Manage My Practice

I’ve been thinking about the medical office of the future. How would you design a building today that is meant to take you into the future? Here are my thoughts.

One of the hallmarks of a well-designed office, today or tomorrow, is flexibility. You want as much functionality as you can possibly get out of each space and use each space for as many purposes as possible.

For instance, a large room with lots of voice and data jacks or wireless and electrical outlets might be used for:

1. Physician meetings, staff meetings or parties
2. Group patient visits
3. In-house health fair
4. Staff or patient training
5. Public meetings
6. War room for disaster management or ad hoc project (medical record scanning prior to an EMR go-live)
7. Conversion to workstations for a merger with another group
8. Place to do group sports or college physicals, flu shot clinics, DOT physicals

I see reception and waiting areas getting smaller as patients have less time and are less willing to wait. Patients may not have to wait at all if you are sending them a text message or Twitter when the doctor is ready to see them. Some practices will not have waiting areas as patients will be escorted directly into exam rooms where the entire visit, from soup to nuts, will take place. Instead of going to the lab, the lab might go to the patient.

Registration may be replaced by check-in kiosks that totally automate the process, including a vitals booth which takes the patient’s weight, blood pressure, oxygen levels and temperature. Patients and their demographic and insurance information may be identified by fingerprints or iris scans. You may have a receptionist avatar greeting patients.

Fixtures are movable – storage cabinets are on wheels and not permanently attached to walls. Any room can be an exam room, a treatment room, a test room, a procedure room, simply by moving the cabinet with the needed items and the machines, which will be handheld. See an example here.

Providers’ phones are their everything. Their mail, patient records, test results, journals, phone calls, and their family pictures are on their phone, so no need for an “office.”

As always, non revenue-producing space is minimized and revenue-producing space is maximized.

The need for storage of paper (records, forms, etc.) is minimized because everything is digitized and stored on the cloud. The need for staff workstations is minimized because many staff work for the practice from home.

Medical records are not viewed on computer screens, they are projected onto walls in any room, at any time. See the TED Talk on the Sixth Sense technology here.

Many patients are seen at home or in the nursing home, with the provider in the office using telemedicine technology or virtual office visits.

Medication samples will not be given at the physician office – they will be distributed at the pharmacy. All medications will be samples (no cost) until it is established that it is the effective medication for that patient’s problem.

Here’s a neat video from Microsoft about healthcare of the future. It will get your mind racing about the possibilities.

Microsoft Health – Future Vision from Microsoft Feed on Vimeo.

It’s frightening and exciting – might there be no need at all for brick and mortar physician offices? I think it’s very likely.

What are your ideas about the medical office of the future?

I think so.

But I know I’m probably in the minority. Many managers do not approve of employees using their phones for social media (Twitter, Facebook, etc.) at work, but I am actually okay with it when used with discretion. Unlike computers, with smart phones you do not need to worry about viruses infecting the office network.

Most managers accept and allow employees who smoke to step outside at least twice a day to smoke a cigarette. Doesn’t it seem fair to allow everyone else to take a phone break to check messages, make calls and text a few people?

Here are some objections I’ve heard to allowing staff to use their phones at work, and my answers.

“They’ll never get any work done if you let them play on their phones all day.”

My Answer: I only hire adults. I expect adults to have a reasonably well-formed work ethic that is demonstrated by doing work first, and doing non-work on breaks and briefly other times. If the practice can’t run without me peeking over their shoulders every hour or so to see if they’re working, then I am not a very good manager.

Performance measures are a great way to set guidelines for what work must be done. If the employee is meeting their performance goals appropriately, why shouldn’t they be able to take a micro-break to catch up on life?

“Employees should do work at work and save their home life for home.”

My Answer: Employees are people with busy lives, lots of commitments and lots of responsibilities outside of work. Every single one of us needs to attend to our personal lives for some part of the day. Most of it can be dealt with at lunch or during breaks, but sometimes people need to attend to their lives at work. I want them to be able do that, within reason, because it is a realistic response to life in 2010.

“What if staff using the Internet on their phones puts the practice at risk?”

My Answer: If you have done a good job of educating your staff about confidentiality and HIPAA, you should have no worries.In short, staff should not reveal any patient information (via spoken, written or digital communication) to any third party for any reason besides those dictated in your Notice of Privacy Practices (NPP). Your HIPAA education plan should be reviewed and updated annually to include any policy changes due to the use of social media for personal and practice purposes.

A loved one was recently hospitalized for surgery in a nearby town. During the experience there were several moments when I had to decide whether or not I would say something to nurses about hand washing and cleanliness. To my great surprise, I was too intimidated to say anything! The one time I did speak up went something like this:

Hey, is that nurse filling my loved ones water pitcher?
Shes trying to make the water not too cold or hot, thats good.
Oh, no, she is letting the water run over her hands and into the pitcher! Should I say something?
Shes probably going to dump out that water and fill it up with water her hands havent been in.
Nope, shes turning off the water. Do I say something?
Me: Hey, that water ran over your hands!
Nurse: Dont worry, I wash my hands all the time.
Me: No, I dont think we should take that chance.
Nurse: Im really hurt that you would think Id do something like that.

This was a personal seminal moment. I could not believe that after working with physicians and nurses in healthcare for 25 years that I would be intimidated about saying something about cleanliness. I was worried about the potential impact that my questioning would have on the care of my loved one. That made me hesitate about saying something until a situation came up where I could not keep quiet. I could not suppress my concern based on the possible impact to my loved one.

What about the nurses reaction? It was defensive, and she was telling me in essence I cant believe youd question my decision-making. In discussing the situation later with my husband (not the patient), he assured me that I had done the right thing. He asked me if I saw the waiter in a restaurant washing his hands at my table, would I then let him dip his hands in my soup?

This hospital experience was 99% wonderful. I thought the hospital paid excellent attention to the needs of the patient and the family. I thought it was clean, the caregivers were very good, and I would recommend the hospital. But the wall is still up about questioning at this hospital and probably every hospital across the US. It is a hard call to tell the professionals that they are doing something wrong. A cleanliness episode can happen so fast that you dont have time to debate yourself about saying something.

How can we make it okay to question caregivers for the benefit of the patient?

NOTE: The date has been changed to July 5, 2011.delayed indefinitely.

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A collective sigh of relief was heard across the land as it was revealed today during the CMS Open Door Forum that the requirement for providers to be enrolled in PECOS has been delayed until January 3, 2011.

Part B MACs (Medicare Administrative Contractors) will be sending revalidation letters to all providers who have not updated their Medicare enrollment since November of 2003, asking them to submit a paper enrollment form or to use the electronic enrollment system PECOS (Provider Enrollment, Chain and Ownership System.) This proactive stance on the part of CMS should help the many managers who have been desperately trying to determine if their providers are in PECOS or not.

An audio recording of today’s call will be available on the ODF website here and will be accessible for downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions click here.

Most patients would be shocked to know that experienced medical office billing staff struggle with understanding the detailed complexities of coding, billing and insurance reimbursement. Even though there are standards for translating services and diagnoses into codes that identify the medical event, insurance companies each have their own rules for how they accept and/or pay for those codes- rules that are subject to change with minimal notice.

I have to admit that at one time I felt strongly that patients needed to take responsibility for understanding their medical benefits plan and advocating for themselves. Everything has become much more complex though, and I have come to believe that as the experts it is our job to understand patients’ benefits and help them receive them. Patients have difficulties understanding their own coverage for a myriad of reasons:

Reasons Why Patients Don’t Understand Their Benefits:

1. The benefit book is not written in a way that many subscribers can understand.
2. Most subscribers will not take the time to read the benefit book and ask questions about the plan at the time they receive the benefit.
3. The benefit book is usually accompanied by a sheet or two of paper that alters the verbiage in the basic book to describe the exact information for the patient’s plan.
4. Not all businesses have an assigned employee to translate benefit books for the staff.
5. Many employers change their plans annually.
6. Most plans do not send representatives to workplaces to review plans with new employees.

To be sure there is the self-serving aspect of advocating for the patient in that we have less to collect from the patient, but I believe it is our job to minimize the patient’s out-of-pocket for them.

Who Are The Stakeholders?

The employer, the insurer/payer, and the healthcare service provider each have different motivations when it comes to paying for patient’s medical service. There is little motivation for each to communicate and collaborate for a good outcome for all. Assuming we are taking for granted each of these entities’ desire to make sure the patient receives excellent quality care, what is the viewpoint of each of these stakeholders?

The employer is concerned with keeping monthly health insurance premiums affordable, and minimizing claims experience. Employers try to keep premiums from increasing at a rapid rate so they can afford the coverage and satisfy employees.

The insurer/payer is concerned with paying out less money in claims than it collects in premiums. Because most insurance companies are for-profit, there is extreme pressure to deliver dividends to shareholders and bonuses to executives.

The healthcare service provider is concerned with charging an amount that does not leave any money on the table, making up for the underpayments of Medicare and Medicaid by the charges to other insurance companies, and keeping expenses as low as possible to offset decreasing reimbursement.

The patient is the ultimate stakeholder and the one responsible for paying an average of 30% of the contracted charge. The patient is typically the least knowledgeable and the least able to walk the maze of terminology and rules to achieve the needed outcome.

How Do Insurers Avoid Paying Claims?

1. Pre-existing condition (if no proof of continuous coverage exists)
2. Other payer responsible (worker’s comp, auto accident, liability)
3. No pre-certification or pre-authorization
4. Did not advise of emergency within 24 hours
5. Not medically necessary
6. Medical records must accompany claim
7. Provider not in network
8. Ineligible on date of service
9. Untimely filing – did not file within deadline which is different for every insurer
10. Non-covered service
11. Not enrolled within timeframe (babies)
12. Escalating premiums to the point that employers seek other coverage.

What Can Medical Offices Do to Advocate for Patients?

1. Provide patients with a brief handout explaining health insurance terminology. Have this information on your website.
2. Compile information about each insurer and each plan that your patients have. A wiki is ideal for this, but a good old-fashioned 3 x 5 card file will do. Yes, the patient has the agreement with the insurer so technically knowing their plan is not your job, but who loses if the insurer doesn’t pay? Yep, you do.
3. Use eligibility software or call the insurers to get the plan information and document this in your master file AND on the patient’s record. Include deductible, co-pay, co-insurance, network information and non-covered services.
4. When the patient arrives in the office, let them know you’ve checked on their plan and what you found out that will relate to this visit. If you find out something that will alter the patient’s payment requirement, call them before the appointment to let them know about it and give them a chance to cancel or reschedule. No surprises!
5. Thoroughly explain any waivers or ABNs (Advance Beneficiary Notice for Medicare patients) you have patients sign for services that their insurers may not pay for.
6. Make sure that any test or service (including lab work) that you send the patient for is provided by an entity approved by their insurer.
7. If you are scheduling the patient for a procedure with your provider, give patients complete information on your charges. Also give them information on estimated charges from any other provider involved in the procedure (assistant surgeon, physician assistant, radiologist, anesthesiologist, pathologist) as well as any facility charges from the hospital or ASC (ambulatory surgery center.) Help patients to check on physician/practices to make sure they are approved for the patient’s plan.
8. If you plan to send the patient a statement for any services, give the patient a sample bill and review how to read it. Have the same thing on your website for patients to refer to.
9. Encourage patients to call, email or make an appointment to talk to you face-to-face about their billing questions. Make it clear your office is glad to help them. Do not become defensive if a patient asks about their bill or questions if it is correct.
10. Don’t be afraid to admit to the patient that your office made a billing mistake if indeed you did. Everyone makes mistakes and as long as you apologize and do not try to shift the blame to the patient or the insurance company, all should be well.
11. If need be, help the patient take the next step in filing a complaint against their insurance company if the company is not fulfilling their responsibility in paying the claim. As the insurance companies often do, arrange a three-way call to discuss the patient’s claim and why it is not paid. Medicare patients receive a quarterly notice that lists claims for the previous 90 days and lists appeal details on the back of the notice.

Photo Credit: Artur Gabrysiak | Dreamstime.com

Read the 2011 update to this article here.

You’ve heard that healthcare is one of the few job markets that is still growing in a down economy and you think you might like to be a medical office manager. The question is: how much do medical practice managers make?

The real answer to this question is “it depends.” Two people in different parts of the United States could have the same job description and one could make $50,000 and another could make $100,00. Most experienced, capable medical practice managers make a good living somewhere in the middle.

What differentiates medical practice managers (and I use this term in a generic sense to cover the variety of titles used in the healthcare field) from other office managers is that they are expected to know something about almost everything. A typical day in the life of a medical manager might well include tasks in the areas of:

• human resources
• risk management
• coding and billing
• credentialing
• accounting
• information technology
• facilities management
• conflict resolution
• physician compensation plans
• marketing
• physician/provider recruiting
• and more! (see my post on what managers do here.)

The medical practice manager is often in the unique position of both answering to the owners (physicians) and managing them – a phenomenon not seen in other industries.

What a medical practice manager earns relates to:

• what the decision maker(s) believes the job is worth, or what they’re willing to pay
• what a consultant or financial adviser has said the job is worth
• what other local practices are paying their managers
• what the previous manager made

Factors influencing the posted salary for a position are:

• the specialty or specialties (single-specialty vs multi-specialty and primary care vs. sub-specialty care)
• the number of physicians/providers
• the number of sites or ancillary services (imaging, physical therapy , medical spa, ambulatory surgery center)
• hospital-owned vs. non-hospital-owned
• if hospital-owned, how the position is graded, or where it fits in the management structure
• billing in-house or outsourced
• financial soundness of the entity
• the entity’s competition in the community
• cost of living factor for region

Factors that might influence the salary ultimately offered YOU for a position are:

• Years of experience in healthcare management
• Years of experience managing the same or similar specialty
• Years of experience managing the same or similar # of physicians
• Stability of jobs over the past 10-15 years
• Special degrees: Master’s, CPA, CPC, Compliance, RN, Lean, Black Belt (Six Sigma)
• Having installed an EMR (electronic medical record)
• References

Where does one look for specific information on what managers make?

The Bureau of Labor Statistics’ (BLS) most recent information reports:

Median annual wages of wage and salary medical and health services managers were $80,240 in May 2008. The middle 50 percent earned between $62,170 and $104,120. The lowest 10 percent earned less than $48,300, and the highest 10 percent earned more than $137,800. Median annual wages in the industries employing the largest numbers of medical and health services managers in May 2008 were:

General medical and surgical hospitals	$87,040
Outpatient care centers	74,130
Offices of physicians	74,060
Home health care services	71,450
Nursing care facilities	71,190

According to a 2009 survey by the Professional Association of Health Care Office Management (PAHCOM), the median salary for health administrators in small group practices is $56,000; for those in larger group practices with 7 or more physicians the median is $77,000.

The silver-back of healthcare salary surveys comes from the Medical Group Management Association (MGMA). The Management Compensation Survey is one of the “golden trio” of surveys that I’ve used throughout most of my professional life. You can view a sample page here: Sample Table (pdf). The survey information is free if you are a MGMA member and participate in the survey yourself. You can purchase the Compensation Survey here.

Many state MGMA groups also sponsor state salary surveys and sell them to non-members. In addition, some local manager groups do limited surveys and make the information available for a fee.

Job descriptions for medical managers can be found under the Library tab at the top of the page.

More articles on medical management can be found under the category of “A Career in Medical Management” on the right-hand side of the page, including “A Day in the Life of a Practice Administrator” and “The 5 IT Skillsets Every Physician Practice Manager Needs to Succeed in 2009 and Beyond.”

Some practices are overwhelmed with patients and can’t find enough hours in the day to see all the patients that want to be seen. Others are in a highly competitive environment and are looking for ways to attract new patients. Here is a list of 50 ways to attract new patients to your practice. Some will be better for primary care, others will be better for sub-specialists. Number One will attract patients to all types of practices.

1. BE NICE TO EVERYONE: patients and their families, staff, hospital staff, vendors, janitors, everyone. What do people say when they recommend someone? “You’ll like him, he’s nice.”
2. Have an open house and offer BP checks, cane/walker checks, free H1N1 shots, etc.
3. Offer free meet and greet visits to let patients meet you before establishing.
4. Take extra unassigned ER call or fill-in for other docs (the ER staff will recommend you to patients.)
5. Visit nursing homes and meet administrators and staff, leave brochures.
6. Do home visits.
7. Have a Saturday morning clinic.
8. Do a radio interview or talk show taking callers’ questions about a medical topic.
9. Visit the pharmacies and introduce yourself to pharmacists, leave brochures.
10. Visit high school guidance counselors in the spring and leave information about college physicals.
11. Place brochures with the Welcome Wagon or Newcomers Club.
12. Join the Chamber of Commerce and attend meetings.
13. Join the Lions, Kiwanis, or Rotary Club.
14. Join the worship center of your choice and become involved.
15. Join a journal club.
16. Join a business leads organization.
17. Take credit cards, offer payment plans and offer a financial hardship program. My book has advice about collecting from patients.
18. Call schools and volunteer to do sports physicals in the spring.
19. Contact the local Parish Nurses and meet them.
20. Volunteer to be available at local school sports events.
21. Start a medical issue support group that meets at your practice.
22. Call local employers and offer to come on site to do physicals, flu shots, wellness talks.
23. Do DOT physicals and take worker’s comp patients.
24. Go visit the home health equipment stores and leave brochures.
25. Specialize in difficult conditions and disease states and advertise that you do.
26. Volunteer at the local free clinic. The volunteers will refer patients to you.
27. Offer to be “on tap” for the local TV station to provide sound bites on the latest topic: vaccines/autism, radiation exposure
28. Send out info to the newspaper every time you attend a meeting, speak, write, or do anything notable.
29. Take Medicaid and insurances offered by local large employers.
30. Tap into social media and have a great website, blog, online registration, online scheduling, online drug refills, etc.
31. Speak about any medical topic, anytime, anywhere.
32. Give travel vaccines.
33. Place a sign outside your practice saying “Now Accepting New Patients.”
34. Meet the local hospitalists group.
35. Offer virtual visits to your established patients.
36. Talk to the local managers group.
37. Make friends with potential referring practices, take lunch, leave brochures. Don’t forget practices in surrounding areas.
38. Have a private line into your practice just for other physicians and practices.
39. Make it incredibly easy for staff from other practices to refer patients to you. Many referral decisions are made based on ease of entry to the practice.
40. Ask satisfied patients to log on to a physician review site and leave a review of your services.
41. Visit daycares and leave information for parents on kindergarten physicals in the summer.
42. Develop “loss leaders” and advertise them: free/discounted flu shots, inexpensive physicals for <19 year olds, etc.
43. Take students in your practice: medical assistants, nurses, phlebotomists, healthcare career students. When they get jobs they will recommend you.
44. Place small ads in the local professional, amateur or high school theater playbill.
45. Round twice a day on your inpatients. Satisfied patients refer other patients.
46. Give a talk at your practice for anyone who thinks they might like to be in healthcare.
47. Moonlight at a local Urgent Care.
48. Give a talk for local nurses. Everyone asks nurses which doctor they would go to.
49. Let local (nice) hotels know you will make house calls over lunch or after clinic hours.
50. SMILE. Never underestimate the value of a smile.

On February 17, 2010 from 2:00PM 3:30PM ET the Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum (ODF) to discuss Medicare provider enrollment issues. During this call, CMS staff will discuss:

• Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for physicians, non-physician practitioners and provider and supplier organizations
• Provider and supplier reporting responsibilities
• Medicare ordering and referring issues
• Revalidation efforts

Afterwards, there will be an opportunity for the public to ask questions.

Open Door Forum Instructions:

**Capacity is limited so dial in early. You may begin dialing into this forum as early as 1:45 PM ET.**

Dial: 1-800-837-1935
Reference Conference ID 52537484
An audio recording of this Special Forum will be posted to the Special ODF website here and will be accessible for
downloading on or around Monday March 1, 2010 and available for 30 days.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to
view Frequently Asked Questions click here.