Manage My Practice

Sometimes employees do not understand or follow the most basic of workplace guidelines. Here is a simple but comprehensive list that you can tweak to make your own. It covers about 25 basics in a short list of ten “Golden Rules”. Make it part of each job description or personnel handbook and/or post it in strategic places.

1. Report to work on time daily. Be ready at your desk to begin work at the designated time. Leave promptly for lunch and return to work when you should, unless you’ve made special arrangements with your supervisor. Take breaks on the honor system and do not abuse the privilege. Clock in and out faithfully.
Command respect from the physicians, managers and employees of (your practice name here) by demonstrating total professionalism in the workplace with your dress, your demeanor and conversation. Represent the practice in a way that would make your Mother and your boss proud of you. Treat your co-workers as you would like to be treated.

Be economical by not wasting time or supplies or doing sloppy work that must be re-done.

Give every patient your total attention, patience and courtesy. Do not assume you know what the patient is going to say, but listen carefully to the patient (in-person or on the phone) so you can assist them to the best of your ability. Remember how good it feels to be the center of someone’s attention and give that gift to every single patient.

Keep your supervisor aware of any problems in your workload, whether too much or too little. Do not expect your supervisor to know if you are falling behind or caught up.

Document all interactions with patients and other medical facilities to assist your co-workers in knowing what you have done, and document your resolution of the situation to the customer’s satisfaction.

Strive for a positive attitude every single day. Don’t whine.

Be a team player. This means both covering for your co-workers and knowing that they will cover you. This means supporting your co-workers to their faces and behind their backs. This means having (your practice name here) goals for your goals, and knowing that your success will be your team’s success, and ultimately, the success of the practice.

Clean up your own messes and act as an adult acts in the workplace: responsibly, maturely, and with thought for others. Accept blame for your own mistakes, knowing that everyone makes them, and that if no one is making any mistakes, nothing is improving.

Contribute to making (your practice name here) a good place to work. Only you can create a place where everyone enjoys working. Only you can make this place a good place to be.

For more medical office rules, read “21 Common Sense Rules for Medical Offices.”

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I have been a fan of Chris Brogan’s for quite awhile now. He is a superstar on the social media landscape and I almost got to meet him once when I lived in Seattle (sigh.) Today I came across his post “5 Things That Small Businesses Should Do Now.” Many medical practices are small businesses (privately owned and operated, with 100 employees or less), but may have not considered any of these options.

Here are Chris’s suggestions and my commentary:

• Start a blog I cant think of any simpler website technology to start and master, and there are cheap and free platforms readily available. Why a blog? Because theyre easy to create, because theyre easy to update, because they encourage repeat visits, and because you can use them in many flexible ways.

My comment: Most practices have websites and it is easy to add a blog to a website. Some administrators and/or physicians would gladly take on a blog, and if not, there are some great writing professionals who can create and write a blog for you. Professional bloggers get to know your practice and your patient demographic and create a voice for your practice that uniquely fits you. A blog extends and enhances your relationship with existing and future patients. It’s all about the communication.

• Start listening People are talking about you. Find out where they are and who they are.

My comment: It has been hard for physicians to come to terms with the fact that patients are publicly rating them. In some cases, physicians are requiring consumers to sign gag orders before becoming patients. The truth is, patients will not be stifled and physicians need to monitor the bandwaves for commentary about them and take it seriously.

• Try Twitter OR Facebook Lets not rush things. Facebook has many more users, but its a bit harder to find customers, prospects, partners and colleagues. Twitter is easier to use and faster to connect with people, but there are far fewer users on there today. Ill let you choose. If you go with Facebook, make a personal account under your own name, and then start a fan page for your business.

My comment: Does this seem too far out? It’s not! At the very least, practices should be learning about the technology and preparing for the time when they will need to jump in. Businesses (who want customers) can no longer hold themselves aloof. You need to be part of the conversation, or at least know where/what the conversation is.

• Get the word out If youre going to spend time building these social sites, lets presume that you want more people to contact you and interact with you through them. Print business cards with the company name, and/or the request for people to join your fan page or follow you on Twitter.

My comment: Your website and your social sites should be on everything you print that patients take home or receive from you, and can also be communicated to patients via automated communication: appointment reminders, messages on hold, emails, and electronic newsletters.

• Try moving the needle now lets really get crazy. See if you can fill the place up with social-media minded folks. Okay, this wont work for every business, but dont be too quick to count out the idea. Lets try inviting them to a store-only special event, or lets give them a discount code. You know, the stuff you already know how to do. Any difference in the results? See if you can do some kind of really special one-day-only push, and what that brings to you.

My comment: This won’t work for every medical practice but it’s ideal for practices with elective services – plastic/cosmetic surgery, allergy, complementary & alternative medicine, sports performance, vision correction, cosmetic dental services, infertility treatment, etc.

I wrote this post for the MGMA In Practice Blog and have republished it here for my readers.

I resigned from my job managing an orthopedic group on Jan. 20, 2009, and I remember thinking, Who leaves a job during a recession? Well, I did, and what follows is what I learned on my three-and-a-half month journey to my new position.

1. Visit the MGMA Career Center job search site often. Try different categories and occasionally check categories you don’t think you fit in you never know. I don’t suggest this because I am writing for the MGMA blog, I suggest it because it is a resource that I believe in.
2. Four state MGMA sites integrate their “jobs boards” with the MGMA Career Center: Colorado, Georgia, New Jersey and Montana. Search other state MGMA sites; some allow non-members to access the job listings.
3. Get a LinkedIn account (free) at LinkedIn.com and complete your profile, connect with colleagues, join groups and start networking. There are healthcare jobs listed exclusively on LinkedIn, as well as an aggregation of jobs listed elsewhere. Joining MGMA’s new LinkedIn group will help expand your network even more.
4. In addition to LinkedIn, be sure to have your expanded resume on the web. MGMA provides a platform for this, as does VisualCV.com (free). I use VisualCV.com because it allows me to include articles I’ve authored, recommendations from former employers and even video. I’ve gotten a number of quality calls from recruiters who saw my expanded resume online.
5. Contact consultants to let them know you are in the market. MGMA has a consulting arm that often places healthcare executives, and you can also search for consultants via the MGMA Member Directory (members only) which at last count numbered about 640.
6. Contact your colleagues and MGMA friends to let them know you’re looking. If you are looking for employment in a particular region or community, contact managers working there and let them know about your search.
7. Look on Craigslist.org. Yes, really! You would be amazed who advertises there.
8. If you expect to relocate, having a home to sell may be a hiring stumbling block because of the housing market. Employers want to know you’ll be available to work when they want you. If you don’t have a home to sell, mention that in your cover letter/e-mail.
9. When you apply for a position, ask the receiver to let you know that your e-mail arrived. If they respond, take the opportunity to respond back, which helps you to stand out from the pack and gives you a name to follow up with in a few weeks by e-mail.
10. There is a pack! Some employers told me they had received more than 200 mostly qualified applications for open positions. How do you stand out in that kind of a crowd? Network, network, network. Find out whether you or someone you know knows someone at the potential employer and work it. LinkedIn has an excellent system for finding out who you know that works at the employer you are targeting.
11. Join more listservs on the MGMA Member Community (members only). Step outside your current/past specialties and join other professional e-mail lists to listen and contribute to the conversation. Respond when someone talks about a job opening.
12. Talk to recruiters. Recruiters don’t owe you anything, but they are worth including in your search. Get into the minds of a recruiters and see what tactics they’re using on social networking platforms to fill jobs.
13. Don’t spend much time on non-healthcare job boards. The likelihood that you will find the job of your dreams on Monster.com or CareerBuilder.com is low.
14. Don’t be afraid to look for a job on Twitter. This is what I tweeted: “Calling on the Power of Twitter: looking for new job: private (phys) practice mgmt/other healthcare opp. Innovator, Blogger. DM me – Thx.” If you want to jump into Twitter but don’t know what it’s all about, read this post at my blog, Manage My Practice, or MGMA’s Twitter guide. Twitter has recruiters, consultants, employers, job boards and colleagues and is one of the fastest-growing social networks. It can significantly expand your networking scope.
15. Share information with other job seekers in your market. Don’t be afraid to share your leads with others it’s good networking karma!
16. Two sites I found useful during my job search are CareerAlley.com and Alltop.com. Career Alley is a good all-purpose site with lots of job search information and resources, such as a tracking spreadsheet that helps you document your leads. Alltop is an ever-growing aggregator of other sites try looking under “jobs” and “careers.”

Remember, the Internet doesn’t replace traditional networking it supercharges it! The important thing is to get out there and make connections, share information and let people know what value you bring to a practice. Even with all the social networking I did, my opportunity came the old-fashioned way: A colleague and consultant I knew well from the state and regional levels of MGMA recommended me for a job, and here I am. Good luck!

For those of you who have not tapped into the amazing wealth of information generously shared by Frank Cohen, go to his site now and see what he has that could help you.

Most recently Frank analyzed the October 2009 NCCI Edits Release 15.3 and organized the information into meaningful categories as well as providing an executive summary.

As a reminder, the CMS website tells us:

The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.

Per Frank’s assessment of the 2009 changes effective on October 1:

There are 706 terminated edit pairs but once again, around half have been terminated retrospectively. Two are terminated back to last quarter (7.1.09), 357 back to April, 2009 and 27 all the way back to January, 2009. This means that, if you were denied payment on edit pairs that are part of this last over the past few quarters, you should be able to resubmit and get paid. The big hitters for terminated codes in both column 1 and column 2 fell within the surgical code category (520 and 513, respectively).

For more information, go to Frank’s site here, go to the Download tab and you will see the link at the top of the page.

Doctors Slash Vaccines Due to High Cost (CNN Money)

Physicians are referring patients to the public health departments for vaccines because insurers won’t reimburse them for the cost of the vaccine, much less a profit to cover the overhead and labor. Physicians want to give high quality care to their patients, but why should they subsidize vaccines? Read about it here.

Ghostwriting: the Dirty Little Secret of Medical Publishing That Just Got Bigger (Public Library of Science)

Surprise! Pharmaceutical companies are writing journal articles and attaching physician names to them. What doesn’t pharma have a hand in today? Read it here.

InQuickER: The Answer to Making a Visit to the ER an In and Out Experience

InQuickER says that the average wait time in the Emergency Room is 3.2 hours. I recently spent 5 hours on a Sunday and 7 hours on a Monday in the ER, although I must say I was grateful that the ER was there. Atlanta-based InQuickER, launched in April of this year, announced the launch of a new service that allows patients with non life-threatening conditions to reduce their waiting time by calling ahead or signing in online. The price to patients is USD 24.99 per visit, and if the patient is not seen within 15 minutes of their “appointment” there is no charge for the ER treatment – no charge for the ER visit, no charge for diagnostic services, and no charge for supplies. Read more here.

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BUILD ON WHAT YOU’RE CURRENTLY DOING:

1. Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.

2. Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.

3. Set a minimum number of providers to be in the office seeing patients at all times the office is open.

4. Have each provider add one new patient visit to his/her schedule weekly.

5. Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)

6. Report PQRI measures to recoup additional Medicare revenue.

7. Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.

8. Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)

9. If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.

10. If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.

ADD TO YOUR CURRENT SERVICES:

11. Allergy testing & treatment

12. Dispensing pharmaceuticals

13. Dispensing nutriceuticals

14. Dispensing Durable Medical Equipment

15. Group patient visits

16. Coumadin Clinic

17. Heart Failure Clinic

18. Diabetes Education Classes

19. Add primary care to specialty care practices

20. Add specialty care to primary care practices

21. Research

22. Joint Ventures with other practices or hospital

23. Lease space to other entities

24. eVisits (virtual visits or email visits)

25. Elective procedures or services

26. Mid-level providers

27. Walk-in clinic

28. Occupational medicine: drug screens, employment physicals, etc.

29. Hospitalists

30. Medical Director of local nursing homes

31. Complementary & alternative medicine (CAM)

32. Aging in Place services

33. Social worker

34. Concierge practice

35. School team physician

EVALUATE YOUR REVENUE CYCLE MANAGEMENT:

36. Are you renegotiating payer contracts regularly?

37. Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?

38. Do staff know what typical new patient charges are to tell the patient?

39. Do you check every patient’s eligibility for insurance benefits immediately prior to every service?

40. Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?

41. Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file? Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?

42. Is your PM system able to download the information from the scan into the patient registration screen? If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?

43. Are your charges being posted daily?

44. Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?

45. Is the documentation for the charges being completed within 24 hours of the service?

46. Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?

47. Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?

48. Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?

49. Are you using ABNs for Medicare patients who want services that Medicare might not pay for?

50. Do you file claims daily?

51. Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?

52. Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?

53. Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?

54. Do you appeal unpaid or underpaid claims?

55. Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?

56. Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?

57. Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?

58. Do you have a policy of not sending statements?

59. Do you collect the patient’s portion of the service at the time of service?

60. Do you collect fees for elective services prior to providing these services?

61. Can your patients make payments online through your website?

62. Do you file a claim with a patient’s estate if they have died?

63. Do you accept cash only from patients who have passed bad checks?

64. Do you accept cash only from patients who have filed bankruptcy with your practice?

65. Do you inadvertently see patients who have been dismissed from your practice?

66. When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?

67. If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?

68. Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)

69. Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?

70. Are you receiving payments via electronic funds transfer (EFT)?

71. Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?

72. Are you posting your RA electronically?

73. Are you protecting your practice from embezzlement? (see my post on this here.)

74. Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?

DECREASE EXPENSES:

75. Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.

76. Send some staff home (sometimes called “low census”) when there are no patients to be seen.

77. Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.

78. Hire an after-school student employee to do routine jobs.

79. Discontinue paying staff for inclement weather closings when the practice is not open.

80. Shop everything. Negotiate existing service contracts. Do not assume anything is non-negotiable. Negotiate the rent.

81. Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers. You will still get your white pages listing free with your phone service.

82. Utilize pre-employment testing to make sure job applicants have the skills you need.

83. Shop postage machines or look into stamps.com.

84. Join a group purchasing entity (hospital, professional association, etc.)

85. Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices. Use purchase order numbers.

86. Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.

87. Make sure office supplies are not going home with the employees. Make sure office supplies that are ordered are “really need” and not “sure would be nice.”

88. Remind patients of their appointments to decrease no-shows. Call patients who no-show and attempt to reschedule (unless they feel better!) Track no-shows and evaluate the reasons for them.

89. Consider charging for no-shows or dismissing patients for no-shows.

90. Have a good recall system in place. If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time. Keep track of annual wellness visits and remind patients to schedule them.

91. Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims. Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.

92. Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.

93. Evaluate your leases - are those big old copiers and faxes worth paying for a service contract?

94. Consider speech recognition/voice recognition and eliminate transcription.

95. Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?

96. Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.

97. Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.

98. Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.

99. Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.

100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.

101. Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses. The people on the front lines will have excellent ideas. In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances. Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere. Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.

Recent news stories about manager embezzlement give us all a black eye. What can managers do to limit their liability, and how can physicians protect the practice without managing the day-to-day operations themselves?

Here are nine suggestions:

1. Perform a thorough background check before hiring a manager, and have your manager bonded.
2. Have your bank statements sent to the physician’s home address and/or make sure the physician has the master access to the bank accounts online. Physicians, have a personal relationship with your practice banker and make time for a short meeting with them quarterly.
3. Have the physician sign your practice checks. Each check should be attached to an invoice that lists the goods or service purchased. Do not order a rubber stamp of the doctor’s signature.
4. Insist on a duplicate, numbered receipt book for staff to give receipts to patients for all over the counter payments.
5. Have your insurance and patient checks sent to a lockbox.
6. Make sure the manager takes time off at least several weeks a year. Managers who are too busy or cant ever get away are a red flag. The physician should review all mail during the managers vacation.
7. Check the monthly credit card statement carefully before making the payment. Keep the card restricted to a relatively low limit to manage your liability. Do not pay practice bills routinely on the card to build frequent flyer miles as this makes it much easier for an employee to hide non-approved expenditures.
8. Have a budget and make sure variances can be explained.
9. Hire a CPA to review the books quarterly. Even if you do not need the services of a CPA for your statement reconciliation, taxes or partners distribution, hire one to review the expenses and receipts, and ensure that the retirement plan is being funded appropriately.

A qualified, ethical manager has nothing to hide and will thank you for following these nine rules. The rules protect the manager as well as the practice.

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