Manage My Practice

Sometimes in the midst of making changes to improve things,
we inadvertently lose the patient.

Sometimes we literally lose the patient because they say
“Everything is changing and I don’t like it – I’m taking my business elsewhere.”

Sometimes we figuratively lose the patient because they feel a distance in not connecting with the staff, or not understanding why things are changing.

How do we hold on to our patients when all around us the world is changing, healthcare is changing and we are changing to stay alive financially and competitively?

•    Focus on each patient you come in contact with and look into their eyes. We forget to look into people’s eyes. If you find yourself not connecting with a patient, ask yourself what color eyes the patient has. In checking, you will connect.

•    Remind yourself of the preciousness of life and of each life you come in contact with.  The job is do are not just “any” job. We are fortunate to do jobs where we are entrusted with people’s most precious possession – their health and their lives.  We are not telemarketers, we are not selling widgets, and we are making a difference in this world. Don’t forget that – YOU are making a difference. No matter how your job touches a life directly or indirectly, you are in healthcare, one of the most challenging and meaningful jobs out there.

•    Even though we sometimes shake our heads over patient expectations, we can still do our best to let patients know that we are sorry when we cannot do what they are asking. We can’t always see everyone who wants to be seen today.  We can’t always get their forms completed, or their medical records copied, or their test results reported back to them immediately, but we can express the understanding that their needs are important to us.

•    Give everyone the benefit of the doubt.  Believe they are human and doing the best they can.

•    Do not think I expect perfection. I don’t. I expect each of you to do the best you can, but I do not expect perfection of myself and I don’t expect it of you.

Thank you for being in healthcare with me.

Mary Pat

Medicare is a federal health insurance program created in 1965 for:

• people age 65 or older,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Medicare Part A - 99% of patients don’t pay a premium for Part A (hospital insurance) because they or a spouse already paid for it through their payroll taxes while working. The $1,100 deductible for 2010, paid by the beneficiary when admitted as a hospital inpatient, is an increase from 2009.   Part A helps cover:

• inpatient care in hospitals (excluding the physician fees), including critical access hospitals
• skilled nursing facilities (not custodial or long-term care)
• some hospice care
• some home health care

Medicare Part B – Part B (outpatient/doctor insurance) base premium for 2010: $96.40/month (no change from 2009.)  Premiums are higher for single people over 65 making more than $85K per year and for couples making over $170K.  Part B premiums cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over.  The remaining Part B costs are financed by Federal general revenues.  In 2010, the Part B deductible is $155.  Part B helps cover:

• physician fees in the hospital
• physician fees in their offices and other outpatient locations
• other outpatient services (x-rays, lab services)
• some services of physical and occupational therapists
• some home health care

Medicare Part C – Medicare now offers beneficiaries the option to have care paid for through private insurance plans.  These private insurance options are part of Medicare Part C, which was previously known as Medicare+Choice, and is now called Medicare Advantage. Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including private fee-for-service (PFFS) plans, local health maintenance organizations (HMOs) and regional preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs), as well as adding payment for additional services not covered under Part A or B. Here is a great article by Maria Todd on how Medicare Advantage plans get paid.
Medicare Part D -  Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare.  The so-called “doughnut hole” is the amount the patient pays between the initial coverage limit of $2,830 and the out-of-pocket threshold of $4,550 – a total of $1720 that the patient is responsible for.

• Initial Deductible: $310
• Initial Coverage Limit: $2,830
• Out-of-Pocket Threshold: $4,550

COMPARISON OF MEDICARE PLANS

Original Medicare Plan

WHAT? The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide.

HOW? Providers can choose to participate (“par”) or not participate (“non-par”.)  Participating providers accept the Medicare allowable and collect co-insurance (20% of the allowable.) Reimbursement comes to the providers.  Non-participating providers may charge 15% more (called the “limiting” charge) than the Medicare allowable schedule, but the patient will receive the check, which is why some non-par practices require payment at time of service for Medicare patients. To be able to charge patients for non-covered services, patients must sign an ABN before the service is provided.

Original Medicare Plan With Supplemental Medigap Policy

WHAT? The Original Medicare Plan plus one of up to ten standardized Medicare supplemental insurance policies (also called Medigap insurance) available through private companies.

HOW? Medigap plans may cover Medicare deductibles and co-insurance, but typically will not cover anything Medicare will not.  Medicare primary claims will “cross-over” to many Medigap secondary claims so the practice does not have to file the secondary Medigap claim.  Patients may still have a small balance that is cost-prohibitive to bill for.

Medicare Coordinated Care Plan

WHAT? A Medicare approved network of doctors, hospitals, and other health care providers that agrees to give care in return for a set monthly payment from Medicare. A coordinated care plan may be any of the following: a Health Maintenance Organization (HMO), Provider Sponsored Organization (PSO), local or regional Preferred Provider Organization (PPO), or a Health Maintenance Organization (HMO) with a Point of Service Option (POS).

HOW? You have to have signed a contract or be grandfathered in (called an “all-products” clause) under an existing contract to see patients and get paid. Primary care providers may have to provide referrals and/or authorization for specialty services and providers. A PPO or a POS plan usually provides out of network benefits for patients for an extra out-of pocket cost.

Private Fee-For-Service Plan (PFFS)

WHAT? A Medicare-approved private insurance plan. Medicare pays the plan a premium for Medicare-covered services. A PFFS Plan provides all Medicare benefits. Note: This is not the same as Medigap.

HOW? Most PFFS plans allow patients to be seen by any provider who will see them. PFFS plans do not have to pay providers according to the prevailing Medicare fee schedule or pay in 15 days for clean claims.  Providers may bill patients more than the plan pays, up to a limit. It would be a good thing to notify patients if your practice intends to bill above the plan payment.

Need more?  Click on CMS (provider-oriented) or Medicare (patient-oriented.)

I’ve had lots of questions about financial policies since I did a webinar on patient collections last year.  Here’s a short course on developing a new financial policy for your practice.  The topic is addressed more comprehensively in my book.

I dislike financial policies that are long and wordy.  I prefer a simple format that everyone can understand and use.

The format I recommend is one with three columns titled:

1. Your Plan
2. What You Do
3. What We Do

Here’s an example of how the three columns would read:

Your Plan

Medicare

What You Do

Pay your deductible ($155 for 2010) and co-insurance (20% of the allowable.)

What We Do

We will file Medicare for you.

I use the front of the financial policy to list all the variations of plans that the practice accepts.  For instance, the Medicares might include:

• Medicare
• Medicare/Medicaid
• Medicare/supplemental policy
• Medicare Advantage Plan (HMO/PPO)
• Medicare Advantage Plan (PFFS)
• Medicare secondary (MSP)
• Railroad Medicare

Lump together any like plans that you will treat the same.  Then decide what you will expect from the patient at time of service or after, and what the practice commits to doing. Don’t forget to address patients being seen out-of-network and self-pay patients.

I use the back of the policy to cover everything that you would like the patient to sign off on. This could include:

• Receipt of Notice of Privacy Policies
• Receipt of Advance Directives/Living Will info
• Agreement to Financial Policy
• Assignment of Benefits to Practice
• Guarantee of Payment

When you put a new policy in place, you have a number of options to educate patients. Here are some:

• Put the policy on your website.
• Send a copy of the policy to all new patients.
• Discuss the policy when you call patients to remind them of their appointment.
• Discuss the new policy at check-in and/or check-out and let patients know it will be in effect at their next visit.
• Circle the patient’s plan on the front, have the patient sign the financial policy on the back, and give them a copy to take with them.

How you decide to educate the patients will depend on how much time you have between making the appointment and seeing the patient and the type of practice you have – primary care versus sub-specialty.

Also, don’t forget to educate your staff.  If they have not had to discuss money before, they will need some coaching and some practice.

If you’d like a free copy of my sample financial policy, shoot me an email at marypatwhaley@gmail.com.

You probably can’t.

But that doesn’t mean I haven’t been guilty of trying to in the past. I have typically had a policy in my personnel handbook saying staff can be terminated for discussing wages. But should you really follow through with that threat? Some managers probably have, but I wonder if it is just a convenient excuse to terminate an employee. I would not terminate an employee because s/he did something that is so, well, human.

Employees are going to talk and most will compare wages because they are anxious to know if they are being treated fairly or if someone else in a comparable job is making more per hour. Fair is a word I formerly hoped would be used to describe me as a manager, but the longer I work managing staff, the less I really believe there is a “fair.” There is no absolute fair in my mind because it is very difficult to treat two people exactly the same.  No two people have exactly the same training, experience and talents, or attitude, so trying to place an exact value on their services is difficult. Each of us believes we bring something special to the job, but how does one assess that quality?

The best that can be done, I believe, is to be ready to justify and defend why you are paying any staff member what you are paying them.  Be ready for that question, as it is sure to come.

Photo credit: © Elvinstar | Dreamstime.com

I sat at the checkout desk in my practice last week for the first time and as always, it was a revelation.  If you haven’t worked your check-in and check-out desks recently, I highly recommend it.

An insured patient that I checked out was shocked when I said the charge for her visit was $100.  She said, “But he was only in the room for ten minutes!”  I was briefly at a loss for words.  I recovered, we agreed on a payment plan, I made a note on her encounter form for the billing office and she left.

I’ve been thinking about our conversation, and thinking about what that $100 is supposed to cover…

1. First, we scheduled the appointment, which was a work-in, so it took several people to take the message, pull the medical record (paper charts), call the patient to assess the problem, determine the need for the appointment and schedule it.
2. When the patient arrived, we checked to make sure her address and phone were the same, quickly checked her eligibility to make sure the insurance on file was still in force, and asked for a photo ID for red flags.  An encounter form was generated at the nurse’s station to notify her of the patient’s arrival.
3. The nurse called her from the reception area, weighed her, and took her into an exam room to take her vitals, take a brief chief complaint, review the medications she is taking and check to see if she needed any chronic medication refills while she was there.
4. The physician came in to see her, asked about any changes since she’d last been seen, reviewed her history of present illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.
5. He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.
6. He marked the encounter form with the level of service and her diagnoses and gave her the form to take to the check-out desk.
7. He refiled the medication reconciliation in the chart, finished documenting the visit, and placed the chart in the bin to be refiled.  The chart was filed, and the encounter form was sent to the billing office.
8. At the billing office the charges and any payment was posted and the claim was filed.  If there was no problem with the claim, it electronically passed through two scrubs and a final one at the payer.
9. If payment was not denied for any of a dozen reasons, the payment would arrive at the billing office and would be posted.
10. Since the patient did not pay at the check-out desk, the patient-responsible balance is billed to the patient.  If the patient pays on the first statement, it has taken 45 to 60 days to receive complete payment.  Since the patient has BCBS, there is a negotiated rate, so the payment will not even total $100.

I know that patients often say “But he only spent 10 minutes with me.”  Checking back with the provider, I find it was typically longer.  Patients tend to underestimate the time as it goes very fast.

The total visit encompassed the work of the phone operator, the medical records clerk, the triage nurse, the check-in person, the nurse, the doctor, the check-out person and the biller.  It took 8 people, and at least 45 minutes of work to make that appointment happen.  Plus, that visit had to help pay the expenses for the rent, the utilities, malpractice insurance, medical supplies, computers, phones and janitorial services.

The practice, the patients and the overseers of healthcare want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.

Photo credit: © Oleg Pidodnya

My book on front-end collections has been doing really well and I’m pleased that a number of people have called me or emailed me with questions.  Here’s one question that a number of people have asked  – “Can you tell me more about knowing what to collect from the patient at check-out”?

Hopefully, you have followed my advice and collected co-pays and previous balances before the visit.  The portion that you collect after the visit is the co-insurance and the deductible.

The guideline on collecting after the visit is directly related to the allowables on the services the patient received.  Allowables are the amount that payers consider payment in full.  Of the total allowable, a portion will come from the payer and the balance will come from the patient.  Knowing that percentage is the secret to collecting at the check-out desk.  The percentage of the allowable that the patient will pay is the critical piece of information you need to successfully and accurately collect after the visit.

Allowables fall into three categories:

1. The Medicare allowable for your area of the country, or state, for the current year.  If you participate with Medicare, you have an allowable, if you do not participate with Medicare, you have a limiting charge that you must use for Medicare patients.
2. The allowables for the payers with whom you have contracts and have agreed to accept their rate for their subscribers.
3. The rates paid by payers with whom you do not have a contract.  Their payment for out-of-network services (non-contracted physicians) will determine the amount owed by the patient.

How Do You Collect This Information – Medicare

Medicare allowables are published every year, both in the federal register and online at the CMS (Centers for Medicare and Medicaid) website.  If you are fortunate enough to have a practice management system that loads this information automatically for you, you are golden.  If not, you will need to enter these manually.  The good news is that very few practices need to add more than 50 – 100 allowables to get started.

You can also use a paper cheat sheet to fill in your top 50 – 100 codes.  Make a chart with your fee, the Medicare allowable, and the 20% of the allowable that Medicare patients must pay at every visit.  A note of caution – many Medicare patients have secondary coverage and it can be difficult to know what the secondary coverage will pay.  Most practices will not collect anything for patients with secondary coverage because it can mean a lot of refunds have to be written when the secondary payments come in.

How Do You Collect This Information – Payers You Have Contracted With

If you have a contract with a payer, they must furnish you with a full allowable fee schedule, or with an payment model.  For example, their payment model may be 150% of the 2007 Medicare schedule.  You will need to go to the CMS lookup page here and get these allowables for your services for 2007 and multiply it out.

Example: the 2007 allowable for 99213 established patient office visit is $56.98 for North Carolina (use your locality)

If the payer is paying 150% of that allowable, it will be $85.47, and if the patient has to pay 20% of that allowable, they will owe $17.09.  Don’t forget to include the deductible in this equation, as the patient will need to satisfy the deductible before the payer will pay you 80% of their allowable.

Some practice management systems will have the ability to take that information and calculate it for you, so be sure to ask your vendor about this before you do the work.

If you are constructing a manual cheat sheet, you’ll have your fee (even though it doesn’t come into play, I suggest practices always keep their fee on cheat sheets, so staff can bring anything unusual to the administrator’s attention.  Also as you increase fees, you have a handy visual.)  Add the payer’s allowable, and calculate the percentage the patient will owe.

Use this same sheet for your payment posters to make sure you are getting paid the correct amount if your practice management system doesn’t do this for you.

By the way, if an insurance company that you have contracted with refuses to give you a schedule of allowables or a payment model, contact your state medical society, your state insurance commisioner, or your state legislators for help.

How Do You Collect This Information – Payers You Have Not Contracted With

If you do not have a contract with a payer, getting information on their allowables can be tough.  Some practices will have the patient pay in full and either file the claim for the patient, or give/mail the patient a claim form for them to submit. In this case, you do not need the allowables.  If your specialty has higher in-office fees due to tests, etc., it may be difficult for a patient to pay $250 – $500 in full at time of service. You may want to consider one of these strategies for collecting at time of service:

1. Collect a deposit based on the total charge.  Let the patient know it is an estimate and that more or less may be owed.  I do not believe in sending statements.  In my book I recommend using a payment portal to securely store patient credit cards, and adjust the remaining balance up or down according to the actual payment.  As payments come in you can develop a knowledge base for what different payers and plans will pay.  This will assist you in estimating the patient’s portion more accurately over time.
2. You can give patients information about the services they most likely will receive at their visit and ask them to call their payer and get information on payment.  This is a great strategy.  If patients are shocked about their portion, they may want to reconsider becoming your patient.  The last thing you want is a patient who is surprised by the payment due after they have received the services.  Some payers supply subscribers with allowable information on their website.
3. You can usually get the allowable information by phone if you have the subscriber’s information, or if you have the subscriber on a three-way conference call, or in the room with you.  This is more typically done when the subscriber is contemplating surgery or an expensive procedure and you are working on a payment plan, or outside financing with them.

Knowing what the patient owes and making arrangements for payment in full at time of service is one of the most significant things you can do to increase your receipts and decrease your accounts receivable. No practice can afford to “wait and see what insurance pays” and bill the patient months after the service has been rendered.

Click here for the December 9th UPDATE I posted on SubroShare’s announcement that they will not be focusing on physicians as clients.

I recently interviewed Stephen Ambrose, the Founder and CIO of SubroShare®, a database of medical record requests. Steve has a lot of passion for his innovative product and envisions SubroShare® playing a starring role in payer contract negotiations.

Mary Pat:  Steve, what is subrogation?

Steve: Subrogation is a legal right and necessary tool used throughout the insurance industry with many types of policies.  It allows insurers to recover part or full amounts of claim monies, which they have previously paid out to, or on behalf of a claimant.

In certain circles, subrogation is considered the “great equalizer” because it allows insurers to reduce or eliminate the passing of unnecessary cost related to third-party liability (TPL) claims, to policyholder premiums and provider reimbursement rates.

Overpayment of health care claims is a form of “waste” in cases where previously paid health care claims are re-billed to a third party and subsequently paid for again as part of a successful injury claim settlement.

Mary Pat: How does your product SubroShare® relate to subrogation?

Steve: First, apart from Medicare’s MSP (Medicare Secondary Payer) program, I know of no law or obligation where injury claimants or their attorneys must proactively volunteer information to a health payer, alerting them of a case, where the payer has a right to recover.  For this reason payers have always been responsible for data mining claim form information, and to this end, use software products and vendor services to do so.

SubroShare® recognizes that the claim form/data itself is limited in holding the correct, identifying data for third party cases.  In many cases, the use of the claims data results in payers having false positives or dead end investigations.  Even claims vendors who claim to use the ‘latest and greatest’ tools, freely admit that they do not find all of the cases available to the payer.

Our company has developed a new patent-pending technology in Collaborative Subrogation®, where we work to connect just one small part of a health provider’s record department with an applicable payer. This is only for certain ROIs (Release of Information) made by the patient or their attorney involved in a patient’s injury claim.

Mary Pat: What is the physician’s office or healthcare provider’s role?

Steve: In most payer agreements, the health provider has a contractual obligation to provide coordination of benefits (COB) and third party liability (TPL) information to the payer, when known.  This is reflected in certain sections of the CMS 1500/UB-04 forms and their 837 data record electronic counterparts.

The SubroShare® exchange handles non-billing TPL data, specific ONLY to those times where a record request is made on a patient of the provider.  This ROI Data, is submitted to SubroShare® at the time of  record request fulfillment, by the provider submitting either a one or two page fax / secure email attachment. The first page is typically only a ¼-page section and the second page is a copy of the request letter, sent by an attorney (if applicable).

Providers can learn more by watching the provider tutorial here.

Mary Pat: How does this sharing of information work within HIPAA rules?

Steve: Under 45-164.501 of the Health Insurance Portability and Accountability Act (HIPAA), the ROI data that is collected and shared between health providers and payers, through the SubroShare® network, is specific to insurance subrogation operations and falls under the HIPAA provision of “Payment”, in the automatic exclusion of “Treatment”, “Payment” and “Operations”.

This means that patient authorization is not necessary, nor can the patient request to withhold the limited disclosure of their PHI to SubroShare and eventually, to their health insurance company.

Finally, every health provider who participates with SubroShare® must sign a HIPAA Business Associate agreement, which is signed digitally on the joining section of our website.

Mary Pat: What is the health plan or payer’s part of this?

Steve: Payer members or Subscriber Entities of SubroShare® login and freely search for established Certified Recovery Reports® within our system.  Once found, the payer downloads the information, which both guarantees policyholder involvement and uniqueness from any existing payer’s claims management software and vendors.

Mary Pat: I can see how this benefits the payer, but how does it benefit the physician practice?

Steve: Under the new HITECH guidelines to go into effect in later 2010, health providers cannot receive compensation from the transfer of PHI. Therefore, we felt it prudent to be able to create financial transparency on both the payer and provider sides of SubroShare®.

Essentially, providers will know the specific payers who downloaded their submitted ROI data, as well as the date of download and patient referenced.  This data, coupled with a provider’s analysis on the amount of paid claims for such patients, provides a clearer picture on the fact that a provider is now becoming a new type of asset to the payer and to an extent, which can be measured by the provider, as well as the payer.  We believe such a change in value could denote an improvement in reimbursement levels within various payer relationships.

Mary Pat: Could payers use this information to deny payment or request a refund for payments already made?

Steve: There are numerous laws and rules, inherent to different states, communities and health plans, allowing for cost avoidance.  This term denotes when a government, commercial or self-insured payer determines that a policyholder’s care should be or will be covered by a payment party other than themselves.

Unfortunately, we cannot keep a health payer from pursuing cost avoidance policies, which they have in place.  However, I’d like to mention that not all plans have this provision; and for those which do, this simply makes the point that it could be a future point of provider-payer negotiation, perhaps with relation to all such claims, not just the ones from SubroShare®.

Mary Pat: If the practice uses an outsourced company to copy medical records, can the medical records company send the information to SubroShare®?

Steve: Yes, provided two conditions are met.

First, the health provider is the one, which joins SubroShare® – not the outsourced company.  Health providers can give their login details and appropriate permissions to their ROI or outsourced information vendor.

Second, the outsourced vendor MUST have an existing HIPAA Business Associate Agreement with any applicable health providers.  I assume this is the case anyway, but if I didn’t mention it the answer would be less than complete.

Mary Pat:  It’s a leap of faith you’re asking a medical practice to take, isn’t it?  Is there any way you give the practice a guarantee of negotiating better fee schedules with payers, or any way you could compensate them for their time?

Steve: I don’t think the leap is that large…here’s why.  Its becoming increasingly obvious that past provider strategies on reimbursement rates will be largely overshadowed and trumped by a tightening healthcare system and monies, which are drying up for many of its participants.  If the monies are not there for payers, they won’t be there for providers.

SubroShare® creates revenue, without charging higher premiums to policyholders, but rather, in redistributing monies, which are generated through the legal industry and might never make their way back into the healthcare arena.  Providers need to look at the information, which they are already holding.  Can it help their valuation and reimbursement with payers?  I suppose that’s up to each payer.  Medicare already has demo programs, which trade off payment for valuable data submission and we expect that to find its way into the private payer sector as well.

Our President and both sides of Congress have made it very clear that finding and reducing waste is one of the top priorities.  Therefore, we want our collaborative model to demonstrate to today’s leaders that payers and providers CAN work together for the good of the system.

Mary Pat:  What would you say to a practice manager to convince them to work with SubroShare?

Steve: As a practice manager, if you are bitter about “what insurers have done TO you?”, then you are not the right practice for SubroShare®.  You’ll probably be coming on through payer mandate, as your payers adopt  these measures.  I will state that voluntary participation will offer you the ability to proactively come to the  negotiating table with results in hand.

If you understand that it’s about future positioning and NOT the payer taking advantage of you, then you’ll  begin to understand the importance of positioning and collaborative strategy.  We’re in a whole new arena of healthcare and old models and adversarial relations will not do well.

There is no cost to join, no cost to participate, no software to buy or integrate and no patient authorization  necessary. All that is required is a fax and a simple internet connection.  Please visit us here or call (804) 750-1389 for more information.

Welcome Denise Price Thomas, practice administrator (32 years) and consultant. Throughout her career, Denise has been passionate about creating positive experiences for patients and customers. She enjoys teaching customer service and effective communication.  She strives to inspire others by using heart-warming stories and humor gleaned from her management experience in her informational, inspirational and motivational presentations.  In addition, “Gladys Friday”, (aka Denise), completes the package of “Health, Hope & Humor” by telling entertaining stories about funny moments in health care settings.

I received a call from a practice administrator who said, “When I am observing the front desk staff, I find them to be helpful and attentive to our patients, however when the patients are visiting with the physician, he receives multiple complaints per day.  I cannot be with them at all times.” This is so true as is in many practices.  The staff is on their best behavior when the administrator, manager or physician is around.

After meeting with the administrator and physicians, it was decided that they were in need of a practice evaluation, to see how things look “from the other side of the desk.”

I was to be there at 10:00 am.  The administrator and physicians were aware but they had elected to keep the surprise to themselves.

I arrived to find the sliding window CLOSED.  Although it was a clear glass (thinking the person on the other side could actually SEE through it) I just knew it would open…..it didn’t.  In fact, nothing happened.  The receptionist was “busy” writing and her head was down.  As I stood there waiting “patiently” (as she thought I WAS a patient), I looked around at all of the real patients, looking through magazines – angrily flipping pages.  I could tell immediately that they had been greeted in the same manner.  There were loud sighs, eyes rolling as they looked at their watch; people were not happy.

After giving it a few minutes, I decided to tap on the CLOSED window.  Still without looking up, she said, “I’ll be with you in a moment!”   After waiting another minute or so…..I decided to put on my brave suit and go for it.  I slid the CLOSED window open and said, “May I see your administrator please?” (still trying not to give it away).  She said, (again without looking up – I still have NOT seen her eyes – nor has she seen mine) “M’AM, I SAID I would be with you in a minute!”  I politely said, “thank you.”

BINGO!  I had located the trouble, when suddenly there appeared before me….the administrator.  I was so happy to see her.  She said, “Denise, come on back.”  She introduced me to the clinical staff and we made our way to the front desk.  She said to the “greeter” at the front desk, “this is Denise, she will be performing a practice evaluation to see how we may improve our services.”  The “greeter” said, “It is SO NICE to meet you.”  No, it really wasn’t.  She decided at that point that she needed to be nice to me when she should have been NICER to her PATIENTS, the reason she was there.

Realizing that she wasn’t really a “people person” to say the least, it was decided that she work in another area in the practice, where she was happier and the person from medical records was much happier working with the patients.

End result, happier patients, happier physicians, happier staff.

Moral of this story:  You can have the most wonderful physicians but if you have a sub-standard staff, patients will not be happy.

Things to look for in a front desk applicant:
Fortune teller – able to know when someone has changed insurance companies, divorced, remarried, deleted insurance, moved, etc.

Air traffic controller – able to smoothly divert patient traffic in an attempt to keep them from running into others and finding out their “time of arrival” is the same as others.  Able to handle maximum doses of STRESS!

Medi-copter pilot – able to hover over an emergency, assess and remove the patient in distress and deliver them to the safest place  AWAY from the lobby – seeking clinical assistance – while remaining calm

Multi-lingual – able to understand multiple languages and be able to effectively communicate

Coach – able to motivate the team, support the team, protect the team while being part of the team’s proactive plan, not the team’s problem

“One Ringy Dingy” – Switchboard Operator– able to pleasantly answer each phone call addressing each one as it is the only call

Multi-tasker – able to effectively & efficiently perform multiple tasks while wearing a smile and a positive attitude – with each patient

Juggler – able to maintain balance while keeping eyes on the patient

Circus trainer – able to be the master of MANY ceremonies

Reservation Concierge – scheduling and rescheduling while exhibiting exceptional customer service skills, GLAD that the person has contacted their practice for “reservations” (an appointment)

Infection Control Officer – ensures cleanliness and minimizes germs

Minimalist – able to work without the clutter igloo around them

Walmart Greeter – happy to see everyone that walks through the door

Helpful characteristics to look for when interviewing a medical front desk applicant:
Unflappable
Patient
Exhibits kindness
Compassionate
Positive attitude
Exhibit good eye contact
Nice soothing voice
Multi-tasker
Non-complainer
Willingness to help others before themselves
Desire to be cross-trained
Does not have the words, “It’s not my job” in their vocabulary

Most healthcare workers that have BEEN a patient or have been with their family member through sickness…..make great healthcare employees.  They KNOW how it feels to be on “The Other Side Of The Desk”

Denise Price Thomas

Note: Denise’s partner in DPT Consulting &Training is Gladys Friday, pictured here.  If you are interested in contacting Denise or Gladys about their services, they can be contacted through their website here or by phone at 704-747-8699 or via email to denisepricethomas@gmail.com.

Note from Mary Pat: The Advance Beneficiary Notice of Noncoverage (ABN) is a collection tool that many medical practices do not know how to implement.  It is particularly difficult to determine who has ownership of this process, because the form must be completed and signed by the patient before the service is provided.  The patient is in the exam room or the lab, ready for the service or test, and a knowledgeable staff person must step in, explain the rules and pricing and obtain the patient’s signature.

Blogger Charlene Burgett does a great job of explaining the ins and outs of using the ABN, and has agreed to share an article originally published on her blog “Conundrum” with MMP readers.

The use of the ABN is required by Medicare to alert patients when a service will not be paid by Medicare and to allow the patient to choose to pay for the service or to refuse the service.

If the practice does not have a signed ABN from the patient and Medicare denies the service, the charge must be written off and the patient cannot be billed for it. The only exception is for statutorily excluded services (those that Medicare never covers like cosmetic surgery and complete physicals for example). In this case, a practice can bill the patient for the non-covered service despite not having an ABN.  It is, however, a good idea to have the ABN signed for non-covered services so the patient is made aware that they are responsible.

If the patient signs the ABN and is made aware of their financial responsibility you may require the patient to pay for this service on the date the service is provided. You may also charge the patient 100 percent of your fee. You do not have to reduce your charge to the Medicare allowable.

With a signed ABN, the practice has proof of the patient’s informed consent to provide the service and their agreement to be financially responsible for the service. In the past, Medicare had a “Notice of Exclusion of Medicare Benefits” (NEMB) that we could provide to the patient (no signature required) to alert them of Medicare’s non-covered services. The ABN has replaced the NEMB.

The typical reasons that Medicare will not cover certain services and that would be applicable are:

1. Statutorily Excluded service/procedure (non-covered service)
2. Frequency Limitations
3. Not Medically Necessary

Statutorily Excluded items are services that Medicare will never cover, such as (not a complete list):

• Complete physicals (excluding Welcome to Medicare Screenings, with caveats)
• Most immunizations (Hepatitis A, Td)
• Personal comfort items
• Cosmetic surgery

For these items, it is a good idea (not a requirement) to complete the ABN and have the patient check the appropriate box under options and sign the ABN. For the sake of the billing department, I strongly encourage the use of ABN’s for statutorily excluded items.

Frequency Limitations are for services that have a specific time frame between services. For example, Medicare allows one pap smear every 24 months if the pap is normal.  If the patient wants one every 12 months for their peace of mind, Medicare will pay for year one and the patient will pay for year two and that pattern continues. The ABN needs to be on file for the year that the patient is responsible for paying.  If the patient fits Medicare’s guidelines for “high risk” they are allowed to have the pap every 12 months and no ABN is required.

Services that are not considered Medically Necessary are those that do not have a covered diagnosis code based on Local Coverage Determinations (LCD).  One example is for excision of a lesion. If the lesion is being removed because the patient just doesn’t like how it looks, that is considered cosmetic surgery. If the lesion is showing some changes (i.e. bleeding, growing, changing color, etc), then it is considered medically necessary because it potentially can be malignant. The removal needs to have diagnosis coding to substantiate the medical necessity and Medicare has Local Coverage Determinations that list all the codes/coding combinations that Medicare will approve for payment.

A rule of thumb in trying to discern the necessity of ABNs is to ask yourself if there may be some times that the service isn’t covered by Medicare.  The times the service isn’t covered, an ABN is required. To illustrate this point, here are two examples:

• EKGs are covered for certain cardiac and respiratory conditions. The only time an EKG is covered for preventive screening is during the patient’s first year enrolled in the Medicare program and when being done during the Welcome to Medicare screening.  After that time, Medicare will never cover an EKG for preventive screening. To notify the patient of this and to show that the patient agrees to be financially responsible for the EKG, an ABN should be completed.

• Another example is for the Tetanus immunization.  Medicare will cover tetanus when medically necessary; if the patient has cut themselves and the tetanus is provided due to that injury.  If the tetanus is provided to the patient because it has been ten years since the last tetanus and the tetanus is not in response to a recent injury, then it will be non-covered because it is not “medically necessary” and the ABN will need to be on file.

ABNs need to be completed in their entirety.  The “Options” box can only be completed by the patient and it states that “We cannot choose a box for you”.  That would appear to be coercion.  A “blanket” ABN, one that is signed by the patient for all services provided within a certain time period, is not acceptable and is illegal.

In addition, there is a small area to provide additional information that can be used by either the patient or the provider’s office. This could be anything pertinent to the information that the ABN covers. The bottom of the form is where the patient signs and dates. We keep the original ABN in the chart behind the progress note for that day. Providers MUST provide a copy of the signed ABN to the patient.

The current ABN form with instructions can be found here.

If a service is denied by Medicare and the physician does not have a signed ABN prior to the service being rendered, the service can not be billed to the patient and will need to be written off.  Sometimes a patient may refuse to sign the ABN – if this happens it is appropriate for the physician to document the refusal and sign, along with having a witness sign.  Medicare will accept this and the patient can be billed for the service if denied by Medicare.

How does Medicare know whether or not you have a signed ABN?  You tell them, by adding a modifier to the CPT code when completing the claim form.  The appropriate modifiers are:

GA:  The ABN is signed, but the service may not be covered.

GY:  A “statutorily excluded” service.

GZ:  The service is expected to be denied as not reasonable or necessary.  This is typically used when there is a secondary payer that requires the Medicare denial before they pay benefits.

The use of the ABN is often misunderstood; however, it is the only way a patient can be informed about their financial responsibility prior to agreeing to a service being rendered.  This is an issue that the OIG has reportedly been interested in investigating for fraud and abuse.

Charlene Burgett, MA-HCM

Note: Readers, how do you make the ABN work in your practice?  Do you train the clinical staff, the physicians, or other staff to recognize the “ABN Moment”?  How do you make it work? Please share your ideas by responding with a comment.