-datecodingandbillingtoolstomakesureitcollectseverydollarowedwithoutclaimingnon-billableservices.Thesefivecorecontentsetsareconsideredcriticaltocodingandbillingsuccess. Thetypicalpracticepurchasesatleastthethreecodebooks—CPT,ICD-9-CM,andHCPCS—andveryoftenCCIandRBRVSguidesaswell.

Physicians’ Current Procedural Terminology (CPT)CPTcodesaredevelopedandmaintainedbytheAmericanMedicalAssociation(AMA).Theyare,inAMA’sownwords,“alistingofdescriptivetermsandidentifyingcodesforreportingmedicalservicesandprocedures.ThepurposeofCPTistoprovideauniformlanguagethataccuratelydescribesmedical,surgical,anddiagnosticservices,andtherebyservesasaneffectivemeansforreliablenationwidecommunicationamongphysiciansandotherhealthcareproviders,patients,andthirdparties”(www.ama-assn.org/ama/pub/category/3882.html).Andasyouknow,CPTcodesareusedtoreportprofessionalservicestopayors.

AMAupdatesCPTcodesannuallyanditiscriticalthatpracticeshaveaccesstothemostcurrentyearCPTforreportingmedicalservices.Eachyearcodesareaddedanddeleted,anditisimperativethatyourpracticeisreferencingtheCPTbookthatcorrespondswiththedateofservice.Additionally,itishelpfultoretainpastversionsofCPTintheeventyouneedtoappealaclaimfromprioryears.

2


International Classification of Disease, 9th Revision (ICD-9)ICD-9-CM(InternationalClassificationofDisease,9thRevision-ClinicalModification)providesinsurancecarrierswiththemedicalreasonapatientvisitedaphysicianorotherqualifiednon-physicianpractitioner.Thismanualisusedtohelpprovidersestablishmedicalnecessityforbilledservices.Themanualalsoallowsproviderstotellaninsurancecarrieraboutbothpastpersonalandfamilyexperienceswithdiseasesand/orhowapatientwasinjured.

AswithCPT,AMAupdatesICD-9codesannually,soitiscriticalthatyouareusingthemostcurrentversionforreportingmedicalservices.PracticesthatdonotstayontopofICD-9changesfrequentlyreceiveunnecessarydenialsorrequestsformedicalrecordsduetoinaccurateorincompletediagnosiscoding.Forexample,failuretocodetothemaximumspecificitywillmostcertainlygenerateadenialfromthepayor.

Healthcare Common Procedure Coding System (HCPCS)HealthcareCommonProcedureCodingSystemisMedicare’ssystemofNationalLevelIIcodesandincludesalistingofproducts,supplies,andservicesnotincludedintheCPTmanual.HCPCSalso“crosswalks”fromCPTprocedurecodestocodesrecognizedforpaymentbyMedicareandMedicaid(G-CodesandQ-Codes).

The Correct Coding Initiative (CCI)CorrectCodingInitiativeedits,developedbyandforMedicare,arealsoused,insomeform,bymanyinsurancecarriers.CCIeditsidentifywhichphysicianservicesarenotappropriatelybilledtogether—calledmutuallyexclusiveprocedures—andwhichshouldbebundledorincludedinamorecomprehensiveservice.ClaimsthatrunafoulofCCIeditsareautomaticallydeniedbyMedicare,unlesstheeditcanbeoverriddenwithamodifierorproperdocumentationtosupporttheexception.CCIeditsareupdatedquarterly.

CCIeditscanbelocatedontheCMSwebsitefreeofcharge.Therearealsosimplifieduser-friendlyversionsavailableforpurchasefromfor-profitentities.

The Resource-Based Relative Value Scales (RBRVS)Resource-BasedRelativeValueScalesisMedicare’sphysicianfeeschedule.ManyprivatepayorsusesomeformofRBRVStosettheirownfeesaswell.Forexample,somepayorsmaycontractwithphysiciansbasedonapercentageofMedicare’sRBRVSfeeschedule.Medicarealsoprovidesguidanceonhowtocorrectlyapplycertainmodifierstoservicesandindicateswhenanadditionalsupplycanbebilledwithaservice.

Medicaresetsnationalfeesforeachservice,andthatamountisadjustedbasedontheGeographicPracticeCostIndex(GPCI)foreachlocality.Inotherwords,Medicarepaymentisadjustedbasedonyourpractice’sgeographiclocation.ThisGPCI-adjustedfeeistheamountthataphysicianwillbepaidbyMedicareforanapprovedandcorrectlybilledservice.Simplyput,aphysicianwhoperformsaserviceinManhattan,Kansas,willbepaidlessthanaphysicianwhoperformsthesameserviceinManhattan,NewYork,becauseofdifferencesinthecostofpracticingineachlocation.

TheMedicarefeescheduleistypicallyupdatedannuallybutcanchangeatmidyear,orevenquarterly.UpdatedinformationisalwaysavailableviatheCentersforMedicare&MedicaidServices’orfiscalintermediaries’websites.

ADDITIONAL RESOURCESPractice ManagementAphysicianpractice,likeanybusiness,maybenefitfromoutsidemanagerialadvice.Numerousresourcesareavailabletohelpyourpracticerunmoreefficiently.Somecanhelpyoucreatemoreeffectiveformsandotherpracticedocuments;someofferguidanceonstrategicandbusinessplandevelopment;somehelpyousuccessfullynegotiatemanagedcareorprivatepayorcontracts;otherscanhelpyoudevelopeffectivepoliciesandprocedures.

ComplianceEverypracticeshouldhaveacomplianceprogramtosatisfystaterequirementsandfederalregulatoryrequirementsoftheOfficeofInspectorGeneral(OIG).Complianceinthiscasereferstocodingandbilling,documentationstandards,anti-kickback,antitrustandself-referrallaws,andafewotherareas.

Ifyou’renotprepared,complianceproblemscanbecostly,andasmallinvestmentingoodcomplianceresourcesupfrontcansaveyoufromfinancialandlegalwoesinthefuture.Therearemanyoff-the-shelfsolutionsforcreatingcomplianceprogramsandcorrectiveactionplans.Practicesthatneedmorecomplexplansorwantplanstailoredtotheiruniqueneedsoftenhireaconsultanttohelpthemdevelopaplan.

AdoptinganOIGcomplianceplanisvoluntary,butitshowsagoodfaithefforttocomplywithstandardssetbypublicandprivatepayors.AnOIGfraudandabusecomplianceplanhassixelements:

1.StandardsofConduct

2.TrainingandEducation

3.AppointmentofaComplianceOfficer

ToolsandResourcesforPracticeSuccess- 25

-Best Practices26

4.OpenLinesofCommunication

5.Monitoring

6.Enforcement

Othercomplianceareastoconsider:•OSHA(OccupationalSafetyandHealthAdministration)setsandenforcesstandardsforemployeeandpatientsafety.y

•HIPAA(HealthInsurancePortabilityandAccountabilityAct)setsstandardsfortransactionsbetweenprovidersandpayors,patientprivacy,andsecurityforelectronicdata.y

Resourcestohelpdevelopandmaintaineffectivecomplianceprogramsareonlypartofthesolution.Stayingup-to-dateonchangesinlawsandregulationsisequallyimportant.Printandelectronicnewssourcescanbehelpful,alertingyoutonewrulesandareasofenforcement.Theyalsooftencontaincompliancecasestudies,soyoucanlearnfromthemistakesofothers.

Part B Newsprovidesweeklynews,analysis,andguidanceoncriticalMedicarephysicianpaymentissues,makingitindispensibletopracticesthatcareaboutbothreimbursementandcompliance.Thispublicationcanbepurchasedatwww.decisionhealth.com/store.

Staff Development and CertificationWhenitcomestomaintainingreimbursementaswellascompliance,yourgreatestresourceisyourstaff.Professionalcertificationsandcredentialsandtheeducationandtrainingthatcomewiththemcanhelpensurethatyourstaffiscompetent,productive,andup-to-dateonthecomplexrulesandregulationsregardingreimbursementandcomplianceforyourpractice.

Toensureaccuratepaymentandminimizeyourexposuretocompliancerisks,staffshouldbeencouragedtotakethenecessarycoursestobecomecertifiedmedicalcodersorcertifiedinspecialty-specificcoding.Manyphysiciansarenowlistingcodingcertificationasaminimumrequirementfornewemployees.

Severalorganizationsoffercertificationprogramsforpracticestaffforafee:•TheMedicalGroupManagementAssociation(www.mgma.com)offerscertificationforphysicianofficemanagersthroughitsAmericanCollegeofMedicalPracticeExecutives(ACMPE).

•PracticeManagementInstitute(www.pmimd.com)isanotherorganizationthatofferscertificationformedicalofficemanagers,medicalcoders,andmedicalinsurancespecialists.

•DecisionHealthofferscertificationandeducationforspecialtypracticecodersthroughitsBoardofMedicalSpecialtyCoding(www.medicalspecialtycoding.com).

•TheAmericanAcademyofProceduralCoders(www.aapc.com)alsooffersavarietyofmedicalcodingcertificationexamsforphysicianpracticesandtheoutpatientfacilityenvironment,aswellasspecialtycertification.

FormoreinformationonOSHA,pleaseseeCMAONCALLDocument#1810,“Cal-OSHAComplianceandInspections.”

FormoreinformationonHIPAA,pleaseseeChapterVIandCMAONCALLDocument#1606,“HIPAAElectronicTransactionRule.”

State and Local Medical Association MembershipItisvitallyimportantforyoutobeamemberofyourstateandlocalmedicalassociations.Together,theymakesurephysicians’voicesareheardbystateandfederallawmakers,thefor-profithealthindustry,governmentregulators,andotherstryingtointerferewithyourabilitytocareforyourpatients.Yourstateandlocalmedicalassociationswillalwaystakeastandonissuesthatimpactthepracticeofmedicine.Theyarepartnersworkingeverydaytodevelopandmaintainaphysician-led,patient-centeredhealthsystem.Associationmembershipoftenprovidesvaluablediscountsonmanyoftheresourcesmentionedinthischapter.

Office Policies and Procedures ManualEverysizebusinessshouldhaveanofficepoliciesandproceduresmanual.Thehighstaffturnoverinmedicalpracticestodaymakesitmorecriticalthanevertohavethesehow-toresourcesatyourfingertips.Itensuresthatinstitutionalmemorystayswiththepracticeevenifyourofficemanagerorotherstaffchoosestoleave.Policiesandproceduresmanualsareusefulfortrainingnewstafforforcross-trainingpurposes.Belowisapartiallistofitemsthatshouldbeincludedinsuchamanual.

•Jobdescriptions(seeChapterIformoreonjobdescriptions)

•Employeeevaluationforms

•Financialpolicies

•Appointmentschedulingpolicies

•Triagepolicies

High-Speed Internet AccessMajorpayorsnowpostpaymentrulesandeligibilityandmedicalpoliciesonlineandalsoallowclaimssubmissionandappealsviatheirwebsites,whichisahugetime-saver.Physiciansmayberequiredtoregisterbeforegainingaccesstotheinformation.

Copies of All Third-Party ContractsPracticesfrequentlylosemoneybecausetheydonotunderstandthespecificsofpayorcontractlanguage.Tobesuccessfulinbillingandcollections,youneedaccesstocurrentinformationabouteachpayor’scontractrequirements,includingfeeschedulebycontractedproductline,paymentrules,authorizationrequirements,timeframesforclaimssubmission,andbillingproceduresforphysicianservices.

Form LettersBecausemedicalpracticesareoftenrequiredtorepeatedlyaddressthesameissues,formlettersminimizeredundancy,savetime,andpromoteconsistency.CMAandcountymedicalsocietiescanprovidemanysuchformatstomembersforfree.∆

Other Publications•Medicaldictionary

•Specialtyrelatedpublications

Formlettersarenotaneffectivemeansofaddressingmedicalnecessityappeals.

KEY CONTACTSSomeofyourmostimportantresourcescanbethoseyoudevelopinhouse,suchasalistofkeycontactsforeachpayor.Compilingahelpfulnetworkofcontactsrequireseffort.Asyouidentifytheseindividuals,alistshouldbecreatedandmadeavailableforofficeuse.Listingsforeachpayorshouldincludethesecontacts:

•Account-SpecificPayorRepresentative•CustomerServiceManager•ProviderRelationsManager•ContractsManager•ClaimsManager/Supervisor•MedicalDirector•ChiefMedicalOfficer

Whenstartingtodevelopyourcontactslist:•Reviewthelistofcontactsprovided bythepayor.

•Makeanoteofapayorrepresentativewhoiseffectiveinhelpingyougetaclaimpaidandtrytousethesamepersonforclaimsinthefuture.

•Askifthereisaspecificpayorrepresentativeassignedtohandleaccountissuesforyourpracticeandifso,whetherthatrepresentativehasauthoritytoresolveissues.

•Tohelpdevelopyourpayorcontactlist,refertothePayorProfilesontheCMAwebsite.(www.cmanet.org/member,under“reimbursementadvocacy”)

ToolsandResourcesforPracticeSuccess- 27

-Best Practices28

CONSULTANTS: A CURE FOR PRACTICE ILLS?Whenbooks,newsletters,conferences,andotherresourcesaren’tspecificenoughtoaddressanindividualpractice’sissues,physiciansoftenturntoconsultantsforhelp.

Aconsultantcanserveasthephysician’sphysician—diagnosingandcuringpracticeailments.Consultantsareindividualswithexpertiseincertainareaswhocanidentifyproblemsandproposesolutions.Agoodconsultantwillfixtheimmediateproblemsidentified.Agreatconsultantwillidentifyprocessimprovementsandtrainingopportunitiestomakesuretheproblemsaresolvedforgood.

Thebestconsultantshavepracticalexperience.They’ve“beenthereanddonethat.”Knowledgeoftheoryisimportant,butinordertoproperlyguideaclient,theconsultantreallyneedstohavewalkedinyourshoes.

Consultativeservicesaren’tcheap,buttheycanbeextremelybeneficialtoastrugglingpracticeandshouldbeconsideredaninvestmentinthefutureofthebusiness.Aswithanyinvestment,however,thepracticeshouldhaveagoodunderstandingofitsexpectationsandlong-termgoalsbeforecommittingprecioustimeandresources.

Youdon’tneedtobearocketscientisttoknowwhenthereareproblemswithinyourpractice.Completingyourownpracticeassessmentbeforehiringanoutsideconsultantisimportant.Someproblemswillbeveryapparent—forexample,decreasedcashflow,workflowbottlenecks,overcrowdedschedulesand/orlongpatientwaittimesleadingtodissatisfiedcustomersandultimatelylossofrevenue.Ifyouhaveidentifiedseriousissueswithinyourpracticeandbelieveyouneedoutsidehelp,weencourageyoutofirsteducateyourself.Beforeyouhireaconsultant:

•Seekassistancefromyourstate,county,andspecialtysocieties.Frequentlytheseorganizationshavedevelopedpracticemanagementtoolkits,complianceguides,andothervaluablepublicationsdesignedtoeducatephysiciansonmedicalofficebestpracticesandimprovingthebottomline.Note:Theseresourcesaregenerallymadeavailabletomembersatnocost,whilenonmembersshouldexpecttopay.

•Encourageyourofficemanageroradministratortojoinstateorlocalofficemanagergroupsorassociations.Participationinthesegroupsisarelativelyinexpensivewaytokeepcurrentonissuesandcanprovideopportunitiestoshareandlearnhowotherpracticesareaddressingchallengessimilartoyourown.

•Organizephysician-to-physicianmeetings.Practiceswillalsobenefitfromphysiciansmeetingwithandtalkingwiththeirpeersaboutpracticemanagementissues.

Ifyouhavedoneyourresearchandbelieveyourpracticeisreadyforaconsultant,werecommendfirstconductingyourownpracticeassessment.Identifyingthoseareasthatneedimprovementcansaveyoumoneybyprioritizingwhatyouwantandexpectfromaconsultant.Note:Formoreinformationonhowtoconductapracticeassessment,seeChapterIII.

Why Consider a Consultant?Aconsultantbringsanoutsideperspectivetotheday-to-dayoperationsofyourpracticeincriticalareasofopportunityandrisk:

•RevenueCycleManagement

•RegulatoryCompliance

•OperationalEfficiency

Specificallyintheseareas,apracticeconsultantcanprovideobjectiveanalysis,guidance,andeducationoneverythingfromcodingandbillingtomedical/legalissuestohowtoeffectivelyrespondtoanaudit.Customizedtrainingforyourspecialty,chartaudits,practicemanagementanalyses,practicestart-ups,mergersandacquisitions,exitstrategiesforphysicians,benefitpackagesforstaffandtax,andfinancialandstrategicplanningarejustafewoftheareaswhereapracticeconsultantmaybenefityourorganization.

How Do You Select a Consultant? Referralsarethebestwaytonarrowdownthechoiceofconsultants.Checkwithyourstate,county,orspecialtysocietyorotherprofessionalorganization.Oftentheseorganizationswillhavevettedreferralsourcesforyouandyoumaybeentitledtodiscountedrates.Interviewtheconsultantdirectlyaboutthefollowing:

•Inquireabouttheparticulararea(s)ofexpertise,style,personality,experience,fees,andavailabilitytoensurethisconsultantcanmeetyourneedsandwillmeshwellwithyourpractice.

•Askwhethertheconsultanthasworkedwithpracticesofyourspecialty,yoursize,yourstructure.Whatworksforfamilypracticemaynotworkforoncology.Similarly,whatworksforanoncologypracticemaynotworkforaprimarycarepractice.

•Asktheconsultantforreferenceswhocanprovideinformationrelevanttotheissuesyourpracticeisfacing.Makesureyoucontacteachofthereferences.Youcanassumeyou’llbecallingahappyclient,butthatdoesn’tmeanyoucan’taskaboutnegativefactorsaswellaspositive.Youcouldgleanusefulandtellinginformationbytakingthisextrastep.

Manyconsultantspromotethemselvesbasedontheirownprofessionalaccomplishments.Butthebestbasetheirsuccessontheaccomplishmentsoftheirclients.Iftheyexcelatwhattheydo,theycanrepresentthepracticeduringanaudit,identifyadministrativeinefficiencies,andultimatelyturnfailingpracticesintopositive-cash-flowbusinesses.

Belowarecommonservicesacomprehensivepracticeconsultantcanoffer:

•Strategicplanningandbudgetingtohelpmaintainviabilityofthepractice

•Trainingandeducation(coding,compliance,andpracticemanagementforstaffandproviders)

•Recommendationandimplementationofcomplianceinitiatives(OIG,HIPAA,OSHA,employmentlaw)

•Chartingreviews(findinglostrevenueandidentifyingpotentialoverpaymentsandliabilities)

•Improvingoperationalefficiency(includingfrontofficeproficiencyandstaffmorale)

•Representingapracticeduringanaudit(privateandgovernmentalpayors)

•Guidingapracticethroughmergersandacquisitions(expansionandaddingancillaryservicestoapractice)

•Addressingrevenuecycleconcerns(stoppingleaksinaccountsreceivable)

•Servingasinterimmanager/administrator/COO/CEO

•Guidingmedicalpracticestart-ups(providersgoingoutontheirownafteryearsinagrouppracticeornewphysicianssettingupapracticerightoutofschool)

•EHRimplementation(selectingasystemthatisrightforyourpracticeandnegotiatingthebestprice)

•Negotiatingmanagedcareandprivatepayorcontracts

•Structuringjointventures(hospitalandphysicianrelationships)

•Regulatoryguidance(Stark,Anti-Kickback,FalseClaimsAct)

•Exitplanning(helpingphysicianspreparetoretireorleaveapractice)

Beware of Unscrupulous ConsultantsInJuneof2001,theOfficeofInspectorGeneral(OIG)issuedaspecialadvisorybulletinaboutthepracticesofbusinessconsultants3.Thebulletinpointedoutthatmostconsultantsarehonest,butphysiciansshouldbeonthealertagainstsomequestionablebusinesspractices:

•Illegalormisleadingrepresentationsthattheconsultantissomehowaffiliatedwith,orcertifiedorrecommendedby,theCentersforMedicare&MedicaidServices,orthatheorshehas“inside”information

•Promisesorguaranteesofspecificresultsthatareimprobableorunreasonabletoexpect

•Encouragingabusivebillingpractices

•Discouragingcomplianceefforts

CHOOSING A CONSULTANTSamplequestionsyoumaywanttoask:•Werethereanyproblemswiththeconsultant’swork,and,ifso,whatdidtheconsultantdotocorrectit?

•Whatdoyouthinktheconsultantcouldhavedonebetterordifferentlyforyourpractice?

•Whatdoyouthinkareareasofweaknessfortheconsultant?

•Howlongdidittakefortheconsultanttoscheduletheengagement,tocompleteit,andtodeliverthefindings?Wasthiswithinyourexpectedorpromisedtimeframe?

•Didtheconsultantrespondtovoicemailore-mailinatimelyfashion?

•Canyoupointtospecific,measurablebenefitsfromtheconsultant’swork?

3OfficeofInspectorGeneralSpecialAdvisoryBulletin,PracticesofBusinessConsultants,June2001-http://www.oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf ToolsandResourcesforPracticeSuccess- 29

-Best Practices30

Thedecisiontohireaconsultantisanimportantonethatrequiresresearch,thought,andscrutiny.Ifyou’vedecidedyourpracticecanbenefitfromconsultingservices,getreferralsfromotherpractices,performathoroughinterview,andconductacompletereferencecheck.Failuretodothislegworkcanresultinwastedstafftimeandmoney.

Ingeneral,becautiousofadvicethatseemstoogoodtobetrue.Physiciansmustalsorememberthathiringaconsultantdoesnotrelieveapracticeofitsresponsibilitytocomplywithfederalandstatelaws.Ultimately,thephysicianisresponsibleforallcodingandbillinginthepractice.

Also,whileconsultantscanofferagreatdealofvaluableadvice,ifthepracticeisnotcommittedtofollowingthroughonsuchrecommendedchanges,you’renotapttoseemanypositiveresults.

Thetoolsdiscussedherearejustafewoftheimportantbasicseverypracticeneedstopromotesuccess—helpfulresourcesyouandyourstaffcantakeoutofthetoolboxagainandagain.Othertoolsareavailableformorespecifictasks.Weencourageyoutoinvestigateandexploretomakesurethatyouhavethetoolyouneedforeveryjob,thatitistherighttoolforyou,andthatitisaqualitytoolthatwilllastandserveyouwell.

-Best Practices32

Time Management and Administrative Simplification: Running Your Practice Efficiently and Effectively!

By Mary Jean Sage, Sage & Associates

Medicalpracticesarestrugglingtosurviveinanindustrybesetbyconstantchangeanddecliningoperatingmargins.WithMedicarephysicianreimbursementprojectedtodecrease30percentoverthenextseveralyearsandmajorhealthplansunwillingtonegotiatecontractratesthatcoverthecostofcare,everypracticemustbeperformingbothefficientlyandeffectivelytoensurefinancialviabilityandqualitycareforpatients.Efficiency—accomplishinggoalswithoutwasteorloss—lowerscostsandincreasesyourreturnperunit.Effectiveness—producingdesiredresults—increasesqualityoutcomesandpatientsatisfaction.Whenapracticeisrunningefficientlyandeffectively,thephysicianisfreetofocusonseeingpatientsratherthandealingwithadministrativehassles.

AccordingtoOwenDahl,authorofThink Business! Medical Practice Quality, Efficiency, Profits,efficiencyforamedicalpracticehingesonthegoalofprovidingvaluetoapatientineverysingleencounter—beitface-to-facetimewiththephysicianoraphonecalltoscheduleanappointment,getaprescriptionrefill,oraskaboutlabresults.

Intoday’senvironment,itiscriticaltocontrolyourcosts.Inreviewingeachserviceyourpracticeprovides,youmustconsiderthesequestions:Doestheservicebringvaluetomypractice?Aremycustomerspleasedwiththisservice?Howmuchdoesthisservicecost?Howcanthisservicebeprovidedmoreefficientlytoreducecostsandincreasequalityofcare?

Thepracticemustprovidethisvalueinacost-effectivewayoryouwillnotbeabletostayinbusiness.Therefore,it’scrucialtoreviewhowday-to-dayworkisperformedandfigureouthowtooptimizeresults.Generally,completingin-housetaskscaninvolvemultiplestaffmembersandmyriadsteps,soyou’llneedtolookateachprocessfromstarttofinish.Askquestions.Often,certainstepshavebeenintegratedintoaprocessandpassedalongasgospelwithnoonehavinganyideawhy.Whenasked,aworkermaysay,“We’vealwaysdoneitthatway.”Makesurestaffknowsandunderstandswhyeachcomponentofataskisnecessary.Thisisalsotheperfecttimetowritedowntheparticularsofeachprocessandcreateorupdateaproceduresmanual.

Inthischapter,wewillfocusonidentifyingerrors,delays,bottlenecks,andinefficienciesthroughpracticeassessment.Wewilldiscusshowtheseerrorsandinefficienciescontributetoreimbursementproblemsandlossofproductivityandgivepointersandtoolsforstandardizingprocessesandimprovingcustomersatisfactionandofficeflow.

LOOKING AT YOUR PRACTICEThefirststepinimprovingefficiencyandeffectivenessisidentifyingwhereyourpracticeissucceedingandwherethereisroomforimprovement.Thereisnobetterwaytodeterminethatthantoperformaself-assessmentofthepractice.Duringyourassessment,youwillwanttocoverthefollowing:

3


•Definingroles

•Front-endprocessing

-Accuracyofinformationcollected

-Appointmentscheduling

-Check-in

-Failuretocollect

-Patientwaittimes

-Check-out

•Latearrivalsandno-shows

•Managingcallvolume

•Operationalandpatientflow

-UtilizingtheInternet

-Clinicalservices/procedures

-Billingsystems

-Othersystemsasappropriate

•Patientsatisfaction(formoreonpatientsatisfaction, pleaseseeChapterIV)

-Surveys

-Results

-Goals

•Avoidingcommontrapsandpitfalls

THE ASSESSMENTConductinganassessmentofyourpracticedoesnothavetobecomplicated.Focusononeprocessatatime(includinginterrelatedwork)andassesseachaspectfromstarttofinish.Generallythisentailsthesebasicsteps:

1.Collectallexistingwrittendocumentationabouttheprocess.

2.Informstaffofyourgoalsandconductaninterviewwitheachstaffpersondirectlyinvolvedintheprocess.

3.Observeprocessesastheyareperformedinrealtime.

4.Participateinorperformthetaskyourself.

5.Developrecommendations.

Belowwe’veprovidedasampleroadmapforconductinganassessmentoftwoessentialprocedures:patientregistrationandcheck-in.Whileitcouldbefollowedjustaswrittenbymostpracticesyouwillgainfarmoreknowledgeandunderstanding

ofyourofficeworkingsbycreatingyourownguidelines,usingthefivestepsoutlinedabove.

Partofthisassessmentwillrequireyoutopretendyouareapatientundergoingregistrationandcheck-in.Thisisanimportantopportunityforyoutoexperiencewhatitisliketobeapatientinyourpractice.Viewingthingsfromadifferentperspectivecanbeveryusefulasyouworktoimprovetheefficiencyofyourpractice. Beforeyoubegin,informstaffaboutyourgoalandinstructthemtoactinthenormalfashion.Makesuretheyunderstandyouareassessingprocessesandnotanyone’sindividualperformance.Writedowneachofthestepssoyouhavearoadmaptofollowaftertheassessmentiscomplete.

Step I–Locate DocumentationFindandreviewanydocumentationyouhaveforcheck-inandregistrationprocedures.Makealistofallformsandpaperworkandkeepitallinafileforeasyaccess.Yourlistshouldinclude:

•Jobdescriptions

•Registrationforms

•Paymentrules

•Pre-authorizationrequirements

•Authorizationprocess

•Otherclinicrules

Step II–Interview StaffAfteryouhavereviewedtheabovedocumentation,youcanbegininterviewingeachstaffmemberdirectlyinvolvedinpatientregistrationandcheck-in.Askstafftowalkyouthrougheachphaseoftheprocess.Detailsareimportant!Afteryouhavecompletedtheinterviews,giveemployeestheopportunitytocommentorsuggestimprovements.

Takedetailednotes.Informationandfeedbackfromtheseinterviewsservesseveralimportantpurposes:

•Testingstaffjobknowledge

•Identifyingbottlenecksandotherinefficiencies

•Creatingneworupdatedjobdescriptions

•Creatinganeworupdatedproceduresmanual

•Creatingneworupdatededucationandtrainingtools

•Creatingorupdatingpatientsurveyquestions

•Encouragingstaffcommentandrecommendations

TimeManagementandAdministrativeSimplification:RunningYourPracticeEfficientlyandEffectively!- 33

-Best Practices34

Step III–ObservationNext,watchstaffastheyconductpatientregistrationandcheck-in.Observetheseprocessestwiceaweekforseveralweeksduringpeakclinichours.Whilethisprocessisnormallythepurviewoftheofficemanageroradministrator,thephysiciancanandshouldbeinvolvedinhowitisperformed.

Listen,watchcarefully,anddocumentanybottlenecks,inconsistencies,orotherissues.Remember,youneedtopayattentiontothetimeeachtasktakestocomplete.Trynottodistractordisruptwhatwouldbethenormalroutine.Askquestionswhennecessaryortoclarifysomethingyoumayhavemissed.Thisisnotthetimetomakesuggestionsorchangecurrentprocesses;waituntilitistimeforyourfinalassessmentinStepV.

Step IV–ParticipationItisimportantthatyouareabletoperformthetasksassociatedwithregistrationandcheck-inbyfollowingthedocumentationyouhaveonhand.

Youshouldalsotakepartintheprocessasifyouareanewpatient.Youremployeesshouldexperiencetheprocessfromthatvantagepointtoo.Havedifferentstaffmembersengageinthisrole-playduringpeakbusinesshoursseveraltimesoverthecourseofonemonth.Eachstaffershouldsitinthewaitingroomandcompletealltheformspatientsarerequiredtocomplete.Takenoteofanyquestionsontheformsthatarenotnecessary.

•Honestlyassessyourwaitingroomforthefollowing:

-Comfort

-Cleanliness

-Readingmaterials

-Seating

-Water

-Restroomavailability

-Lighting

-Medical/educationalliterature/pamphlets

•Observeotherpeopleinthewaitingroomandnoteanyrelevantremarksoverheard.

•Completetheformsasanynewpatientwould.

-Notethetimeittakesfromthemomentyouarriveatthereceptionistwindowuntilyousitdowntobegincompletingforms.

-Completetheformsasthoughyouareatyourownphysician’soffice.

-Documentthetotaltimeittakesyoutocompletetheforms.

-Onceyou’vereturnedtheformstothereceptionist,notetheamountoftimeittakesthereceptionisttoentertheinformationfromtheformsintothepracticemanagementsystemandreadyyourchartforrooming.

-Now,notetheamountoftimeittakesfortobeescortedtoanexamroom.

Step V–Create Recommendations and Implement ChangeOnceyou’vecompletedtheprevioussteps,deficiencieswillhavebecomeveryapparent.Nowitistimetodosomethingwiththeresults.Makesureeachtaskorserviceyou’veobservedisnecessary,bringsvaluetoyourpractice,andisperformedwellinacosteffectivemanner.Asafinalstep,tocompleteyourassessment:

•Analyzebackgroundgathered.

•Reviewnotestakenduringtheinterview,observation,andparticipationphases.

•Outlineyourrecommendations.

•Determinethecostofanychanges.Willitbecost-effectiveandaddvaluetomaketherecommendedchanges?

•Meetwithstafftodiscussandfine-tunerecommendations.

•Formalizeandimplementrecommendations.

•Monitorprogress.

•Creategoal-orientedincentives.Forexample,ifyouarehavingproblemswithyourscheduling(schedulesaren’tfull,youarefrequentlydoublebooked,etc.),offeringanincentivetocorrecttheseissuescanbemuchmoremotivatingthancorrectiveaction.

Acknowledgeareaswherethepracticeisperformingwell.Thereisnosurerwaytomotivateyourstaffthantopraisethemwhenajobiswelldone.

Ontheflipside,alsopointupareaswherethereisroomforimprovementandprocessesthatneedtobereorganizedorrestructured.Youwillneedtodevelopplanstobringtheseareasintocompliancewithyourgoalsforthepractice,itsoperation,itsquality,anditsprofitability.Yourgoalshouldbetolookattheentirepracticewithinasix-monthperiod.

Somepractices,ratherthanconductthisassessmentallbythemselves,willaskamedicalpracticemanagementconsultanttoperformitorofferguidance.Yourstatemedicalassociation,localmedicalassociation,orprofessionalsocietymaybeabletoreferyoutopracticeconsultantsinyourarea(seeChapterII).TheMedicalGroupManagementAssociation(MGMA,www.mgma.org)andNationalSociety

ofCertifiedHealthcareBusinessConsultants(NSCHBC,www.smdmc.org)canalsodirectyoutosuchadvice.

Asyouformulaterecommendationsforchange,rememberthatwhileyoucancutcostsbyreducingemployeetime,it’snottimetostarthandingoutpinkslips.Beingoverstaffedisobviouslyafinancialdrain,butbeforemakingchangesyouneedtomakesureallemployeedepartmentsarefunctioningastheyshould.Whileyoumaybeoverstaffedinonearea,youmaybeunderstaffedinothers;forexample,youmayfindthatoneofyourfrontofficeworkershastimeonherhands,butyourbillingandcollectionstaffisclearlyshorthanded,judgingfromthevolumeofaccountsover90days.Inthisinstanceyoumaywanttoconsidershiftingsomeofyourresourcesfromthefrontofficetotheback.

IDENTIFYING AND ELIMINATING VARIANCESVarianceinthewaytasksareperformedcancontributesignificantlytobreakdownsinprocesses,whichcancreatepracticeinefficiencies.Therestofthischapterfocusesonrecommendationsthatwillhelpeliminatethesevariances,increasepracticeproductivity,andreducerework.

Defining RolesManyproblemsinphysicianpracticescanbetracedbacktoalackofwrittenjobdescriptions,policies,andprocedures.Compoundingtheseproblemsarehighstaffturnover,inadequatetraining,andlackofcommunication.Failuretomaintainemployeejobdescriptionsandpoliciesandproceduresmanualsseverelylimitsabusiness’sabilitytoachieveoptimalefficiency.

Successfulbusinessesmaintainmanualsthatclearlydefineemployeerolesandprovidestep-by-stepinstructionsonhowtocompletetasks.Suchmanualsandinstructionswillallowyoutoquicklyidentifysystembreakdowns,measurequalityofworkandproductivity,evaluatestaffinglevels,holdemployeesaccountable,andpreventunnecessaryworkandotherredundanciesthatincreasethecostofdoingbusiness.Well-thought-out,documentedprocessescontributesignificantlytoasmoothoperation.Formoreinformationontheimportanceofapoliciesandproceduresmanual,pleaseseeChapterI.Ω

Front-End Processing

Accuracy of information Errorsandomissionsindatafieldsontheclaimform—suchasincorrectpatientdatesofbirth,insuranceaddresses,insuranceidentificationnumbers,andpatientaddresses—frequentlygeneratedenialsorrequestsforadditionalinformation.Bothcreateduplicativeworkanddelayreimbursement.

Toreduceinaccurateclaims,patientinsuranceinformationshouldbeverifiedatthetimeofschedulingandre-verifiedatcheck-in.Thereceptionistorschedulershouldalwaysobtainacopyofthefrontandbackofthepatient’sinsurancecard,whichletsyourofficeverifyeligibilityandbenefitsbeforethevisitandrecheckitbeforethepatientisseenandtheclaimsubmitted.It’salsousefultoprintoutthepatient’sdemographicandinsuranceinformationatcheck-in,havethepatientconfirmtheinformationwithhisorherinitials,andfilethatdocumentwiththechart.

AsamplejobdescriptionisavailableintheAppendix.


-Best Practices36

Somepracticemanagementsystemswillflagdiagnosiscodesnotcodedtothemaximumspecificityandmodifierissues.Ifyoursystemdoesnotincludethisfunctionality,havestaffspot-checkclaimsforaccuracybeforetheygooutthedoor.Whilethisisanadditionalstep,thegoalistotouchaclaimonce.Wheninaccurateinformationissubmitted,itcoststhepracticemoney:Typicallyyoureceiveeitheradenialorrequestformoreinformation,whichrequiresatleastthreetimesthestafftimeasitwilltospot-checktheclaiminthefirstplace.Beyondstafftime,there’sthecostofmaterialsusedtoresendorappealaclaim,andofcourse,delaysinpaymentitselfarecostly.AccordingtotheAdvisoryBoardCompany,aWashington-basedresearchorganization,anestimated90percentofclaimdenialsarepreventableand67percentofdenialsarerecoverable.Alladditionalstafftimerequiredtoaddresstheseissuestakesawayfrompatientcare.

Appointment Scheduling and Check-InEveryonefeelstheimpactofanimproperlymanagedappointmentschedule—physicians,staff,andpatients.Ifemployeesschedulingappointmentsarenotproperlytrainedinhowtotriagepatientsandallottheappropriateamountoftime,eitheryourschedulewillhavegapsor,moreoften,thephysicianwillrunbehind,whichfrustratespatients.Beforetacklingaschedulingproblem,takethetimetolookbackatpastschedulestorecognizewhatisn’tworkingandconsiderwhatmightbeabetterapproach.Thenmakeacommitmenttoinstitutechanges.

Beginbylookingatafewweeksofyourscheduletoassesstrends.Lookfor:

•Production

-Numberofpatientsseeneachday

-Averagenumberofpatientsseeneachday

-Newpatients

-Returning/establishedpatients

•Numberofdouble-bookedappointments

•Numberofpatients“squeezedin”

•Numberofno-shows

•Numberofrescheduledappointments

Next,spendafewdaysgatheringdataontheamountoftimespentwitheachpatient.Thisisbestdonewithatimeflowstudy.

Attheendofeachday,staffshouldcalculatethewaittimebetweeneachstepintheprocess.Aftercompletionofthetimestudyassessment,determinetheaveragewaittimeforeachstep.YoumayalsowanttoconsideraskingyourpatientstocompletesimilartimestudiesΩ

Thenextstepistoanalyzethedataandorganizeitintoareportthatidentifiesareaswhereyourpracticeisdoingwellandareaswhereyourpracticeneedsimprovement.Forexample,youmayfindthatyourphysicianisoftenrunningbehindbecausetheschedulerisroutinelydoublebooking,squeezingpatientsin,ornotschedulingtheappropriateamountoftimeforvisits.Inthesecases,yourpracticeshouldconsiderwrittenprotocolsforyourschedulerthatclearlydefineconditionsthatrequire

AsampletimestudyassessmentformisavailableintheAppendix.

immediateattentionandshouldbefitintothescheduleversusthosethatcanbeseenwithinafewdays.Exceptionsshouldonlybemadebythephysician.

Anotherpossibilityisthatyourpracticeconstantlyrunsbehindbecausethephysicianisspendingmoretimewithpatientsthanisactuallyscheduled.Practicescanavoidthistypeofproblembycreatingwrittenprotocolsthatclarifyhowtotriageapatient,includingwhattypesofquestionstoask,aswellastheappropriateamountoftimetobescheduleddependingonthepatient’sconditionorreasonforbeingseen.Forexample,pre-andpost-opappointmentsmayonlyrequire10or15minuteswiththephysician,whereasannualphysicalexamsmayrequire60minutesandnewpatientvisitsmayrequire30minutes.Iftheschedulerisnotaskingtherightquestionstodeterminetheappropriateamountoftimetoallot,thephysicianwillbeunabletostayonschedule.

Creatingtherightscheduleforeachpracticerequiresanunderstandingofwhyithasn’tbeenachievedpreviously,predictingschedulingneeds,andunderstandinghowthephysicianworksandwhatactionswillpromoteamoreefficientworkday.

Failure to collectCollectingco-pays,coinsurance,deductibles,andpastduebalancesfromthepatientatthetimeofserviceisoftenoneofthemostoverlookedtasksinaphysicianpractice.Becausethemajorityofpaymentscomefrommanagedcareplans,it’seasytoforgetthatchargespaiddirectlybypatientsareanimportantsourceofrevenue,andnotcollectingtheseupfrontcanhavesignificantimpact.Infact,co-payscanrepresentasmuchas20percentofaphysician’sincome.

Beyondimpactsontheimmediaterevenuestream,billingafterthefactrunsupexpensesaswell.Studieshaveshownitcancostapracticeatleast$5to$7togenerateastatement.Soifapracticefailstocollectaco-payandlaterbillsforit,the$20dueturnsintoonly$13to$15.Multiplythatbythenumberofpatientsyouseeinadayanditquicklyaddsup.AndaccordingtoaU.S.DepartmentofCommercestudy,abilitytocollectdropsto74percentat90daysandto30percentat180daysforpaymentsnotcollectedatthetimeofservice.

Accordingly,considerimplementinganofficepolicyrequiringthatco-pays,coinsurance,deductibles,andunpaidbalancesbepaidatthetimeofservice.Clearlycommunicatethisruletopatientsbeforetheirvisitandinyourfinancialpolicydocuments,whichpatientsshouldsignannually.Inevitably,ahandfulofpatientswillshowupwithoutthecash,checkbook,orcreditcardtomaketheco-pay.BepreparedbylocatingthenearestATM,andeitherdirectthepatientthereoroffertoreschedulethevisitforadaywhenthepatientcanarrivewiththeproperpayment.Ifyouremainfirmonthispolicy,itisunlikelythatpatientswillforgetthenexttimearound.∆

Check-OutAfterexamination,physiciansfrequentlyrequestthatpatientsschedulefollow-up,pre-op,orpost-opvisitsforlaterdates.Failuretoscheduletheseappointmentsatcheck-outcanimpactpatientcareandcreateadditionalworkdowntheroadintheformofscheduling-relatedphonecalls.

Dependingonthepatient’stypeofinsurance,coverage,andservicesperformed,additionalmoneymaybedueatcheck-out.

BALANCE BILLINGCaliforniaphysiciansshouldbeawarethatonJanuary8,2009,theCaliforniaSupremeCourtputanendtothecontroversysurrounding“balancebilling”ofHMOenrolleesintheemergencycarecontext-thepracticebyout-of-networkproviderstobillpatientsthebalanceofanemergencycarebillthatthepatients’Knox-Keeneplanrefusedtopay.The Court in Prospect Medical Group v. Northridge Emergency Medical Group,__Cal.Rptr.3d__,2009WL36855(2009)(Prospect),ruledthattheKnox-KeeneActprohibitsthispracticeofbalancebilling.Thecourtclarifiedthatprovidersmayonlyseekrecourseagainstthepayors,notpatients,forunderpayments.TheDepartmentofManagedHealthCaretoohastakenactiontoprohibitnoncontractedprovidersfrombalancebillingforemergencycareservices,promulgatingaregulation,28C.C.R.sec.1300.71.39,thatdefinessuchpracticestobean“unfairbillingpattern.”TheProspectdecisionandtheDMHC’sregulationmakeitclearthatbalancebillingforemergencycareservicesisnolongerpermittedifthepatientiscoveredbyaKnoxKeene-regulatedplan(HMOs,certainPPOs,andanydelegatedmedicalgroupsorriskbearingorganizations).FormoreinformationabouttheProspectdecisionanditsimplications,seeCMA’sBalanceBillingToolkitatwww.cmanet.org.

Practicesshouldexercisecautionwhenitcomestoturningpatientsawayforfailuretopaybalancesdueatthetimeofservice.Patientswhoseconditionisurgentshouldbeseenregardless.


-Best Practices38

Toavoidthesetime-consumingandcostlypitfalls,itisbestpracticetohaveastaffmemberavailableuponpatientcheck-outtoconfirmwiththepatientwhetheranyadditionalappointmentsneedtobescheduledandtocollectanyadditionalpaymentduebeforethepatientleavestheoffice.

Late Arrivals and No-ShowsLatearrivalscreateabacklogforthereceptionistanddelaythephysician,whichcauseslongerwaitsforotherpatients.No-showscanleavegapsintheschedule,reducepracticerevenue,andcontributetotimelyaccessissuesforpatients.

Toavoidthesedisruptionsinyourscheduleandrevenueflowandprovidebetteraccessforyourpatients,itisagoodideatosetsomestafftimeasideeachdaytocallpatientstoremindthemoftheirappointments.Alternatively,anautomatedappointmentconfirmationandreminderservicecanhelpreducemissedappointmentsorlatearrivalsandrelievestaffofthetaskofmanuallycallingpatients.Ofcourse,automatedservicescostmoney,sorunacost-benefitanalysistoseewhichoptionisrightforyourpractice.

Duringthemanualorautomatedconfirmationcall,patientsshouldberemindedtobringtheirinsurancecard,patienthistory,andanyotherneededinformationforthevisit.Ifyourpracticerequiresthataco-payordeductiblebepaidattimeofservice,includethatreminderaswell.Clearlystatingyourpractice’spoliciesonlatearrivalsorno-showsisagoodidea,too.Forexample,yourofficemayrequirepatientsmorethantenminuteslatetoreschedule,orspecifythatthephysicianmaydischargeapatientfromthepracticeifheorsheisafrequentno-show.

Beforedischargingapatient,beawareofstateandfederallawsregardingpatientabandonment.y Managing call volumeFormanymedicaloffices,thevolumeofphonecallsreceiveddailyisoverwhelming.Oftenthefrontdeskisswampedwithincomingcalls,causingfrustrationandpatientdissatisfaction.Whencallvolumeisheavy,inadequatephonesystemsmayresultindroppedcallsorpatientsmayhangupduetolongwaits.Duringpeakperiodspatientcallsmaynotbereturnedpromptlyandpatientsarrivingforappointmentsmayhavetowaittocheckinbecausefrontdeskstaffarestuckonthephone.Somepracticeshaverespondedbyinvestinginexpensivephonetreesolutions,butfrequentlytheseonlyannoypatientsratherthansolvethevolumeissue.

Phonesthatringoffofthehookcausedisruptionsandcontributetostafferrors.However,phonelinesarestillthemostcommonformofcommunicationinapractice,sounderstandingwhatmakesyourphoneringisextremelyimportanttoyourpractice’ssuccess.

Ourphysicianpracticevolunteersdecidedtoexaminewhatmadetheirphonesring.Fortwoweekstheycollectedinformationaboutthenatureofincomingcalls(seesampletrackingsheetinAppendix).Callstoscheduleappointmentscomprisedlessthanhalftheload;othercallswereappointmentcancellations,rescheduling,inquiriesaboutlabresults,requestsforprescriptionrefills,callsfrompharmacieswithformularyconflicts,requestsfordirections,questionsaboutofficepolicies,andinsurancequestions.Somewerefromrepeatcallerswhoweresimplyfrustratedthattheyhadnotyetheardbackfromthephysicianorfromthestaffregardingthestatusoftheirprescription,authorization,orreferral.

Formoreguidanceonterminatingthephysician-patientrelationship,seeCMAONCALLDocument#0805,“TerminationofthePhysician-PatientRelationship.”Moreinformationaboutpatientdischargeistypicallyavailablethroughyourmalpracticecarrier.

Onepracticedetermineditwasspendingmorethan$20,000perphysicianperyeartryingtomanagecallsthatcouldhavebeenavoided.Institutingbetterprocessesandminimizingtheneedforpatientstocallimprovedpatientsatisfactionandreducedcosts.

Toreduceunnecessarycallvolume,youwillneedtosystematicallyevaluatethereasonforthecallsandcreateaplanforchange.Belowisalistofcalltypesandrecommendationsthatcanhelpyoumanagethecallvolumeinyourpractice:

Call Type RecommendationCancelingorreschedulinganappointment •Implementanappointmentremindersystem(manualorautomated)tocontactpatients1to2dayspriorto

scheduledvisit.Necessaryreschedulingcanbehandledatthesametime.

•Havepatientsfilloutanappointmentremindercardatcheck-outandmailittothem1weekinadvance.

•Developafirmpolicyonno-showsandclearlycommunicateittoyourpatients.

Directionstotheoffice •Ifmakingmanualappointmentremindercalls,confirmthepatientknowswhereyouarelocated.Ifnot,providegeneraldirections.

•Ifusinganautomatedappointmentreminderservice,themessagetopatientsshouldincludethegenerallocationofyouroffice,includingcrossstreets.

•Postthisinformationonyourwebsite(ifapplicable).

•Includegeneraldirectionsinyournewpatientorientationpackageandsendtopatientsbeforetheirscheduledvisits.

Officepolicies •Mailnewpatientsafullorientationpackageaheadoftheirscheduledvisits.Includeinformationonyourofficepolicies.

Clinicalquestions •Establishclearboundariesaroundclinicalquestions,suchaswhenitisappropriateforofficestaffvs.aphysiciantoanswerapatientquery.

-Callsrequiringphysicianattentionshouldberouteddirectlytophysicianalongwiththepatient’schart,whichisplacedinapre-designatedspot.

•Establishcallbackhours,publishtheminnew-patientinformationmaterials,andremindpatientsofthesewhentheycall.

•Followthroughonacommitmentmadetocontactapatient,evenifyoudon’thavetheneededinformationortestresultsyet.

•Considerimplementingasecuresystemviayourpractice’swebsitethatallowspatientstosendmessagestotheirphysicianandtorequestappointments,referrals,andprescriptions.Thisisaflexibilitywayforpatientstorelayamedicalquestionat10p.m.andforphysicianstorespondwhensuitableorconvenient.


-Best Practices40

Call Type RecommendationInquiriesaboutlab/testresults •Developaninternalprocessforhandlinglab/testresultsandapolicyonhowresultsarecommunicatedto

thepatient:

• Internal process:

-Resultsthatcomeinviamailorfaxareplacedinfolder.

-Chartsarepulled,resultsareattached,andchartisplacedinadesignatedspotforphysicianorpractitionerreview.

-Reviewersignsoffontheresultandindicatestheappropriateaction(physiciancall,MAcall,practitionercall,e-mailtopatient,scheduleanappointment,etc.).

• Make sure patients are aware:

-Howlongitwillgenerallytaketoreceiveresults

-Howtheywillbenotified

-Whowillnotifythem

-Whentheyshouldcheckbackwiththepractice(iftheyhaven’theardafterxnumberofdays,haveadditionalcomplications,havequestions,etc.)

-Note:Itisimportanttofollowthroughonacommitmentmadetocontactapatient,evenifyoudon’thavetheneededinformationortestresultsyet.

Requestsforprescriptionrefills • Calls from patients: Ifyourpracticeusesanautomatedphonesystem,considerincludingamessagethatencouragespatientstocontacttheirpharmacyforprescriptionrefillrequests.

• Calls from pharmacies: -Setasideacertaintimeofdaytoreviewroutinerefillrequestsreceivedbyfaxorphone(e.g.,duringlunch

hourand/orafter5p.m.).Urgentrequestsshouldbehandledbasedonpatientneeds.

-Chartshouldbelocated,messageorfaxattached,andthechartplacedindesignatedspotforphysicianreview.

-Pharmacyiscontactedviaphone/fax.

-Patientshouldbecontactedviaphone/e-mailtoadvisethemofthestatusoftheirprescription.

•Provideinformationabouttheprescriptionrefillprocessviayourwebsite(ifapplicable).

•Includethisinformationintheorientationpackagesmailedtonewpatients.

•Postthisinformationinyourwaitingroom.

Authorizationsandreferrals •Explaintheprocessforobtaininganauthorizationorreferraltothepatient:

-Howlongwillittake

-Howandwhenwillthepatientbenotified

-Whenthepatientshouldcheckbackandwithwhichpractice(iftheyhaven’theardafterx numberofdays,etc.).

-Note:Itisimportanttofollowthroughonacommitmentmadetocontactapatient,evenifyouhaven’tyetobtainedtheauthorization/referral.

Formularyconflicts/pharmacyquestions •Physiciansandtheirofficestaffhaveaccesstoformularyreferencesoftware,suchasEpocratesRx(www.epocrates.com),freeofcharge.Thesetypesofproductsprovidephysicianswithaccesstotheformulariesofmostmajorpayors.Verifyingwhetherthemedicationyourpracticeisabouttoprescribeisinthepatient’sformularyorrequiresanauthorizationcandrasticallydecreasepharmacycallbacks.

•Consideradedicatedfaxlinetoreceiveallpharmacyinquiries/requests.

Repeatcallers •Clearlycommunicatingwhencallswillbereturnedcandecreasethenumberofrepeatcallers—forexample,“callswillbereturnedwithinonebusinessday.”Handleurgentrequestsasneeded.

Nowitistimetoidentifywhatmakesyourpractice’sphonering.Werecommendusingthecallvolumetrackingsheetforonetotwoweeks.Anystaffmemberresponsibleforansweringthephoneshouldusethisformtotrackcallsbyfrequency,timeofday,andissue..Noteanyadditionalissuesinthespaceprovidedonyourworksheet.Useonesheetperstaffpersonperday.Totalupthenumberofcallsperdayforaone-weekperiod.Attheendoftheweek,chartoutthecallvolumeforeachtopic.Identifythetopfiveissuesanddetermineifissuesdifferbasedondayoftheweek.Ω

Youmayalsowanttoconsidersolicitingfeedbackfromyourpatientsregardingtheirsatisfactionwithyourphonesystem.Whileinthewaitingroom,youcanaskpatientstocompleteabriefsurveyabouttheirexperiencewhencontactingyouroffice.Ω

Onceyou’vereviewedandaddressedthevolumeofcalls,assesswhetheryourpracticehassufficientphonelinecapacitytohandleit.Contactyourphonecompanytorequestareportonbusysignals,abandonedcalls,andpeakcallvolume.Typicallythereisafeeforthistypeofinformation,butitisaninexpensivewaytohelpyourpracticeassesswhetheryouneedtoaddlinesormakechangesthatwillimprovecustomersatisfactionandaccess.

Avoiding Common Inefficiencies

The Physician’s TimeApractice’sbiggestexpenseisthephysician.Thegoalistobeefficientandproductiveandtomakesurethephysicianisusinghistimeandotherresourceswisely.

ScheduleYourmajorsourceofrevenueisyourpatients.Regardlessofyourfinancialmode ofpractice(capitation,contractedfeeforservice,non-contractedself-pay),yourgoalshouldbetohaveafullscheduleofpatientseachdayandhandlethat scheduleeffectively.

DelegateManyphysicianscomplainthattheyhavetoomanymeetingstoattend,toomuchbusinesscorrespondencetoreadandreview,andtoomuchpaperworktocomplete.Delegatetheseadministrativetasks.Letyourofficemanagerstartdoingsomerealmanagement.Ifthatemployeedoesn’thavethenecessarymanagementeducation,investinginsucheducationwillultimatelysaveyoutimeandmoney.

Organize and PrioritizeUseataskorganizer,suchasaDayRunner,MicrosoftOutlooktasklist,orasimplehandwrittento-dolist,toplan,organize,andprioritizeyournon-patientappointmenttasks.Byprioritizingyournon-patienttasks,youcanexpecttosave30minutesadayandusetherestofyourtimemoreproductively.Forexample,ifyouhaveprioritizedyourtasksandthereisano-show,youcanusethattimetoaccomplishoneofthetasksonyourlistratherthanwastingtime.

Performaself-inventorytodeterminehowwellyoumanagethislist.Overaperiodofaweekor10days,lookathowmanyofthosetasksinyourorganizerareactuallybeingaccomplished,howmanyarebeingdismissedorforgotten,andhowmanyarebeingbumpedintoanotherday.Ifyouareaccomplishinglessthan90percentof

AsamplecallvolumetrackingsheetisavailableintheAppendix.

AsamplepatientsatisfactionsurveyisavailableintheAppendix.


-Best Practices42

whatyousetouttodo,somethingiswrong.Itcouldbeoverlyambitiousplans(beingunrealistic)oritcouldbeevents,people,orhabitsthatgetinyourway.Identifytheproblemandfindasolutionsoyoucanmakethemostofeachdaywithoutworkinglongerhours.

Start on TimeStartboththemorningandafternoonontime.Sage&Associates,aCaliforniapracticemanagementconsultingfirm,estimatesthatlatestartscostapracticeroughly$2perminute.Thisexpensecomesstraightoutofprofits,sinceexpenseshavealreadybeenincurred.Yourstaff,especiallytheschedulers,canhelpthephysicianstayontrack,butthephysicianmustbecommittedtostartingontime.

Practice Preventive AdministrationEveryphysicianshoulddevote,onaverage,anhouradaytoadministrativework.Thisistrueevenifyouareinagrouppracticeandyouarenotthemanagingpartner.Bymakingthisapriority,youaremuchlesslikelytofallbehindonormissimportantdeadlinesthatcouldhavefar-reachingconsequences.Forexample,failingtoreviewandrespondtoacontractchange(suchasafeeschedulechange)withintherequiredtimeframescouldlockyouintothoseratesforanotheryear.

Whiledoingthis,makeeveryattempttoprocessallcorrespondence,chartnotes,labwork,refillrequests,andthelikewithin24hours.Delayscanleadtounnecessarywork:Forexample,staff ’sinabilitytolocateamedicalrecordcanholduptheprocessofroomingthepatientandconsequentlyputthephysicianbehindfortherestoftheday.

OFFICE COMMUNICATIONSKeepingcommunicationhealthyandopeniscertainlyimportant,butyoumustalsodeterminethebestforumtocommunicatevarioustypesofinformation,beitsensitive,generic,orpositive.Yourgoalshouldbetimely,thoughtful,healthycommunicationthatmakesthebestuseofeveryone’stime.

ManageStaffMeetingstoMakeThemMeaningfulCommunicationwithinthepracticeisakeycomponentofsuccess.Inadditiontopromotingteamworkandprovidinganopportunityforstafftoworkcollaboratively,officemeetingsareagreatwaytoensureopencommunicationbetweenstaffmembers.

Startbymakingacommitmenttokeepthemeetingmeaningful.Giveeveryoneenoughnoticesotheycanattendpreparedandthemeetingcanbewellplanned.Structurethemeetingbydefiningitspurposeandsettinganagendathataddressesthatpurpose.Theagendaneedstobemanaged,withaspecifiedamountoftimeforeachitem.Managethemeetingtoassureit

isaninformationalexchangeanddoesnotbecomemonopolizedbyoneortwopeopleordegenerateintoagripesession.

Evenaninformalfive-minutehuddleeverymorningtoreviewtheday’sscheduleandplanaheadprovidesanopportunitytoexplorepotentialproblemsorconflictsandidentifyactionstoresolvethem.

MAKE THE MOST OF THE VISITWhenseeingpatientsintheoffice,makethemostofthatvisitbyhandlingwhatevertasksyoucanatthattime.Forexample:

•Reviewprescriptionsandissueappropriaterefills,topreventtheneedforacallfromthepatientorpharmacy30daysdowntheroad.

•Conveythefindingsofanyconsultationordiagnosticreports.

•Havethepatientscheduleasmanyfollow-upappointmentsaspossiblebeforeleaving(i.e.,aseriesofprenatalvisits,post-opvisits,wellnessexams).

•Remindpatientstoschedulereturnappointmentsforsuchthingsasannualpapsmears,mammograms,flushots,orrepeatstudies,topreventunnecessarymailingcosts.

USE YOUR ONLINE RESOURCESGetyourstaffoffthephoneandontotheInternet.Onlineisafarbetterwayforyourstafftocommunicatewithreferringpractices,verifyinsuranceeligibilityandbenefits,obtainauthorizations,andcheckonclaimsstatus.AsseeninFigure2,a2006Millimanstudyfoundthatasolophysiciancansavemorethan$42,000peryearbyincreasingelectronictransactionssuchasclaimssubmission,eligibilityverification,referralcertification,pre-authorizations,claimsstatus,andpaymentposting4.

4Phelan,JohnandNaugle,Andrew,ElectronicTransactionSavingsOpportunitiesForPhysicianPractices,MillimanTechnologyandOperationsSolutions,Revised2006.

Figure 2 - Milliman Technology and Operations Solutions: Electronic Transaction Savings Opportunities for Physician Practices - Revised January 2006

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Claims Referrals Preauthorization Payment Posting Claim Status

Manual Cost Electronic Cost

Utilizing Automation and Information Technology (IT)Asmentionedabove,solophysicianpracticescansavemorethan$42,000peryearbyutilizingtechnology.Automationcansavestafftime,increasepatientsatisfaction,anddecreaseyourbottomlineallatthesametime.Herearesomesuggestionsonhowyourpracticecanbecomemoreeffectivebyimplementingtechnologysolutions:

Instant MessagingElectroniccommunicationsavesanunbelievableamountoftimeandmakesintra-officecommunicationmoreefficient.Intra-officee-mailandinstantmessagingaregreatwaystotransmitinformationinrealtime,withminimalsteps.Herearetwoeasywaystouseelectronicmessagingwithinthepractice:

•Thebillingofficecansendamessagetothereceptionistwhenaslow-payingpatientisspottedontheappointmentschedule.Thereceptionistcanthendirecttheseslow-payingpatientstothebillingdepartmentbeforetheyleavetheoffice.Thescheduleshouldberoutinelyexaminedaheadoftimebythebillingoffice,not“ifthere’stime.”

•WhenMrs.Brownarrivesforherappointmentshetellsthereceptionistshealsoneedstopickupanewprescriptionforherhusband.ThereceptionistcansendaninstantmessagenotifyingthenursethatMrs.Brownwillbeaskingforthisprescription.ThenursecanaccessMr.Brown’srecordandcanhavetheprescriptionreadybythetimeMrs.Brownseesthephysician.

Bothofthesearestepsstaffmemberscantakeattheirdesks,savingtime.

On-Hold MessagingOn-holdmessagingisaninexpensiveandefficientwaytoprovidegeneralinformationtoyourpatients.Itbeatssubjectingthepatienttosilence(andwonderingifthey’vebeendisconnected)ormusictheydon’tcarefor.Usethismessagingforpatientreminders(timeforflushots)andasameansofmarketinganynewservicesbeingofferedbythepractice.Itisalsoagoodopportunitytointroduceanynewprovidersorstaffmembersofthepractice.Makesureyouareabletochangethemessagesfrequentlyandwithease.

HIPAA COVERED ENTITY STATUSAsaphysicianpractice,youwillbeconsideredaHIPAAcoveredentityandsubjecttoHIPAAPrivacy,Security,andTransactionsenforcementbytheappropriatefederalagencyifyouconductoneormoreoftheHIPAAstandardtransactions.Evenifyouonlysendpaperclaimstothird-partyinsurers,itispossiblethatelectronicallyverifyingapatient’seligibility(submittinganeligibilityinquiryusingtheHIPAAstandardformat)willresultinyourbecomingacoveredentity.TheadvantagesofusingtheHIPAAStandardTransactionsareprofoundintermsofrevenuecycleandpracticeefficiency,sotheprospectofbecomingaHIPAAcoveredentityshouldn’tinitselfholdyoubackfromthisdecision.Inanycase,manyoftheHIPAAprivacyandsecuritystandardsarealreadyrequiredofanyCaliforniaphysicianbyexistingCalifornialaw.FormoreinformationonHIPAAstandardtransactions,includingacompletelistofelectronictransactionscoveredbytheHIPAATransactionRule,pleaseseeCMAONCALLDocument#1606,“HIPAAElectronicTransactionRule.”HIPAAisalsodiscussedinmoredetailinChapterVI.


-Best Practices44

E-PrescribingE-prescribingcanreducethestepsrequiredofamanualprescribingsystem.Itcanalsodecreasethevolumeofcallsfromthepharmacyregardingillegiblescrips.Anumberofhealthplans,includingMedicare,areplanningtoofferbonusincentivestophysicianpracticesthatusee-prescribing.Medicare’sprogramwillbeimplementedin2009.

EMR/EHRElectronicMedicalRecords(EMR)orElectronicHealthRecords(EHR)certainlyrequireafinancialinvestmentfromthepractice,aswellasalargeinvestmentintimefortrainingandimplementation.However,havingaccesstodatafromanywhere,reducingcostsinvolvedwithpapercharts(suchaspaper,transcription,andrecordstorage),andimprovingpracticeproductivityshouldbeenticingincentivestoconsiderthemovetowardEMR/EHR.

IfitappearsfinanciallyprohibitivetoimplementanEMR/EHRinyourpracticerightnow,considerusingahostingcompanytoprovidetheservice.ThesystemitselfresidesatthehostingcompanyandthepracticeaccessesallfunctionsandfeaturesviatheInternet.ThehostingcompanyisresponsibleformaintainingandupgradingthesystemandkeepingallrecordsHIPAAcompliant.Thishasproventobeamuchmorecost-effectivewayforsoloandsmallgrouppracticestoadvanceintotheageoftheelectronichealthrecord.ForamorecomprehensivediscussiononEHRselectionandimplementation,pleaseseeChapterVII.

Benchmark Your PracticeUseyourpracticemanagementsystemandschedulingsystemtoprovidethebenchmarkingdatasoyoucantrackandassesspracticeperformance.Typicalbenchmarkingincludesproductivity,income,operatingexpense,andfinancialmanagement.ChapterVprovidesanin-depthdiscussiononbenchmarkingandhowyourpracticeshouldusesuchperformancemeasuresfora“snapshot”ofhowthepracticeisdoing.

Use Your Practice Management System EffectivelyItisestimatedthatmostmedicalpracticesonlyuseabouthalfthefunctionalityintheirpracticemanagementsystems.Talkwithyourvendortolearnmoreaboutthestandardreportsyoursystemcreatesaswellashowtocreatecustomreports.Systemreportsarecriticaltomeasureapractice’sprogresstowardgoalsandidentifyareasofopportunity.

STRATEGIES FOR EFFICIENCY AND EFFECTIVENESS IN YOUR PRACTICE

Become Proficient at Managing Your PracticeContinuingeducationinpracticemanagementisimportanttophysicians,theirofficemanagers,andtheirstaff.Itisstronglyrecommendedthatyouincludethecostofthesecoursesinyourbudget.

Invest in Good StaffAsdiscussedinChapterI,oneofyourpractice’smostimportantassetsisyourpersonnel.Toattractandretaingoodstaff,youhavetocompensatethemwell.Wehaveallknownthatonestaffpersonwhowasabletodotwicetheworkofeveryoneelse.That’swhoyouwantonyourteam.Below-averageworkersarecostly.Payextraforgoodworkersandyou’llneedfewerofthem.Investinginandretainingqualified,dedicatedstaffcanmakeorbreakyourpractice.Thisisacriticalareawhereitjustdoesn’tmakesensetocutcorners.Bysomeestimates,thecostofturnovercouldbeasmuchasathirdofanemployee’sannualsalary5,sofindingandretainingtherightemployeesinyourpracticeiscritical.

Eliminate Frequent OvertimeIfovertimeisfrequentorexcessive,evaluatewhetheryourpracticeshouldconsiderhiringadditionalstafftogettheworkdone.First,overtimeshouldbeauthorizedeitherbythephysicianorofficemanager.Thiswillensuretheovertimehoursarereallynecessary.Second,thereshouldbeaclearunderstandingbetweenofficemanagerandemployeeofwhatistobeaccomplishedduringtheovertimethatisauthorized.Oncetheovertimehasbeenused,thephysicianorofficemanagershouldconfirmthattheagreed-ongoalsweremet.

Overtimepaycoststhepractice150percentoftheemployee’shourlyrate,soitisimportanttoevaluatehowmuchovertimeyouarepayingonaverageeachmonth.Ifthatamountisequaltoorgreaterthanthecostofapart-timeorfull-timeemployeeatthehourlyrate,itistimetoconsiderhiringadditionalstaff.Itwillpreventburnoutanderrorsthatoccurwhenstaffisoverworked.

Use Bonus SystemsConsiderrewardingstaffformeetingproduction-andcollection-relatedgoalsandforcontrollingoverheadcosts.Ifyouofferincentivesforachievingpredefinedgoals,staffaremorelikelytobecomeinvestedintheoutcomeoftheirwork,meaningamoreeffective,efficient,andprofitablepractice.

5BusinessandLegalReports,WhatistheCostofEmployeeTurnoverinYourCompany?,http://www.blr.com/landingPR/index.aspx?landingPRID=1

Closely Review Your OverheadLeftunmonitored,overheadcanquicklygetoutofcontrolandeatintoprofit.Thekeystocontrollingitarecreativityandstrivingtoimproveoperations.Inphysicianpractices,overheadprimarilyconsistsoflabor,rent,insurance,andpurchasedservices.Whilethoseareascanhaveabigimpactonnetincome,don’toverlookthesmallerexpensesthatcanalladdup.

Fortheneworinexperiencedmanager:

•Reviewyourbills.Closelyexamineinvoicesfor unusualcharges.

•Competitivelybidyourpurchases.Comparepricesonproductsorserviceswithlittledifferentiation,suchasgeneralliabilityinsurance,employeebenefits,andservices.

•Renegotiatedeals.Don’twaitfortherenewalperiodtorenegotiateterms,especiallyifyouareimportanttothevendor.

•Weighleasingvs.buying.Leasingcanhelpyouconservecapital,butitisimportanttodeterminewhetherthetotalcostislowerinaleaseoraloan.

Stick to Your BudgetOfcourse,youfirstneedtodevelopabudgetandsticktoit.Onamonthlybasis,youshouldreviewactualcostsvs.budgetedcoststodeterminethevariance.Thiswillhelpyouplanforchanges,identifyareasthatneedattention,andstaywithinbudget.

Allofthetipsandadviceinthischaptermayseemoverwhelming,particularlyforabusymedicalpractice,butalittletimeandeffortupfrontwillsaveyoualotoftimeandmoneyinthelongrun.Moreimportant,thesetipswillhelpkeepthepractice’sdoorsopenandallowthephysiciantofocusonprovidinghigh-qualitycaretopatients.


-Best Practices46

Assessing Customer Expectations and Improving the Patient Experience

By Debra Phairas, president of Practice and Liability Consultants, and Mary Jean Sage, Sage & Associates

Itisimportantthatphysicians,administrators,andstaffdonotbecomecomplacentaboutcustomerservice.Merelyassumingthatyourpracticeprovidesexcellentcustomerserviceisnotenough.Moreover,justbecauseyou’vealwaysdonethingsacertainwaydoesn’tnecessarilymeanthereisn’troomforimprovement.Inthischapter,wewilldiscusscontinuousassessmentandqualityimprovementmeasuresyoucantaketoensurehighsatisfactionforbothpatientsandreferringphysicianswhoarevitaltoyourpractice.

Intoday’smarket,especiallywiththemovetowardconsumer-directedhealthcare,ithasbecomeessentialforaphysicianpracticetobecustomerserviceoriented.Thismeansrecognizingthatpatientsandreferringphysiciansarecustomersandthencontinuallyreinforcingthatphilosophy.Inthepast,patientstolerated30-minutewaittimes.Butrecentstudiesshowthattolerancethresholdhasdroppedto13to15minutespastthescheduledappointmenttime.

SOLICITING FEEDBACKIdeally,apracticeshouldcontinuouslysolicitfeedbackfromitspatients.Onewaytoobtainfeedbackisthroughyourreceptionist.Thereceptionisthasmoreface-to-facetimewiththepatientthananyofyourotherstaff,andthoseencounterscanyieldinvaluableinformationaboutthepatientexperience.Thereceptionistshouldkeepalogofobservationsfromthoseinteractionsandsharetheinformationduringtheregularofficemeetings.Inaddition,haveaprocessinplaceformoreseriousissuestobebroughttothephysician’sorofficemanager’sattention.

Anotherexcellentwaytogetfeedbackistosurveyyourpatients.Apermanent,lockedboxonthepremiseswherepatientscandeposittheircompletedsurveyformsisanexcellenttooltocollectongoingfeedbackandalsoimmediatelyaddressissuesastheydevelop.

Ataminimum,werecommendpracticesconductpatientsatisfactionsurveysatleasttwiceayear.Discusswithstafftheintent,benefits,andimportanceofthesesurveys.Youmayalsowanttoconsiderofferingincentivestoyourstaffforencouragingpatientstoparticipate,forahigherresponserate.

Youcanalsopromoteresponsesbyplacingsurveysinmultiplelocationsonsite,forexample,ontheclipboardwithotherformspatientsneedtofillout,displayedinthewaitingroom.andineasilyaccessibleplasticwallholdersintheexamrooms.Patientsarelesslikelytoparticipateinsurveysthatrequirethemtomailbackresponses;responsewillbemuchgreateriftheycanconfidentiallydroptheformintoasecuredboxatthebeginningorendofthevisit.

Ifyouhavecomputer-savvypatients,youmaywanttotakeadvantageofelectronicsurveysavailableonline.Severalvendorsofferonlinesurveytoolsthatcanbecustomizedtomeetyourindividualneedsandwillautomaticallytabulateconfidentialresponses.Youcanplaceacomputerinthereceptionroomsopatientscancompletethesurveyastheywaittobeseen.ProvideaURLsotheycancompletethesurveyat

4


homeorworkiftheyprefer.Theseonlinesurveytoolsalsoletyousurveyyourownstafffortheirperceptionsofthepractice,benefits,officemanager,morale,physicianmanagementabilities,andotherimportantfactorsthatmaybeimpactingyourbottomline.

Resultsshouldbetabulatedeitherbythephysicianortheofficemanagerandthenpresentedtothemanagingpartnerorowner.Ifyourpracticehasperformedpatientsatisfactionsurveysinthepast,itishelpfultocomparethesesoyoucantrackprogress.Afterpresentingresultstothephysician(s),discussresultswithemployeesindividuallyinordertogivepraiseorprovidecoachingforfutureimprovement.

Theresultsofanysurveycanbeveryinformative.Forexample,theymayshowthatthereceptionistissullen,isfrequentlyoccupiedwithpersonalphonecalls,orignorespatients.Conversely,youmayfindthatpatientsviewthereceptionistasveryfriendly,efficient,andpersonable.Inanycase,itisimportanttobetransparentwithemployeesaboutwhatyoulearn.Forthisreason,werecommendthatalljobdescriptionsincludeaperformancemetricbasedonpatientsatisfactionsurveyresults.Achievementofthatgoalshouldbeconsideredduringyearlyperformancereviewsforpossiblesalaryincrease.Alsodocumentanddiscussdeficienciesanddevelopacorrectiveactionplan.

Itisalsoimportanttoevaluatefeedbackonphysician-patientcommunication.Itcanbeenlighteningforphysicianstoseehowtheirbedsidemannerandcommunicationskillsareviewedbypatients.Patientsatisfactionsurveysalsogivemanagingphysicianpartnerstheopportunitytoshareconstructivefeedbackwithphysicianemployees.

Patientsmayalsoindicatethattheythinktheofficeshouldberedecoratedorupdated,thatthejanitorialeffortneedsimprovement,orthatcommunicationoftestsresultscoulduseimprovement.Onephysicianweworkedwithwassurprisedtofindoutthatwhenhewasconcentratingonlisteningtothepatient,hewasfrowningandpatientsperceivedhislookas“mean.”Infact,hehadaverywarm,friendlysmileandthissurveyfeedbackremindedhimtosmilewhenhewaslistening.Theresultsofthesesurveyswillgiveyouatruepictureofhowpatientsperceiveyourpracticeandareusefultoolsforprovidingbettercustomerservice.Ω

UNDERESTIMATING THE VALUE OF PATIENT SATISFACTIONSomepracticesbelievepatientsatisfactionsurveysarenotworthdoing—thatthedataisunreliableortheycan’tjustifythecost.Thetruthisthattheycanhelpyouidentifywaysofimprovingyourpractice,whichwilltranslateintobettercareandhappierpatients.

It’sessentialforthesuccessofanypracticetosatisfypatientsandthoroughlyunderstandtheirneeds.Addressingpatientneedsalsoisthebasisofallqualitymanagementprograms.Apatientsatisfactionsurveyshowsyourstaffandthecommunitythatyou’reinterestedinqualityandthatyouarelookingforwaystoimprove.

Anothergoodreasonfordoingapatientsatisfactionsurveyissimplytoremaincompetitive.Theenvironmentphysiciansworkintodaydemandsthatdataonpatientsatisfactionbeusedtoempowerconsumers.Ifphysiciansdon’tgetonboard,makethedataasgoodaspossible,andearnashighascoreaspossible,theyaregoingtobehurtinthemarketplace.

AsamplepatientsatisfactionsurveyisincludedintheAppendix.

AssessingCustomerExpectationsandImprovingthePatientExperience- 47

-Best Practices48

Remember,thesearethestepstofollowinconductingpatientsatisfactionsurveys:

•Doit.

•Useit.

•Trackit.

•Repeatit(often).

Manypracticesdoasatisfactionsurveyandthendonothingwiththeresults.Itcan’tbeemphasizedstronglyenoughthatifyouaregoingtoconductasurveyyoumustplantoanalyzetheresultsandthenusethem!Ifyouarenotgoingtodotheanalysisorusetheresultstoimprovethepractice,thenthereisnousewastingthetimeormoneytodothesurvey.

Mostpracticesurveys(whendoneonceayearorevensemiannually)askaboutofficevisitsthathappenedalongtimeago,andthepatientmayonlyhaveavaguerecollectionofthatvisit.Amoreeffectivewaytoascertaintheirsatisfactionistoaskpatientstocheckoffafewboxesinasurveyatthetimeofthevisitorviaapostcardmailedtothemwithinadayofthevisit.Keepthesurveysimplewithjustafewquestionsthataddressanypractice’sthreegeneralgoalswheninteractingwithpatients:

•Qualityissues-isthepatientsatisfiedwithhisorhermedicalcare?

•Accessissues-isiteasytomakeanappointmentorgetareferral?

•Interpersonalissues-arethephysiciansandstaffcaringandcompassionate?

Youmaythinkthatqualityismoreimportantthanaccess,butpatientsthinkdifferently.DatafromtheNationalCommitteeforQualityAssurance(NCQA)hasshownthatpatientsplaceaccessatthetopoftheirlistofwhatmakesthemsatisfied.

Highpatientsatisfactionlevels,documentedbyongoingsurveys,canbeveryeffectiveinhelpingapracticegainaccesstoanewhealthplanorinsurerorconvincingapayornottodropyoufromaplaninwhichyouarealreadyparticipating.Surveydatadocumentingthevalue-addedservicesyouhaveprovidedtoenrolleescanalsosometimesbeadecidingfactorinsecuringhigherpaymentsforyourservicessincethecarrierwillnotwanttoloseyou.

PHYSICIAN REFERRAL SATISFACTION SURVEYSForspecialists,customersarebothpatientsandreferringphysicians.Inadditiontopatientsatisfactionsurveys,itishelpfultoperformreferralsatisfactionsurveysonanannualbasis.Youmaydiscoveraperceptionthatyourofficeisnothandlingreferralsorauthorizationsefficientlyorthatpatientsarenotscheduledinatimelyfashion.

Onephysicianweworkedwithlearnedthathisbluntmanneraboutcommunicatingtheneedforweightreductionwithfemalepatientswasdisconcertingtothepointthatpatientsbegancomplainingtotheirprimarycarephysicians,whothenstoppedreferringpatientstohim.

Whilemanyphysicianshaveasetprocessforcommunicatingpatientstatuswithreferringphysicians,youmayalsowanttoconsidercustomizingyourapproach.Forexample,onephysicianspecialistreportsthathekeepsathree-columnlistbyhisdictationstationindicatingwhichphysiciansprefertobetelephoned,faxed,orsentconsultlettersasfollow-upontheirpatients.

Implementing Referring Physician Satisfaction SurveysThesurveyforreferringphysiciansshouldbequickandeasytocomplete.Respondentsshouldbeabletoprovideanonymousandconfidentialfeedback.Surveyresponseratesaregenerallyhigherwhenparticipantscananswerquestionsfreelywithoutfearofbeingidentified.

Makealistofyourpotentialreferringphysicians(youcangetaddressesfromeitherthelocalmedicalsocietyorhospital).Sendthesurveywithacoverletterthankingphysiciansforreferralsandexpressingyourdesiretobetterservethemandtheirpatients.Youcanassurethemofanonymitybymentioningthatyouaresendingthissurveyto,say,over50physicians.

Ifyouworkwithaconsultant,considerhavingtheconsultingofficemailoutthesurveyonyourbehalf.Responsescangodirectlytotheconsultanttoanalyzeinwriting,furtherreassuringrespondentsthattheiridentitywillnotbeknown.

Alsopromoteanonymitybyprovidingself-addressedstampedenvelopesthatlistyouraddressinboththeaddresseeandaddressorspots,toeaseconcernsaboutbeingidentifiedbyreturnaddressorofficeletterhead.Ifyouhavecomputer-savvyreferringdoctorsandtheire-mailaddresses,anotheroptionistodesignacustomonlinesurveyusingananonymoussurveytool.

Forphysiciansingroups,itishelpfultoanalyzethefeedbackbyindividualpractitionersoresultsmaybediscussedone-on-oneandyoucandevelopanappropriateactionplan.Ω

AsamplereferringphysiciansurveyandsamplecoverletterareavailableintheAppendix.

AssessingCustomerExpectationsandImprovingthePatientExperience- 49

-Best Practices50

Understanding Your Revenue Stream

By Linda Cole, Alan Morrison, and Melissa Lukowski, athenahealth, and Debra Phairas, Practice and Liability Consultants

Intoday’senvironmentofdecreasingreimbursement,consumer-directedhealthcare,andincreasingcomplexityaroundpayor-specificpaymentrulesandmedicalpolicies,itisimperativeforsoloandsmallgrouppracticestounderstandandmanagetheirrevenuestreams.Failuretodosocansignificantlyimpactapractice’sviability,whichdirectlyimpactsaccesstocare.Operatinginefficientlyandineffectivelycanalsohaveasignificanteffectondeliveryofqualitycare.Giventhetremendousdemandsonalreadyverybusyofficestaff,howcanapracticeknowthatitmaybefacingtoughtimesaheadandavoidfinancialcrisis?

Thekeytopreventingrevenueshortfallsistoproactivelymonitorwhatiscominginthedoor.Whileitmayseemunthinkabletoaddonemoretasktoyouralreadyoverwhelminglistofthingstodo,proactiverevenuemonitoringhelpsyouunderstandwhatyoucandependonafewweeksdowntheroad.Moreimportant,ithelpsyouidentifywhatmaynotbetheresoyoucanplanaccordingly.Thischapterpresentssimpletechniquesandtipsformanagingyouraccountsreceivable(AR)throughprovenbestpracticesin:

•Measuringdaysinaccountsreceivable(DAR)bypayor,service,andprovider

•Managingself-payrevenuestemmingfromco-pays,coinsurance,deductibles,andother“non-covered”services

•Benchmarkingkeyfinancialindicators

•UnderstandinghowtominimizeDAR

Thesetechniquesarekeytostayingintheblackandallowingphysicianstoshifttheirfocusfromfinancialconcernsandadministrativehasslestoprovidingqualitycare.

MEASURING DARThefirststepinunderstandingyourrevenuestreamistolookathowlongittakesforyoutoreceivepaymentforservicesyouperform.Beingawareofthetimeframesrequiredtorealizerevenueiscriticaltoknowingwhatyouneedtodotostayintheblack.Forexample,California’spromptpaylawsrequirepaymentofallpreferredproviderorganization(PPO)claimswithin30workingdaysofreceipt.IfyourpracticehasnotreceivedpaymentonaPPOclaimafter30workingdays,thestaffshouldbecheckinginwiththepayortofindoutwhy.∆

Infact,youmaybedueinterestforlatepayment.

DARisanindustrytermthatmeasurestheamountoftimeittakesforyourpracticetoreceivepaymentinfullforservicesprovidedbythepractice.DARiscalculatedbydividingthetotaloutstandingARbytheaveragedailycharge.Whilethisequationmaynotmakealotofsenseatfirstglance,thecomponentsareactuallyquitestraightforwardonceexaminedinfurtherdetail.

TherearedifferentwaysofcalculatingyouraverageoutstandingARandaveragedailycharge.Whilesomesuggestedmethodsuseaveragesbasedon365days,others

5


Remember,inCalifornia,thetimelypaymentclockdoesn’tstarttickinguntilthepayorreceivesacleanclaim.Acleanclaimisonewithnoerrors,omissions,deficiencies,missingdocumentation,etc.

calculateaveragesbasedonaseven-dayperiod,typicallythefinalweekofthemonth.Thereisnorightorwrongway,butoneoftheadvantagesofusingseven-dayaveragesisthatthesenumberstendtomorereadilyreflectbillingbehaviorchanges,whichprovidesearlywarningindicatorsforthepractice.Forourexample,wewillbaseourcalculationonseven-dayaverages.

ToarriveatyourtotaloutstandingAR,youwillwanttoaveragetheoutstandingARoveraone-weekperiod(sevendays),typicallythelastsevendaysofthemonth.

Forexample,ifwearecalculatingtheoutstandingARonJanuary112/25,12/26,12/27,12/28,12/29,12/30,and12/31andthendivideby7togettheaverageoutstandingAR.

Forexample:

Date Outstanding A/R12/25 $115,000.0012/26 $120,000.0012/27 $105,000.0012/28 $108,500.0012/29 $102,500.0012/30 $107,000.0012/31 $109,000.00Total $767,000.00

OnceyouhaveyourtotaloutstandingARfortheseven-dayperiod,dividethetotalby7togettheaverageoutstandingAR.Inthisexamplewewoulddothefollowing:

$767,000 / 7 days = Average outstanding AR of $109,571.43

Nowthatyou’vecalculatedyourpractice’saverageoutstandingAR,youwillwanttocalculatetheaveragedailycharge.Theaveragedailychargeinthisexampleisalsobasedonaseven-dayaverageof60days’worthofaverages,whichadmittedlysoundsabitconfusing.Note:Theaveragedailychargedatashouldbebasedonthedatebilledratherthanthedateofservice(DOS)toaccuratelycalculatetheDAR.Youdon’twanttoincludethelagtimebetweenDOSanddatebilledinyourDARcalculation,asitisnotpartofthemeasurementofhowlongittakesapayortopayyourclaim.

Usingthesamedaterangeintheexampleabovetocalculatetheaveragedailychargeon12/25,youwouldaddup60days’worthofyourbilledcharges,or10/25through12/25,anddivideby60togettheaveragedailychargefor12/25.For12/26,youwilladdupthebilledchargesfrom10/26through12/26anddivideby60togettheaveragedailychargefor12/26,andsoonthrough12/31.

Example:

Date Average Daily Charge (based on 60 days of billed charges)

12/25 $2,850.0012/26 $3,175.0012/27 $2,450.0012/28 $2,240.0012/29 $3,570.0012/30 $3,400.0012/31 $2,450.00Total $20,135.00Average $2,876.43

NowthatyouhavecalculatedbothyouraverageoutstandingARandyouraveragedailychargefortheperiodof12/25through12/31,youarereadytocalculateyourDAR.

Example

Average Outstanding AR = $109, 571.43Average Daily Charge = $2876.43$109,571.43 / $2875 = 38.09 DAR

ThiscalculationisalsohelpfulindeterminingyourDARbypayor.Forexample,let’ssaythatinanygivenmonth,yourunyouraverageoutstandingARforAetna,anditis$10,000.Let’salsoassumethatyouraveragedailychargewithAetnais$400.CalculatingDARbytheequationoutlinedabove,youwouldhaveaDARof25dayswithAetna($10,000/$400=25days).Whatthismeansisthat,onaverage,Aetnapaysyouwithin25daysfromthedatethatyouentertheclaimintoyourpracticemanagementsystem.

Asopposedtolookingatstraightcycletimecategories(i.e.,30,60,90,and120days),whichonlyfactorsinprocessingtime,DARconsidershowlongittakesforapracticetoreceivepaymentbasedonthedollaramountoftheservice.Thetheoryisthathigher-dollarservicesforwhichpaymentremainoutstandinglongerhavemoreofanimpactonapractice’sbottomline.

Withoperatingcostsontherise,revenuebecomeslessvaluablethelongeritremainsunbilledorinthehandsofothers.Forthevastmajorityofpractices,thelargestpercentageofrevenuecontinuestocomefromthird-partypayors.Overthepastseveralyears,however,insurershaveprogressivelyincreasedthepatient’sshareofcostbyincreasingco-payments,deductibles,non-coveredservices,andotherout-of-pocketexpenses.Itisimperativeforthepracticetoknow,understand,andbekeptup-to-dateoneachpayor’srulesforclaimsubmission.Failuretounderstandapayor’suniquepaymentrulesand

UnderstandingYourRevenueStream- 51

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medicalpolicieswillincreasethecostofprovidingmedicalcareandlowerprofitmargins.Alltoooften,practicesdonotbecomeawareoftheserequirementsuntiltheirclaimsaredeniedorrejectedbythepayor,requiringadditionalstafftimeandpotentiallyphysiciantimeformedicalnecessityappeals,andincreasingDAR.∆

Itisequallyimportantthatthepracticehavepoliciesinplacetocollectthecoinsuranceandoverduebalanceamountsduefromthepatientatthetimeofservice.Iftrendscontinue,moreofthecostofhealthcarewillcontinuetoshifttothepatient.Therefore,thepracticemusthaveadefinedprocessforunderstandingwhatthepatientowesatthetimeofserviceandprotocolsforhowtocollectbeforethepatientleavestheoffice.∆

REVENUE BY PAYORThesimplestepstoanalyzepayorDARareasfollows:

Paint the PictureTounderstandwhereoutstandingrevenuesitsbypayor,runastandardARagingreportthatcategorizesyouroutstandingARbyincrementsoftime(e.g.,lessthan30days,31to60days,61to90days,etc.).ThisreportwillgiveyouasnapshotofyourARbypayorandanindicationofhowlongittakeseachpayortocorrectlypayaclaim.MostpracticemanagementsystemshavestandardARreportsthatcanberunbypayor.Checkwithyourvendoraboutasystem’sreportingcapabilities.

Ensure that the Outstanding AR is in Line with the Total Payor VolumeRuntheagingreporttoshowoutstandingARbypayor.Ifthetotaldollaramountintheover-60-dayscategorydoesnotreflectthesamepercentageasyouroverallchargevolumewiththatpayor,itisimportanttoexaminethatpayormoreclosely.Forexample,ifCignarepresents5percentofyourtotalchargevolumeonaverage,yettheoutstandingARover60daysforthispayoris15percentofyourtotaloutstandingAR,thisshouldbearedflagthatyouneedtoinvestigatefurther.

Drill into the SpecificsAssumingyouhavedonetheaboveandknowwhichpayorsyoushouldexaminefurther,itisimportanttodigintothedetailstoseeifyoucanidentifyanyimportantpatternsortrends.Refineyourreportcriteriatolookatthefollowing:

•Reportbyservice/CPTcode:Tellsyouhowlongittakesforyoutoreceivepaymentforeachserviceyouperform.IfyoudiscoverthataparticularCPTcodehasanabnormallyhighamountoftotaloutstandingAR,itcouldindicateachangeinpayorpolicyorevencredentialingrequirementsforcertainprocedures.ThekeyhereistoidentifytrendsthatarenegativelyimpactingyourARandactquickly.

•Reportbyrenderingprovider:WillhelpyouidentifyprovidersthathaveahigheroutstandingARamountrelativetotheirpeerswithagivenpayor.Ifthisscenarioexists,itcouldindicateapotentialcredentialingproblemorthataprovideroremployeeisnotsubmittingchargespromptly.Itcouldalsoindicatethataprovider’scodingneedstobereviewed.Perhapsthephysicianiscodingforaprocedurethatisnotpayableperthepayor’smedicalorpaymentpolicies.Regardlessoftherootcause,proactivelyrunningandmonitoringthisreportwillhelpyouframetheappropriatequestionsforthepartiesofinterest.

Afewstateshavelawsinplacethatprohibitthecollectionofunpaidorunderpaidclaimbalancesdirectlyfromthepatient.Consultthelawsinyourstatetoconfirm.

Onceyouhavedeterminedwhichpayorsaretakinglongertopayand,asaresult,addingtoyourpracticecosts,youcandevelopasetofstepstopursuetheissuewiththepayor.

Whileterminatingacontractwithapayormaynotbeanoption,thisdatamaybeusefulinrenegotiatingyouragreementsor,ataminimum,inhelpingyoutargetyoureffortstoimprovepaymenttimes.TherearemanysourcesofinformationonpayorbenchmarksthatwillallowyoutocompareyourDARwiththatreportedbyotherpractices.Oneexcellentsourceiscompiledbyathenahealth,Inc.,andisavailableatnochargeonitsPayerViewwebsiteatwww.athenapayerview.com.YoumayalsowanttocheckwithyourstatemedicalandspecialtysocietiesorMedicalGroupManagersAssociation(MGMA)forinformationonDARbenchmarks.

MANAGING SELF-PAY REVENUEAsyoudidinyouranalysisofoutstandingARbypayor,itisimportanttoanalyzetheamountrepresentedbyself-pay.Asthecostofco-pays,coinsurance,deductibles,andout-of-pocketexpensesshoulderedbypatientscontinuestorise,sodoesthedifficultyofcollectingthisrevenue.Practicesareassuminganincreasinglycomplexcollectionsburdenthatisdrivingoperationalcostsupandloweringmargins.Inreviewingyourself-payAR,youwillwantto:

Determine Which Payors Contribute Most to Your Self-Pay BusinessWhichpayorshavepolicieswithhigherdeductibles,co-pays,orcoinsuranceforwhichthepatientisresponsible?Whichtools(e.g.,real-timeclaimadjudication,deductibletrackerinformationviaeligibilityverification)dothesepayorsmakeavailabletoassistyouindeterminingthepatientresponsibilityatthetimeofservice?It’salsoimportanttohaveaclearunderstandingoftheservicesthatwillbeperformed.Forexample,whatcareisthepatientgoingtoreceive?Whatisthepatient’scoverageforthatcare?Whatistheremainingdeductible?

Unfortunately,manypayorsdonotprovideup-to-dateinformationonremainingdeductiblesforindividualpatients.Youwillhavetodosomeproactiveresearchonwhichtoolspayorsaremakingavailabletohelpyoudeterminepatientresponsibility.Thosethatdoprovidedeductibleinformationtypicallydosoviatheirwebportal.Othermajornationalpayors(suchasCigna)offeronlinetoolstohelpyouestimatethepatientresponsibility.Ifthepayorinquestiondoesn’thaveanysuchtools,werecommendthatyoudevelopapolicywherebyyouwillcollectacertainpercentageatthetimeofservice.Manypracticesfinditeasiertoissuepatientrefundsthantochasethedollars.

Establish a Clear Financial PolicyOneofthemosteffectivetoolsformanaginganypractice’sself-payaccountsreceivableisawell-documentedofficepolicy.Thepracticemustsetexpectationswithbothstaffandpatients,andtheneffectivelycommunicatethoseexpectations.Coordinationbetweenthefrontdeskstaffandthebillingdepartmentisessentialtothesuccessfulmanagementofself-payaccountsreceivable.Makesurethatstaffunderstandandcanexplainyourfinancialpoliciesandcanansweranypatientquestions.Itisstronglyrecommendedthatstaffalsoexplainyourpaymentpoliciestonewpatientscallingtomakeappointments.Patientsshouldberequiredtoreadandsignyourfinancialpolicybeforebeingseenforthefirsttimeandagainannually.Theinternalpolicyshoulddetailproceduresforthefollowingsituations:

BALANCE BILLINGCaliforniaphysiciansshouldbeawarethatonJanuary8,2009,theCaliforniaSupremeCourtputanendtothecontroversysurrounding“balancebilling”ofHMOenrolleesintheemergencycarecontext-thepracticebyout-of-networkproviderstobillpatientsthebalanceofanemergencycarebillthatthepatients’Knox-Keeneplanrefusedtopay.TheCourtinProspect Medical Group v. Northridge Emergency Medical Group,__Cal.Rptr.3d__,2009WL36855(2009)(Prospect),ruledthattheKnox-KeeneActprohibitsthispracticeofbalancebilling.Thecourtclarifiedthatprovidersmayonlyseekrecourseagainstthepayors,notpatients,forunderpayments.TheDepartmentofManagedHealthCaretoohastakenactiontoprohibitnoncontractedprovidersfrombalancebillingforemergencycareservices,promulgatingaregulation,28C.C.R.sec.1300.71.39,thatdefinessuchpracticestobean“unfairbillingpattern.”TheProspectdecisionandtheDMHC’sregulationmakeitclearthatbalancebillingforemergencycareservicesisnolongerpermittedifthepatientiscoveredbyaKnoxKeene-regulatedplan(HMOs,certainPPOs,andanydelegatedmedicalgroupsorriskbearingorganizations).FormoreinformationabouttheProspectdecisionanditsimplications,seeCMA’sBalanceBillingToolkitatwww.cmanet.org.


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•Co-payments:Paymentisexpectedattimeofservice(TOS).

•Out-of-networkvisits:Full(bestpractice)orpartialpaymentisexpectedatTOS.

•Co-insurance/deductible:Bestpracticeshouldbetorequirepaymentofthisamountinfullatthetimeofservice.

•Outstandingbalances:Paymentinfullisexpectedattimeofservice.Ideally,theaccountwillbeautomaticallyflaggedinyourpracticemanagementsystemwhentherearebalancesdue.Absentthisfunctionalityinyourbillingsystem,itisstronglyrecommendedyouhaveaprocessinplacetoflagthechartorencounterformsothatthereceptionistcancollect,ifpossible,anyoutstandingmoniesdueatpatientcheck-in.Physiciansshouldexercisecautioninthisareatoensuretheydonotturnawaypatientsforfailuretopayabillandthenbechargedwithpatientabandonment.

•Paymentplans:Ifyourpracticechoosestoofferpaymentplans,youmaywish,dependingonthecircumstances,torequireatleastpartialpaymentbeforethenewservicesareprovided.Establishconsistentcriteriafordevelopingpaymentplansandmakesurebillingstaffispreparedtoanswerpatientquestionsaboutoutstandingorpastdueaccounts.Ω

Verify Coverage Each Time a Patient Is SeenMostpayorwebsiteswillprovideyouwithquickaccesstopatienteligibilityandbenefitsinformation.Ifthepatientisshowingasineligible,askthatpersonwhetherheorshehaschangedinsurancesincethelastvisit.Ifthebenefitsinformationdisplayedonthepayorwebsiteindicatestheservicewillnotbecovered,itisbesttoadvisethepatientinadvance.

Define Your Collections PolicyThelongerittakestocollect,thelessyouwillcollect.At90days,accountsreachacriticaldepreciationperiodof.5percentperday.AccordingtoaU.S.DepartmentofCommercestudyofdepreciationofaccountsheldinhouse,at120days,yourabilitytocollecthasdroppedsignificantlyandtheaccountsaremuchmoredifficulttowork.By180days,yourabilitytocollectdropstolessthan30percent.

Seriouslyconsiderreferringaccountsover120dayspastduetoareputablecollectionagency.Youcancontactyourstateandlocalcountymedicalassociationsforcollectionagenciesinyourarea.Youmayalsowanttoaskanotherpracticeifitishappywiththeagencyitisusing.

Agoodcollectionagencywillreporttothecreditbureaus,provideyouwithcollectionandagingreportssimilartothoseyourpracticemanagementsystemgenerates,andmeetwithyouregularly.

REGULARLY MONITOR FINANCIAL BENCHMARKS Benchmarkingisthepracticeofcomparingindustrybestpracticesagainstyourowntoidentifyareasthatneedimprovement.Thefinancialbenchmarksandratioanalyseswewilldiscussinthissectionarenotabsolutesthatyourpracticemustachieve.Instead,theyaretoolsforexaminingandanalyzingyourbusinessandcanhelpyouidentifyandaddressinefficienciesthatimpactyourpracticeoverhead,staffingproductivity,andultimately,yourincome.Yourofficemanagerorbillingservice

SamplefinancialpolicyformsandnoticesareavailableintheAppendix.

PHYSICIAN COMPENSATION AND COST SURVEYOnebenchmarkingresourcethatprovidesawealthofspecialty-specificinformationistheMedicalGroupManagersAssociation(MGMA)’syearlyPhysicianCompensationandCostSurvey.Yourspecialtysocietymayalsoconductsuchstudies.

shouldpreparethisinformationforyouonamonthlybasisandshouldalsoprovideyear-to-dateinformation.Itisimportanttoanalyzethisdataoversixto12monthsforhighsandlows.

Ideally,yourofficemanagerwillhaveastrongbackgroundinthebusinessofmedicineandcanassistyoubyanalyzingandreportingonthekeybenchmarks.Themanagershouldbeencouragedtostaycurrentwithindustrybenchmarks.

Thefollowingratiosandinformationshouldbepresentedanddiscussedwiththephysicianwithinsevendaysafterthecloseofeverymonthtoensureyouarereviewingthemostcurrentdata.

Gross Collection Percentage

Gross Collection Percentage = Collections / Charges

Thegrosscollectionpercentagemeasuresthepercentofgrosscollectionstobilledcharges.Ifyouhavenotupdatedyourfeescheduleforseveralyears,ifyourproductionhasremainedthesame,andifthisratiodecreases,itindicatesyouhaveagreedtoacceptdeeperdiscountsinyourcontracts.Thiswouldbeasignthatyouneedtoupdateyourusualandcustomaryratesand/ortorenegotiateyourcontracts.AdjustedorNetCollectionPercentage

Adjusted Net Collection Percentage = Net Collections / (Billed Charges -Adjustments)

Theadjustednetcollectionpercentagecandirectlymeasuretheabilityofthestafftocollectmoneyduethepracticeafterdiscountsandcontractualadjustments.Inaddition,thisinformationcanprovideinsightintosubstandardcontractsorpayornonperformance.Thisratioshouldbeover95percent.Ratiosabove100percentcanindicatethatproduction/volumeorbilledchargeshavedecreasedduringthisperiodorthatadditionaladjustmentsarebeingtakenthatareabovethenorm.Anauditofexplanationofbenefits(EOBs)matchedwithclaimsandchartsshouldbeperformedmonthlytomakesurestaffiscorrectlyappealingunderpaidclaimsandnotmakinginappropriateadjustments.

It’salsocriticalthatthephysicianandofficemanagerknowandunderstandthetermsofthecontractssigned,includingthereimbursementratesagreedto,paymentrules,andmedicalpolicies.Manypracticemanagementsoftwaresystemsletyouenterreimbursementratesandwillimmediatelyflagaccountswhenthepaymentamountdoesnotmatchthecontractedrate.Checkwithyoursoftwarevendoraboutwhetheryoursystemhasthisfunctionality.

Aging Spread Comparison Thisratioisspecialtyspecific.Yourpercentageinthesecategoriesshouldbecomparedtoyourspecialtynorms.

Days in AR 0-30 31-60 61-90 91-120 120+ TotalARBalance(shouldequal100%)

Total$amountineachARcategory

$72,000 $14,400 $9,600 $8,400 $15,600 $120,000

%ineachcategory(dividetotalAR

balancebyamountineachcategory)

60% 12% 8% 7% 13% 100%


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Thegoalformostspecialtiesistohavelessthan15percentoftheirclaimsinthe120-days-and-overcategory.Theoldertheaccount,thelesslikelythepracticeistocollectontheamount.

HOW CAN A PRACTICE IMPROVE ITS DAR?Onceyouhaveexaminedthestepsyoucantaketoreviewrevenueandidentifyareasofconcern,itistimetolookathowyoucanproactivelyimproveyourDAR.

HerearebestpracticesthatwillhelpyouimproveDAR:

TOS Charge EntryEmploytime-of-service(TOS)chargeentryasaguidingprincipal.TOSchargeentryhelpsyoudecreaseDARbydecreasingthetimeittakesforthepayortoreceiveyourclaimandforyoutoreceivepayment.

Understand Payor RequirementsOnewaytodecreaseDARistounderstandhowmuchofyouroutstandingARisduetopayordenialsthatremainunresolved.Doyourpartbyunderstandingthepayor’smedicalandpaymentpoliciessothatyouaresubmittingacleanclaimandavoidingappealsonthebackend.Everytimeyoutouchaclaim,itcostsyourpracticemoneyandreducesprofit.

Use Electronic TransactionsThekeytostreamliningyourtransactionswithallpartiesistocompletetransactionselectronicallywheneverpossible.Whileelectronicclaimsubmissionismoreexpectedtodaythaninthepast,makeapointofbillingelectronicallywheneverpossible,atleastforyourmajorpayors.AdditionalinformationonHIPAAcompliancecanbefoundinChapterVI.y

Verify Eligibility and Benefits InformationManydenialsstemfrompatienteligibilityissues.Preventthesebyverifyingeligibilityandbenefitseachtimeapatientisseeninyourpractice.

Sign up for Electronic Remittance and EFTElectingtoreceiveyourEOBselectronically(referredtoaselectronicremittanceadviceorERA)andpayments(referredtoaselectronicfundstransferorEFT)canshaveasmuchasfivetoeightdaysfromthestandardtimeframeforpayment,byeliminatingthewaitforUSPStodeliverpaperEOBsandchecks.Andhavingfundstransferredelectronicallyeliminatestheneedtophysicallydepositapapercheck.TogetherERAandEFTcanmeanagreatdealofsavingsinprocessingtime.Foranin-depthdiscussiononEFT,seeCMAONCALLDocument#1609,“ElectronicFundsTransfer.”

BEYOND AR BENCHMARKINGInadditiontomonitoringyourARcloselyandbenchmarkingagainstspecialtynorms,itisequallyimportanttokeepaneyeonotherbenchmarksthataffectyourpractice’sviability.

Foranin-depthdiscussionofHIPAAelectronictransactionandcodesetrules,pleasereferenceCMAONCALLDocument#1606,“HIPAAElectronicTransactionRule.”

BACK TO BASICSFormoreinformation,seeCMA’sbillingandcollectionstoolkit,BacktoBasics:AStep-by-StepGuidetoMaximizingYourCashFlow.BacktoBasicswasdesignedtohelpphysiciansbecomemoresuccessfulintheirpractices.Thisself-instructionalworkbookwillteachphysiciansandtheirofficestaffhowto:

•Gaingreatercontrolofthepractice’sbottomline•IncreaserevenuewhiledecreasingdaysinA/R•Identifycommonpitfallsofthebillingandcollectionsprocess

•Monitorpayorcompliancewithcontractterms•Developskillstoeffectivelyandefficientlymanagecollections

•Fosterpositiveworkingrelationships•DiscoverotherpracticemanagementresourcesavailabletoCMAmembers

Thetoolkitcanbealsobeusedtotestexistingstaff ’sknowledgeorasaninterviewtooltotestnewapplicants’skilllevel.

Keyfinancialindicatorsthateveryphysicianneedstoknowaboutandmonitoronamonthlyandyearlybasis:

1.PhysicianProductivity2.RevenueandNetIncome3.OverheadRatios4.StaffingRatios

Physician Productivity Understandwhatlevelofproductivityisneededtoachievefinancialgoals.Learnaboutbenchmarknormsforyourspecialtyregardingnumberofyearly/monthly/dailyofficevisits,hospitalvisits,surgeries,andprocedures.

TheMGMAPhysicianCompensationReportprofilesthenumberofofficevisits,hospitalvisits,andsurgeryorproceduresbymean,median,25th,,75th,and90thpercentile.Workrelativevalueunitsarealsoprofiled.Physiciannetincomeisonefactorofphysicianproductivity.Ifyouareatthe25thpercentileofproductivity,youmayalsofindthatyouareinthe25thpercentileofnetincome.Inhigherrentorstaffcostareas,oftenitisnecessarytoperformatthe60thpercentiletoachievemediannetincomes.

Revenue and Net IncomePrepareprofitandlossreportsmonthlyandunderstandrevenueandnetincomenormsforyourspecialty.Yourprofitandlossreportisafinancialmanagementtool,notjustanaccountingtool.Itisimportanttoknowwhatthetypicalphysicianinyourspecialtycollectsinactualrevenueandwhatthenetincomenormsareforthespecialty.Inadditiontoproductivitystandards,theMGMAPhysicianCompensationReportprovidesdataoncharges,collections,andphysiciancompensationandnetincomebyspecialty.

Overhead Ratio by Expense CategoryPrepareprofitandlossreportswithitemexpenseratiosforyourspecialty.Aneurosurgeon,forexample,willhavealoweroverheadratiothanafamilypracticephysician.Mostphysiciansknowtheirtotaloverheadratio,butdonotknowhowtheindividuallineitemexpensescomparewiththoseofothersintheirspecialty.Inphysicianpracticemanagement,wetranslateeachlineitemexpenseintoapercentageofnetcollections.Forexample,youwanttoconvertrentcostsintoaratiotocollectionsoractualrevenuereceived,notbilledcharges.

Example Overhead Ratio

Rent costs = $48,000Net collections = $500,000Divide 48,000 / $500,000 = 9.6% of net collections goes toward rent

UsingaprogramlikeQuickbooksorMicrosoftExceltotrackthisinformationcanmakeiteasiertoquicklyaccessthedata.Alternately,encourageyourCPAtoaddacolumnonyourprofitandlossreportthatdivideseachcategoryofexpenseintocollectionstodemonstratetheratioyouarespendingforthistypeofexpense.

Createseparatelineitemcategoriesforrevenue-producingsupplieslikeimmunizations.Thesecategoriesshouldnotbeincludedinthemedicalsupplycostsforitemslikecottonballsandthelike.


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Forbenchmarkingpurposes,separateoutphysicianownercompensationfrommid-levelemployees(physicianassistant/nursepractitioner)andotherstaff,includingphysicianemployees.Ifthepracticeisacorporation,theownerphysician’scompensationisoftenincludedintheoverallexpenses.Organizethecorporationprofitandlossreportsothatphysiciancompensationandexpensesappearatthebottomafterpracticeexpenses,toshowthetrueoperatingcostexpensesforbenchmarkingpurposes.

Compareyourtotaloverheadandlineitemratioswithbenchmarkstodetermineifyouareoverorunderthenorm.Staffandrentarethetwobiggestexpensecategoriesforphysiciansandshouldbecarefullymonitoredandconsidered,forexample,whentakingonnewrentspace.Iftherentnormsforyourspecialtyare7percentandthenewspaceisprojectedtocost12percent,yournetincomewilldecreaseunlessrevenueincreasesoryouareabletocutcostsinotherareas.Projectthecostandoverheadratioforthenewspacetoyourcollectionstoseeifyoucanaffordthatspace.Perhapsyouwillbehiringanotherprovidertoassistwithyourpractice,increasingthecapacityforpatientvisit,whichshouldincreasegrossrevenue.

Sample Profit and Loss Report

Revenue

PatientFees $530,000

Refunds -$15,000

TotalNetRevenue $515,000

Overhead ExpensesActual Expense % of Net

Revenue

AccountingandLegal $5,150 1.00%

BankCharges $250 0.05%

DuesandSubscriptions $3,500 0.68%

Insurance

General $1,800 0.35%

Malpractice $9,000 1.75%

Health,DentalStaff $15,400 2.99%

Workers’Comp $2,926 0.57%

Medical Supplies

Immunizations $20,600 4.00%

RegularMedicalSupplies $5,150 1.00%

Office

OfficeExpenseOther $2,000 0.39%

OfficeSupplies $10,300 2.00%

Postage $900 0.17%

Rent $36,050 7.00%

Staff Wages

Actual Expense% of Net Revenue

Manager $45,000 8.7%

Billing $38,000 7.4%

FrontOffice $32,000 6.2%

MedicalAssistant $34,000 6.6%

MedicalRecords $5,000 1.0%

TOTALSTAFFWAGES $154,000 29.90%

TaxesPayroll $11,781 2.29%

Telephone $5,000 0.97%

TOTALOVERHEAD $283,807 55.11%

MDNetIncome $231,193

Staffing RatiosTherearetwokeyratiostoanalyzeandcomparetodetermineifyourstaffingpatterniswithinnorms—staffwagesaspercentofrevenueandfull-time-equivalentstaffingratios.

Staff Wages as Percent of RevenueCompareaveragestaffwagestonetrevenue/collectionsforyourspecialtybytypeofstaff.Itisimportanttoseparatestaffbytypeintheprofitandlossreport.Thefollowingexampleshowstheareasthatareoverorunderthebenchmarksofwhatotherphysiciansarespendingonthetypeofstaffmembers.Theratiosshouldbesimilar,evenwithnationalbenchmarks,becausereimbursement(e.g.,Medicare)ratesadjustforoverheadinsomeareas.Veryhighcostareas,forexampleSanFranciscoorLosAngeles,maybe3to5percentoverbenchmarknormsforstaffcosts.

Revenue - $515,000

Staff Wages Your Practice Benchmark

Manager $45,000 8.7% 5.50%

Billing $38,000 7.4% 6.00%

FrontOffice $32,000 6.2% 6.50%

MedicalAssistant $34,000 6.6% 5.00%

MedicalRecords $5,000 1.0% 2.00%

TotalStaffWages $154,000 29.90% 25.00%

Full-Time-Equivalent (FTE) Staffing RatiosStaffingbenchmarksshouldbeexpressedasfull-timeequivalents(FTE).Dividethenormalhoursworkedperweekby40hours(fulltime)toobtaintheFTEforeachposition.ThenaddtheseuptoobtainyourtotalstaffFTEratioforthepracticebyphysician.Ifyouhavemorethanonephysicianinthepractice,youwillwanttodeterminethenumberofFTEphysicians,thendividetheFTEstaffbyFTEphysiciansto

obtainthecomparison.CompareyourstaffFTEwithbenchmarkstoseeifyouhavetheusualamountofstaffforthevariouspositionsandwhereyoumaybeunderoroverthenorms.

Example: Based on a Solo Physician Practice

StaffHrs Worked

Per Week FTE Benchmark % Variance

Manager 24 0.60 0.30 +50.00%

Billing 32 0.80 0.75 +6.25%

FrontOffice 40 1.00 1.10 -10.00%

MedicalAssistants 40 1.00 0.80 +20.00%

MedicalRecords 10 0.25 0.33 -32.00%

Total 146 3.65 3.28 +10.14%

Analysis of Staffing RatiosItisimportanttolookatstaffingcostsasapercentofpracticerevenue.Ifthepracticeishighperformingandatthe90thpercentileofrevenueandphysiciannetincomeascomparedwithbenchmarks,theseratiosmaybehigherthanthenorms.Morestaffareneededforhigher-performingpractices,andifthephysiciannetincomeisatthe90thpercentile,thesestafflevelsareprobablynecessary.

IfyourFTEsarewithinthenorm,butthepercentofnetrevenueishigh,yourpracticemayhavethecorrectamountofstaff,butthewagesmaybeatthetopofthepayscalesduetostafflongevity.Abilling,collection,orphysicianproductivityissuecouldalsobecontributingfactorsforlower-than-expectednetrevenue.Eitherway,ifoneofthetwonumbersisoutsideofthenorm,itshouldtriggeralookatwhythecollectionsseemlowerthanusualorphysicianproductivityappearsbelowthenorm.

Ifbothindicators,staffingpercentofrevenueandFTEs,arebelowthenorms,thepracticemaybeunderstaffed.Intheexampleinthechartabove,boththemedicalrecordspercentofrevenueandFTEswerebelowthenorm.Thismaybethereasonwhymedicalrecordfilingisbehind.Itcouldbethatthereisnotenoughstaffforfiling/pullingcharts.

Alsointheaboveexample,themedicalassistantcategorywashigherthanthenormforbothstaffingpercenttorevenueandFTEs.Thisfindingmayindicateoverstaffinginthatarea.Itcouldmeanyoushouldconsidershiftingsomeofthemedicalassistant’stimetohelpthemedicalrecordspersonpullandfilecharts.

Itcannotbeemphasizedstronglyenoughhowimportantitisforsoloandsmallgrouppracticestounderstandandmanagetheirrevenuestreams.Byfollowingtheadviceinthischapter,youwillbebetterpoisedforfinancialsuccessintoday’schallenginghealthcareenvironmentandwillbeabletofocusonprovidinghigh-qualitycaretoyourpatientsratherthanonwhetheryouwillbeabletokeepyourdoorsopen.


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Practical Steps Practices Can Take to Ensure HIPAA Compliance

By David Ginsberg, PrivaPlan Associates

MostmedicalpracticesfeeltheyhavedonealltheyneedtodotosatisfyHealthInsurancePortabilityandAccountabilityAct(HIPAA)requirementsandarereluctanttodedicatepreciousresourcestoadditionalcomplianceefforts.However,anumberofgapscanexposemedicalpracticestopatientidentitytheftandviolationofstatelawsthatmaybefarstricterthanHIPAArequirements.

RatherthanreviewingHIPAAregulationsindepth,thischapterprovidesanoverviewofinformationthatwillhelpyouremainHIPAAcompliant.

HIPAA ENFORCEMENTHIPAAenforcementisreal.ThelatestdatafromtheOfficeofCivilRights(OCR)showthatcomplaintsandinvestigationsareincreasing.AsseeninFigure1below,HIPAAcomplaintshaveincreasedsince2003by117%.Mostcomplaintsareinitiatedbydisgruntledemployees.

Figure 1 - Health Information Privacy Complaints Received by Calendar Year

0

1000

2000

3000

4000

5000

6000

8000

7000

9000

Partial CY2003

2004

6534

2005

6853

2006

7332

2007

8132

3744

Forthesereasons,itismorecriticalthaneverforphysicianstoreviewtheircurrentpoliciesandproceduresandupgradethem,ifnecessary. FederallawdoesnotcreatewhatisknownasaprivatecauseofactionunderHIPAA.Inotherwords,individualscannotsueforaprivacyorsecurityviolationcitingtheHIPAAregulation.OnlythefederalgovernmentcanenforceHIPAAandtakecoveredentitiestocourtforviolations.However,somestateshaveallowedprivatepartiestobringactionsseekingremediesforviolationsofHIPAA.

So,whileHIPAAenforcementhasbeendrivenbycomplaintstoeitherOCRortheCentersforMedicare&MedicaidServices(CMS),thesecaseshaveopenedthedoorforsuccessfulprivatelawsuitsagainstphysicianswhenaprivacyorsecurityviolationoccurs.

6


HIPAA COMPLIANCE RESOURCEForanin-depthguidetoHIPAAcompliance,medicalpracticescanpurchaseacompletedo-it-yourselftoolforHIPAAcompliancedevelopedbytheCaliforniaMedicalAssociation(CMA)anditsHIPAApartner,PrivaPlanAssociates,atwww.privaplan.com.PhysiciansinotherareasshouldcontacttheirstateandlocalmedicalassociationsorPrivaPlanformorespecificinformationaboutHIPAAcompliance.

HOW CAN YOU LOWER YOUR RISK?ThebestdefenseagainstaHIPAA-relatedactionistonothaveaprivacyorsecurityviolationoccur.HerearetheminimumstepsanyHIPAA-coveredentityshouldtake:

1.PeriodicallyreviewyourHIPAAprivacyandsecuritycomplianceefforts.

2.Ensureyourpoliciesandproceduresareup-to-date.

3.Ensurethatyourpoliciesandproceduresactually“work,”areunderstoodbyemployees,andareimplemented.

4.Ensureyourtrainingisup-to-dateforallemployees,boardmembers,keycontractors,etc.Employeesshouldberequiredtoannuallyreviewandsignastatementthattheyhavereadandunderstandtheoffice’sHIPAAprivacypolicies.(Thisinformationshouldbestoredinpersonnelfiles.)

5.Ensurethatkeyproceduresareinplace(suchasthecomplaintprocedure).

6.Ensurethatyourbusinessassociateshavewrittenagreementsinplace.

7.Ensurethatyoureportandrespondtoanyandallprivacyandsecurityincidents.

8.Ensurethatyourworkforceandpatientsunderstandtheywillnotberetaliatedagainstiftheycomplainaboutornotifyyouofaprivacyorsecuritybreach.

MEDICAL IDENTITY THEFTMedicalidentitytheftisontherise.Insomecasesprotectedhealthinformationisstolentosubmitfraudulentclaims;inotherstheinformationisbeingusedtoobtainhealthcarecoverageitself(i.e.,theidentityofaninsuredindividualisassumed).Andtheriskcomesnotonlyfromoutsidesourcessuchashackers.Youmustalsoensurethatsensitivepatientdataisavailableonlytostaffwhoneedtoaccessthatdata.

Some Practical Steps You Can Take

Establish (and Follow) Workforce Clearance Procedures Ithasbecomeincreasinglyimportanttodoeffectivecriminalbackgroundchecksonemployeeswhowillhaveaccesstoprotectedhealthinformation.Besuretofollowstateandfederallawsregardinghowyounotifyanewemployeeofanimpendingbackgroundcheckandhowyouapplythefindings.

Develop Effective Workforce Access and Authorization ProtocolsInthe“olddays”itwouldtakealargetrucktostealinformationonevenasmallsolopractice’spatients.TodayitrequiresaUSBthumbdriveandafewminutes.Asmoreandmoreorganizationsconverttoelectronichealthrecordsanduseportabledevices,thisthreatbecomesgreater.

Areemployeesrestrictedtoaccessingonlytheinformationneededfortheirjobs?Ifnot,mostpracticemanagementsystemshavesecurityfeaturesthatwillallowyoutolimitaccessbyuser.Westronglyrecommendcontactingyourvendortofindouthowtousethisfeature.

Establish Effective Workforce Termination ProceduresPoliciesshouldbeinplacetoterminateallaccesstoprotectedhealthinformation,includingsystemsandbuildingaccess,immediatelyupontheterminationofan

PracticalStepsPracticesCanTaketoEnsureHIPAACompliance- 61

-Best Practices62

employee.Policiesshouldbeinplacetodiscouragethesharingofsystempasswords.Ifyouprovidestaffwithkeystoyouroffice,makesureeachkeyisclearlystamped“Donotduplicate.”Thiswillalertlocksmithsnottomakeduplicatekeys.Finally,becautiouswhengivingemployeesorothersaccesstoyourMedicareandMedicaidprovidertransactionaccessnumbers(PTAN).Therehavebeenmanycaseswherethesenumbershavebeenacquiredfraudulentlytosubmitbogusclaims.ThisalsoappliestootherpersonalinformationthatcanbeusedtoobtainMedicareandMedicaidprovidernumbers.Ifyoususpectyourprovidernumberhasbeenstolen,reportitimmediately.CheckwithyourlocalMedicareandMedicaidfiscalintermediaryabouthowtoreportfraud.

Routinely Review System ActivityItisimportanttoroutinelyreviewsystemactivityandconducttechnicalauditstomonitorsuspiciousactivity.Yourpracticemanagementsystemshouldhaveauditingcapabilitiestotrackemployeeactivityinpatientaccounts.Youmaynothavedoubtsabouttheintegrityofyourstaff,buteventrustedstaffmaybeinappropriatelyaccessing/usingpatientinformation.Scheduleenoughtimeeverymonthtogooverreportswithyourofficemanageroradministrator.Makesureyouunderstandthedataandaskquestionsifyoudon’t.

Maintain Data and Equipment in an Encrypted ModeAllelectronicdevicesanddatashouldbepasswordprotectedtopreventtheft.

Use Security RemindersUseperiodicsecurityremindersandalertstokeepyourworkforcevigilantandonthelookoutforsecurityincidents.

Thesestepsare,ofcourse,justpartofyouroverallHIPAAcomplianceprogram.Makecertainyourorganizationhasdoneeverythingitcantoprotectsensitivedata.

COMPLIANCE REVIEWS AND INVESTIGATIONSInthecaseofacomplaintorinvestigation,HIPAArequirescooperationfromcoveredentities,sometimesincludingallowinginvestigatorsaccesstofacilities,records,andotherinformationatanytime,withoutnotice.Ω

NOTICE OF PRIVACY PRACTICESAllphysicianscoveredbyHIPAAarerequiredtoprovidetheirpatientswithawrittennoticeoftheprivacypractices(NPP)theyusetoprotectpatients’healthinformation.Coveredphysiciansthatmaintainaphysicaldeliverysitemustposttheirprivacypracticesinaprominentplacelikelytobeseenbypatients.

HIPAAalsorequiresthatproviderswitha“directtreatmentrelationship”usetheirbestefforttohavethepatientsignanacknowledgementofreceipt.

Ifyouatsomepointreviseyourprivacypractices,youneedonlymaketherevisedversionavailableupon request(andofcoursereplaceyourexistingpostedNPPaswellastheoneyouprovidetonewpatients).YoudonotneedtoresendtherevisedNPPtoallexistingpatients.

AlistofinformationthatmightberequestedinaHIPAAinvestigationorcompliancereviewisincludedintheAppendix.

Alsorememberthatifyouhaveawebsite,youmustprominentlyposttheNPPonyourwebsiteandmakeitavailabletoviewerswhorequestacopy.

SampleNPPsinEnglishandSpanishareavailableaspartofPrivaPlan’sHIPAAcompliancetoolkit.

PROTECTING INDIVIDUALS WHO COMPLAINCoveredentitiesshouldbeespeciallyvigilantwhenhandlingcomplaintssothereisnottheimpressionofretaliation.Suchasignalmaynotalwaysbeobvioustoyou,buttoyouremployeesorpatientswhocomplain,sometimesevensubtleandunrelatedactionscanfeellikeretaliation.Forexample:

•Reschedulingpatientswhohavecomplainedor“passingthemoff ”tootherproviders

•Disciplininganemployeewhohascomplainedforanunrelatedworkplaceaction

Some Practical Tips1.Besureyouhavewrittenpoliciesandproceduresandthateverymemberofyour

workforcehasbeentrainedintheseprocedures.

2.ReviewyourcurrentNoticeofPrivacyPracticesandbesureitclearlystatesthattheindividualwillnotbepenalizedorretaliatedagainstforfilingacomplaint.

3.Reviewyourcomplaintandwhistleblowerpoliciesandprocedures.TheCMA/PrivaPlanHIPAAPrivacyandSecurityComplianceToolkitcontainsappropriatelanguageforthis.Thetoolkitisavailableforpurchaseatwww.privaplan.com.

4.Wheneverapatientormemberoftheworkforcefilesacomplaint,immediatelyensurethatyourkeymanagers,owners,andotherrelevantsupervisorsunderstandtheyshouldbecarefulnottoactinawaycanbeeninterpretedasretaliatoryorintimidating.

5.Ofcourse,handlecomplaintsimmediatelyandwithfulldocumentation.

6.IfyoufindyouhavelegitimatelyviolatedHIPAA,implementacorrective actionplan.

PracticalStepsPracticesCanTaketoEnsureHIPAACompliance- 63

-Best Practices64

Successful Preparation and Implementation of an Electronic Health Records System

By David Ginsberg, PrivaPlan Associates

Selecting,purchasing,andimplementinganelectronicmedicalrecords(EMR)orelectronichealthrecords(EHR)systemisoneofthemostcomplexandresource-intensiveactivitiesanymedicalpracticecanundertake.Despiteadvancesintechnology,evenwiththebestplanningandpreparation,problemswillundoubtedlyarise.Experiencehasshownthatfirmresolveandcommitmentisnecessarytowithstandthesepressures.Keytomaintainingthisresolveisappreciationofthebusinesscaseforadoptinganelectronichealthrecordssystem.

EMR VS. EHRManypeopleusethetermsEMRandEHRinterchangeably.Sowhatisthedifference?

Ingeneral,EMRsystemsreplacethepapermedicalrecordsorchartsmaintainedwithinaphysician’spractice.EMRsystems,whichhavebeenaroundformanyyears,canrangefromthescanninganddigitizingofpaperrecordsandmedicalchartstomorecomplexsystems.

Electronichealthrecord,orEHR,referstosystemsthatgobeyondsimplyprovidinganelectronicformofamedicalrecord.AnEHRisacomprehensivehealthrecordandincludesthefollowing:

•Interoperability:theabilitytoexchangeinformationwithothersources—forexample,toorderlaboratorytestsandintegrateresultsdirectlyintotherecord.

•Decisionsupport:theabilitytouseinformationaboutthepatientwithintheEHRincombinationwithexternalinformation(suchasdiabetescareguidelines)toguidethephysicianinpatientcare.Decisionsupportcanalsoincludewarningsandalertssuchasapotentialdruginteractionduringtheprescription-writingprocess.

•Continuityofcare:theabilitytoexchangeandinterfacepatientclinicaldatawithotherhealthcareproviderssuchashospitalemergencydepartmentsorspecialistsandprovidepatientswiththeirownpersonalhealthrecord.

Throughthesefeatures,EHRscanprovideincreasedcommunication,coordination,anddecisionsupport.Additionalbenefitsincludereducedmedicalerrors,improvedqualityofcare,andsavingofphysiciantime78.Byreducingerrors,improvingtimelyphysicianaccesstonecessarypatientinformation,reducingadversedrugevents,andprovidingclinicaldecisionsupport,EHRscanimprovequalityofpatientcare.

Forthesereasons,thischapterwillfocusonEHRsratherthanEMRs.WewilldiscussthestepsyoushouldtaketodeterminewhetheranEHRisrightforyourpracticeandifso,howyoucanavoidmistakescommonlymadeduringtheselectionandimplementationphases.

7


7Berman,Jeff.“SafetyCentersandEMRs.”Health-ITWorld,2004.Availableathttp://www.health-itworld.com/emag/050104/183.html(accessedAugust11,2004).8Hier,Daniel,AdamRothschild,AnneLeMaistre,andJoyKeeler.“DifferingFacultyandHouseStaffAcceptanceofanElectronicHealthRecord.”InternationalJournalofMedicalInformatics74,no.7/8(2005):657-662.

WHAT IS A BUSINESS CASE? Mostmedicalpracticesdon’tthinkintermsofbusinessstrategies,returnoninvestment,long-termcashflowanalysisandprojection,etc.Theyshould,however,becauseimplementinganEHRisoneofthemostimportantbusinessdecisionsapracticecanmake.

Abusinesscaseisasetofconsiderationsthatjustifyaparticularbusinessstrategy,investment,orprocess.Itistherationaleforaparticularbusinessdecision.Becauseofthecomplexityandcostinvolvedwithelectronicsystems,itisimperativethatmedicalpracticesidentifythebusinesscasesforsuchasignificantbusinessdecision.Throughouttheimplementation,medicalpracticesmayneedtorememberandrearticulatethebusinesscaseinordertomakenecessarydecisions.

HerearepotentialbusinesscasesforimplementinganEHRinthecurrentenvironment:

1.Reducingofficestafftimespentlookingforpapercharts.

2.Providingaccesstomedicalrecordsanywhereandanytime.Thiscanimprovequalityandcontinuityofcarealongwithefficiency,notably,forexample,foranon-callphysicianoramultiple-locationpractice.

3.Improvinglegibilityofmedicalrecords.Illegibilityofthepaperrecordalonecancauseerrors.Handwrittenandhard-to-readnotesarereplacedbycomputerizedtext.

4.Accessingdrugrecallorotherpatientalertsbasedoncriteriasuchastheprescriptionmedicationsthesystemhasonfile.

5.Reducingfilingtimebyautomaticallyloadinglaboratoryresultsandotherdiagnostictests.

6.Reducingfilingtimeandpaper-handlingbyscanningdocumentsandappendingorattachingtothemedicalrecord.

7.Reducingtimespentfillingoutformsandtrackingandmanagingprescriptions,laboratoryresults,ordiagnostictestorders.

8.Reducingtimespentcopyingrecordsforthenumerousrecordsandaccessrequests/transfersapracticereceives.

BusinesscasesforimplementinganEHRinthefutureorwithemergingbestpractices:

1.Implementingevidence-basedpracticesusingclinicalguidelinesandotherdata.

2.Improvingpatientsafetyandqualityimprovement.

3.Abilitytoreviewqualitymetricsandreportdatatohealthinsurers’pay-for-performanceprograms.

4.Increasingtheabilitytoshareinformationwithhealthinformationexchangesandhealthinformationnetworks(suchasanimmunizationregistryoraregionalhealthinformationnetwork).

5.Improvingtheabilitytoanalyzepatientpopulationsandparticipateinclinicaltrials.

Alloftheabovebusinesscasespointtothemostimportantbusinesscase,whichistheabilitytoimprovequalityofcare.

AdiscussionaboutEHRpreparationisnotcompletewithoutreviewinghowpracticemanagement(PM)softwarefitsin.MostEHRvendorsnowincludeanintegratedPMmodulethatincorporatesbillingandcollectionsor,ataminimum,cancreateaninterfacewithyourPMsystem.Withoutanintegratedbillingandcollectionsmoduleorinterface,yourpracticewillbeforcedtoperformdualentryofpatientdemographicandbillinginformation,whichcanbeasignificantdrainonstafftime.

THE EHR IMPLEMENTATION PROCESSManypracticeshavestaffwhoarealreadyoverwhelmedandfindtheiradministrativeoverheadsteadilyincreasing.Commonly,officesstruggletokeepupwiththetremendousdemandsofthird-partypayors,referralmanagement,scheduling,andpaperwork.

Itisalsoachallengeformanypractices,especiallythoseinruralareas,torecruit,train,andretainqualifiedandexperiencedstaff.SelectingandimplementinganEHRsystemcanplaceadditionalstrainonstaffandresources.Ifpracticesdon’tplanforthischange,theywilllikelycreatemoreworkanddefeattheintendedpurposeofincreasingefficiency.Experiencehasshownthatamultistepprocessisthebestwaytoplanforchange,including: •Performinganeedsassessment

•Performingareadinessassessment

•Performingaworkflowanalysis

•Creatingyourroadmapforselectingandimplementingasystem

Inthischapter,wewillwalkyouthrougheachofthesesteps.

THE BEST WAY TO DO A NEEDS ASSESSMENTPerforminganeedsassessmentisyourfirststepintheEHRselectionandimplementationprocess.Itisastepthatwon’tbefinisheduntilyoucompletetwoadditionalsteps:thereadinessassessmentandtheworkflowanalysis.

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Theneedsassessmenthasoneprimarypurpose:tohelpyouclearlydefinewhatyouneedinanEHR.Intheprocess,youmaydiscoverthatyourneedscanbemetwithoutanEHR,perhapsbyimprovingyourbusinessprocessesoruseofformsorimprovingyourcurrenttechnologyandcomputersystems.

Thebestwaytocompleteaneedsassessmentistoinvolveallthe“stakeholders”whowillultimatelyusetheEHR.Thisissometimesknownasa“facilitative”processbecauseitfacilitatesfeedbackfromallinvolvedpeople.Itnotonlyassuresthatyouwillhaveappropriatefeedbackandinformation;italsocreatesasenseofownershipandinvolvementintheprocess,whichmayimprovephysicianandstaffbuy-inanduseofthesystemlateron.

Stakeholdersincludejustabouteveryoneinatypicalphysicianpractice:

•Officemanagersoradministrators

•Frontdeskandschedulingpersonnel

•Billingandcollectionsstaff

•Filingstaff

•Medicalassistantsornurses

•Physicians,nursepractitioners,andphysicianassistants;aswellasotherhealthcareproviders,ifapplicable

•Yourbillingservice,ifyouuseone

•Yourcomputersupportstaff,ifapplicable

Performingtheneedsassessmentisrelativelystraightforward.Onceyourteamisassembled,askallparticipantstodescribehowtheybelieveanEHRwillimprovetheirjobandwhattheybelievetheyneedfromasystem.SomepeoplemaynothaveseenanEHRbeforeandwon’tknowhowtodescribepotentialbenefitsofimplementingone.Somepracticesfinditvaluabletohaveaweb-baseddemonstrationofonesystemjusttogetanoverview,ortovisitacolleaguewhoisalreadyusinganEHR.

COMPLETING A READINESS ASSESSMENTThenextphaseofpreparationisareadinessassessment.Thisisaveryimportantstepandshouldnotbeoverlooked.Manypracticeshavedoneagoodjobdefiningtheirneedsandselectinganappropriatevendor,onlytofailintheirimplementationbecausetheywerenotready.SometimesthereadinessassessmentwillrevealenoughdeficienciesinthepracticetowarranteitherdelayingordiscontinuingyoursearchforanEHRuntilthedeficienciesareaddressedandresolved.

Thereadinessassessmentlooksatbothyourinternalandexternalenvironment.Belowaresomeareasyoushould

evaluate.Usethisasaguideandaddanyotherreadinessquestionsthatmaybeappropriateforyourpractice.TheanswerscanhelpyoudetermineyourEHR“roadmap”(describedinthenextsection)ordecidewhetherornottomoveforwardwithanEHR.Theycanalsohelpyoufigureoutwhethertoresolvesomeorallofthesereadinessissuesbeforeproceedingorconcurrentlywithimplementation.

Areadinessassessmentinvolvesaskingyourselfthefollowingquestions:

1. What is the financial status of the practice?

Why this is important: Ifyourpracticeishavingacashflowproblemandfindingitdifficulttokeepupwithbills,orthephysicianshavenotyetbeenabletoachieveprojectedearnings,thenpurchasinganEHRwillonlycompoundthesituation.Similarly,ifyouhaveafinancialchallengeonthehorizon(perhapsyouareplanningtohireanewphysicianandsubsidizethesalaryuntilthatpersoncanpayhisorherownway),anEHRmaynotbethebestpurchaseforyourpracticeatthistime.

Considerations:•Isthereasignificantidentifiableaccounts receivableproblem?

•Arefinancialchallengesonthehorizon? •CanthepracticeaffordanEHR?

2. What is the practice’s strategic plan?

Why this is important: IfacquiringandimplementinganEHRisnotpartofyourstrategicplan,youmayneedtoconsiderdelayingorreprioritizing.

Considerations:•Aretherecompetingcorporateprioritiessuchaspracticemerger/acquisitionsoraffiliations?

3. Are you implementing other technology?

Why this is important:Implementingothertechnology(forexample,anewdiagnosticdeviceorpracticemanagementsystem)mayrequiresignificantstaffresourcesforaperiodoftime.ItmaynotbewisetoplacecompetingdemandsonalreadylimitedstaffbyconcurrentlyimplementinganEHR.

Considerations: •Whatkindoftechnologyisbeingimplemented? •Howmuchstafftimeorresourceswillbeallocatedforimplementationoftheothertechnology?

4. Are there any major staffing changes on the horizon?

Why this is important: Anychangeofkeyphysiciansorstaffcanbeastrainonapractice,andanEHRprojectcouldwindupcreatingacompetitionforresources.TrainingstafftouseanEHRastheypreparetoleavethepracticeisalsoproblematic.Andthestressoflosingorreplacingaphysician,officemanager,orkeybillingpersonmakesconcurrentimplementationofanEHRimpractical.

Considerations:•Whichstafforphysiciansareleaving?•Whatroledotheyplayinthepractice?•Whatistheretirementorleavedate?•Doyouhaveasuccessionplaninplace?

5. Is the practice understaffed today?

Why this is important:Ifthepracticeisunderstaffedtoday,introducinganewEHRsystemwillcompoundthatproblem,andfailureofimplementationcouldresult.

Considerations: •Inwhatareasisthepracticeunderstaffed?•Doyouhaveplanstohirenewstaff?

6. Where will the new computer server be placed? Is there enough room for any additional equipment?

Why this is important: Oftenapractice’sexistingserversitsinaclosetthatisnotair-conditionedandhasinadequatepower.AnEHRsystemmayentailbiggerserversandmoreworkstations.Theservercertainlymustoperateinanair-conditionedenvironmentwithenoughspacetobeaccessibletosupportpersonnel.

Theserverlocationmustalsobephysicallysecuredandprotectedfromunauthorizedaccess.

Considerations:•Isthereadequatespace?•Isthereadequatepower?•Isthefacilitycapableofadditionalcablingforcomputers(i.e.,asbestosormortarwalls)?•Doyouhaveergonomicfurnituretosupportcomputerworkstations?Willyouneedtoadjustheightsofdesksorchairs?

•Istherefiresuppressionforthecomputerservers?•Howisthepowerqualityandreliabilityinyourarea?•Doyouhavepowerbackup?•Isthereadequateair-conditioning?

7. Are your existing charts ready for conversion?

Why this is important:Usuallyapracticewilldevelopsomeformofconversionplanforexistingcharts.Ifthechartscurrentlyareout-of-dateortoothick,youmightconsiderreviewingthembeforeimplementinganEHR.Thinningofthechartmightimmediatelybringsomereliefintermsofspaceandeaseoffilingfornewinformationinthephysicalchart.However,beforeyoudiscardanymedical


-Best Practices68

recordinformation,westronglyrecommendyouconsultwithanattorneyoryourmalpracticecarrierorboth.Medicalrecordsserveasabasisforplanningandmaintainingqualityofpatientcareandwhenpatientrecordsaredevoidofimportantinformation,othertreatingphysiciansandhealthprofessionalsmayremainunawareofimportantaspectsofapatient’scondition.Additionally,ifmedicalrecordsaretobedestroyed,precautionsshouldbetakentoprotecttheprivacyofthisinformation.ItisaviolationoftheConfidentialityofMedicalInformationActtonegligentlydisposeof,abandon,ordestroymedicalrecordsinamannerthatfailstopreservetheirconfidentiality(CivilCode§56.101).

Considerations:•Areyououtofspaceatthispointintime,orwillyoubesoon?

8. Do you have plans to relocate?Whythisisimportant:Ifyourpracticeisabouttorelocate,seriouslyconsiderpostponingthenew-systemimplementationuntilafterthemove.Relocationdemandssignificantstaffandmanagementresources.

Considerations: •Whendoyouplantorelocate?•Doesthenewfacilityhaveenoughroomforanyadditionalequipment?

9. Do you have physician champions for the EHR?

Why this is important:ItisessentialtohaveasmanyphysicianchampionsaspossiblewhowillleadorsupportthecauseforimplementinganEHR.Oftenpracticesincludesomephysicianswhowanttomoveaheadwiththischangeandotherswhofinditdifficulttogiveupoldwaysofdoingthings—makingimplementationverychallenging.Moreover,staffersmayfeelanxiousthattheEHRwillreplacetheirjobs,whichcreatessometensionandopposition.

Considerations: •Dochampionsexist?•Doyouanticipateresistance?

External enviroment readiness factors:

10. Do you have quality high-speed Internet connectivity?

Why this important: High-speedconnectivityisessentialfordataexchange,suchaselectronicallyreceivinglaboratoryresults.

Considerations:•Isredundanthigh-speedconnectivity,suchasDSLorcable,availableinyourarea?•Isitaffordable?

11. Is your IPA or area hospital offering a discounted or subsidized EHR?

Why this important: Ifyoubelongtoanindependentphysicianassociation(IPA)ornetwork,itmayofferadiscountedsolution.Similarly,somehospitalsofferdiscountedorsubsidizedsystemsandmayalsoprovideimplementationandhostingsupport.

THE IMPORTANCE OF COMPLETE MEDICAL RECORDSIncompletemedicalrecordscanalsojeopardizeaphysician’sabilitytoobtainproperreimbursement.Withincreasedcostcontainmenteffortsbythird-partypayors,physicians’medicalrecordsaresubjecttoincreasedscrutiny.Incompletemedicalrecordsalsointerferewithotherphysicians’abilitytoperformpeerreviewandthereforemaintainthequalityofhealthcaredelivery,exposingaphysiciantopossibledisciplinaryactionorseveresanctionbyoutsidereviewagencies.Finally,medicalrecordsareoftenaphysician’sbestevidenceinaprofessionalliabilitylawsuit,andinadequaterecordsmayunderminetheabilitytodefendoneself.y

Formoreinformationonmedicalrecordretentionandcontentsofmedicalrecords,seeCMAONCALLDocument#1160,“RetentionofMedicalRecords”andDocument#1135,“ContentsofMedicalRecords.”

Considerations: •DoesthediscountedorsubsidizedEHRincludeanintegratedpracticemanagementsystem?

•Arethereanydrawbackstothedeal?

PERFORMING A WORK FLOW ANALYSISConcurrentwiththereadinessassessment,youshouldbegintheworkflowanalysis.Aworkflowanalysisinvolvesreviewinghowyourpracticecompletestheworkassociatedwiththepatientencounterandallrelatedcomponents.Someexamples:

1.Schedulingtheinitialvisit

2.Schedulingfollow-upvisits

3.Schedulingreferralsordiagnostictests

4.Receivingandreviewingtestsorreferralresults

5.Prescribingmedicationsandhandlingrefills

6.Enteringclinicalnotes

7.Billingandcollections

Theworkflowsorprocessesinyourpracticerequireinformationintakeaswellasoutput.Someexamples:

Informationyoumayobtainfrompatientsandenterintotheirmedicalrecords:

•Demographicandbillinginformation

•Medicalhistoryform,listofcurrentmedications,etc.

•Formsthepatientsignsthatarethenfiled,suchastheHIPAAacknowledgmentofreceiptoftheNoticeofPrivacyPractices,awaiverform,informedconsent,andsoforth

•Providernotes,includingvitalsigns,chiefcomplaint,andnotesfromtheexamination/consultationandassessment/plan

•Documentationofcallstoverifyinsuranceeligibilityandbenefits,whichisenteredintothebillingsoftware

•Copiesofpriormedicalrecords

Informationyoumayexportfromthepatient’schart:

•Referralformsfordiagnosticservices,suchasreferencelaboratoryrequisitionformsorradiologyreferralforms

•Referralstootherphysiciansorhealthcareproviders

•Areportornarrativetosendtothereferringphysician

•Prescriptions

•Referralauthorizationformstosendtothehealthinsurer

HIPAA AND ELECTRONIC HEALTH RECORDS (EHR)ImplementinganEHRoftenrequiresanewevaluationandassessmentofexistingHIPAAprivacyandsecuritypractices.Thisassessmentmustfocusonwhetherexistingsafeguardsaresufficientorinneedofimprovement.ManypracticescurrentlyhaveweakHIPAAcomplianceplansinplaceorhaveallowedtheirHIPAAcomplianceplanstolapse.ThisproblemcanbeexacerbatedbyimplementationofanEHR.

EHRsystemsgreatlyexpandvulnerabilitiesofprotectedhealthinformation.Inapaper-basedpractice,achartormedicalrecordmustbephysicallyaccessedinordertobecompromised.Sincethereisonlyone“copy”oftherecordavailable,itcanbeguardedandprotectedfromunauthorizedaccesswithrelativelysimplesafeguards(lockingtheoffice,lockingthechartracks,restrictedaccessafter-hours,andsoforth).

Withpapercharts,identitythievesseekingtostealallyourpaperrecordstoextractSocialSecuritynumbersorinfoonhealthstatusorbenefitswouldneedtofindawaytobreakintoyourfacilityundetectedandprobablyuseatrucktocartawayallthecharts.WithanEHRtheycansimplybreakinandstealthecomputerserver,orifyouuseanunencryptedorweaklyencryptedwirelesssystemtotransferinformationinternally,theycanparknearbyandhackintoyoursystemusingwirelessInternetaccess.

Itisveryimportanttobewaryofanyvendor’sclaimthatasystemis“HIPAAcompliant.”ItisnotpossibleforasystemitselftobeHIPAAcompliant.Onlyacoveredentitysuchasaphysiciancanbe“HIPAAcompliant.”Acoveredentityisanorganizationthat,byvirtueofprovidinghealthcareservicesandbillingforthemusingelectronicmeans,issubjecttotheprovisionsofHIPAA.Thevendor’sEHRcansimplyhelpyourpracticebeHIPAAcompliantbyofferingahighlevelofsecurityorallowingyoutoquicklyidentifywhether,forexample,theNoticeofPrivacyPracticeshasbeengiventothepatient.Sowhileasystem’sfeaturesandcapabilitiesareimportant,equallyimportantisyourownimplementationandconfigurationofitsfeaturesandcapabilities.FormoreinformationondeterminingwhetheranorganizationorindividualisacoveredentityunderHIPAA,visitCMS’swebsiteathttp://www.cms.hhs.gov/HIPAAGenInfo/Downloads/CoveredEntitycharts.pdf.


-Best Practices70

Youcansimplifytheworkflowanalysisbybreakingitdownintotypicalclassificationsofpatientencounters.Theseclassificationsarecalleddomains.Eachdomainhasitsownsetofprocessesthatcanbemapped.Forexample:

•Newpatientforwellvisitorpreventivecare

•Newpatientforsickorproblem-orientedvisit

•Establishedpatientforchronicconditionperiodiccare

•Establishedpatientforasickorproblem-orientedvisit

•Patientmedicationmanagementincludingrefills

•Patientbilling,calls,andinteraction

WHY DO A WORK FLOW ANALYSIS?Theworkflowanalysiswillcreateabaselineforeachpatientencounter,domain,orprocess.Thisbaselinecanidentify:

1.Timetakenpertask

2.Labororpersonnelresourcespertask

3.Informationneededtocompletethetask

4.Difficultiesreceivingthisinformationinatimelymanner

5.Informationthatmustbegeneratedandsentoutforeachtask

6.Difficultiesgeneratingorsendingthisinformation

7.Errorsthatmayoccurwhileperformingthesetasks

8.Otherobstacles

Byanalyzingeachdomain,amedicalpracticecanidentifyproblemsandpossiblesolutions.OftenthesolutionsdonotrequirecomputerizationorEHRsystems,butmaybecorrectedbyothersystemchangessuchasuseofchartnotetemplates,improveddocumentmanagement,orevenbettertranscriptionsystems.

Ultimately,thebenefitoftheworkflowanalysisistoensureyoudon’tapplyacomputersolutiontoabrokenprocess.Applyingacomputersolutiontoabusinessprocessthatdoesn’tworkwillonlyexacerbatetheproblemratherthanalleviateit.

Formoredetailedinformationonperformingaworkflowanalysis,pleaseseeChapterV.

HIPAA CONSIDERATIONS IN SELECTING AN EHRMostpracticesarerelativelyfamiliarwiththeHIPAAprivacyrule.Practiceswithpaperchartsoftenrelyonstickynotes,labels,andothernotesonthefrontofthechart(orinsidethechart)relatedtoHIPAAprivacyobligations.KeyHIPAAprivacyobligationsthattypicallyaredocumentedthisway:

1.ChartsflaggedtoindicateapatientwasnotgivenaNoticeofPrivacyPractices.

2.Anyspecialprivacyprotectionsrequestedbythepatient(restrictionsonuseanddisclosureofhis/herdata).

Foramorein-depthdiscussiononHIPAA,pleaseseeCMAONCALLDocuments#1603,“HIPAAACTSMART–IntroductiontotheHIPAAPrivacyRules,”#1600,“HIPAASecurityRule,”and#1606,“HIPAAElectronicTransactionRule.”

3.Any“confidentialcommunicationschannels”orspecialwaysthepatientwouldorwouldnotliketobecontacted(forexample,appointmentremindersonlyonacellphoneandnotahomephone).

4.Informationaboutfamilyorfriendswhoareauthorizedbythepatienttocallorbecalledregardingthepatient’sconditionandcare.

5.Disclosureaccountinglogthatlistsanydisclosureofprotectedhealthinformationnotpursuanttothepatient’ssignedauthorizationorforroutinetreatment,payment,orhealthcareoperations.

ImplementinganEHRrequiresanewworkflowforthesedocumentsandalerts.Evaluatingtheease-of-useandfunctionalityoftheseshouldbeakeyconsiderationinvendorselection.y

WHAT IS IT YOU NEED? TheneedsandreadinessassessmentsandtheworkflowanalysisareimportanttohelpyoudecideifanEHRistherightsolutionforyourpractice.Oftenthisprocessidentifiesotherstepsthatcan(andshould)betakenfirst.SomepracticeswillwinduppostponingEHRimplementationforadefinedperiodoftime;othersoptforanindefinitedelay;stillothersconcludetheyarereadytomoveahead.

WHAT ABOUT DISEASE REGISTRIES?Justasdocumentmanagementorvisittemplatesareanexcellentsolutionpriortoimplementinganelectronichealthrecord,onlinediseaseregistriescanalsobeofvalue.Onlinediseaseregistriesallowamedicalpracticetorecordclinicalnotes,patientvitals,andlabresultsintoapresetdisease-specifictemplate.Theregistrythenprovidesphysiciansandclinicianswithpromptsoralertsrelatedtoclinicalbestpractices.Theonlineregistrycansimplifymanagementandreportingofpatientswithcertainchronicdiseases.OnceapracticeimplementsanEHR;however,itwillbeabletoreplacetheonlineregistrywithanintegratedsolution.

READY FOR AN EHR? THE NEXT STEPSTheworkflowanalysiswillassistyouinselectingandpurchasingasystem.Aswesuggestedearlier,eachmedicalpracticeshouldanalyzethekeypatientdomainsandworkflows,togetaspecificoutlineofthetypicalpatientcarescenariosthatarerelevanttoyourpractice.Forexample,apediatricpracticewilltypicallyhaveawell-childvisitwithaccompanyingscheduledimmunizations,whereasacardiologypracticemayhaveconsultationsandfollow-upcareastheirtypicalpatientencounter.

Inmappingtheworkflowforthesetasks,youcanlearnwhatkindoffunctionalityorfeaturesareimportantinanEHR.Thesekeyfeaturesalsobecomepartofthescenariosyouwillpresenttothevendorwhenaskingforademonstrationduringyourselectionprocess.Ratherthanrelyingonavendor-drivendemonstration(wheretheyshowallthe“bellsandwhistles”butperhapsignorethedetails)werecommendaskingthevendortodemonstratehowapatientrecordiscreatedandmanagedbasedonseveralofyourmostcommonscenarios.Thatwayyoucancompareonevendortoanotherandgetadetailedviewofhowyoumustusethesoftwareforyourcommonworkflows.Ifasystemishardtouseandlookslikeitwillcreatemoreworkforthephysicians,theimplementationmayfail.Onlyascenario-baseddemonstrationprovidesthislevelofinformation.Onceyouhavenarrowedyourselection,itisalsoimportantto“test-drive”thesystemyourself.Youwillwanttoseehowasystemhandlesallstepsofthepatientencounterprocess.

CREATING AN EHR ROAD MAPAroadmapisasimple-to-followoutlineofthestepsamedicalpracticeshouldtakerelativetothesearchfor,selectionof,andimplementationofanelectronicheathrecordssystem.BecauseimplementinganEHRislikelytobeoneofthemostcomplexandcomprehensivebusinessmovesanymedicalpracticecanmake,itisimportanttohaveawell-definedplan.

Theroadmapshouldidentifythestepsneededtoimproveyourpractice’sreadinessandpreparationpriortoimplementation;itshouldalsohelpguidetheprocessofselectingvendorsandsystemcandidates,evaluatingsystems,makingafinalselection,andnegotiatingtheagreement.Inaddition,itoutlinesthemanystepsneededforasuccessfulimplementation,suchasconversionofrecords,training,accommodatingreductioninresourcesandproductivity,changeinworkflowsandprocesses,andsoforth.

Belowisanexampleofwhataveryhigh-levelroadmapmightlooklikeforamedicalpractice,aftertheneeds,readiness,andworkflowanalysesareconducted.Eachofthesetasksinturnwillentailnumerousindividualtasks.


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XYZ Family Physicians of Central California—EHR Implementation Roadmap

Task Due Date

UpgradeWindowsnetworkandrenovateofficetocreateaserverroom

Setuseraccessforallnewusers

Implementpapertemplates

CompleteMedicarefraudandabuseplanandbeginregularchartaudit

Completechartthinningandarchiving

CompletefinalneedsassessmentandkeyfunctionsfortheEHR

Preparescenariosforvendorreview

Choosethreevendorsandreviewviaweb-baseddemonstrations

Selecttwofinalistsandconductdetailedon-sitereviews

Checkreferencesandvisitotherpracticesusingthesesystems

Negotiatebestpriceconfigurationwithbothsystems

Finalselection

Contractsigned

Initialtrainingandconversionplanning

Selection,timing,andimplementationofanEHRrequirecarefulconsiderationandplanningandwillconsumeanenormousamountofresources.Butwhendonecorrectly,ithelpspracticesrealizeworkflowefficiencies,improvecommunicationandcoordination,andmostimportant,improvethequalityofpatientcare.y

Formoreinformationonfactorstoconsiderinanelectronicmedicalrecordorelectronichealthrecord,seeCMAONCALLDocument#1132,“ElectronicMedicalRecords.”

-Best Practices74

Building a Defensible Fee Schedule: An Analytical Approach to Establishing and Maintaining Charges

By Frank Cohen, MPA, MIT Solutions Inc.

Important Note: The fees and other amounts referred to in this chapter are shown as examples only. The publisher makes no suggestions or recommendations as to fees charged by individual practitioners.

Thefeeschedule,sometimesreferredtoasthechargemaster,isthesinglemostimportantfinancialtoolwithinthemedicalpractice.Aswithanyotherbusiness,thefeeschargedreflectthevalueoftheproductsandservicesdelivered.Whenyoustripawaytheclinicalcomponentofamedicalpracticeitis,inreality,justanotherbusiness.Andlikeanyotherbusiness,amedicalpracticemustdealwithexpenses,employees,insurance,taxes,andjustabouteveryotherbusiness-relatedissue.

Ifweaccepttheimportanceofthefeeschedule,itissurprisingthatsomanypracticescreateandmaintaintheirfeescheduleswithoutasolidunderstandingofthebasicmethodologyinvolved.Practicesuseabroadarrayofmethods—somethatfollowlogicalpathsandothersthataretiedtomodelsthatfavorthepayorsratherthanthephysicians.Webelievephysiciansshouldsubscribetoaphilosophyofindependence;thattheirdecisionsshouldbebasedonsoundeconomicandmarket-drivenprin-ciples;andthattheyshouldnotbeheldhostagetopayors.

Themethodsforestablishingadefensiblefeescheduleoutlinedinthischapterarecomplex.Youmayfindyouneedtheassistanceofabookkeeper,accountant,orprac-ticeconsultanttocompletethestepsitoutlines.Butbecauseadefensiblefeescheduleissovitaltoapracticessuccess,theprocessofestablishingsuchascheduleiswellworthit.

Inthischapter,wewilllookatfeeschedulingfromsixbasicperspectives:

1.BenchmarkingusingRBRVS

2.Econometricmodels,suchascostplusmarkup

3.Volumetricmethods,suchastimeandRVU(relativevalueunit)-basedmethods

4.Comparativeanalysesusingnationalandlocalaveragefees

5.Globalanalyticalmodelingusingcategoricalconversionfactors

6.Acuityfactors,whichmeasurethelevelofcomplexityoftheservicesandproce-duresprovidedtoapatientpopulation

Absentsomelogicalmethod,apracticeisleftwithtwoalternatives:guessingandaskingotherphysicians.Theformermakessolittlesenseitdoesnotbeardiscus-sion;thelatter,inthebroadeststrokeofinterpretation,couldexposeyoutoantitrustchargesifitlookslikeyouhadanagreementwiththoseotherphysiciansonrates.Besides,basingfeesonthoseofanotherpractice(whosemethodologymayitselfbeinquestion)significantlylowersyourchancesforhavingareasonablefeeschedule.

Feeschedulesneedconstantreviewandevaluation.Ifthepracticeislosingmoneyonaparticularprocedure,youwon’tfixthatbydoingmoreofthisprocedureorbetting

8


onthe“makeitupinvolume”principle.Ifthefeeforaparticu-larprocedureseemshigherthanreasonable,itisjustasimpor-tanttoconsiderreducingthatfeeasitistoconsiderincreasingaprocedurefeethatisbelowareasonablethreshold.

Aproperandthoroughfeescheduleanalysisinvolvesmuchmorethanraisingfeesandmayactuallyhavenothingtodowithfeeadjustmentsatall.Raisingfeesiseasy;anyonecandoitwiththestrokeofapenortaponthekeyboard.Butitwon’tsteeryourpracticetowardanacceptedandviablebusinessmodel.

Establishingandmaintainingafeescheduleforamedicalprac-ticecanbeaseasyascalculatingaratioofMedicarereimburse-mentorascomplexasincorporatingreal-timemarketecono-metricdynamics,suchastheConsumerPriceIndex(CPI),theMedicalEconomicsIndex(MEI),laborratefluctuations,andotherrelatedfinancialindicators.Formostpractices,realityfallssomewhereinthemiddle.

Theprimarypurposeoftheinformationinthischapteristohelpyourpracticereachalevelofprofitabilitythatallowsittothrivewithinamarketanddeliveraconsistentlyhighqualityofpatientcare.

WHAT IS A FEE SCHEDULE?Itisimportanttodefinewhatconstitutesapractice’sfeeschedule.

Itmayactuallybeeasiertodefinewhatafeescheduleisnot.Afeescheduleisnotsimplyadatabasethatassignsachargetoeachprocedureorservicedeliveredbyaphysician.Also,afeescheduleisnotaknee-jerkreactionaryinstrumentthatisusedtovalidateanamountapayorclaimstobereasonable.Afeescheduleisaconcisetoolthatgivespatients,payors,regulators,andreviewersaclearpictureofhoweverypracticedefinesthevalueofitsservices.Awell-developedand-maintainedfeeschedulesendsasignalthatthepracticeismarketsensitive,fiscallyresponsible,andorganizationallysound.

Fee Schedule Philosophy Itisnoteasytoconclusivelysaywhatdrivesthedecisionshealthcareprofessionalsmakewhendevelopingtheirfeeschedules.Historically,feescheduleswereconstructedbasedonanideaofcostandprofitability.Aphysicianprovidedaserviceforapatient,billedtheinsurancecompany,andgotpaid—amodelthatseemsnonexistentnowadays.Withinthepastdecade,feeschedulemethodologieshavebeenreducedtoaracetocontrolwrite-offsanddisallowances,ameasureoftheunreasonablenessofpayors.Inessence,mostpracticeshavesettledonafeeschedulethatisbasedonwhatpayorsarewill-ingtoreimburse.

Thefeeschedulephilosophyadvancedinthischapteristhatpracticesshouldadoptamethodologythattakesadvantageofaccurateinternalandexternaldata.Futurecontractreim-bursementlevelsarebasedlargelyonchargelevelsoftoday.Establishingpracticefeesaccordingtowhatanotherentity/payorviewsasfairmayverywelllimityourpractice’sabilitytonegotiateaccuratefeesthatcovercostsinthefuture.

METHODOLOGICAL CONSIDERATIONSWithinthefeeschedulingmethodology,severalvariablesmustbeconsidered.Somearedirectlyrelatedtoandwithinthepractice’scontrol,includingexpenses,conversionfactors,totalcompensation,andtosomedegree,payormix.Somevariables,however,maybeoutsideofthepractice’scontrol,suchasmarketdynamics,malpracticecosts,populationfluctuations,andsupplycosts.Yourfeescheduledevelopmentshouldnotbedrivenbyspecificchargesusedbyotherpracticeswithinthesamemarketarea.Itiscrucialthatyourmethodologydependonpractice-specificvariables,tominimizeanyantitrustconcernsandtomakesureyourfeescheduleisbasedonyourpractice’sowninternaldynamics—notonthoseofanotherpracticethatmaynothaveasimilarbusinessmodel.

Additionally,byusinglargeaggregatedatasetsforbenchmark-ing,apracticecancompareitschargestructurewiththatofitspeergroup.Whilecomparativedatashouldnotbethesoledeterminantforthefeeschedule,itishelpfulforunderstandingthevalueotherphysicianswithinthesamespecialtyplaceonservicesprovidedtopatients.

WHAT IS A CONVERSION FACTOR?Initssimplestform,aconversionfactor(CF)isavalueusedtoconvertsomeunitofmeasurementintoacharge.Forexample,ifyoutakeacartotheshopforrepair,youwillnormallygetanestimateoftherepaircost.That’sdonebytakingtheaveragenumberofhoursitwouldtakeacertifiedmechanictofixtheproblem(fromaflat-ratebookoraChilton’smanual)andmultiplyingitbythehourlyrate.Forourpurposeshere,theconversionfactorisaper-unitvaluethatismultipliedbytherelativevalueunits(RVU)toconvertitintoafee(orcharge)foraparticularmedicalserviceorprocedure.

Forcalendaryear2008,theMedicareCFis38.0870,meaningthatforeveryRVUassignedtoaprocedure,thedollarvalueisapproximately$38.09.ThisCFisassignedforreimbursementunderthePhysicianFeeScheduleDataBase(PFSDB)asdesignatedbyCMS.OtherpayorsmayusedifferentCFvalues,andeachpracticewillhaveitsownCFvaluesforproceduresbasedonthefeesthatitcharges.

BuildingaDefensibleFeeSchedule:AnAnalyticalApproachtoEstablishingandMaintainingCharges- 75

-Best Practices76

WHAT IS THE CF USED FOR?TheCFhasseveraldifferentuses.Itcanensurethatapractice’sfeescheduleisnotbelowtheMedicareFeeSchedule(MFS)allowableamount.ThepracticecandoarapidcursorycheckbysimplycalculatingtheconversionfactorforeachprocedurecodeandascertainingthatthevalueisnotbelowthecurrentyearMedicareCFamount.Ifitisbelow,thatmaymeanthefeeistoolow.

TheCFisalsousedtoestablishfeesfornewproceduresortore-priceaberrantfeesforexistingprocedures.Thisaspectisparticularlyimportantwhenyouarelookingforbenchmarkstouseinthefeeanalysisprocess.

CALCULATING CONVERSION FACTORSIncalculatingCF,therearetwobasicmodelsthatwewilluse.ThefirstcalculatesaCFforeachprocedurecodeandusesthattoprofilethefeescheduleoneprocedurecodeatatime.ThesecondmodelusestheseindividualCFvaluestocalculatecer-tainCFstatistics,suchascentralmeasurements(mean,median,mode,etc.)andvariability(variance,standarddeviation,etc.).

ThebasiccalculationgivenbyCMStodeterminetheMedicareallowablemultipliestheCFbytheRVUsgiveninthePFSDB.Theformula,simplystated:

Fee = CF x RVU

Forexample,let’ssaywehaveaprocedurewith3.22geographi-callyadjustedRVUs.Followingourformula,wewouldhavetheCF(38.0870)xRVU(3.22)=Fee($122.64).Usingsomebasicalgebra,then,wecouldrearrangetheformulatocalculatetheCF,asfollows:

CF = Fee / RVU

Inanotherexample,let’ssaythepracticecharges$190forthissameprocedure.Applyingtheaboveformula,wecalculateitsCFastheFee($190)/RVU(3.22)=CF(59.01).

ItisimportanttonoteherethatwhilethemethodologyusedtocreateeachRVUisthesameforallprocedurecodes,marketforcesnormallyaffecthowtheCFisapplied.Forexample,manypracticeshavereceivedcallsfromprospectivepatientswonderingwhatitwillcostforanofficevisit.Veryfew,how-ever,receivethesamecallsinquiringaboutthecostof,say,anappendectomy.EventhoughthemethodologytodevelopRVUsforsurgicalproceduresandEvaluationandManagement(E/M)servicesareexactlythesame,E/Mproceduresaremorevisibleandmorecompetitiveinnature.Thereforeitisimpor-tant,inconductingstatisticalmeasurementsofCFvalues,thateachmajorcodingcategorybetreatedindividually.

CALCULATING MEASUREMENTS OF CENTRAL TENDENCYTherearethreeprimarymethodsusedtocalculatethecentralCFmeasurementforanygroupofprocedurecodes:theaverage,themedian,andtheweightedaverage.

Average (Least Accurate)Addingaseriesofvaluestogetherandthendividingbythetotalnumberofentriesorrecordswillresultinanaverage.Todeterminetheaverageconversionfactor,wefirstcalculatetheconversionfactorforeachcode,obtainthenumberofproce-durecodesinthesample,andthendividethetotaloftheCFvaluesbythenumberofrecords.

Thetablecontainsasampleofvaluesforsevenprocedurecodes.

Code Fee RVU Frequency CF

Code1 $1,087 10.215 1 106.42

Code2 $365 5.343 7 68.31

Code3 $1,114 13.713 12 81.24

Code4 $2,487 14.051 1 177.65

Code5 $529 6.185 12 85.53

Code6 $887 14.222 60 63.37

Code7 $996 14.173 108 70.27

Totals 652.79

IfweadduptheCFvalues,wegetatotalof652.79.Dividethisbythenumberofrecordsusedtogetthattotal(7)andwegetanaverageof$93.26(652/7=93.26).

Theproblemwithanaverageisthatitdoesnotconsider(orgiveweightto)thevalueofoneprocedureoveranother.Inessence,theCFforeachprocedurewithinthesampleisgivenequalvalue,whichmaysignificantlyskewtheresultssincesomelow-frequencyproceduresmayhaveindividualCFvaluesthatareoutliers,oroutsideareasonablerange.That’sbecausepracticescommonlyspendmoretimeanalyzingandpricingprocedurestheyperformquiteoftenthantheydoforproce-durestheyperforminfrequently.

The Median (More Accurate)Anotheroptionistocalculatethemedianinsteadoftheaver-age.Eventhoughalargenumberofoutliersmaystillskewthefinalresult,themedianisdesignedtomeasurethemiddleofthesample;halfthevaluesarebelowandhalfthevaluesareabovethemedianvalue.

Code Fee RVU Frequency CF

Code6 $887 14.222 60 63.37

Code2 $365 5.343 7 68.31

Code7 $996 14.173 108 70.27

Code3 $1,114 13.713 12 81.24

Code5 $529 6.185 12 85.53

Code1 $1087 10.215 1 106.42

Code4 $2,487 14.051 1 177.65

Usingthesamesetofsevencodesasabove,wefirstcalculatetheindividualCFusingthesamemethodasbefore.Then,wesorttheCFvaluesinascendingorder(lowesttohighest).Themedian,ratherthantakingtheaveragemeasurementofthevalues,looksatthepositionofthevalueswithinthedatabase.Inessence,themedianisamuchbettermeasurementofcentraltendencywhenthereisagreatdealofvariabilityoftheCFvaluesorthefrequenciesbeingreported.

Togetthemedian,takethemiddlemeasurement;inthiscase,itisthefourthentry,orCode3($81.24).Thismethodworkswellwhenthereisanoddnumberofrecords.Ifthereisanevennumberofrecords,taketheaverageofthemiddletwo.

The Weighted Average (Most Accurate)Amoreaccuratemethodistofactorinthefrequenciesforthecodesandthereforegivemoreweighttothoseproceduresthatareused(orreported)moreoften.Thismethodmoreaccuratelyrepresentstheactivityofthepractice.Byfactoringthefre-quency,wecancalculatetheweightedaverage,whichmoreaccuratelymeasurestheconversionfactorbasedonthenumberoftimeseachcodeisreported.Again,wewillusethesamedatasetasthepriortwoexamples.

1 2 3 4 5 6 7

Code Fee RVU Frequency Total Fees Total RVU CF

Code1 $1,087 10.215 1 $1087 10.215 106.42

Code2 $365 5.343 7 $2,555 37.401 68.31

Code3 $1,114 13.713 12 $13,368 164.556 81.24

Code4 $2,487 14.051 1 $2,487 14.051 177.65

Code5 $529 6.185 12 $6,348 74.22 85.53

Code6 $887 14.222 60 $53,220 853.32 63.37

Code7 $996 14.173 108 $107,568 1530.684 70.27

Totals $186,633 2,684.45

Thefirststepistomultiplythefeeforeachprocedure(column2)bythefrequencyforthatprocedure(column4)togetthetotalchargesforthatrecord(column5).ThenextstepistomultiplythetotaladjustedRVU(column3)bythefrequency(column4)foreachproceduretogetthetotalRVUforthatrecord(column6).Next,wegetthesumoftheproductsofthetotalfeesandtotalRVUsforallentriesinourdataset(ortable).Finally,wedividethegrandtotalfeesbythegrandtotalRVU.Theresultwillbethefrequencydistributedaverage,ormean,forthegroupofcodesrepresented.

Usingtheabovetable,wecalculatedthesumofthefeestobe$186,633andthesumoftheRVUstobe2,684.45.DividingtheRVUsintothefees,wegetadistributedmeanof69.52.Whilethisislessthantheothercalculations,itmoreaccuratelyrepre-sentstheactivitywithinthepractice.


-Best Practices78

BENCHMARKING FEESAbenchmarkisastandardagainstwhichsomethingcanbemeasuredorjudged.Sinceitisnearlyimpossibleforaprac-ticetocalculatemarketvalueforanysingleprocedurecodeorgroupofprocedurecodes,itisacceptableforapracticetobenchmarkitsfeesagainstanexternalsetofstandards.

Inthisfirststep,webegintoestablishbenchmarksagainstex-ternalmetrics.Thismay,tosome,feelliketheoldwayofdoingbusiness,butinfactitrepresentsamodelforsettingreasonableandlogicallimits.Usingbenchmarkmethodsmayprovetobethemostcomplexofwhatwewilldiscusshere,however,theyalsotendtobetheeasiesttodefend,sotheycanbeapowerfultoolfornegotiatingprofitablecontracts.

Whilenotconsideredevenareasonablefeeschedulebymany,theMedicareFeeSchedule(MFS)isusedtoensurethatchargesarenotbelowtheMFS’sallowableamountor,formanypractices,belowaratiooftheMFSallowable.

TheResource-BasedRelativeValueScale(RBRVS),acompo-nentoftheMFS,establishesandcomparestheconversionfactor(CF)levelsforeachcodeand,moreimportant,eachcodingcategory.GlobalCFvalueshelpusseethebiggerpictureasitrelatestooverallchargelevelswithinhomogenousgroups.Forexample,comparingthemean(average)conversionfactorforallsurgicalproceduresforgeneralsurgeonsagainstthesamemetricforageneralsurgerypracticewouldgivethepracticeahigh-levelviewoftheoverallchargestructureforitssurgicalprocedures.

ThePhysician/SupplierProcedureSummaryMasterFile(PSPSMF)contains100percentofallclaimssubmittedtoMedicareduringacalendaryear.Thisdatabasecontains5billionclaimsrepresentingeverybillableprocedurecodeperformedbynearlyeveryphysicianintheUnitedStates.Andbecausethemajorityofpracticessubmittheir”reasonable”chargestoMedicare,thePSPSMFisanexcellentdatasourcetodetermineaveragechargelevelsbynationalandstateaggre-gatesforeachprocedurecodebyspecialty.

COMPETITIVE FACTORAfterfinancialaspectsareconsidered,competitiondrivesfeesinnearlyeveryindustry.Practicesthatchoosetobecom-petitive,eitherbyspecialtyorlocation,maywanttobemoresensitivetothefeestheycharge.ThisisparticularlytrueforE/Mcodes,astheyareoften“shopped”bypatientsinhighlycompetitiveareas.Forthepurposeofthefeeanalysis,competi-tivenessisbrokendownintofivelevels,frommostcompetitive(Level1)toleastcompetitive(Level5).Inthemostcompeti-tivepractices,fewerprocedureswillberecommendedforfeeincreaseandforthoseproceduresthatdomeetthecriteria,theincreaseamountwillbeless.

Level 1 -Very competitivePracticesthatchoosetobeverycompetitiveintheirpricing.Thesepracticesareusuallylocatedinahighlypopulatedurbanareaorcity,competingwithmanyotherphysiciansforbasicprimarycarebusiness.

Level 2 -Somewhat competitivePracticesthatchoosetobeconservativelycompetitive.Whiletheyrecognizetheneedtoadjusttheirfeesreasonably,theymaybeinacompetitivemarketormayofferonlygeneralprimarycareservices,suchasawalk-incenterorurgentcarecenter.

Level 3 -Average competitivePracticesthatchoosetomaintainanaveragecompetitivepres-ence.Theywanttheirfeestofallinthecentralrangeforsimilartypesofphysiciansintheirarea.

Level 4 -Not very competitivePracticesthatchoosetobesomewhatlesscompetitivethanthoseinLevel3.Thiswillresultinmoreproceduresbeingflaggedforincreaseandaslightlyhigherincreaseforthoseflagged.

Level 5 -Not competitive at allPracticesthatchoosetobenoncompetitiveintheirpricingstructure.Atthislevel,theincreaseswillbemuchmoresignifi-cantthaninlowerlevels,aswillbetheamountoftheincreases.

COST-BASED METHODS Inmanybusinesses,feesareestablishedbasedonastandardcost-plus-markupmethodology,asisusedinretailing.Forexample,ahardwarestoremaywanta70percentmarkuponcertainbuildingproducts,sothepricingforsuchproductsiseasy:Add70percenttothecostoftheproduct.Manysmallbusinesses,especiallysoleproprietorships,failbecausetheownerdoesn’tunderstandtheconceptofthemethod.Whenalawyercharges$500perhour,thatisn’twhatthelawyermakes;that’sthegrossrevenuebeforeexpenses,taxes,etc.Ifaconsul-tantwantstoearn$50perhour,heorshecan’tcharge$50perhour;oneneedstocharge$50perhouraboveandbeyondthecostofdeliveringtheservices.

Noteherethatthecriticalcomponentisknowingthecostofdeliveringservices,andthatknowledgehasbeenaholygrailamonghealthcareprovidersforaverylongtime.Thinkaboutthebasicconcepthere:Doyouknowwhatyourhardcostistoperformanofficevisit?Ortoperformaminorsurgicalprocedure?Ortoseeapatientasafollow-uptoamajorsurgi-calprocedure?Theoverwhelmingmajorityofpracticesdon’t.Thefullimplicationsofknowing(ornotknowing)thecostsofdeliveringservicestoapatientpopulationisbeyondthescope

ofthischapter.Yethowcanweintelligentlysignamanagedcarecontractthatpromisesacertainfeeforacertainprocedurewhenwedon’tknowifthatfeeisaboveorbelowourcost?Theanswer,ofcourse,iswecan’t.

Fromtheperspectiveofafeeanalysis,wecanusecostseitheronanindividualbasisfordeterminingcontractprofitabilityorgloballytocreateafeeschedulebasedonthiscost-plus-markupmethod.Thefirststepistodetermineourcosts.Thatisaloteasierthanmostpeoplethink.

ThefirststepinvolvesbuildingabasicRBRVStableliketheoneinFigure3below.OnlyincludeproceduresthathaveanRVU.Itemsthatdon’tareusuallysupplies,suchasdrugs,cast-ingmaterial,etc.,anddevelopingafeeforthoseisrelativelysimple;youknowwhatyoupaidforthem,soaddingamarkupisassimpleasaddingyourmarkupratiotothecost.

ForRVU-basedprocedures,wemultiplytheRVUbythefrequencyandthendividethisintothetotalexpensesforthedataperiod.Forexample,ifapracticeweretoreportatotalof18,000RVUsduringthedataperiodanditsexpenses(minusthecostofnon-RVUsupplies)were$615,600,wecouldcalcu-late$34.20asthecostperRVU($615,600dividedby18,000RVUs).Thisallowsustodotwothings:calculatetheaveragecostperprocedureandcreateacost-plus-markupfeeschedule.

Theformerisarelativelysimpleprocedure:MultiplythecostperRVUtimestheRVUvalueforthatprocedure,whichisreadilyfoundinthepublicdomain.So,forexample,amid-leveloutpatientconsult(99243)hasanassociatednon-facilityun-adjustedtotalRVUof3.43.MultiplythisbythecostperRVU($34.20)andyougetahardcostof$117.30.Remember,thisisthecostbasedonwhatyouincludedinyourtotalexpenses.Ifyouincludedphysiciancompensation,thisrepresentstotalcosts,includingwhatthephysicianearns.

Usingthismodeltocreateormaintainafeescheduleisquiteabitsimplerthanapproachingitfromaline-itemperspec-tive.TakethecostperRVU,addamarkup,andmultiplythisnumberbytheRVUfortheindividualcode.Forexample,let’ssaywewanttohavea100percentmarkupoverourexpenses.MultiplythecostperRVUinthisexampleof$34.20by2andyouhaveacharge-per-RVUvalueof$68.40.MultiplythisbytheRVUfortheindividualprocedureandyouhavethenewfee.Ifweextendthistotheaboveexample,thenewfeeforthe99243procedureis$234.60(totalRVUof3.43multipliedbythecharge-per-RVUof$68.40).

Itisimportanttorememberthatjustbecauseyoubillusingaparticularfeedoesn’tmeanyouwillbepaidtheamountyoucharge.Thatrarelyifeverhappens.Whenyou’reconsideringusingacharge-basedmethodology,it’svitaltohaveahandleon

youraveragecollectionratiosbypayortypetoensurethat,inanycase,yourcostsdonotexceedcollection.

BENCHMARKING USING RBRVSRBRVShas,since1992,undergonequiteabitofreviewandrevisionandasaresulthasbecomeauniversallyacceptedmethodforfinancialbenchmarkingwithinmedicalpractices.Somemisconceptionsdostillprevail,suchasthenotionthateverypayorusesRBRVStodevelopitsfeeschedule.Thatsim-plyisn’ttrueanditcanbeeasilydisprovenjustbycalculatingtheconversionfactorforeachfee.

WhatistrueisthatRBRVS,asarelationalmodel,worksverywellwithinaclosedsystem,suchasamedicalpractice.Sinceitisrelational,itisquiteeffectiveinbalancingafeeprofilebetweencategoriesofcodesandbetweencodeswithinagivencategory.RBRVShelpstoassignarealparttoafee—thatofresourceconsumption.Contrarytopopularopinion,RVUsdonotmeasureproductivity,butratherconsumption—inotherwords,thevalueoftheresourcesthatareconsumedwhenaserviceisdeliveredoraprocedureisperformed.Later,whenwelookatusingacost-plus-markupmethod,youwillseehowwellRBRVSworksatfirstestablishingline-itemcostvaluesforeachprocedure.

Establishing Charge Thresholds TheMinimumChargeThreshold(MinCT)ismeasuredasaratiooftheMedicareFeeSchedule(MFS)andenablesapracticetodeterminethepointatwhichthefeeforaproceduremaybeconsideredbelowtheminimumamount.However,whileadropbelowthisthresholdmaytriggerareview,whenyou’reconsideringcompetitiveness,itdoesnotalwaysmeanthefeeshouldbeadjusted.

TheCFamountiscalculatedbymultiplyingtheMinCTratio(below)foreachcompetitivecategorybythecurrentMedicareCF.Thefollowingtableillustrateshowthatwouldworkusingthecurrentyear’sMedicareconversionfactorandmultiplyingitbytheMinCTfactor.Inthiscase,weusedthe2008CFof38.0870.

Figure 1 VeryCompetitive 1.1250 42.84788

SomewhatCompetitive 1.3125 49.98919

AverageCompetitive 1.5000 57.1305

NotVeryCompetitive 1.6875 64.27181

NotCompetitiveatAll 1.8750 71.41313

TheMaximumChargeThreshold(MaxCT)isalsomeasuredasaratiooftheMFSandenablesthepracticetodeterminethe


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pointatwhichthefeeforaproceduremaybeconsideredabovethemaximumamount.Inessence,theMaxCTistheceilingforthefeeschedulemodel.However,whilethefeeforaprocedureabovethisthresholdmaytriggerareview,inconsideringcompet-itivenessitdoesnotalwaysindicatethefeeshouldbeadjusted.

TheCFamountiscalculatedbymultiplyingtheMaxCTratioforeachcompetitivecategory(below)bythecurrentMedicareCF.Thefollowingtableillustrateshowthiswouldworkusingthe2008Medicareconversionfactorof38.0870.

Figure 2 Competitive Factor Min. Charge

ThresholdCF Amount

VeryCompetitive 3.0000 114.261

SomewhatCompetitive 3.5000 133.3045

AverageCompetitive 4.0000 152.348

NotVeryCompetitive 4.5000 171.3915

NotCompetitiveatAll 5.0000 190.435

Itisimportanttorememberthatthechargethresholdsareestab-lishedtotriggeraneventonly—reviewingthefeeforaprocedureindepthandagainstotherbenchmarks.Also,justbecausethefeeforaproceduremeetsoneoftheabovecriteriadoesnotneces-sarilymeanthefeeshouldbeautomaticallyadjusted.

Data ElementsInordertoperformafeescheduleanalysis,youwillneedaccesstothefollowinginformation:

•FeeSchedule

oProcedurecodew/modifier,ifany

oUsual,customary,andreasonable(UCR)amountoryourbilledcharge

oAnnual(orotherperiodized)frequency

oMedicarePhysicianFeeScheduleDatabase(www.cms.hhs.gov),whichcontainsallRVU,GPCI,andcriticalusageinfo

•Physician/SupplierProcedureSummaryMasterFile(PSPSMF)(locatedontheCMSwebsiteatwww.cms.hhs.gov).ThisfileisproducedbyCMSandrepresents100percentofallMedicareclaimsubmissions.

•Localeconometricdata(inflationaryrates)

•ConsumerPriceIndex,MedicalEconomicIndex,andlocal,regionalandnationalinformation

Withthisdatainhand,wecanmoveontotalkaboutthetoolsnecessaryforaphysicianpracticetoconductaproperfeeanalysis.

Building the Spreadsheet Tobegin,webuildaworksheettoserveasthebasisformanyofthedifferentfeeanalysismodelswewilldiscuss.

1.Startbylistingtheprocedurecodeincolumn1andthemodifier(ifany)inthenextcolumn.

2.Listthefeechargedtocommercialorprivatepayors(yourUCR)incolumn3.

3.Then,incolumn4,enterthefrequency(totalperyearorTPYbelow)atwhichyoubilledthiscodeduringtheanalysisperiod.

4.Nextdeterminethegrosschargesforeachprocedurecode.Todothis,multiplythefrequencyforeachcode(column4)bythefee(column3)andplacethisnumberincolumn5(TotFee).

5.InordertodevelopbothMFSandCFcomparisons,thetotalgeographicallyadjustedRVUforeachcode(column6)andthetotalRVUsbaseduponfrequencycalculations(column7)mustbeincluded.ToobtaintheMFS(non-facility)amount(column8),multiplythegeographicallyadjustedRVUbythecurrentMedicareCF(38.0870for2008).YoucanlocatethegeographicallyadjustedRVUdataonlineatwww.cms.hhs.gov/PFSlookup.Clickon“PhysicianFeeScheduleSearch.”

6.Next,calculatethepracticeconversionfactor(column9)foreachprocedurecodebydividingthefee(column3)bytheadjustedRVU(column6).

7.OnceyouhaveperformedthisexerciseforeachCPTcodethatyoubill,youwillwanttocalculatethedistributedCF(bottomofcolumn9)bymajorcodecategory.AmajorcodecategoryisdefinedbyCPTasthefollowing:

a.Surgery(10000-69999) b.Radiology(70000-79999 c.Pathology(80000-89999) d.Medicine(90000-99199and99500-99999) e.E/Mservices(99201-99499)Medicine-90000

through99999(excludingE/Mcodes) f.HCPCSII-prefixAthroughprefixV

FormoreinformationonCPTcodesandwheretoobtainthem,seeChapterII.

8.TocalculatethedistributedCF,dividethegrandtotalfee(bottomofcolumn5)amountbythegrandtotalRVU(bot-tomofcolumn7)amountforeachmajorcodecategory.

Figure3providesasampleofwhatacompletedtablewouldlooklike: Figure 3

1 1a 3 4 5 6 7 8 9

Code Modifier(if applicable)

Fee TPY TotFee RVU TotRVU MFS-NF CF

10060 $70 59 $4,130 2.07 122.13 $78.45 33.82

10140 $55 33 $1,815 2.51 82.83 $95.12 21.91

11040 $95 919 $87,305 1.01 928.19 $38.28 94.06

11050 $35 40 $1,400 0.81 32.40 $30.70 43.21

11422 $300 12 $3,600 3.53 42.36 $133.78 84.99

11720 $35 61 $2,135 0.74 45.14 $28.04 47.30

11730 $115 358 $41,170 1.77 633.66 $67.08 64.97

11750 $379 208 $78,832 3.76 782.08 $142.49 100.80

20550 $37 42 $1,554 1.93 81.06 $73.14 19.17

28090 $250 10 $2,500 9.16 91.60 $347.14 27.29

28126 $510 103 $5,2530 8.67 893.01 $328.57 58.82

28286 $775 313 $24,2575 9.76 3,054.88 $369.88 79.41

28296 $1450 409 $59,3050 18.45 7,546.05 $699.21 78.59

28298 $1410 403 $56,8230 16.70 6,730.10 $632.89 84.43

29540 $29 116 $3,364 0.94 109.04 $35.62 30.85

29580 $375 9 $3,375 2.47 22.23 $93.61 151.82

Total $1,687,565 21,196.76 79.61

Adjusting the FeesThefirststepindeterminingwhichproceduresmayneedafeeadjustmentistoidentifyfeesthatareundertheMFSallowableamount,bycomparingtheCFforeachprocedurecodetothecurrentyear’sMedicareCF(38.0870for2008).IftheCFforthecodefallsbelowtheMedicareCFforthecurrentyear,itisidentifiedasbeingbelowtheMFSallowableamount,ortheamountpublishedbyCMSforapracticeinagivengeographiclocation.

Thenextstepistoidentifycodeswherethecostofprovidingtheserviceexceedsthecollectionamount.Thatisaccomplishedbyreviewingresultsofthecostaccountinganalysis.(ThisisonlyvalidifthecostperRVUislessthan120percentoftheMedi-careCF.)IfthecostperRVUforthepractice,ascalculatedinthecostaccountinganalysis,isgreaterthan120percentoftheMedicareCF,thenitnormallyindicatesthatthepracticehasexpenseproblems,notfeeproblems,andsimplyraisingthefeeforaprocedureinthiscasewillnotresultinanassociatedincreaseinreimbursement.

Next,identifycodesbelowtheminimumchargethreshold(MinCT).ThisisbasedonaCFcalculatedasaratiooftheMedicareCF(38.0870for2008).ProcedurecodesinthetablethathaveaCF(column8)lessthanthisvalueareidentifiedwitha“Y”incolumn10andincludedintheanalysisforpossiblefeeadjustmentslater.Finally,identifygroupsthathavefeesinexcessoftheMaxCT,wheretheCF(column8)isinexcessoftheMaxCTratio(seefigure2).


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Figure4demonstrateswhatacompletedtablemaylooklike.

Figure 4 1 2 3 4 5 6 7 8 9 10 11

Code Fee TPY TotFee RVU TotRVU MFS-NF CF MFS MinCt MaxCT

10060 $70 59 $4,130 2.07 122.13 $78.45 33.74 Y Y

10140 $55 33 $1,815 2.51 82.83 $95.12 21.87 Y Y

11040 $95 919 $87,305 1.01 928.19 $38.28 94.06

11050 $35 40 $1,400 0.81 32.40 $30.70 43.16 Y

11422 $300 12 $3,600 3.53 42.36 $133.78 84.99

11720 $35 61 $2,135 0.74 45.14 $28.04 47.30 Y

11730 $115 358 $41,170 1.77 633.66 $67.08 64.97

11750 $379 208 $78,832 3.76 782.08 $142.49 100.80

20550 $37 42 $1,554 1.93 81.06 $73.14 19.13 Y Y

28090 $250 10 $2,500 9.16 91.60 $347.14 27.29 Y Y

28126 $510 103 $5,2530 8.67 893.01 $328.57 58.82

28286 $775 313 $24,575 9.76 3,054.88 $369.88 79.41

28296 $1450 409 $59,3050 18.45 7,546.05 $699.21 78.59

28298 $1410 403 $56,8230 16.70 6,730.10 $632.89 84.43

29540 $29 116 $3,364 0.94 109.04 $35.62 30.98 Y Y

29580 $375 9 $3,375 2.47 22.23 $93.61 151.82 Y

Notethattheletter‘Y’hasbeenplacedintheMinCT/MaxCTfieldsforcodesthatmetoneormoreofthecriteriaoutlinedabove.Thepractice,ofcourse,mayuseanymethodtoidentifycodesthatmeetorfallwithinthecriteria.Inthistable,forex-ample,procedurecode10060hasbeenidentifiedashavingafeebelowbothMedicareandtheMinCT.Code29580isidentifiedashavingafeethatisgreaterthanthedes-ignatedMaxCT.Thisdoesnotmeanthefeewillautomaticallybereduced;however,reducingthefeemaybeanoptionbasedonreimbursementfromallpayors.∆

Determine the Fee Adjustment AmountNowthatyouhavedeterminedwhichcodesshouldbereviewed,youneedtodeter-minewhetheranadjustmentiswarranted.Whilethedeterminationofhowmuchtoadjustafeecangetquitecomplex,formostpeopleitisbasedonanunderstandingofandexperiencewiththeeconomy,bothnationallyandinaspecificlocale.Listedbelowareseveralsourcesthatmaybeconsultedinthepercentadjustment.

•Categoricalconversionfactors.

•MedicareEconomicIndex(MEI).

•MedicalcomponentoftheConsumerPriceIndex(CPI).

•Localandnationalinflationaryindices.

•Otherrelevantdata(i.e.,DepartmentofHousingandUrbanDevelopmentinfo,todetermineincreaseinleaseamounts,ortheDepartmentofWageandLabor,todeterminetheaveragesalarybyspecificSICcode).

Iftheinformationorindicatorsareunknown,lookonline.Forexample,typing“con-sumerpriceindex”intoanyInternetsearchenginewillyieldconsiderablematerialonthesefinancialmetrics.

NegotiatingtheRVU/CFmodelcanbetricky.Forcalendaryears2007and2008,CMShasincludedwhatisknownastheBudgetNeutral-ityActreductionfactor.ThispolicyrequiresthattheworkRVUisfirstreducedbyabout12percentbeforebeingusedtocalculatetheMFS.Thereasonwementionthisistoavoidconfu-sionwithregardtobackingouttheconversionfactor.Forexample,ifyouweretotakethepublishedMFSallowableamountanddivideitbythecalculatedgeographicallyadjustedtotalRVU,youwouldnotgetthecurrentyearconversionfactor.Unfortunately,thereisnotsufficientspacetodiscussthisindetail;however,youcanfindadequateresourcesontheCMSwebsite(www.cms.hhs.gov)orthroughanInternetsearch.

Establish RBRVS-Based Adjustment AmountForproceduresthatarebelowMFS,undertheMinCT,orovertheMaxCT,thegoalistoutilizeeitherthemeanorthemedianconversionfactorforthatcodecat-egory—whichevermosteffectivelymeasuresthecentraltendencyofthecategoryconversionfactor.

IfthiscentralmeasurementoftheCFforthecodecategoryisbelowtheminimumchargeamountestablishedearlier,theminimumchargeamountcouldbeused.Similarly,ifthecentralmeasurementoftheCFforthecodecategoryisabovethemaximumchargeamountthatwaspreviouslyestablished,themaximumchargeamountcouldbeused.

Themodifier,totalfee,andtotalRVUcolumnscalculatedinprevioustableshavebeenhidden,astheyarenotrequiredtoperformthisexercise.Basedontheworkcompletedsofar,afeeanalysistablemaylooksomethinglikethefollowing:

Figure 5

1 2 3 5 7 8 9 10 11 12

Code Fee TPY RVU MFS-NF CF MFS MinCt MaxCT New Fee

10060 $70 59 2.07 $78.45 33.82 Y Y $165.19

10140 $55 33 2.51 $95.12 21.91 Y Y $200.20

11040 $95 919 1.01 $38.28 94.06

11050 $35 40 0.81 $30.70 43.16 Y $64.56

11422 $300 12 3.53 $133.78 84.99

11720 $35 61 0.74 $28.04 47.30 Y $58.92

11730 $115 358 1.77 $67.08 64.97 $125.32

11750 $379 208 3.76 $142.49 100.80 $413.00

20550 $37 42 1.93 $73.14 19.13 Y Y $153.98

28090 $250 10 9.16 $347.14 27.29 Y Y $729.40

28126 $510 103 8.67 $328.57 58.82 $638.17

28286 $775 313 9.76 $369.88 79.41

28296 $1450 409 18.45 $699.21 78.59

28298 $1410 403 16.70 $632.89 84.43 $1,536.48

29540 $29 116 0.94 $35.62 30.98 Y Y

Calculating the Net Financial ImpactThefinalimpacttothepracticeofafeescheduleadjustmentisnormallylessthanthedifferencebetweenthenewfeeandthecurrentfee.Thisisduetocollectionbasedonpayormix.UnlessthebilledchargefortheprocedureisbelowtheMedicarerate,anincreaseinafeewillnotresultinanincreaseinMedicarereimbursement.Thesameholdstrueformostmanagedcareplansandinsurers.

Onesimplewaytocalculatethenetfinancialimpactistomultiplythegrossimpactbytheaveragecollectionpercentforthepractice.Todothis:

1.InFigure6,below,subtractcolumn2fromcolumn12todeterminethevarianceandenterthatnumberintocolumn13.

2.Next,multiplythefrequency(column3)bythevariance(column13)togetthegrossimpactandenterthatvalueintocolumn14. Amoredetailedcalculationwilltakeintoaccountthepayormixthatwouldbeaf-fected(primarilytrueindemnityorcommercialfee-for-servicepayors).


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3.Tocalculatethenetimpact,multiplythepercentcollectionexpected(47.58per-centforthisexample)bytheexpectedfrequency(column3)andenterthisvalueintocolumn15.

Themodifier,totalfee,RVU,totalRVU,andMaxCTcolumnscalculatedinFigures3and4havebeenhidden,astheyarenotrequiredtoperformthisexercise.

Figure 6 1 2 3 9 10 12 13 14 15

Code Fee TPY MFS MinCt New Fee Variance Gross Net

10060 $70 59 Y Y $165 $95 $5,605 $2,667

10140 $55 33 Y Y $200 $145 $4,785 $2,277

11040 $95 919

11050 $35 40 Y $65 $30 $1,200 $571

11422 $300 12

11720 $35 61 Y $59 $24 $1,459 $694

11730 $115 358

11750 $379 208

20550 $37 42 Y Y $154 $117 $4,914 $2,338

28090 $250 10 Y Y $729 $479 $4,790 $2,279

28126 $510 103 $638 $128 $13,184 $6,273

28286 $775 313 $775 $0 $0 $0

28296 $1450 409

28298 $1410 403 Y $1,536 $126 $50,778 $24,160

29540 $29 116 Y Y $75 $46 $5,336 $2,539

29580 $375 9

TIME-BASED CALCULATIONSLawyersdoit.Accountantsdoit.Andmanyconsultantsdoit.Whatdotheseprofessionalshaveincommon?Theychargebytime.Thisisanage-oldinstitutionoffeescheduling;chargingbyaunitoftime.Noticethatwedidn’tsay“chargingbythehour.”Thoseofyouwhohavedealtwithattorneysoflatemayhavenoticedthattheychargebysmallerincrements,suchas15-minuteorevensix-minuteperiods.So,here’sthe$64,000question:Ifotherprofessionalscandoit,whycan’tphysicians?Andtheansweristhattheycan!

Therearebasicallytwowaystogoaboutconstructingatime-basedfeeschedule.Thefirstissimplytopickanhourlyamountoutoftheair—say$450.Thesecondistoincorporateexistingdata—suchascost,charge,orrevenueperhour—tocreateabenchmarkforthesetypesofcalculations.

New Time-to-Charge RatiosThisiswherewepickarateoutoftheair.Thisdoesn’tmeanthatthereisn’tsomelinktoreality.Itjustmeansthatwearen’tconsideringexistinginternaldatatodoso.Forexample,let’ssaythelocalattorneysaregetting$400anhourforservicesrendered.Mostphysicianshavespentmoretimeinschoolandtrainingthatthetypicalattorney,soaunitchargeof$450perhourwouldcertainlypassmusterasareasonableamount.

Convertingthishourlyratetoachargeforaprocedure,however,isalittletrickierthanitwouldbeforanattorney.Thephysician’sservicesaremoreredundant—they

dothesamethingsoverandover,andwhilethevarietyofdiagnosesandtreatmentissuesishuge,thechargeisbasedontheprocedure,notthefinaloutcome.Andphysicianswanttomaintainthesamechargeforthesameprocedureforallpayormodels.Ineffect,thisrequiresfiguringouttheaveragetimespentforeachprocedure.Thismeansweneedsomekindofstandardreferencetodefinetheamountoftimespentoneachprocedure.Thisreferencecanbearrivedatinoneoftwoways:Thepracticecaneithercreateitoruseanestablishedstandard.Creatingitfromscratchwouldentailanexperimentalprocessofrecordingtheamountoftimespentoneachprocedure,withasamplesizelargeenoughtocreateameanormediantimethatisstatisticallysignificant.TheotheroptionwouldbetousetheRelativeValueScaleUpdateCommittee(RUC)timestudy.Alinktothetimestudycanbefoundatwww.cmanet.org/bestpractices.

Regardlessofthestandardused,themodelwillbethesame.ForthefollowingexamplewearegoingtousetheRUCstudy.Themethodologyisactuallyverysimple:Multiplytheaveragenumberofminutesfortheprocedurebythechargeperhour(inthiscase,reducedtochargeperminute).Followingfromabove,let’slookatanexampleforthis.

Let’sassumethepracticehasdecidedonahypotheticalrateof$450perhour.Dividingby60minutes,thiscomesoutto$7.50perminute.TheRUCstudyreportstheaveragenumberofminutesforE/Mvisit99213as23.Multiplythe$7.50perminutebythereported23minutesanditequalsachargeof$172.50.Becausethisisacommonprocedureandweunder-standpatients’sensitivitytoofficevisitcharges,itprobablyisn’tasurprisethatthisseemsexcessive.Somepractices,seekingtobesensitivetotheneedsoftheircommunity,reducethevalueforE/Mcodesinaccordancewithinternalstandards.Thisstepalwayswarrantsconsideration.Forexample,withinthesamepracticeyoumayfindthatthephysiciansworkatdifferentpaces.

Ifwerunthesameanalysisforasurgicalcode,say49000(explorationofabdomen),thechargewouldbethechargeperminute($7.50)multipliedbytheaverageRUCminutes(304)toendupwithachargeof$2,280.

Existing Charge-to-Time RatioThedatasourcereferencesarethesamehereasintheaboveexample.Thedifferenceisthatthepracticehasexistingdatasupportingacharge-to-timeratio.Forexample,supposethepracticereported(foraparticularphysician)2,080workhourswithtotalchargesof$500,000.Dividingout,wegetapproxi-mately$240perhour(or$4perminute).Goingbacktothe99213usedintheexampleabove,weseethatthefeewouldbe$92($4perminutetimes23minutes).Forthesurgicalprocedureexample,thefeewouldbe$1,216($4perminutemultipliedby304minutes).

Work RVUsUsingworkRVUsdoesabitofanendrunaroundthetime-to-chargeratio,butitisjustaseffectiveamethodology.TheworkRVUiscalculatedprimarilybasedonthenumberofminutesreportedintheRUCstudy,whichgivesusapowerfulrelation-shipbetweenchargeperworkRVUandchargeperRUCmin-ute.ThedifferenceisthattheworkRVUincludesbothRUCtimeandeffort,sosomeconsideritamoreaccuratemetric.

Backtoouraboveexample,let’stakethephysicianwhore-portedthe$500,000ingrosschargesforagivenyear.Inthatsamedataperiod,thatphysicianreported5,656workRVUs.Divideoutandyougetanaveragecharge-to-workRVUratioof$88.40.

Movingintotheanalysis,wetaketheworkRVUsreportedfor99213(0.92)timestheratioof$88.4andwegetafeeof$81.38.Forthesurgicalcode49000,thefeewouldbe$1,100($88.4times12.44workRVUs).

Theonlycaveat:InestablishingthefeeusingworkRVUsonly,thepracticeisdiscountingtherelativecostassociatedwiththeseprocedures.Insomecasesthatcanbesignificant.ThepracticemaywanttoconsiderusingthetotalRVUratherthanjusttheworkRVUas,inthecurrentRBRVSmodel,theprac-ticeexpenseRVUisalsoaderivativeofthesameRUCtime.

GLOBAL CONVERSION FACTORSConversionfactorsaredollarvaluesthatareusedtoconverttheRVUvalueforaprocedureintoafee.Forexample,theMedicareconversionfactoriscurrently38.0870.For2008,procedurecode99213hasatotal(non-geographicallyadjusted)totalRVUof1.68.Multiplyingthetwotogether,weseeaMedicarenon-adjustedallowableamountof$63.67forparticipatingphysicians.

Forourpurposes,wewanttoapplyalittlealgebraand,us-ingthepractice’scurrentfee,divideitbytheRVUtogetthepractice’sconversionfactorforacode(orgroupofcodes).Forexample,ifthepracticecurrentlycharges$92fora99213,di-vidingbythetotalRVUof1.68,thepractice’sconversionfactoristhen$54.76.Accumulatingthisdatabymajorcodecategory,thepracticeisthenabletocalculatethemedianand/ormeanconversionfactor.

Forourpurposeshere,wesuggestcalculatingconversionfactorsbythemajorcodecategoriesasreferencedearlierinthischapter:

•Surgical-10000through69999

•Radiology-70000through79999

•Laboratoryandpathology-80000through99999


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•Evaluationandmanagement-99201through99499

•Medicine-90000through99999(excludingE/Mcodes)

•HCPCSII-prefixAthroughprefixV

TocalculatethemedianCFforthesurgicalgroup,thepracticewouldlisttheindi-vidualCFforeachsurgicalprocedureinaspreadsheet,sorttheminascendingorderbyCF,andthentakethemiddlevalueasthemedian.Ifthereisanevennumberofvalues,taketheaverageofthemiddletwo.Forexample,ifthepracticelistednineCFvaluesinthespreadsheet,itwouldusethefifthasthemedianastherewouldbefourvaluesbelowandfourvaluesabovethefifth.Iftherewere10,youwouldjusttaketheaverageofthevaluesinpositionfiveandsix.

Let’stakeapracticethathasgonethroughthisscenario,calculatedsurgicalconver-sionfactors,andcomeupwithamedianCFof100forthesurgicalgroup.Theme-dianforallphysicianswiththeirspecialtyfromthenationaldatabaseis111.Inthiscase,thepractice’ssurgicalCFisaround90percentofthenationalaverage,indicat-ingthatitsglobalchargemodelisbelowthatofitspeers.

Figure7givessomeexamplesofglobalCFvaluesbycategoryfordifferentgeographiclocations:

Figure 7

State Surgical Radiology Pathology Medicine E/M Weighted Avg

MD 86.52 98.94 80.87 76.90 56.27 73.67

ME 81.56 99.39 103.30 63.66 54.54 68.94

MI 70.34 86.10 86.51 73.54 51.72 65.12

MN 74.18 75.17 61.40 64.06 58.11 65.32

Remember,theglobalCFcalculationsdon’tnecessarilypinpointissueswithindividualcodesbutratherpointthepracticetoothermethods,suchasaveragechargecompari-sons,tohelpyouunderstandthecomparativerelationshipsbyindividualcode.

CHARGE DATA COMPARISONS Onceanewrecommendedfeeschedulehasbeenestablished,therevisedfeesshouldbecomparedtonationalandstateaveragechargelevels(availableatatwww.cmanet.org/bestpractices)forthosecodes.Thiscomparisoncanbeperformedusingdatathatisspecialty-specificorspecialty-agnostic.ThedataisalsocompiledfromthePhysician/SupplierProcedureSummaryMasterFile.Remember,theoverwhelmingmajorityofphysiciansandpracticessubmittheircommercialchargestoMedicare,asopposedtojusttheMedicareallowable.Therefore,thechargedatabasecontainsreasonablechargesand,simplyput,thedatabaseishuge.Incalculatingtheaverages,ifthepracticechoosestodosoitself,itshouldusetotalchargessubmitted,anddosoonlyfornon-modifiedcodes,sincephilosophiesforchargingformodifiersareinconsistent.

Inusingthisdata,becarefulnottomakeadjustmentstotherecommendednewfeesbasedsolelyonaveragechargelevels,oratleastdon’tdosoexpectingtogetaone-to-oneratioofreimbursement.Thisdatamay,however,beusedtoassessthefeeswithinthecommunity,definedbybothspecialtyandgeographicboundaries.It

canbeassumedthatthechargedataforallpractices,allclaims,andallspecialtiesistheaveragechargedatarepresentingjustthat:theaverageforallpractices.Therefore,ifthepracticedoessomethingspecial(cancercenter,tertiaryfacility,etc.),itwouldreasonabletoexpectthepractice’schargestobehigherthanaverage.Thesameholdstruefortheothersideofthespectrum.

Theonlytimethisdatashouldbeusedinconsideringafeescheduleadjustmentiswhentherearemajorvariancesbetweenthepractice’sfeescheduleamountandtheaveragecharges.Thechargedatabaseisreallynomorethanatooltounderstandthevaluethatotherprovidersplaceontheworktheydo.Figure8providesasamplefeecomparison:

Figure 8

Code Description Fee National Median

National Mean

Local Mean

Below National Mean

Below State Mean

10060 Drainageofskinabscess $70 $120.00 $130.56 $122.74 1 1

10140 Drainageofhematoma/fluid $55 $150.00 $176.24 $109.56 1 1

11050 Trimskinlesion $35 $44.74 $50.68 $55.81 1 1

11720 Debridenail,1-5 $35 $38.45 $49.05 $45.66 1 1

11730 Removalofnailplate $115 $103.63 $112.49 $116.64 -

11750 Removalofnailbed $379 $250.00 $265.28 $204.33 -

20550 Injtendonsheath/ligament $37 $100.00 $109.99 $91.05 1 1

28090 Removaloffootlesion $250 $610.00 $659.33 $551.09 1 1

28126 Partialremovaloftoe $510 $567.30 $604.78 $505.55 1

29540 Strappingofankleand/orft $29 $48.63 $51.99 $53.87 1 1

THE COHEN ACUITY FACTOR (CAF)Thefinalstepinestablishingafeescheduleisconsiderationofspecialservices,procedures,orworkthepracticedoesthatexceedsthatofitspeergroup.Remember,asinanyotherbusiness,experience,timeinspecialty,specialservices,uniqueness,andothersuchfactorsallplayapartindeterminingthevalueofthepractitioner.ACPAwhospecializesinforensics,forexample,maycommandahigherfeethanotherCPAs.Ahealthcareconsultantwhospecializesincompliancelitigationsupportmaycommandahigherfeethanotherconsultants.Andsimilarly,aphysicianwhospecial-izesinamorearcaneareaorsimplydoessomethingbetterthanotherphysiciansmayalsocommandahigherfee.

Sincethisisachapterontheimportanceandpowerofanalytics,weproposeamethodtomeasurethelevelofacuityoroverallcomplexityoftheservicesandpro-ceduresprovidedbyaphysiciantoagivenpatientpopulation.Thetheoryisthis:Ifwhatyoudoismorecomplexthanyourpeergroup,thenitiseasytodefendahigherfeeschedule.

TheCohenAcuityFactor(CAF)isavaluethatmeasurestherelativecomplexityoftheservicesandproceduresprovidedtoaspecificpatientpopulationbyamedicalpracticeand/ormedicalprovider.Itisnamedafteritsdeveloper,FrankCohen,andisreportedasaratioofworkRVUstoprocedure.DevelopingtheCAFisaccomplishedusingthenationalMedicaredatabasethroughfactoringofRVUvaluesinconnectionwiththeproceduresandservicesdeliveredtothatpatientpopulation.

Whilethedatacanbecalculatedbyphysician,specialty,and/orpractice,comparisonstothenationalaveragesarealwaysspecialty-specific.


-Best Practices88

How It WorksRVUsmeasureconsumptionofaresource,whethertime,effort,fixedorvariableexpenses,risk,etc.ThehighertheRVUvalue,thegreatertheconsumptionofthoseresources.Therefore,inmostcircumstancesthehighertheconsumptionofresources,thegreaterthecomplexityoftheserviceorprocedurebeingmeasured.ThisisparticularlytruewiththeworkRVUandismostapparentinE/Mcodes,althoughcertainlynotrestrictedtothatcategory.Forexample,CPTcode99204hasahigherRVUvaluethanCPTcode99202andthereforeconsumesmoreresourcesandisgenerallymorecomplexinitsapproach.

UsingtheworkRVU,wecanisolatetheconsumptionofresourcestophysiciantimeandeffort.Thisisimportant,asitintentionallyobscureswhatissometimesapotentiallyinflatedassessmentofthecostofthetechnologyassociatedwithsomeprocedures.Asnotedabove,thehighertheRVUvalue,thegreatertheresources,andhencethegreatertheoverallcomplexityofthatprocedureorservice.

Usingthisassumption,ifweweretoaveragetheratioofworkRVUsperprocedureforagivenpatientpopulationbyphysicianorspecialty,wecouldmeasuretheaveragelevelofcomplexityoftheservicesandproceduresdeliveredtothatpopulationbythatproviderentity.

CalculatingtheCAFisarelativelysimpleaffairandcanbecompletedusingtheini-tialRBRVStablewecreatedatthebeginningofthischapter.ThekeyistoonlylistproceduresthathaveworkRVU(ortotalRVU)values.Then,totalthespecificRVUvaluesanddividebythetotalfrequencyinthetable.

1.ThefirststepistomultiplytheRVUsforeachcode(column5)bythetotalfrequency(column4)forthatcodeandcalculatethesumoftheproductstogetagrandtotalforthiscolumn(column6).

2.Next,wetotalthefrequencyofuse(column4)codestogetthetotalfre-quencyforallcodesinthetable(448inthisexample).

3.AddthetotalRVUs(column6). 4.DividethegrandtotalRVUsbythetotalfrequencyfortheRVU-based

proceduresperformedduringthestudyperiod.

Inthebelowtable,youcanseeifwedividethetotalRVUsbythetotalfrequency,wewouldgetthefollowingacuityfactorforthissample:

934.63 Total RVUs / 448 total frequency = 2.09 Acuity Factor

Thatmeansthatforthepatientpopulationmeasured,theaveragenumberofRVUsperprocedure(orAcuityFactor)is2.09.Figure9providesanexampleofaCAFcalculation:

Figure 9

1 2 3 4 5 6

Procedure Code

Modifier Description Annualized Frequency

Factored adjusted Non-Facility RVU

Total RVUs

19240 58 Removalofbreast 1 30.59 30.59

19240 78 Removalofbreast 4 30.59 122.38

20200 51 Musclebiopsy 4 2.68 10.70

20200 Musclebiopsy 8 5.35 42.80

20520 Removalofforeignbody 1 4.83 4.83

1 2 3 4 5 6

Procedure Code

Modifier Description Annualized Frequency

Factored adjusted Non-Facility RVU

Total RVUs

20550 51 Injtendonsheath/ligament 1 0.86 0.86

20550 59 Injtendonsheath/ligament 7 1.72 12.05

20550 LT Injtendonsheath/ligament 15 1.72 25.82

20550 RT Injtendonsheath/ligament 11 1.72 18.93

20550 Injtendonsheath/ligament 218 1.72 375.24

20551 59 Injtendonorigin/insertion 1 1.69 1.69

20551 Injtendonorigin/insertion 23 1.69 38.87

20552 RT Injtriggerpoint,1/2muscle 1 1.65 1.65

20552 Injtriggerpoint,1/2muscle 106 1.65 174.71

20553 Injtriggerpoints,=/>3 2 1.86 3.71

20600 LT Drain/inject,joint/bursa 7 1.55 10.88

20600 Drain/inject,joint/bursa 38 1.55 58.90

Totals 448 934.63

ThekeyistocomparetheCAFforthepracticetothatofapeergroup.Com-parisonscanbemadebetweenphysicianswithinthegroupcanbecomparedtonationaland/orlocaldatacalculatedusinganappropriatedatabase.Ifthepractice’sCAFisgreaterthanthecomparisongroup’s,thatwouldprovidegreaterdefensibilityforahigherfee.

Thefollowinggraphsillustrateacomparisontootherphysicianswithinthegroupandthenationalaverageforthisspecialty.

Figure 10 - Work Acuity as a Percent of Practice by Physician

0%

50%

100%

150%

200%

ADC DEB JDD JWH MJD RAF RAN WHS WML

Figure 11 - Work Acuity as a Percent of National Ave by Physician

0%

100%

200%

300%

500%

400%

600%

ADC DEB JDD JWH MJD RAF RAN WHS WML


-Best Practices90

IftheCAFforthepracticeislowerthantheCAFforthenationalaverage,asdemonstratedinthisexample,itwouldindicatethatwhatthepracticedoesislesscomplex,andsometimeslower-than-averagefeeswouldbereasonable.

SUMMARYAprimarygoalofthephysicianpracticeistobeprofitable.Developingandmain-tainingafeescheduleforthephysicianpracticeisasimpletask,butdevelopingandmaintainingafeeschedulecorrectlyisnot.Failuretofollowstandardbusinessprin-ciplesiswhatfrequentlykeepsaphysicianpracticefromachievingfinancialsuccess.

Whenaproperfeeschedulehasbeendeveloped,practicesshouldremembertoroutinelymeasurethefeeschedule’sperformancebymeasuringitagainstEOBandothervalidationdata.Itisrecommendedthatpracticesestablisharegularscheduleforreview.Thisreviewmaybedoneeveryquarter,everysixmonths,oronceayear.Thefrequencyofreviewisn’timportant;theactionis.Practicesthatallowtoomuchtimetopassbetweenreviewsmayfindthemselvesstartingtheentireprocessover—anunnecessaryandburdensomechore.

-Best Practices92

Surviving Out-of-Network: One Physician’s Experience

By Frank Cohen, MPA, MIT Solutions Inc.

Important Note: The fees and other amounts referred to in this chapter are shown as examples only. The publisher makes no suggestions or recommendations as to fees charged by individual practitioners.

In1897aSwedishimmigrant,caughtupingoldrushfever,tookallthemoneyhehadandjourneyedfromSeattletotheAlaskanfrontiertofindhisfortune.Twoyearsofprospectinginthewildernessfinallypaidoffwhenhestruckgold.Hisnewfoundwealthwasshortlived,however.Thestaketohisclaimwasdisputed.Heeventu-allysettledtheargumentbysellinghisstaketotheotherclaimantfor$13,000.Hisadversaryeventuallyextracted$5millionworthofgoldfromthestrike.

TheSwedishimmigrantretreatedbacktoSeattleandmovedinwithhissister.Heandafriendenlargedthefriend’sshoerepairshopintoaretailshoestore.Theygrewthebusiness,expandingtootherlocations.Decadeslater,afterbuyingouthisfriendtoprovideemploymentopportunitiesforfamilyoffspring,hisfamilybusinessaddedclothinglines,allthewhiledependingonsuperiorcustomerservicetomaintainacompetitiveedge.

Tokeepupwithchangesintheworldaroundhim,thisSwedishimmigrantwhobe-ganasafailedgoldprospectorendedupcreatingwhathasevolvedintoperhapsthepremierclothingretailerinAmerica.HisnamewasJohnNordstrom.HiscompanycametobenamedNordstromInc.

ItallstartedwhenaprospectorintheAlaskanwilderness,theloserofadispute,decidedtogoinanewdirection.HecouldhavewanderedthemountainsofAlaskaorthestreetsofAnchorageuntilhediedofoldage,complainingthathe’dbeentreatedunfairly.Hecouldhavefoughtthebitterfightwithhisgoldstrikeadversarytopreservewhathehadworkedsohardtoacquire.

Yethechosetolookfornewopportunity.Insodoing,hefrequentlychangedandevolvedhisbusinessmodeltomeettheneedsofchangingeconomictimes.Andasitisoftensaid,“Therestishistory.”

CREATING AN OPPORTUNITYSowhatdoesthishavetodowiththepracticeofmedicineanyway?

WhileIclaimtobenoJohnNordstromandmychildrenmostcertainlywon’tbeleftwiththeemploymentopportunitieslefttoaSeattleNordstromoffspring(sorrykids),I’vefoundinspirationinhowacrustyprospectornotonlyfoundawaytosucceedwhenchangecameuponhim,butheusedextraordinarycustomerservicetomakeithappen.

ThepracticeofmedicineisnotwhatIthoughtitwouldbe.Thebusinessofmedicineisconsiderablymorecomplicatedthanwhenmyfatherwasapracticingphysician.Itiscontrolledbyforcesfarbeyondmypersonalreach.Muchofthewaythingsarenow,Idonotlike.

9


ForawhileIcomplainedbitterlythatthepracticeofmedi-cineisnotasitshouldorusedtobe.Yet,Idon’twanttobeafailedprospectorwanderinginthewildernesscomplainingthatthingsarenotfair.ThisiswhereIfindinspirationinthestoryofJohnNordstrom.

Afewyearsago,practicingmedicineoutsideofhealthinsur-ancenetworkswasaconceptthatnevercrossedmymind.Ididn’t’evenknowwhatan“out-of-networkprovider”was.Butthat’swhatI’vebecome.Morphingmypracticetoanout-of-networkenvironmenthasnotbeenaparticularlyeasyprocess,butithasworkedandI’mgladI’monthatroad.

I’manophthalmicplasticsurgeon.WhenItellmystorytofel-lowphysicians,thoseinotherspecialtieslamentthatitiseasierforaspecialistsuchasmetodothis.Theparadoxformeinallthisisthatafamilymedicinedoctordownthehallwayinmymedicalofficebuildingismyrolemodel.Hemadeitworkyearsago.We’reatthetwoextremesofspecialization.Ifwebothmadeitwork,socanyou.

I’vemadeupmymindthatmedicineisnotalldoomandgloom.ItisnotthewayIwantedittobe,butthereisenormousopportunitybeforeus.There’sopportunitytofindabetterwaytotakecareofpatients.There’sopportunitytotakebackthepracticeofmedicine.There’sopportunitytostopyourpersonalincomefromitsunrelentingcontraction.

Thereisenormousopportunitybeforeus.

PLAN YOUR STRATEGY FOR SUCCESSWephysiciansclingdearlytotheimplicitpromisethatifweworkhardtobecomedoctors,andthereafterspendendlesshourstakinggoodcareofourpatients,thenAmericansocietywillrewarduswithanincomecommensuratewithoureduca-tionandtraining.

Thisimpliedpromiseisfading.Nomorecanadoctorcompleteyearsoftraining,setupaprivatepractice,unlockthefrontdoor,turnonthephone,andlivehappilyeverafter.Theeconomicsnolongerworkthatway.

Ourreactiontothisfadingpromiseisoftentofeelfrustratedordefeated.Fromthisperspectivewe’reoftentemptedtoreacttochangesinthebusinessofmedicinewithoutadequatefore-thought,or,evenworse,wereactimpulsively.

Manyphysicianshavethoughtfullyplannedoutandsucceededinofferingtheirservicesoutsidetraditionalhealthinsurancephysiciannetworks.Otherswho’veangrilyannouncedwithoutplanning,“We’recancellingallournetworkcontractstoday!”havefailed.

Iimploreyoutoplanthoughtfullyforyoursuccessasanout-of-networkprovider.Bethoroughandcomplete.

APPROACHING THE DECISIONSoyou’rewonderingifyoushouldstepawayfromyourcon-tractualrelationshipwithaninsurancecarrier.Nodoubtyou’reawarethatmanypeoplethinkphysiciansarepoorbusinesspeopleandyou’dliketoprovethemallwrong.Isuggestyoudelveintoyourpracticefinancesforanswers.

Propose a Salary for YourselfTodate,yourpersonalincomeprobablyboileddowntowhateverwasleftintheaccountafterthebillswerepaid.Thatamountisprobablyshrinkingoryouwouldn’tbereadingthis.Startattheoppositeend.Ratherthansettleforwhat’sleft,identifyareasonablesalaryforyourself.Forthepurposesofexample,let’sproposeagrosssalaryof$240,000peryear.

Calculate the Hourly Cost of Doing BusinessDecidehowmanyhoursyouwanttoworktogeneratethatpersonalincome.Determinetheproportionofthosehoursthatwillbespentgeneratingcharges(seeingpatients,formostofus),versustheproportionthatwillbespentperformingnonreimbursableduties.Nonreimbursabledutieswillincludepracticemanagement,coordinationofpatientcare,vacations,andcontinuingeducation.

Youmightsayforexamplethatyou’dliketowork50hoursperweekspending40hoursperweekseeingpatients,withsixweeksoutoftheofficeperyear.Thiswillannualizeoutto40chargeablehoursperweekmultipliedby46weeksperyear(52weeksminus6weeksofvacation)or1,920hoursperyear.

Nextdeterminethegrossreceiptsyouwillneedtoreceiveperhourtogeneratethesalaryyou’dliketoreceive.Toexpanduponourexample,ifyoudivide$240,000(grosssalary)by1,920hours,youwillneedtogenerate$125perhour.

Next,calculatethehourlyoverheadcost.Lookatthean-nualizedcostofrunningyourpracticeasidefromyoursalary.Let’ssayforexample,thatoverthepast12monthsyourtotalexpenseswere$300,000.Dividethisnumberbythenumberofhoursyouplantospendgeneratingincome,inthiscase,1920.Thiscalculatestoanhourlyoverheadcostofjustover$156.

You’llnowwanttocalculatethegrossreceiptsperhouryou’llneedtogeneratetomeetyourbudget.Todothis,addyoursal-ary($125/hour)toyourhourlyoverheadexpense($156/hour).Thisequals$281perhour.Thisistheamountofmoneyyou’llneedtogenerateperhouroftimespentseeingpatients,tomeetyourproposedbudget.

9Pleasenotethisisanarbitraryfigureandisforillustrationpurposesonly. SurvivingOut-of-Network-OnePhysician’sExperience- 93

-Best Practices94

Finallycalculatethechargesorusualandcustomaryrates(UCR)perCPTcoderequiredtofityourbudget.Let’suseahypotheticalEvaluation&Management(E/M)code99XXX.Let’ssayyoutypicallyspend10minuteswithapatientforthiscode,andthatyoucancompletesixoftheseexamsperhour.Ifyou’recalculatingthetimenecessaryforacodewithaglobalperiod,don’tforgettoincludeaveragetimespentinfollow-upvisits.CalculatetherequiredUCRforthisCPTcodebydivid-ingyourproposedhourlyincomebythetimespentforthiscode.Forexample,dividingyourrequiredhourly$281chargebysixvisits,leadstoachargeofjustunder$47forCPTcode99XXX.YouwillneedtorepeatthisanalysisforeachofyourmostcommonlyusedCPTcodes.Forexample:

Gross receipts per hour ($281) / 6 visits = $47 UCR for CPT 99XXX.

GoingthroughanddetermininghowmanyofeachprocedureorserviceyoucurrentlyprovideeachmonthonaveragewillprovideabasisforyourUCRpercode.ThisanalysiswillalsoallowyoutoidentifywhetheryourUCRshouldbeadjusted(upordown),willidentifyservicesthatdon’taddvalue,orwhetheryoushouldconsiderpromotingservicesthatdo.

Determine Whether Contracted Fees Meet YourBudgetary RequirementsOnceyou’vegottenthisfar,itshouldbeeasytocompareyourbudgetedCPTchargestothefeeschedulesinyourthirdpartycontracts.IfyoufindshortfallswithmorethanahandfulofCPTcodesandtheseshortfallsaren’tbalancedoutbyothercodeswherereimbursementisgreaterthanyourbudgetarygoal,you’veidentifiedthiscarrierasaproblem.

PayattentiontoMedicarefeesfortworeasons.First,Medicareratesareslatedtodecreasebyupto30percentoverthenextfewyears.ManycommercialpayorsofferfeeschedulesthatarebasedonapercentageofcurrentyearMedicarerates.IfanyofyourcontractsarebasedonapercentageofMedicare,youcanexpectthemtodeclineaccordingly.

Second,mostinsurancecontractsincludecoordinationofben-efitslanguagethatstatesthatwhenMedicareisprimaryandthecommercialpayorissecondary,thecommercialpayorwillonlypayuptothecontractedrate.

Example

For a particular service, Medicare allows $100 but the commercial payor contract pays only $80.

• Physician bills Medicare $100.

• Medicare pays $80.

• Commercial Payor pays nothing.

Increasingly,commercialpayorsareofferingratesthatarebelowtheMedicarefeeschedule.Moreover,thecoordinationofbenefitslanguageprohibitsthephysicianfrombillingthepa-tient,requiringthepracticetowrite-offtheunpaidbalance.

Quantify the Hassle FactorThisisagoodtimetoidentifycarriersthatcauseunduegriefinthepracticeofmedicine.Quantifyingthe“hasslefactor”isdifficult,butcanandshouldbedone.Forexample,youshouldnotethosepayorswithwhichyourpracticehasthemostprob-lemsonaregularbasis.Considertheamountoftimeandworkboththephysicianandstaffdevotetoinappropriatetreatmentauthorizationdenials,claimdenials,appealingunfairmedicalpolicies,obtainingpriorauthorizations,checkingclaimsstatus,unfairbundlingedits,andotherunfairpoliciesthatresultinunnecessaryrework.Whenyouadduptheamountoftimeandresourcesthepracticemustspendaddressingtheseadministra-tivehasslesandmultiplythatbytheaveragehourlyrate,youwilllikelyfindthatcertainpayorsaredrainingyourresources.Yourassessmentmayfindthatthehighestnegotiatedrateswillturnouttobethelowest.

Ifyouidentifyapayorthatappearstomeetyourbudgetrequire-ments,butleadsthepackinadministrativehassles,youmaywanttorethinkyourcontractualrelationship.Sometimestheadmin-istrativeburdenofcontinuingtoworkwithapayorissimplytoocostlyandnolongerbringsaddedvaluetothepractice.

Choose to Make a Change Ifyou’veidentifiedaproblematicpayor,you’llneedtoact.Amongyouroptionsatthispointaretoadjustyourbudgetbyloweringyourproposedsalaryorreducingyourofficeoverhead.Alternatively,youcouldconsiderincreasingthenumberofhoursyouseepatients.YoushouldsetupacomplianceprogramtoinsureyourCPTcodingisaccurate.Regularreviewofyourcodingcomparedwithyourbilledchargesnotonlyhelpspre-ventovercoding,italsohelpstoensurethatyouarenotleavingmoneyonthetablebyundercodingorinadvertentlyomittingservicesthatshouldhavebeenbilled.

Ifyouarelikemostphysicians,you’veprobablyalreadyex-haustedtheseoptions,whichiswhyyou’restillreadingthis

article.Yourremainingchoicesaretonegotiatereasonabletermswiththepayorortobecomean“out-of-networkprovider.” Ifthepayorisunwillingtonegotiatereasonabletermsandyouhavealreadyattempt-edorgiventhoughtfulconsiderationtotheoptionsabove,itmaybetimetoconsiderbecominganout-of-networkphysician.Thefreedomofcontrollingyourownpracticebyrejectingtheremarkableencumbrancesinherentinpracticinginsideinsurancenetworkscanbefulfilling.IhavefoundthatitisawaytotakebettercareofpatientsontermsthatIandmypatientsmutuallyagreeupon.Ω

IDENTIFY A STRATEGYHaveyouidentifiedthatyouwillneedtoleaveasinglenetwork,multiplenetworks,orperhapsallnetworks?Ifso,youwillneedtodeterminewhatpercentageofyourpracticesfinancesarederivedfromeachofthepayorsinquestion.Moreover,howwillyoumarketyourservicestothosepatientsasanout-of-networkprovider?

Review and Understand Contract Exit CriteriaMostofussignedpayorcontractsastheywerepresentedtous,presumingwehadnochoicebuttodoso.Insodoingwemayhaveunwittinglyagreedtoprohibitivetermsthatlimityourabilitytoterminatewhenyouwantto.

Examplesofissuesthatyoumayhavetodealincludebutarenotlimitedto:durationofterminationnotificationperiod;gagclausesthatseeminglyprohibityoufromtalk-ingtoanattorney,consultant,orpatientaboutthematter;andrestrictionsonyourabilitytolimitorcloseyourpracticetonewpatientsunlessyoudothesamewithotherpayors.Forexample,onepayorcontractinexistencewillonlyhonortermina-tionsthatarereceivedwithin180daysoftheanniversaryofthedatethecontractwaseffective.Tofurthercompoundtheproblem,ifyoufailtoterminatethecontractwithintherequiredtimeframe,byevenoneday,youarestuckforanothertwoyears.

Beforeyouexitapayornetwork,you’llneedtoobtainacopyofthecontractandreviewtheterminationprovisions.Itisimportantthatyoufollowthoseprovisionstoensurethatyouhavesuccessfullyterminatedtheagreement.Ifyoudonothaveacopyofthecontractyoushouldrequestonefromthepayorinwritingviacertifiedmailwithreturnreceipt.Ω

Determine How Your Practice’s Finances Will be Affected Thestrategyyouchoosewilldependprimarilyonthepercentageofyourpracticefinancesaffectedbythethirdpartycontractsinquestion.Clearly,itwouldbeunwisetocancelacontractthatturnsawayalargepercentageofyourpatients,unlessyouhaveaplantoreplacethem.

Youcanquicklydeterminethepercentageofreceiptsfromeachpayorbycreatingareportcalledthepayormix.Thisreportcomparesthetotalbilledchargesandpay-mentsreceivedfromeachpayortothegrandtotalpaymentsreceivedtodeterminethepercentagefromeach.JustbecausePayorBcomprises20percentofyourgrossbilledchargesdoesnotmeanthatPayorBcontributes20percentofthereceipts.

Intheexamplebelow(Figure1),24percentoftheoverallbilledchargesareattributedtoPayorB,yetthispayoronlycontributesto18.40percentofthetotalreceipts.Thisindicatesthereisanissuewiththiscontract,whetheritbethereimbursementrateorpar-ticularpayorpolicies,thedataindicatesathoroughreviewofthiscontractiswarranted.

BALANCE BILLINGCaliforniaphysiciansshouldbeawarethatonJanuary8,2009,theCaliforniaSupremeCourtputanendtothecontroversysurrounding“bal-ancebilling”ofHMOenrolleesintheemergencycarecontext-thepracticebyout-of-networkproviderstobillpatientsthebalanceofanemergencycarebillthatthepatients’Knox-Keeneplanrefusedtopay.TheCourtinProspectMedicalGroupv.NorthridgeEmergencyMedi-calGroup,__Cal.Rptr.3d__,2009WL36855(2009)(Prospect),ruledthattheKnox-KeeneActprohibitsthispracticeofbalancebilling.Thecourtclarifiedthatprovidersmayonlyseekrecourseagainstthepayors,notpatients,forunderpayments.TheDepartmentofManagedHealthCaretoohastakenactiontoprohibitnoncontractedprovidersfrombalancebillingforemergencycareservices,promulgatingaregula-tion,28C.C.R.sec.1300.71.39,thatdefinessuchpracticestobean“unfairbillingpattern.”TheProspectdecisionandtheDMHC’sregulationmakeitclearthatbalancebillingforemergencycareservicesisnolongerpermittedifthepatientiscoveredbyaKnoxKeene-regulatedplan(HMOs,certainPPOs,andanydelegatedmedi-calgroupsorriskbearingorganizations).FormoreinformationabouttheProspectdecisionanditsimplications,seeCMA’sBalanceBillingToolkitatwww.cmanet.org.

AsampleletterforrequestingcopiesofyourcontractsisavailableintheAppendix.

AsamplecontractterminationletterisavailableintheAppendix.AlsointheAppendixisasampleletterthatyoucanusetonotifyyourpatientsofyourdecisiontoterminateahealthplancontract.

SurvivingOut-of-Network-OnePhysician’sExperience- 95

-Best Practices96

Figure 1 - Sample Payor Mix: Time Period - January 1, 2008 through June 30, 2008

Payor TotalBilledCharges %ofTotal BilledCharges

TotalPayment %ofTotalPayments

Medicare $33,000 12% $14,850.00 11.19%

Medicaid $13,750 5% $3,437.50 2.59%

ManagedMedicade (ifapplicable)

$19,250 7% $5,197.50 3.92%

Medicare Advantage

$8,250 3% $3,712.50 2.80%

Worker’sComp $27,500 10% $16,500.00 12.43%

PayorA $52,250 19% $26,125.00 19.68%

PayorB $66,000 24% $24,420.00 18.40%

PayorC $33,000 12% $19,800.00 14.92%

Self-Pay $22,000 8% $18,700.00 14.09%

Total $275,000 100% $132,742.50 100.00%

Inaddition,youwillwanttorunareportofpatientnamesbypayor.Ideally,thisreportwillincludethepatient’smailingaddressthatcanlaterbeusedtocreatemailinglabelsfornoticesyouwillwanttosendtoyourpatientsshouldyoudecidetoterminateanyofyourcontracts.∆

Thestrategyyouchooseshouldbeonethatdoesnotsubstantiallydisrupttheflowofpatientsthroughyourpractice.Ifyouhaveonlyoneproblematicpayorandthepercentageofyourgrossreceiptsissmall,yourapproachwillbefardifferentthanifyouhavealargepayorornumeroussmallpayorswithwhichyoumustresolveissues.

Tailor a Strategy to Your Circumstances

Wean Your Practice from a Contract Ifaproblematiccarrierhastoogreataninfluenceonyourpracticefinancestosustainanabruptcancellation,yourapproachwillneedtobemoremethodical.Firstyou’llneedtodecidewhetherpatientsfrommorereasonablecarrierswill“fillintheblanks”inyourappointmentschedule,shouldyoudecidetocancelyourcontractwiththatcarrier.

Ifyoubelievetheywill,thebeststrategywillbetoorchestrateaslowunwindingofyourrelationshipwiththepayorbylimitingorclosingyourpracticetonewpatientswithPayorX.ThisgivesyoutheabilitytoslowlydecreasethepercentageofPayorXpatientsinyourpracticewhileallowingtimetoadjustfinancially.Itcanalsobeeasieronyourexistingpatients.DependingonthevolumeofbusinessfromPayorXitcouldtake6monthsorlongertosuccessfullyweanyourpracticefromthepayor.Oncethevolumehasbeenreducedtoalevelofminimalfinancialimpact,youcancomfortablyterminatetheagreement.

Terminate a Contract OutrightPerhapsyou’vedeterminedthatmostpayorsmeetyourbudgetand“hasslefactor”criteriaandnoactionisnecessary,butasinglepayorwithminimalinfluenceonyourpractice’sfinancesisyouronlyproblematiccontract.Inthisscenario,thebestapproachwilllikelybetosimplyterminatethatsinglecontract.Ifyou’vegotabusypracticewhereinpatientswithlessproblematicpayorswillfillintheappointmentslots,youarelesslikelytonoticeanydisruption.Whencommunicatingwiththirdpartypayorsonmattersofthisimportance,alwaysusecertifiedmailwithreturnreceipt.Ω

Itisextremelyimportanttoregularlymonitoryourpayormix.Onceapayorreaches30percentofyourbusiness,theycanstarttohavesignifi-cantcontroloveryourpractice.Forexample,ifapayormakesamaterialchangetoapaymentrule,medicalpolicyortotheirfeeschedulethatyoufindobjectionableitismuchmoredifficulttowalkawaywhenapayor“owns”suchalargeportionofyourpractice.

AsamplecontractterminationletterisavailableintheAppendix.

Become an Out-of-Network ProviderOvertime,youmayalsodecidethatyouwouldliketoleavetheworldofcontractingandbecomeanout-of-networkprovider.ThisstrategyisnearanddeartomyheartbecauseIbelieveitreturnsmanagementofpatientcarewhereitbelongsandusedtobe-betweenthedoctorandpatient.Itcanaffordyoutheopportunitytomarkedlyimprovethecareyouofferpatientsand,forme,hasreturnedthejoyandfulfillmenttothepracticeofmedicine.Asanout-of-networkprovideryouwillcareforpatientsoutsidetheconstraintsofthirdpartycontracts.ThiswillallowyoutofollowCPTcodingguidelineswithoutbeingvictimizedbyarbitraryandcapriciousthirdpartymedicalandpaymentpolicies,allowingyoutobepaidappropriatelyfortheservicesyouprovide.

However,leavingallpayornetworksatthesametimeisnotrecommended.Thedecisiontobecomeanout-of-networkproviderisonethatrequirescarefulconsiderationandplanning.Abruptterminationofallofyourpayorcontractsatoncecouldhaveadeleteriouseffectontheviabilityofyourpractice.

WhenIbeganpracticingmedicineintheearly1990s,thereimbursementcrunchwashitting.Everyyearatnationalmeetingswewereadvisedtocounterthecutsbyseeingperhapstwomorepatientsperdayintheclinic.Thatstrategyworkedgreat.Butthenwewentbackthenextyearandreceivedthesameadvice,andthenextyear,andthenextyear…..Nowwe’reallseeingtwiceasmanypatientsaswedidtwentyyearsagoandpatientsarecomplainingandrightfullyso,inmyopinion,thattheyfeellikethey’rebeingherdedlikecattle.

Perhapsit’stimeforyoutosetyourprofessionalGPSonanewtarget.

DEVELOP AN OUT-OF-NETWORK STRATEGIC PLANItisbeyondthescopeofthischaptertothoroughlyanalyzespecificcontractterminationorcontractweaningstrategies,excepttosaythatmaintainingadiversifiedthirdparty“bookofbusiness”willallowyoutomaneuverbetteramongthirdpartypayorissuesthanifyoumaintaindependenceonafewpayorsforthemajorityofyourpracticereceipts.(Refertopayormixfigureabove.)

Change Your Practice MindsetWipefromyourinnocentlipsthestatement“Wedon’ttakethatinsurance,”andpolitelyadmonishyourstafftodothesame.Instead,replacethatmindsetwith:

“ We work with all insurance carriers. We are contracted providers with some, but have found it necessary to care for some patients

from outside their carrier’s network. Yet, we desire to care for anyone who seeks our services and will work very hard to make it work for you even if we’re not a contracted provider.”

Help Patients Understand What It Means to Be Out-of-NetworkOneofyourearliestandperhapsgreatestchallengeswillbehelpingyourpatientsunderstandtheimpactofyourout-of-network(OON)statusonthem.Understandably,patientsarefearfulofseekingyourserviceswhen“you’renotinmynetwork.”Theyhavenoideawhatwillhappeniftheygotoadoctoroutsideoftheirnetwork.Yourfirsthurdlewillbetoconfirmforthemtheirout-of-pocketexpenseswillbeafford-able.You’llthereforeneedtobeabletohelpthemsortthroughthesometimescomplicatedpoliciesoftheircarrier.

Whenyoustart,thiswilllikelyseemquiteburdensometoyourstaff,butovertimeyou’lllearntorecognizepatternsofinsur-ancecarrierbehavior.You’lldevelopcontactswiththirdpartypayors,andtheprocesswillbecomeroutine.

Duringthecourseoftheconversationwhennewpatientscall,weaskwhatkindofinsurancetheyhave.Ifwearenotcontractedwiththatpayor,weinformthemthatweareanout-of-networkprovider.Asmentionedabove,weareverycarefulNOTtotellthem“Wedon’ttakeyourinsurance.”Inthecaseofanofficevisit,patientsareusuallymostconcernedaboutwhetherwewillbillandtheirinsurancecarrierwillpayfortheservices.Wetellcallerswewillgladlybilltheircarriersontheirbehalfandadvisethemwhetherornottheyhaveout-of-networkcoverage.Withthisdegreeofassurance,patientsgenerallyscheduleanappointment.Note:Manypayorsarenowrefusingtohonortheassignmentofbenefitsthepatientsignedandarenowsendingpaymentsforout-of-networkservicestothepatient.Itisimportanttofamiliarizeyourselfwithwhichpayorsinyourareadoanddonothonorassignmentofbenefits.Somestatesalsohavelawsrequiringpayorstohonortheas-signmentofbenefits.

Werecommendthatpatientscontacttheirinsurancebenefitsdepartmentforspecificsofwhattheycanexpectwhentheyseeanon-contactedprovider.Werecommendpatientsask“HowwillmybenefitschangewhenIseeanout-of-networkpro-vider?”Wethenbrieflydescribethedifferentpaymentpercent-agesanddeductiblesthatmayapplywhenyouseeanout-of-networkphysician.

Thehandlingofout-of-networkprovidersituationsfromasingleinsurancecarriercanvarywidelyfromoneenrolleetothenextsowe’reverycarefulnottotellsomeonehowtheircarrierwillhandletheirvisitwithoutcheckingwiththecar-rierfirst.Onepopularinsurerinourareaallowsustoverifyapatient’spolicyandbenefitsovertheinternet.Otherswilltell


-Best Practices98

usoverthephone.Occasionallyacarrierwon’ttellusanything,leavingituptothepatienttomakethecall.

Asmentionedabove,simplyknowingwewillbillandthattheyhaveout-of-networkbenefitstypicallymakesapotentialpatientcomfortableenoughtomakeanappointment.I’masurgeon,somanyfirstappointmentsleadtosurgery.Patientsalmostalwayswanttoknowaheadofsurgerywhattheirout-of-pocketexpenseswillbe.Oncewe’veevaluatedsomeoneandplannedasurgicalprocedure,wedon’ttypicallyhavemuchtroublefindingoutfromthecarrierhowmuchtheywillpay.

Findingoutwhotocontactattheinsurancecompanyisnotalwayseasy.Frequentlythecustomerservicestaffisveryun-familiarwiththistopicandgivesinaccurateanswers.Findingtherightsourceattheinsurermaybeabitofaproject.Thisisoneplacewherecomparingnoteswithalocalout-of-networkworkgroupcanbeveryhelpful.

Whenyou’reout-of-network,you’lldiscoverthatpayorshandlemodifiersandotherpaymentrulesdifferently.Idoalargenumberofbilateralsurgicalprocedures.EverygovernmentandprivateinsurancecarrierwithwhichI’veworkedreducesthefeeofthesecondprocedureinmultipleproceduresituationsby50percent.OnecarrierthatInowbillout-of-network,ignoresthe50percentreductionrule,payingtheirpercentageofthesecondprocedurethesameasthefirst.ThishascausedmetoaltermyOONfeeschedule.Youmayalsoneedtomakesimilaradjustments.

Understand How the Carrier Handles Out-of-NetworkPatient CareFindingoutallyoucanabouthowpayorshandleout-of-networkprovidersisimportant.Onceyouhavefoundtheappropriatepayorcontacts,findoutwhatyoucanaboutOONpaymentpolicies,feeschedules,copayments,deductibles,etc.Asmentionedabove,somepayorsrefusetohonorassignmentsofbenefitswithout-of-networkcareandwillissuepaymenttothepatient.Inthissituationitisimportanttocollectpaymentbeforeoratthetimeofservice.Again,youshouldbefamiliarwithlawsinyourstate.

Revisit Your Fee ScheduleMostoftenyourfeeschedulebearsnorelationshiptowhatyouexpecttobepaidforyourservices.Rather,yourfeesarelikelysetrightaboveyourmostfavorablethirdpartypayor.Intheinsuranceworld,thisisimportantasmostcontractsinclude“lesserof ”languagethatsaystheywillpaythelesserofeitherthecontractedrateorthefullbilledcharges.

Thesenumbersmightrightfullysendyourpatientintocardiacarrestandwillthusneedtoberevisited.Remember,youcan

workwithpatientsonanindividualbasisbasedontheirabilitytopay.Yourfeescheduleshouldberevisitedannuallyandbasedonanyincreasedpracticecostspluscostoflivingincreases.

Reinvent Your Services to Make Them Worth the ExpenseInshort,usetheNordstromstrategyofsuperiorpatient(cus-tomer)servicetovalidatetheincreasedout-of-pocketexpensetoyourpatients.Thisisthegratifyingandfulfillingpart.

Ibelievethatwhilethequalityofmedicalcareweareabletoofferourpatientsimproveseachyear,thequalityofserviceweoffercontinuestodeteriorate.However,inresponsetodeclin-ingreimbursementandincreasingdifficultiesdealingwiththirdpartypayors,wearetryingtoseetoomanypatientsintoolittletime.Tocontaincosts,we’reallowingourfacilitiestoageandwe’rereplacingreceptionstaffwithansweringmachines.Tocopewithanincreasinglycomplexbillingenvironmentwe’reshiftingstaffresourcesawayfrompatientcareandintothebill-ingdepartment.Attheendoftheday,we’releftwithtoomanyreportsandpaperworktoaddressbecauseweareseeingmorepatientsthanwecancomfortablyhandle.We’reundertakingthisprocessofcarecoordinationwhenweareundulyfatigued.Toooften,coordinationofcaregetsdelayedbeyondwhatisa“bestpractice”timeframe.Unfortunately,thisistherealityaswetrytocopewiththecircumstancesbeingforceduponus,butIbelievethereisabetterway.

Thisapproachcanbringyourpracticeclosertotheidealofmedicalpracticeyouoncehopeditwouldbe.You’llquicklyfindthatifyouchargefeescompatiblewiththevalueofyourservices,you’llbeabletospendagreateramountoftimewitheachpatientandseefewerpatientsinaday.Soon,you’llnoticethatyouhaveasmallerstackofchartstodealwithandyourstaffwilllikelybehappier.

I,likeyou,believethequalityofserviceIoffermypatientsisfaraboveaverage.Infact,90percentofdoctorsprobablythinkthequalityofservicetheyofferisaboveaverage.Evenifyou’repartofthat90percent,Iencourageyoutobeopentothepos-sibilitythatthereisstillroomforimprovementwhenpursuingcompetitiveedge.

Toimprovethepatientexperience,youwillwanttoputyourselfinthepatient’sshoes.Whathappenswhenpatientscallyouroffice?Aretheyexposedtoamind-numbingchoiceofrecordedmessagesandmenuoptionsorconsistentlyplacedonholdforminutesatatime.Oncethepatientgetstoaliveperson,howknowledgeable,personable,andhelpfulisthestaffmember?Isyourschedulesooverburdenedthatthepatientmustwaitthreeweeksforanappointmenttotreatabladderinfection?Onceapatientarrivesforanappointment,whatistheexperiencelike?Isthecarpetwarnandtheupholsterydirty?Doesyourread-

ingmaterialbelonginamuseum?Isthestafffrazzled?Isthetypicalwaittimelongenoughtoreadatatteredtwo-year-oldReader’sDigestfromcovertocover?

Andwhenthepatientisfinallytakentotheexamroom,howharriedisthestaffpersonwhopossiblyhasalreadyworkedup35patientstoday?Howlongdoesthepatientsitinacoldstarkexaminingroomonahardexamtablewearingadisposablepa-pergown?Whenyoufinallyarriveonthescenedoyouappeartobeinahurry?Haveyouhadtimetoreviewtheirchartaheadoftimesothatyouknowwhytheyarebeingseen?Doyouhavethetimetolookthepatientintheeye,visitwiththemandhearthelonguneditedversionofthehealthconditionathand?Doyouhavethetimetothoroughlyaddressthepatient’sconcerns?Isthestaffleftansweringthepatient’squestionsafteryouhur-riedlymoveontothenextexamroom?Didyoureallytakecareofthepatientintheheartfeltmannerconsistentwithwhatyouthoughtyouwouldbeabletoprovidebackwhenyouwereinmedicalschool?Formoreinformationonpatientsatisfaction,referbacktoChapterIV.

MyintentionisnottobeatupthemodernAmericanphysicianwhohasdedicatedhisorhercareerandlifetocareforpeople.Butoureffortstocopewiththechangesputuponushavehadnegativeconsequencesnotonlyforus,butalsoforthepatientswedesiretohelp.Ithinkthere’sabetterway.Mypracticehasgonethroughametamorphosis.Ithasbeenagratifyingexperi-ence.Yetifyoutalktomypatients,somewouldtellyouIhavenotreachedtheservicegoalstowhichIstrive.Therearesomanythingswecandotobebettertoserveourpatients.Thefollowingisapartiallistofsuggestionsandgoalsthatshouldbeconsideredregardlessofthetypeofinsuranceyourpatienthas:

a.Reinvent your philosophy. Decideinyourheartthatyouwantyourpracticetobeaplacewherepeoplewillreceiveexemplaryservice,notjustgoodmedicalcare.Makeupyourmindthatyoureallycareaboutwhetheryourofficewastespatients’time.Embracetheideathatpatientsdeeplyappreciatethetimeyouspendwiththem.Makeityourpersonalconcernthatpatientshavein-crediblygoodexperienceswhethertheycontactyourofficebytelephoneorinperson.Ifyouadoptthisphilosophy,every-thingelsewillfallintoplace.Reinventyourphilosophyaboutpatientcareandsharethatphilosophyandexpectationswithyourstaff.

b. Spruce up the waiting room and other patient areas. Shampoothecarpetandupholstery,dustthebaseboards,andgetridoftheclutter.Providecurrentreadingmaterials.Careabouttheenvironmentyourpatientsareinandmakeitlookthatway.

c.Shorten waiting room time. Ihaveheardalltheexcusesand,sadly,haveusedthemmy-selfoverandover.Istillbelievethatifwereallytry,wedon’thavetomakepatientswait.Therearenogoodexcuses.

d. Lengthen patient visit times. Ifyouarepaidwhatyourservicesareworth,youwillbeabletoofferthetimetodelivertheserviceyouwanttodeliver.

e.Offer more personalized care. Fromthereceptionisttothebillingperson,treatpeopleasthoughtheyarespecial.

Develop a Pay-at/Before The-Time of Service PolicyOneofthemanythingsIknewIshoulddobutneverquitegotaroundtodoingrightwastoimplementapolicytocollectpaymentatthetimeofservice.I’lladmitthatwearestillnotasgoodasweshouldbewithofficevisits,buthavediscovereditisanecessitywithsurgicalprocedures.Evenifyoudon’tchoosetoseepatientsasout-of-networkprovider,theincreasingpreva-lenceofhighdeductibleplanswilllikelyforceyoutocollectpaymentpriortoelectivesurgicalprocedures.

Whenweareworkingwithapatientpriortoelectivesurgery,wefindoutinadvancethecarrier’sout-of-networkpayratefortheCPTcode(s)we’reproposing.Wethendeterminetheremainingportionthepatientwillowebysubtractingthecar-rier’spaymentfromourout-of-networkfeeschedule.Wetellthepatientinadvancetheywillberesponsibleforthisamountplusanydeductible.Roughlytendaysbeforesurgerywecheckthepatient’sremainingdeductible.Manytimeswecandothisonline.Wecollectthepatient’sportionofthefeeideallyoneweek(fivebusinessdays)priortosurgery.

Nextwesubmittheclaimtothepayor.Asmentionedprevi-ously,somecarrierssendpaymentdirectlytothepatientratherthantheproviderforout-of-networkservices.Wetrytosoftenthefinancialblowtopatientsbycollectingonlythepatient’sout-of-pocketportionpriortosurgery,presumingthepatientsendsuspaymentassoonastheirinsurancecompanypays.

Unfortunately,wefoundthatpatientsdidn’tfollowthroughandwehadtorescindthatpolicyandcollectfullpaymentfromthesepatientsatthetimeofservice.∆

Develop a Strategy to Keep Track of StuffOften,Igetthefeelingthatpayorpersonnelknowverylittleabouttheircompany’sout-of-networkpolicies.Frequently,theyappeartobelearningalongwithus.Weoccasionallyreceiveinformationfromthemthatjustwasn’tplausible.Wecallbackhopingforadifferentcustomerservicerepresentativeand


-Best Practices100

receivemoreappropriateanswers.Thankfully,wecarefullydocumenteachofthesecon-versationsinthemedicalrecord.Afewtimeswehavehadtolookbackonthatdocu-mentationtoprovewewereactingoninformationgivenbyacarrierrepresentative.

Whilewesubmitclaimselectronicallyduetothespeedofpaymentanddecreasedcosts,wetryhardtocommunicateimportanttransactionsbycertifiedmailorfaxsowehavearecordofinteraction.Insituationswherewehandlemattersbyphone,wecarefullyrecordnotonlythefactsoftheconversationinthemedicalrecord,butalsothetime,date,andnameofthepersonwithwhomwearedealing.

Create a SpreadsheetImentionedabovethatwenevertellapatienthowtheirinsurancecarrierwillhandleourout-of-networkstatusuntilwe’vespecificallyverifiedthepatient’sownpolicyin-formationwiththepayor.That’slargelybecauseasinglepayormayofferhundredsofdifferenttypesofpolicieswithdifferingdeductibles,co-payamounts,andutilizationandauthorizationrequirements.Inourarea,localgovernmententitiesareinsuredthroughthesamepayorthatsomeunionsandself-insuredbusinessesare,yettheirout-of-networkproviderpracticesareverydifferent.Wethinkwearebetterabletohelpourpatientsifweknowhowcarriershandleout-of-networkproviderissuesforeachofthesecontractedentitiessowe’reintheprocessofcollectingdatatobetterassistourpatients.Itisgreatinformationtosharewithothersinanout-of-networkproviderworkgroup.

Train Your StaffLikemostdoctors,I’veapproachedtheroleofemployerwithnotraining,andnoex-pertise.I’vemadeplentyofmistakesovertheyears.ButInowhavemyselfconvincedthatI’velearnedafewthingsthroughtheyears.

ThemostvaluablelessonI’velearnedasamanagerofpeopleisthatalmostallpeoplewilldotherightthingalmostallthetimeifgiventherighttoolstodoso.UsuallywhenmistakesaremadeitisbecauseI’vesetupaproblem-pronesituationwherefailureisalikelyoutcome.

Tosuccessfullynavigatethisnewwayofdoingbusinessasanout-of-networkpro-vider,takethetimetoadequatelytrainyourstaff.Ifyoudo,yourchancesofsuccessincreasedramatically.

Startbyobtainingstaffbuy-intotheconcept.Makethemawareoftheproblemsyou’retryingtoovercome.MystaffandIconcludedtogetherthatweneededtoleavenetworksaswejointlysearchedforwaystocopewithimpendingcutsinourcon-tractedfees.Wedideverythingwecouldtoputoffcontracttermination.Bythetimewemadethedecisiontoterminate,itwasobvioustoallthatitwastheonlyoption.

Mygreatstaffwasverymotivatedtodowhatwasnecessaryforourpracticetotrans-formasithas.Theydidnotseethistransformationasadisruptiontotheirlives.Theysawthebenefitandwantedtomakeitwork.

Get ready to ApologizeForthefirstfewmonthswespentagreatdealoftimeexplainingtopatientsthatwewerenavigatinginunchartedwatersasanout-of-networkphysician.Weaskedfortheirpatienceandpromisedthemwewoulddotherightthingwhenwemademis-takes.Inevitably,you’llfindthatmuchofthelearningwillbedoneafteryou’velefta

Somestateshavepassedlawsthatprohibitout-of-networkphysiciansfromcollectingdirectlyfrompatients.Yourstateorlocalcountymedicalsocietycanconfirmwhetheryoupracticeinoneofthosestates.

payornetwork.Ourpatients,surprisingly,understood.Wemadesomemistakesandhadtoswallowourprideonafewoccasions.Asthemonthsworeon,theapologiesbecamelessfrequentaswebecamemoreexperienced.

BE OPTIMISTICHistoryisrepletewithexamplesofhowgoodthingshaveevolvedfromdifficultcircumstances.

Themodernmedicalmarketplaceisevolving.Thehandofoutsideforcesinvadingourpracticesisreal.Ourabilitytocareforpatientshasbeenwoefullyimpacted.

Caringforpatientsoutsideofaninsurancenetworkisadecisionthateachphysicianmustmakeindividually.I’vefoundthechallengegratifying.IfeelmuchlesspressedtomaintainanunsustainablepatientvolumeandIlovebeingabletospendmoretimewithmypatients.

AsImentionedearlier,myinspirationinthismatterwastheprimarycaredoctordownthehallinmymedicalofficebuilding.Helikestakingcareofhispatients,limitinghispracticetot24patientsperday.Hespendsaround45minutesdoingacompletephysicalexam.Heknowshispatientswellandtheylovehim.

Hetoldmerecentlyofaconversationinahospitaldoctor’scafeteria.Colleagueswerelamentingabouttheillstateofmedicalpractice,agreeingitwassobadthattheywereallencouragingtheirchildrentogoindifferentcareerdirections.Whentheconversationturnedtohim,heexplainedthatnotonlywashissonheadingofftomedicalschoolbutitwaswithhisblessing.Thisfamilypractitionerhasfoundawaytomakeagoodliving,deliveringmedicalcarethatbothheandhispatientsbelieveissuperior,andhelikeshiscareer.Ifhehadtodoitoveragainhewould.

JohnNordstromfoundopportunitywhenthingsdidn’tturnoutashehadhoped.Sodidthefamilypractitionerdownthehall.Socanyou.


-Best Practices102

CMA On-Call ..........................................................................................................................................................103

Sample Job Description: Medical Receptionist ...........................................................................................................104

Sample Job Description: Business Manager ................................................................................................................105

Sample: Job Application ............................................................................................................................................107

Sample Form: Interview Report .................................................................................................................................109

Sample Form: Personal Reference Check Worksheet ..................................................................................................110

Sample Form: Past Employer Reference Check ..........................................................................................................112

Sample Form: Staff Performance Appraisal ................................................................................................................113

Sample Form: Employee Grievance ...........................................................................................................................117

Sample Form: Employee Corrective Action ................................................................................................................118

Sample Form: Time Flow Study (Staff ) ......................................................................................................................119

Sample Form: Time Flow Study (Patient) ...................................................................................................................120

Sample Form: Call Volume Tracking Sheet .................................................................................................................121

Sample Survey: Patient Satisfaction ...........................................................................................................................122

Sample Survey: Patient Satisfaction (Spanish) ............................................................................................................124

Sample Letter: Referring Physician Satisfaction Survey Cover Letter ..........................................................................126

Sample Survey: Referring Physician Satisfaction ........................................................................................................127

Sample Interview and Document Request for HIPAA Compliance Reviews ................................................................128

Sample Letter: Request Copy of Payor Contract .........................................................................................................130

Sample Letter: Contract Termination ........................................................................................................................131

Sample Letter: Patient Notice of Contract Termination ..............................................................................................132

Sample Notice: Patient Responsibility for Non-Covered Services ................................................................................133

Sample Agreement: Payment for Non-Covered Services .............................................................................................134

Sample Form: Patient Financial Responsibilities ........................................................................................................135

Contributor Bios .......................................................................................................................................................136

Appendix

CMA On-CallThistoolkitreferencesmanydocumentsthatexplaininmoredetailtheissuesandlawsdiscussed.Thesedocumentsareknownas“CMAOn-Call”documents.CMAOn-CallistheCaliforniaMedicalAssociation’sonlineinformation-on-demandlibrary.CMAOn-Callisarepositoryofthousandsofpagesofmedical,legal,regula-tory,andreimbursementguidance.AlldocumentsareavailablefreetoCMAmem-bersonthemembers-onlywebsiteatwww.cmanet.org/member.Nonmemberscanpurchasethesedocumentsfor$2perpageintheCMAbookstoreatwww.cmanet.org/bookstore.

YouwillneedAdobeAcrobatReadertoviewanddownloadallCMAON-CALLdocuments.Ifyoudonothavethisprogramonyourcomputer,itisavailablefreeintheCMAOn-Callareaonline.JustclickontheAdobeiconandfollowtheinstructions.

TolocateanOn-Calldocument,youcansearchinthreeways:Document Number:Ifyouknowthenumberofthedocumentyou’relookingfor,enterthatnumberintothesearchbox.Ifyouareattemptingtosearchbykeyword,thesearchresultwilllistalldocumentsthatcontainthatkeyword.

Keyword: Typeakeywordsearchintothesearchbox.Whensearchingfortwoormorewords,use“and”or“or”(e.g.,needlesorsyringes,HMOandcontracts).

Topic: SelectfromthetopiclistontheOn-Callpage.TopicheadingsforthemostpartparallelthechaptersofCMA’sCaliforniaPhysician’sLegalHandbook,suchas“ManagedCare,”“MedicalBoard,”andotherfamiliarmedical-legalterms.Toseealistofdocumentsbytopic,simplyselectthattopic.

On-Call Documents Referenced in this Toolkit

Doc. # Title

0233 Pre-EmploymentInquiries(Chapter1)0217 OverviewofSelectPhysicianPracticeEmploymentIssues(Chapter1)1810 Cal-OSHAComplianceandInspections(Chapter2)1606 HIPAAElectronicTransactionRule(Chapter2)0805 TerminationofthePhysician-PatientRelationship(Chapter3)0124 LatePayment(Chapter5)1606 HIPAAElectronicTransactionRule(Chapter5)1609 ElectronicFundsTransfer(Chapter5)1160 RetentionofMedicalRecords(Chapter7)1135 ContentsofMedicalRecords(Chapter7)1603 HIPAAACTSMART-IntroductiontotheHIPAAPrivacyRules(Chapter7)1600 HIPAASecurityRule(Chapter7)1606 HIPAAElectronicTransactionRule(Chapter7)1132 ElectronicMedicalRecords(Chapter7)

Appendix- 103

-Best Practices104

SAMPLE JOB DESCRIPTION: Medical Receptionist

Position:MedicalReceptionist

Reports to:OfficeManager

Responsibilities:Responsibleforreceivingpatientsandvisitors,determiningtheirneedsanddirectingthemaccordingly.Answerstelephone,makesappointments,receivespayments,andissuesreceipts.Performsotherclericalandadministrativetasksasrequired.

Duties of the Position:

•Greetsvisitorsandpatients,determinestheirneeds,anddirectsthemaccordingly. •Answersquestionsandgivesinformationdirectlyorviathetelephonewithinthelimitsofknowledgeandmedicalpracticepolicies. •Makesandchecksoffappointments,givingroutinenon-medicalinstructionsinpreparationforthepatient’svisittothepractice. •Retrievesandfilesmedicalrecords,letters,reports,andmiscellaneousitemsasrequested.Purgesmedicalrecordsmonthly. •Collectsfees,issuesreceipts,andcounselspatientsconcerningtheiraccountswhennecessary.Countsandbalancesmoney

attheendoftheday. •Typeshospitallists.Typeshospitalordersforphysicians.Scheduleshospitaladmissions.Schedulessurgery.Securesinfor-

mationfromhospitalsconcerningconsultations. •Researchesfilestodetermineifpatienthasvisitedpracticebefore.Organizesmedicalrecordsfornewpatients. •Openspractice,doeshousekeepingchores,runserrands,andclosespracticeasrequired. •Handlesrefillsforprescriptionsaccordingtomedicalpracticepolicy. •Performsotherdutiesasrequired.

Position Requirements:GraduationfromhighschoolwithcoursesinEnglishandtyping.CertifiedMedicalOfficeManager(CMOM)certificationisdesirable.Previouspatientcontactworkinamedicalpracticewouldbeanadvantage.Iftheapplicantdoesnothaveexperience,threemonthson-the-jobtrainingwillbeprovided.Beabletooperateatranscriptiondeviceandoperateacomputer(word-processing)andtype60wordsperminutewithaccuracy.Possessesthetactrequiredforworksituationsthatinvolvedealingwithpatientstosecurepaymentofdelinquentaccounts.Possessthetacttoworkeffectivelywithpatients,physicians,andotheremployees.Possessapreferencefordealingwithpeoplewhoareillandneedhelp.Possesstheverbalabilitytodiscussmedicalandfinancialproblemswithpatientsandbeclearlyunderstood.

Position Relationships:Doesnotsuperviseanyotheremployees.Receivessupervisionfromtheofficemanager.

Authority Boundaries: Reportstotheofficemanagerinallmatters.

Appendix- 105

SAMPLE JOB DESCRIPTION: Business Manager (page 1 of 2)

Position:BusinessManager

Reports to: Physicians

Responsibilities:Responsibleforalladministrative,financial,personnel,clerical,housekeeping,andmaintenancefunctions.Plans,programs,allocates,andassignsdutiestotheemployees.Monitorstheactivitiesofallclinicaloperatingcomponentstoensurethepracticesuccessfullymeetsitsobjectives.Advisesandseeksconsentfromphysicianstocoordinateandmanagetheactivitiesoftheclinic.

Duties of the Position: •Supervisesandcoordinatestheactivitiesofallclinicpersonnel.

•Organizesandassignsdutiestoemployeesrelatingtobookkeeping,payroll,collections,insuranceclaimfiling,typing,medicalrecords,answeringthetelephone,housekeeping,appointmentschedulingandx-ray.

•Monitorsclinicpersonneltoensureemployeesareperformingtheirdutiesinamannerdesignedtomaintainahighlevelofpatientcare.

•Maintainsasufficientflowofworkthroughouttheclinicbyevaluatingproductionandrevisingproceduresaccordingly.

•Standardizesproceduresandinitiateschangeswherenecessary.Constantlyreviewsprocedurestodetermineifthereisamoreefficientandlesscostlywaytoconductthebusinesswithoutsacrificingpatientcare.

•Directsoperationstoprepareandretainrecords,files,andreportsaccordingtovariousgovernmentalandpracticestan-dards.Preparesandimplementsarecordsretentionanddispositionprogramforthepractice.

•Interviews,tests,hires,andterminatesemployees,andverifiesinformationonemploymentapplicationforms.Arrangesforbackgroundchecksonapplicantsforemployment.Conductsperiodicperformanceandsalaryreviews.

•Reviewsandapprovesweeklytimerecordsofallclinicemployees.Approvesallsickandemergencyleaveinaccordancewithclinicpolicy.Establishesandschedulesvacationsforallemployees.

•Prepares,maintains,andprovidessecurityforthepersonnelrecordsofallemployees.Retainsapplicationsfromapplicantsforemployment.

•Createsandadministersanon-the-jobtrainingprogramfornewemployeesasrequired.

•Schedulesandconductsperiodicstaffmeetingswiththeemployeestoinformthestaffofchangesintheclinicpolicyandtoresolveproblemsthatareaffectingoperatingeffectiveness.Preparesandretainsminutesofsuchmeetings.

•Schedulesmeetingsforthephysicians.Notifiesthosewhoaretoattend.Handlesthelogisticsofmeetings.Attendsphysi-cianmeetingsasdirected.Reportsonthestatusoftheclinic.Takesorarrangestohavetakenminutesofeachmeeting.Maintainsthephysician’smasterschedule.Preparestheagendaforallphysicianmeetings.

•Ensuresthatahighlevelofcleanlinessexistsintheclinicatalltimes.Takesstepstoensurethephysicalplantisingoodoperatingcondition.

•Preparesthevariousclinicpayrollsorarrangestohaveanoutsideagencypreparethem.Typesorwriteschecks.

•Preparesincomestatementsandbalancesheetsonthevarioussetsofbooksmaintainedbytheclinic.Mayprepareotherfinancialandstatisticalreportsforreviewbythephysicians,eitheronascheduledbasisorasrequested.Workswiththeclinicaccountingfirmandlegalcounselasnecessary.

•Reviewstheentireaccountingsystemtoensureitisoperatingwithinthelimitsofwell-definedinternalcontrolstandards.

•Workswithphysiciansandclinicaccountanttoprepareabudgetfortheclinic.Duringtheyear,comparesactualtopro-jectedbudgetperformancetoensureadherencetothebudget.

-Best Practices106


•Reviewsallinvoicesandstatementsreceivedfromvendorsforpayment.Checksallinvoicesfordiscountsearned.Consultswithphysiciansbeforeorderinganysuppliesorequipmentexceeding$100invalue.Securescompetitivebidsforsuppliesandequipment.

•Reviewsordersforsupplies,equipment,narcotics,etc.,fromthevariousoperatingsectionsfortheclinic.Ordersallsupplies,equipment,narcoticsetc.Usesprenumberedpurchase-orderforms.

•Monitorsoutstandingaccountsreceivable.Workswithcreditandinsurancecounselingclerkstoensureconstantattentionispaidtothebalancesoutstanding,andstepsarebeingtakentoreducethereceivables.

•Performsotherdutiesasrequired.

Position Requirements: Graduationfromarecognizedcollegeoruniversitywithabaccalaureateinbusinessadministration,personneladministration,oraccounting.Experiencemaybesubstitutedforeducation.Ifexperienceissubstituted,thesecondjobrequirementbecomesmandatoryandtheapplicantmusthaveexperienceinaccountingorpersonneladministration.Fourormoreyearsofprogressivelyresponsibleexperienceinahospital,businessoffice,oramulti-physicianmedicalpracticeisdesirable.Possessthetactnecessarytodealeffectivelywithpatients,physicians,andemployees.Beabletomotivateemployees.Possesstheabilitytothinkclearlytomakejudgmentdecisionsininitiatingbusinessofficepolicy.Possessknowledgeofmodernofficeequip-ment,systemsandprocedures.Beabletooperateanelectricaddingmachinetypewriter,calculator,andcomputer.

Position Relationships:Supervisesreceptionists,medicaltranscriptionist,registerednurses,andacombinationlaboratory/x-raytechnician.Receivessupervisionfromthephysicians.

Authority Boundaries: Allmajorpolicyandoperatingdecisionsarecarriedoutbythebusinessmanager,butmadebythephysicians.

Appendix- 107

Application for Employment

02/24/04 HS F-CHR001a 1 of 2

All applicants for employment are required to complete and submit this TriNet Employment Application.

TriNet 1100 San Leandro Blvd. San Leandro, CA 94577

Name of Company/Location Please Print

Applicant Information LEGAL NAME as shown on your Social Security Card SOCIAL SECURITY NUMBER Last First Middle

HAVE YOU EVER WORKED UNDER ANOTHER NAME? IF YES, UNDER WHAT NAME(S): Yes No COMPLETE HOME ADDRESS include PO Box, Apt. #, etc. Street City County State Zip Code

HOME PHONE BUSINESS OR OTHER PHONE E-MAIL ADDRESS ( ) - ( ) - Position Applying For JOB TITLE/TYPE OF WORK DESIRED SALARY AVAILABLE START DATE

$ARE THERE ANY LIMITATIONS ON THE HOURS, DAYS OR TIME YOU ARE AVAILABLE TO WORK? (If so, explain) YOUR AVAILABILITY?

WILL YOU BE ABLE TO PERFORM THE ESSENTIAL JOB FUNCTIONS FOR THE POSITION YOU ARE APPLYING FOR WITH OR WITHOUT REASONABLE ACCOMMODATION?

Full time Yes No

Part time Yes No

Over time Yes No

Temporary Yes No

YES NO (If no, describe the function(s) that cannot be performed:

IF EMPLOYED, CAN YOU SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE U.S?

HAVE YOU WORKED FOR OR APPLIED FOR A POSITION AT THIS COMPANY BEFORE?

DO YOU HAVE ANY RELATIVES WORKING HERE?

Yes No

Yes If yes, what position(s)? No

Yes No

If yes, who:

HOW DID YOU LEARN ABOUT THIS OPENING? ARE YOU OVER EIGHTEEN YEARS OF AGE? YES NO

IF UNDER 18, DO YOU HAVE A WORK PERMIT? YES NO

HAVE YOU EVER BEEN CONVICTED OF A CRIME? (Exclude convictions for marijuana-related offenses for personal use more than two years old; convictions that have been sealed, expunged or legally eradicated, and misdemeanor convictions for which probation was completed and the case was dismissed.) Yes

No

If yes, please describe the nature of the crime(s), the date and place of conviction and the legal disposition of the case. The Company will not deny employment to any applicant solely because the person has been convicted of a crime. The Company, however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for.

Education Begin with most recent college/university/technical school

NAME OF EDUCATIONAL INSTITUTION/LOCATION MAJOR NO. OF YEARS

GRADUATE Yes/No

DIPLOMA/DEGREE Yes/No

ANY PROFESSIONAL DESIGNATIONS OR OTHER TRAINING/EDUCATION RELATED TO THE JOB YOU ARE APPLYING FOR:

BE SURE TO COMPLETE PAGE 2

SAMPLE: Job Application

-Best Practices108


Application for Employment

02/24/04 HS F-CHR001a 2 of 2

COMPLETE ALL JOB HISTORY REGARDLESS OF RESUME ATTACHMENT

May we contact your current employer? Yes No

Employment History list current/most recent position firstNAME OF EMPLOYER ADDRESS/LOCATION DATES EMPLOYED From To

TYPE OF BUSINESS POSITION/TITLE SALARY Starting Final

MANAGER’S NAME MANAGER’S TITLE PHONE

( ) -REASON FOR LEAVING:

NAME OF EMPLOYER ADDRESS/LOCATION DATES EMPLOYED From To




NAME OF EMPLOYER ADDRESS/LOCATION DATES EMPLOYED From To




APPLICANT’S CERTIFICATION AND RELEASE I certify that the facts given in my resume’ and/or Application for Employment are true and correct. I understand that if employed, any false or misleading statements, omissions, or failure to fully answer any requested item on this application or on any document used to secure employment shall be grounds for rejection of this application or for my termination from employment, if I am employed, regardless of when such information is discovered. I authorize the Company to secure background information on my work record, education, and other matters related to my suitability for employment. I authorize my references and background sources to disclose information about me to the Company, without giving me prior notice of such disclosure. I hereby release the Company, my former employers, and all other sources from any and all claims, demands, or liabilities arising out of or in any way related to securing such information or disclosures. I understand that nothing contained in the application, or information conveyed during any interview, which may be granted, or during my employment, if hired, is intended to create an employment contract between the Company and me. I understand that any employment with this Company is “at will,” which means that either I or the Company can terminate the employment relationship at anytime with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of the Company has any authority to alter the foregoing unless a specific term of employment is in writing and signed by the Company President.

APPLICANT SIGNATURE DATE

Appendix- 109

SAMPLE FORM: Interview Report

Completed by: _________________________________ Date: _____________________________________

Applicant Name: _______________________________ Position Applying for: ______________________Street Address: ______________________________________________________________________________City: _________________________ State: _________________________ Zip Code: _________________

Requirements for Position: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Requirements Held by Applicant: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Skills: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Appearance: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Interpersonal Skills: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Questions Asked: Responses Given:1.__________________________________ 1.____________________________________________________ __________________________________ ____________________________________________________

2.__________________________________ 2.____________________________________________________ __________________________________ ____________________________________________________

3.__________________________________ 3.____________________________________________________ __________________________________ ____________________________________________________

4.__________________________________ 4.____________________________________________________ __________________________________ ____________________________________________________

Results of Skill Test: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

General Remarks: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

-Best Practices110

SAMPLE FORM: Personal Reference Check Worksheet (page 1 of 2)

Applicant’sFullName: __________________________________________________________________________________

PositionAppliedfor:__________________________________ Dept.:_________________________________________

PersonContacted:____________________________________ Phone#:_______________________________________

Completedby:________________________________________Date:__________________________________________

Thisis[yourname]fromDr._________________________‘soffice.[Candidate’sname]hasappliedforapositionwithusandhaslistedyouasapersonalreference.Ifyouhaveafewminutes,Iwouldliketoaskyouafewquestions.

1.Howlonghaveyouknown[candidate’sname]andinwhatcapacity?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

2.Howwouldyoudescribe[candidate’sname]’sabilitytogetalongwithothers?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

3.Howabouthis/herdependability?Haveyouhadtheopportunitytoobservehis/herworkhabits?Doeshe/shecompleteproj-ects,showupontime?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

4.Haveyouobservedtraitsofpersonalresponsibility?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

5.Whatabouthis/herjudgmentinmakingdecisions?Ishe/sheaself-starter?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

6.Whataresomeofhis/herstrengths/accomplishments?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Appendix- 111

SAMPLE FORM: Personal Reference Check Worksheet (page 2 of 2)

7.Whatdoyouadmiremostabout[candidate’sname]?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Comments

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Thisformcanalsobeusedasatemplateforwrittenverificationformsenttopersonalreferences.

-Best Practices112

SAMPLE FORM: Past Employer Reference Check

Applicant’sFullName: __________________________________________________________________________________

PositionAppliedfor:__________________________________ Dept.:_________________________________________

PersonContacted:____________________________________ Dept.:_________________________________________

Company&Address:__________________________________ Phone#:_______________________________________

Completedby:________________________________________Date:__________________________________________

Thisis[yourname]fromDr._________________________‘soffice.[Candidate’sname]hasappliedforapositionwithusandhaslistedyouasapreviousemployer.Ifyouhaveafewminutes,Iwouldliketoaskyouafewquestions.

1.DatesofEmployment:_________________________________________________________________________________

Position(title):________________________________________________________________________________________

SalaryuponLeaving:___________________________________________________________________________________

2.JobResponsibilities: __________________________________________________________________________________

______________________________________________________________________________________________________

3.Quality/Quantity: ____________________________________________________________________________________

______________________________________________________________________________________________________

4.PersonalQualities/WorkRelationships:____________________________________________________________________

______________________________________________________________________________________________________

5.Dependability/Attendance:_____________________________________________________________________________

______________________________________________________________________________________________________

6.Strengths:___________________________________________________________________________________________

______________________________________________________________________________________________________

7.Weaknesses:_________________________________________________________________________________________

______________________________________________________________________________________________________

8.ReasonforLeaving:___________________________________________________________________________________

______________________________________________________________________________________________________

9.RehireStatus:________________________________________________________________________________________

______________________________________________________________________________________________________

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Thisformcanalsobeusedasatemplateforawrittenverificationformsenttopreviousemployers.

Appendix- 113

SAMPLE FORM: Staff Performance Appraisal (page 1 of 4)

SECTION 1: General Information

Last: ___________________________________ First: _____________________________ MI: ____________ Department: _________________________ Employee ID: __________ Job Title: ______________________Type of Review: ______________________ Date of Review: ____________________ Date of Hire: _______

SECTION 2: Job Performance

FOREACHCATEGORY,RATEEMPLOYEEWITHCORRESPONDINGNUMERICALAPPRAISAL.Example:“Good”shouldberatedaseither“5”or“6.”Circlethenumberandenterinfarleftcolumn.

(1)QUALITY

1 or 2Alwaysbelow

acceptablestandards

3 or 4Oftenbelow

acceptablestandards

5 or 6Usuallymeets

acceptablestandards

7 or 8Oftenexceeds

acceptablestandards

9 or 10 Consistentlyexceeds

moststandards

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

(2)QUANTITY

1 or 2Seldomfinishesrequiredvolume

withinallottedtime

3 or 4Meetsminimumtimeandvolume

requirements

5 or 6Completes

satisfactoryvolumeofworkwithintime

given

7 or 8Frequentlycompletesmorethanexpected

volumewithinallottedtime

9 or 10 Completesmore

thanexpectedvol-umewithinallotted

time

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

(3)

JOB KNOWLEDGE

1 or 2Alwaysneeds

assistanceexecutingroutinetasks

3 or 4Oftenneeds

remindingandclarificationto

executeroutinework

5 or 6Performsroutinetasks;occasionallyneedsassistance

7 or 8Acceptsfull

responsibilityforperformingroutinetasks;questionsare

infrequent&relevant

9 or 10 Executestasks

withoutassistance;oftenfunctionsas

sourceofinformation

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

Work Habits(4)

ATTENDANCE&

PUNCTUALITY

1 or 2Undependable;

oftentardyorabsentwithoutpropernotice

3 or 4Poorattendance;sometimeslate

5 or 6Acceptable

attendanceandpunctuality

7 or 8Rarelyabsentorlate

9 or 10Perfectattendancerecord;consistently

punctual

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

-Best Practices114


(5)FOLLOWINGDIRECTIONS

1 or 2Routinelydoesnotfollowdirections/

procedures;insubor-dinatetosupervisors

3 or 4Frequentlydoesnotfollowdirections/procedures;triestodomanythingshis/

herownway

5 or 6Usuallyfollows

instructions;abidesbyestablished

procedures

7 or 8Consistentlyfollowsacceptedprocedureandlooksfordirec-tionwhenindoubt

9 or 10Alwaysfollows

acceptedprocedure;oftenofferssugges-tiontoimprovees-tablishedprocedures

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

(6) PLANNING/

ORGANIZATION

1 or 2Seldomsetspriorities

effectively

3 or 4Belowaverageinsettingpriorities

5 or 6Setsprioritiesatan

acceptablelevel

7 or 8Frequentlysetspri-oritieseffectively

9 or 10Consistentlysets

prioritieseffectively

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

(7) INITIATIVE

1 or 2Performsonlyrequiredwork;

nevervolunteerstoundertakework

3 or 4Performsroutinework;expresses

littleinterestinworkmethodimprovement

5 or 6Expressesinterest

inperformingworkmoreeffectively

7 or 8Usuallyseekswaysto

dojobbetter

9 or 10Sharesnewideas:hasimplemented

effectivechangesintheorganization

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

(8)ADAPTABLE/

FLEXIBLE

1 or 2Refusestolearnnewtasks;reactspoorlytochangingprocedures

andpriorities

3 or 4Slowtoaccept

change;adaptswithdifficulty

5 or 6Adaptsacceptable

withlittleoppositiontochange

7 or 8Adaptswellto

changewithlittleornoresistance

9 or 10Adaptswithease;re-spondstochangeasa

positivechallenge

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

Interpersonal Skills

(9)COMMUNICA-

TION

1 or 2Hasdifficultyex-

pressingwritten/oralthoughts;inabilityto

correspond

3 or 4Frequentlyfailsto

communicateclearlyandaccurately

5 or 6Acceptablecommu-nications,bothoral

andwritten

7 or 8Understandsandex-pressesclearly,both

oralandwritten

9 or 10Superiororaland

writtencommunica-tionskills;com-

municatesclearlyandaccurately

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

Appendix- 115


(10)WORKING

RELATIONSHIP

1 or 2Isaconstantsourceofconflict;distrustedbyotherstaffmembers;

ignoresrequests

3 or 4Isofteninvolvedinconflict;doesnot

getalongwellwithothers;seldomhelpsothers

5 or 6Workswellwithothers;willgive

assistanceifasked

7 or 8Isalwaystactfulandcourteous;frequentlygivesassistancewith-

outbeingasked

9 or 10Hasearnedrespectofothers;alwaysgivesassistancewithout

beingasked

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

__________ Total number of quality points

Comments: __________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

SECTION 3Describethemajorstrengthsandassetsastheyrelatetothejobperformance.

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

SECTION 4Indicateareaswheretraining,development,and/orimprovementsneedtooccur.Specifywhataction(s)willbetakenbythesupervisorandemployeetoachievethesechanges.Pleaseattachanactionplancompletewithtimetable.

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

SECTION 5 (Employee Comments)

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

-Best Practices116


SECTION 6Checkifanyattachmentsaccompanythisformandlistadditionalattachments,ifneeded.

qJobDescription qSpecificjobduties/responsibilitiesqCertificates/licenses(ifapplicable) qActionplan

SECTION 7 (Certification)Iunderstandmysignatureindicatesthisreviewhasbeendiscussedwithme,butdoesnotnecessarilysignifythatIagreewithitscontents.IamawareIcanmakeadditionalcommentsinwritingfollowingthisperformanceappraisal.

EmployeeSignature:_______________________________________________________________ Date: _____________

AdministrativeSupervisor#1Signature:_______________________________________________ Date: _____________

AdministrativeSupervisor#2Signature:_______________________________________________ Date: _____________

Appendix- 117

SAMPLE FORM: Employee Grievance

Employee Name: ____________________________________________________________________________

Job Title: ______________________________________________ Dept: _____________________________

Supervisor: ____________________________________________ Dept: _____________________________

Describe Grievance: _________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Suggested Solutions: _________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Employee Signature: ___________________________________________________ Date: ______________

To be completed by supervisor:

Investigations/interviews: ____________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Disposition/Action Plan: _____________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Supervisor’s Signature: _________________________________________________ Date: ______________

-Best Practices118

SAMPLE FORM: Employee Corrective Action

Employee Name: _______________________________________________ Hire Date: _________________

Job Title: ______________________________________________ Dept: _____________________________

TYPE OF ACTION: (CheckOne)

qVerbalWarningqFinalWarningqDischarge qWrittenWarningqDisciplinarySuspension

Previous Correction Actions: (Typeofaction,offense,date)

___________________________________________________________________________________________

___________________________________________________________________________________________

I. INCIDENT: Describethesituation(behavior,performance,policyviolation,etc.)thatoccurred.Includedates(s),time(s),location(s),peopleinvolved,witnesses,effectsofincidentonemployee’sworkorotheremployees,andallotherrelevantcircum-stancesorcontributingfactors.Pleasebespecificinstatingobservablebehaviorsandcommentswheneverpossible.

___________________________________________________________________________________________

___________________________________________________________________________________________

II. GOALS AND TIMEFRAME FOR IMPROVEMENT: Whatspecificactionsaretobeaccomplished,andwithinwhattimeframe,toimprovethebehavior/performance?

___________________________________________________________________________________________

___________________________________________________________________________________________

III. FOLLOW-UP REVIEW DATE: ________________

IV. CONSEQUENCES:Whatwillhappenifemployeefailstomeetthegoalssetwithinthedesignatedtimeframe?

___________________________________________________________________________________________

___________________________________________________________________________________________

V. EMPLOYEE’S COMMENTS: Mysupervisorhasreviewedtheabovesituationwithmeandmycommentsareasfollows:

___________________________________________________________________________________________

___________________________________________________________________________________________

Supervisor’s Signature: _________________________________________________ Date: ______________

Iunderstandthatmysignatureindicatesonlythatthisincidenthasbeenreviewedwithmeanddoesnotindicateagreementordisagreementwiththeactiontaken.

Employee Signature: ___________________________________________________ Date: ______________(Notrequiredforverbalwarning)

Appendix- 119

SAMPLE FORM: Time Flow Study (Staff )

Patient Name: ______________________________________________________________________________

Doctor: ________________________________________________________ Day of Week: _______________

I. Appointment type:(checkone)

q FirstExamq Recheckq AcuteIllnessq Immunizationq InjuryOther

II. Time: (everyonewhoencountersthepatientrecordsthetimetothenearestminute)

ScheduledAppointmentTime: ___________________ am/pm

Timeˇ Time Spentˇ

a. Pt. arrival time and sign in _____________

b. Receptionist checks pt in ___________ ____________ (*subtractbfroma)

c. Chart readied for rooming ___________ ____________ (subtractcfromb)

d. Pt. called to exam room ___________ ____________ (subtractdfromc)

e. MA leaves room ___________ ____________ (subtractefromd)

f. Dr. enters room ___________ ____________ (subtractffrome)

g. Dr. leaves room ___________ ____________ (subtractgfromf )

h. Pt. check out w/ reception ___________ ____________ (subtracthfromg)

Total visit time = ____________ (Subtractarrivaltimefrompt.checkouttime)

Total time spent waiting = ____________ (Addtimespentinrowsb,c,d,f,andh)

Total time spent with MA, Nurse, Physician = ____________ (Addtimespentoneandg)

Itisrecommendedthattheofficeassessmentbeperformedinconjunctionwithpatientwaittimecalculatoronfollowingpage.

*Ifpatientarrivesearly,subtractbfromscheduledappttimeratherthanarrivaltime.

-Best Practices120

SAMPLE FORM: Time Flow Study (Patient)

(Tobecompletedbypatientaspartoftheofficeassessment)

Patient Name: ______________________________________________________________________________

Doctor: ________________________________________________________ Day of Week: _______________

Status Time (example 9:30)

Timeofscheduledappointment

Timeofarrival

Timecheckedinforappointment

Timecalledtoexamroom

TimeMA/nurseleavesexamroom

Timedoctorentersroom

Timedoctorleavesroom

Timeofcheckout

Comments:

Pleasehandinyourcompletedcardattheappointmentdeskwhenyouleave.Thankyouforhelpingustoimproveyourexperi-encewithourpractice.

Appendix- 121

SAMPLE FORM: Call Volume Tracking Sheet

DayofWeek:____________

Time of Day

Issue 9-10am 10-11am 11am-12pm 12-1pm 1-2pm 2-3pm 3-4pm 4-5pm Total

Scheduling

Rescheduling

Authorizations

Referrals

Labs/testresults

Rxrefills

Billingquestions

Questionsfornurse/physician

Patientdemographics

Forms

Labs

Pharmacy

HealthPlan

Directions

Repeatcalls

Other

Total

-Best Practices122

SAMPLE SURVEY: Patient Satisfaction (page 1 of 2)

[Insertpracticename/logohere]Patient Satisfaction Survey

Wewouldlikeyourfeedbackontheservicesweprovidesowecanmakesurethatwearemeetingyourneeds.Yourresponseswillhelpustoimprovetheservicesweprovide.Allresponseswillbekeptconfidentialandanonymous.Thankyouforyourtime.

Your Age:_______Your Sex: qMaleqFemale

Your Race/Ethnicity: qAsianqPacificIslanderqBlack/AfricanAmericanqAmericanIndian/AlaskaNative

qWhite(NotHispanicorLatino)qHispanicorLatino(AllRaces)qUnknown/Mixed

Doyouconsiderthispracticeyourregularsourceofcare?qYesqNo

Pleasecirclehowwearedoinginthefollowingareas: GREAT(5) GOOD(4) OK(3) FAIR(2) POOR(1)

EASE OF GETTING CARE:

Abilitytobeseentimely 5 4 3 2 1

Hoursofoperation 5 4 3 2 1

Convenienceofpracticelocation 5 4 3 2 1

Promptreturnoncalls 5 4 3 2 1

WAIT TIMES:

Timeinwaitingroom 5 4 3 2 1

Timeinexamroom 5 4 3 2 1

Timespentwaitingforteststobeperformed 5 4 3 2 1

Timespentwaitingfortestresults 5 4 3 2 1

STAFF:

Provider: (Physician, Physician Assistant, Nurse Practitioner)

Listenstoyou 5 4 3 2 1

Takesenoughtimewithyou 5 4 3 2 1

Explainswhatyouwanttoknow 5 4 3 2 1

Givesyougoodadviceandtreatment 5 4 3 2 1

Nurses and Medical Assistants:

Friendlyandhelpfultoyou 5 4 3 2 1

Answersyourquestions 5 4 3 2 1

Receptionist:

Friendlyandhelpful 5 4 3 2 1

Answersyourquestions 5 4 3 2 1

All others:

Friendlyandhelpful 5 4 3 2 1

Answeryourquestions 5 4 3 2 1

©2008Practice&LiabilityConsultants

Appendix- 123

SAMPLE SURVEY: Patient Satisfaction (page 2 of 2)

Pleasecirclehowwearedoinginthefollowingareas: GREAT(5) GOOD(4) OK(3) FAIR(2) POOR(1)

Payment:

Whatyoupay 5 4 3 2 1

Explanationofcharges 5 4 3 2 1

Collectionofpayment/money 5 4 3 2 1

Facility:

Cleanlinessbuilding 5 4 3 2 1

Easeoflocatingthepractice 5 4 3 2 1

Comfortandsafetywhilewaiting 5 4 3 2 1

Privacy 5 4 3 2 1

Confidentiality:

Keepsmypersonalinformationprivate 5 4 3 2 1

Thelikelihoodofreferringyourfriendsandrelativestous: 5 4 3 2 1

What do you like best about our practice? ________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

What do you like least about our practice? ________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Suggestions for improvement? _________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Thank you for completing our Survey!


-Best Practices124

SAMPLE SURVEY: Patient Satisfaction (Spanish) (page 1 of 2)

[Insertpracticename/logohere]Encuesta De Satisfacción Para el Paciente

Quisiéramossaberquepiensausteddelosserviciosdesaludqueofrecemosparaasegurarnosqueestamossatisfaciendosusnece-sidades.Susrespuestassetomaránencuentaparamejorarnuestrosservicios.Susrespuestasserántomadasconfidencialmenteyanónimamente.¡Graciasporsutiempo!

Su Edad:_______Su Sexo: qMusculinoqFemenino

¿Considera esta clínica su Centro de cuidado principal? qSíqNo

Su Raza/Etnicidad: qNoSé qOrientalqNegro/africanoAmericanoqIslaPacificaqIndioAmericano/nativodeAlaskaqBlanco(NoHispanoniLatino)qHispanooLatino(TodaslasRazas)

Porfavorcalifiquelosserviciosenlassiguientesáreasycirculeelnúmerodeacuerdoconlacalidaddecadaservicio:

MUYBUENO

(5)

BUENO

(4)

REGULAR

(3)

POBRE

(2)

MUYPOBRE

(1)

FACILIDAD DE RECIBIR CUIDADO:

Habilidadparaobtenerunacita 5 4 3 2 1

HorasdeserviciodelCentro 5 4 3 2 1

LugardondeseencuentraelCentro 5 4 3 2 1

Rapidezencontestarleporteléfono 5 4 3 2 1

EL CONSULTORIO:

TiempoenlasaladelCentro 5 4 3 2 1

Tiempoenelcuartodeexamen 5 4 3 2 1

Tiempoqueesperaparaquelehagenunexamen 5 4 3 2 1

Tiempodeesperaparaobtenerlosresultadosdelexamen 5 4 3 2 1

EMPLEADOS:

Proveedor: (Doctor, Asistente Médico, Enfermera Practicante)

Leescuchan 5 4 3 2 1

Setomansuficientetiempoconusted 5 4 3 2 1

Leexplicanloqueustedquieresaber 5 4 3 2 1

Ledanbuenosconsejosytratamiento 5 4 3 2 1

Enfermeras:

Sonamistososyamablescuandoleayuden 5 4 3 2 1

Lecontestansuspreguntas 5 4 3 2 1

Recepcionista:

Amablesydispuestosenayudarle 5 4 3 2 1



Appendix- 125

SAMPLE SURVEY: Patient Satisfaction (Spanish) (2 of 2)

Porfavorcalifiquelosserviciosenlassiguientesáreasycirculeelnúmerodeacuerdoconlacalidaddecadaservicio:

MUYBUENO

(5)

BUENO

(4)

REGULAR

(3)

POBRE

(2)

MUYPOBRE

(1)

Todos Los Demás:

Amablesydispuestosenayudarle 5 4 3 2 1


Pago:

Loqueustedpaga 5 4 3 2 1

Explicacióndecargos 5 4 3 2 1

Coleccióndepago/dinero 5 4 3 2 1

Lugar:

Elconsultorioestáenordenylimpio 5 4 3 2 1

Esfácildeencontrarellugardondedebeir 5 4 3 2 1

Sesientecómodoysegurocuandoestáesperando 5 4 3 2 1

Hayprivacidad 5 4 3 2 1

Confidencialidad:

Miinformaciónpersonalsemantieneenprivado 5 4 3 2 1

Laprobabilidadderecomendaraparientesyamistades: 5 4 3 2 1

¿QuéesloquemáslegustadenuestroCentro?________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

¿QuéesloquemenoslegustadenuestroCentro?______________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

¿Tienesugerenciasparamejoramiento?______________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

¡Gracias por su tiempo en llenar esta encuesta!


-Best Practices126

SAMPLE LETTER: Referring Physician Satisfaction Survey Cover Letter

[PhysicianLetterhead]

[Date]

ReferringMDNameReferringMDAddressCity,State,Zip

Dear[insertreferringphysicianname]:

Mypracticeisperformingananonymousreferralsatisfactionsurvey.Wegreatlyappreciateyourreferralsandwishtogiveyoutheopportunitytocommentonmyservicestoyouandyourpatients.

Pleasetakeamomenttofillouttheformandmailitintheselfaddressedandstampedenvelopethathasouraddressasthesenderandrecipienttoprotectyouranonymity.

Commentsareespeciallyhelpful,particularlyifpatientshavemadecommentstoyou.MystaffandIsincerelyappreciateyourhonestopinionstocontinuetoprovideexcellentserviceandimprovewhereneeded.Wearecommittedtothehighestqualitymedicalcareaswellaspatientandreferringphysiciansatisfaction.

Please complete and return the survey by ____________.

PleaseacceptmythanksforyourtimeandcooperationandIlookforwardtoacontinuedprofessionalrelationship.

Sincerely,NameofPhysician


Appendix- 127

SAMPLE SURVEY: Referring Physician Satisfaction


[Insertpracticename/logohere]

Referring Physician Satisfaction Survey

Weappreciateyourreferrals!Itisourgoaltoprovidepatientsandreferringphysicianswithexcellentservice.Pleaseletusknowhowwearedoing.

1. Is our office accessible for you to make referral appointments for your patients? qYesqNo

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

2. Is our office staff courteous and helpful? qYesqNo

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

3. Does our staff handle referral and prior authorization requests appropriately? qYesqNo

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

4. Do you receive progress reports in a timely manner? qYesqNo

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

5. Are your patients pleased with the medical care they receive in our office? qYesqNo

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

6. Are your patients pleased with the attention and communication they receive from the physician? qYesqNo

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

7. Is it important to you that the physicians will accept all patients regardless of the ability to pay? qYesqNo

Comments:____________________________________________________________________________________________

______________________________________________________________________________________________________

Thankyouforyourtimeandeffort.Pleasereturnthisformintheenclosedenvelope.

-Best Practices128

Sample Interview and Document Request for HIPAA Compliance Reviews (page 1 of 2)

Thislist,obtainedfromtheU.S.DepartmentofHealthandHumanServices’OfficeofE-HealthStandards,isanexampleofinformationthatmightberequestedofyouduringaHIPAAinvestigationorcompliancereview.Thislistshouldnotbereliedonascomplete.However,itwillgiveyouagoodideawhetheryoucurrentlyhavetheappropriatedocumentation.

1. Personnel that may be interviewed •President,CEO,ordirector •HIPAAcomplianceofficer •Leadsystemsmanagerordirector •Systemssecurityofficer •Leadnetworkengineerand/orindividualsresponsiblefor: •administrationofsystemswhichstore,transmit,oraccesselectronicprotectedhealthinformation(EPHI) •administrationsystemsnetworks(wiredandwireless) •monitoringofsystemswhichstore,transmit,oraccessEPHI •monitoringsystemsnetworks(ifdifferentfromabove) •Computerhardwarespecialist •Disasterrecoveryspecialistorpersoninchargeofdatabackup •Facilityaccesscontrolcoordinator(physicalsecurity) •Humanresourcesrepresentative •Directoroftraining •Incidentresponseteamleader •Othersasidentified

2. Documents and other information that may be requested for investigations/reviews •Policiesandproceduresandotherevidencethataddressthefollowing: •Prevention,detection,containment,andcorrectionofsecurityviolations •Employeebackgroundchecksandconfidentialityagreements •Establishinguseraccessfornewandexistingemployees •ListofauthenticationmethodsusedtoidentifyusersauthorizedtoaccessEPHI •ListofindividualsandcontractorswithaccesstoEPHItoincludecopiespertinentbusinessassociateagreements •ListofsoftwareusedtomanageandcontrolaccesstotheInternet •Detecting,reporting,andrespondingtosecurityincidents(ifnotinthesecurityplan) •Physicalsecurity •EncryptionanddecryptionofEPHI •Mechanismstoensureintegrityofdataduringtransmission-includingportablemediatransmission(i.e.laptops,cell

phones,blackberries,thumbdrives) •Monitoringsystemsuse-authorizedandunauthorized •Useofwirelessnetworks •Granting,approving,andmonitoringsystemsaccess(forexample,bylevel,role,andjobfunction) •SanctionsforworkforcemembersinviolationofpoliciesandproceduresgoverningEPHIaccessoruse •Terminationofsystemsaccess •Sessionterminationpoliciesandproceduresforinactivecomputersystems •Policiesandproceduresforemergencyaccesstoelectronicinformationsystems •Passwordmanagementpoliciesandprocedures •Secureworkstationuse(documentationofspecificguidelinesforeachclassofworkstation(i.e.,onsite,laptop,and

homesystemusage) •DisposalofmediaanddevicescontainingEPHI


Appendix- 129

Sample Interview and Document Request for HIPAA Compliance Reviews (2 of 2)


• Other Documents: •Entity-widesecurityplan •Riskanalysis(mostrecent) •Riskmanagementplan(addressingrisksidentifiedintheriskanalysis) •Securityviolationmonitoringreports •Vulnerabilityscanningplans •Resultsfrommostrecentvulnerabilityscan •Networkpenetrationtestingpolicyandprocedure •Resultsfrommostrecentnetworkpenetrationtest •Listofalluseraccountswithaccesstosystemsthatstore,transmit,oraccessEPHI(foractiveandterminatedemployees) •Configurationstandardstoincludepatchmanagementforsystemsthatstore,transmit,oraccess

EPHI(includingworkstations) •Encryptionorequivalentmeasuresimplementedonsystemsthatstore,transmit,oraccessEPHI •OrganizationcharttoincludestaffmembersresponsibleforgeneralHIPAAcompliancetoincludetheprotectionofEPHI •Examplesoftrainingcoursesorcommunicationsdeliveredtostaffmemberstoensureawarenessandunderstandingof

EPHIpoliciesandprocedures(securityawarenesstraining) •Policiesandproceduresgoverningtheuseofvirusprotectionsoftware •Databackupprocedures •Disasterrecoveryplan •Disasterrecoverytestplansandresults •Analysisofinformationsystems,applications,anddatagroupsaccordingtotheircriticalityandsensitivity •Inventoryofallinformationsystemstoincludenetworkdiagramslistinghardwareandsoftwareusedtostore,transmitor

maintainEPHI •Listofallprimarydomaincontrollers(PDC)andservers •InventorylogrecordingtheownerandmovementmediaanddevicesthatcontainEPHI

-Best Practices130

SAMPLE LETTER: Request Copy of Payor Contract


[Date]

PayorName(ContactNameorDepartmentofProviderRelations)AddressCity,State,Zip

ToWhomItMayConcern:

Thisletteristorequestacopyoftheoriginalsignedandexecutedcontractbetweenmypracticeandyourorganization.

Ifchangeshavebeenmadetotheoriginalcontractsincethedateitwasexecuted,pleaseforwardacopyofeachandeveryletternotifyingmypracticeofeachmodification,includingthedatethatthemodificationwaseffective.

Thankyouforyourpromptattentiontothisrequest.

Sincerely,(NameofPhysician)

Appendix- 131

SAMPLE LETTER: Contract Termination


[Date]

[PayorName] SENTVIACERTIFIEDMAILAttn:ContractProcessing[StreetAddress][City,StateandZip]

RE:[PayorName]CONTRACTTERMINATION

DearProviderContractProcessing,

ThepurposeofthisletteristoinformyouthatIdonotagreewith[PayorName]’sproposaltomodifymycontract,whichisscheduledtobecomeeffective[insertdatehere].

Thisletterservesasformalnoticeofmyintenttoterminatemycontractwith[PayorName].Thisterminationshallbeeffective[Date].

Sincerely,[NameofPhysician][NameofPractice][StreetAddress][City,State,Zip][TAXID#][NPI]

-Best Practices132

SAMPLE LETTER: Patient Notice of Contract Termination


[Date]

[PatientName][StreetAddress][City,StateandZip]

Dear[nameofpatient]:[Nameofinsurer]hasrecentlynotifiedmypracticethattheyarechangingthetermsofmycontract.Unfortunately,[Nameofinsurer]hasofferedmypracticeacontractthetermsofwhichIamunwillingtoaccept.[Youmaywishtoinsertastatementhereaboutthespecifictermsthatyoufindobjectionable.]Basedupon[nameofinsurer]’soffer,Iwillnolongerbeparticipatingprovidersasof[insertdatehere].Asofthatdatewewillbeconsideredout-of-networkproviders.

Ihavegreatlyappreciatedtheopportunitytoserveasyourphysicianandwillbeverypleasedtocontinueinthatrole.Ifyouwishtocontinuetoreceivemedicalservicesfromouroffice[optional:wearewillingtoworkwithyouandhavepaymentpoliciesforpatientswhowishtopayusdirectly],youmaywishtoreviewyourbenefitsunderyour[nameofinsurer]insurancepolicytodeterminewhethertheywillprovideanyreimbursementforoutofnetworkservices.Ifyouhavequestionsaboutyourbenefits,youmaywishtotalkwithyouremployer’sbenefitmanager,asthesemattersaredeterminedbythem.

Asalongstandingmemberofthiscommunity,Iamdeeplycommittedtothehealthofthecommunityandregretverymuchthisintrusionintoourrelationship.IhopeIcancontinuetobeofservicetoyouandwillworkwithyoushouldyouelecttocontinueundermycare.

Sincerely,[NameofPhysician]

Appendix- 133

SAMPLE NOTICE: Patient Responsibility for Non-Covered Services


Thefollowingservicesaregenerallynotcoveredbymanagedcareplansandinsurancecompanies:cosmeticsurgery,fertilitytreatments,andservicesdeemed“experimental”and/or“investigational.”Eachhealthplanmayexcludeorlimitcoverageforotherservices.ThelawsofCaliforniaprohibitsomeexclusions,butonlyforhealthplansthatarelicensedbythestate.Youneedtodiscusswithyourinsurerwhethertreatmentprovidedinthisofficeiscoveredandthereforepaidforbytheplan.IfyouhavequestionsaboutthelawyoumayalsocontactCalifornia’sDepartmentofManagedHealthCarebycalling(888)HMO-2219,www.dmhc.ca.gov,ortheDepartmentofInsuranceat(800)927-HELP,www.insurance.ca.gov.

Youareresponsibleforpaymentforservicesprovidedtoyouwhicharenotcoveredbyyourhealthplan.

-Best Practices134

SAMPLE AGREEMENT: Payment for Non-Covered Services


AGREEMENTTOPAYFORNON-COVEREDSERVICES

I,[Patient’sName],understandthatthe[TypeofService]prescribedbymyphysicianisnotcoveredbymyinsurerorhealthplan,[becausetheplandoesnotfeelthatitismedicallynecessary].Therefore,theservicewillnotbepaidforbymyinsurerorplan.Ithereforeagree,inadvance,topaymyphysician’susualandcustomaryrateforprovidingsuchservicestome.

__________________________________________________________PatientSignature Date

_________________________________________PrintName

SAMPLE FORM: Patient Financial Responsibilities


Co-Payment and Deductible: Youareresponsibleforyourdeductibleandco-payment.Ifyourdeductiblehasbeensatisfied,wewillbillyourhealthplan.Ifyourdeductiblehasnotbeensatisfied,paymentisrequiredatthetimeofservice.Yourco-paymentisalsodueatthetimeofservice.

Medicare:We[accept][donotaccept]Medicareassignment.Youareresponsibleforyourdeductibleandco-payment.Ifyouhaveasec-ondaryinsurancecarrier,aportionofyourco-paymentmaybecovered.

Non-Covered Services:Ifweprovideservicestoyouthatarenotcoveredbyyourhealthplan,youwillberesponsibleforpaymentinfullforthoseser-vices.Yoursignature,below,constitutesagreementtopayforsuchservices.

Appointment Cancellation Charge:Afullappointmentfeemaybechargedforappointmentscancelledwithoutaminimumoftwenty-fourhoursnotification.

Payment Arrangements:Paymentsmaybemadeincash,[bycheck],[orbyVISAandMASTERCARD].

Services Charges/Late Fees:Anybalancecarriedtothenextbillingcyclewillbesubjecttoaservicecharge:

Forabalancelessthan $________ $________permonth

Forabalancebetween $________and$________ $________permonth

Forabalanceover $________ $________permonth

Collections:Ifitisnecessarytoassignyouraccounttoacollectionagencyand/orattorney,youwillberesponsibleforallofourcollectionagencyandattorneyfeesandcosts.

Wearehappytodiscusswithyouanyquestionsrelatingtotheinformationabove.Wethankyouforchoosing[NameofPrac-tice]foryour[NameofSpecialty]services.Weareproudtobeyourphysician[s].

________________________________________________________________________________________________PrintName PatientSignature Date

Appendix- 135

-Best Practices136

CONTRIBUTORS

Frank Cohen,MPAisthesenioranalystforMITSolutions,Inc.,developersofanalyticalanddecisionsupporttoolsandsystemsforhealthcareorganizations.

www.mitsi.org

Linda Coleisdirectoroflearninganddevelopmentforathena-health,aleadingproviderofinternet-basedbusinessservicesforphysicianpractices.Thecompany’sserviceofferingsarebasedonproprietaryweb-basedpracticemanagementandelectronicmedicalrecordsoftware,acontinuouslyupdatedpayerknowl-edge-base,andintegratedback-officeserviceoperations.

www.athenahealth.com

David GinsbergiscofounderandpresidentofPrivaPlanAssociates,Inc.Hehasmorethan25yearsofexperienceinthehealthcareindustry,includingphysicianpracticemanage-ment,electronichealthrecords,electronicdatainterchange,andHIPAA.

www.privaplan.com

Jay Lechtman,MA,isvicepresidentofplanninganddevelop-mentforDecisionHealthProfessionalServices,theconsult-ingandcustomizededucationdivisionofDecisionHealth.DecisionHealthservesthedecisionsupportneedsofhealth-careprofessionalsthroughtimelynewsandexpertguidanceinrevenuemanagement,regulatorycomplianceandbusinessoperationsimprovement.

www.decisionhealth.com

Dan Lensink,M.D.,isaboardcertifiedophthalmologisttrainedin,andlimitinghispracticetoplasticsurgeryoftheeyes.He’sbeeninprivatepracticeforeighteenyears,firstinFresno,andforthepast10yearsinRedding.

www.lensinkeyesurgery.com

Melissa Lukowskiisdirectorofpayoroutreachforathena-health,aleadingproviderofinternet-basedbusinessservicesforphysicianpractices.Thecompany’sserviceofferingsarebasedonproprietaryweb-basedpracticemanagementandelectronicmedicalrecordsoftware,acontinuouslyupdatedpayerknowl-edge-base,andintegratedback-officeserviceoperations.


Alan Morrisonisengagementmanagerforathenahealth,aleadingproviderofinternet-basedbusinessservicesforphysi-cianpractices.Thecompany’sserviceofferingsarebasedonproprietaryweb-basedpracticemanagementandelectronicmedicalrecordsoftware,acontinuouslyupdatedpayerknowl-edge-base,andintegratedback-officeserviceoperations.


Debra PhairasispresidentofPractice&LiabilityConsultants,anationallyrecognizedfirmspecializinginpracticemanage-mentandmalpracticeprevention.Herbackgroundincludesmedicalclinicadministrationandlosspreventionmanagement.

www.practiceconsultants.net

Mary Jean Sage,isfoundingprincipalandseniorconsultantforTheSageAssociates,aleadingmultispecialtyproviderofhighqualityhealthcaremanagementconsultingservices.MaryJeanisanationallyrecognizedspeaker,consultant,andeducator,withmorethan20yearsexperienceinthehealthcarefield.

www.thesageassociates.com

Sean M. Weiss,CPC,CPC-P,CCP-PisvicepresidentandseniorconsultantwithDecisionHealthProfessionalServices,theconsultingandcustomizededucationdivisionofDeci-sionHealth.DecisionHealthservesthedecisionsupportneedsofhealthcareprofessionalsthroughtimelynewsandexpertguidanceinrevenuemanagement,regulatorycomplianceandbusinessoperationsimprovement.

www.decisionhealth.com

I Introduction 1 1 2 3 - The Physicians Foundation · 2018-02-14 · Chapter V returns to the topic...

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Transcript of I Introduction 1 1 2 3 - The Physicians Foundation · 2018-02-14 · Chapter V returns to the topic...