Manage My Practice

Editor’s Note: DataPlus is MMP’s very first sponsor and I want to thank Frank and his crew for their support!  If you would like to sponsor this blog and have over 5,000 readers a month see your flash ad, contact me via email at marypatwhaley@gmail.com.

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The old saying “If you can’t measure it, you can’t improve it” certainly holds true in medical practices today. With falling payer reimbursement it is more important than ever to collect every single dollar your practice is due.

Most practices have sought additional income streams by adding ancillary services. Paying close attention to data can improve decision-making for such services and can dramatically improve revenue without adding any providers or even new patients!

Having ready access to the elusive data within practice management systems can be difficult, but most systems can report the basics.  It is imperative that data is trended over a period of time so that trends can be spotted, benchmarks compared, and improvement plans developed.  Measuring data and comparing it to the MGMA Cost Survey (find it at mgma.com) is one of the best places to start.

1. Collection Rates/Ratios: Two collection rates are measured in medical practices. One is gross collections and the other is net collections, the latter being the most important.

A gross collection rate is payments divided by charges and will depend on an artificial number – how high the charges are set above negotiated allowables – making it not particularly meaningful.

A net collection rate, however, provides a means to benchmark the health of collection efforts. Net collections, simply stated, demonstrate what percentage of collectible dollars (after negotiated contract write-offs)  a practice is actually collecting.   A net collection rate above 95 percent –when calculated correctly – denotes a healthy practice.

2.   Denials: Denials are a significant portion of the cost of running a practice in that services that are provided but not paid for reduce the profitably of those that are. Accurately identifying denials and the reasons for them can help prevent them in the future, thus increasing productivity and lowering expenses. Identifying denial trends by specific payer or payer group, by CPT code, and by origin – whether at the front desk, with coding errors, or in credentialing – is equally important.

3.    Evaluation & Management (E & M) Bell Curve: “Overcoding” and “undercoding” are commonly used terms, but how are they measured? Bell curve trending of E&M data can quickly identify areas where providers may be under coding, resulting in lower revenues, or over coding, resulting in the potential for audits. The difference between a Level 2 and a Level 3 E&M code can mean thousands of dollars in losses per provider per year. Documentation is critical to demonstrating the level of care provided to each patient.

The traditional primary care bell curve below demonstrates that level 3 visits typically comprise about 50% of your established patient encounters, level 2 and 4 visits together about 20% each, and level 1 and 5 visits together about 10%.  When plotted on a graph and drawing a line between each, the shape resembles a bell.

4.    Bad Debt: Bad debt is defined as dollars that could have been collected, but were not.  Break this category into controllable factors and non-controllable factors.  Issues that you should have been able to control are timely filing write-offs, credentialing errors, lack of follow-up, and incorrect information provided by the patient.  Non-controllable issues are bankruptcy,  patient failure to pay, and payers retroactively denying coverage due to unpaid premiums.

Reducing bad debt by just two percent can mean tens of thousands of dollars to the bottom line of a practice. The ability to quickly identify bad debt trends facilitates the development of an improvement plan.

5.    AR Days: AR (accounts receivable) days are a measurement of the average time a dollar stays in an accounts receivable before being collected. The ability to measure, benchmark, and lower AR days provides a means to a significant increase in revenue.  Some best practices that reduce AR days are filing insurance daily, sending statements daily, collecting appropriately at check-in and check-out, working denials quickly, discounting self-insured for time of service payment in full, and using an eligibility tool to check every single patient’s insurance.

6.   Encounters: Accurately reporting and separating encounters for most practices is an arduous task of counting fee tickets or using tick sheets. Few practice management systems accurately provide this information. An encounter is much more than a service code. Being able to segregate office encounters from surgical cases, and reporting by payer, time, and location can help identify opportunities for improvement.

7.   Referral Sources: It is fundamentally prudent for specialty practices to know the origin of patient referrals. This data is rarely reliable or easily created in most practice management systems. Practices need to know not only the source of patient referrals, but also what type of patients (by insurance, by procedure, etc.) are being sent by those sources, and if the referrals from a particular source have increased or decreased over time.

8.    Payer Mix: It is not uncommon for practices to drop payors due to perception, and not because of actual data or trends. Emotions sometimes come into play and can result in a provider demanding that a payer be dropped because their rates have changed (or other perceptions). This simply does not make sense. Being able to accurately produce and graph data on major payers without hours and hours of work is of high strategic value to a well-planned business decision. It can answer questions about the impact on a practice if a particular payer is dropped, or how those patient slots would be filled.  Remember to keep adding payers to the practice when feasible; the loss of your largest payer can be minimized if many smaller ones are on board.

9.    Under Payments: One of the more significant ways to improve a practice’s revenue is the swift and accurate identification of carrier underpayments. Identification of underpayments is not simply comparing the payment to an allowable fee schedule.  Practice management systems that have any type of payment audit functionality commonly do not take into account circumstances such as modifiers, or multiple surgical procedures that payers routinely inaccurately apply, causing underpayments.  Having a system to automatically and systematically apply these rules is essential. MGMA states that providers are underpaid an average of six percent of revenue. What does that mean to a practice? The numbers can be astounding to a surgical group, and the identification and collection of those underpayments can be insurmountable.

10.    Fee Schedule Comparison: It can be difficult to determine what payers are reimbursing by contract for specific codes or ranges of CPT codes. The ability to have immediate and accurate access to this data is crucial in payer negotiations. It is important to remember that the payer already has this information and is betting that the practice does not!

It is now more important than ever for practice managers to have access to the critical information outlined above. It is also important to note that not just any one of the above Key Practice Indicators should be used to determine the financial health of your practice, but all, or a combination of them.

The buzzword among practices today is “Dashboards.” The ability to have these Key Practice Indicators in one simple report is proven to increase efficiency, as well as provide a meaningful way to present information to providers. One example of a dashboard is below.

About the author: Frank Trew is the Founder and CEO of DataPlus and  has over 25 years of practice management experience and has served in executive positions in large and small practices. In 1999, as the COO of a large orthopaedic group in Nashville, he was frustrated by an inadequate access to data that limited his ability to measure and improve the bottom line. The development of a data warehouse was the solution.

In 2000, after hearing how this data was a key practice management tool, many of Frank’s peers also wanted to use it improve their practices. DataPlus was formed as a result and has been providing MegaWest, HealthPort, and Centricity users with this unique tool ever since.

Employing a simple to use “point and click, drag and drop” reporting tool, along with an advanced Contract Management and Revenue Recovery System, DataPlus provides key management data across all specialties and throughout the United States.

Frank invites readers to visit the DataPlus website at www.mydataplus.com. Frank may be contacted via email at ftrew@mydataplus.com or by telephone at (888) 688-3282.

There seem to be a lot of people searching for rules for medical offices.  I’ve never heard of such rules, but since people are looking for them, I thought I’d write some.

1. Medical offices are professional workplaces and staff need to dress, speak, and purport themselves professionally.
2. Patients are customers and customer service should be paramount.  Give all patients the utmost respect and practice compassion, compassion, compassion.
3. If it didn’t get documented (on paper or electronically), it wasn’t done.  If it didn’t get documented, you can’t charge for it.
4. HIPAA.  First of all, please spell it correctly.  One P, two As.  Secondly, know what it means and make it so!
5. Never enter an exam room without knocking.
6. Confirm patient identity (name, date of birth, etc.) before giving injections, taking specimens or performing a procedure.

   

   Image via Wikipedia

7. Remove very sick or very angry patients from the front desk immediately.  Take the sick ones to exam rooms and take the angry ones to the manager’s office.
8. Do not use medical jargon with patients.  If they don’t know what you’re talking about, they might be too intimidated to ask.
9. Wash your hands. Often.  No matter what you do in the practice.
10. The office should be CLEAN, fresh and up-to-date.  No dying plants, no magazines more than 9 months old, no dust bunnies behind the doors, no stained seating or carpets.
11. Train staff to apologize, and to apologize sincerely.
12. Complaints from patients and staff need to be addressed in 2 weeks or less.
13. Medical equipment is to be maintained and tested annually for safety and performance.
14. Once a medical record is finalized, the only changes to a paper record are single line strike-throughs with corrected information and initials, or addendums.  There are no changes to electronic records, only addendums.
15. Patients don’t understand insurance.  Be the expert.
16. Shred confidential practice paperwork and patient-identified information on-site.
17. Keep medications (including sample medications) in locked cabinets and use a good inventory system to log the use and replacement of stock.
18. Strive to meet patients at their communication level. Use graphics, translated materials and interpretive services when needed.
19. Don’t expect patients to be on time for their appointments when the provider isn’t.
20. Don’t make copies from copies.
21. Give everyone the benefit of the doubt.  There’s always more to the story. Okay, this is really a rule for life in general, but it works in medical offices too.

Leave a comment and tell me what rule you would add.

Many practices and providers take their patient schedule for granted.  They overlook the opportunity to improve both productivity and effectiveness by managing their schedule. Here are ten tips for office managers to make sure that the patient schedule works for you and for your practice.

1.    Evaluate the schedule template with the providers and nurse manager quarterly.

By using actual issues from the previous period, discuss what has worked and what has not.   Have providers share their concerns and

discuss their recommendations for change.   Nursing often has many ideas to improve the flow of patients through the practice and is a valuable source of information.  Keep track of changes made and evaluate their effectiveness at the following meeting.

2.    Standardize visits types.

There are many reasons an individual provider likes their “own” schedule. As managers, we know that this makes it very difficult for the front desk staff to do their jobs.  Standardization reduces the potential for errors and disruption that proprietary schedules may cause.  Your role in the discussion with providers will be that of facilitator, staff advocate, and coach.

Bring forward options for standardized visit types.  Many practices use a block template based on 10, 15 or 20-minute blocks of time.  The number of blocks used per visit type are agreed to and used to fill the schedule.  There may be additional restrictions placed on the schedule such as no more than one new patient per half-day session.  Minimize the number of restrictions or ideally eliminate them to assure your days are as flexible as possible to meet your patient needs.  You may also want to consider open access scheduling.  Moving to this system often takes time and effort to eliminate the backlog of booked patients but once fully in place can be very successful.

3.    Track scheduling errors and issues perceived to be scheduling errors monthly.

Errors in scheduling cause patient dissatisfaction, back up your waiting room, and lead to stress and possibly short tempers.   Ask providers and staff to tell you when they think patients are scheduled incorrectly.  Track this over time to determine if changes in the system are needed, how visit type use can be improved, and what training may be needed.

4.     Know where scheduling bottlenecks are.

What is your average wait time in the office per provider?  Do a time study on each provider and measure how long it actually takes for a patient to get through an office visit.  Note the time they arrive for check in and registration functions, their time in the waiting room, when the nurse completes check in functions in the exam room, when the provider enters the exam room, when the provider leaves the exam room and when the patient exits the office.   Overlay this on your schedule.  The information you gather will help you identify bottlenecks and provide meaningful data to share with your providers when recommending a change in the schedule template.

5.     Know how much a visit is worth in revenue.

Adding one visit per day by addressing schedule gaps, clinical start times, no-show appointments or changing the length of visits will increase your revenue.  If your provider works four days per week and 48 weeks per year at an average visit reimbursement of $75, one additional visit per day will add $14,400 in annual revenue to the bottom line!

6.    Train your scheduling staff and update the training regularly.

Training a new staff member often brings up questions the entire staff can benefit from.  Be sure to keep track of questions and include answers in future written training materials as well as in staff meeting discussions.  Develop a training checklist for scheduling staff and have both the trainer and new employee initial when each area is mastered.  This checklist can also be used for annual performance reviews.   For current staff, take a look at their computer terminals and see what “sticky notes” are posted there, indicating areas that need special consideration or additional training.

7.    Have the schedule be a frequent agenda item for staff meetings.

Get the staff perspective on what is working and what is not on a regular basis.  You may find that nursing can provide a great deal of information on how the schedule impacts patient flow from their perspective. Take time for staff to discuss “what if” scenarios and how they would handle a particularly difficult situation.  The goal is to have a schedule that staff understands, is user friendly and is consistently used.

8.    Have a policy on the number of providers out at one time for vacation or holidays and follow it.

Everyone deserves time off but having many providers out at once can lead to a very hectic week for those remaining.  Plan as much in advance as possible for time away.  If you do end up with a number of providers out at once, remember that the person remaining will also be responsible for reviewing lab and radiology results for their colleagues as well as answering questions regarding patients that they may not know.  Allow extra time in the schedule for this.

9.    Know what changes in demand to expect during the year and plan for it.

Do you have more requests for acute visits in January, camp physicals in April, or school sports physicals in August?  Minimize last minute adjustments to your schedule by knowing any seasonal trends in scheduling.  Take a look at the schedules from past years to predict when you need more or less acute slots and adjust your schedule template for this. Manage the time you’ve allotted by marketing efforts in the office and local papers reminding your patients to schedule in advance.

You may also want to consider adding additional clinical hours during this time to make sure you can meet demand.  Consider asking part time providers for extra hours per week or using per diem staff.

10.    Deal with your patient no-shows.

Consider writing a policy on no-shows if you do not have one.  If you have one, follow it.  Make sure that your policy follows any state regulations to avoid patient abandonment claims.

Educate your patients.  Develop a set of professional communications about your visit cancellation and no-show policy that begin with your welcome to the practice letter.  Post a notice of your policy in your waiting room.  Send letters following each no-show and then the termination letter stating the reason for the termination and that the patient is still responsible for their account balance.   Be the contact person on the letter so that if the patient calls with questions, they speak with you rather than take up provider time or that of your staff.

If you have a patient that consistently no-shows but the providers do not want to terminate them from the practice, determine what other help you can provide to get the patient to the visit on time.  Consider additional reminder calls, assistance with other services such as transportation, or offering the ability to come in and wait without a scheduled time.   Though this may take more staff time, the revenue from the appointment should make it worth your while.

Donna Izor, MS, FACMPE is founder of West Pinnacle Consulting, LLC. Her 20 years of experience as a medical practice executive lends her special expertise in the areas of primary care and specialty practices, employed inpatient physicians, regulatory oversight, facility design, physician compensation and relations, and new program development. She has worked with academic, community hospital, and private practices.  You can contact Donna at donna.izor@gmail.com.

Note: I am republishing this to my email subscribers because none of the links worked the first time around. I’ve fixed everything now – so sorry for the error – must have been healthcare fatigue!

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I’ve noticed that a lot of people in healthcare seem unusually tired and even, if I dare say so, somewhat cranky.  This includes me.  I’ve decided we’re all suffering from healthcare fatigue – fatigue from dealing on a daily basis with so much change, uncertainty, and financial stress.  Here’s my top ten list of healthcare management stressors accompanied by posts I’ve written that discuss the topic or suggest resources for the challenge.

10. Red Flags Rules – on again, off again, patients don’t want to have their pictures taken or let you copy their driver’s licenses.

• Red Flags Rules (RFR) Delayed for the Fifth Time – This Time Until December 31, 2010
• Red Flags Rule and Identity Theft Prevention: You Don’t Have To, But You Should!

9. HIPAA - don’t be fooled, HIPAA is not something we handled years ago and it’s taken care of; there are new requirements and penalties associated with HIPAA breaches.  HIPAA is a biggie and something that now infiltrates almost every facet of healthcare.

• ARRA Changes Rules for HIPAA – Did You Miss These Three February Deadlines?

8.  Employment Uncertainty – both for you and your staff – the aftermath of layoffs can be even more demoralizing to those who didn’t lose their jobs.  Also, many healthcare entities are still freezing raises.  If I hear one more time “we’ll just have to do more with less” I might just scream.

• My Take on “10 Ways to Keep Employees Happy” in Medical Practices
• Dear Mary Pat: Should Staff Be Allowed to Use The Internet on Their Smart Phones at Work?

7. Unrealistic Workloads – directly related to #9, most staff and managers have much more work to do than they did just two years ago. Couple that with the ability for managers to be available and work by computer, phone, text message, email or Skype 24/7 and you have fatique that you understand only when you truly, truly stop and wind down for more than three days at a time.

• Long Vacations are Good for Employees, the Company and Me!

6.  Hospitals Buying Practices – this could be a good thing or a bad thing, but as you and I know, change is completely unnerving to most people.  Hospitals have very different cultures than private practices and trying to marry the two takes skill, patience and excellent leadership.

• Change in the Group Medical Practice: Customers, Consequences, Control, and Culture

5.  Stimulus Money for Using EMRs – it’s a big decision and many practices are very nervous about purchasing an EMR.  Many think that meaningful use components are unrealistic and even more are fearful of the inevitable productivity drop when the EMR is implemented and for months afterwards.

• ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?
• FAQ on HITECH, Meaningful Use, Eligible Providers, and the Stimulus Money
• Ten Reasons Why (Some) Physicians Aren’t Rushing to Adopt EMRs
• Electronic Medical Record Guru Rosemarie Nelson Reveals Best EMR Product on the Market Today

4. Unhappy Patients – lots of patients are also trying to do more with less (argghhh!) and are avoiding coming to the doctor whenever possible.  The front desk staff and the phone staff in particular are getting a lot more heat when they inform patients they’ll have to make an appointment.

• 50 Customer Service Ideas to Treat Your Patients to Friendly, Easy and Unexpected Service
• How To Be A Billing Advocate for Your Patients
• How to Apologize to a Patient
• A Memo to the Staff: The Preciousness of Patients

3.  PECOS – be glad if you don’t know what PECOS stands for, or be very, very afraid.

• Providers Without a PECOS Record Will Receive a Letter From Their Medicare Administrative Contractor (MAC)
• My Notes from the CMS Open Door Forum on May 19, 2010: PECOS, DMEPOS and Blue Ink on Paper Forms
• Is Your Practice Ready for the 60-Day PECOS Countdown?

2. Medicare Reimbursement – this year has been as exhausting as watching a single point of ping pong played for hours – there will be cuts, there won’t be cuts, there will be cuts, there won’t be cuts.  Gird your loins as the November 30 deadline looms for the next potential cuts.

• Deja Vu All Over Again: The Medicare Fee Cut is Pushed Back to November 30, 2010
• Attention Medical Practice Staff: Medicare Changes the Rules for Credentialing and Retro-Billing
• 91 Physician Organizations Sign Statement Naming Congress in “Mismanagement of the Medicare Program” and Imploring it to “Honor its Obligation”

1. The Bottom Line – we have RAC audits, more pre-certification and pre-authorization and pre-notification requirements, more denials, high deductible plans, formularies and 50 other things that are making it difficult to know which hoop to jump through to get paid.  Expenses continue to go up, reimbursement continues to go down, and the healthcare world spins faster and harder, making us all wonder when it will, or if it ever will slow down.

• There is No Such Thing as a 10-Minute Office Visit
• The ABN: The Most Misunderstood and Underutilized Document in Healthcare
• 101 Ideas for Increasing Revenue and Decreasing Expenses in Your Medical Practice
• How to Develop a New Financial Policy For Your Practice: A Short Course

Sometimes a job just gets a little old, and even the best employees need a little something to get them re-engaged and excited again.  Try one of the ideas below at your practice and let me know in the comments the ways you keep your staff energized and engaged!

1.  Provide a career track and offer multiple levels of learning jobs. For instance, break the receptionist job into steps (see below) and set time lines for attaining those goals.  You may want several steps to be accomplished at 90-days, more at 6-months, and more at 12-months.  There may be monetary awards, honor awards, or qualifications for other acknowledgements.

• Pre-registering patients by phone – demographics
• Making appointments & mini-register for new patients
• Registering patients face-to-face – demographics
• Understanding insurance plans and registering their insurance
• Taking photo ID or taking photos and explaining the Red Flags Rule
• Collecting co-pays
• Answering basic patient questions
• Answering advanced patient questions
• Reviewing the financial policy with patients
• Reviewing the Privacy Policy with patients.

2.  Offer certifications and credentials – support staff emotionally, time-wise and financially so they can attend face-to-face or online courses.

3.   Offer specific responsibilities and the title of lead person for that responsibility – don’t assume you know what staff are or are not capable of – they might surprise you!

4.  Meet every 6 months or every quarter to set goals.  A job can be a drag if there’s nothing new to learn or to accomplish.

5.  Set up process improvement teams to work on problems that everyone complains about – give them the responsibility to come up with solutions and try them out.

6.  Involve them in social media marketing of the practice.  Make sure they understand your social media plan ( you do have a plan, don’t you?),  give them guidelines to work within and let them work on your website, your blog, and your Facebook page.

7.  Install a wiki (many are free) and have them work on loading all the practice knowledge into the wiki.  Have different staff responsible for different parts of the wiki and set goals for adding all the information that runs your practice every day.

8. “Walk a Mile in My Shoes” – this is also great for getting the clinical and administrative staff to understand each other better.  Have the staff shadow each other and take turns seeing parts of the practice they don’t know much about.  I recently participated in this at my hospital and shadowed a nurse (and asked a million questions) for about an hour.  It was wonderful!  I felt better equipped to work with my hospitalist service after having been on a patient floor for just a short time.

9.  If you are a practice that receives referrals from others, have staff responsible for regularly touching base with staff from referring practices and asking how service can be improved.  Teach staff about relationship building and remember that it’s the staff that often choose where the patient is referred to instead of the provider.

10.  Have staff take turns going with you to meetings, seminars and local events where you represent the practice and introduce them to everyone.

11.  Forward listserv discussions to employees and have them monitor the discussions and bring things to you that they want to know more about.

12.  Encourage employees to become the practice expert in a payer, an employer, a referrer, a process or a protocol and help them learn about their topic by sending them information from the web or your professional organizations.

13. Have the staff put together an internal or external newsletter and help them with concepts of internal and external marketing.

Most medical practice managers do not aspire to be television, radio or (heaven forbid) YouTube celebrities, but it does happen.  Medical practices, hospitals, surgical centers, nursing homes and other medical entities are rich fodder for the news these days.  So how do you weather the request for a sound bite without putting your practice in jeopardy?  Follow these simple rules and you’ll be an asset to your practice in no time.

1. The media is your friend, treat them that way.  Encourage reporters and journalists to call you for updates on your practice (new doctor, new facility, enhanced website, patient appreciation, health fair activities, etc.) AND to comment on new stories.
2. Remember that “No comment” translates in the media as “I’m hiding something.” Some information, even if it is a repeat or a rehash, is better than “no comment.”
3. Have your physicians and other administration agree that there is only one spokesperson and that they will refer all requests from the media to you.
4. If you are asked a question that you cannot or do not want to answer, probably in relation to something negative about your practice, the format to follow is:
   • Tell them that you are not able to answer that question,
   • Tell them why you can’t tell them (I don’t have that information at this time OR I’ve not received the report on this yet OR this matter is still being reviewed/evaluated/investigated at this time),
   • Tell them what you can tell them, which might be ‘We do know…” OR “What is clear at this time…” OR “What we’ve been told…”
5. If the media isn’t calling you for news, call them!
6. Nothing is off the record and you can’t unring that bell.  Once you’ve said it, it is out there.

Don’t forget that doctors and healthcare are in the spotlight constantly these days and that negative press is not good for your practice, or the industry at large.  Protect your practice by being a confident, competent and knowledgeable practice administrator.

From the Federal Trade Commission:

“At the request of several Members of Congress, the Federal Trade Commission is further delaying enforcement of the “Red Flags” Rule through December 31, 2010, while Congress considers legislation that would affect the scope of entities covered by the Rule. Today’s announcement and the release of an Enforcement Policy Statement do not affect other federal agencies’ enforcement of the original November 1, 2008 deadline for institutions subject to their oversight to be in compliance.”

Read more here.

My post and resources on Red Flags Rule here and in the Manage My Practice Library.

Front Desk/Check-In

• Greets patients and visitors to the practice
• Registers patients in the practice management system which may mean entering information given verbally or on registration forms
• Collects identification and insurance cards and copies or scans them for the record, may photograph the patient for the record
• May collect co-pays or other monies
• Prints encounter form (also called superbill, routing slip, or fee ticket) with updated information, or updates information on the encounter form
• Has patient sign financial agreement, receipt of privacy policy, benefits assignment, etc.
• May answer phone calls, take messages and make appointments
• Directs visitor (drug reps, salespersons, etc.) appropriately

Medical Records

• Primary responsibility for the integrity and management of the medical record, whether paper or electronic
• Controls record filing (paper) or indexing (electronic)
• Fulfills requests by patients, attorneys, insurance companies, and social security for release of records
• May manage paper faxes and messages by attaching to charts and delivering to provider
• May prepare paper charts for chart audits by payers or others
• May be the HIPAA Officer

Medical Assistant, LPN or RN

• May assist Physician, Nurse Practitioner or Physician Assistant with procedures
• Depending on state laws, may give injections
• May perform procedures independently (ear wax removal, staple removal, etc.)
• Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
• May perform phlebotomy (draw blood)
• May collect specimens, perform basic laboratory tests and chart results
• Provides patient education verbally and by providing written materials
• May schedule tests or procedures ordered by the provider
• May schedule surgery and prepare surgery packets for providers (*this may be delegated to a surgery scheduler if this position exists)
• Calls patients about test or procedure results; returns patients calls with answers after consulting with provider
• Prepares exam room for procedures (PAP smears, excisions, etc.), marks specimens for lab and pathology
• Cleans exam room after each patient and stocks exam and procedure rooms with supplies
• May be responsible for ordering office medications and medical supplies
• May perform lab controls daily and check and record temperatures on lab refrigerators and freezers

Triage Nurse

• Takes incoming calls from patients and gives them medical advice according to predetermined nursing protocols
• Makes decisions about patients needing to be seen urgently, same day or next day
• May be delegated callbacks from providers or other nurses
• May see walk-in patients and triage their condition

Lead Nurse, Charge Nurse, or Nurse Supervisor

• Assigns clinical staff specific responsibilities
• Manages clinical staff schedules, using agency or temporary staff as needed
• Performs annual competency exams on staff
• Ensures all staff are current on licenses, continuing education and CPR
• Problem-solves patient issues
• May be responsible for ordering office medications and medical supplies
• Has responsibility for medication sample closet upkeep
• May perform annual evaluations fro clinical staff
• Responsible for equipment maintenance and makes recommendations for medical equipment as needed
• May be the Patient Safety Officer and the Worker’s Compensation Coordinator

Referral Clerk

• Reviews orders written by providers and determines where test and procedures may be performed based on patient’s insurance
• May provide the patient with information about the test or procedure cost and what the patient’s financial responsibility is estimated to be
• Pre-authorizes, pre-certifies, or pre-notifies the test or procedure if required by the patient’s insurance company
• Schedules the test or procedure
• Provides the patient with information about preparation for the test or procedure

Lab Technologist/ Phlebotomist

• Receives laboratory requisitions from provider and collects specimens according to provider order
• Provides Medicare patients with an Advance Beneficiary Notice if any lab test or procedure to be performed in the office will not be covered by Medicare
• Performs tests or packages specimens to be transported to reference lab
• Receives results back from the labs and matches them to charts
• Performs lab controls daily and checks and records temperatures on lab refrigerators and freezers

Check-out Desk

• Reviews services received by patients, checking to make sure that all services received were checked on the encounter form
• Enters charges in the computer system for services received
• Tells patient if any additional monies are owed if co-pay was collected at check-in
• May sign patient on to a payment plan if needed
• Takes monies owed, posts monies and produces a receipt for the patient
• Makes return appointment for the patient if needed, or enters recall into the practice management system

Biller or Collector

• Corrects claims that are rejected from the claims scrubber, clearinghouse or payer
• Files secondary and tertiary claims as needed, electronically or via paper
• Posts receipts from insurance companies and patients and edits any electronic remittance advice; may post from lockbox account on the web
• May prepare deposits and/or make deposits
• Generates patient statements
• May check eligibility on patients with appointments and call patients whose insurance is not active (*may be delegated to a financial counselor if this position exists)
• Calls patients who have not made payments in response to statements
• May turn patients over to third-party collectors
• Takes phone calls from payers or patients about billing issues and resolves issues

Coder

• Reviews notes from inpatient or outpatient encounters and codes them according to the documentation
• May post charges for services rendered
• Audits chart documentation for quality purposes to ensure that provider coding and documentation is synchronous
• Introduces changes in procedure (HCPCS) and diagnosis (ICD-9) codes and educates staff on the use of new codes
• Ensures encounter forms and practice management software is updated appropriately with new and deleted codes
• May be delegated the Compliance Officer

Billing Supervisor

• Reviews the work of coders, billers and collectors and performs quality audits to benchmark acceptable error rates
• Prepares or reviews deposits and tracks daily charge, collection, write-off and deposit information, watching for monthly abberations by payer or date
• Reviews Accounts Receivable (A/R) reports, looking for trending or specific problems to be addressed with staff or payers
• Brings to the attention of the Office Manager or Administrator any issues with non-standard payment trends, denials or non-covered services.
• Performs evaluations for billing department staff
• Takes escalated patient complaints
• May credential providers with new payers or recredential providers with payers or hospitals

Office Manager, Practice Administrator, or Practice Manager (see the Library tab for job descriptions) see my posts on what an administrator does here, and a day in the life of an administrator here

• Performs all human resource functions for the practice
• Has ultimate responsibility for all money flowing in and out of the practice – makes deposits, pays bills, etc.
• Contact person for all computer system, equipment and phone system issues
• Responsible for day-to-day operations, advises supervisors on issues and problems
• Resolves escalated patient complaints
• Meets with vendors and researches possible practice purchases
• Negotiates all practice contracts
• Meets with staff and providers on a regular basis

These descriptions will not perfectly fit most practices, this is just a generalization.  Each practice divides duties based on the number and skills of the staff in their office, and their specialty.  These descriptions should help to define what the basic tasks are in most practices.

When Matthew Browning first described YNIO (Your Nurse Is On), I was really surprised to learn what his product was.  I don’t know what I expected, but it wasn’t the elegant solution to staffing he described.

Here’s the description from the YNIO website:

Your Nurse Is On^TM was developed in 2000 by a trained Family Nurse Practitioner in response to the inefficient relief staffing procedures found in healthcare today. With today’s challenging environment of cost savings and instant communications it became apparent that calling replacement staff one at a time was no longer an adequate solution.

With the improvements in internet telephony that occurred around 2005, we created a system that allows you to call any available nurse to fill your vacant shift. You now have the power to contact many nurses, in any order you choose, on whatever device they prefer. Since the nurses on our system make their availability known in advance, you will never disturb another unavailable nurse or waste your time calling them.

I could really relate to this solution! Who among us hasn’t spent hours on the phone filling staff slots, getting coverage for unexpected medical leaves, and trying to piece together coverage for routine vacations?

YNIO distills the product down to four easy steps:

1. Scheduler creates a request for staff.
2. YNIO contacts all available staff – instantly.
3. Staff receives the request and accepts or rejects the shift.
4. Scheduler is immediately notified.

And what are the proposed benefits to a facility using YNIO?

• Save time – system can call dozens of nurses simultaneously
• Save money – no more dollars wasted calling nurses who are unavailable
• Fill shift vacancies – expanded pool of available nurses
• Increased employee morale – decreased shift vacancies can decrease shift call outs, injuries and burnout
• Increased efficiency – leverage technology to save money, save time, quickly fill shift vacancies and save paperwork with our paperless billing and performance tracking systems.

This sounds like a needed solution for practices, nursing homes, hospitals, and home health agencies.  I am also fascinated by the creative process of innovation and delivery to the market and asked Matt a few questions about the development of his product.

MARY PAT: Matt, what does it take (emotionally, financially and otherwise) to conceive an idea and bring it to the market?

MATT: I believe it begins with a personality that is inclined to analyze situations and procedures with an eye toward improvement. “How can we make this, or do this, better than we are today?” As this behavior becomes internalized and part of our daily routine, we begin to generate ideas, “maybe this could work” type of thoughts that can result in some solid ideas, proposals and hypotheses. This stage of innovative thought is rather common and many people have an idea that could “change the world,” however an idea at this stage is often lacking a “vision” of how it can interact with our current realities, change existing processes, improve outcomes, save time and reduce expenses. The basic business infrastructure, legal processes, finances and team that are very important considerations to bring an idea from conception to market are often not understood, at this point of the innovation cycle, by the inventor and are definite challenges. These challenges may be the reason that many potential innovations are never brought to market.

So, besides an idea, and a ‘vision’ of how it fits into the world, flexibility, determination and persistence may be the most required traits for the innovator. The key to this game is teamwork, assemble the highest quality team you can, rely on experts for knowledge outside of your personal domain and remember that the objective is bringing the product or process to the world to make it a better, safer, more enjoyable place for as many people as possible. Success is often a direct result of service to others and bringing your innovation to the world can be a great service.

On the emotional and financial fronts, expect the endeavor to take twice as long as you expect and to cost twice as much as you expect. Having an awesome team and a supportive social network are invaluable to the eventual success. I am fortunate to have a very supportive family that believes in me and our innovation and they have been very tolerant of the extraordinary amount of hours and obligations that are part and parcel of this innovator’s life. To summarize, I believe a good idea can become a vision that with a very dedicated individual can become a team working toward the release of an innovation commercially. Hard work, perseverance, flexibility, ability to learn and the ability to delegate are all requisite as well.

MARY PAT: What’s been your lowest moment to date in bringing your product to market and what has been your highest?

MATT: My personal and corporate nadir occurred, ironically, during one of the best events of my life, the birth of my son, Arthur. Our product, YourNurseIsOn.com, was struggling through the “proof of concept” phase, after nearly a year in development and design, when my wife had an unexpected, emergent delivery of our son. We were traveling in Florida on a doctor-approved combination business and family trip, when our son decided he was coming into the world, nine weeks early. Aside from a very difficult and dangerous birth experience, we were over 1500 miles from our home in New Haven, CT. Our company was being run from my laptop and mobile phone and I was juggling a fully packed calendar of business obligations all while running from ICU to NICU, for 5 weeks. It was two months before I was able to safely return my family to our home in New Haven. In addition the amazing amounts of time needed for both my wife, Phoebe, and my son, I still needed to meet with potential customers, conduct regular tech meetings, solicit further investment and continue to work on intellectual property issues, technological challenges and personnel needs.

We had invested our life’s savings to get to this point and now, with this amazing, yet traumatic family event, we began to question many of the decisions that had brought us to this place and time. Out of time, out of money and out of my home, it was easy to think how much ‘better’ it would be if I ‘just’ worked as a Family Nurse Practitioner as I was trained to do and could bring home a regular ol’ paycheck for ‘only’ 40 hours. Those questions never last for long, the ‘vision,’ never sleeps, it never relents and it can become all-encompassing and turn us into 4am to 11 pm machines but, occasionally, even entrepreneurs are human

Conversely, our highest point to date has been our attendence at HIMSS 2010 this March. We were selected to present at the Healthcare IT Venture Fair and after an exciting presentation we were no longer unknowns to the major players in the healthcare arena. When big names like Intel, Blue Cross, GE, McKesson, Blank Rome and the United States of America take note of your product and want to engage in investment, customer and business development discussions, you begin to realize that the power of the innovation is becoming recognized. The time since HIMSS10 has been a constant blur of inquiries, customer demos, partner requests, commercialization deals, amazing pilot discussions, customer implementations and, of course, investors.

MARY PAT: Is this a product that can be affordably scaled for any customer, or do you anticipate the ROI being on target for a specific type/size of customer?

MATT: Our product, YourNurseIsOn.com, is a Software as a Service (SaaS) product that helps allocate the right healthcare staff, where they are needed, when they are needed there, by instant, 2-way text, phone and/or email communications. We are a Software as a Service (SaaS) platform that allows for quick and easy adoption, keeps customer costs low and removes their maintenance responsibilities.

We offer a number of value propositions for the customers including faster speed of fulfillment, decreased nurse vacancy, reduced overtime spending, increased patient-provider contact hours, improved patient outcomes, license management, call order adherence, expanded communications capabilities and amazing compliance reporting performance. Flexible scheduling, with all the extra communications needed, has become a best practice for healthcare workforce recruitment and retention. YourNurseIsOn.com makes these communications effortless. For organizations that rely on communicating with a distributed workforce, to operate around the clock, our solution is quickly becoming indispensable.

The ROI metrics are being compiled presently and should prove to be favorable for any size organization. We expect the return on investment period to be very brief as we can provide over 8 hours of phone calling in under 30 minutes and provide the 2-way text and email channels for improved efficiencies. Our soon to be announced pilot with a nationally recognized health provider network will soundly demonstrate our scalability for any sized facility, organization or governmental body.

MARY PAT: Where do you want YNIO to be in 5 years?

MATT: YourNurseIsOn.com is focused on excellent customer experience, and service, for every single client that engages our services, and we will continue with that focus relentlessly as we continue to grow and scale our platform. YourNurseIsOn.com is well poised to become the de-facto communications method for healthcare organizations that need to contact and confirm their specialized, distributed workforces on demand. The ability to easily reach specific individuals, that are qualified and available for a specific function, in a quick and easy manner on any device of their choosing will only become more important given the coming increases in healthcare demand and simultaneous scarcity of all healthcare providers. YourNurseIson.com has the ability to efficiently deliver caregivers where they are needed, not only in institutional settings, but in the communities where the majority of care is being delivered. YNIO, with its international patent -pending status will be the communications ‘glue’ that holds it all together.

MARY PAT: Many people are predicting that NPs and other mid-level providers will be the future of primary care if physician shortages play out as expected.  What do you think?

MATT: Personally, as a nurse practitioner, I feel that this is all too often the focus of discussions about the future of healthcare and is, just as often the beginning of contentious debate that ends in a turf war between doctors and other providers. I do not believe that either of us are the future of healthcare. I believe that we cannot possibly train sufficient numbers of providers to care for the onslaught of demand that is quickly approaching. The future of primary care will lie in the hands of the individual, their families and their communities. This will be supported by tele-medicine, bio-sensors and smart homes to begin and eventually lead to caregiver robots and software algorithms diagnosing and treating your ailments:

• A wristwatch, scale and shoes that track your fitness regimen, downloaded nightly into your Personal Health Record and gently recommending tomorrow’s diet or workout schedule.
• Personal reminder software to gently prod you to take your medicine, engage in physical activity or to remember a wellness event or medical appointment.
• Accentuated reality software to help make informed dietary, activity or purchase selections based on wellness scales, provider recommendations or personal preferences.
• The ability to export this information to your Electronic Health Record to share with your providers, specialists or family
• A smart home with a bed that signals that Grandma woke up later than usual after a restless night, a chemical sensor toilet that signals she may be a bit dehydrated, a pill bottle that alerts when she hasn’t opened it- these types of events triggering personal reminders, check-in requests to a neighbor, visit requests to family, or send an alert to her community caregivers, etc. If no one is able to check on her status, emergency services could be automatically notified.

Couple these technologies with instant, 2-way, verifiable communications systems, and these networks will provide the bulk of care in the near future. There simply are not enough resources to provide care any other way. I hope to see NPs continue to expand their roles, earn autonomy and continue to provide excellent care to millions of people. NPs, MDs, therapists, etc. are all going to be in short supply and high demand. All of these professionals are important to the healthcare delivery team and will have to be allocated with, supported by and communicated to with advanced technologies to expand their practice reach, improve their collective effectiveness, begin to decrease costs, and continually improve outcomes.

******

It was a real pleasure talking with Matt and getting to know more about YNIO and more about him (the geek in me enjoyed the geek in him!)  I truly appreciate how open he was in the interview. Thanks, Matt!

The YNIO (Your Nurse Is On) website is here. Matt recently guest posted on HealthcareIT Today which can be found here. You can connect with Matt here:

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